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CRONOS (Cross-Cultural Research on the Nutrition of Older Subjects). Third edition

Foreword
References
1. Objective of CRONOS
2. Sampling
3. Supervision
4. Format of data collection forms
5. Content of data collection forms
6. Examples of survey forms
7. List of variable codes
8. Collection of qualitative data (RAP)
References

Rainer Gross, editor

Foreword

Two of the major demographic phenomena of recent decades have been the expansion of the elderly population [1, 2] and the growth of urban populations [3].

By the year 2020, the proportion of the population over 55 years of age in developing countries is due to increase by 72% [1]. World Health Organization (WHO) census and demographic projections call for the percentage of the population of the third world living in cities to increase from 16.7% in 1950 to 43.5% in 2000, a 2.6-fold increase. In many Latin American countries, more than 70% of the people already live in cities.

Recent surveys of the nutrition, diet, and health of elderly people in developed countries have been conducted in the Netherlands [4], the United States [5], and 14 European countries [6]. Multicentre research encompassing industrialized, transitional, and deprived populations of elderly people has been concluded in the southern Pacific region [7] and is in progress elsewhere [8]. However, there are still major gaps in our knowledge of the profiles of nutritional status, patterns of intake, and health status of the elderly in most of Asia and Latin America, especially in urban areas. Nutrient intake requirements and recommendations for older people need to be documented. Diet-disease relationships as modified by the genetic, environmental, and lifestyle characteristics that prevail in the third world, which differ markedly from those of the industrialized world, need to be defined.

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It is felt that comparative multinational and multicultural studies allow for a more profound understanding of the universal aspects of ageing and its intrinsic and extrinsic modifiers, because the truly common elements can be extracted by contrasting diverse geographic experiences [6-8]. Cognizant of the needs and opportunities in multicentre research in community gerontology, especially in developing countries and in the urban centres that have been largely ignored [3], but also recognizing the pitfalls in interpreting cross-sectional data on ageing [2, 9], the consortium of eight countries, in collaboration with academic institutions in the European Community, undertook a pilot Reconnaissance study from November 1992 to March 1993 to assess the feasibility, comparability, and validity of research instruments designed to study nutrition in the elderly.

The following document is based on a joint research experience of nine research centres in Latin America and East Asia which was financially supported by the Commission of the European Community. It is the objective of the document to stimulate scientific South-South cooperation with the assistance of the North. Although this protocol is related to particular research sites in specific countries, it can also be used by other research groups from other countries.

References

1. Kinsella KG. Aging in the third world. CIR Staff Paper No. 35. Washington, DC: Center for International Research, US Bureau of the Census, 1988.

2. World Health Organization. Health of the elderly. Report of a WHO expert committee. Technical Report Series 779. Geneva: WHO, 1989.

3. Gross R. Solomons NW, eds. Tropical urban nutrition. Sonderschriftenreihe Nr. 196. Eschborn, Germany: Gesellschaft für Technische Zusammenarbeit (GTZ), 1987.

4. Lowik MR, Schrijver J. Odink J. van den Berg H. Wedel M, Hermus RJ. Nutrition and aging: nutritional status of “apparently healthy” elderly (Dutch nutrition surveillance system). J Am Coll Nutr 1990;9:18-27.

5. Hartz SC, Russell RM, Rosenberg IH, eds. Nutrition in the elderly: the Boston nutritional status survey. London: Smith-Gordon, 1992.

6. de Groot LCPGM, van Stavern WA, Hautvast JGAJ, eds. EURONUT-SENECA Eur J Clin Nutr 1991; 45(suppl 3)

7. Andrews GR Health and ageing in the developing world. In: Evered D, Whelan J. eds. Research and ageing population. Chichester, UK: Wiley, 1988:17-37.

8. Wahlqvist M, Davies L, Hsu-Hage BH-H, Kouris-Blazos A, Scrimshaw NS, Steen B. van Staveren WA, eds. Food habits in later life: descriptions of elderly communities and lessons learned. Jointly published on CD-ROM by the United Nations University Press, Tokyo, and the Asia Pacific Journal of Clinical Nutrition, 1996.

9. Solomons NW. Nutrition and ageing: an overview with notes on their investigation and communication in developing countries. In: Pongpaew P. ed. Proceedings of the I Asian Workshop on Nutrition in Metropolitan Areas. South East Asia J Trop Med Public Health 1993; 23(suppl 3):114-9.

1. Objective of CRONOS

The aim of the Cross-Cultural Research on the Nutrition of Older Subjects (CRONOS) project is to obtain information for use in improving the nutritional and health condition of underprivileged population groups in developing countries. The means of obtaining the necessary data is a multidisciplinary research approach using the disciplines of nutrition, medicine, public health, and food policy. Elderly people in developing countries are vulnerable to impaired health and nutrition from illness and senescent changes. This may be compounded in elderly migrants to third world cities by problems of economic disruption (monetary economy) and cultural dislocation. However, health and social services lack the technical expertise to focus on the living conditions of this population group.

Declining mortality in infants and children and increasing life expectancy during the last 50 years in developing countries are changing the composition of the population. The percentage of the elderly in the population has increased, and this trend is expected to continue. This increase is likely to lead to social and economic problems due to the associated high risk of disability and morbidity and the need for medical services.

The goals of updated and improved understanding of the health situation, specifically as it relates to diet and nutrition, would be to:

· assess the impact of the demographic patterns of urbanization, migration, and worldwide ageing on the nutrition, diet, and health of understudied populations in different parts of the world;

· relate age contrasts (old versus young) to the interaction of dietary intake and lifestyle with function and self-perceived health;

· determine the magnitude of the gap between urban social classes in the nutritional status and food security of the elderly;

· begin to develop an outline of the disease components and the geographic specificity of the morbidity patterns that will confront rural and urban health services for low-income elderly people.

To describe the nutritional situation of the elderly living in rural and urban communities in selected developing countries in a multicentre, cross-cultural setting.

Specific objectives

· To describe and compare the socio-economic background of the elderly according to:

- region (Asia, Latin America, etc.);
- country;
- rural versus urban setting;
- income group, formal education, and occupation;
- age group (35-44 years and 60-74 years);
- gender.

· To describe the dietary intake of the elderly and to identify factors affecting availability and access to foods.

· To assess nutritional and health status by means of:

- selected anthropometric measures; haemoglobin;
- blood pressure;
- self-perceived health status and health problems.

· To characterize and compare lifestyle factors that may affect food intake and nutritional and health status of the elderly specifically related to:

- physical activities;
- social activities;
- use of drugs, tobacco, etc.;
- socio-demographic and economic situation.

· To elaborate hypotheses and research proposals for further collaborative studies between the participating research centres.

2. Sampling

2.1 Population to be studied
2.2 Sampling procedure

2.1 Population to be studied

Three communities of at least 6,000 inhabitants will be selected in each country. Each of these three communities should have socio-economic and demographic characteristics that make them typical of the country with regard to:

· the rural population,
· the poor urban population, or
· the middle-class urban population.

Four groups of 50 people, each representing elderly men and women (aged 60 years, 0 months, to 74 years, 11 months) and middle-aged men and women (aged 35 years, 0 months, to 44 years, 11 months) will be studied in each of the three communities. The individuals to be surveyed should have lived in the same community (or in similar rural or urban communities) for at least five years and should be able to understand and answer the survey questions independently. Institutionalized urban elderly people also may be included in the study. However, psychogeriatric patients in nursing homes and those who are not able to answer the questions independently will not be enrolled in the study. Records should be kept of the latter to estimate the biases introduced by their omission.

2.2 Sampling procedure

The people to be studied in each community will be selected by the following steps:

1. A map of the community will be obtained (or made) showing blocks, streets, and households. Blocks and then households will be numbered consecutively starting from a corner randomly selected and following a route previously defined.

2. If reliable statistics about the households are not available, a census will be conducted on all families living in the community with questions on family composition (age and gender of all members) and socio-economic characteristics (education of the head of the family and other appropriate local markers of social class).

Note: Besides providing the total numbers of elderly and middle-aged people, the census will give us data needed to situate the community within the country and to evaluate possible bias introduced by the replacement of non-respondents.

3. All eligible elderly people (probably more women than men; ideally around 300 individuals) in each study community (rural, low-income urban, and middle-income urban) will be numbered consecutively following an ascending order determined by the number of the household, age (youngest first), and gender (female first).

Example:

Elderly No.	Household No.	Age (years)	Gender
001	003	60	F
002	003	70	M
003	005	65	M
004	005	66	F
005	008	62	F
006	008	68	M
007	008	73	F

4. A second list with a systematic sample of 150 elderly people, numbered consecutively as above, will be drawn from the first list of elderly people. The second list should include 150 people to have a sufficient number to compensate for non-respondents and the anticipated unequal proportion of men and women due to underrepresentation of men. The sample will be selected by taking individuals at a regular interval, x, down the list, the starting point being chosen from 1 to x at random. The interval x will be determined by dividing the total number of elderly people in the list by 150. The second list will be split into one list of women (e.g., 80 women) and one of men (e.g., 70 men). The first SO names on each list will be selected, and the others (e.g., 30 women and 20 men) will be used to replace non-respondents.

Examples:

A. If the list contains 300 elderly people, the interval will be 2 (300/150), and the starting point could be the first or the second person on the list. In this case the sample will include the 1st, 3rd, 5th,... and 149th person, or the 2nd, 4th, 6th,... and 150th person.

B. If the list contains 400 elderly people, the interval will be 2.666 (400/150), and the starting point will be the first, second, or third person on the list (2.666 is rounded to 3). For example, if the second person on the list is selected as the starting point, the sample of 150 elderly people will include the 2nd, 5th (2 + 2.666 = 4.666 rounded to 5), 7th (4.666 + 2.666=7.332 rounded to 7),... and 399th (398.000 rounded to 399) person on the list.

Note: The reason for selecting communities with at least 6,000 people is to ensure that a minimum of 300 elderly people can be listed (we are assuming that in all communities the elderly constitute at least 5% of the population). Studying two or more elderly persons from the same household poses no problem for the external validity of the results (there is no selection bias), but it may affect the internal validity (information bias), since the answers of one elderly person can influence the answers of the other if they are both present during the interview.

5. The middle-aged men and women will be selected by the same procedures as in steps 1 to 4.

3. Supervision

The reliability of data collection in a survey essentially depends on:

· the survey method,
· the precision of the instruments used,
· the ability of the survey workers,
· the supervisor.

In practice, a supervisor is appointed to ascertain the true situation in a survey. The rationale for this is that a supervisor is better trained and has more experience than the survey workers. The degree of variance in the collected data provides an indication of the reliability of the data collection.

