Journal of Gerontology & Geriatric Medicine Category: Medical Type: Research Article
Cognition and Differences in Self-Report and Biochemical Measurement of Dietary Intake: Food For Thought
- Kay Wrona Klymko1*, Hossein Yarandi2, Marybeth Lepczyk3, Lori Klymko4
- 1 College Of Nursing, Florida Health Care Plans, Wayne State University, Detroit, Michigan, Holly Hill, Florida, United States
- 2 College Of Nursing, Wayne State University, Detroit, Michigan, United States
- 3 Geriatric Center Of Excellence And Rosa Parks Geriatric Center, Detroit Medical Center, Detroit, Michigan, United States
- 4 Registered Dietitian, Solaris Healthcare Plant City, Plant City, Florida, United States
*Corresponding Author:Kay Wrona Klymko
College Of Nursing, Florida Health Care Plans, Wayne State University, Detroit, Michigan, Holly Hill, Florida, United States
Received Date: May 05, 2017 Accepted Date: Jun 09, 2017 Published Date: Jun 23, 2017
Few studies have considered cognitive performance in older adults when assessing dietary intake with self-report measures. This pilot study used a small sample (N = 50) of predominantly African American older adults in a geriatric primary care center to better understand the role that cognition may play in obtaining an accurate assessment of dietary intake based on self-report. Two types of dietary self-report measures (Dietary Risk Assessment [DRA], Dietary Health Questionnaire [DHQ 11] Food Frequency Questionnaire [FFQ] combined with a Picture-Sort method) were used to compare the differences in self-report measurement of selected nutrients with two biochemical markers of nutritional status (total cholesterol, serum carotenoids) among participants grouped by levels of cognitive function. Two commonly used cognitive assessment tools (MMSE 11-SV, MiniCog) were found to identify dietary intake risk when cognitive function may be limited. Although the differences in dietary self-report measures and biochemical marker measures were not found to be related to cognitive function, the authors consider explanations to stimulate further research on this challenging topic.
Dietary intake is an important contributor in the etiology, prevention and management of chronic illnesses prevalent in older adults . In addition to chronic medical conditions, older adults may face declining cognitive capacity, including memory loss and executive function deficit and the risk grows as they get older . It is reported that increasing age is one of the strongest risk factors for dementia, with moderate to severe memory impairment gradually increasing from 4.4% for ages 65 to 69 years to 20.1% for ages 80-84 years . Brain aging, secondary effects of chronic illness or nutritional deficiencies can account for loss of cognitive function among older adults [4-7].
Maintaining an adequate diet can be challenging for older adults as appetite decreases, the presence of chronic illness and medication use increases and memory loss or executive function deficits emerge [1,8]. It is critical that health care providers accurately assess the food consumption of the older adults in their care to help them maintain optimal health and quality of life. However, declining cognitive function may make it difficult for seniors to provide accurate assessments of dietary intake. Although it is well known that chronic illness and brain aging are associated with cognitive difficulty, few studies have considered cognitive performance in older adults when assessing dietary intake with self-report measures [8-10]. Thus, there is a critical need to understand the role cognitive difficulty may play in obtaining an accurate assessment of dietary intake. This pilot study measures dietary intake using two types of self-report measures and compares differences in these self-reports with two biochemical markers of nutritional status (total cholesterol, serum carotenoids) among a small sample of older adults grouped by different levels of cognitive function.
Setting and Sample
During a routine clinic visit, clinic staff introduced the study to patients and interested patients were contacted by project staff. Individuals who met the eligibility criteria were invited to participate and informed consent was obtained. A sample of 50 participants were recruited for this study, which was adequate to achieve 80% power to detect an effect size of 0.35 at a 0.05 level of significance . The study was approved by the University and Medical Center’s Human Investigation Committee and Institutional Review Boards.
