Journals of Gerontology: SERIES A Copyright 2001 by The Gerontological Society of America

2001, Vol. 56A (Special Issue II):54–64

Nutrition and Quality of Life in Older Adults

Eleni Amarantos,1 Andrea Martinez,2 and Johanna Dwyer3

1Frances Stern Nutrition Center, New England Medical Center, Boston, Massachusetts.

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2Schools of Medicine and Nutrition and 3Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University,
Boston, Massachusetts.

Good nutrition promotes health-related quality of life (HRQOL) by averting malnutrition, preventing dietary de-
ficiency disease and promoting optimal functioning. However, definitions of quality of life also encompass life sat-
isfaction and both physical and mental well-being. Nutrition and diet have not been a part of mainstream research
on quality of life and are not included among key quality of life domains. This article explores connections between
diet and nutritional status in relation to HRQOL measures and overall well-being among older adults.

T HE goals of this review are fourfold. First, we define

terms such as health-related quality of life (HRQOL),
functional impairment, and functional status. Second, we
describe some common methods for measuring quality of
life. Third, we examine some of the relationships between
nutrition, nutritional interventions, and HRQOL in older
persons. Finally, we provide recommendations for assessing
and monitoring nutrition and HRQOL in older adults. This
article focuses primarily on diet and nutritional status as
they relate to HRQOL and functional status. However, the
need for assessing and taking into account other sensory,
psychological, and social aspects of food and eating is rec-
ognized.
Definitions
Appendix Table 1 provides definitions for such terms as
quality of life, functional impairment, functional status, and
nutritional status that are used in the article. The term func-
tional status is usually restricted to physical status (as as-
sessed by such measures as the activities of daily living
[ADLs] or the Karnovsky Index) (1,2) and the behavioral
competence to carry out very simple tasks that involve cog-
nitive components, such as those in the instrumental activi-
ties of daily living (IADLs). Nutritional status is a multidi-
mensional concept that includes dietary, anthropometric,
biochemical, and clinical indicators of nutritional health.
Thus, nutritional status is essentially a description of medi-
cally related characteristics and, as such, the concept is
somewhat circumscribed in its focus. It fails to include sen-
sory, psychological, and social aspects of food and eating
that may also be important to the individual. Quality of life is
also a concept with multiple dimensions that include the sub-
jective sense of physical and/or mental well-being. In its
broadest and most inclusive sense, it is sometimes referred to
as “life satisfaction.” A more specific and circumscribed use
of the term is HRQOL. HRQOL focuses on the changes in
physical and mental health dimensions that may occur with
disease, aging, or alterations in functional status.
Reasons for Concern
The reasons for measuring HRQOL and functional status
are that they provide a means of identifying and monitoring
the impact of disease and interventions on the physical and
mental health of elderly individuals as they themselves per-
ceive this impact. Health-related quality of life is especially
important among older persons because many of them are
affected with chronic health problems and therefore tradi-
tional indices, such as reduced morbidity, may be less
meaningful to them than subjectively assessed symptomatic
improvement. Some of the causes of decreased HRQOL
may be preventable and others are treatable with appropri-
ate interventions. Thus, the potential for improving quality
of life is considerable. Health-related quality of life is also
more relevant to the subjective reality of the individual’s
daily life and to life satisfaction than are traditional mea-
sures of morbidity and mortality. Patient perspectives are
especially important in chronic diseases since changes in
HRQOL occur as the disease waxes and wanes, as well as
with advancing age. Health care professionals may forget or
fail to inquire about patients’ HRQOL and emotional status
because other urgent tasks intrude. Short questionnaires that
ask about these issues and are incorporated routinely into
patient visits can provide information on HRQOL that alerts
clinicians to changes that otherwise might go unrecognized.
If health-related quality-of-life measurement tools are in-
cluded in the visit, professionals are more likely to spend
time on such issues with patients (3). Medical and scientific
technology has sustained and prolonged the lives of many
older people. Although life extension is an advance, some
older individuals survive but suffer a good deal of discom-
fort and disability. HRQOL measures help to highlight and
quantify these problems, alert health professionals to their
occurrence, and may trigger interventions that can amelio-
rate these problems. HRQOL measures may also help clar-
ify the psychological implications of various interventions
and procedures and help in tailoring interventions so that in-
dividual well-being is maximized (4).
Dimensions of Quality of Life
Researchers in the social and biomedical sciences con-
ceptualize and use the term “quality of life” differently. The
broadest use of the term quality of life by social scientists
refers to overall life satisfaction. Some of the dimensions
(constructs or domains) that are covered in life satisfaction

