D

JYa

b

c

d

e

a

ARRA

KDDDO

1

oipD

vI

A3

s(

0h

Maturitas 76 (2013) 160– 164

Contents lists available at ScienceDirect

Maturitas

jo u r n al hom epa ge: www.elsev ier .com/ locate /matur i tas

ietary patterns and functional disability in older Korean adults

inhee Kima,b, Yunhwan Leea,b,∗, Soon Young Leea,b, Young Ok Kimc,oon-Sok Chungb,d, Sat Byul Parkb,e

Department of Preventive Medicine and Public Health, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, Republic of KoreaInstitute on Aging, Ajou University Medical Center, 164 World cup-ro, Yeongtong-gu, Suwon, Republic of KoreaDepartment of Food and Nutrition, College of Natural Science, Dongduk Women’s University, 60 Hwarang-ro 13-gil, Seongbuk-gu, Seoul, Republic of KoreaDepartment of Endocrinology and Metabolism, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, Republic of KoreaDepartment of Family Practice and Community Health, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, Republic of Korea

r t i c l e i n f o

rticle history:eceived 29 March 2013eceived in revised form 2 July 2013ccepted 8 July 2013

eywords:ietietary patternsisabilitylder adults

a b s t r a c t

Objectives: This study examined the relationship between dietary patterns and disability in the Koreanelderly.Study design: We used data from a cross-sectional study of 327 men and 460 women aged ≥65 years whocompleted the 2005 Korea National Health and Nutrition Examination Survey.Main outcome measures: A single 24-h dietary recall method was used to assess dietary intake and dietarypatterns were identified by cluster analysis. Functional disability was assessed by the activities of dailyliving (ADL) and instrumental ADL (IADL) scales. The association of dietary patterns with ADL and IADLdisability was analyzed by logistic regression adjusting for age, marital status, education, householdincome, region, chronic conditions, body mass index, smoking, alcohol drinking, physical activity, andenergy intake.Results: Two dietary patterns were identified in both men and women: the modified traditional dietarypattern, characterized by a relatively lower consumption of white rice, but higher consumption of fruits,dairy products, and legumes, and the traditional dietary pattern, characterized by high consumption ofwhite rice. After controlling for covariates, in men, those who engaged in modified traditional dietary

pattern, compared with traditional dietary pattern, showed a lower likelihood of ADL disability (oddsratio [OR] = 0.17, 95% confidence interval [CI]: 0.05–0.56). In women, the modified traditional dietarypattern compared with the traditional pattern was associated with a significantly decreased risk of ADL(OR = 0.45, 95% CI: 0.23–0.90) and IADL disability (OR = 0.45, 95% CI: 0.28–0.72).Conclusions: The modified traditional dietary pattern is associated with a decreased risk of functionaldisability in older Korean adults.

. Introduction

Korea’s population is rapidly aging, with those aged 65 yearsr older comprising 11.8% of the total population in 2012, and it

s projected to increase to 32.3% by 2040 [1]. With aging of theopulation disability has become a critical public health issue.isability is a well-known predictor of health care utilization,

Abbreviations: KNHANES, Korea National Health and Nutrition Examination Sur-ey; ADL, activities of daily living; IADL, instrumental ADL; HEI-2005, Healthy Eatingndex-2005; KDRIs, dietary reference intakes for Koreans.∗ Corresponding author at: Department of Preventive Medicine and Public Health,jou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 443-80, Republic of Korea. Tel.: +82 31 219 5085; fax: +82 31 219 5084.

E-mail addresses: jhkim06@ajou.ac.kr (J. Kim), yhlee@ajou.ac.kr (Y. Lee),olee@ajou.ac.kr (S.Y. Lee), yok@dongduk.ac.kr (Y.O. Kim), yschung@ajou.ac.krY.-S. Chung), sbpark@ajou.ac.kr (S.B. Park).

378-5122/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.maturitas.2013.07.011

© 2013 Elsevier Ireland Ltd. All rights reserved.

institutionalization, and mortality in the elderly and can lead topoor quality of life [2]. Maintaining high physical function is, there-fore, considered a major contributor to successful aging [3].

Diet is discussed as an important modifiable risk factor offunctional disability [4]. Previous epidemiological studies haveexamined single foods or nutrients in relation to disability [5,6].However, because people usually consume various foods with com-plex combinations of nutrients through meals it is difficult toexamine the effects of a single nutrient on health outcomes. Thedietary pattern approach, which examines the overall diet, is analternative method that can better characterize foods and nutri-ents consumed in combinations [7]. Only few studies have assesseddietary patterns and their relationship with disability. In a study of

French women aged 65 and over, greater adherence to the Mediter-ranean diet was predictive of less functional disability [8]. In theNHANES, Healthy Eating Index-2005 (HEI-2005) scores were asso-ciated inversely with disability among older Americans [9].

ritas 7

icTcdiao

2

2

NodD[tt

SNtp(vm(3

2

stoevfgnuospsfliewestp

2

a7t1g

J. Kim et al. / Matu

Dietary patterns of older people in Asia tend to differ from thosen western countries. Asian populations, including Koreans, typi-ally consume rice as a staple food and high plant foods [10,11].hus, results from previous studies may not directly apply to Asianountries, including Korea. Moreover, the relationship betweenietary patterns and disability among the older Korean population

s not established. The aim of the current study was to examine thessociation between dietary patterns and functional disability inlder Korean adults, using a nationally representative data source.

