IUNS - International Union of Nutrition Sciences

CRONOS

CRONOS (KRONOS) is the ancient Greek God of time, from which we get the word "chronology." Chronology - or the passage of time - is one of the two factors involved in human ageing; one only reaches advanced age to the extent that he or she evades mortality from accidents, violent aggression and acute infectious diseases. The other factor is the progressive changes in tissue structure and in the function of the body known as "senescence." The longer one lives, the more senescent processes effect changes on one's body.

CRONOS also has come to mean the acronym for the Cross-Cultural Research on Nutrition of Older Subjects, a research initiative of the International Union of Nutritional Sciences (IUNS). It responds to two important demographic currents in low-income nations with profound implications for health: urbanization and increased longevity. It was conceived and designed within a process of pilot testing and review within the Committee II/3 on Urbanization and Nutrition of IUNS. Pilot studies conducted in five Asian countries (China, Indonesia, Malaysia, Philippines, Thailand) and three countries in Latin America (Brazil, Guatemala, Mexico) tested the procedures of the original draft protocol and their cost, complexity and acceptance by the populations of interest. This was called the "reconnaissance" phase. The protocol was subsequently redrafted to provide an improved field instrument.

The third annual issue of the Food And Nutrition Bulletin in September 1997, was entitled "Development of a Protocol to Study the Interactions of Nutrition, Ageing, and Urbanization in Developing Countries." The volume summarizes experiences in research on older persons in developing societies including the EURONUT-SENECA 12-nation study in Europe and the IUNS-Food Habits in Later Life: A cross-cultural approach in six nations (Australia, China, Greece, Japan, Philippines, Sweden). From the point of view of the new, the CRONOS multicenter study has two components. The first is a narrative history of the reconnaissance phase involving the eight-site pilot study. It covers lessons learned and corrections applied. The second component was the presentation of a revised protocol, one which incorporates all of the 134 discreet variables, listed into a 36-page protocol with explicit detail as to how to collect, code and interpret the data. This is authored by Dr. Rainer Gross. In summary, the protocol calls for enrolment of 600 persons equally divided between men and women. The sample is also equally divided between young adults (aged 35 to 45 years) and older adults (aged 60-75 years). Three age-balanced and sex-balanced - but geographically and socioeconomically distinct - populations of healthy, free-living men and women of 200 subjects each are to be enrolled in each of the three strata. The strata are: rural agrarians; urban low-income; urban elite.

Two committees of the IUNS are currently promoting and overseeing the recruitment and execution of CRONOS-protocol studies in developing and transitional societies. The original committee, that on Urbanization and Nutrition (Committee II/3) is involved with the phases of data-collection in the field and data inventory. The IUNS Committee II/4 on Ageing and Nutrition has joined the effort at the level of data analysis and coordination of the entire data-sets from all eventual participating sites.

We hope that access to participation in CRONOS should be of interest to the readers of the SCN News. It has been the experience in Southeast Asia in Indonesia, the Philippines, and Vietnam, that the CRONOS protocol provides an excellent vehicle for creating Masters degree research proposals. We recommend that research groups working in low-income countries contact us concerning the joining of a concerted consortium to coordinate diverse studies. Please contact the authors of this note.

Reference: Gross R, Solomons NW, Hautvast JGAJ (eds) (1997) Development of a protocol to study the interactions of nutrition, ageing, and urbanization in developing countries Food and Nutrition Bulletin 18: (Supplement) p 305.
Noel W Solomons, MD, Chair, IUNS Committee II/3 on Urbanization and Nutrition, email: cessiam@tikal.net.gt; Rainer Gross, PhD, Vice-Chair, Committee II/3 on Urbanization and Nutrition, email: urgross@ibm.com

Committee II/4 Nutrition and Ageing
Food Habits in Later Life (FHILL) Program Report 1999

As the food supply changes and there is considerable pressure on young people to conform to a global fast-food culture, the older members of society represent, in many cases, the principal repository of the food knowledge and skills. So, on the one hand, they are an invaluable food and health resource for their community but, on the other hand, a growing body of evidence shows that many health problems amongst the aged are diet related and nutritionally dependent. To this end, the need for descriptive studies of food and health among the aged was identified more than a decade ago. It not only aimed to document traditional food habits and beliefs but also to predict health and survival outcomes. This information is used for intervention programs and in the development of culturally-sensitive dietary guidelines, known as Food-based Dietary Guidelines or FBDGs.^1-3