54
 NUTRITION AND QUALITY OF LIFE
include general behavioral competence, perceived quality of
life, psychological well-being, physical/physiological status
(4), and other environmental factors (such as living alone)
that can be objectively assessed and that may also influence
one’s satisfaction with his or her lot (5). Appendix Table 2
describes each of these dimensions in greater detail. The do-
mains and constructs encompassed by the HRQOL mea-
sures are much narrower and more specific than those em-
ployed by social scientists. The HRQOL concept is more
biomedically oriented, focusing upon physical and mental
health dimensions that change with disease, changes in
functional status, or treatment of these changes.
Some researchers find it helpful to think of the various
measures of life satisfaction and quality of life as constitut-
ing a hierarchy, similar to that popularized by Abraham
Maslow (6) in his “hierarchy of basic needs.” The most ba-
sic needs are simply measures of functional status, such as
ADLs (1), which focus on physical function, and minimal
psychological and social functioning required for indepen-
dent living (IADLs) (7). Although these basic functions
have some nutritional aspects, few are specified precisely or
evaluated when these tools are used. For example, the ADL
(1) has an item that evaluates the ability to eat indepen-
dently, and the IADL (7) has items that evaluate the ability
to shop and cook, but none of the dimensions of these tools
are specific to nutrition except as they relate to these basic
functions. Other measures of functional status, such as the
Karnovsky Index (2), also involve very basic needs. More
complex or higher level functions related to food and eating,
such as the ability to choose one’s own diet or enjoyment of
food, are not included in any of these instruments. Food-,
eating-, and nutrition-related functions and dimensions
tapped by HRQOL tools are also limited in their scope and
focus on “basic needs” or vegetative functions rather than
on higher order sensory and cognitive dimensions of food
and eating. This is understandable, since much of the initial
interest in nutrition focused on nutritional status as it was
associated with medical treatments and HRQOL. However,
other dimensions of food and eating that involve enjoyment
are also important, especially for older persons. Global tools
that measure overall life satisfaction and quality of life do
not explicitly tap these nutritional dimensions.
Uses of Health-Related Quality-of-Life Measures
in Nutrition
It is important to determine which dimensions are of
greatest interest when one is selecting tools to measure
quality of life. Many or only a few dimensions may be in-
volved, even when the focus is limited to HRQOL. The uses
to which HRQOL measurements will be put largely deter-
mine what dimensions the tools need to include. Common
uses include the following: providing data to assist in clini-
cal decision making; evaluating differences in quality of life
between populations and/or individuals; helping to eluci-
date factors that contribute to changes in quality of life; de-
termining this dimension in surveys of health care quality;
and evaluating the effectiveness of interventions. HRQOL
measures are also used as screening tools for improving
management of chronic diseases and illnesses in patients.
55
RELATIONSHIP BETWEEN NUTRITION AND CHANGES IN
QUALITY OF LIFE IN OLDER ADULTS
Age-Associated Changes That Affect Quality of Life
The relationships between nutrition, aging, and quality of
life are recursive. Aging-caused or aging-associated factors
alter certain aspects of nutrition, such as the sense of smell
and taste, ability to chew and swallow, and gastrointestinal
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and bowel function, and these in turn may influence quality
of life. At the same time, poor nutrition and lack of physical
activity can lead to lack of appetite, inability to perform
ADLs, changes in quality of life, morbidity, and mortality.
Appendix Table 3 summarizes some of the physical and
psychological changes that occur with aging that have po-
tential adverse impacts upon the nutritional aspects of
HRQOL (8–10). These include changes in body composi-
tion, physiology, disease burden, and social functioning. All
of these changes potentially influence the individual’s
HRQOL. Poor nutrition causes many of the changes in
functional status that take place during aging. Therefore, it
is important to assess diet and nutritional status when evalu-
ating HRQOL and to alter poor nutritional status whenever
it is possible to do so (8,11,12). It is also important to tap
other dimensions of experience associated with dietary be-
haviors, such as taste, enjoyment, and social aspects of an
elderly person’s eating experiences. There is therefore a
need to measure functional status and HRQOL, in addition
to nutritional status.
Benefits of Food and Nutrition on Quality of Life
Good nutrition improves HRQOL by promoting health,
preventing dietary deficiency disease, and ameliorating or
averting secondary malnutrition that is caused by or associ-
ated with other disease. Food and nutrition are essential
components of “the good life.” Good food is a sensory and
psychological pleasure in its own right. Meals may also add
a sense of security, meaning, order, and structure to an el-
derly person’s day; imbue that person with feelings of inde-
pendence, control, and sense of mastery over his or her
environment; and provide opportunities for making food
choices. Eating with others may increase social interactions.
When the social aspects of eating are attended to, food con-
sumption may increase, thereby improving nutritional status
(13). The positive psychological and social aspects of eating
are important pleasures of life, which can persist into old
age. They have potent contributions to well-being that must
not be forgotten (14).
The sequelae of malnutrition include physical, mental,
and social disability. If inadequate dietary intake continues
for a long time (e.g., weeks or months), undernutrition re-
sults. If undernutrition is extreme, it results in diminished
muscle mass and vigor, functional impairment, and de-
creased HRQOL (15,16). Malnutrition also causes lack of
enjoyment in eating and anorexia, which may generate psy-
chological, medical, and social problems. Some relevant ex-
amples are noted in Appendix Table 4. The associations
between malnutrition and disability can operate in both
directions. Malnourished individuals are likely to be dis-
abled, and disabled individuals are at greater risk for nutri-
tional problems because of their greater dependence on oth-
56 AMARANTOS ET AL.
ers (17). Undernutrition can also cause stigmatization of the
afflicted elderly person by others. For example, very thin,
cachectic individuals are viewed as being ill and are often
singled out by healthier elderly individuals as being “old
and sick” (18).