. Methods

.1. Study population

Data came from a cross-sectional study of the 2005 Koreaational Health and Nutrition Examination Survey (KNHANES)f non-institutionalized residents in the Republic of Korea, con-ucted by the Korea Centers for Disease Control and Prevention.etailed information of the survey design is provided elsewhere

12]. KNHANES employs a multistage cluster sampling for the selec-ion of household units. Prior to the survey, all participants signedhe informed consent forms.

KNHANES is composed of four surveys: the Health Interviewurvey, Health Behavior Survey, Health Examination Survey, andutrition Survey. Among the 3730 aged ≥65 years who completed

he Health Interview Survey one third was randomly selected toarticipate in the other surveys. The study sample consisted of 796330 men, 466 women) aged ≥65 years who completed four sur-eys. We excluded those with missing values on marital status (1en), household income (2 women), and anthropometric measures

2 men, 4 women). The final sample for the analysis comprised of27 men and 460 women.

.2. Dietary assessment

Dietary intake was assessed by an interviewer-administered,ingle 24-h dietary recall. Trained staffs instructed the participantso describe all the foods and beverages they consumed in the previ-us day. Food models, bowls, cups, and spoons were used to assist instimating portion sizes. To conduct a dietary pattern analysis, indi-idual foods were consolidated into 16 food groups based on theood groups classified in the food composition table [13]: grains andrain products, potatoes and starches, sugar and sweets, legumes,uts and seeds, vegetables, mushrooms, fruits, meat and its prod-cts, eggs, fish and shellfish, seaweeds, milk and dairy products,ils, beverages, and seasoning. The food groups were then recon-olidated into 20 food groups. Because the intake of grains and grainroducts is high in Koreans, this food group was divided into fourubgroups [14]: white rice, other grains, noodles and dumpling, andour and bread. Because kimchi (traditionally fermented cabbage)

s a national side dish in Korea it was separated into a single veg-table group. Mushrooms were included as vegetables and alcoholas separated from the beverages. Energy and nutrient intake of

ach food was calculated using the food composition table [13] andummated up for each food group. The percentage of energy con-ributed by each food group was calculated and used in the dietaryattern analysis.

.3. Functional disability

Functional disability included the activities of daily living (ADL)nd instrumental ADL (IADL). Disability in ADL was assessed by

items: dressing, washing, bathing, eating, transferring, usinghe toilet, and incontinence. Disability in IADL was assessed by0 items: grooming, housework, preparing meals, doing laundry,oing outside, using public transportation, shopping, managing

6 (2013) 160– 164 161

money, using the telephone, and taking medicine. The responseoptions to individual items included no difficulty, some difficulty,were unable, or did not do the activities (never done in life or cando the activity but chose not to), without other’s help or use ofaids. Individual responses were dichotomized as either not dis-abled (0 = no difficulty or did not perform the activity) or disabled(1 = some difficulty or unable to do). ADL or IADL disability wasdefined as disabled in one or more ADL or IADL items.

2.4. Covariates

Sociodemographics included age (65–74, ≥75 years), mari-tal status (married vs. not married, including single, widowed,divorced, or separated), education (less than elementary schoolvs. elementary school or higher), monthly household income(<50, 50–99, ≥100 in ten thousand Korean won), region (rural,city, or metropolitan), and physician-diagnosed chronic condi-tions (diabetes mellitus, hypertension, stroke, angina or myocardialinfarction, and arthritis). Smoking status (never, former, or cur-rent), drinking of alcoholic beverages (never, former, or current),and physical activity were obtained by self-report. Physical activitywas categorized as sedentary, low (below the recommended level),and recommended (≥150 min/week of moderate-intensity and/or≥75 min/week of vigorous-intensity aerobic physical activity) [15].Body mass index (BMI) was calculated as measured weight (kg)divided by height squared (m2).

2.5. Statistical analysis

All data were analyzed using IBM SPSS Statistics 19.0 (Inter-national Business Machines Corp. Armonk, NY, USA), taking intoaccount the survey’s complex sampling design. Because genderdifferences in disability have been widely reported [16], and asignificant interaction between dietary patterns and gender withrespect to disability was observed in our data, all analyses wereperformed separately by gender.

