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Kwon, Lee, Kim, Park, Lim, Kim, and Kim: Effects of an educational program for improving the dietary quality of older adults at risk for dysphagia in South Korea∗
Research Article

J Nutr Health 2018;51(5):445-454.

Published online: 20 January 2018

DOI: https://doi.org/10.4163/jnh.2018.51.5.445

Effects of an educational program for improving the dietary quality of older adults at risk for dysphagia in South Korea∗

Sooyoun Kwon1, Youngmi Lee2, Oksun Kim3, Hae Ryun Park2, Young Suk Lim2, Chorong Kim2, 4, Hee Young Kim5, †

1Department of Food and Nutrition, Shingu University, Seongnam, Gyeonggi 13176, Korea

2Department of Food and Nutrition, Myongji University, Yongin, Gyeonggi 17058, Korea

3Department of Food and Nutrition, Jangan University, Hwaseong, Gyeonggi 18331, Korea

4Food & Nutrition Team, Korea University Guro Hospital, Seoul 08308, Korea

5Department of Occupational Therapy, Honam University, Gwangju 62399, Korea

† To whom correspondence should be addressed. tel: +82-62-940-5075, E-mail: guruma2000@naver.com

∗ This study was funded by the Health Promotion Fund, Ministry of Health, & Welfare, Republic of Korea (15–01).

Received 11 May 2018       Revised 18 May 2018       Accepted 29 August 2018

Copyright © 2018 The Korean Nutrition Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Changes in eating habits and malnutrition due to dysphagia are important health problems for older adults. This study investigated the effects of an educational program aimed at improving diet quality in community-dwelling older adults at risk for dysphagia in South Korea. Methods: We assessed 27 individuals in the experimental group and 26 individuals in the control group between September and October 2015. All participants were aged 65 years or older and were at risk for dysphagia. A combined diet and exercise program was applied to the experimental group (n=27) for six weeks. We examined changes in participants' eating habits and their knowledge and attitudes concerning dysphagia risk. The nutrition intake of all participants was measured before and after the intervention using 24-hr dietary recall. Results: There was a significant increase in knowledge of dysphagia risk in the experimental group, with scores increasing from 3.7 to 7.1, out of 10 points (p<0.001). There were also significant improvements in eating habits after the intervention in the experimental group, with scores increasing from 21.9 to 28.3, out of 36 points (p<0.001). The attitude score of participants in the experimental group increased significantly, from 15.2 to 16.7, out of 20 points (p=0.016). Conclusion: Developing educational programs can help older adults living in the community lead a healthier lifestyle and improve their ability to manage their diet.

Keywords: chewing problem, swallowing problem, education program, dietary guides, exercise guides

References

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Fig. 1.
Number of participants in the educational program
jnh-51-445f1.tif
Fig. 2.
Contents of the educational program for improving the dietary quality: Dietary guide and exercise guide
jnh-51-445f2.tif
Fig. 3.
Satisfaction of participants with the educational program (n = 27)
jnh-51-445f3.tif
Table 1.
Schedule of the educational program for improving the dietary quality
Time Main contents Details
1st (1st week) • Test operation outlines • Test operation and total contents explanation
• Exercise guide • Right posture at a meal
  • ‘Health Stretching' and ‘Health Plus Stretching'
2nd (4th week) • The review of ‘Health Stretching' • ‘Health Stretching' and ‘Health Plus Stretching'
• Dietary life guide • Dietary life guide
– Food guide • How to drink water and beverage safely
– Cooking guide • How to eat bread and rice cake
3rd (5th week) • The review of ‘Health Stretching' • ‘Health Stretching' and ‘Health Plus Stretching'
• Dietary life guide • How to cook grains
– Cooking guide • How to cook meat/fish/egg/beans
– Menus guide • How to cook vegetables
4th (6th week) • Dietary life guide • ‘Health Stretching' and ‘Health Plus Stretching'
• Overall review • How to cook fruits
• How to cook milk and dairy products

• Standard menus for the aged who have the difficulty of chewing and swallowing

Table 2.
General character of the respondents before program (n (%) or mean ± SD)
Character Experimental group (n = 27) Control group (n = 26) t-value1)
Gender      
Men 11 (40.7) 14 (53.8) 0.913
Women 16 (59.3) 12 (46.2)
Age
65 ∼ 74 5 (18.5) 14 (53.8) 7.188∗∗
≥ 75 22 (81.5) 12 (46.2)
Average 78.5 ± 4.5 75.0 ± 5.6 21.274∗
Perceived health status
Very bad 1 (3.7) 3 (11.5) 16.695∗∗
Bad 12 (44.4) 1 (3.8)
Fair 10 (37.0) 10 (38.5)
Good 3 (11.1) 12 (46.2)
Very good 1 (3.7) 0 (0.0)
Average 2.7 ± 0.9 3.2 ± 1.0 –2.059∗
Height (m) 1.6 ± 0.1 1.6 ± 0.1 –2.145∗
Weight (kg) 58.5 ± 11.8 63.2 ± 10.2 –1.536
BMI (kg/m²)
Underweight (< 18.5) 2 (7.4) 0 (0.0) 5.151
Normal (18.5 ∼ 22.9) 14 (51.9) 12 (46.2)
Overweight (23 ∼ 24.9) 6 (22.2) 5 (19.2)
Obese I (25 ∼ 29.9) 4 (14.8) 9 (34.6)
Obese II (30 ∼ 39.9) 1 (3.7) 0 (0.0)
Average 23.2 ± 3.4 23.8 ± 2.9 –0.693
1) by χ2-test or Student's t-test