Excessive dietary intake and insufficient physical activity
also may pose health and mental health problems, especially
when they result in obesity, as studies of obese elderly indi-
viduals in rural Pennsylvania have shown (19). The con-
sequences of obesity include increased risk of diabetes,
cancer, cardiovascular disease, and premature death (20).
Excessive intake of alcohol also has a well-known toxic ef-
fect on mental health, social interaction, physical health and
well-being, and HRQOL. Both inadequate and excessive in-
takes of some vitamins and minerals may also cause health
and mental problems in older individuals (21).
Specific Nutritional Problems and Associations With
Functional Status and Health-Related Quality of Life
Some common nutritional conditions and problems asso-
ciated with aging that may affect quality of life were de-
scribed in Table 3. Table 4 describes examples of some of
the types of malnutrition and their possible association with
two measures of functional status. These conditions have
been studied extensively from the pathophysiological stand-
point, with an emphasis on how their occurrence modifies
health status, but links between them to quality of life have
rarely been studied.
Each of these malnutrition-related conditions may affect
functional status differently. The specific nutritional dimen-
sions affected are usually not documented completely, nor
is the degree to which malnutrition is associated with each
disease or how it adversely impacts outcomes.
Tools for Measuring Quality of Life
Many measures and scales have been used to address and
quantify the impact of nutrition on HRQOL. Until recently,
most were used only in research studies. Today they are
used increasingly in clinical settings as well.
Different types of HRQOL tools are needed for each pur-
pose. HRQOL measures include general/generic tools (see
Appendix Table 5) that can be used in many conditions, and
disease-specific tools (see Appendix Table 6) that are de-
signed for specific conditions. The generic tools, such as the
Medical Outcomes Study 36-Item Short-Form Health Sur-
vey (SF-36) (22), assess general health from a holistic
standpoint. Disease-specific tools focus on specific health,
functional, and other problems (e.g., psychological and so-
cial) associated with a specific disease or condition, and
also contain some general questions. One example of such a
tool is the Kidney Disease Quality-of-Life Questionnaire
(KDQOL) (23), which is used extensively among patients in
end-stage kidney disease (24).
Appendix Table 7 provides examples of some recent
studies of HRQOL among persons who varied in their nutri-
tional status or who were afflicted with diseases that have
nutritional implications. These variations affected HRQOL
differently.
RECOMMENDATIONS FOR ASSESSING AND MONITORING
NUTRITION AND QUALITY OF LIFE IN OLDER ADULTS
Selecting a Tool
The search for the perfect HRQOL measurement tool has
led to the development of many tools, but none has been uni-
versally recognized as perfect or adopted as a “gold standard.”
However, useful criteria for sorting out the “better” tools
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among those that exist include practicality, content, scaling,
aggregation, reliability, validity, and specificity for the target
group (25). These are provided in Appendix Table 8.
The most appropriate tool depends on the goals of the
user, the resources available, and how the results or data
will be used. Performance assessment or patient-related de-
cision making requires one sort of tool, while a research
study may require another. Measurement strategies for each
application also vary. For example, an immediately accessi-
ble, computerized, HRQOL assessment that is self-adminis-
tered permits the patient or health care professional to iden-
tify and quantify perceived HRQOL, and may be more
appropriate for clinical purposes than an interviewer-admin-
istered paper-and-pencil tool that takes weeks to analyze
(26). One-item and/or one-concept tools may be better
suited for population surveys. In outcomes research, a short
form with additional, more specific questions may be of
greatest assistance. For example, the KDQOL (23) is useful
in outcomes research involving kidney disease, whereas a
multi-item short form may be more appropriate for evaluat-
ing the quality of health care (e.g., SF-36) (22).
The content of the quality-of-life measurement tool is im-
portant. For some purposes, not only HRQOL but additional
dimensions of the food and eating experience and functional
status are all relevant and should be measured. At the very
least, some of these dimensions need to be assessed.
The form in which output of data is produced from the use
of the measuring tool is also important, especially if many
different health care providers must use and interpret these
data. Some tools, such as the Nottingham Health Profile
(23), that present data as profiles provide independent scores
or subscales for each of the categories examined within the
measurement tool (27). This type of scoring makes it easy to
pinpoint areas that are of concern and permits comparisons
to norms. It also provides a means of examining changes
within each domain or between individuals and helps in
tracking an individual longitudinally. If the instrument pro-
vides scores compared with an appropriate normative popu-
lation, the profile also permits one to assess the patient in
comparison with others. A second method of presenting re-
sults involves assigning a single score that encompasses all
categories contained in a tool (e.g., Campbell’s Index of
Well-Being) (28). Some tools (e.g., the Sickness Impact Pro-
file [SIP]) (29) can be presented in both ways, as a compos-
ite score and with subscores by categories (27).
Two potential problems related to data collection are
“floor” and “ceiling” effects. Sometimes a tool is designed
with questions targeted to a “healthier” group. These tools
are unable to pick up differences on the lower end of func-
tioning and result in low scores across the board when indi-
viduals, such as those who are extremely disabled, are eval-
uated. This phenomenon is referred to as the “floor effect.”
 NUTRITION AND QUALITY OF LIFE
For example, if one were to ask a population of terminal
cancer patients if they liked the hospital food, the responses
would probably be negative. However, it would be false to
assume that the food was unacceptable based on the results
in this single population.
The higher end of the scale can also be overlooked, re-
sulting in a “ceiling effect.” For example, if a group of
healthy, older bodybuilders were asked about their ability to
eat without assistance, to shop, or to carry groceries home
from the supermarket, all would report carrying out activi-
ties with ease, and all would obtain high scores. However, it
would be impossible to distinguish between them. One way
to avoid floor and ceiling effects is to make sure the ques-
