Telemonitoring to improve nutritional status in community-dwelling elderly: design and methods for process and effect evaluation of a non-randomized controlled trial.

BACKGROUND: A good nutritional status is key for maintaining health and quality of life in older adults. In the Netherlands, 11 to 35% of the community-dwelling elderly are undernourished. Undernutrition or the risk of it should be signalled as soon as possible to be able to intervene at an early stage. However, in the context of an ageing population health care resources are scarce, evoking interest in health enabling technologies such as telemonitoring. This article describes the design of an intervention study focussing at telemonitoring and improving nutritional status of community-dwelling elderly. METHODS: The PhysioDom Home Dietary Intake Monitoring intervention was evaluated using a parallel arm pre-test post-test design including 215 Dutch community-dwelling elderly aged > 65 years. The six-month intervention included nutritional telemonitoring, television messages, and dietary advice by a nurse or a dietician. The control group received usual care. Measurements were performed at baseline, after 4.5 months, and at the end of the study, and included the primary outcome nutritional status and secondary outcomes behavioural determinants, diet quality, appetite, body weight, physical activity, physical functioning, and quality of life. Furthermore, a process evaluation was conducted to provide insight into intervention delivery, feasibility, and acceptability. DISCUSSION: This study will improve insight into feasibility and effectiveness of telemonitoring of nutritional parameters in community-dwelling elderly. This will provide relevant insights for health care professionals, researchers, and policy makers. TRIAL REGISTRATION: The study was retrospectively registered at Clinical-Trials.gov (identifier NCT03240094 ) since August 3, 2017.

Determinants of lifestyle behavior change to prevent type 2 diabetes in high-risk individuals.

BACKGROUND: Although there are many effective lifestyle interventions for type 2 diabetes (T2DM) prevention, insight into effective intervention pathways, especially of long-term interventions, is often lacking. This study aims to provide insight into the effective intervention pathways of the SLIMMER diabetes prevention intervention using mediation analyses. METHODS: In total, 240 participants at increased risk of T2DM were included in the analyses over 18 months. The intervention was a combined lifestyle intervention with a dietary and a physical activity (PA) component. The primary and secondary outcomes were change in fasting insulin (pmol/L) and change in body weight (kg) after 18 months, respectively. Firstly, in a multiple mediator model, we investigated whether significant changes in these outcomes were mediated by changes in dietary and PA behavior. Secondly, in multiple single mediator models, we investigated whether changes in dietary and PA behavior were mediated by changes in behavioral determinants and the participants' psychological profile. The mediation analyses used linear regression models, where significance of indirect effects was calculated with bootstrapping. RESULTS: The effect of the intervention on decreased fasting insulin was 40% mediated by change in dietary and PA behavior, where dietary behavior was an independent mediator of the association (34%). The effect of the intervention on decreased body weight was 20% mediated by change in dietary and PA behavior, where PA behavior was an independent mediator (17%). The intervention significantly changed intake of fruit, fat from bread spread, and fiber from bread. Change in fruit intake was mediated by change in action control (combination of consciousness, self-control, and effort), motivation, self-efficacy, intention, and skills. Change in fat intake was mediated by change in action control and psychological profile. No mediators could be identified for change in fiber intake. The change in PA behavior was mediated by change in action control, motivation, and psychological profile. CONCLUSION: The effect of the SLIMMER intervention on fasting insulin and body weight was mediated by changes in dietary and PA behavior, in distinct ways. These results indicate that changing dietary as well as PA behavior is important in T2DM prevention.

Effect and maintenance of the SLIMMER diabetes prevention lifestyle intervention in Dutch primary healthcare: a randomised controlled trial.