During the course of a survey, the supervisor collects data on the variables expected to be the most unreliable. The selection of these variables should be made on the basis of the experiences of the Reconnaissance. In all cases, the supervisor should take comparative measurements of anthropometric data on height and weight.

About 10% of the households visited by survey workers should be selected at random for a cross-check. Besides providing data for a reliability check, the cross-check also provides a supervisor an excellent opportunity to identify difficulties encountered by the survey workers in recording data in order to be able to introduce subsequent measures during the survey to alleviate or minimize the difficulties.

4. Format of data collection forms

There are two distinct types of survey forms:

· survey form for individual data
· survey form for supervision purposes

1. A three-digit field for the household number should be located at the top of each survey form. Before commencing the survey, a unique household number should be assigned to each form and the assigned number should be written on each page of the form. In this way the survey will be protected against accidental exchange of pages between households, and also no two families will be given the same identification number (household number).

2. Each assigned variable should be given a sequential number.

3. A variable may be recorded as a response to a question, an observation, a measurement, or a calculation. Thus, the age of a person can be ascertained by asking the person during an interview or by reading a birth certificate. The data obtained will likely be the same in each case. However, more accurate data can probably be obtained if a survey worker measures the distance from the home to the water supply than if the worker asks the individual during the interview how far the water supply is from the home. Decisions concerning the variables, even more than a decision concerning the type of survey, must take into account the local cultural and socioeconomic conditions. For standardization, it is important that the type of question for each variable be fixed and the question type be stated after the number of each variable on the survey form:

e.g., 2.) Measurement: or 5.) Question:

Variables that result from calculations carried out during the data analysis by the computer do not appear in the survey form.

4. The text of the questions to be asked during the survey must be stated in full on the form, so that the survey worker has no doubts about the wording during the interview. This means that the questions on the survey form should be stated as briefly, but as precisely, as possible. The questions must be stated so that the answer is not obvious from the question (suggestive questions must be avoided).

The local language of the target community often differs from the national language. In these cases, the questions and answers on the survey form should be written in the language that the people of the target community use to communicate among themselves. If the questions were initially written in the national language, the quality of the translation into the local language should be checked by reverse translation back into the national language.

5. As for the questions, all possible responses are listed on the survey form. These responses must not be read by the interviewed person. The interviewed person should not be aware of the potential answers in order to prevent a bias in his or her answers and to ensure spontaneity. The survey worker must convert the freely given answers to code numbers according to the respective answer categories.

6. The answer categories for closed questions should be coded (e.g., male = 1; female = 2). The answer categories on the survey form should be completed with the corresponding code for each question. For size measurements, such as height, weight, or age, the appropriate unit, such as centimeters, kilogrammes, or years, should be given.

7. On the right side of the form, a field for each variable will be identified, in which the number of the coded answers will be entered. The number of the spaces in the field will correspond to the maximum number of digits in the anticipated response, either a code or a measurement.

E.g.,

8. If a question is answered by “no,” the code number 1 should be given.

9. The code numbers 9 and 99 should, in principle, be reserved for use when the interviewed person gives no answer.

10. The code numbers 8 and 88 should, in principle, be reserved for use when the interviewed person answers, “I don’t know.”

11. When an answer is given that has not been provided for in the coding, it should be recorded as “other.” It is suggested that number 7 or 77 be reserved for this purpose.

12. There should be no additional recording of possible answers, because this adds considerably to the workload of data entry and the later analysis, and because it is impossible to maintain standardization when several survey workers are engaged.

13. Each variable should have its own unique code name, which should consist of not more than eight letters. The code name of each core variable is mentioned later in the description of the variables. Uniform codes are necessary for merging the data of the different surveys.

e.g., Variable code: GENDER

In contrast to the individual forms, the variable code of the supervision forms can be selected by each country, since the reproducibility of the collected data should be carried out in each country separately.

14. Some data needed for analysis are based on further derived calculations, and it is necessary to standardize the codes of these variables as well. For example, the body mass index is calculated from body stature and weight. These variables do not appear in the survey form but will be analysed later during data processing. These variables are marked in this Research Protocol by square brackets [].

5. Content of data collection forms

5.1 demographic and socio-economic variables
5.2 social behaviour and practices
5.3 Self-perceived health
5.4 Illness and illness impact
5.5 Impairments
5.6 Physical activities (optional)
5.7 Risk factors
5.8 Cognitive functioning
5.9 24-hour recall
5.10 Food behaviour and practices (optional)
5.11 Food security (optional)
5.12 Anthropometric measurements
5.13 Blood parameters
5.14 Physical performance test (optional)

5.1 demographic and socio-economic variables

1. Observation: Gender

1 = Male
2 = Female
Variable code: GENDER

3. Question: What is the place of your birth?

1 = Rural
2 = Urban
Variable code: PLACE

5. Question: What is your marital status?
1 = Married or common-law union
2 = Widowed
3 = Single, never married
4 = Divorced or separated
Variable code: MARSTAT

Question: What other people live with you in your household?

Definition of a household: A household includes all persons for whom meals are prepared using the same cooking facilities and who eat together, and who over the last 30 days have spent at least three nights per week in the building occupied by the household.

The second part of this definition is generally only useful in urban areas, as in agricultural societies other household arrangements may exist.

Name	Age	Gender	Relationship to you

It is recommended that the interviewer ask for all characteristics for each individual before passing to the next person. In this way the matrix is filled in row by row and not column by column.

Gender:
1 = Male
2 = Female

Relationship to the interviewed person:

00 = Interviewed person
01 = Spouse
02 = Father
03 = Mother
04 = Son
05 = Daughter
06 = Brother
07 = Sister
08 = Grandson
09 = Granddaughter
10 = Father-in-law
11 = Mother-in-law
12 = Son-in-law
13 = Daughter-in-law
14 = Other relative
15 = Maid
16 = Other employee
77 = Other non-relative
88 = Does not know
99 = No answer

7. Question: How many children do you have?
Variable code: CHILDREN

8. Observation. Number of children loving in the household
Variable code: CHLDHOUS

9. Question: How many grandchildren (children of your children) do you have?
Variable code: GRDCHLD

10. Observation. Number of grandchildren living in the household
Variable code: GCHLDHOU

11. Observation: Number of non-relatives living in the household
Numbers 15,16, 77 of relationship codes
Variable code: NORELHOU

12. Observation. Number of relatives living in the household
Total number of household members minus number of non-relatives
Variable code: RELHOU

[13. Calculation. Proportion of related to non-related household members]
(Number of non-relative household members + 1) / (Number of relative household members + 1)
Variable code: RELNONR

14. Question: How many days last week did you not sleep in this household?
Variable code: SLEEPWK

15. Question: How many months last year did you not live in this household?
Variable code: SLEEPMTH

16. Question: How many years have you lived in this community?
Community as defined by survey Variable code: YEARCOMM

17. Question: How many years have you lived at this address?
Variable code: YEARADDR

Household Income

Question: From which of the following sources do you receive income (list all that apply) and what amount do you receive monthly from each source (ask this part if culturally acceptable)? Sample questions follow (18-24)

Source
Amount per month

18. Question: How high is the monthly pension(s) that you receive directly?
Variable code: INCPENS

19. Question: How much money do you receive monthly from regular employment in your major occupation?
Variable code: INCEMREG

20. Question: How much money do you receive monthly from your occasional employment(s)?
Variable code: INCEMPOC

21. Question: How much money do you receive monthly from any charitable organization(s)?
Variable code: INCBENEF

22. Question: How much money do you receive monthly from government social assistance?
Variable code: INCSOCIA

23. Question: How much money do you receive monthly from your family?
(e.g., children, pension of spouse)
Variable code: INCFAMIL

24. Question: How much money do you receive monthly from other sources?
Variable code: INCOTHER

[25. Calculation: Total]
Variable code: INCTOTAL

[26. Calculation: Pension as percentage of total income]
(Pension(s) / Total income)×100
Variable code: PINCPENS

[27. Calculation. Wage from active regular employment(s) as percentage of total income]

(Regular wages(s)) / (Total income) × 100
Variable code: PINCREG

[28. Calculation: Income from occasional employment(s) as percentage of total income]
(Occasional employment(s) income) / (Total income) × 100
Variable code PINCOC.

[29. Calculation: Income from charitable organization(s) as percentage of total income] (Income from charitable organization(s)) / (Total income) × 100
Variable code: PINCBENF

[30. Calculation: Income from government social assistance as percentage of total income] (Income from government social assistance) / (Total income) ×100
Variable code: PINCSOCA

[31. Calculation. Income from family as percentage of total income]
(Income from family) / (Total income) × 100
Variable code: PINCFAM

[32. Calculation. Income from other sources as percentage of total income]
(Income from other sources) / (Total income) × 100
Variable code: PINCOTH

33. Question: Apart from yourself, how many people do you support with your income? Variable code: SUPPINCO

34. Question: What is your level of formal education?
According to UNESCO, a person needs at least three consecutive years of school to be able to read and write. Ask this question in a manner appropriate to the country in order to code the answer finally in the following manner.
1 = No school
2 = Up to 3 years
3 = 3 years to completion of primary school
4 = Some or completion of secondary school
5 = Some or completion of university or equivalent
6 = Some postgraduate education
Variable code: EDUCATIO

Living conditions

35. Observation: Type of house
1 = Single-household building
2 = Multiple-household building
Variable code: TYPHOUSE

36. Observation: Major building material of wall of main entrance
1 = Straw or bamboo
2 = Wood
3 = Clay
4 = Stone
5 = Tiles or bricks
6 = Cement
Variable code: WALL

37. Observation: of kitchen
1 = Inside the house
2 = Outside the house
Variable code: KITCHEN

38. Question: What is the source of the energy that you use for cooking?
1 = Wood
2 = Petroleum
3 = Gas
4 = Electricity
7 = Other (specify)___________
Variable code: ENERGY

39. Question: Where do you store your food?
This question is related not to harvested products but to foods, such as those of animal origin or vegetables, that are used on a day-by-day basis in a household.
1 = No food stored
2 = Open storage
3 = Ventilated closed cupboard
4 = Refrigerator
Variable code: STORAGE

40. Question: Where do you get your drinking water from?
01 = Own tap, inside the house
02 = Own tap, outside the house
03 = Public tap
04 = Water tank
05 = Private well
06 = Public well
07 = River or lake
08 = Spring
09 = Buy water
77 = Other
88 = Don’t know
99 = No answer
Variable code: WATER

41. Observation: Luxury goods
1 = No item
2 = Watch
3 = Radio
4 =TV
5 = Two items
6 = All three items
7 = Other (specify)_____________
Variable code: LUXUR

5.2 social behaviour and practices

42. Question: In the last month, how many times have your children and/or grandchildren who do not live with you visited you?
Variable code: VISITS

43. Question: In the last week, how many times have you had visits or social contacts with friends, neighbours, or relatives?
Variable code: SOCONTAC

44. Question: In the past month, how many times have you participated in religious activities?
This question may not be feasible in all countries. It is assumed that religion (and ethnicity) should be controlled for in community selection and that religious affiliation therefore should not need to be asked.
Variable code: RELACTIV

45. Question: In the past month, how many times have you attended social/cultural events (e.g., movie, theater, concert, wedding feast, market, community pub/cafe)?
Variable code: EVENT

46. Question: Do you have a hobby (e.g., gardening, sewing, Sniffing, fishing, painting, playing a musical instrument)?
Hobby is defined as an activity that involves some physical activity and results in a product.
1 = No
2 = Yes
If yes: What kind of hobby?_________
Variable code: HOBBY

47. Question: In the last month, how many times have you participated in the following caring activities: babysitting, caring for an elder, caring for an ill person, working on a community committee?
Variable code: VOLUNT

Question: In the past week, have you engaged in any of the following activities?