tions being asked appropriately assess the relevant aspects
of HRQOL that are being studied. A current need is to de-
velop more complete inventories of nutrition and eating-
related factors at varying levels of function.
Finally, it is critical that the HRQOL tool being used has
been validated in the specific population being studied (e.g.,
elderly renal patients). Many disease-specific tools, such as
the Osteoporosis Quality-of-Life Questionnaire (30), and
the KDQOL have been well validated and are available.
They should be given priority in use.
Recommendations
In quality-of-life studies, it is critical to define the dimen-
sions of HRQOL, functional status, and other relevant as-
pects of the food and eating experience (as they relate to
sensory, psychological, and social dimensions) pertaining to
the person or study in question (31). It is also important
to obtain a detailed description of the measurement tool(s)
to be used, including dimensions explored and the reliability
and validity of the instrument (27). Such information should
be available when the research is planned and presented
when research is reported. It allows researchers to compare
their results with other quality-of-life studies.
For clinical determination of HRQOL, our preferred in-
strument is the versatile SF-36 (22). There is an abundant
amount of research on its validity and reliability among el-
derly individuals in clinical and free-living settings (32). It
provides enough detail to be useful; it is easy to administer,
brief, and well accepted with relatively high participation
rates (82% among those aged 65–74 years and 73% among
those aged 75 years according to one study). Also, it has
already been used in several large studies involving the
health of elderly individuals.
For research, the tool selected depends on the purpose of
the study. In addition, if a specific disease is being studied,
it may be advantageous to use disease-specific tools in addi-
tion to generic tools. For example, study (24) of hemodialy-
sis patients uses a combination of the Karnovsky Index,
Campbell’s Index of Well-Being (28), SF-36 (22), and the
KDQOL (23).
The measuring tools specified for assessing achievement
of national goals, such as the Healthy People 2010 (33) ob-
jectives in relation to nutrition and quality of life may be
more appropriate for public health purposes. Specific tools
specified for gathering this information include the Healthy
Days and Years of Healthy Life measures (33). The Healthy
Days measures consist of Self-Rated Health, a Healthy Days
57
index, and Activity Days. These are defined and described
in greater detail in Appendix Table 9.
For descriptions of nutritional status in a clinical setting,
the Nutrition Screening Initiative checklist may be useful,
but it does not directly measure HRQOL (34,35). The Nutri-
tion Screening Initiative checklist (32) examines clinical
features of the patient, eating habits, living environment,
functional status, and mental/cognitive status. In short, it is
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valuable in exposing barriers to good nutritional status and
can be adapted according to the setting in which it is admin-
istered. Two observer-administered instruments of func-
tional status are the ADL (1) and the Karnovsky Index (2).
Conclusions
A broader conceptual model of the nutritional dimensions
of health-related life satisfaction, including affect and cogni-
tive sense of control, is needed. Proper nutrition prevents
health problems; it can improve health, help avert impair-
ments in functional status, and increase quality of life and
well-being in older adults. This statement may be obvious to
nutrition professionals, but still needs to be recognized and
made operational in the rest of the health care community (as
well as by providers and policymakers). Nutrition and diet
therapy are adjunctive interventions that can improve out-
comes of medical treatment among elderly individuals (36).
Many diseases that are known to be related to nutrition also
affect functional independence and status. Most research in
the field of nutrition has omitted investigations on the role of
nutrition therapies on quality of life (12,23,37–50). Most
quality-of-life tools in use today include very few or no
items that directly relate to nutrition. There is a need to de-
velop generic tools that do so (23). In the meantime, the ex-
isting tools can be used to assess the impact of nutritional
status and quality of life. More studies relating nutrition to
quality of life will illustrate and strengthen claims that nutri-
tion improves quality of life. In a sector where many are
competing for limited reimbursement dollars, health-related
quality-of-life outcomes are an asset. In fact, health econo-
mists have used health-related quality-of-life measures for
valuation and decision making in health care (25).
At present, the most widely accepted methods for mea-
suring quality of life that can be self-administered include
the SF-36 (22), the SIP (29), and the Nottingham Health
Profile (23). Other dimensions of life enjoyment involving
food need to be developed.
In assessing associations between nutrition and quality of
life in older persons, it is helpful to control for coexisting
diseases. These associations vary by disease severity, as
well as type of disease (e.g., kidney disease vs arthritis).
The most salient aspects of nutrition that affect quality of
life also vary by setting. For example, among free-living
older persons, convenience of food preparation may be very
important, whereas in assisted care, a menu that includes
choices and favorite foods is more important. In brief, nutri-
tion’s impact on quality of life in each setting and disease
will vary depending on all of these factors.
Quality-of-life measures should be routinely employed in
clinical, research, population, and policy-related situations.
Standardized measures are vital. In the future, perhaps deci-
58 AMARANTOS ET AL.
sions for reimbursement for health services related to nutri-
tion should include quality-of-life measures.
The Appendix Table 10 provides nutrition-related re-
sources that may be useful for older persons.
Acknowledgments
This research was commissioned by the International Life Sciences Institute
and is based in part upon work supported by the U.S. Department of Agricul-
ture (Agreement 58-1950-9-001). Any opinions, findings, conclusions, or rec-
ommendations expressed in this publication are those of the author(s) and do
not necessarily reflect the view of the U.S. Department of Agriculture.
We also acknowledge the contribution of Grace Kang, MS, RD, in the
completion of this article, and Sharon Ployer, who typed the final draft.
Address correspondence to Johanna Dwyer, DSc, RD, Frances Stern
Nutrition Center, 750 Washington Street, Boston, MA 02111. E-mail:
jdwyer1@lifespan.org
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 NUTRITION AND QUALITY OF LIFE 59