Between 1988-1993 the IUNS Committee "Nutrition and Ageing" established the international "Food Habits In Later Life" (FHILL) Program,^4,5 which was coupled to a socio-anthropological methodology known as RAP "Rapid Assessment Procedures".⁶RAP encouraged the expression of the food culture of the study communities and, within the framework of food habits inquiries, allowed for modification of the survey instrument. RAP was used to obtain information on food and health beliefs and to examine other factors possibly affecting food intake.^7,8,9 An FHILL goal has been to provide tools for communities to establish their own assessment procedures.

BOX 1
Initial Geographic and Ethnic Surveys (FHILL Phase I-Bibliography)
Australia (Greek & Anglo-Celt)
Kouris-Blazos A, Wahlqvist ML, Trichopoulou A, Polychronopoulos E, Trichopoulos D (1996) Health & Nutritional Status of elderly Greek migrants to Melbourne, Australia Ageing 25:177-189.
Kouris-Blazos A, Wahlqvist M, Wattanapenpaiboon N (1999) 'Morbidity mortality paradox' of Greek-born Australians: possible dietary contributors Aust J Nutr Diet 56(2):97-107.
Wahlqvist ML, Kouris-Blazos A, Trichopoulou A & Polychronopoulos E (1991) The Wisdom of the Greek Cuisine and Way of Life: Comparison of the Food and Health Beliefs of Elderly Greeks in Greece and Australia Age & Nutr 2(3):163-173.
Wahlqvist ML, Kouris-Blazos A (1996) Olive oil - Nutrition and Biological value. In: World Encyclopaedia of the Olive. Int Olive Oil Council.
Wahlqvist ML, Kouris-Blazos A, Hsu-Hage BH-H (1997) Ageing, Food Culture & Health SE Asian J Trop Med Pub Health 28(2): 100-112.
Wahlqvist M, Kouris-Blazos A, Wattanapenpaiboon N (1999) The significance of eating patterns: an elderly Greek case study Appetite 32:23-32.
China
Side X, Mingtang S, Shuquan Z, Zhaomei M, Yinzhi X, Yujun L, Jun W, Kui J (1991) Anthropometric and dietary survey of elderly Chinese Br J Nutr 66(3):355-62.
Greece
Trichopoulou A, Kouris-Blazos A, Vassilakou T, Gnardellis Ch, Polychronopoulos E, Venizelos M, Lagiou P, Wahlqvist ML & Trichopoulos D (1995) The diet and survival of elderly Greeks: A link to the past Am J Clin Nutr 61(6S):1346-1350.
Guatemala
Hermann D, Solomons NW, Mendoza I, Gonzales C, Quershi AK (1998) Anthropometric measures and indices of body composition among Guatemalan elderly: relation with self-rated health and activities of daily living and comparison with other sites in the "Food Habits in Later Life" multicentre study Asia Pac J Clin Nutr 7:55-64.
Hermann DR, Solomons NW, Mendoza I, Quershi A (in press) Self-rated health and its relationship to functional status and well-being of elderly Guatemalan subjects The J Nutr, Health Ageing.
Indonesia
Purba M, Lukito W, Wahlqvist ML, Kouris-Blazos A, Hadisaputro S, Lestiani L, Wattanapenpaiboon N, Kamso S (in press) Food intake and eating patterns of Indonesian elderly before the economic crisis in Asia Pac J Clin Nutr.
Japan
Darmadi I,: Wahlqvist ML, Horie Y, Kouris-Blazos, Wattanapenpaiboon N, Sugase K, Horie K (1998) Food predictors of later life status in Japanese Elderly. Proc of Australian Clinical Nutrition Society, Brisbane, Australia, Nov 1998.
Horie K, Sugase K, Horie Y (1997) Intakes of food and nutrient and health relationship in the Japanese elderly by gender and by living arrangements. Proc 16th International Congress of Nutrition, Montreal, Canada, p59.
South Africa
Charlton KE, Labadarios D, Lombard CJ, Louw ME (1996) Vitamin D status of older South Africans S Afr Med J 86:1406-1410.
Charlton KE, Bunn AE, Lombard CJ, Marais AD (1996) Body composition assessment of older coloured South Africans: no association between obesity and conventional cardiovascular risk factors S Afr J Food Sci Nut 8:123-130.
Charlton KE, Fourie JM, Steyn K, Lombard CJ (1997) Prevalence of hypertension among the elderly coloured population of the Cape Peninsula. S Afr Med J 87 (Cardiovascular suppl 2): C75-C80.
Charlton KE, Levitt NS, Lombard CJ (1997) The prevalence of diabetes mellitus and associated risk factors in elderly coloured South Africans S Afr Med J 87: 364-367.
Charlton KE, Kruger M, Labadarios D, Wolmarans P, Aronson I (1997) Iron, folate and vitamin B12 status of an elderly coloured population in Cape Peninsula Eur J Clin Nutr 51: 424-30.
Charlton KE, Ferreira M (1997) Food and health beliefs of an urban sample of coloured older persons. S Afr J Food Sci Nutr 9:9-13.
Charlton KE, Wotmarans P, Lombard CJ (1998) Evidence of nutrient dilution with a high sugar intake in older South Africans J Hum Nutr Diet 11:331-343.
Charlton KE, Wolmarans P, Kruger M, Labadarios D, Marais AD, Lombard CJ (1998) Micronutrient status of older coloured South Africans S Afr Med J 88(5):653-658.
Sweden
Augustsson O, Eriksson BG, Rosenhall U, Rothenberg E, Warne B, Steen B (1994) The Johanneberg study - a sociomedical survey in an urban elderly population. I. General presentation of the study including an analysis of non-response and identification of risk groups Scan J Soc Med 22:283-292.
Rothenberg E, Bosaeus I, Steen B (1993) Intake of energy, nutrients and food items in an urban elderly population Aging Clin Exp Res 5(2):105-116.
Rothenberg E, Bosaeus I, Steen B (1994) Food habits, food beliefs and socio-economic factors in an elderly population.

