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The IUNS study of food habits in later life: A critique

Abstract
Introduction
Operational background to the IUNS-FHLL study
Study aims
Comparisons between the two studies
Parameters of interest and survey methods
Conclusions
Acknowledgements to IUNS-FHLL study investigators
References

Bridget H.-H. Hsu-Hage and Mark L. Wahlqvist

The authors are affiliated with the Department of Medicine in Monash University in Clayton, Victoria, Australia.

Mention of the names of firms and commercial products does not imply endorsement by the United Nations University.

Abstract

The Committee on Nutrition and Aging of the International Union of Nutritional Sciences (IUNS) organized a project entitled Food Habits in Later Life (FHLL) that studied the nutritional and health problems of the elderly from 13 communities in six countries. Demographic, food intake, anthropometric, and health-related data were obtained from a total of 2,013 individuals who participated in this cross-cultural, multicentre study. The methods developed and used in this project will be useful for other groups interested in designing cross-cultural, multicentre studies.

Introduction

The International Union of Nutritional Sciences (IUNS) study Food Habits in Later Life (FHLL) is one of the many community studies of food-health relationships in the elderly. The experience of the IUNS-FHLL study, however, differs from that of other studies because of its cross-cultural design. The IUNS-FHLL study has the attributes of an ecological investigation and the related limitations. The ethnological and anthropological focus represents an advantage, in that the range of variation of the nutritional exposure under consideration is much greater among populations than within any particular population. The IUNS-FHLL study is unique in the scope of the variables studied. It offers great opportunity for academic discussions about the methods used. The findings open up further research questions for studies of the relations between food and health in the elderly.

The main purpose of this paper is to consider methodological issues in a cross-cultural study of food habits in the elderly. The experience of the IUNS-FHLL study will be presented and discussed in an attempt to compare its elements with those set out in the study on the Nutritional and Food Security Situation of Rural and Urban Elderly from Selected East Asian and Latin American Developing Countries, the Reconnaissance phase of which led to the development of the CRONOS (Cross-Cultural Research on the Nutrition of Older Subjects) project.

Operational background to the IUNS-FHLL study

The coordinating centre, its role and responsibility

The IUNS-FHLL study was coordinated from the Monash University Department of Medicine at the Monash Medical Centre in Melbourne, Australia. The role of the coordinating centre includes the development of the study protocol, questionnaires and fieldwork methods, strategies for cross-cultural data analyses, and documentation in book form [1]. Most importantly, the coordinating centre is charged with the responsibility of ensuring that the project is carried out in accordance with the objectives set out.

The participating centres were recruited initially from members of the IUNS Committee on Nutrition and Aging who were about to embark on a research project in the area of geriatric nutrition, and later from those investigators who were interested in the elderly and the objectives of the IUNS-FHLL study. Each participating centre was asked to provide its own funding.

The coordinating centre in Melbourne undertook to develop a survey instrument that was cross-culturally robust and capable of documenting a wide range of nutritional, health, and lifestyle indicators pertaining to elderly people living in developing and developed countries. It also undertook to conduct 4 of the 13 community surveys. The first IUNS study was carried out on aboriginal Australians in Fitzroy Crossing, Western Australia. Although the number of people in this group who had survived to the age of 70 was inadequate to fulfill the sample-size requirement, it was in this particular study that the cross-cultural experience began to accumulate. Subsequent experience with older Greeks in Spata, Greece, and Melbourne, Australia, and with Australians of British descent in Melbourne opened up further discussions about how cross-cultural data on the elderly should be collected.

Between 1988 and 1991, more research centres had adopted the IONS study protocol. Comparable data were collected in Gothenburg, Sweden (study headed by Professor Bertil Steen), rural and urban Tianjin, China (study headed by Professor Sun Ming-Tang), Beijing, China (study headed by the late Professor Daphne Roe), four communities in Japan (study headed by Professors Yoshimitsu Horie and Toshiko Teshima), and Manila, Philippines (study headed by Mrs. Patrocinio Ma. de Guzman).