Appendix

Table 1. Definitions of Quality of Life

Term Source Definition
Nutritional status A multidimensional concept that involves the end result of dietary intake, anthropometry, biochemical,
and clinical indicators of nutritional health.
Quality of life WHO (37) An individual’s perception of his or her position in life in the context of the culture and value systems in

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Health-related quality of life
Impairment
Functional impairment
Functional status
Disability
which he or she lives and in relation to goals, expectations, standards, and concerns. It is affected in
complex ways by the person’s physical health, psychological state, level of independence, social
relationships, and how the person relates to salient features of his or her environment.
Healthy People 2010 (33) Quality of life is “an overall sense of well-being, when applied to an individual. It denotes a pleasant and
supportive environment when it is applied to a community.”
Healthy People 2010 (33) Factors that clearly affect the physical or mental health of individuals and communities
WHO (37) Any loss or abnormality of psychological, physiological, or anatomical structure or function
Katz (1) Any impairment in ADLs
Katz (1) The determination of an individual’s capabilities to perform basic activities (ADLs or IADLs), which are
necessary for daily life
WHO (37) Any restriction of ability to perform an activity in the manner or within the range considered normal for a
human being that results from an impairment

Note: WHO  World Health Organization; ADLs  activities of daily living; IADLs  instrumental activities of daily living.

Table 2. Dimensions of Quality of Life

Dimension Description
Behavioral competence Any outwardly perceptible aspect of a person, for example, the person’s health, cognitive functioning, use of
time, and social dimensions.
Perceived quality of life Subjective evaluation of both mental and physical status by the respondent.
Psychological well-being Individual’s self-assessment of mental health or his or her subjective reports of overall life satisfaction, and any
present positive or negative experiences or objective judgments by others of his or her emotional status.
Objectively assessed aspects of the environment The physical environment and settings (e.g., home, nursing home, hospital, etc.) are highly associated with
quality of life as are social environments (e.g., living with relatives, alone, etc.). These aspects are explored in
this dimension.
Physical/physiological status This includes such factors as pain, mobility, and appetite as assessed either by the individual respondent or by an
objective observer.

Source: Birren, J. (5).

Table 3. Age-Associated Nutritional Changes That May Affect Quality of Life

Change (Source)
Changes in body composition (10)
Functional changes
Diminished thirst mechanism and decreased body water
Age-related changes in nutrient needs (9)
Changes in taste, vision, and smell (8,14)
Broken bones, edentulous, or missing or false teeth (30)
Increased disease incidence
Increased use of over-the-counter or prescription drugs (14)
Social changes: loss of family, friends, etc.
Decreased income
Possible Consequences
Decreased muscle mass, strength, and ability to perform ADLs
Increased adipose tissue, obesity, and risk/severity of associated degenerative disease (osteoarthritis,
diabetes mellitus, and high blood pressure)
Lower body water with greater risk of dehydration and alcohol intoxication
Increased susceptibility to dehydration
Deficiency (e.g., vitamin B12) or toxicity (e.g., vitamin A due to decreased clearance)
Decreased enjoyment of food
Limited food choices due to inability to prepare food consistency restrictions
Changes in nutritional requirements or failing to satisfy may lead to increased incidence of disease,
(increased DRI’s for B6 and vitamin D, decreased independence, and dietary restrictions
Changes in appetite, nutrient requirements (e.g., increased requirements for vitamin B6 and vitamin D),
and increase in possible drug-nutrient interactions
Depression, decreased intake
Loneliness and isolation (14)
Increased food insecurity, insufficient access to food, and undernutrition (14)

Notes: For more complete descriptions of these and related problems see Dwyer (17). ADLs  activities of daily living; DRI  dietary reference intakes.
60 AMARANTOS ET AL.