The FHILL study investigated the food habits, health, lifestyle and body composition^4,10-12 of 2013 older people around the world - including Greece, Sweden, Australia (Anglo-Celts and Greek-born), South Africa, China, Japan, Guatemala, the Philippines and Indonesia (see Box 1). Moreover, potential markers of 'youthful' ageing are also being investigated with cutaneous microtopography (skin wrinkling in sun unexposed sites) and dehydroepiandrosterone (DHEA) with the purpose of identifying nutritional and non-nutritional factors associated with a younger biological age for a given chronological age.^13,14 The major finding from Phase I (comparative descriptive study) highlighted that it is possible to achieve comparable health in old age in different cultural settings with widely differing food habits.^15-19 At the same time, there is the opportunity for nutritionally related health improvement within and between cultural settings.

Phase II (mortality follow-up) of the FHILL study commenced in 1993 and aimed to examine prospectively the effect of food patterns, social and lifestyle variables on survival in five-to-six year interval mortality follow-up studies of the older cohorts (see Box 2). From the analyses of mortality data from the elderly Greeks in rural Greece, and Greek-born and Anglo-Celtic Australian cohorts, has come an understanding that food patterns, even as late as 70 years and onwards, remain predictive of survival and are also associated with function and morbidity. In particular, the retention of a varied, but traditional food pattern (e.g. high in plant food, low in animal food) appears to be important for longevity and has implications for the development of FBDGs. Also, the retention of traditional eating patterns (e.g. early breakfast, main meal consumed in the middle of the day as opposed to the evening) may also protect against obesity and elevated fasting blood glucose. Data from a two-year follow-up of the South African cohort found that in men, a low baseline BMI and raised serum ferritin levels were associated with increased mortality, whereas in women, being diabetic and having a waist/hip ratio in the upper tertile were associated with mortality. Information of this type may be useful to screen the general health risk of older adults at primary care level and provide indications for social or medical intervention.