In June 1992 a workshop in Boston, Mass., USA, funded by the United Nations University brought together data from all participating centres as well as from large-scale studies of the elderly in Europe (EURONUT-SENECA), Australia (Adelaide, by Caroline Horwath), New Zealand (Mosgiel, by C. Horwath, W. J. Busby, and A. J. Campbell), and northern China (by Xi He Zhao). The value of cross-cultural approaches in the study of food and health relationships in the elderly was debated. The IUNS-FHLL study fulfilled its first objective when the data collected for the study and other studies were finally documented in book form [1].

General approaches in the conduct of the study

By means of telecommunications, the coordinating centre assisted investigators of a participating centre in setting up the study. Where appropriate, efforts were made to ensure that each centre collected information relevant to the community studied. For example, there are obvious differences in food beliefs among the elderly of different food cultures. Investigators of each participating centre were encouraged to use qualitative anthropological techniques and, where possible, trained anthropologists in enquiries about food culture.

The IUNS-FHLL study is one of the early studies that attempted to employ methods developed for Western populations to collect massive cross-cultural data from elderly people in both developing and developed countries. Both the questionnaire and the methods were adopted from existing studies.

Study aims

The IUNS-FHLL study

The aims of the IUNS-FHLL study were (1) to describe the health status, lifestyle, and range of food habits (present and past) among the aged in developed and developing countries and (2) to determine to what extent food habits and lifestyle variables predict health status in the aged.

The first objective defined the parameters (health status, lifestyle, and range of food habits), the target population (the elderly), and the relative economic development in places in which the study populations resided (developed and developing countries). It also indicated a cross-sectional study design (“to describe”).

The second objective tested data collected from within a centre; the results have been reported elsewhere [2, 3]. To achieve this objective, the mode of data collection emphasizes the individual rather than the group level. The cross-cultural comparisons are equally important, although we are testing several approaches by which such comparisons may be scientifically meaningful and practically useful for the elderly.

CRONOS

The general objective of CRONOS is to describe the nutritional situation of the elderly in rural and urban communities in selected developing countries in a multicentre, cross-cultural setting. This objective has both a research and a development aspect. The research interest concerns the nutrition of the elderly, similar to the IUNS-FHLL or the EURONUT-SENECA projects, with an extended advantage in that the intervention strategies appropriate for the community studied will be identified and developed. The study also aims to bring together a wider research network among the European, East and South-East Asian, and Latin American research centres.

The CRONOS study aims to fill the gap in our understanding of the nutritional status of the elderly in developing countries. In its use of Western approaches to understand the nature and causes of nutritional problems in elderly populations of the developing world, CRONOS is no different from the IUNS-FHLL study.

The mention of rural and urban elderly people, however, set the scene for the presumption of finding differences between the elderly in the countryside and the metropolitan areas of developing countries. The question of how urbanization may affect the nutritional status of the urban elderly is unique and worthy of in-depth investigation. The nutritional status of the rural elderly is likely to be affected as a country becomes urbanized.

Comparisons between the two studies

Similarity

Both studies are primarily interested in the nutritional and health status of the elderly.

Distinction

The CRONOS study has a focus on rural and urban comparisons which is not specifically mentioned in the IUNS-FHLL study, although the IUNS-FHLL study also studied both rural and urban communities. The interest in rural and urban comparisons in the CRONOS study is built on the assumption that urbanization is inevitable in developing countries today and that preventive measures will be needed to cope with the rapid socio-economic transformation.

Study design and subjects

The IUNS-FHLL study

IUNS-FHLL is a cross-cultural study of 13 elderly communities drawn from 11 locations, primarily in the Asia Pacific Region, which represent 7 distinctive ethnic backgrounds. The sample size for each community is given in table 1.

The IUNS-FHLL study began with cross-sectional data collection, with the intention of doing follow-up observations every five years. Representative samples of people aged 70 years or more were studied; in communities in which such people represented less than the upper decile of the population, people under 70 were studied. The elderly were representative of the community being studied, but not the country. Approximately 100 men and women were selected randomly from the telephone directory, local or community register, or electoral rolls. Psycho-geriatric patients in nursing homes and subjects unable to answer questions independently were excluded from the study. All study centres aimed for a participation rate of at least 60%.

