AN ASSESSMENT OF ASSOCIATIONS BETWEEN FUNCTIONAL ABILITY, NUTRITION, AND DENTITION IN HOMEBOUND OLDER ADULTS by DENISE M. DeSALVO A THESIS Submitted in partial fulfillment of the requirements for the degree of Master of Science in the Department of Nutrition in the Graduate School of The University of Alabama TUSCALOOSA, ALABAMA 2010
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AN ASSESSMENT OF ASSOCIATIONS BETWEEN FUNCTIONAL ABILITY,
NUTRITION, AND DENTITION IN HOMEBOUND OLDER ADULTS
by
DENISE M. DeSALVO
A THESIS
Submitted in partial fulfillment of the requirements for the degree of Master of Science
in the Department of Nutrition in the Graduate School of
The University of Alabama
TUSCALOOSA, ALABAMA
2010
Copyright Denise M. DeSalvo 2010 ALL RIGHTS RESERVED
ii
ABSTRACT
The relationship between nutrition, oral health, and functional ability has not been well
investigated. The purpose of this research was to examine the associations between functional
ability, dentition status, and the intake of specific dietary components in a group of homebound
older adults. This cross-sectional study was a secondary analysis of data from a longitudinal
study investigating causes of under eating in homebound older adults.
Descriptive statistics, correlation and linear regression analyses were conducted.
Participants’ baseline physical function summary score, a proxy measure for functional ability,
was the dependent variable. Mean dietary intakes of energy, protein, calcium, phosphorus,
vitamin C, vitamin D, vitamin K, and the mean oral health index summary score were the
independent variables. Average age of the 230 participants was 79.1 ± 8.6 years. The study
population was 79% female, 62% Caucasian, and 38% African American.
Statistical analysis revealed that physical function was significantly (p < .05) correlated
with participants’ oral health score and vitamin K intake. The oral health score was a single
number representing an assessment of multiple factors including chewing, swallowing, pain, dry
mouth, denture use, and number of remaining natural teeth. A lower oral health summary score
was indicative of better overall oral health. Therefore, the negative association between the
physical function score and oral health score meant that as physical function improved oral
health improved and vice versa. The oral health score and vitamin K intake were also the only
variables to significantly predict physical function in the final linear regression.
iii
These results provide interesting insight into the impact of nutrition and dentition on
homebound older adult functional ability and offer guidance for future research. This study
highlights a need for additional research especially in the homebound segment of the older adult
population to better understand the scope of their needs. There is also a need for consistency in
defining, measuring, and researching older adult functional ability. Finally, future research must
be carefully designed to provide useful results that address homebound older adult nutritional,
dental, and functional needs, and their quality of life.
iv
LIST OF ABBREVIATIONS AND SYMBOLS
p Probability associated with the occurrence under the null hypothesis of a value as
extreme as or more extreme than the observed value
α Value that defines the limits for rejecting a null hypothesis
g Gram, a unit of measure of weight
H01 Hypothesis 1
kcal Kilocalories, a unit of measure of energy
mg Milligram, a unit of measure of weight
mcg Microgram, a unit of measure of weight
< Less than
> Greater than
≤ Less than or equal to
≥ Greater than or equal to
= Equal to
± Plus or minus a value
% Percent
v
ACKNOWLEDGMENTS
I would like to take this opportunity to thank my colleagues, friends, and University of
Alabama faculty members who have helped me with this research project. I am most grateful to
Dr. Jeannine Lawrence, my thesis advisor, for sharing her knowledge, experience, and research
expertise regarding older adult nutrition. I would also like to thank all of my committee
members, Dr. Olivia Kendrick, Dr. Yasmin Neggers, and Dr. Jen Nickelson for their support and
input, and for the knowledge they have imparted in my progress toward this academic goal. I
would also like to thank Dr. Julie Locher for sharing her research, thereby allowing me the
opportunity to conduct this thesis research.
This research would not have been possible without the support of my friends and family.
