Relation between nutritional status of surgically treated elderly

Relation between nutritional status of surgically treated elderly

Skokowska
Probl
Hig Epidemiol
B, et al. Relation
2015, 96(1):
between
199-204
nutritional status of surgically treated elderly patients and selected chronic diseases
199
Relation between nutritional status of surgically treated
elderly patients and selected chronic diseases
Związek stanu odżywienia osób w podeszłym wieku leczonych chirurgicznie
z wybranymi schorzeniami przewlekłymi
Beata Skokowska 1/, Grażyna Bączyk 1/, Danuta Dyk 2/, Izabella Miechowicz 3/
Department of Nursing, Faculty of Health Sciences, Poznan University of Medical Sciences, Poland
Department of Nursing Anesthesiologists and Intensive Care, Poznan University of Medical Sciences, Poland
3/
Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poland
1/
2/
Wstęp. Obecność schorzeń przewlekłych wpływa na stan odżywienia
osób w podeszłym wieku. Współwystępowanie patologii upośledza
funkcjonowanie osób starszych.
Cel badań. Ocena związku pomiędzy stanem odżywienia i występowaniem
chorób przewlekłych u osób leczonych chirurgicznie w różnych okresach
starości.
Materiał i metody. Zastosowano kwestionariusz Subiektywnej Globalnej
Oceny Stanu Odżywienia (SGA) oraz NRS 2002 – formularz przesiewowej
oceny ryzyka związanego z niedożywieniem. Grupę badaną stanowiło 150
osób, leczonych operacyjnie w wieku 65-98 lat (M=73,74; SD=6,28).
Introduction. The occurrence of chronic diseases affects nutritional status of
elderly people. A coexisting pathology impairs the activity of the elderly.
Aim. To assess the relation between nutritional status of surgically treated
elderly patients and the occurrence of chronic diseases at different periods
of old age.
Material & Methods. The Subjective Global Assessment of Nutritional Status
(SGA) questionnaire and NRS-2002 – a screening form for malnutrition
risk assessment were used. The examined group consisted of 150 subjects
treated surgically at the age of 65-98 years (M=73.74; SD=6.28).
Wyniki. Prawidłowy stan odżywienia (SGA=A) stwierdzono u 80,7%
badanych (p=0,000025). Niedożywienie bądź ryzyko jego wystąpienia
(SGA=B) stwierdzono u 19,3% badanych. Istotnie statystycznie najczęstszym
schorzeniem współwystępującym u badanych było: nadciśnienie tętnicze
(64%) (p<0,001). W analizie wpływu chorób na stan odżywienia wg
SGA, istotną zależność stwierdzono u chorych z nadciśnieniem tętniczym
p=0,0047. Stwierdzono związek wieku z ryzykiem związanym ze stanem
odżywienia (p=0,000009). Chorzy starsi uzyskiwali wyższą punktację
w skali NRS 2002. Stwierdzono związek wieku i stanu odżywienia na
poziomie istotności (p=0,033). U badanych starszych stwierdzono niższe
wartości średniej wskaźnika BMI. Współwystępowanie nadciśnienia
tętniczego zwiększa różnice w licznie otrzymanych punktów i wzrost ryzyka
związanego ze stanem odżywienia NRS 2002, p=0,045.
Results. Proper nutritional status according to SGA=A was found in 80.7%
of the respondents (p=0.000025). Malnutrition or the risk of its occurrence
(SGA=B) was found in 19.3% of the respondents. Arterial hypertension
(64%) (p<0.001) was the most statistically significant co-morbidity among
the respondents. In the analysis of the illness impact on nutritional status
according to SGA a significant relation was found among the patients
with arterial hypertension p=0.0047. The relation between age and
risk associated with nutritional status (p=0.000009) was observed. The
elderly patients gained higher scores in the NRS 2002 scale. The relation
between age and nutritional status was found at the level of significance
(p=0.033). The elderly respondents revealed lower mean BMI values. The
coexistence of arterial hypertension increases the differences in the number
of obtained scores and the increase of the risk associated with nutritional
status NRS 2002, p=0.045.