48. Reading a book?
1 = No
2 = Yes
Variable code: BOOK

49. Reading a newspaper or magazine?
1 = No
2 = Yes
Variable code: NEWSPAP

50. Watching television?
1=No
2=Yes
Variable code: TV

51. Listening to radio or audio equipment?
1 = No
2 = Yes
Variable code: RADIO

53. Question: Do you have someone to whom you feel close?
1 = No
2 = Yes
Variable code: CLOSE

54. Question: Do you feel lonely?
1 = No
2 = Yes, sometimes
3 = Yes, often
Variable code: LONELY

55. Question. Do you have someone who helps you when you are sick?
1 = No
2 = Yes
Variable code: SICK

56. Question. If you need help in an emergency, do you have someone you can call?
1 = No
2 = Yes
Variable code: EMERGENC

57. Question: Do you feel satisfied with the respect shown to you by the people around you?
1 = No
2 = Yes
Variable code: RESPECT

5.3 Self-perceived health

58. Question: Next I have some questions about your health. Generally speaking, how would you describe your health?
1 = Excellent
2 = Good
3 = Fair (neither poor nor good)
4 = Poor
5 = Extremely poor
Variable code: HEALTHRA

59. Question: In general, how do you think your physical health affects your daily activities?
1 = Does not affect it at all. Everything is OK
2 = Practically does not affect it
3 = Affects it sometimes
4 = Affects it quite a lot
5 = I am not able to work or to engage in daily activities
Variable code: ACTIVITY

60. Question: Would you say your health is better than, the same as, or not as good as that of most people your age?
1 = Not as good
2 = Same
3 = Better
Variable code: RATEOTHE

5.4 Illness and illness impact

61. Question. During the past 12 months, how many times did you see a practitioner, doctor, or healer?
1 = 0-2 times
2 = 3-6 times
3 = >6 times
Variable code: VISDOC

62. Question: What was the reason for visiting a practitioner, doctor, or healer?
1 = Mainly routine visit
2 = Mainly treatment
3 = Both
Variable code: CAUSEDOC

63. Question: How many days did you spend overnight in a hospital during the past 12 months?
1 = None
2 = 1-21 days
3 = >21 days
Variable code: TIMEHOSP

64. Question: How many days did you spend ill in bed at home during the past 12 months? 1 = 0-3 days
2 = 4-14 days
3 = >14 days
Variable code: TIMEILL

Question: During the last month, have you been bothered by any of the following?

65. Cough?
1=No
2=Yes
Variable code: COUGH

66. Diarrhoea?
1 = No
2 = Yes
Variable code: DIARRHEA

67. Fever?
1 = No
2 = Yes
Variable code: FEVER

68. Diabetes?
1= No
2 = Yes
Variable code: DIABETES

69. Hypertension?
1 = No
2 = Yes
Variable code: HYPERTEN

70. Arthritis or arthrosis?
1 = No
2 = Yes
Variable code: ARTHRIT

71. Osteoporosis?
1 = No
2 = Yes
Variable code: OSTEOPOR

72. Cataract?
1 = No
2 = Yes
Variable code: CATARACT

73. Urinary tract problems?
1 = No
2 = Yes
Variable code: URINARY

74. Other?
1 = No
2 = Yes
Variable code: HEAPROBL

5.5 Impairments

76. Question: Do you still have your own teeth?
1 =No
2 = Yes, but many are lost
3 = Yes, most of them
Variable code: TEETH

77. Question: Do you wear dentures?
1 = No
2 = Yes
Variable code: DENTURES

78. Question: Do you have problems with chewing?
1 = No
2 = Yes
Variable code: CHEWING

79. Question: Is your eyesight good enough both to see things clearly at a distance and to read close up?
1 = Without eyeglasses
2 = With some type of visual aid
3 = Partially blind
4 = Blind Variable code: SEEING

80. Question: How good is your hearing?
This question is related to hearing capacity (without a hearing aid).
1=No problem
2 = Can hear only if spoken to loudly
3 = Nearly deaf
Variable code: HEARING

81. Question: How difficult is it for you to walk about a kilometre?
1 = Not difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult but possible
5 = Cannot do it
Variable code: WALKING

82. Question: How many falls have you had in the past year?
Variable code: FALLS

83. Question: How many times did you go out of your house during the last 24 hours? Variable code: OUTGOIN

84. Question: Do you use a cane?
1 = No
2 = Yes
Variable code: CANE

85. Question: Do you have problems with a stiff back when you get up in the morning?
1 = No, never
2 = Yes, sometimes
3 = Yes, very often
4 = Yes, always
Variable code: BACK

5.6 Physical activities (optional)

This part is optional and should be used only in elderly populations.

PA1 Question: How difficult is it for you to walk across a room?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 =Very difficult
5 = Cannot do it
Variable code: ROOMWALK

PA2 Question: How difficult is it for you to sit for about 2 hours?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: SITTING

PA3 Question: How difficult is it for you to get up from a chair after sitting for long periods?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: GETUP

PA4 Question: How difficult is it for you to get into and out of bed without help?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: GETBED

PA5 Question: How difficult is it for you to climb one flight of stairs without resting?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: CLIMBST

PA6 Question: How difficult is it for you to lift or carry a weight over 5 kg, such as a heavy bag of groceries?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: CARRY

PA7 Question: How difficult is it for you to stoop, kneel, or crouch?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: CROUCH

PA8 Question: How difficult is it for you to bathe or shower without help?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: BATHING

PA9 Question: How difficult is it for you to eat without help?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: EATING

PA10 Question: How difficult is it for you to dress without help?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: DRESSING

PA11 Question: How difficult is it for you to comb your hair without help?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: COMBING

PA12 Question: How difficult is it for you to use the toilet without help?
1 = Not at all difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult
5 = Cannot do it
Variable code: USETOIL

5.7 Risk factors

86. Question: Do you smoke?
1 = No
2 = Yes, cigarettes
3 = Yes, cigars
4 = Yes, pipes
Variable code: SMOKING

87. Question: Have you smoked in the past?
1 = No
2 = Yes, cigarettes
3 = Yes, cigars
4 = Yes, pipes
Variable code: SMOKPAST

88. Question: Do you drink alcohol?
1 = No
2 = Yes, at social events only
3 = Yes, at meals only
4 = Yes, outside of meals
Variable code: ALCOHOL

89. Question: With whom do you drink alcohol?
1 = Alone
2 = Only with friends
Variable code: ALCOSOC

90. Question. Have you lost more than 3 kg during the last month?
1 = No
2 = Yes
Variable code: WTLOSS

5.8 Cognitive functioning

The following questions serve to evaluate short-term memory functions. Long-term memory is difficult to evaluate, unreliable, and useless for CRONOS. To assess the memory, a series of simple questions will be asked. A total of at least 10 points must be obtained to be able to answer the questionnaire reliably.

Question: What is the date (day, month, and year), day of the week, and season today?
Each correct response equals 1 point (total 5 points).

Question. What is the location of the interview site?
Correct location equals 2 points.

1. Show the subject 10 standard objects for 1 minute, then hide them from the subject’s view. The objects are pencil, comb, ring, matches, watch, spoon, key, button, coin, and eyeglasses.

2. Then ask the subject to list the months of the year, forwards and then backwards (score twice).
0 = Impossible
1 = With some difficulty
2 = Normal

3. Then ask the subject to recall the objects that were shown.
Each correct object recalled equals 1 point (total 10 points)

[91. Calculation. Total memory score]
The total memory score will be calculated automatically and does not enter into the questionnaire.
Variable code: MEMORY

5.9 24-hour recall

Specific objectives

· To describe the dietary intake and food habits of the elderly, and to identify factors associated with food habits;
· To recommend that the focus, at the group level, be on the description of dietary intake, which provides information on nutrient intake

Core
1. Energy
2. Protein (animal and
3. Carbohydrates (total)
4. Fat (total)
5. Calcium
6. Iron
7. Retinol
8. Carotene
9. Vitamin Be
10. Vitamin B2
11. Niacin equivalent
12. Vitamin C

Optional
1. Dietary fibre
2. Fatty acids vegetable)
3. Dietary cholesterol
4. Phosphorus
5. Zinc
6. Pyridoxine
7. Folic acid
8. Vitamin

Methods of data collection

Core: The 24-hour food recall method will be used for data collection. By means of an interview, the actual food intake of an individual is recalled for the preceding day, starting from the first food or drink taken after waking up to the last food or drink taken before sleeping. Midnight snacks, or any food taken by the subject when he or she awakes at night or at dawn (within the 24-hour period), are included in the food record. Across the 300 individuals sampled, the interviews should include recalls for all days of the week and, when possible, an even representation of days. If this is not possible, the distribution of recalls according to the days of the week and the season when the recall was done should be reported.

Optional: For centres that intend to describe not only the mean food and nutrient consumption of the group, but also group means and distribution, and/or classification of individuals according to the distribution of intake, repeated 24-hour food recalls and/or the use of a food-frequency questionnaire in combination with a 24-hour food recall may be the most appropriate methods to use.

Time of implementation of 24-hour recall

· For countries where seasonality in food availability is pronounced, carry out the 24-hour recall during the worst season;

· Do 24-hour recalls spread over one to two months to cover intake variations (do not cross over between two different seasons).

Previous day from waking up to sleeping (including night snacks)

Estimation of food portions

· Survey the markets and shops for types of food sold;
· Check on types of utensils used at home;
· Use household measures, photos, and models of foods during study.