Table 4. Examples of Possible Associations Between Nutritional Issues and Functional Impairments
Extreme Chronic Chronic Vitamin B12 Osteoporosis
Measure Obesity Undernutrition Dehydration Alcohol Deficiency and Osteomalucia
ADLs (1)
Inability to bathe oneself X X X X X X
Inability to get dressed independently X X X X X X
Inability to go to the toilet independently X X X X X X

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Inability to get in and out of bed/chair independently X X X X X X
Inability to control urination and bowel movements X X X
Inability to feed oneself X X X X
IADLs (7)
Inability to use public or private transportation X X X X X X
Inability to cook for oneself X X X X
Inability to perform household cleaning and laundry independently X X X X X X
Inability to manage money without assistance X X X
Inability to take medicine daily without assistance X X X
Inability to use telephone without assistance X X X

Table 5. Examples of General (Generic) Tools for Measuring Health-Related Quality of Life
Name (Source) Categories Explored
Sickness Impact Profile Physical status, psychosocial
(29) status, and degree of
independence
Karnovsky Performance Ability to carry out normal
Status Scale (2) activities, ability to work,
ability to care for self
Visual analog scales
(32,38)
SF-36 (22,31,39) Physical functioning, physical Consists of 36 questions from Interviewer,
role limitations, bodily
pain, mental health, mental
role limitations, social
functioning, vitality, and
general health perceptions
Campbell’s Index of Well- Examines life satisfaction and Consists of two parts; i) IGA
Being (28) psychological well-being.
Nottingham Health Profile Six dimensions including
(19,23,29) emotional reactions, social
isolation, physical mobility,
pain, energy, and sleep
ADLs (1) and IADLs (7) Six basic activities examined: One of eight (A–G or other) Can be self-
bathing, dressing, toileting,
transferring, continence,
and feeding. IADLs include
more complex activities re-
lated to social life, including
cooking, cleaning, laundry,
using the telephone, using
public or private transporta-
tion, managing money, and
taking medicine.
Description How Administered Examples of Uses Other Comments
Consists of a list of state- Interviewer or self- Policy formulation or Lengthy and can be
ments. The respondent administered program planning costly. An eating
chooses the statements behavior checklist
that best relate to his or has been developed
her health status. and adopted from it.
Consists of ten questions. Administered by a Often used in clinical Note: not actually a
Clinician gives subject clinician settings quality-of-life tool
a score from 1–100 unless it is self-
(0 represents death and administered
100 represents normal
or disease-free subject).
Respondent rates Self-administered Often used in clinical Easy to fill out. Have
characteristics on a line settings been used in studies
of quality of life on
various antihyper-
tensive medications.
General population sur- Extensively used in
eight scales (noted in the computer, or self- veys, clinical trials, many studies
previous column), which administered and clinical practice
are broken up into two
summary measures:
physical health and
mental health.
Not a comprehensive
and ii) OLS tool
Consists of 38 statements Self-administered Intended for primary Statements are unequally
that subjects are asked to health care to evaluate distributed among
answer with a “yes” or perceived distress the six categories.
“no.” The responses are across various Not found to be
then given a score. populations. Proposed effective in picking
uses: surveys and up change in status.
intervention studies
in combination with
clinical interview.
Used to evaluate elderly
assigned, depending on administered and chronically ill
degree of independence/ patients for ability to
dependence in each perform essential life
function functions

Continued on next page

 NUTRITION AND QUALITY OF LIFE 61

Table 5. Examples of General (Generic) Tools for Measuring Health-Related Quality of Life (Continued)
Name (Source) Categories Explored Description How Administered Examples of Uses Other Comments
EuroQOL (40,41) Mobility, self-care, usual activi- Standardized generic Self-administered Patient health status Derived from tools, in-
ties, anxiety/depression, measure for describing diary cluding the Sickness
pain/discomfort, and self- health statistics Impact Profile (29)
evaluation of overall health and the Nottingham
Health Profile (23)

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COOP/WONCA charts Assess functional status of pa- Score functioning on each of
(29,42) tients in primary care set- six items over 2 weeks
tings, feelings, physical fit- and then summarize in
ness, daily activities, social 5-point scale with picto-
activities, and overall gram from best to worst
changes in health
RAND health status Physical health (mobility, self- Self-administered Used for community- Tool is long, did not
measures care, physical activities), dwelling populations provide global mea-
mental health (depression, (including elderly sure of quality of life
anxiety, vitality), social individuals and those (only separate scores
health (interpersonal inter- with chronic disease) for each measure).
actions in social life, home New measures (see
and family, etc.), and reference 22) now
general health perceptions available.
(including health outlook)

Note: SF-36  Medical Outcomes Study 36-Item Short-Form Health Survey; ADLs  activities of daily living; IADLs  instrumental activities of daily living;
IGA  index of global affect; OLS  overall life satisfaction; COOP/WONCA  The Dartmouth/Northern New England Cooperative Project/World Organization of
Family Doctors.