Wnioski. 1. Wiek stanowi jeden z niezależnych czynników ryzyka
wystąpienia zaburzeń stanu odżywienia na podstawie NRS 2002.
2. Stwierdza się wzrost ryzyka współwystępowania nadciśnienia tętniczego
związanego ze stanem odżywienia.
Conclusions. 1. Based on NRS 2002, age is one of the independent risk
factors in the occurrence of disturbances in nutritional status. 2. The risk
of coexistence of arterial hypertension associated with nutritional status
has been observed.
Słowa kluczowe: osoby starsze, stan odżywienia, choroby przewlekłe
Key words: elderly people, nutritional status, chronic diseases
© Probl Hig Epidemiol 2015, 96(1): 199-204
Adres do korespondencji / Address for correspondence
www.phie.pl
Nadesłano: 30.12.2014
Zakwalifikowano do druku: 01.01.2015
Introduction
Demographic transformation, progress of civilization and medicine as well as general improvement of
existential conditions have influenced the increase of
the elderly population. The extension of the statistical
dr Beata Skokowska
Pracownia Praktyki Pielęgniarskiej, Collegium Adama Wrzoska
ul. Dąbrowskiego 79, 60-529 Poznań
tel. 784 055 906, 61 854 68 64, e-mail: [email protected]
duration of life and inevitability of aging pose a serious challenge for the societies. Although the process
of ageing itself occurs at a different pace in different
people and is conditioned by numerous factors, e.g. genetic, socio-economic or connected with past diseases,
200
old age is not an illness, but a period of human life
particularly vulnerable to the occurrence of pathology,
ending in each case with death.
The elderly people differ on many levels of their activity, therefore the subperiods have been distinguished,
such as early old age including people between 60-74
years of age, late old age between 75 and 89 years and the
period of longevity, which includes 90-year-old and older
subjects [1]. Regardless of whether the process of ageing
occurs with or without co-morbidities, their different
symptomatology as well as biochemical changes associated with age are a challenge for Gerontology [2, 3]. The
process of ageing itself is not a sufficient factor to induce
pathology, however it can support it. Multidisease and
polypharmacy have crucial impact on the patient health
condition and contribute to an increase of difficulty in
defining the norm and pathology in this age group [2],
and occurring changes are reflected in the dietary habits
and nutritional status of the elderly [2].
Chronic obstructive pulmonary disease (COPD)
is an example of the influence of chronic disease on
nutritional status. It is estimated that malnutrition
affects 10-15% of patients in the mild stage of the disease, while in advanced stage it affects as many as 50%
of patients, which confirms that the weight and muscle
mass loss is a negative prognostic indicator [4].
On the other hand, among the patients with
arterial hypertension an inverse relation is observed,
where overweight and obesity are the risk factors of
the disease occurrence [5, 6].
Nutritional status of people, regardless of their
age, is the basis for the determination of their current
health condition and enables the structural, biochemical and functional evaluation of the organism [7].
Preparing the elderly patients for the surgery
one needs to consider the homeostatic dysfunctions,
limited possibilities of adaptation to disturbances
caused by the disease, co-morbidities and frequent
malnutrition.
Aim of the study
Evaluation of relation between nutritional status
and the occurrence of chronic diseases at different
periods of old age in surgically treated patients.
Material and methods
The studied sample consisted of patients aged
65 years and older, admitted to a General Surgery
Department of the regional hospital for surgical treatment between March 2009 and December 2010. The
selection criterion for the examined group were: age,
surgical treatment and lack of cancer.