The goal of recruiting at least 100 men and women aged 70 years or more from each study community was impractical in some communities where the population of free-living elderly people was less than the target number. This phenomenon indicates that the life expectancy in the elderly communities studied may be different or that the upper decile of the population from which the elderly sample is drawn falls below the age of entry of 70 years.

To achieve the sample size needed, the investigators lowered the age of entry (e.g., ABOR, CBJ, and FIL in table 1) or enlarged the geographic boundary (e.g., redefined the sampling frame). The IUNS-FHLL study adopted the approach of including those falling into the upper age decile of the study community. In some instances, a sample size of fewer than 100 men and women was accepted (ABOR and GRK-S).

The CRONOS study

The CRONOS study aims to test the hypotheses that there are differences in nutritional and health conditions between urban and rural elderly people and between middle- and low-income elderly people. It is proposed that 100 rural and 200 urban elderly people (aged 60 to 70 years) be sampled. Of the 200 urban elderly, 100 each will be sampled from low and middle-income families.

Furthermore, CRONOS will sample an equal number of younger counterparts from the community studied. This would allow for comparisons between adults aged 35 to 40 years and the elderly, in an attempt to characterize the effect of ageing. All strata include an equal number of men and women. The exclusion criteria are identical to those of the IUNS-FHLL study.

The site selection was predetermined to include five countries in Asia and three in Latin America. For each country, a rural and an urban community are studied, so that a total of 16 communities are studied.

Comparisons between the two studies

Similarity

Both studies are cross-sectional and take account of the apparent sex differences in nutrition and ageing. The IUNS-FHLL study is cross-cultural. Because of the particular sites selected, the CRONOS study is also cross-cultural.

Distinction

Because of its main interest in the effect of urbanization on the nutrition of the elderly, the CRONOS study is designed to remove factors associated with urbanization. The study design allows for consideration of potential differences between rural and urban elderly people and between low-income and middle income urban elderly people.

Parameters of interest and survey methods

The IUNS-FHLL study was concerned with the nutritional status of elderly people in various parts of the world. Nutritional status may be assessed in numerous ways. In this section we describe the variables and survey instrument of the IUNS-FHLL study.

TABLE 1. Participating communities: community code, location, ethnic origin and sample size (men. women. and total).

Code	Location	Rural or urban	Ethnic origin	Men		Women		Men and women		Total
				Young	Old	Young	Old	Young	Old
ABORa	Fit Cross, Australia	Rural	Aboriginal	16	4	16	7	32	11	43
ACA	Melbourne, Australia	Urban	British	42	7	40	6	82	13	95
GRK-M	Melbourne, Australia	Urban	Greek	66	28	59	36	125	64	189
GRK-S	Spata, Greece	Rural	Greek	32	19	31	22	63	41	104
SWE	Gothenburg, Sweden	Urban	Swedish	52	21	80	64	132	85	217
FILa	Manila, Philippines	Urban	Filipino	33	41	109	98	142	139	281
JPN-O	Okazaki, Japan	Semi-urban	Japanese	28	15	33	13	61	28	89
JPN-H	Hiroshima, Japan	Urban	Japanese	37		53		90		90
JPN-K	Kumamoto, Japan	Semi-urban	Japanese	43		48		91		91
JPN-Y	Yokohama, Japan	Urban	Japanese	28		40		68		68
CBJa	Beijing, China	Urban	Chinese	80	45	124	56	204	101	305
CTJ-R	Tianjin, China	Rural	Chinese	73	10	79	19	152	29	181
CTJ-U	Tianjin, China	Urban	Chinese	107	19	102	32	209	51	260
Total				846		1,167		2,013		2,013

a. The upper docile of the community was sampled: 50 years and older for Beijing women and Aboriginal Australians, and 55 years and older for Beijing men and Filipinos.

Questionnaire information was available from all study communities. In some centres, anthropometric measurements, blood pressure measurement, and blood tests were also performed to collect biological data (table 2).