∗ p < 0.05, ∗∗ p < 0.01

Table 3.
The knowledge1) change between before and after the educational program1) (n (%) or mean ± SD)
Items Experimental group Control group
  (n = 27)     (n = 26)  
Before After p3) Before After p3)
You can prevent choking if you slightly bend your heads 11 (40.7) 25 (92.6) 0.001∗∗ 6 (23.1) 7 (26.9) 1.000
while eating            
It is helpful to lie down for 30 minutes when you get choked while eating 6 (22.2) 20 (74.1) 0.001∗∗ 13 (50.0) 11 (42.3) 0.774
It is better to eat cooked rice in water or soup when you 1 (3.7) 12 (44.4) 0.003∗∗ 2 (7.7) 1 (3.8) 1.000
are having difficulties with swallowing            
It is better to abstain from meat if you are having 11 (40.7) 16 (59.3) 0.267 14 (53.8) 8 (30.8) 0.109
difficulties with chewing and swallowing            
Drinking water while eating is helpful to prevent choking 7 (25.9) 18 (66.7) 0.003∗∗ 6 (23.1) 8 (30.8) 0.754
Difficulty in chewing and swallowing can lead to deficiency 9 (33.3) 19 (70.4) 0.013∗ 7 (26.9) 10 (38.5) 0.453
of vitamin intake            
It is better to eat hard-boiled rice rather than soft-boiled 16 (59.3) 17 (63.0) 1.000 22 (84.6) 22 (84.6) 1.000
rice if you are having difficulties with chewing and swallowing
It is better to eat clear soup rather than thick soup if you 15 (55.6) 20 (74.1) 0.227 7 (26.9) 5 (19.2) 0.687
are having difficulties with chewing and swallowing.            
When eating hard vegetables like carrots, you'd better eat 20 (74.1) 26 (96.3) 0.070 23 (88.5) 24 (92.3) 1.000
them after cooking            
It is better to drink yogurt and eat it with a spoon if you are having difficulties with swallowing 5 (18.5) 19 (70.4) 0.001∗∗ 5 (19.2) 6 (23.1) 1.000
Total (10 points)2) 3.7 ± 2.0 7.1 ± 1.8 < 0.001∗∗∗ 4.0 ± 1.5 3.9 ± 1.4 0.729

1) Percentage of respondents who correctly answered questions of nutrition knowledge 2) 0 point = incorrect or I do not know, 1 poin = correct 3) p-value by McNemar test and paired t-tests ∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001

Table 4.
The change of eating habits related to chewing and swallowing between before and after the educational program1) (mean ± SD)
Items Experimental group Control group
  (n = 27)     (n = 26)  
Before After t-value2) Before After t-value2)
I ate vegetables every day 2.33 ± 0.92 2.70 ± 0.54 –2.431∗ 2.85 ± 0.46 2.81 ± 0.57 0.254
I ate fruits every day 2.04 ± 1.06 2.37 ± 0.84 –2.082∗ 2.00 ± 0.98 2.08 ± 1.06 –0.570
I ate meat, fish, beans and so on as side dishes 1.59 ± 0.84 1.85 ± 0.82 –1.192 2.08 ± 0.85 2.15 ± 0.88 –0.337
every day            
I ate dairy products like milk or yogurt every day 1.37 ± 1.08 1.52 ± 1.12 –0.700 1.85 ± 1.19 1.62 ± 1.30 1.140
I ate three meals a day regularly 2.63 ± 0.79 2.89 ± 0.42 –1.568 2.27 ± 1.04 2.42 ± 0.99 –1.280
I had a balanced diet 1.89 ± 1.22 2.67 ± 0.68 –3.083∗∗ 1.96 ± 1.04 1.88 ± 1.14 0.420
I did warm-ups (mouth and tongue exercises) 0.30 ± 0.78 2.19 ± 1.21 –7.174∗∗∗ 0.54 ± 1.03 0.50 ± 1.11 0.328
before having a meal            
I had my meal with a correct posture 1.78 ± 1.25 2.37 ± 0.97 –2.126∗ 2.62 ± 0.75 2.27 ± 1.04 1.671
I ate slowly, chewing my food well 1.63 ± 1.25 2.48 ± 0.98 –3.426∗∗ 2.08 ± 1.16 1.92 ± 1.32 0.610
I was seated for about 30 minutes after meals 1.93 ± 1.21 2.19 ± 1.04 –0.908 1.54 ± 1.27 1.73 ± 1.22 –0.655
I cooked the hard and tough food until it was 1.56 ± 1.16 2.41 ± 0.84 –3.349∗∗ 1.31 ± 1.32 1.81 ± 1.33 –1.612
soft            
I brushed my teeth after meals 2.81 ± 0.48 2.70 ± 0.61 0.901 2.46 ± 0.95 2.23 ± 1.14 1.063
Total (36 points) 21.85 ± 5.75 28.33 ± 5.22 –5.530∗∗∗ 23.54 ± 4.84 23.42 ± 5.03 0.127
1) 0 = never, 1 = sometimes (2 ∼ 3 times per week ), 2 = usually (3 ∼ 5 times per week), 3 = a always (6 ∼ 7 time es per week) 2 2) by paired
t-test

∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001

Table 5.
The change of the attitude related to chewing and swallowing between before and after the educational program1) (mean ± SD)
Items Experimental group Control group
  (n = 27)     (n = 26)  
Before After t-value2) Before After t-value2)
I will try not to eat food difficult to chew and 3.15 ± 0.60 3.15 ± 0.86 0.000 3.04 ± 0.77 2.96 ± 0.66 0.527
swallow            
I will try to increase my ability to chew and 3.30 ± 0.61 3.52 ± 0.75 –1.803 3.15 ± 0.68 3.04 ± 0.66 1.000
swallow            
I will seek expert advice when I have a problem with chewing and swallowing 2.89 ± 0.80 3.41 ± 0.80 –2.762∗ 2.73 ± 0.92 2.73 ± 0.67 0.000
I will change the cooking method when I have a problem with chewing and swallowing 3.15 ± 0.66 3.44 ± 0.70 –1.986 2.85 ± 0.73 2.85 ± 0.78 0.000
To chew and swallow better, I will exercise 2.70 ± 0.87 3.22 ± 0.80 –2.762∗ 2.50 ± 0.91 2.38 ± 0.85 0.570
before I eat a meal            
Total (20 points) 15.19 ± 2.70 16.74 ± 2.74 3.678∗ 14.27 ± 3.23 13.96 ± 2.63 0.617

1) 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree 2) by paired t-test ∗ p < 0.05

Table 6.
The change of dietary consumption between before and after educational program1) (mean ± SD)
Nutrients Experimental group Control group
  (n = 27)     (n = 26)  
Before After t-value2) Before After t-value2)
Energy (kcal) 1,347.76 ± 550.90 1,227.00 ± 511.61 0.960 1,513.67 ± 635.39 1,644.80 ± 522.99 –1.104
Protein (g) 53.73 ± 28.33 44.24 ± 17.29 1.820 62.54 ± 31.45 64.19 ± 26.10 –0.295
Fat (g) 22.50 ± 18.99 22.10 ± 18.29 0.099 34.76 ± 28.64 31.44 ± 14.73 0.593
Carbohydrate (g) 232.26 ± 102.58 220.51 ± 94.11 0.517 233.64 ± 69.62 277.94 ± 81.37 –2.659∗
Calcium (mg) 388.86 ± 233.82 350.13 ± 179.26 0.803 575.00 ± 391.49 505.52 ± 297.03 0.759
Iron (mg) 13.37 ± 7.28 14.36 ± 7.41 –0.530 14.74 ± 6.91 16.87 ± 7.53 0.759
Sodium (mg) 3,268.75 ± 2,056.21 2,532.86 ± 1,108.29 1.640 4,121.39 ± 1,844.19 3,779.48 ± 1,984.22 0.988
Potassium (mg) 2,201.01 ± 1,237.25 2,308.15 ± 958.38 –0.438 2,665.66 ± 1,064.47 3,068.94 ± 1,279.80 –1.679
Vitamin A (μgRE) 638.30 ± 572.15 969.33 ± 808.34 –1.973 672.78 ± 568.67 989.59 ± 556.71 –2.006
Thiamine (mg) 0.94 ± 0.49 0.94 ± 0.69 0.011 1.06 ± 0.40 0.99 ± 0.39 0.696
Riboflavin (mg) 0.86 ± 0.62 0.90 ± 0.61 –0.280 1.07 ± 0.46 1.15 ± 0.47 –0.712
Niacin (mg) 12.66 ± 8.26 10.02 ± 5.55 1.426 13.21 ± 6.44 13.03 ± 5.52 0.130
Vitamin C (mg) 68.65 ± 49.60 71.59 ± 37.81 –0.272 76.77 ± 45.44 122.91 ± 68.40 –2.720

1) by paired t-test ∗ p < 0.05

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