The data collection included: nutritional status
assessment using the SGA questionnaire (Subjective
Probl Hig Epidemiol 2015, 96(1): 199-204
Global Assessment) and NRS 2002 (Nutritional Risk
Screening – a screening form for malnutrition risk
assessment), analysis of medical documentation,
anamnesis of the patient, physical examination,
anthropometric measurements, i.e. body height and
weight measurements in order to calculate BMI.
Based on SGA – the screening tool for nutritional
status assessment, the patients were divided into
2 groups: of the patients with correct nutritional status
(SGA) – A and the patients with suspected malnutrition or average malnutrition (SGA) – B.
The NRS 2002 scale was used for the assessment
of nutritional status and an increased demand related
to the disease severity.
The research was conducted after obtaining the
patients’ informed consent for participation. The
project was approved and obtained a positive opinion
no. 144/09 of Ethics Committee of Poznan University
of Medical Sciences of 05.02.2009.
Depending on different aims of the study various
statistical methods were used. The level of significance
was declared to assess the strength of the relation and
the significance of differences was α<0.05.
The statistical analyses were performed using the
programs: Statistica 9.0, StatXact8 and IBM SPSS
19.0 PL. The descriptive statistics included: arithmetic mean, standard deviation and median. The
parameters on the nominal scale were described with
the number and the corresponding percentage value.
The assumptions of parametric tests were verified with
the Chi square test. In case of meeting assumptions
for parametric tests the comparisons were performed
using the t-Student test. In case when the parametric
test did not meet the assumptions, the nonparametric
Mann-Whitney test was used for the needs of comparison. The comparison of the categorical variables
was performed using the Chi square test, Fisher’s exact
test or Fisher-Freeman-Halton test. In the absence of
normal distribution the RS Spearman’s rank correlation coefficient was investigated.
Results
The research was conducted in a group of 150 people at the age of 65-98 years (M =73.74; SD=6.28)
including 70 women (M=73.89; SD=6.41) and 80
men (M=73.61; SD=6.19). The hospitalization time
varied from 3 to 49 days (M=7.44; SD=5.68). The
women stayed at the hospital department for 4-36
days (M=7.43; SD=5.04), and men for 3-49 days
(M=7.45; SD=6.22) (Tab. I).
In 33.3% of the respondents the primary causes of
hospitalization were the diagnosis of gallbladder, bile
ducts diseases and hernias in 30%, followed by bowel
diseases (16.7%). The lowest proportion of patients
Skokowska B, et al. Relation between nutritional status of surgically treated elderly patients and selected chronic diseases
had identified genitourinary problems (4%) and other
diseases (4.7%) (p<0.001).
Nutritional status by SGA and age of patient
Proper nutritional status according to SGA=A was
found in 80.7% of the respondents (p=0.000025).
Malnutrition or the risk of its occurrence (SGA=B) was
found in 19.3% of the patients (significant differences at
the level of p=0.00002). There was no significant difference in the prevalence of malnutrition or its risk with
respect to the age variable p=0.109754 (Tab. II).
Statistically significantly more subjects were in the
period of early old age (58%) and late old age (40%)
than in the longevity stage (2%) (Tab. III).
Relation of nutritional status and occurrence
of chronic diseases
The most statistically significant co-morbidity
was arterial hypertension (64%) (p<0.001). Significantly less frequent were the diseases such as: diabetes
(21.3%), varicose veins of lower extremities (14%),
Table I. Frequency of variable: diagnosis
Diagnosis
Frequency
Percent
Bowel diseases
25
16.7
Lower limbs vascular diseases
Diseases of gallbladder and bile ducts
Thyroid diseases
Diseases of genitourinary system
Hernias
Other
Total
χ2=124.13; p=0.000
12
47
8
6
45
7
150
8.0
31.3
5.3
4.0
30.0
4.7
100.0
anemia (4%) and peptic ulcer (3.3%), history of bowel
resections (1.3%) (Tab. IV).
Also the impact of diseases on nutritional status by
SGA was analyzed. A significant relation was observed
in patients with arterial hypertension p=0.0047.