Biomarkers of nutritional status
Socio-economic demographic data
Dietary intake of older adults
Relationship between self-report measures and biochemical markers reflecting dietary intake
Cognitive function and the differences in standardized self-report dietary intake measures and biochemical markers of dietary consumption
Differences in standardized self-report dietary intake measures and biochemical marker scores according to established clinical cut points of cognitive functioning
This pilot study, using a small sample of predominantly African American older adults in a geriatric primary care center, attempted to better understand the role that cognition may play in obtaining an accurate assessment of dietary intake based on self-report. Two cognitive assessment tools commonly used in primary care practice settings were found to both be potentially adequate in identifying dietary intake risk when cognitive function may be limited. The fact that both cognitive assessment tools performed the same and with the same dietary index (fiber) is noteworthy, as the MiniCog can be easily and rapidly integrated (5 minutes) into a busy practitioner’s assessment. Moreover, the Dietary Risk Assessment (DRA) tool’s significant relationship of the fruit and vegetable index to the serum carotenoid’s index supports prior findings on the validity of this tool for use in dietary assessment with this population . Although the DHQ 11 with the picture sort method did not demonstrate a similar relationship, it was useful in its ability to generate an individualized computer printout of an individual’s dietary intake (e.g., total daily calories, individual nutrients in comparison to recommended intake). However, the DHQ 11 combined with a picture sort-method, was found to be time consuming in its administration (~ 60 minutes) and processing was challenging, therefore may be better reserved for research purposes as opposed to use by practitioners.
The inability of the difference in dietary assessment measures (subjective measure [e.g., fruit and vegetable index as self-reported] and objective measure [e.g., serum carotenoids]) to be related to cognitive function was surprising. It would seem intuitive that there would be a greater spread between what one says they ate and what the body shows it ate according to how cognitively impaired an individual is. But, the small sample size could be an answer for the lack of relationship. Several alternative and challenging explanations may also be considered. Could it be that people do not accurately report their dietary intake, whether they are cognitively impaired or not? While the literature has reported on the inaccuracies of dietary self-report, the role of cognitive function has not been given a good deal of attention . In the OPEN (observing protein and energy nutrition) study to assess dietary measurement error using self-report instruments (e.g., Food Frequency Questionnaire [FFQ]) and biomarkers of energy and protein intake among 484 men and women, age 40-69, the investigators found 35% of men and 23% of women under-reported intake using the FFQ; however, cognition was not explored . Alternatively, Morris et al., (2003) found the food frequency questionnaire as a reasonable dietary assessment method, even in the presence of cognitive impairment in a biracial sample of older adults in the Chicago Health and Aging Project.
Could it be, and “food for thought,” that reporting dietary intake accurately is a “last to go” phenomenon, such that, one must be severely cognitively impaired before an individual cannot recall foods they have eaten? The picture sort method used with the DHQ 11 in this study may have served as a memory aid to individuals more impaired and thereby suppressing the expected differences in subjective and objective measurements for cognitively impaired individuals. Also, the pleasure older adults find in eating when faced with so much loss in other physical realms, may make the time spent in thinking of foods (what has been eaten and what is going to be eater) a cognitive function that considerable time is devoted to, and making memories easier to recall.
Future directions for study learned from this small pilot study, would be to further explore the effect of severe cognitive impairment in comparison to those determined to be dementia-free. Moreover, a study of an ethnically homogeneous sample may help to provide internal validity. Given the wide age range in the sample of this study (61-90 years), future study may consider additional analyses for younger and older adults with sectoring the sample by median age for additional analyses. Moreover, the use of linear and logistic regression models while controlling for age, education and income when examining cognitive functioning and dietary intake measures would provide a more robust understanding of the associations. It must be appreciated that the cognitive screening tools used in this study (MMSE and Mini-cog) do have their limitations of significant ceiling effects which may limit inference from the simple analyses that were conducted in this study.
Brief cognitive screening assessments may assist in the identification of older adults who have unhealthy dietary intakes. To improve the accuracy of nutritional status assessment in older adults, researchers and practitioners alike, may need to account for cognitive functioning in their sample and patient population. More research is needed to better understand how the use of cognitive function assessment may be used to guide individually tailored dietary intake assessment.
The authors wish to express their appreciation to the Detroit Medical Center (DMC) for funding this research with the DMC Faculty Scholar Award.
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Citation:Klymko KW, Yarandi H, Lepczyk M, Klymko L (2017) Cognition and Differences in Self-Report and Biochemical Measurement of Dietary Intake: Food For Thought. J Gerontol Geriatr Med 3: 014.
Copyright: © 2017 Kay Wrona Klymko, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.