Interviewer-administered questionnaires

Information was collected by interviewer-administered rather than self-administered questionnaires. The one-to-one interview is imperative for the study of communities such as the elderly, in which the prevalence of illiteracy and disability is high. More importantly, the one-to-one interview provided opportunities for the interviewer to make observations that would provide information not gathered in the questionnaire.

TABLE 2. Methods used to gather and information gathered from each study community

Method	ABOR	ACA	GRK-M, -S	SWE	FIL	JPN-H, -K,-O, -Y	CBJ	CTJ-R, -U
Questionnaires	Yesa	IUNS (modified)	IUNS	IUNS	IUNS	IUNS	IUNS (modified)	IUNS (modified)
Food intake	Yesa	FFQ	FFQ	FFQ	24-h recall, FFQ	3-d and 24-h recall	24-h recall, FFQ	3-d and 24-h recall
Anthropometryb	WT, HT, BMI, WHR, TSF	All	All	All	WT, HT, BMI	WT, HT, BMI, WHR	All except WHR	All
Blood pressure	No	Yes	Yes	Yes	Yes?c	No	Yes	Yes
Blood tests	No	Yes	Yes	Yes	Yes?c	No	No	No

a. Rapid assessment procedures (RAP) were used to obtain demographic and community food intake information.
b. FFQ, food-frequency questionnaire; WT, body weight; HT, stature; BMI, body mass index; WHR, waist-to-hip ratio; TSF, triceps skin fold thickness.
c. Information not available.

Health status

Health status was assessed by questions about well-being, medical conditions, medication use, and memory.

The health section of the Multi-Level Assessment Instrument (MAI) [4] was used to obtain information on self-rated health, health behaviour, and health conditions. Self-reported medication use was assessed by a 21-item checklist of the OARS (Older Americans Resources and Services) questionnaire [8]. Questions were also asked about vitamin supplements and the use of various health aids.

Well-being and feelings of worry, depression, tiredness, sleeplessness, and contentedness with life were assessed by a seven-item questionnaire of the WHO Western Pacific study [6].

Memory was tested by questions adapted from the WHO Western Pacific study [6] that asked the subject to recall correctly the year, month, day of the week, and his or her home address, and whether the subject had difficulty in remembering peoples names.

Food habits

Usual food intake, food intake in the distant past, beliefs about food and health, cooking methods and facilities, eating environment, and eating difficulties were assessed to evaluate individual food habits.

Anthropological methods (rapid assessment procedures) [9] were used to obtain information on food and health beliefs and to examine further other factors possibly affecting food intake [10-12]. The development of the food habits questionnaire encouraged the expression of the food culture of the study communities and allowed for modification within the framework of enquiring about food habits.

The food-frequency questionnaire was used in study communities where seasonal intake of foods was evident (Australia, Greece, and Sweden). The foods listed in the questionnaire were modified in accordance with local food supply and cultural food preferences. A three-consecutive-day 24-hour recall method was used in Chinese and Japanese study communities, where the food-frequency questionnaire had not been used previously and was virtually untested during the early development of this study.

Nutrient intake data were analysed by using country-specific food composition tables. Micronutrient intakes were compared with two-thirds of the US Recommended Dietary Allowances (RDAs) to assess the adequacy of intake. Because of differences in country-specific food composition tables, data for certain nutrients were not available, such as zinc and magnesium for Chinese and Japanese subjects and folacin, vitamin B₆, and vitamin B₁₂ for most subjects. A qualitative assessment of intake was made by identifying foods consumed that are good sources of these nutrients.

Food intake data derived from the food-frequency questionnaire or three-day recalls were categorized into 13 major food groups and 43 subgroups. The usual food intakes were presented in grams per day for selected food groups. The food intake variety score was calculated on the basis of the 43 subgroups [13]. The energy intake, percentage of energy from carbohydrate and fat, and percentage of retinal equivalent and thiamine intakes that were less than two-thirds of the US RDA were also values of interest.