BACKGROUND/OBJECTIVES: To assess the effectiveness of the SLIMMER combined dietary and physical activity lifestyle intervention on clinical and metabolic risk factors, dietary intake, physical activity, and quality of life after 12 months, and to investigate whether effects sustained six months after the active intervention period ended. SUBJECTS/METHODS: SLIMMER was a randomised controlled intervention, implemented in Dutch primary healthcare. In total, 316 subjects aged 40-70 years with increased risk of type 2 diabetes were randomly allocated to the intervention group (10-month dietary and physical activity programme) or the control group (usual healthcare). All subjects underwent an oral glucose tolerance test and physical examination, and filled in questionnaires. Identical examinations were performed at baseline and after 12 and 18 months. Primary outcome was fasting insulin. RESULTS: The intervention group showed significantly greater improvements in anthropometry and glucose metabolism. After 12 and 18 months, differences between intervention and control group were -2.7 kg (95% confidence interval (CI): -3.7; -1.7) and -2.5 kg (95% CI: -3.6; -1.4) for weight, and -12.1 pmol l-1 (95% CI: -19.6; -4.6) and -8.0 pmol l-1 (95% CI: -14.7; -0.53) for fasting insulin. Furthermore, dietary intake, physical activity, and quality of life improved significantly more in the intervention group than in the control group. CONCLUSIONS: The Dutch SLIMMER lifestyle intervention is effective in the short and long term in improving clinical and metabolic risk factors, dietary intake, physical activity, and quality of life in subjects at high risk of diabetes.

Serum micronutrient concentrations and childhood asthma: the PIAMA birth cohort study.

BACKGROUND: Research suggests an influence of micronutrients on childhood asthma. So far, evidence mainly originates from cross-sectional studies using nutrient intake data, which is not an accurate measure of nutrient status. This study aimed to investigate the cross-sectional and prospective associations between serum concentrations of magnesium, vitamin D, selenium, and zinc and prevalence of (severe) asthma, atopy, and bronchial hyperresponsiveness (BHR) in childhood. METHODS: In the Prevention and Incidence of Asthma and Mite Allergy birth cohort study, serum nutrient concentrations were available for a 4-yr-old subgroup (n = 372) and for a different 8-yr-old subgroup (n = 328). Yearly questionnaires inquired about asthma prevalence until 8 yr of age. Allergic sensitization was measured at 4 and 8 yr of age; BHR was measured at 8 yr of age. Data were analyzed with logistic regression and generalized estimating equations models. RESULTS: There was a consistent (non-significant) inverse association between serum magnesium concentrations and asthma prevalence. Serum vitamin D concentrations measured at age 4 were inversely associated with asthma at ages 4-8 [e.g., cross-sectional association between vitamin D tertile 3 vs. 1 and severe asthma: odds ratio (OR): 0.49, 95% confidence interval (CI): 0.25-0.95], whereas vitamin D measured at age 8 was positively associated with asthma at age 8 (e.g., cross-sectional association between vitamin D tertile 3 vs. 1 and severe asthma: OR: 2.14, 95% CI: 0.67-6.82). CONCLUSIONS: Our study contributes to the evidence that children with higher serum magnesium concentrations are less likely to have asthma. The associations between serum vitamin D concentrations and asthma were age-dependent.

Positive and negative experiences of social support and long-term mortality among middle-aged Dutch people.

This study investigated the relation between positive and negative experiences of social support and mortality in a population-based sample. Data were derived from Dutch men and women aged 20-59 years who participated in the Doetinchem Cohort Study in 1987-1991. Social support was measured at baseline and after 5 years of follow-up by using the Social Experiences Checklist indicating positive (n = 11,163) and negative (n = 11,161) experiences of support. Mortality data were obtained from 1987 until 2008. Cox proportional hazards regression models, adjusted for age and sex, showed that low positive experiences of support at baseline were associated with an increased mortality risk after, on average, 19 years of follow-up (hazard ratio = 1.26, 95% confidence interval: 1.04, 1.52). Even after additional adjustment for socioeconomic factors, lifestyle factors, and indicators of health status, the increased mortality risk remained statistically significant (hazard ratio = 1.23, 95% confidence interval: 1.01, 1.49). For participants with repeated measurements of social support at 5-year intervals, a stable low level of positive experiences of social support was associated with a stronger increase in age- and sex-adjusted mortality risk (hazard ratio = 1.57, 95% confidence interval: 1.03, 2.39). Negative experiences of social support were not related to mortality.