Table 6. Examples of Disease-Specific Tools for Measuring Health-Related Quality of Life

Name (Source) Categories Explored
Osteoporosis Symptoms, physical and
Quality-of-Life emotional function, ADLs,
Questionnaire and leisure.
Kidney Disease and Generic core explores physical role 134-item questionnaire: Self-reported by
Quality-of-Life limitation, social functioning,
Questionnaire (43–45) emotional well-being, pain,
energy/fatigue, and general
health perceptions. Disease-
targeted multi-item scales
explore symptoms/problems,
cognitive function, effects of
kidney disease, burden of
kidney disease, work status,
sexual function, quality of
social interaction, sleep, social
support, dialysis staff
encouragement, and patient
satisfaction.
Functional Living Feelings of overall well-being,
Index-Cancer (46) comfort, morale and
functionality
Description How Administered Examples of Uses Other Comments
Consists of 30 questions Interviewer-based Used for measuring health-
questionnaire related quality of life in
patients with
osteoporosis. Used for
program planning and
policy formulation.
Measures quality of life in
takes about 30 dialysis patients individuals with kidney
minutes to complete or administered disease
by a trained
interviewer
24 questions with Self-evaluation by Used to measure quality of Allows a quick and
response options the patient life of patients with easily repeated
along a continuous cancer; can be used to self-evaluation of
scale, ranging from assess the patient’s a patient over time
1 to 7 minutes, maxi- response to therapy
mum score of 154

Note: ADLs  activities of daily living.

62 AMARANTOS ET AL.

Table 7. Examples of Studies Involving Quality of Life and Specific Diet/Nutrition-Related Conditions Common in Older Adults
Quality of Life or
Functional Status
Condition Reference Goal Tool Used Setting, Population, and Design Outcome
Obesity Han and To quantify the impairment SF-36 (Dutch version) (47) 2156 women and 1885 men Subjects with high BMIs and
colleagues (20) of health-related quality between the ages of 20 and large waist circumferences
of life attributable to 59 living in the Netherlands were more likely to have

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body fatness in 1995. Waist circumfer- impaired quality of life
ence and BMI were obtained and disability affecting
for each subject. Random basic activities of daily
cross-sectional study. living.
Undernutrition Ritchie and To assess the nutritional ADLs (1) Older adults living in an urban
colleagues (48) status of frail older area
adults living in an urban
area and to identify
factors associated with
nutritional insufficiency
Jensen and To relate nutrition screening Nutrition Screening Initiative 5373 participants with a mean Aged 75 years, use of 3
colleagues (19) to functional limitations (Level I and II screens) age of 71, living in rural medications, and an
and health care charges areas of Pennsylvania. albumin concentration of
Subjects were part of a 35.0 g/l were significant
nonprofit physician group predictors of both func-
in September of 1994. tional limitation and health
care changes. Poor appe-
tite, eating problems,
income $6000/year, eat-
ing alone, and depression
were significant predictors
of functional limitation.
Renal disease Meyer and Quality of Well-Being Scale,
colleagues (49) Symptom Checklist-90R,
Patient Symptom Form
Osteoporosis/ Silverman and To learn about the physical, ADLs and other questions Cross-sectional survey of 100 Direct health-related quality-
hip fracture Cranney (30) emotional, and social extracted from the SIP, free-living, postmenopausal of-life measurement for
limitations experienced NHP, McMaster Health women with chronic assessment and evalua-
by postmenopausal Index Questionnaire, symptoms due to vertebral tion of treatment in pa-
women with osteoporosis Andrews-Withey Quality- fractures related to tients with osteoporosis,
of-Life Scale, Rand Corp osteoporosis elicits a more accurate
instruments, and the Duke picture of patient’s status
University of North
Carolina Health Profile
Cancer Ottery (50) Patient-General Subjective
Global Assessment of
Nutritional Status
Note: SF-36  Medical Outcomes Study 36-Item Short-Form Health Survey; BMI  body mass index; ADLs  activities of daily living; SIP  Sickness Impact
Profile; NHP  Nottingham Health Profile.