Among the group of patients qualified to SGA=B,
arterial hypertension occurred in 41.38% of the respondents (Tab. V).
Assessment of risk associated with nutritional
status and age
The relation between age and risk associated with
nutritional status was confirmed (p=0.000009). Elderly
patients obtained higher scores in the NRS 2002 scale.
The relation between age and nutritional status
was confirmed at the significance level (p=0.033).
Among the elderly respondents lower mean values of
BMI indicator were observed (Tab. VI).
The coexistence of arterial hypertension increases
the differences in the number of obtained scores and
an increase of risk associated with nutritional status
NRS 2002, p=0.045 (Tab. VII).
Table III. Frequency of variable: old age periods
Frequency
Percent
60-74 years of age /early old age/
Period of old age
87
58.0
75-89 years of age /late old age/
Od 90 years of age /longevity/
Total
χ2=73.56; p=0.000
60
3
150
40.0
2.0
100.0
Table IV. Frequency of variable: co-morbidities
Co-morbidities
Table II. Age and nutritional status by SGA
Variable
n
Average
Standard
Median
deviation SD
Min
Max
Age & SGA=A
121 73.355
6.213
73.000 65.000 98.000
Age & SGA=B
29
6.393
75.000 65.000 90.000
75.345
201
Chi2
p
Varicose veins of lower extremities
Frequency Percent
21
14.0
77.76
0.000
Diabetes
Arterial hypertension
State after bowel resection
Anemia
Peptic ulcer disease
32
96
2
6
5
21.3
64.0
1.3
4.0
3.3
49.31
11.76
142.11
126.96
130.67
0.000
0.001
0.000
0.000
0.000
Table V. Nutritional status by BMI and co-morbidities
Variable
n
Average
Standard
deviation SD
Median
Min
Max
Lower
quartile
Upper
quartile
p
BMI & VVoLE
Yes
No
21
126
27.786
26.890
4.472
4.225
27.300
26.600
19.200
18.600
40.000
42.900
24.600
23.800
30.210
29.400
0.409
BMI & Diabetes
Yes
No
31
116
28.075
26.736
3.873
4.326
28.000
26.550
19.200
18.600
35.500
42.900
25.000
23.850
31.040
29.100
0.059
BMI &Arterial hypertension
Yes
No
94
53
27.699
25.811
4.142
4.228
27.400
25.800
20.200
18.600
42.900
40.000
24.400
23.000
30.400
28.000
0.004
BMI & State after bowel resection
Yes
No
2
145
22.755
27.077
5.720
4.229
22.755
26.700
18.710
18.600
26.800
42.900
18.710
24.000
26.800
29.730
0.238
BMI & Anemia
Yes
No
6
141
26.150
27.055
2.943
4.308
26.900
26.700
21.400
18.600
29.200
42.900
24.000
24.000
28.500
29.800
0.724
BMI & Peptic ulcer disease
Yes
No
5
142
24.340
27.113
2.109
4.287
23.600
26.850
22.600
18.600
28.000
42.900
23.500
24.200
24.000
29.800
0.089
* Lack of ability to weight in 3 patients
202
Probl Hig Epidemiol 2015, 96(1): 199-204
Table VI. Age and risk associated with nutritional status
Pairs of variables
n
R Spearman
t(n-2)
p
Age & NRS 2002
150
0.353
4.589
0.000
Age & BMI
147
-0.176
-2.151
0.033
* Lack of ability to weight in 3 patients
Table VII. NRS and arterial hypertension
Variable
n
Standard
Average deviation Median Min
SD
NRS 2002
Yes 96 2.167
& arterial
No 54 1.944
hypertension
Max
p
0.474
2.000
0.00 3.000 0.045
1.089
2.000
0.00 6.000
Discussion
Human nutritional status is affected by multiple
factors. Malnutrition in the old age may arise from
co-existing diseases and disability, moreover, the predictive factors with negative influence on nutritional
status may be: large intake of medications, socioeconomic status, i.e. loneliness, isolation, dietary restrictions due to financial situation as well as poor oral
hygiene, including absence of teeth and inappropriate
prosthetics [3, 8].