Social factors

Social factors, including social activity, network, and support, were measured by questions adopted from MAI [4]. The questions were available to the Greeks (GRK-M and GRKS), the Swedes, and the Japanese (JPN-O) and were modified for use with the Australians of British descent and the Chinese in Beijing and Tianjin.

Social activity, which included time spent in meetings, at church, and in hobbies, was assessed by 22 questions. Social networks were assessed by 12 questions dealing with contact with friends and relatives, feelings of loneliness, and degree of support.

Lifestyle

Information on activities of daily living (ADL), exercise, sleep, and substance abuse was obtained to explore lifestyle cross-culturally. ADL questions were adopted from the WHO 11-country study [5]. The questions consisted of a 14-item check-list enquiring about degrees of difficulty in performing basic bodily functions and tasks such as using the toilet, eating, and walking between rooms.

To assess exercise patterns, questions were asked about how often the subject left the house and how much time was spent per day or week in various activities. Questions were asked about sleeping patterns, including the times of waking and going to sleep, number of hours slept per night, and whether a nap was taken during the day. Questions were also asked about smoking habits and alcohol consumption.

Anthropometry

A standard protocol was developed for use in the study. Not all study centres had a complete set of anthropometric data (table 2). Where the collection anthropometric data was possible, the study protocol was followed. All measurements were taken twice and included:

· body weight with light clothes on, to the nearest 0.5 kg;

· height in standing position without shoes and socks, to the nearest 0.5 cm;

· waist circumference at the level of the umbilicus, with light clothes on, in standing position with abdomen relaxed, arms at the sides, feet together, and weight equally divided over both legs, to the nearest 0.5 cm;

· hip circumference at the level of maximal gluteal protrusion, with light clothes on, in standing position with abdomen relaxed, arms at the sides, feet together, and weight equally divided over both legs, to the nearest 0.5 cm;

· mid-upper-arm circumference (MUAC) in standing position, arm relaxed, without sleeves, and legs apart, to the nearest 0.5 cm;

· triceps (TSF), biceps, suprailiac, and subscapular skinfold thicknesses, in millimetres, measured with a Harpenden or Holtain caliper (Dyfred, Wales, UK); measurements with either caliper agree reasonably well.

· Body mass index (BMI) was calculated as weight in kilograms divided by height in metros squared (kg/m2);

· Waist-to-hip circumference ratio (WHR) [14] was calculated as waist circumference divided by hip circumference;

· Mid-upper-arm muscle circumference (MUAMC) was calculated from the equation MUAMC = MUAC - (3.14 × TSF), where MUAC is midupper-arm circumference and TSF is triceps skin fold thickness;

· Mid-upper-arm muscle area (MUAMA) was calculated from the equation MUAMA = [MUAC - (3.14 × TSF)]²/12.56, where MUAC is midupper-arm circumference and TSF is triceps skin fold thickness;

· Fat-free mass (FFM) in kilograms, total body fat (TBF) in kilograms, and percentage of body fat [15] were estimated from body weight, height, age, and sex; the approach makes it possible to compare body fatness among the study communities, because more direct measures were not available from all centres. FFM was calculated from the equation FFM = 0.395 × WT + 0.282 × HT + 8.4 × sex-0.144 × age-23.6, where WT is body weight in kilograms, HT is height in centimetres, sex is 1 for men and 0 for women, and age is in years.

Blood pressure was measured twice on the right arm, with the person resting in a sitting position. Korotkoff phases I and V were recorded for systolic and diastolic pressure, respectively. Blood pressure data were available in most study communities except the Aboriginal Australians and the Japanese.

Blood tests

Venous blood in fasting subjects was sampled from Australians of British and Greek origin and from subjects in Sweden. Blood tests were performed at the research laboratory where the study was carried out. Biological markers measured included:

· haematology:full blood examination, plasma folic acid in nmol/L, and plasma vitamin B₁₂ in pmol/L;

· lipids: serum total cholesterol, triglycerides, high density lipoprotein cholesterol, and low-density lipoprotein cholesterol [16], in mmol/L;

· serum fasting glucose in mmol/L;

· iron status: serum iron in mol/L, serum ferritin in g/L, percent iron saturation, and iron-binding capacity in mol/L;

· immune function: white blood cell count (WBC) in 10⁶/L and total lymphocyte count (TLC) in 10⁶/L.