Table 8. Suggested Criteria Used to Evaluate Quality-of-Life Tools

Criteria Definition
Practicality Suitable for administration under actual conditions of use
Content Addresses dimensions of greatest interest
Scaling Scaling must be sufficient to highlight differences between subjects (especially clinically meaningful differences)
Aggregation The manner in which the data are arranged. The data can be grouped together or listed individually.
Reliability Reproducibility
Validity Tool effectively measures the area of concern

Table 9. Year 2010 Objectives of the U.S. Department of Health and Human Services Relating to Nutrition and Quality of Life
Tool Function of Tool Goal
Self-Rated Health Helps predict health outcomes such as functional status, mortality, To increase the percentage of persons reporting good, very good, or
and use of community services excellent general health to 90% by 2010
Healthy Days Index Provides information regarding health-related quality of life in the To increase the amount of healthy days to at least 26 over the last 30
populations being studied by 2010
Activity Days Used to monitor rates of disability To increase days able to do usual activities to at least 28.7 over the
last 30 by 2010
Years of Healthy Life Used to evaluate progress of Healthy People 2000 year To increase years of healthy life to at least 66
 Table 10. Nutrition Resources for Older Adults
Resource Phone Number Fax Number Web Site Address E-Mail Address Professional General
Administration on Aging (202) 619-0724 (202) 260-1012 http://www.aoa.dhhs.gov aoainfo@ban-gate.aoa.dhhs.gov X X
US Department of Health and Human Services (800) 677-1116
330 Independence Avenue, SW
Washington, DC 20201
Administration on Aging (305) 348-1517 X X
National Policy and Resource Center on Nutrition
and Aging
National Association of Nutrition (616) 531-9909 (616) 531-3103 X X
and Aging Service Programs
2675 44th Street, SW, Suite 305
Grand Rapids, MI 49509
Meals on Wheels Association of America (703) 548-5558 (703) 548-8024 http://www.projectmeal.org mowaa@tbg.dgsys.com X
1414 Prince Street, Suite 202
Alexandria, VA 22314
American Diabetes Association (703) 549-1500 http://www.diabetes.org/ customerservice@diabetes.org X X
Attn: Customer Service 1-800-DIABETES membership@diabetes.org
1660 Duke Street
Alexandria, VA 22314
American Heart Association (214) 373-6300 http://www.americanheart.org/ X X
National Center 1-800-AHAUSA1
7272 Greenville Avenue 1-888-myheart
Dallas, TX 75231
Food and Nutrition Information Center (301) 504-5719 (301) 504-6409 http://www.nal.usda.gov/fnic fnic@nal.usda.gov
Agricultural Research Service, USDA
National Agricultural Library, Room 304
10301 Baltimore Avenue
Beltsville, MD 20705-2351
The American Dietetic Association (312) 899-0040 (312) 899-1979 http://www.eatright.org/ X X
216 W. Jackson Boulevard, Suite 800
Chicago, IL 60606-6995
NUTRITION AND QUALITY OF LIFE

Food and Drug Administration (301) 443-3170 http://www.fda.gov/ X X

HFE-88
Rockville, MD 20857
National Institute of Aging http://www.nih.gov/nia/healt X X
Nutrition Program for the Elderly (703) 305-2286 http://www.usda.gov/fcs webmaster@fns.usda.gov X X
3101 Park Center Drive
Alexandria, VA 22302
The American Geriatrics Society (212) 308-1414 (212) 832-8646 http://www.americangeriatrics.org info.amger@americangeriatrics.org X X
770 Lexington Ave., Suite 300
New York, NY 10021
Additional Health-related Resources
Healthfinder http://www.healthfinder.gov X X
Medline X X
NIH Health Information Page http://www.nih.gov/health/ X X

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 64

Table 10. Nutrition Resources for Older Adults (Continued)

Phone Number Fax Number Web Site Address E-Mail Address Professional General
Additional Health-related Resources
National Institute on Aging http://www.nih.gov/nia X X
Department of Health and Human Services http://www.hhs.gov X X
Food and Drug Administration http://www.fda.gov X X
National Institutes of Health http://www.nih.gov X X
Administration on Aging http://www.aoa.dhhs.gov X X
Arizona Dietetic Project http://www.ag.arizona.edu X
American Dietetic Association http://www.eatright.org/ X X
Vitamin E—Medical Sciences http://pharminfo.com:80/pub X
American Academy of Family Practice (816) 333-9700 http://www.aafp.org/ fp@aafp.org X X
8880 Ward Parkway
Kansas City, MO 64114
American Medical Association http://www.ama-assn.org/ X X
American Society on Aging http://www.asaging.org info@asaging.org X X
833 Market Street, Suite 511
San Francisco, CA 94110
AMARANTOS ET AL.

The Gerontological Society of America http://www.geron.org/ geron@geron.org X

1030 15th Street, NW, Suite 250
Washington, DC 20005-1503
Nutrition Research Centers
Jean Mayer USDA Human Nutrition Center on Aging http://www.hnrc.tufts.edu/ X
Beltsville Human Nutrition Research Center http://www.barc.usda.gov/bhnrc X
Grand Forks Human Nutrition Research Center http://www.gfhnrc.ars.usda.gov/ X
Western Human Nutrition Research Center http://www.whnrc.usda.gov/index.htm X

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