· Use the best available local food composition table (if in doubt, consult http://www.crop.cri.nz/foodinfo/infoods/infoods.htm);

· Provide information on definition and method of analysis for each nutrient;

· Provide information on units used to express amount of each nutrient.

· Personnel with knowledge of the food composition and skills in estimating food portions;
· Recommend that regional training be held to ensure uniformity in carrying out the protocol;
· Number of days needed to train: 5.

· approximately 45 minutes survey time per elderly subject;
· travel time to reach study site and to locate re spondents;
· time for calculation;
· time for coding (both activities, 30 minutes per re call);
· computer costs;
· visual aids, such as household measures, photos, food samples, scales, etc.;
· accommodation and travel expenses of workers;
· incentives for elderly respondents.

The aim of the food intake study is to describe the dietary intake and food habits of the elderly and to identify factors associated with food habits. At the group level, the following variables will be used to describe nutrient intake:

Core nutrient intake calculations

Variable code	Item
KCAL	Energy (kcal/day)
PLANTPRO	Plant protein (g/day)
ANIMPRO	Animal protein (g/day)
TOTALPRO	[Total protein (g/day)]
CARBOHYD	Carbohydrate (g/day)
FAT	Fat (g/day)
CALCIUM	Calcium (mg/day)
IRON	Iron (10-1 mg/day)
VITA	Vitamin A (RE/day)
RETINOL	Retinol (pa/day)
CAROTENE	ß-Carotene (pa/day)
VITB1	Vitamin B1 (10-2 mg/day)
VITB2	Vitamin B2 (10-2 mg/day)
NIACIN	Niacin (10-1 mg/day)
VITC	Vitamin C (mg/day)

Optional nutrient intake calculations

Variable code	Item
FIBRE	Dietary fibre (10-1 g/day)
POLYUNFA	Polyunsaturated fatty acids (10-1 g/day)
SATURFA	Monounsaturated, saturated fatty acids (10-1 g/day)
TOTALFA	Total fatty acids (10-1 g/day)]
CHOLESTE	Cholesterol (mg/day)
PHOSPHOR	Phosphorus (mg/day)
ZINC	Zinc (10-2 mg/day)
VITB6	Vitamin B6 (10-2 mg/day)
FOLIC	Folic acid (pa/day)
VITB12	Vitamin B12 (10-2 pa/day)

The food sources of these nutrients will be determined. The nutrient base that will be used for nutrient conversion of food data will be the best available food composition table for application to the population studied. In the event that there is none, it is recommended that countries from Asia and Latin America do not use the FAO’s Food Composition Table for East Asia and Food Composition Table for Latin America, which are extremely out of date. New, updated food composition databases are being developed under INFOODS and are already completed for South-East Asia, the Western Pacific, China, Central America, Mexico, and the Caribbean. If the appropriate table is in doubt, check the INFOODS web site for the most appropriate available database (http://www.crop.cri.nz/foodinfo/infoods/infoods.htm)

Because of differences in the methods employed in food analysis and the mode of expression of the results, each country should provide the coordinator for the food consumption study with the following information:

· definition of terms
· sampling procedure
· detailed method of analysis for each nutrient
· mode of expression for the different nutrients

5.10 Food behaviour and practices (optional)

Information related to food habits obtained from the 24-hour recall includes:

· meal patterns;
· food groups and sources of nutrients;
· methods of preparing food;
· whether food is prepared at home or purchased.

· Do you include certain foods in your meals for health reasons? If yes, why?
· Do you avoid certain foods?
· What is the main reason you avoid these foods?
· What do you especially like to eat?
· Are you on a specific diet? If yes, what kind of diet is it?

However, the classifications of food have to be adapted to the local perception and culture.

FP1 Question: Do you avoid certain foods or food ingredients?
1 = No
2 = Yes (go to FP18)
8 = Don’t know (go to FP18)
9 = No response (go to FP18)
Variable code: AVOID

FP Question: If yes, what foods or food ingredients do you avoid, and why?

The following classification may need to be adapted to the cultural situation of the population in the research area.

Type of food	Variable code
FP2 Meat in general	MEAT
FP3 Pork	PORK
FP4 Beef	BEEF
FP5 Fatty meat	FATMEAT
FP6 Cured meat or meat products	CURED
FP7 Eggs	EGG
FP8 Dairy products	DAIRY
FP9 Seafood	SEAFOOD
FP10 Fats and oils	FAT/OIL
FP11 Sugar or sugar products	SUGARS
FP12 Pastries (pies, cakes)	PASTRIES
FP13 Salt and salty foods and food ingredients	SALTY
FP14 Carbonated beverages	BEVERAGE
FP15 Coffee	COFFEE
FP16 Food with lots of additive (preservatives, colours, etc.)	ADDITIVE
FP17 Others, specify_______________	OTHFOOD

Name of respondent: ____________
Date: _____________________
Identification: ________________
Name of interview: __________

Time of meal	Meal type	Name of dish	Where prepared	Method of preparation	Food items or food ingredients	Food item description	Amount or size measure of food item	Food item weight (g)a		Food item codea
								APb	EPc

a. Food item code and food item weight will be entered in the office.
b. As purchased.
c. Edible portion.

Codes for main reason for avoiding food:
01 = Not avoided
02 = Indigestion
03 = Dislike taste
04 = Religious or cultural reasons
05 = Food allergy or sensitivity
06 = Inconvenient to buy or prepare
07 = Expensive
08 = Taking drugs
09 = Illness or other health reasons
77 = Others, specify
88 = Don’t know
99 = No answer

FP Question. What foods do you especially like to eat?

The following classification may need to be adapted to the cultural situation of the population in the research area. To force the respondent to give priority, a maximum of only four answers may be given.

Type of food	Variable code
FP18 Pastries (cakes, pies)	CAKES
FP19 Ice cream, sherbet, yoghurt	ICECREAM
FP20 Noodles (spaghetti, vermicelli, etc.)	NOODLES
FP21 Cured or smoked meats (ham, sausages, etc.)	SMOKED
FP22 Meat dishes (barbecued, stewed, fried, etc.)	MEATS
FP23 Milk or milk products	MILK
FP24 Sweets	SWEETS
FP25 Rice	RICE
FP26 Vegetables	VEGETABLE
FP27 Fruit	FRUITS
FP28 Others, specify 1 = No 2 = Yes 8 = Don’t know 9 = No response	OTHLIKE

FP29 Question: Do you include certain foods or food ingredients in your meals for health reasons, and if so, why?
1 = No (go to FP45)
2 = Yes
8 = Don’t know (go to FP45)
9 = No response (go to FP45)

FP Question: If yes, what foods or food ingredients and why?

Type of food	Variable code
FP30 Raw green leafy vegetables	GREENVEG
FP31 Yellow vegetables	YELLOVEG
FP32 Other vegetables	OTHVEGET
FP33 Yellow fruits	YELLFRUI
FP34 Vitamin C-rich fruits	VITCFRUI
FP35 Other fruits	OTHFRUIT
FP36 High-fibre or coarse bread	HIGHFIBR
FP37 Unrefined cereals	UNREFIND
FP38 Yoghurt	YOGHURT
FP39 Margarine	MARGARIN
FP40 Garlic	GARLIC
FP41 Tea	TEA
FP42 Dietary supplements, specify________	DIETSUPP
FP43 Health foods, specify________	HEALTHFD
FP44 Others, specify________	OTHEFOOD

Codes for main reason for including food in the diet:
1 = Aid in digestion
2 = Diuretic
3 = Lower blood pressure
4 = Ease pain
7 = Others, specify__________
8 = Don’t know
9 = No response

FP45 Question: Are you on a specific diet?
1 = No (go to FP59)
2 = Yes
8 = Don’t know (go to FP59)
9 = No response (go to FP59)

FP Question: What kind of diet is it?

Type of diet	Variable code
FP46 Low-calorie/energy	LOWCAL
FP48 Low-salt	LOWSALT
FP49 Low-protein	LOWPROT
FP50 Low-fibre	LOWFIBRE
FP51 High-calorie/energy	HIGHCAL
FP52 High-protein	HIGHPROT
FP47 Low-fat	LOWFAT
FP53 High-fibre	HIGHFIBR
FP54 Bland	BLAND
FP55 Diabetic	DIABETIC
FP56 Vegetarian	VEGETARI
FP57 Otters, specify__________	OTHDIET

FP58 Question. How long have you been on this diet?
1 = Less than one year
2 = 1-3 years
3 = More than 3 years
8 = Don’t know
9 = No response

5.11 Food security (optional)

Specific objective: to gather information on accessibility of food at the individual level

FS1 Question: Do you have enough food throughout the whole year?
1 = Have more than enough food to eat
2 = Have enough food to eat
3 = Sometimes do not have enough food to eat
4 = Often do not have enough food to eat
8 = Don’t know
9 = No response
Variable code:

FS2 Question: During the past month, did you skip any meals?
1 = No (skip FS3 and FS4)
2 = Yes
8 = Don’t know (skip FS3 and FS4)
9 = No response (skip FS3 and FS4)
Variable code:

FS3 Question: If yes, on how many days during the last month did you skip at least one meal?
1 = Every day
2 = Two days a week
3 = One day a week
4 = Two days
5 = One day
7 = Others, specify
8 = Don’t know
9 = No response
Variable code:

FS4 Question: What is your main reason for skipping meals?
1 = Not enough money
2 = No transportation
3 = No harvest
4 = No appliance for food preparation or storage
5 = No time for preparation or eating
6 = Not feeling well
7 = Reduce weight
8 = Religious reasons
77 = Others, specify
88 = Don’t know
99 = No response
Variable code:

5.12 Anthropometric measurements

107. Weight

Instrument: SECA model 770 digital weighing scale (SECA, Hamburg, Germany) with a unit precision of 0.1 kg (100 g)

Technique: Body weight is measured to the nearest 0.1 kg with the subject clothed only in a light paper garment with slits for measuring tape. Weight should be measured in the morning, after breakfast, preferably after emptying the bladder. Calibrated scales must be used, if necessary placed on a wooden board to prevent torsion of the scale on an uneven surface. Scales should be calibrated regularly [1].

Special considerations: Use of a standard cloth or paper garment is ideal.

Variable code: WEIGHT

108. Height

Instrument: Microtoise with a unit precision of 0.1 cm (1 mm) (CMS Weighing Equipment, Ltd., London, or UNICEF, Copenhagen)

Technique: The standing body height (stature) is measured to the nearest 0.1 cm using a microtoise fixed to the wall. The subject should stand (without shoes) on a horizontal platform with his or her heels together and with the Frankfurt plane horizontal. The subject draws himself or herself to full height without raising the shoulders, with hands and arms hanging relaxed, and with the feet flat on the ground [1].