Box 2: Mortality Follow-up (FHILL Phase II Bibliography)
Charlton KE, Lambert EV et al. (1997) Physical activity, change in blood pressure and predictors of mortality in older South Africans-a 2-year follow-up study S Afr Med J 87:1124-1130.
Darmadi I, Wahlqvist ML, Horie Y, Horie K, Sugase K, Kouris-Blazos A, Wattanapenpaiboon N (1998) Body mass index as a predictor of all-cause mortality in a Japanese elderly population. Proc of Nutrition Society of Australia 22:184.
Horie K, Sugase K, Horie Y (1998) Follow-up studies on the relationship between mortality and food and nutrient intake by gender in elderly Japanese Proc 2nd Asian Congress of Dietetics Seoul, Korea, August 1998, p 280.
Kouris-Blazos A, Wahlqvist ML (1998) The traditional Greek food pattern and overall survival of elderly people. Aust J Nutr Diet 4(S):20-23.
Kouris-Blazos A, Gnardellis C, Wahlqvist ML, Trichopoulos D, Lukito W, Trichopoulou A (in press) Are the advantages of the Mediterranean diet transferable to other populations? A cohort study in Melbourne, Australia.
Kouris-Blazos A, Wattanapenpaiboon N, Mylvaganam A, Wahlqvist ML, Trichopoulou A (in press) Olive oil and longevity.
Trichopoulou A, Kouris-Blazos A, Wahlqvist ML, Gnardellis CH, Lagiou P, Polychronopoulos E, Vassilakou T, Lipworth L, Trichopoulos D (1995) Diet and overall survival in elderly people Br Med J 311 (7018):1457-1460.

Mortality follow-up studies of older Japanese and Swedes have also been completed and will soon be analysed, along with the Greek and Anglo-Celtic cohorts. The mortality follow-up of the Guatemalan cohort is planned. The value of the cross-cultural survival data not only relates to food patterns, but will allow interpretation of the influence of social activity, social support, sleep patterns, physical activity, body composition and other biological markers (e.g. immune function, DHEA and iron stores) on survival. WHO and FAO have now applied the FBDG framework to the nutritional and health needs of the aged.³ The results from the FHILL project should provide valuable information for their development.

References

1.

WHO/FAO (1996) Preparation and use of food-based dietary guidelines. Report of a joint FAO/WHO consultation Nicosia, Cyprus. WHO, Geneva.

2.

Wahlqvist ML, Worsley T, Harvey P, Crotty P, Kouris-Blazos A (in press) Food-based Dietary Guidelines for the Western Pacific. The shift from nutrients & food groups to food availability, traditional cuisines & modern foods in relation to emergent chronic non-communicable diseases. WHO, Geneva.

3.

Wahlqvist ML, Kouris-Blazos A, Savige G (in press) Food Based Dietary Guidelines for older adults: healthy ageing and prevention of chronic non-communicable diseases. In: Nutritional Guidelines for the Elderly. WHO, Geneva.

4.

Wahlqvist ML, Kouris A, Davies L & Scrimshaw N (1988) Development of a survey instrument for the assessment of food habits and health in later life. In: Dietetics in the 90's. Role of the Dietitian/Nutritionist, ed M Moyal. J Libbey Eurotext, Paris.

5.

Wahlqvist ML, Kouris A (1990) Trans-cultural aspects of nutrition in old age Age Ageing 19(s):43-52.

6.

Scrimshaw N, Kouris-Blazos A, Taub B, Wahlqvist ML, Davies L (1995) Rapid Assessment Procedures for use in the elderly. In: Wahlqvist et al, (eds). Cross-cultural study of food habits and health status in later life: Description of elderly communities and lessons learnt. Asia Pacific J Clin Nutr, Melbourne.

7.

Wahlqvist ML, Kouris A, Gracey M, Sullivan H (1991) An anthropological approach for the study of food & health in an indigenous population Food & Nutrition Bulletin 13(2):145-149.

8.

Kouris A, Wahlqvist ML, Trichopoulou A, Polychronopoulos E (1991) Use of Combined Methodologies in Assessing Food Beliefs and Habits of Elderly Greeks in Greece. Food Nutr Bull 13(2):139-144.

9.

Rothenberg E, Bosaeus I, Steen B (1994) Food habits, food beliefs and socio-economic factors in an elderly population. Scan J Nutr/Naringsforskning 38:159-65.

10.