Characterization of different groups of elderly according to social engagement activity patterns.

OBJECTIVE: The aim of this research was to segment older people in subgroups with similar social engagement activity patterns in order to better target public health interventions. DESIGN: Cross-sectional data, collected in 2005 by Dutch community health services (response 79%), from 22026 independently living elderly aged 65 or older were used. Cluster analysis was performed to derive subgroups with common social engagement activity patterns, which were compared for their self-perceived health, mental health, physical health, and loneliness. RESULTS: Among the independently living older people, five subgroups were identified with different patterns of social engagement activities: less social engaged elderly, less social engaged caregivers, social engaged caregivers, leisure engaged elderly, and productive engaged elderly. The subgroups differed significantly in social engagement activities, socio-demographics, and health (p < 0.001). The groups with the highest relative numbers of older people who were frequently engaged in leisure and productive-related activities, also included relatively more elderly with a good self-perceived health (85.8% versus 58.8%), mental health (91.3% versus 74.6%), physical health (97.7% versus 73.0%), and elderly who were not lonely (70.0% versus 52.0%) when compared to the least healthy subgroup. CONCLUSION: Older people could be segmented in subgroups based on similar social engagement patterns. Groups with elderly who were less socially engaged demonstrate to be possible target groups for public health interventions, given the relatively high shares of unhealthy older people among them.

Skipping breakfast, alcohol consumption and physical inactivity as risk factors for overweight and obesity in adolescents: results of the E-MOVO project.

OBJECTIVE/BACKGROUND: To investigate the association between skipping breakfast, alcohol consumption and physical inactivity with overweight and obesity in adolescents. The design comprises cross-sectional electronic health survey (E-MOVO). SUBJECTS/METHODS: Over 35 000 Dutch adolescents in grade 2 (13-14 years of age) and grade 4 (15-16 years of age) of secondary educational schools were recruited by seven community health services. Analyses were performed on 25 176 adolescents. Body mass index was calculated from self-reported body weight and height. Frequency of skipping breakfast per week, amount of alcoholic drinks consumed per occasion, and numbers of physical active days per week were considered as determinants for overweight and obesity. RESULTS: In grade 2, adjusted odds ratios for the association with overweight were 2.17 (95% CI: 1.66-2.85) for skipping breakfast, 1.86 (1.36-2.55) for alcohol consumption and 1.73 (1.19-2.51) for physical inactivity. Statistically significant associations with overweight were also found in grade 4. In grade 2, dose-response relations (P for trend <0.05) were present between all risk factors and overweight. In a multivariate model containing all risk factors, breakfast skipping showed the strongest relation with overweight (OR 1.68, 95% CI 1.43-1.97 for grade 2, OR 1.32 95% CI 1.14-1.54 for grade 4) and obesity. CONCLUSIONS: Skipping breakfast, alcohol consumption and physical inactivity were associated with overweight in second and fourth grade adolescents. The associations were strongest for younger adolescents. The most important risk factor for overweight and obesity was skipping breakfast.

Gender, cohort and geographical differences in 10-year mortality in elderly people living in 12 European towns.