Specifically, I wish to thank Deborah, Byron, and Michelle. In every circumstance each of you
listened to my concerns, offered continual encouragement, and always seemed truly interested in
my work. While I have gained much in this process, I realize how much more there is to know.
I consider myself fortunate to have experienced this process--it has truly been an experience of a
lifetime. Thank you all very much.
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CONTENTS
ABSTRACT ................................................................................................ ii
LIST OF ABBREVIATIONS AND SYMBOLS ...................................... iv
analyzed to provide a single score, the physical function subscale score, representative of
participants’ baseline level of physical function.
Baseline oral health summary scores from the original study were used to represent
participants’ oral health status in the present study. Researchers in the parent study developed an
abbreviated Oral Health Quality of Life Questionnaire (Appendix E) based on an existing and
more detailed oral health tool described elsewhere.70 The adapted tool contained 7 questions
related to chewing, swallowing, mouth pain, and denture use. The number of intact natural teeth
was also measured and recorded on the oral health survey. Questionnaires were analyzed to
provide a single oral health summary score ranging from 0 to 9. A lower score indicated better
oral health and fewer issues with chewing, swallowing, and/or mouth pain, whereas a higher
score indicated poorer oral health and more difficulty with chewing, swallowing and/or mouth
pain.
DATA ANALYSIS
In the secondary analysis, participant demographic data were characterized with
descriptive statistics including total number, mean, minimum, maximum, standard deviation, and
percent. Correlational analyses were used to determine the relationships between physical
function and the level of dietary intake for each study nutrient, the oral health summary score,
and demographic characteristics. Pearson’s correlation coefficients were measured comparing
the physical performance score to the level of dietary intake of energy, protein, calcium,
phosphorus, vitamins C, D, and K, the oral health index summary score, BMI, age, gender,
ethnicity, education level, marital status, living arrangement, level of food security, and Meals on
35
Wheels participation. Correlation coefficients were considered significant at α = 0.05. Multiple
linear regression analyses were also performed. In the final model, physical performance score
was the dependent variable; the dietary intake of energy, protein, calcium, phosphorus, vitamins
C, D, and K, and the oral health index summary score were the independent variables. All data
were analyzed using SPSS (version 17.0, 2007, SPSS Inc, Chicago, IL).
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CHAPTER 4
RESULTS
Two hundred thirty eight participants were originally enrolled in the parent study.
However, in this secondary study, data were analyzed only for those participants who had
completed all home interview questionnaires and all three dietary recall interviews.
Demographic information for these participants is shown in Table 1. Participants included 49
men and 181 women with a mean age of 79.1 ± 8.58. Approximately two-thirds (61.7%) were
Caucasian and one-third (38.3%) were African American. The educational level of the
participants was diverse, ranging from the level of having completed no formal education
through completion of a professional or graduate level of education. Although the majority were
widowed, more than 68% of the older adults in the study lived with someone else. Most were
food secure and did not participate in the Meals on Wheels Program. BMI scores ranged from
12.7 to 65.2 with a mean of 27.6 ± 8.33.
Physical function score and dietary intake data for study variables are shown in Table 2.
Although the possible score range for physical function score was 0 to 100, the mean physical
function score for the homebound participants in the study was 13.47 ± 4.47 with a range of 10
to 29. Average energy intake for the study population was 1,507 kilocalories per day. Average
protein intake was 62 grams per day. Of the three vitamins and two minerals studied,
participants’ average intake of calcium and vitamin D was below the recommended AI level for
both men and women; participants’ average intake for vitamin K was below the recommend AI
for men.71 Average daily intakes for other nutrients met or exceeded recommended amounts.
37
Table 3 presents the results from participants’ Oral Health Quality of Life
Questionnaires. The questionnaire assessed issues regarding chewing, swallowing, mouth pain,
dry mouth, and denture use. A physical count of the number of remaining natural teeth of each
participant was also conducted as part of the study. Scores were summarized into a single number from 0 to 9 as the oral health index summary score. Lower scores indicated better oral health. The mean oral health index summary score for this study population was 1.17 ± 1.71.