Wahlqvist ML, Hsu-Hage BH-H, Kouris-Blazos A, Lukito W, eds. (1995) Food Habits in Later Life: A Cross-Cultural Study. Melbourne: Asia Pac J Clin Nut & United Nations University Press (CD Rom).

11.

Rothenberg E (1994) Validation of the food frequency questionnaire with the 4-day record method and analysis of 24-hour urinary nitrogen. Eur J Clin Nutr 48(10):725-35.

12.

Kouris-Blazos A, Wahlqvist ML, Trichopoulou A, Polychronopoulos E, Trichopoulos D (1996) Health & Nutritional Status of elderly Greek migrants to Melbourne, Australia Ageing 25:177-189.

13.

Purba M, Kouris-Blazos A, Wattanapenpaiboon N, Wahlqvist ML (1988) Cutaneous microtopography, well-being, functional and health status among elderly Greeks and Anglo-Celtic Australians Proc Nutr Soc Aust 22:121.

14.

Purba M. Kouris-Blazos A, Wattanapenpaiboon N, Wahlqvist ML, Steen B, et al. (in preparation) Can skin wrinkling in a sun unexposed site be used as a marker of biological age.

15.

Wahlqvist ML, Kouris-Blazos A, Hage B, Lo CS, Gracey M, Sullivan H, Trichopoulou A, Polychronopoulos E, Sun MT, Side X, Steen B, Rothenberg E (1992) Food Habits in Later Life: A Cross-cultural Study. Preliminary Results from communities in Australia, Greece, China & Sweden Age Nutrition 3:151 -154.

16.

Wahlqvist ML, Lukito W, Hsu-Hage BH-H (1994) Nutrition and Ageing in Development In: MR Biswas, M Gabr (eds). Nutrition in the 90s - Policy Issues. Oxford University Press, Oxford p84-108.

17.

Wahlqvist ML, Hsu-Hage B, Kouris-Blazos A, Lukito W (1994) Food Habits in Later Life: A Cross-cultural Study. In: Nutrition in a sustainable environment, ed M. Wahlqvist et al. Proc of the XVth International Congress of Nutrition. Smith-Gordon, UK p345-353.

18.

Wahlqvist ML, Hsu-Hage B, Kouris-Blazos A, Lukito W (1995) Food Habits in Later Life-An Overview of Key Findings Asia Pac J Clin Nutr 4(2): 1 -11.

19.

Wahlqvist ML, Kouris-Blazos A, Lukito W, Hsu-Hage B (1994) Water soluble vitamin intakes in the elderly: Cross-cultural findings in the IUNS study. In: Rosenberg IH (ed). Nutritional Assessment of Elderly Populations: Measure and Function. New York: Raven Press p225-233.

Submitted by Drs Wahlqvist and Kouris-Blazos. Dr M Wahlqvist was Head of Medicine at Monash University for 12 years and is now Professor of Medicine, Associate Dean and Director of the International Health & Development Unit of the Asia Pacific Health & Nutrition Centre, and the FAO Centre of Excellence in Food Quality, Safety and Nutrition at Monash University. He is Editor-in-Chief of the Asia Pacific Journal of Clinical Nutrition. Dr A Kouris-Blazos is Deputy Director of the International Health and Development Unit and lecturer in human nutrition at Monash University. Contact information: 8^th fl, Menzies Bldg, Monash University, Wellington Rd, Clayton, Melbourne, Victoria 3168, Australia; tel +61 3 9905 8145; fax +61 3 9905 8146; email mark. wahlqvist@med.monash.edu.au and antigone.blazos@med.monash.edu.au

You know you getting old when your idea of weight lifting is standing up!

1.	WHO/FAO (1996) Preparation and use of food-based dietary guidelines. Report of a joint FAO/WHO consultation Nicosia, Cyprus. WHO, Geneva.

2.	Wahlqvist ML, Worsley T, Harvey P, Crotty P, Kouris-Blazos A (in press) Food-based Dietary Guidelines for the Western Pacific. The shift from nutrients & food groups to food availability, traditional cuisines & modern foods in relation to emergent chronic non-communicable diseases. WHO, Geneva.

3.	Wahlqvist ML, Kouris-Blazos A, Savige G (in press) Food Based Dietary Guidelines for older adults: healthy ageing and prevention of chronic non-communicable diseases. In: Nutritional Guidelines for the Elderly. WHO, Geneva.