The analysis of the results indicated that changes
in nutritional status were observed both in terms of
deficiency and excess. Malnutrition or the risk of its
occurrence was recognized based on SGA in 19.3%
of the respondents. Based on the analyses of BMI
levels distribution, performed in accordance with
the WHO classification, overweight and obesity were
diagnosed respectively in 42% and 23.3% of the
respondents. Among the most commonly diagnosed
chronic diseases were: arterial hypertension in 64% of
the respondents, diabetes and varicose veins of lower
extremities, respectively in 21.3% and 14% of the
respondents.
The results of our own research indicate as well
that in the group of elderly subjects with arterial
hypertension, malnutrition or the risk of its occurrence were observed in over 40% of the subjects with
SGA=B. However, when analyzing the entire group
(n=150), the hypertension was diagnosed in 64% of
the respondents, where average BMI was 27.7 kg/m2.
The presented research results confirm that age
is an independent risk factor of malnutrition and
directly influences the NRS result. The subjects over
70 years of age were the group with particular risk of
malnutrition, which confirms the predictive value of
NRS 2002 questionnaire [9].
Moreover, it needs to be emphasized that malnutrition or the risk of its occurrence were recognized in
nearly one-fifth of the respondents (19.3%), which
confirms the suitability of using the SGA scale in
our research as the simple screening tool in the nu-
tritional status assessment. The effectiveness of the
scale was also confirmed with the results of the study
conducted in India on the group of 106 patients with
COPD [10].
The negative influence of chronic diseases on
nutritional status was also confirmed in the studies of
Gariball and Forster [11] who examined the relation
of nutritional status in elderly subjects with co-morbidities.
Presenting the study results of Duda et al. [12]
conducted among elderly women with ischemic heart
disease or hypertension it was indicated that often
overweight and obesity correlated positively with the
severity of the disease processes [12].
Skop et al. [13] in the studies evaluating health
status and nutritional status of a group of 89 subjects
(including 53 women and 36 men) at the age of 60-90
years, noted that overweight was observed in 21.7%
of women and 38.7% of men, and obesity in 41.3%
of women and 9.7% of men, whereas low BMI values
which might indicate the protein-energy malnutrition
were observed in 9.7% of men and 2.2% of women.
Among chronic diseases the most common were arterial hypertension (50% of women and 44.3% of men),
ischemic heart disease (22% of women and 30.3% of
men) and Atherosclerotic Peripheral Vascular Disease
(34.5% of women and 25% of men) [13].
The course of disease may lead to disorders of nutritional status due to adverse symptoms coexisting in
many diseases, disability, lack of interest in nutrition
among the medical personnel and an increase in demand on nutrients and destructive catabolism [14].
In Poland the disorders of nutritional status are
still a serious problem. Overweight, especially appleshaped (abdominal) obesity, predisposes to metabolic
disorders, of which clinical effects are an increase of
risk of both arterial hypertension and diseases of cardiovascular system [15].
The confirmation that civilization diseases resulting from incorrect nutrition occur more often among
elderly people can be found in the studies WOBASZSENIOR, indicating high prevalence of overweight
and arterial hypertension. Moreover, the study results
indicated that bad and mediocre level of nutrition
occurred in about 1/3 of the elderly population in
Poland [16].
Among the reasons of such status quo the awareness of the healthy lifestyle importance should be taken
into account. According to Olszanecka-Glinianowicz et
al. [17], a questionnaire survey conducted in a group
of 37557 subjects confirmed that younger respondents
had higher levels of healthy lifestyle awareness and of its
influence on the development of obesity, type 2 diabetes
and cardiovascular diseases. The Multivariate Regres-
Skokowska B, et al. Relation between nutritional status of surgically treated elderly patients and selected chronic diseases
sion Analysis revealed that low level of education and
village as a place of residence were the most important
factors reducing the awareness of the impact of lifestyle
on health status [17].