While close to 80% or more of the older adults reported no issues with chewing, swallowing, or
mouth pain, approximately one-third (32.8%) reported issues with dry mouth. Similarly, 63.9%
reported having dentures, but only 40% reported wearing them all the time. Evaluation of the
individual questions comprising the index revealed that 43 subjects (18.7%) reported chewing
mouth pain, and 75 subjects (32.6%) reported dry mouth at least or more often than some of the
time. Of the 147 (63.9%) participants that reported having dentures, 15 of them (10.2%)
reported they wore them none of the time (there was no data for 83 participants (36.1%) on this
question). On average, participants had eight remaining natural teeth.
Bivariate correlations are shown in Table 4. Participants’ oral health index summary
score and dietary intake of vitamin K were the only variables significantly associated (p < .05)
with physical function; the association between the oral health index summary score and vitamin
K intake was not significant. None of the demographic variables, including gender and race,
were significantly associated with physical function; therefore none of these variables were
included in the final model. Variables tested in regression analyses, with physical function as the
dependent variable included dietary intake of energy, protein, calcium, phosphorus, vitamins D,
C, and K, the oral health index summary score, BMI, age, gender, ethnicity, education level,
marital status, living arrangement, level of food security, and Meals on Wheels participation.
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Table 1. Demographic Data (n = 230)
Variable % Total Range Mean ± Standard
Deviation Age 60 - 99 79.1 ± 8.58 Gender Male 21.3% Female 78.7% Ethnicity African American 38.3% Caucasian 61.7% Highest level of education completed None 5.7% Elementary 4.3% Middle School 27.8% High School 40.9% Technical/Junior College 7.4% College 10.0% Graduate/Professional 3.9% Marital status Married 29.6% Widowed 58.7% Divorced/Separated 10.9% Never married 0.9% Living arrangement Alone 31.7% Spouse/Significant other 24.3% Other family member 37.4% Friend 1.7% Spouse & Other family member 3.0% Paid help 0.9% Other family member & friend 0.4% Other family member & someone else 0.4% Food secure 92.2% Food insecure with no hunger evident 11.0% Food insecure with hunger evident 7.0% MOW (baseline total) No 94.8% Yes 5.2% BMI (n = 229) 12.7 - 65.2 27.59 ± 8.33
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However, only two variables, dietary intake of vitamin K and the oral health index summary
score, were significant predictors (p < .05) of participants’ level of physical function, and were
therefore included in the final regression model (Table 5).
Table 2. Physical Function Score and Dietary Intake Data (n = 230)
Variable Range Mean ± Standard
Deviation
Physical function score 10.00 - 29.00 13.47 ± 4.47
Energy (kcals) 230.00 - 3005.97 1507.20 ± 468.48
Total protein (g) 6.26 - 123.07 62.24 ± 20.11
Vitamin D (mcg) .00 - 27.89 8.67 ± 6.00
Vitamin K (mcg) 1.54 - 847.53 104.32 ± 107.34
Vitamin C (mg) 1.05 - 453.97 115.07 ± 73.39
Calcium (mg) 150.19 - 3493.98 773.76 ± 467.33
Phosphorous (mg) 15.15 - 2301.24 1004.36 ± 367.75
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Table 3. Oral Heath Quality of Life Information (n = 230)
Variable % Total Range Mean ± Standard
Deviation Oral health index summary score 0 - 9 1.17 ± 1.71 Difficulty chewing None of the time 81.3% Some of the time 11.3% Most of the time 6.5% All of the time 0.9% Difficulty swallowing None of the time 79.6% Some of the time 15.2% Most of the time 2.6% All of the time 2.6% Mouth pain None of the time 85.7% Some of the time 10.0% Most of the time 3.0% All of the time 0.9% Dry mouth None of the time 67.4% Some of the time 23.0% Most of the time 7.0% All of the time 2.8% Dentures Yes 63.9% No 36.1% Wear dentures (n = 147) None of the time 10.2% Some of the time 12.2% Most of the time 15.0% All of the time 62.6% Number of natural teeth 0 - 31 8.25 ± 9.69
41
Table 4. Correlational Analysis of Physical Function, Oral Health, and Diet
Physical Function SF - 36 p value
Oral Health Index Summary Score* -0.18 0.006***
Energy (kcals) 0.008 0.901
Total Protein 0.035 0.593