BACKGROUND: In 1988/89, 2586 randomly selected elderly of both sexes born between 1913 and 1918 and living in 19 centres of 12 European countries participated in the SENECA Study on Nutrition and the Elderly in Europe. Differences in nutritional and health status as well in lifestyle factors, namely dietary habits, between the elderly living in the several centres were observed. OBJECTIVE: To study gender, cohort and geographical differences in 10-year mortality in elderly people from the SENECA Study. DESIGN: Longitudinal study. Information on vital status of the elderly people who participated in the baseline study performed in 1988/89 was obtained by standardized procedures in 1999, until 30 April. RESULTS: In all centres, men had higher mortality rates than women. A cohort effect in mortality is observed, particularly in men. A geographical pattern in mortality also more evident in men is shown. In fact, elderly men living in Eastern Europe, represented by the Polish centre, had the highest average hazard rate, 108, while those living in Southern Europe, including the French, the Swiss, the Italian, the Spanish and the Portuguese centres, had the lowest average hazard rates, ranging from 52 in Betanzos/Spain to 67 in the two French towns. Finally, those living in Northern Europe, represented by the Danish, the Dutch and the Belgian centres had intermediate values, from 68 in Roskilde/ Denmark to 85 in Culemborg/the Netherlands. Kaplan-Meier survival curves confirmed the gender, cohort and geographical differences in survival (log-rank test P 0.0001). CONCLUSION: The gender and geographical differences in mortality observed in elderly people living in different regions of Europe put in evidence the potential for increasing the life expectancy in Europe through intervention programs tackling the lifestyle and socio-economic factors behind those differences.

Evaluation of dietary quality in relationship to nutritional and lifestyle factors in elderly people of the US Framingham Heart Study and the European SENECA study.

OBJECTIVE: To evaluate dietary quality of European and American elderly subjects using different derivatives of dietary patterns (dietary scores and clusters) and to investigate the relationship of these approaches to nutritional and lifestyle factors. DESIGN: Data from the cross-sectional SENECA baseline study and Framingham Heart Study (original cohort and offspring) were used for data analysis. Food intake data were summarised into dietary clusters and into dietary scores (Healthy Diet Indicator and Mediterranean Diet Score). These measures of dietary quality were then tested for associations with lifestyle factors and measures of nutritional status. SUBJECTS/SETTING: The study population, aged 70-77 y, consisted of 828 subjects from Framingham, MA (USA) and 1282 subjects from the following European centres: Hamme, Belgium; Roskilde, Denmark; Padua, Italy; Culemborg, The Netherlands; Vila Franca de Xira, Portugal; Betanzos, Spain; and Yverdon, Burgdorf and Bellinzona, Switzerland. RESULTS: Dietary intake varied widely across the European and American research centres. In general, Southern European centres and Framingham had higher mean diet scores, indicating a higher dietary quality, than Northern European centres (MD-scores: 4.2-4.4 vs 2.7-3.5). Cluster analysis identified the following five dietary patterns characterised by: (1) sugar and sugar products; (2) fish and grain; (3) meat, eggs and fat; (4) milk and fruit; and (5) alcohol intake. The meat, eggs and fat pattern had significantly lower average dietary quality, as measured with all three diet scores than all other groups except the alcohol group. The fish and grain group had significantly better Mediterranean diet scores than all other groups. CONCLUSIONS: Dietary scores and dietary clusters are complementary measures to classify dietary quality. The associations with nutritional and lifestyle factors indicate the adequate categorisation into dietary quality groups. SPONSORSHIP: European Union, US Department of Agriculture, Agriculture Research Service, under agreement (58-1950-9-001), Haak Bastiaanse-Kuneman Foundation.

Snack patterns of older Europeans.

OBJECTIVE: To describe the snack consumption of older people from several European towns. Subjects with similar snack patterns are clustered into groups to explore the contribution of snacks to daily energy and micronutrient intake. DESIGN: Data from the 1993 Survey in Europe on Nutrition and the Elderly: A Concerted Action (SENECA) follow-up study were collected from a random, age-stratified sample of inhabitants of small traditional towns in Europe. Food intake data collected by the 3-day estimated record method were used for grouping snack foods into 15 food groups. From these data daily energy intake and intake of calcium; iron; and vitamins B-1, B-2, B-6, and C were calculated. Additional self-reported data were collected for health status, presence of chronic diseases, and activity level. SUBJECTS/SETTING: The study population consisted of 379 men and 428 women aged 74 to 79 years and who were inhabitants of the following towns: Haguenau, France; Romans, France; Padua, Italy; Culemborg, The Netherlands; Yverdon, Switzerland; and Marki, Poland. STATISTICAL ANALYSES: Cluster analysis was used to classify subjects into groups based on similarity in snack patterns. RESULTS: In general, older people from the various European towns consumed the same snack types. Five distinct snack patterns emerged from our analyses. The large group light snackers had a low snack use and low energy and micronutrient intakes. Alcohol drinkers and dairy snackers had a high snack use and high intakes of energy and several vitamins and minerals. Fruit and vegetable snackers and sweet drinkers often had intake values between the other 3 groups. APPLICATIONS: Our study indicates the existence of identifiable snack patterns that coincide with different intakes of energy and micronutrients. Especially in countries in which people derive high percentages of energy through snacking, the identification of snack patterns can improve dietary advice, gearing it to personal needs.