4.	Wahlqvist ML, Kouris A, Davies L & Scrimshaw N (1988) Development of a survey instrument for the assessment of food habits and health in later life. In: Dietetics in the 90's. Role of the Dietitian/Nutritionist, ed M Moyal. J Libbey Eurotext, Paris.

5.	Wahlqvist ML, Kouris A (1990) Trans-cultural aspects of nutrition in old age Age Ageing 19(s):43-52.

6.	Scrimshaw N, Kouris-Blazos A, Taub B, Wahlqvist ML, Davies L (1995) Rapid Assessment Procedures for use in the elderly. In: Wahlqvist et al, (eds). Cross-cultural study of food habits and health status in later life: Description of elderly communities and lessons learnt. Asia Pacific J Clin Nutr, Melbourne.

7.	Wahlqvist ML, Kouris A, Gracey M, Sullivan H (1991) An anthropological approach for the study of food & health in an indigenous population Food & Nutrition Bulletin 13(2):145-149.

8.	Kouris A, Wahlqvist ML, Trichopoulou A, Polychronopoulos E (1991) Use of Combined Methodologies in Assessing Food Beliefs and Habits of Elderly Greeks in Greece. Food Nutr Bull 13(2):139-144.

9.	Rothenberg E, Bosaeus I, Steen B (1994) Food habits, food beliefs and socio-economic factors in an elderly population. Scan J Nutr/Naringsforskning 38:159-65.

10.	Wahlqvist ML, Hsu-Hage BH-H, Kouris-Blazos A, Lukito W, eds. (1995) Food Habits in Later Life: A Cross-Cultural Study. Melbourne: Asia Pac J Clin Nut & United Nations University Press (CD Rom).

11.	Rothenberg E (1994) Validation of the food frequency questionnaire with the 4-day record method and analysis of 24-hour urinary nitrogen. Eur J Clin Nutr 48(10):725-35.

12.	Kouris-Blazos A, Wahlqvist ML, Trichopoulou A, Polychronopoulos E, Trichopoulos D (1996) Health & Nutritional Status of elderly Greek migrants to Melbourne, Australia Ageing 25:177-189.

13.	Purba M, Kouris-Blazos A, Wattanapenpaiboon N, Wahlqvist ML (1988) Cutaneous microtopography, well-being, functional and health status among elderly Greeks and Anglo-Celtic Australians Proc Nutr Soc Aust 22:121.

14.	Purba M. Kouris-Blazos A, Wattanapenpaiboon N, Wahlqvist ML, Steen B, et al. (in preparation) Can skin wrinkling in a sun unexposed site be used as a marker of biological age.

15.	Wahlqvist ML, Kouris-Blazos A, Hage B, Lo CS, Gracey M, Sullivan H, Trichopoulou A, Polychronopoulos E, Sun MT, Side X, Steen B, Rothenberg E (1992) Food Habits in Later Life: A Cross-cultural Study. Preliminary Results from communities in Australia, Greece, China & Sweden Age Nutrition 3:151 -154.

16.	Wahlqvist ML, Lukito W, Hsu-Hage BH-H (1994) Nutrition and Ageing in Development In: MR Biswas, M Gabr (eds). Nutrition in the 90s - Policy Issues. Oxford University Press, Oxford p84-108.

17.	Wahlqvist ML, Hsu-Hage B, Kouris-Blazos A, Lukito W (1994) Food Habits in Later Life: A Cross-cultural Study. In: Nutrition in a sustainable environment, ed M. Wahlqvist et al. Proc of the XVth International Congress of Nutrition. Smith-Gordon, UK p345-353.

18.	Wahlqvist ML, Hsu-Hage B, Kouris-Blazos A, Lukito W (1995) Food Habits in Later Life-An Overview of Key Findings Asia Pac J Clin Nutr 4(2): 1 -11.

19.	Wahlqvist ML, Kouris-Blazos A, Lukito W, Hsu-Hage B (1994) Water soluble vitamin intakes in the elderly: Cross-cultural findings in the IUNS study. In: Rosenberg IH (ed). Nutritional Assessment of Elderly Populations: Measure and Function. New York: Raven Press p225-233.