To the best of our knowledge, this is the first study of its kind to examine the nutrition knowledge, competencies and attitudes amongst relatively healthy older adults, and the results might be useful for guiding nutrition strategies in a multi-ethnic population. Gender, ethnicity, the self-reported ability to understand nutrition information, and having access to help from family and friends are significant factors associated with nutrition knowledge of the older adult population with normal nutrition status.
Though some studies have been conducted on nutrition literacy among Asian older adults [20, 30], their instruments were specially designed for their respective local populations. Thus, it is difficult to compare the nutrition literacy levels of our participants with that of other studies. We found nutrition knowledge and other aspects of nutrition competencies and attitudes (such as responsibility of food decisions, consumption of home-cooked meals, and consumption of simpler meals when alone/with spouse) differ significantly between the genders. Education was associated with the self-reported ability to seek and verify nutrition information while caregiving arrangements might have an influence on the responsibility of food decisions and consumption of home-cooked meals among the study population. Moreover, higher nutrition knowledge index is found to be associated with being female, of Chinese ethnicity, self-reported ability to understand nutritional information, and having access to help from family/friends.
Males were found to have a lower nutrition knowledge index. They were also more likely to leave food decisions to others, less likely to consume home-cooked meals, and more likely to consume simpler meals when alone/with spouse. These suggest that more support might need to be offered to older male adults to improve their nutrition knowledge so that they are able to make appropriate food choices, especially when they are dining out. On the other hand, it remains unclear why males prefer to leave food decisions to others and this could potentially be explored as a future research study.
Education is known to contribute to an individual’s ability to better understand, and remember different information , and educated adults were suggested to be more motivated and interested in nutritional health [19, 29]. This is in line with our bivariate analyses which showed that older adults with higher education levels had a higher proportion with the self-reported ability to seek and verify nutrition related information compared to those with primary education levels. The current study did not find an association between age and nutrition knowledge index. Previous studies on older adults noted that nutrition knowledge decreased as age increased [19, 20, 43]. However, Parmenter et al. found a non-linear trend between different age cohorts and nutrition knowledge scores, and suggests the influence of upbringing and lifestyle on nutrition knowledge . Lin and Lee reported that while dietary habits of the older Taiwanese were strongly influenced by Chinese traditional food-related beliefs (i.e. heaty foods, cold foods, etc.), education had an effect on these beliefs. Higher educated individuals were less likely to report their food choices being influenced by these traditional beliefs. The cohort in the present study is highly educated, 13.0% had education levels of University and above compared to 5.8% of Singapore’s general population aged 65 years and above. Our findings on the lack of association between age and nutrition knowledge could have been due to the higher education levels, which could have equipped individuals with better abilities for seeking and verifying nutrition information. .
Older adults who are cared for by family or others reported a higher likelihood of consuming home cooked meals compared to those who are self-reliant for care. Moreover, the former group is more likely to leave food decisions to the discretion of others compared to those who are self-reliant for care. These suggests that employed caregivers or family members living together with older adults should be included in nutritional education programs targeted at the older adults as they play an important role in ensuring the nutrition health of their older dependents.
Findings on the factors associated with higher nutrition knowledge index from this study highlighted that older male adults need more assistance to improve their nutrition knowledge compared to the female counterparts. Our results which showed that older female adults had higher nutrition knowledge than males are similar to what was reported by Aihara and Minai in the Asian older adults population and by Shatenstein et al in the Western older adults population [30, 31]. This could be due to females taking on more domestic responsibilities, including meal preparation and food choices , and are thus more likely to be familiar with nutrition related information. It is also important to note the self-reported ability to understand nutrition information and having access to family and friends for help are contributing factors to the learning and encoding of nutrition knowledge, and therefore yielding a higher nutrition knowledge index. Nutritional educational programs which offer small incremental blocks of information content was suggested to booster learning and maximize retention of nutrition among adults . Such an approach may be useful in designing of the nutrition strategies to mitigate age-related declines in comprehension amongst older learners. The role that social networks play in the nutritional well-being of older adults has been well established in literature [47-49]. In this study, about 14% to 20% of older adults reported obtaining their nutrition information through their social networks. This implies that interventions for improving nutrition literacy should incorporate group-based activities that allows for social interactions and community bonding. . Though majority of the participants in this study reported that nutritional value as a crucial factor influencing their food choices, almost half of the study cohort were more likely to eat simpler meals (i.e. biscuits and milo/pickled vegetables with rice) when dining alone or with spouse. This again highlights the importance of social networks in influencing the nutrition behavior of older adults where they eat more and eat better in social environments with family or friends . Community-based programs that enables older adults to gather in common social spaces to partake in meals together which concurrently allow for the formation of an informal social network may be effective targeted approach to help improve nutritional intake, particularly among older adults who tend to eat alone as a result of poor social network.
Our study found that ethnicity was associated with NKI with older Chinese adults scoring better NKI than others. This finding is similar to that of a previous study conducted in Malaysia, the study’s sample consisted of Malays (46.0%), Chinese (32.0%), Indians (6.0%), and other minority groups (16.0%) aged 60 to 96 years old . The authors found that those of Chinese ethnicity had the highest proportion with good nutrition knowledge compared to the other groups. This suggests that there is a place for targeted and culturally appropriate outreach in order to improve the nutritional knowledge of other ethnic groups.
Sources of Nutrition Information
Understanding the sources for nutrition information among the older population is crucial in developing nutrition educational outreach methods. Our study participants reported television (40.0%) as one of the most common sources of information, followed by printed materials like newspapers (39.3%). Similarly, studies on Asian older adults have also found television to be one of the most commonly cited resource of nutritional information, which range from 49.7% to 79.8%, followed by printed materials, social networks and health professionals [20, 30]. Our reported proportion of internet as a source of information as being higher compared to recent studies done in Midwest US on older adults aged 60 years and above (0.4%)  and Australia older adults aged 65 years and above (19.0%)  was a novel finding. This could be due to the higher education levels and socioeconomic status seen in our participants compared to Singapore’s general population aged 65 years and above. This finding opens up the possibility of internet-based nutrition educational and lifestyle programs, which has shown great potential in increasing access to nutrition information, and in improving older adults nutrition knowledge [53, 54]. Additionally these programs are capable of reaching a wide population of individuals at low costs .
There are four limitations in this study. Firstly, the participants in this study were relatively healthy and educated with normal nutritional status (MUST = 0). Future studies could examine other older population group such as those at risk of undernutrition. Nevertheless, this is the first study to have looked at this healthy population in Singapore. Secondly, the cross-sectional design means that causal relationship between nutrition knowledge, competencies, attitudes, and factors associated with them could not be established. Future studies are needed to understand and confirm the associations in this study. Thirdly, the psychometrics properties of the NLQ have yet to be established, future studies are planned to validate the questionnaire. Lastly, associations between nutrition knowledge, competencies and attitudes and dietary habits could not be determined due to a lack of dietary intake information. Future studies could capture dietary intake to examine the associations.