A multifactor occurrence of arterial hypertension
and the fact that it is a chronic process was taken up
in the studies conducted by Suliburska et al. [18]. It
revealed that patients with hypertension consumed
food containing excess fat, cholesterol and vitamin
A with a simultaneous insufficiency of fiber, antioxidants, calcium, potassium and magnesium. The
presented results showed inappropriate eating habits
and nutritional status disorders in rural areas [18].
The relation between lifestyle and diet among
adolescents and young adults as a risk factor of chronic
disease, premature morbidity and mortality among the
elderly and their social consequences were confirmed
in the reports of Dwyer [19].
In a group of subjects with arterial hypertension,
both in our own research and in the reports of Tripathy
et al. the impact of overweight, obesity and age on the
coexistence of hypertension was confirmed [5]. The
relation between high BMI and arterial hypertension
were confirmed by the results of studies of Ijarotimi
et al. [6].
In Poland, the causes of death among the adult
population are mainly diseases of cardiovascular diseases, arterial hypertension, obesity, tumors, diabetes,
osteoporosis, which prominently contribute to the
shortening of life expectancy. The other determinants
of incorrect nutrition, as for example gender, age, education, place of residence, lifestyle, indirectly determine the diet and therefore nutritional status [20].
Słowińska et al. [21] emphasizes that in the primary and secondary prevention of chronic metabolic
diseases the diet plays a significant role, together with
lifestyle [21]. Incorrect nutrition (excessive con-
203
sumption of saturated fatty acids, cholesterol, sugars,
salt, alcohol, and low intake of dietary fiber) plays
a significant role among unhealthy behaviors [15].
On the other hand, Barendregt et al. [22] emphasize the adverse effect of malnutrition on the
physiological functions of the organism, particularly
in debilitated subjects who experienced complications
after surgery or in the course of acute diseases. It causes
mental activity deterioration, increase of anxiety and
depression, impairment of muscle cells activity and
cardiac muscle mass loss leading to a decrease of its
volume, bradycardia and hypotension predisposing
even to peripheral circulatory failure. Large weight loss
and fasting predispose to hypothermia. In turn, the
vitamin deficiencies, electrolyte and mineral disorders
intensify the changes in the activity of cardiovascular
system and kidneys. Protein deficiencies adversely affect the structure and function of respiratory muscles
and cause the digestive tract dysfunctions.
The cascade of changes weakens the immune
system (cellular immunity) and significantly delays
the process of healing [22].
According to the most recent recommendations
of the American Heart Association, healthy nutrition and correct body mass are two of seven elements
of lifestyle which reduce the risk of cardiovascular
diseases [23].
Conclusions
1. Age of patients is one of independent risk factors
of nutritional disorders based on NRS 2002.
2. It was found that the risk of arterial hypertension
associated with nutritional status increases.
3. Elderly patients require special care provided by
individual prophylactic programs, which should,
among others, include the transfer of knowledge
in the field of nutrition.
Piśmiennictwo / References
1. Grodzicki T, Kocemba J, Skalska A (red). Geriatria
z elementami gerontologii ogólnej. Via Medica Gdańsk
2007.
2. Skorupka A, Dzięgielewska S, Myszka W. Niedokrwistość
u pacjentów z chorobami przewlekłymi w wieku podeszłym.
Now Lek 2007, 76, 2: 110-113.
3. Wieczorowska-Tobis K. Zmiany narządowe w procesie
starzenia. Pol Arch Med Wewn 2008, 118(Suppl): 63-69.
4. Posłuszna D, Dobroszyńska A. Assessment of nutritional
status of patients with chronic obstructive pulmonary disease
(COPD) and the impact of diet on COPD risk. Pneumonol
Alergol Pol 2011, 79(2): 109-15.