Fluid intake of elderly Europeans.

Dehydration is a common fluid disorder which occurs in residents, hospitalised and community-dwelling elderly people. In this study the intake of water and fluids of community-dwelling elderly Europeans is presented in relation to risk factors of dehydration: mental state, ability to perform activities of daily living (ADL), medicine use and body composition. As part of the SENECA-study of 1993, data were collected from a random age-stratified sample (birth cohorts 1913-1918) of inhabitants of small traditional towns in Europe. Food intake data were collected by using the dietary history method. The study population consisted of 629 men and 696 women of the following towns: Hamme/Belgium, Roskilde/Denmark, Haguenau/France, Romans/France, Padua/Italy, Culemborg/the Netherlands, Lisbon/Portugal, Yverdon/Switzerland, Marki/Poland and Ballymoney-Limavady-Portstewart/Northern Ireland/United Kingdom. Fluid intake of elderly people varied between the towns of Europe and between men and women. A high percentage of the female population had a water intake below the cut-off value of 1,700 g. In most towns about 70 percent of daily water intake came from the food groups 'Milk products', 'Alcoholic drinks', 'Juices' and 'Other non-alcoholic drinks'. The consumption of 'Other non-alcoholic drinks' contributed most to daily fluid intake. In the total female population, women with the lowest water intake (first tertile) scored negatively on factors influencing fluid intake (mental state, ADL) in comparison to women of the second and third tertile. However, in the distinct towns no unequivocal relationship emerged between those factors and fluid intake. Yet, women were found to be at higher risk of dehydration because of much lower water intakes than men and because of the overall relationship between a low fluid intake and a poor mental state and ADL problems.

Energy expenditure at rest and during activities: A comparison between young and elderly women.

Energy expenditure at rest (resting metabolic rate, RMR) and during several activities was measured in 20 young (age 19-27 years) and 19 elderly (age 65-78 years) females. Fat-free mass (FFM) was estimated by means of a four compartment model which accounted for variability in water and bone mineral in the FFM. RMR was lower (P < 0.05) in the elderly (mean ± SE 3.55 ± 0.05 kJ/min) compared to the younger females (3.92 ± 0.09 kJ/min). However, after correction for differences in FFM between the groups, RMR was 3.71 ± 0.07 kJ/min and 3.77 ± 0.06 kJ/min for the elderly and young, respectively, and the difference was not significant. Energy expenditure (EE) during several activities, standing with arm movement, bicycling at 25 Watts, and walking at 3 km/h, were not different between the two groups. However, the physical activity ratios (PAR) for the activities were higher (P < 0.05) in the elderly (1.61 ± 0.03, 3.29 ± 0.07, 4.11 ± 0.16, respectively) than in the young (1.47 ± 0.03, 2.93 ± 0.05, 3.58 ± 0.14, respectively). EE due to physical activity alone (total EE minus RMR) was significantly higher for all activities in the elderly, except for walking at fixed speed of 3 km/h. After correction for the lower relative FFM in the elderly, differences between age groups disappeared. EE for walking 500 m at an individually selected speed was higher in the elderly, although they selected a lower walking speed. Differences between young and elderly decreased when step frequency was taken into account. It is concluded that EE due to physical activity in elderly women is higher than in younger females, but that the differences in EE due to physical activity are largely attributable to differences in body composition. © 1996 Wiley-Liss, Inc.