Variable code: HEIGHT

109. Arm span

Instrument: A 2-m metal bar graduated in centimetres and millimetres with a unit precision of 0.1 cm (1 mm).

Technique: The arm span is measured by the primary examiner with the help of an assistant whose responsibility it is to support the measuring bar in a perfectly horizontal position at the level of extension of the arms. The subject faces the wall, against which the measuring bar is supported gently by the assistant. The subject is asked to touch the wall with his or her chest and to extend the arms maximally from the sides of the body in the horizontal plane at the level of the shoulders. It is the job of the primary examiner to adjust the arms so that they are both as close to horizontal as possible. The assistant moves the bar to the level of the arms and applies the tip of the longest finger of the right hand to the bar, and the primary observer records the reading to the nearest 0.1 cm at that level of the bar. The primary observer then applies the tip of the longest finger of the left hand to the bar at the other extreme and records the reading to the nearest 0.1 cm. The arm span is recorded as the numerical distance between the right-hand and left-hand readings, expressed to the nearest 0.1 cm.

If the subject cannot extend one arm to the full 90 degrees and 180 degrees, the measurement is taken with the subject facing forward using the one arm that has full lateral extension and 90-degree extension. The centre of the sternum is used as the point of reference extending to the tip of the longest finger on the index hand. The assistant stands in front of the subject supporting the bar in the horizontal plane, guiding the good arm to the horizontal plane with the finger applied to the bar, and recording the reading at the centre of the sternum to the nearest 0.1 cm. The primary examiner stands behind the bar on the same side as the subject and takes the fingertip measurement, recorded to the nearest 0.1 cm. The corrected arm span is recorded with an asterisk and is calculated as the measured hemi-arm span times 2, to the nearest 0.2 cm.

If neither of the arms can be moved into the appropriate 90-degree horizontal extension and 180-degree planar extension, a missing value is recorded for arm span.

Variable code: ARMSPAN

[110. Calculation: Body mass index (BMI)]

This variable will be automatically calculated by weight (kg)/height (m)².

Variable code: BMI

[111. Calculation: Body mass index calculated through arm span (BMA)]

This variable will be automatically calculated by weight (kg)/arm span (m)².

Variable code: BMA

112. Mid-upper-arm circumference (MUAC)

Instrument: Non-stretch measurement tape with marker (available from Ross Laboratory, Columbus, OH, USA) with a unit precision of 0.1 cm (1 mm).

Technique: The circumference of the left upper arm is measured at its midpoint. The midpoint is located after bending the left arm to a 90-degree angle at the elbow. The upper arm should be approximately parallel to the trunk. Using an insertion tape, the examiner identifies and marks the midpoint of the arm, halfway between the tip of the acromial process and the tip of the olecranon process. The skin should be marked at this point before the arm is repositioned for the circumference measurement. The left arm is then extended alongside the body. The person’s hand is placed through the loop of an inelastic, flexible tape measure. The tape is placed at the marked midpoint and pulled just snug around the arm, but not so tight that the tissues are compressed. This measurement is recorded to the nearest 0.1 cm, and successive measurements should agree within 0.5 cm.

Variable code: MUAC

113. Triceps skinfold

Instrument: Skinfold calipers with a unit precision of 2 mm.

Technique: This measurement is taken with the person standing with the feet spread about 15 cm apart and the weight equally distributed between the two feet [2]. The triceps skinfold thickness measurement is taken with the left arm extended along the side of the body. The measurement is taken on the back of the left arm over the triceps muscle at the level marked for the circumference measurement. The examiner gently grasps a double fold of skin and subcutaneous adipose tissue between the fingers and thumb within 1.0 cm of the marked level. The fold of skin must be on the back of the arm, in the midline and parallel to the long axis of the upper arm. The skinfold is raised in a line with the upper arm. The skinfold is grasped in such a way as to separate the subcutaneous adipose tissue from the underlying muscle. The skinfold is held while the jaws of the calipers are placed perpendicular to the length of the skinfold at the level of the marked midpoint. After about 3 seconds, the measurement is read and recorded to the nearest 2 mm, and successive measurements should agree within 4 mm.

Variable code: TRICEPS

114. Biceps skinfold

Instrument: Skinfold calipers with a unit precision of 2 mm.

Technique: This measurement is taken with the person standing with the feet spread about 15 cm apart and the weight equally distributed between the two feet. The skinfold is picked up on the front of the arm directly above the centre of the cubital fossa. The calipers should be applied to the skinfold at the same marked level as for the triceps skinfold measurement (see above) but on the ventral (front) side of the left arm. The biceps skinfold thickness measurement is taken with the left arm extended along the side of the body. The measurement is taken on the front of the left arm over the biceps muscle at the level marked for the circumference measurement. The examiner gently grasps a double fold of skin and subcutaneous adipose tissue between the fingers and thumb within 1.0 cm of the marked level. The fold of skin must be on the front of the arm, in the midline and parallel to the long axis of the upper arm. The skinfold is raised in a line with the upper arm. The skinfold is grasped in such a way as to separate the subcutaneous adipose tissue from the underlying muscle. The skinfold is held while the jaws of the calipers are placed perpendicular to the length of the skinfold at the level of the marked midpoint. After about 3 seconds, the measurement is read and recorded to the nearest 2 mm, and successive measurements should agree within 4 mm.

Variable code: BICEPS

115. Subscapular skinfold

Instrument: Skinfold calipers with a unit precision of 2 mm.

Technique: This measurement is taken with the person standing. Subscapular skinfold thickness is measured just posterior to the inferior angle of the left scapula [2]. The examiner gently grasps a double fold of skin and subcutaneous adipose tissue between the thumb and fingers, on a line from the inferior angle of the left scapula to the left elbow. Grasping the skinfold separates subcutaneous adipose tissue from the underlying muscle. The skinfold is held gently while the calipers are positioned perpendicular to the length of the skinfold. The jaws of the calipers are applied lateral to the fingers, at a point lateral to-and just inferior to-the inferior angle of the scapula. After about 3 seconds, the measurement is read and recorded to the nearest 2 mm, and successive measurements should agree within 4 mm.

Variable code: SUBSCAP

116. Suprailiac skinfold

Instrument: Skinfold calipers with a unit precision of 2 mm.

Technique: This measurement is taken with the person standing. The place of measurement is on the midaxillary line immediately superior to the iliac crest. The skinfold is picked up obliquely just posterior to the midaxillary line and parallel to the cleavage lines of the skin. The skinfold is gently pulled away from the underlying muscle tissue, and the jaws of the calipers are applied at right angles. The skinfold remains held between the fingers while the measurement is taken. As the jaws of the calipers compress the tissue, the caliper reading diminishes for 2 to 3 seconds, and then the measurements are taken to the nearest 2 mm. Successive measurements should agree within 4 mm.

Variable code: SUPRAIL

[117. Calculation: Total skinfold]

Sskinfolds (mm) = triceps + biceps + subscapular + suprailiac skinfolds

Variable code: TOTSKINF

[118. Calculation: Body density]

Body density (BD) shall be estimated from the log of the total skinfold using the age (c) gender (m) regression equation [3]:

BD = c - m × log S skinfolds (mm)

Variable code: BODYDENS

[119. Calculation: Percentage of body fat]

The percentage of body fat (%BF) shall be calculated using the equation by Siri [4] and Gibson [5]:

%BF = (4.95/BD-4.5) × 100

Variable code: PBODYFAT

[120. Calculation: Total body fat]

The total body fat (TBF) shall be calculated as:

TBF(kg)= %BF × weight (kg)

Variable code: TBODYFAT

[121. Calculation: Lean body mass]

The lean body mass (LBM) or fat-free mass shall be calculated as:

LBM (kg) = weight (kg) - TBF (kg)

Variable code: LBODYMAS

[122 Calculation Mid-upper-arm muscle area]

The mid-upper-arm muscle area (M) results from the midupper-arm circumference (MUAC) and the triceps skinfold thickness (TSK) and is used widely as an indicator of the total body muscle mass. The following equation shall be used:

M (mm²) = [MUAC-( p × TSK)]²/4p

Variable code: MUAMA

[123. Calculation: Mid-upper-arm fat area]

The midupper-arm fat area (F) is calculated as:

F (mm²) = MUAC²/4p -M

Variable code: MUAFA

124. Waist (abdominal) circumference

Instrument: Non-stretch measurement tape with marker with a unit precision of 0.1 cm (1 mm).

Technique: The abdominal circumference gives an estimate of intra-abdominal fat. It is taken with the person standing with the feet spread about 15 cm apart and the weight equally distributed between the two feet. The superior border of the right iliac crest and the umbilicus are located and gently marked. The measurer sits beside the subject and threads the inelastic, flexible tape through the slit of the garment and extends it around the person’s abdomen at the level halfway between the two marks (not at the level of the umbilicus). The plane of the tape is positioned so that it is parallel to the floor. The tape is held in position snugly but not so tightly as to compress the skin, and the person is instructed to breathe naturally. This measurement is recorded to the nearest 0.1 cm at mid-respiration, and successive measurements should agree within 1.0 cm.

Special considerations: Taken using garment with appropriate slits; measurement taken in mid-respiration.

Variable code: WAIST

125. Hip circumference (largest circumference below umbilicus)

Instrument: Non-stretch measurement tape with marker and a unit precision of 0.1 cm (1 mm).

Technique: The hip circumference itself is not particularly informative, but together with abdominal (waist) circumference, it has been used as an indicator of risk of diabetes and other chronic diseases [2]. It is taken with the person standing with the feet spread about 15 cm apart and the weight equally distributed between the two feet. The maximum protrusion of the buttocks is observed. This may require tightening of the gown. The examiner sits beside the person and extends an inelastic, flexible tape measure around the subject’s hips at the level of the maximum protrusion. When the tape is positioned, the plane of the tape should be parallel to the floor. The tape is held in position snugly but not so tight as to compress the skin. This measurement is recorded to the nearest 0.1 cm, and successive measurements should agree within 1.0 cm.

Variable code: HIP

126. Knee height

Instrument: Knee-height caliper with a unit precision of 0.1 cm (1 mm).