Vitamin D 0.106 0.109
Vitamin K 0.184 0.005***
Vitamin C 0.041 0.535
Calcium 0.009 0.893
Phosphorus 0.063 0.344 * N = 229 ** p < .05 *** p < .01 Table 5. Final Regression Model - Physical Function as Dependent Variable Model Summary
Model R R Square Adjusted R
Square Std. Error of the
Estimate
1 .252a 0.064 0.055 4.3528 a. Predictors: (Constant), VitK, oral health index summary score baseline Coefficientsa
Model Unstandardized Coefficients Standardized Coefficients
B Std. Error Beta t Sig. (Constant) 13.227 0.454 29.15 .000 Oral health index summary score baseline -0.447 0.169 -0.171 -2.647 .009** Vitamin K 0.007 0.003 .177 2.75 .006** a. Dependent Variable: PF SF-36 subscale baseline * p < .05 ** p < .01
42
CHAPTER 5
DISCUSSION
The purpose of this research was to examine associations between oral health, dietary
intake and functional ability in homebound older adults. Results of this secondary data analysis
revealed that the oral health index summary score, a measure of overall oral health status derived
from individual factors such as such as chewing ability, swallowing ability, dry mouth, and
mouth pain, and dietary intake of vitamin K were both significantly correlated with, and
In developing the hypotheses for the present study, there was an expectation of finding a
statistical association between physical function and energy or protein or both. The parent study
of this secondary analysis was an investigation of factors associated with under-eating in
homebound older adults, therefore it seemed logical to expect a relationship between physical
function and energy intake. Similarly, because muscle strength and endurance are components
of physical function, an association between protein, a component of muscle tissue, and physical
function was also anticipated. Therefore the significant findings associated with vitamin K in the
secondary analysis were unanticipated. Hypothetically, the significant finding with vitamin K
could be explained by the fact that some of the study participants were receiving home health
care services because of recent hospitalizations. It is possible these subjects were hospitalized
for anticoagulation treatment and received therapeutic diets restricted in vitamin K during the
hospital stay. As a result, post hospitalization subjects would have lower dietary intakes of
vitamin K foods because of medical treatment for one or possibly multiple chronic health
conditions, and functional decline is associated with chronic illness.82 This hypothesis however,
requires future study for proof of certainty.
There were several limitations to the current research. First, this was a secondary
analysis of baseline data from a longitudinal study, resulting in a cross-sectional design. The
study sample was relatively small with only 230 subjects and disproportionate by race and
gender. Two-thirds of the study sample were Caucasian and three-fourths were female. The
sample was also limited to a very specific segment of the older adult population, the homebound
older adult segment, and more specifically, homebound older adults receiving home health care
47
because of a recent illness or hospitalization. One final limitation was that the research data for
the study was based on participant self-report.
While the outcomes of this research investigation were unexpected in terms of the finding
related to vitamin K, there are data to confirm the findings with respect to dentition and
function.72,73 There has also been previous research linking micronutrients to function and/or
dentition.67,79,80,82,83 It is also possible that previous research may have found associations with
vitamin K had researchers included the vitamin in the analyses.
In conclusion, the results of this thesis research provide some interesting insights into the
impact of nutrition and dentition with respect to homebound older adult functional ability.
However, there is an evident need for additional research in the homebound older adult segment
of older adults. There is also a need for consistency in measuring functional ability, and there is
most definitely a need for more research with regards to the potential relationship between
vitamin K and physical function in this population.
48
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