Although there were some restrictions on reaching some of the study centres, such as Tianjin in 1988, there was frequent telecommunication between the coordinating centre and the investigators of each participating centre. The main purpose of inter-centre communication was to ensure that the protocol was fully understood so that an appropriate questionnaire might be developed for use in the prospective elderly community.

Communication among investigators within China, Japan, or Australia was more convenient and more frequent than communication between countries, such as China and Japan or Sweden and Australia.

There clearly are advantages for centres of similar socio-cultural background to communicate at all stages of the study. Collaborative studies, such as the IUNS-FHLL study, benefit from having a coordinating centre with specific roles and responsibilities. As telecommunications gradually make their way to developing countries, it is important to facilitate and budget for frequent communication.

Inter-centre standardization

A standardization procedure is usually used in epidemiological research, in which characteristic-specific rates of a standard population are used to adjust the crude rate derived from the study population so that weighted averaging of characteristic-specific rates can be achieved in accordance with the standard distribution of selected characteristics. The philosophy of standardization in population-based research is therefore to achieve compatibility of the characteristics being studied. This is particularly important if the research findings are to be generalized to a wider population with similar attributes or compared with findings from communities of disparate socio-cultural experience.

Standardization thus depends upon the study conditions or purposes. Standardization must meet the needs of the investigators. Inter-centre standardization in a cross-cultural study consists of obtaining core variables (from questionnaires or biological data) that are common to populations of different cultural background. This may be complemented by Inter-centre standardization in the methods or equipment used to obtain a particular measurement.

If Inter-centre standardization means having identical questionnaires and research approaches for all participating centres, then the IUNS-FHLL study failed to comply. All IUNS-FHLL study centres unmistakably appreciated and understood the core research interest in health status, food habits, social factors, and lifestyle. Where there was financial constraint or where a specific question was culturally objectionable, the notion of standardization required further justification.

The IUNS-FHLL study was a learning experience in cross-cultural research. No assumptions were made about how elderly people in the various communities might eat and live. By documenting or describing the health situation, food habits, and lifestyle, and by using instruments acceptable to the 13 communities, we began to learn the similarities and dissimilarities among them.

The other aspect of standardization concerns laboratory methods for blood tests and measurement procedures for anthropometry and blood pressure. The IUNS-FHLL study relied on the protocol summarized above in the section “Parameters of interest and survey methods.”

Assessment of dietary intake

Several methods of assessing dietary intake are common in population-based research. The advantages and disadvantages of each of these methods may be found in nutrition textbooks as well as refereed articles. Technically, the 24-hour recall (for single or multiple days) and food-frequency questionnaire are retrospective. The 24-hour recall relies on short-term memory and the food-frequency questionnaire on long-term memory. Furthermore, the 24-hour recall method measures food intake in the immediate past, whereas the food-frequency questionnaire is concerned with usual intake.

The food diary (usually for multiple days) and the weighing method record the intake of foods and beverages as they are consumed. The two methods register present intake and do not rely on memory, but they may be unsuitable for illiterate subjects. Because many elderly people are illiterate, the use of these methods in elderly subjects was considered impractical.

The food habits of a population are sensitive to food availability and household economy, and their final expression depends on the socio-cultural affinity of individuals. Food habits may be assessed from aspects of eating, including current and past food intake. The IUNS-FHLL study was a study of food habits and health status in the elderly and was concerned with food intake of the elderly at both the individual and the group levels and in both the present and the past.

The IUNS-FHLL study adopted a food-frequency questionnaire for use initially in elderly Greeks and Swedes and later in British Australians. The food frequency questionnaire relies on standard portion sizes to estimate the usual intake. This is feasible for European food cultures but not for traditional Asian food cultures, in which food is placed in the centre of the table and shared among the members of the extended family.

The use of three-consecutive-day 24-hour recalls in the Chinese and Japanese communities was a circumspect decision and should not be interpreted in any other way but as pragmatic.