Technique: The knee height is measured with the person sitting in a chair. It is important that the leg be supported so that the knee and corresponding ankle are each bent to a 90-degree angle. It is performed with a specific sliding broad-blade caliper (available from Medical Express, 5150 S.W. Griffith Drive, Beaverton, OR 97005, USA). The observer must kneel beside the lateral side of the lower left leg and place the fixed blade of the calipers under the heel of the foot. The shaft of the calipers is positioned so that it passes over the lateral malleolus and just posterior to the head of the fibula. The movable blade is placed over the anterior surface of the thigh, above the condyles of the femur about 4.0 cm proximal to the patella. The shaft of the calipers is held parallel to the shaft of the tibia, and pressure is applied to compress the tissues. This measurement is recorded to the nearest 0.1 cm, and successive measurements should agree within 0.5 cm.

Special considerations: Use the sitting position.

Variable code: KNEE

127. Calf circumference

Instrument: Non-stretch measurement tape with marker with a unit precision of 0.1 cm (1 mm).

Technique: Calf circumference is considered the most sensitive measure of muscle mass in the elderly, superior to arm circumference. It indicates changes in fat-free mass with ageing and with decreased activity. Calf circumference is measured with the person sitting in a chair. It is important that the leg be supported so that the knee and corresponding ankle are each bent to a 90-degree angle. The observer must kneel beside the lateral side of the left calf and place a loop of tape around the calf. The loop is moved up and down the calf to locate the largest circumference. The tape is pulled snugly around the calf but should not be so tight as to compress the tissues. This measurement is recorded to the nearest 0.1 cm, and successive measurements should agree within 0.5 cm.

Special considerations: Use the sitting position.

Variable code: CALF

5.13 Blood parameters

Blood pressure

128. Systolic 5 min rest

Variable code: SYST5

129. Systolic 10 min rest

Variable code: SYST10

Instruments: Mercury sphygmomanometer, preferably with “zero-muddler” device, or digital blood pressure recorder with a unit precision of 1 mm Hg.

Technique: Apply cuff to right arm. Inflate cuff. Determine systolic pressure by the point of appearance of the I sound (auscultatory) or as indicated on the digital panel (electronic).

Special considerations: A variety of cuff sizes should be available for appropriate selection for size of arm.

130. Diastolic 5 min rest

Variable code: DIAST5

131. Diastolic 10 min rest

Variable code: DIAST10

Instruments: Mercury sphygmomanometer, preferably with “zero-muddler” device, or digital blood pressure recorder with a unit precision of 1 mm Hg.

Technique: Apply cuff to right arm. Inflate cuff. Determine diastolic pressure by the point of transition to the IV sound (auscultatory) or as indicated on the digital panel (electronic).

Special considerations: A variety of cuff sizes should be available for appropriate selection for size of arm.

[132. Calculation: Hypertension]

A cut-off point must be specified before hypertension can be identified.
1 = No
2 = Yes

Variable code: OBSHYPER

Blood chemistry

133. Haemoglobin

Instruments: Finger-prick lances apparatus (e.g., auto-click) with disposal lancers; disposal container for lancets; spectrophotometer for rapid tests with capillary tubes and cuvettes (e.g., Compur Minilag, Munich, Germany, or Hemocue, Mission Viejo, CA, USA).

Technique: Cyanomethaemoglobin.

Special considerations: Use locally available method for microsample that has been well calibrated.

Variable code: HB

134. Haematocrit

Instruments: Finger-prick lances apparatus (e.g., auto-click) with disposal lancets; disposal container for lancets; microhaematocrit centrifuge. Technique: 5 minutes of centrifugation in a calibrated microhaematocrit centrifuge.

Variable code: HAEMATOC

5.14 Physical performance test (optional)

Physical performance tests have been developed in the United States. Some of the performances asked for are culturally biased towards the West and therefore may not accurately measure physical capability. For example, it would be senseless to ask an elderly person to write a sentence in communities where many elderly people are illiterate. Wheelchairs are uncommon in developing countries. They are often too expensive, and elderly people often live with their families and therefore do not need to rely on their own mobility. Therefore, the NHANES III (part I) and Reuben’s Physical Performance Test (PPT) (part II) have been modified to reduce these biases.

Part I. NHANES III

1. Health status screener (1 = no, 2 = yes)

a) _______ Apparent restriction
b) _______ Presently in wheelchair
c) _______ Recent surgery
d) _______ Injury
e) _______ Other health condition, specify _______

2. Repeated chair stand (1 = no, 2 = yes)

a) _______ Refused to perform chair stand (if yes, go to 4)
b) _______ Time to perform five stands (seconds)
c) _______ Number of stands if less than five
d) _______ Chair height (centimetres from floor to seat)

3. Independent stand (1 = no, 2 = yes)

Ask: “Are you able to stand by yourself without holding onto anything?”

a) _______ Unable to perform independent stand (if yes, go to 4)
b) _______ Refused to perform independent stand (if yes, go to 4)
c) _______ Number of seconds independent stand held

4. Measured walk (1 = no, 2 = yes, 8 = irrelevant)

a) _______ Has person been observed to walk without help from someone else? (if yes, go to c)
b) _______ Ask: “Are you able to walk around without holding on to another person? You may use a cane or walker.” (if no, go to part II)

Ask person to walk a 3-m distance.

c) _______ Refused to walk 3-m distance, trial A (if yes, go to part II)
d) _______ Number of seconds needed to complete walk, trial A
e) _______ Total number of steps, trial A

Ask person to walk a 3-m distance again

f) _______ Refused to walk 3-m distance, trial B (if yes, go to part II)
g) _______ Number of seconds needed to complete walk, trial B
h) _______ Total number of steps, trial B
i) Pain reported on walking (1 = no, 2 = yes)

Type of floor surface

j) _______ Linoleum, tile, wood, clay, or stamped earth
k) _______ Low-pile carpet
l) _______ Thick-pile carpet

Use of device

m) _______ Cane
n) _______ Walker
o) _______ Other device

Scores

Walking test: trial A + trial B _______ seconds
Total number of steps: trial A + trial B_______

Part II. Reuben’s physical performance test

Write time used (round to the nearest 0.5 second)- code afterwards

Task		Score
1. Simulate eating a bowl of beans with a spoon		___
___seconds £ 10 s=4
	10.5-15 s=3
	15.5-20 s =2
	> 20 s = 1
2. Lift a book above shoulder level		___
___seconds £ 2 s = 4
	2.5-4 s = 3
	4.5-6 s=2
	> 6 s=1
3. Pick up a coin from floor		___
___seconds £ 2 s = 4
	2.5-4 s = 3
	4.5-6 s = 2
	> 6 s = 1
	unable = 0
4. Turn 360 degrees		___
___seconds discontinuous steps = 0
	continuous steps = 2
	unsteady (grabs, staggers) = 0
	steady = 2
5. 50-foot walk		___
___seconds £ 15 s=4
	15.5-20 s = 3
	20.5-25 s = 2
	>25s=1
	unable = 0
Total score (sum of 1-5)		___

6. Examples of survey forms

6.1 Supervision form
6.2 Individual form

6.1 Supervision form

CRONOS - SUPERVISION FORM Page 1
1.) Individual number

2.) Survey team

01)
02)
03)
04)
05)
06)
07)
08)
09)
10)
11)
12)

3.) Supervisor

1)
2)
3)

4.) Date of survey

D/M/Y
(Day, month, year)

5.) Place of survey (village/suburb)

1)
2)
3)

6.) Age group

1)
2)

.........................................................................................
Date Signature of survey worker

CRONOS - SUPERVISION FORM
Page 2

1.) Individual number

2. Age

Year of birth____________________
(to be verified if records are available)

18. Pension

60. Would you say your health is better than, the same as, or not as good as that of most people your age?

1 = Not as good
2 = Same
3 = Better
8 = Don’t know
9 = No answer

61. During the past 12 months, how many times did you see a practitioner, doctor, c healer?

1 = 0-2 times
2 = 3-6 times
3 = >6 times
8 = Don’t know
9 = No answer

75. Are you receiving medical treatment?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

88. Do you drink alcohol?

1 = No
2 = Yes, at social events only
3 = Yes, at meals only
4 = Yes, outside of meals
8 = Don’t know
9 = No answer

107. Weight (0.1 kg)

108. Height (0.1 cm)

6.2 Individual form

CRONOS - SUPERVISION FORM
Page 1

1.) Individual number

1. Gender

1 = Male
2 = Female

2. Age (yr)

Year of birth__________________
(to be verified if records are available)

3. What is the place of your birth?

1 = Rural
2 = Urban
8 = Don’t know
9 = No answer

4. What is your religion?

Enter as many local religions as necessary by broad categories,
e.g., Protestant, Catholic, Muslim, Buddhist, etc.

1=
2=
3=
4=
5=
6=
7= Other
8= Don’t know
9= No answer

5. What is your marital status?

1 = Married or common-law union
2 = Widowed
3 = Single, never married
4 = Divorced or separated
8 = Don’t know
9 = No answer

CRONOS - SUPERVISION FORM
Page 2

1.) Individual number

What other people live with you in your household?

Name	Age	Gender	Relationship to you

6. Total number of household members

7. How many children do you have?

8. Number of children living in the household

9. How many grandchildren (children of your children) do you have?

10. Number of grandchildren living in the household

11. Number of non-relatives living in the household

14. How many days last week did you not sleep in this household?

15. How many months last year did you not live in this household?

16. How many years have you lived in this community?

17. How many years have you lived at this address?

CRONOS - SUPERVISION FORM
Page 3

1.) Individual number

From which of the following sources do you receive income and what amount do you receive monthly from each source?

Source of income	Amount per month
18. Pension
19. Active regular employment
20. Occasional employment
21. Charitable organization
22. Government social assistance
23. Family
24. Other

33. Apart from yourself, how many people do you support with your income?

34. What is your level of formal education?

1 = No school
2 = Up to 3 years
3 = 3 years to completion of primary school
4 = Some or completion of secondary school
5 = Some or completion of university or equivalent
6 = Some postgraduate education
8 = Don’t know
9 = No answer

35. Type of house

1 = Single-household building
2 = Multiple-household building
8 = Don’t know
9 = No answer

36. Major building material of wall of main entrance

1 = Straw or bamboo
2 = Wood
3 = Clay
4 = Stone
5 = Tiles or bricks
6 = Cement
8 = Don’t know
9 = No answer

37. Location of kitchen

1 = Inside the house
2 = Outside the house
8 = Don’t know
9 = No answer

38. What is the source of the energy that you use for cooking?

1 = Wood
2 = Petroleum
3 = Gas
4 = Electricity
7 = Other
8 = Don’t know
9 = No answer

CRONOS - SUPERVISION FORM
Page 4

1.) Individual number

39. Where do you store your food?

1 = No food stored
2 =Open storage
3 = Ventilated closed cupboard
4= Refrigerator
8 = Don’t know
9 =No answer

40. Where do you get your drinking water from?

01 = Own tap, inside the house
02 = Own tap, outside the house
03 = Public tap
04 = Water tank
05 = Private well
06 = Public well
07 = River or lake
08 = Spring
09 = Buy water
77 = Other
88 = Don’t know
99 = No answer

41. Luxury goods

1 = No item
2 = Watch
3 = Radio
4 = TV
5 = Two items
6 = All three items
7 = Other (specify)
8 = Don’t know
9 = No answer

Social behaviour and practices

42. In the last month, how many times have your children and/or grandchildren who do not live with you visited you?

43. In the last week, how many times have you had visits or social contacts with friends, neighbours, or relatives?

44. In the past month, how many times have you participated in religious activities?

45. In the past month, how many times have you attended social/cultural events (e.g., movie, theater, concert, wedding feast, market, community pub/cafe)?