5. Tripathy V, Satapathy KC, Gupta R. Hum Ecol 2006, 14:
77-82.
6. Ijarotimi OS, Keshinro OO. Nutritional knowledge, nutrients
intake and nutritional status of hypertensive patients in
Ondo State, Nigeria. Tanzan J Health Res 2008, 10(2):
59‑67.
7. Gawęcki J, Hryniewiecki L. Żywienie człowieka. Podstawy
nauki o żywieniu. Wyd Nauk PWN, Warsaw 2003.
8. DiMaria-Ghalili RA, Amella E. Nutrition in Older Adults:
Intervention and assessment can help curb the growing threat
of malnutrition. Am J Nurs 2005, 105(3): 40-50.
9. Cerantola Y, Grass F, Cristaudi A, et al. Perioperative
Nutrition in Abdominal Surgery: Recommendations and
Reality. Gastroenterol Res Pract 2011: 1-8.
10. Gupta B, Kant S, Mishra R. Subjective global assessment of
nutritional status of chronic obstructive pulmonary disease
patients on admission. Int J Tuberc Lung Dis 2010, 14(4):
500-5.
204
11. Gariballa S, Forster S. Associations between underlying
disease and nutritional status following acute illness in older
people. Clin Nutr 2007, 26: 466-473.
12. Duda G, Maruszewska M, Wieczorowska-Tobis K i wsp.
Choroby somatyczne a sposób żywienia i wybrane wskaźniki
stanu odżywienia kobiet w wieku podeszłym. Żyw Człow
2003, 30(3/4): 810-815.
13. Skop A, Kolarzyk E. Ocena sposobu żywienia i stanu zdrowia
starszych mieszkańców domów pomocy społecznej. Now Lek
2005, 74(4): 480-483.
14. Khalid U, Spiro A, Baldwin B, et al. Symptoms and weight
loss in patients with gastrointestinal and lung cancer at
presentation. Support Care Cancer 2007, 15: 39-46.
15. Skop-Lewandowska A, Ostachowska-Gąsior A. Stan
odżywienia osób z rozpoznanymi chorobami układu
sercowo-naczyniowego. Probl Hig Epidemiol 2009, 90(4):
604-607.
16. Waśkiewicz A, Sygnowska E, Broda G. Ocena stanu zdrowia
i odżywienia osób w wieku powyżej 75 lat w populacji polskiej
badanie Wobasz-Senior. Bromat Chem Toksykol 2012,
XLV(3): 614-618.
Probl Hig Epidemiol 2015, 96(1): 199-204
17. Olszanecka-Glinianowicz M, Chudek J. The level of health
education in the Polish population. Ann Agric Environ Med
2013, 20(3): 559-565.
18. Suliburska J, Bogdański P, Duda G, et al. An assessment
of dietary intake and state of nutritional in hypertensive
patients from rural and urban areas of Greater Poland. Ann
Agric Environ Med 2012, 19(3): 339-343.
19. Dwyer J. Starting down the right path: nutrition connections
with chronic diseases of later life. Am J Clin Nutr 2006,
83(suppl): 415-20.
20. Gertig H, Przysławski J. Bromatologia zarys nauki o żywności
i żywieniu. PZWL, Warsaw 2006.
21. Słowińska MA, Wądłowska L. Stan zdrowia a model żywienia
osób w wieku 75-80 lat. Now Lek 2008, 77(4): 294-298.
22. Barendregt K, Soeters PB, Allison SP. Wpływ niedożywienia
na funkcje fizjologiczne. [w:] Podstawy żywienia klinicznego. Sobotka L (red). PZWL, Warsaw 2007: 19-21.
23. Lichtenstein AH, Appel LJ, Brands M, et al. Diet and Lifestyle
Recommendations Revision 2006. A Scientific Statement
From the American Heart Association Nutrition Committee.
Circ 2006, 114: 82-96.