Data processing and management

A total of 2,013 elderly people participated in the IUNS-FHLL study. The data were first compiled by each participating centre. This involved data entry, transcribing questionnaire information and biological measurements into a computer, and data correction. Primary data were stored in personal computers with dBASE software [17]. The entire database was then exported to the SAS environment [18] and formatted for later use.

The food intake data, initially entered as intake frequency using dBASE software, were converted into food intake in grams per day and nutrient intake in appropriate units per day. Food intakes were classified by food group. Food intake was converted into nutrient intake in either a dBASE or an SAS environment.

The first objective of the study was achieved through descriptive data analyses of all variables relevant to demography, health status (self-reported status and biological measurements), food beliefs, intake and habits, social factors, and lifestyle. The variables were either categorical or continuous. Categorical variables were reported as percentages of the total. Descriptive statistics, including the mean, standard deviation, minimum, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and maximum, were analysed. These statistics were presented for those aged less than 79 years and for those aged 80 years and over, separately for men and women. A separate group of those less than 70 years old was created for centres whose minimum age for entry was below 70 years (CBJ and FIL). For these centres, those aged 70 years and over were not further divided into two groups.

Centre-specific tables were generated for all variables and formed the appendices of the CD-ROM Food Habits in Later Life [1].

Dissemination of results

The results of the IUNS-FHLL study have been reported in several ways. There are results of individual studies (e.g., the participating centres of the IUNS-FHLL study) and results of the study as a whole. Both kinds of results have been reported at various international meetings and in articles submitted to journals. The documentation of the results from all centres is included in Food Habits in Later Life, published on CD-ROM [1], which is intended to be used by nutritionists, geriatricians, gerontologists, anthropologists, social workers, epidemiologists, medical practitioners, and other health professionals for teaching, research, scholarly discussion, and reference.

Conclusions

The IUNS study Food Habits in Later Life was a significant research undertaking. It was a comprehensive study that addressed the nutritional and health problems of contemporary elderly communities across several cultures. Its approach and philosophy were driven by the community and were culturally responsive.

In order to balance between what may be possible for cross-cultural comparisons and what is likely to be a culturally appropriate approach for the elderly community studied, the IUNS-FHLL study adopted various methods, including questionnaires. The challenge has been for the IUNS-FHLL study to present its data in balanced form without deviating from the study objectives.

Acknowledgements to IUNS-FHLL study investigators

INNS Committee on Nutrition and Aging: M. L. Wahlqvist, L. Davies, B. H.-H. Hsu-Hage, Y. Horie, H. Hermanova, A. Kouris-Blazos, D. M. Prinsley, D. Roe, N. S. Scrimshaw, N. W. Solomons, B. Steen, M-T. Sun, A. Trichopoulou, W. A. van Staveren, and X-H. Zhou. British Australians: M. L. Wahlqvist, A. Kouris-Blazos, B. H.-H. Hsu-Hage, and W. Lukito. Greek Australians: A. Kouris-Blazos and M. L. Wahlqvist. Greeks in Spata, Greece: A. Kouris-Blazos, A. Trichopoulos, E. Polychronopoulos, and M. L. Wahlqvist. Swedes in Gothenburg, Sweden: B. Steen, E. Rothenberg, O. Augustsson, B. G. Eriksson, V. Sundh, and B. Warne. Filipinos in Manila, Philippines: P. Ma. de Guzman. Japanese in Okazaki, Japan: Y. Horie, K. Horie, and K. Sugase. Japanese in Hiroshima, Japan: R. Inai. Japanese in Kumamoto, Japan: Y. Kasugai. Japanese in Yokohama, Japan: T. Teshima and H. Nishikawa. Chinese in Beijing, China: D. Roe and Y. Wang. Chinese in rural and urban Tianjin, China: S. Xi, M-T. Sun, and G-F. Gu.

We wish to thank Mrs. Antigone Kouris-Blazos, project coordinator between 1988 and 1991, for her contribution to the study. Our sincere thanks extend to the elderly and their families for making this project possible.

References

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