46. Do you have a hobby (e.g., gardening, sewing, knitting, fishing, painting, playing a musical instrument)?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

If yes: What kind of hobby?......................................................

47. In the last month, how many times have you participated in the following caring activities: babysitting, caring for an elder, caring for an ill person, working on a community committee?

In the past week, have you engaged in any of the following activities?

48. Reading a book?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

CRONOS - SUPERVISION FORM
Page 5

1.) Individual number

49. Reading a newspaper or magazine?

1= No
2 = Yes
8= Don’t know
9 = No answer

50. Watching television?

1= No
2 = Yes
8= Don’t know
9 = No answer

51. Listening to radio or audio equipment?

1= No
2 = Yes
8= Don’t know
9 = No answer

52. Do you have someone with whom you can discuss problems?

1= No
2 = Yes
8= Don’t know
9 = No answer

53. Do you have someone to whom you feel close?

1= No
2 = Yes
8= Don’t know
9 = No answer

54. Do you feel lonely?

1= No
2 = Yes, sometimes
3 = Yes, often
8= Don’t know
9 = No answer

55. Do you have someone who helps you when you are sick?

1 = No
2 = Yes
8= Don’t know
9 = No answer

56. If you need help in an emergency, do you have someone you can call?

1 = No
2 = Yes
8= Don’t know
9 = No answer

57. Do you feel satisfied with the respect shown to you by the people around you?

1= No
2 = Yes
8= Don’t know
9 = No answer

Self-perceived health

58. Next I have some questions about your health. Generally speaking, how would you describe your health?

1 = Excellent
2 = Good
3 = Fair (neither poor nor good)
4 = Poor
5 = Extremely poor
8= Don’t know
9 = No answer

CRONOS - SUPERVISION FORM
Page 6

1.) Individual number

59. In general, how do you think your physical health affects your daily activities?

1 = Does not affect it at all. Everything is OK
2 = Practically does not affect it
3 = Affects it sometimes
4 = Affects it quite a Lot
5 = I am not able to work or to engage in daily activities
8 = Don’t know
9 = No answer

60. Would you say your health is better than, the same as, or not as good as that of most people your age?

1 = Better
2 = Same
3 = Not as good
8 = Don’t know
9 = No answer

Illness and illness impact

61. During the post 12 months, how many times did you see a practitioner, doctor, or healer?

1 = 0-2 times
2 = 3-6 times
3 = >6 times
8 = Don’t know
9 = No answer

62. What was the reason for visiting a practitioner, doctor, or healer?

1 = Mainly routine visit
2 = Mainly treatment
3 = Both
8 = Don’t know
9 = No answer

63. How many days did you spend overnight in a hospital during the post 12 months?

1 = None
2 = 1-21 days
3= >21 days
8 = Don’t know
9 = No answer

64. How many days did you spend ill in bed at home during the post 12 months?

1 = 0-3 days
2 = 4-14 days
3 = >14 days
8 = Don’t know
9 = No answer

During the last month, have you been bothered by any of the following?

65. Cough?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

CRONOS - INDIVIDUAL FORM
Page 7

1.) Individual number

66. Diarrhoea?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

67. Fever?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

68. Diabetes?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

69. Hypertension?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

70. Arthritis or arthrosis?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

71. Osteoporosis?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

72. Cataract?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

73. Urinary tract problems?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

74. Other?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

75. Are you receiving medical treatment?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

CRONOS - INDIVIDUAL FORM
Page 8

1.) Individual number

Impairments

76. Do you still have your own teeth?

1 = No
2 = Yes, but many are lost
3 = Yes, most of them
8 = Don’t know
9 = No answer

77. Do you wear dentures?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

78. Do you have problems with chewing?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

79. Is your eyesight good enough both to see things clearly at a distance and to read close up?

1 = Without eyeglasses
2 = With some type of visual aid
3 = Partially blind
4 = Blind
8 = Don’t know
9 = No answer

80. How good is your hearing?

This question is related to your hearing capacity with no hearing aid

1 = No problem
2 = Can hear only if spoken to loudly
3 = Nearly deaf
8 = Don’t know
9 = No answer

81. How difficult is it for you to walk about a kilometre?

1 = Not difficult
2 = A little difficult
3 = Somewhat difficult
4 = Very difficult but possible
5 = Cannot do it
8 = Don’t know
9 = No answer

82. How many falls have you had in the past year?

83. How many times did you go out of your house during the last 24 hours?

84. Do you use a cane?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

85. Do you have problems with a stiff back when you get up in the morning?

1 = No, never
2 = Yes, sometimes
3 = Yes, very often
4 = Yes, always
8 = Don’t know
9 = No answer

CRONOS - INDIVIDUAL FORM
Page 9

1.) Individual number

Risk factors

86. Do you smoke?

1 = No
2 = Yes, cigarettes
3 = Yes, cigars
4 = Yes, pipes
8 = Don’t know
9 = No answer

87. Have you smoked in the past?

1 = No
2 = Yes, cigarettes
3 = Yes, cigars
4 = Yes, pipes
8 = Don’t know
9 = No answer

88. Do you drink alcohol?

1 = No
2 = Yes, at social events only
3 = Yes, at meals only
4 = Yes, outside of meals
8 = Don’t know
9 = No answer

89. With whom do you drink alcohol?

1 = Alone
2 = Only with friends
8 = Don’t know
9 = No answer

90. Have you lost more than 3 kg during the last month?

1 = No
2 = Yes
8 = Don’t know
9 = No answer

Cognitive functioning

What is the date (day, month, and year), day of the week, and season today? ______

Each correct response equals 1 point (in total 5 points)

What is the location of the interview site? ______

Correct location equals 2 points

Show the subject 10 standard objects for 1 minute, then hide them from the subject’s view. The objects are pencil, comb, ring, matches, watch, spoon, key, button, coin, and eyeglasses.

Then ask the subject to list the months of the year, forwards and then backwards (score twice). ______

0 = Impossible
1 = With some difficulty
2 = Normal

Then ask the subject to recall the objects that were shown. _______

Each correct object recalled equals 1 point (in total 10 points)

91. Total score of memory test

CRONOS - INDIVIDUAL FORM
Page 10

1.) Individual number

Anthropometric measurements

107. Weight (0.1 kg)

108. Height (0.1 cm)

109. Arm span (0.1 cm)

112. Mid-upper-arm circumference (0.1 cm)

113. Triceps skinfold (2 mm)

114. Biceps skinfold (2 mm)

115. Sub scapular skinfold (2 mm)

116. Suprailiac skinfold (2 mm)

124. Waist circumference (0.1 cm) (at level halfway between umbilicus and right iliac crest)

125. Hip circumference (0.1 cm) (largest circumference below umbilicus)

126. Knee height (0.1 cm)

127. Calf circumference (0.1 cm)

Blood pressure

128. Systolic 5 min rest

129. Systolic 10 min rest

130. Diastolic 5 min rest

131. Diastolic 10 min rest

Blood chemistry

133. Haemoglobin (g/L)

134. Haematocrit (%)

7. List of variable codes

5.10 Food behaviour and practices, 5.11 Food security, and 5.14 Physical performance test are not included.

ACTIVITY	How physical health affects daily life activities
AGE	Age (yr)
ALCOHOL	Drink alcohol
ALCOSOC	With whom drinking alcohol
ANIMPRO	Animal protein (g/day)
ARMSPAN	Arm span (cm)
ARTHRIT	Bothered by arthritis or arthrosis last month
BACK	Problems with a stiff back in the morning
BATHING	How difficult to bathe or shower without help
BICEPS	Biceps skinfold (mm)
BMA	Body mass index calculated through arm span (kg/m2)
BMI	Body mass index (kg/m2)
BODYDENS	Body density
BOOK	Read a book last week
CALCIUM	Calcium (mg/day)
CALF	Calf circumference (cm)
CANE	Using a cane
CARBOHYD	Carbohydrate (g/day)
CAROTENE	ß-Carotene (µa/day)
CARRY	How difficult to lift or carry weights over 5 kg
CATARACT	Bothered by cataract last month
CAUSEDOC	Reason for visiting practitioner, doctor, or healer
CHEWING	Problems with chewing
CHILDREN	Number of children
CHLDHOUS	Number of children living in the household
CHOLESTE	Cholesterol (mg/day)
CLIMBST	How difficult to climb one flight of stairs without resting
CLOSE	Have someone to whom subject feels close
COMBING	How difficult to comb hair without help
COUGH	Bothered by cough last month
CROUCH	How difficult to stoop, kneel, or crouch
DENTURES	Wear dentures
DIABETES	Bothered by diabetes last month
DIARRHOE	Bothered by diarrhoea last month
DIAST5	Diastolic blood pressure after 5 min rest
DIAST10	Diastolic blood pressure after 10 min rest
DISCUSS	Have someone to discuss problems with
DRESSING	How difficult to dress without help
EATING	How difficult to eat without help
EDUCATIO	Level of formal education
EMERGENC	Have someone to call when need help in emergency
ENERGY	Source of energy for cooking
EVENT	Number of times attended social or cultural events last month
FALLS	Number of falls last year
FAT	Fat (g/day)
FEVER	Bothered by fever last month
FIBRE	Dietary fibre (10-1 g/day)
FOLIC	Folic acid (µa/day)
GETBED	How difficult to get in and out of bed without help
GETUP	How difficult to get up from chair after sitting for long periods
GCHLDHOU	Number of grandchildren living in the household
GENDER	Gender of the interviewed person
GRDCHLD	Number of grandchildren
HB	Haemoglobin (g/L)
HAEMATOC	Haematocrit (%)
HEALTHRA	Description of own health
HEAPROBL	Bothered by other health problems last month
HEARING	How is hearing without any hearing aid
HEIGHT	Height (cm)
HIP	Hip circumference (cm)
HOBBY	Have a hobby
HOUSEMEM	Total number of household members
HYPERTEN	Bothered by hypertension last month
INCBENEF	Monthly income from charitable organization(s)
INCEMPOC	Monthly income from occasional employment(s)
INCEMREG	Monthly income from regular employment(s)
INCFAMIL	Monthly income from family
INCOTHER	Monthly income from other sources
INCPENS	Monthly income from pension(s)
INCSOCIA	Monthly income from government social assistance
INCTOTAL	Total income
IRON	Iron (10-1 mg/day)
KCAL	Energy (kcal/day)
KITCHEN	Location of kitchen
KNEE	Knee height (cm)
LBODYMAS	Lean body mass (kg)
LONELY	Feel lonely
LUXUR	Luxury goods
MUAC	Mid-upper-arm circumference (cm)
MARSTAT	Marital status
MEMORY	Total memory score of cognitive functioning
MUAFA	Mid-upper-arm fat area (mm2)
MUAMA	Mid-upper-arm muscle area (mm2)
NEWSPAP	Read a newspaper last week
NIACIN	Niacin (10-1 mg/day)
NORELHOU	Number of non-relatives living in the household
OBSHYPER	Observed hypertension
OSTEOPOR	Bothered by osteoporosis last month
OUTGOIN	Number of times out of house last 24 hours
PBODYFAT	Percentage of body fat
PHOSPHOR	Phosphorus (mg/day)
PINCBENF	Percentage of income from charitable organization(s)
PINCFAM	Percentage of income from family
PINCOC	Percentage of income from occasional employment(s)
PINCOTH	Percentage of income from other sources
PINCPENS	Percentage of income from pension(s)
PINCREG	Percentage of income from regular employment(s)
PINCSOCA	Percentage of income from government social assistance
POLYUNFA	Polyunsaturated fatty acids (10-1 g/day)
PLACE	Place of birth (urban or rural)
PLANTPRO	Plant protein (g/day)
RADIO	Listened to radio or audio equipment last week
RATEOTHE	Own health in relation to people of same age
RELACTIV	Number of times participated in religious activities last month
RELHOU	Number of relatives living in the household
RELIGION	Religion of the interviewed person
RELNONR	Proportion of relatives to non-related household members
RESPECT	Feel satisfied with respect shown by people around
RETINOL	Retinol (µa/day)
ROOMWALK	How difficult to walk across the room
SATURFA	Saturated fatty acids (10-1 g/day)
SEEING	Eyesight good enough to read and see things at a distance
SICK	Have someone who helps when sick
SITTING	How difficult to sit for 2 hours
SLEEPMTH	Number of months last year did not live in this household
SLEEPWK	Number of days last week did not sleep in this household
SMOKING	Smoke now
SMOKPAST	Smoked in the past
SOCONTAC	Number of visits or social contacts (with a without meals) with friends, neighbours, a relatives last week
STORAGE	Food storage
SUBSCAP	Subscapular skinfold (mm)
SUPPINCO	How many persons do you support with your income
SUPRAIL	Suprailiac skinfold (mm)
SYST5	Systolic blood pressure after 5 min rest
SYST10	Systolic blood pressure after 10 min rest
TBODYFAT	Total body fat (kg)
TEETH	Has own teeth
TIMEHOSP	Number of days last year spent ill in hospital
TIMEILL	Number of days last year spent ill in bed
TOTALFA	Total fatty acids (10-1 mg/day)
TOTALPRO	Total protein (g/day)
TOTSKINF	Total skinfolds (mm)
TREATMEN	Is on a treatment
TRICEPS	Triceps skinfold (mm)
TV	Watched TV last week
TYPHOUSE	One or more families in the building
URINARY	Bothered by urinary tract problems last month
USETOIL	How difficult to use the toilet without help
VISDOC	Number of times seen a practitioner, doctor, or healer last year
VISITS	Number of visits from children or grandchildren who do not live in the household (with or without meals) last month
VITA	Vitamin A (RE/day)
VITB1	Vitamin B1 (10-2 mg/day)
VITB2	Vitamin B2 (10-2 mg/day)
VITB6	Vitamin B6 (10-2 mg/day)
VITB12	Vitamin B12 (10-2 µg/day)
VITC	Vitamin C (mg/day)
VOLUNT	Number of times participated in caring activities last month
WAIST	Waist circumference (cm)
WALKING	How difficult to walk about 1 km e
WALL	Major building material of wall where main entrance is located
WATER	Source of drinking water
WEIGHT	Body weight (kg)
WTLOSS	Lost more than 3 kg last month
YEARADDR	Number of years lived at this address
YEARCOMM	Number of years lived in this community
ZINC	Zinc (10-2 mg/day)

8. Collection of qualitative data (RAP)

The quantitative studies described, including those that include formal socio-economic and behavioural questionnaires, report their results in numerical terms. For quantitative information, e.g., socioeconomic status, reproductive histories, and nutrient intakes, formal questionnaires and data collection forms are required. Qualitative studies can contribute to designing them more effectively. In addition, understanding the human dimension of descriptive findings requires supplementation with qualitative research whose findings are mainly verbal. The methodologies for the latter are modifications of those used by anthropologists. To best understand the nutrition and health issues affecting the elderly, both approaches are desirable. Anthropological methods permit detailed recording of the sociocultural context in which health-seeking behaviour occurs, in order to better understand and interpret the behaviour. When they are focused on a limited age group and specific issue they become “rapid assessment procedures” (RAP) [6, 7]. They differ greatly from traditional ethnographic studies but have in common with them the following techniques:

Informal interview

Somewhat open-ended questions are asked on certain topics. The researcher follows a general outline but may incorporate additional subjects as appropriate. The responses may be noted but are not recorded in detail at the time. They are written up later.

Conversation

Important data can also be obtained through informal individual or small-group conversation. Some people are more at ease in an informal setting and talk more freely.

Observation

Careful observation of events and behaviour provides valuable non-verbal clues as to what is actually occurring.

Participant observation

The researcher participates in and observes the sociocultural context of a household or community, and thus gains important insights into everyday life.

Focus groups

Informal interviews with small groups of people have often been used by anthropologists. More recently, professionals in fields such as market research have adapted and refined the technique. Focus groups can help to check information with a large number of people and to obtain reactions to intended innovations (e.g., health educational materials, the location of a clinic, the introduction of community health workers) [8]. They are not successful in eliciting information considered private or concerning behaviour that might be subject to disapproval, since people usually are reluctant to share such information in a group setting.

Focus groups have a number of uses in the study of nutrition- and health-related attitudes and behaviour of the elderly, including formulation of questions for the formal interview questionnaire; supplementation of the information on community knowledge, beliefs, attitudes, and perceptions about health and health resources; development of research hypotheses for additional studies; and development of vocabularies and approaches for nutrition and health education programmes.

Field notes

Take brief notes on the observations and interviews conducted. Time must be set aside each day specifically for expanding and editing field notes. The key words in the notes will be reminders of many phrases and ideas. While expanding on the notes, add comments and impressions in parentheses. Consider carefully the advantages and disadvantages of tape recorders, remembering that it will be necessary to interpret or transcribe the recordings, which is very time-consuming. Even with tape recordings, continue to take brief notes. Never use a tape recorder without permission from the person(s) interviewed.

Techniques for interviews and conversations

· Respect the confidentiality of the interview, and be very careful not to comment about persons interviewed (or their children) to the neighbours.

· Do not influence or bias responses.

· Do not influence a question by introducing your attitudes and behaviour.

· Try to work in as much depth as possible. Avoid being satisfied with superficial answers or moving too quickly from one topic to another.

· When you want to be sure that you have heard clearly what the informant said or that the informant really intended to say what you heard, you can avoid the necessity of repeating the question by reflecting back the response.

· Be patient. It is not necessary to be asking questions and talking constantly. Create pauses to allow time for you and the informant to think. That way, the informant is likely to feel more comfortable and may elaborate on a point.

· Do not interrupt an informant’s work. The informant is doing a favour by participating in the research.

· Always note the time the interview began and ended, who was present, who was in the house during the interview, and the name(s) of the informants. At the start and during the interview, estimate how much time is available (for the respondent) and note signs of impatience or need to finish.

· Do not make false promises or create erroneous perceptions in order to obtain the cooperation of the family selected for interview.

· Always be truthful about the purpose of the interviews, the objectives of the study, and the reasons for the researchers’ presence in the community. Explain the project in terms the informant will understand.

· During the interview use a moderate, friendly tone of voice; be natural. Do not pose the questions in an imperative manner, as this approach may inhibit or disturb the informant. Use local vocabulary and expressions and observe local customs.

In the context of ethnographic work, to observe means to examine with all of the senses an object, an individual, a group of people, an event, etc., with the objective of describing it. In a study of nutrition and health-related behaviour, the researcher will observe the community, the health resources, and the selected households. The meaning of many of the behaviours observed will vary with the culture and must be interpreted appropriately.

References

1. de Groot LCPGM, van Staveren WA. Nutrition and the elderly. A European collaborative study in cooperation with the World Health Organization Special Programme for Research on Aging (WHO-SPRA) and the International Union of Nutritional Sciences (IONS), Committee on Geriatric Nutrition. Manual of Operations. Euronut Report 11. Wageningen, Netherlands: EURONUT, 1988.

2. WHO Expert Committee on Physical Status. Physical status: the use and interpretation of anthropometry: report of a WHO expert committee (WHO Technical Report Series 854) Geneva: World Health Organization, 1995.

3. Durnin JV, Womersley J. Body fat assessed from total body density and its estimation from skinfold thickness. Measurements on 481 men and women aged from 16 to 72 years. Br J Nutr 1974;32:77-97.

4. Siri WE. Body composition from fluid spaces and density. In: Analysis of methods and techniques for measuring body composition. Washington, DC: National Academy of Sciences, National Research Council, 1961:22344.

5. Gibson RS. Anthropometric assessment in growth. In: Principles of nutritional assessment. New York, Oxford: Oxford University Press, 1990:163-86.

6. Scrimshaw SCM, Hurtado E. Rapid assessment procedures for nutrition and primary health care. Anthropological approaches to improving programme effectiveness. Los Angeles, Calif, USA: UCLA Latin American Center, 1987.

7. Scrimshaw NS, Gleason OR. Rapid assessment procedures. Qualitative methodologies for planning and evaluation of health related programme. Boston, Mass, USA: International Nutrition Foundation for Developing Countries, 1992.

8. Dawson S. Manderson L, Tallo VL. A manual for the use of focus groups. Boston, Mass, USA: International Nutrition Foundation for Developing Countries, 1993.