Cluster analysis was conducted using the K-means method togenerate the dietary patterns. The descriptive characteristics of thestudy population were presented as mean and standard deviation(SD) or percentage. Difference in percentage of energy from foodgroups and in nutrient intake by dietary patterns was analyzedusing the t test. Difference of participants’ characteristics betweendietary patterns was determined using the t test for continuousvariables and chi-square test for categorical variables. Using logisticregression analysis, risks of functional disability, with the tradi-tional dietary pattern as the reference group, were shown as oddsratio (OR) with 95% confidence interval (CI), adjusting for covari-ates. Significance was defined as 2-sided P value < 0.05.

3. Results

3.1. Percentages of energy from food groups and daily nutrientintakes by dietary patterns

In men, the modified traditional dietary pattern (41.6%) and tra-ditional dietary pattern (58.4%) were identified by cluster analysis(Table 1). The modified traditional dietary pattern received 34% ofenergy from white rice and consumption of most food groups wassignificantly higher in this pattern than in the traditional dietarypattern. In contrast, the traditional dietary pattern received 67%of energy solely from white rice and consumption of white riceand kimchi in this pattern was significantly higher, compared with

the modified traditional pattern. With respect to nutrients, men inthe traditional dietary pattern, compared with the modified tra-ditional dietary pattern, showed a significantly higher percentageof energy from carbohydrate (more than 75% of energy) but lower

162 J. Kim et al. / Maturitas 76 (2013) 160– 164

Table 1Percentage energy contribution from food groups and daily nutrient intakes by dietary patterns of respondents aged ≥65 years, 2005 KNHANES.

Men (n = 327) Women (n = 460)

Modifiedtraditional (n = 136)

Traditional (n = 191) P-valuea Traditional (n = 309) Modifiedtraditional (n = 151)

P-valuea

Mean SD Mean SD Mean SD Mean SD

Percentage of energy from food groupsWhite rice 33.7 11.4 67.0 10.8 <0.001 70.7 11.1 35.2 14.6 <0.001Other grains 9.7 12.5 3.4 5.2 <0.001 3.8 5.5 17.2 15.9 <0.001Noodles and dumpling 9.0 14.7 0.3 2.2 <0.001 0.4 3.0 6.2 12.8 <0.001Flour and bread 4.0 9.2 1.0 3.1 0.003 0.5 2.1 3.3 8.8 <0.001Potatoes and starches 1.1 3.6 0.6 2.0 0.217 0.5 2.1 1.4 4.4 0.005Sugar and sweets 1.4 2.2 0.8 1.8 0.011 0.8 1.9 1.2 1.8 0.052Legumes 4.4 5.0 3.2 3.9 0.064 2.7 4.4 4.2 4.5 0.009Nuts and seeds 1.1 2.5 0.7 2.2 0.143 0.6 1.4 0.9 2.9 0.165Vegetables 3.6 2.3 3.9 2.9 0.260 4.0 3.8 4.1 2.9 0.774Kimchi 1.4 1.3 1.8 1.6 0.033 1.8 1.9 1.4 1.3 0.010Fruits 2.2 4.3 0.8 2.8 0.018 0.8 2.9 2.6 5.0 <0.001Meat and its products 6.9 9.9 2.1 5.2 <0.001 1.9 4.6 4.9 9.8 0.001Eggs 1.1 2.1 0.3 0.9 <0.001 0.4 1.6 1.2 2.0 <0.001Fish and shellfish 5.3 7.0 4.3 5.2 0.171 3.5 5.3 5.3 6.9 0.026Seaweeds 0.4 1.0 0.6 1.6 0.137 0.7 2.0 0.6 1.1 0.374Milk and dairy products 1.8 3.8 1.3 3.4 0.292 1.0 3.0 3.0 5.2 0.001Oils 2.9 3.0 2.1 2.2 0.014 2.2 2.9 3.1 2.9 0.003Beverages 1.1 2.1 1.5 2.5 0.152 1.1 2.6 1.3 3.2 0.510Alcohol 6.0 13.3 1.8 5.1 0.002 0.3 1.8 0.4 2.3 0.654Seasoning 3.3 3.5 3.2 3.4 0.885 2.9 3.1 2.9 3.3 0.891

NutrientEnergy (kcal/day) 2053.6 739.8 1739.7 517.8 <0.001 1433.3 497.0 1582.4 518.3 0.009Carbohydrate (% of energy) 65.0 9.6 75.4 7.1 <0.001 77.2 7.2 68.1 9.5 <0.001Protein (% of energy) 17.0 4.7 13.7 3.0 <0.001 13.3 3.6 16.0 4.9 <0.001Fat (% of energy) 18.1 7.8 10.9 5.2 <0.001 9.5 5.2 16.0 7.1 <0.001Carbohydrate (g) 310.3 118.2 315.6 94.9 0.682 269.5 90.1 264.2 85.7 0.574Protein (g) 82.4 39.8 58.5 23.4 <0.001 47.6 23.7 62.9 28.5 <0.001Fat (g) 40.8 28.3 20.8 12.8 <0.001 15.6 11.7 29.1 18.7 <0.001Fiber (g) 8.8 4.5 7.5 3.8 0.021 6.2 3.5 7.1 3.6 0.071

K eviat

pd(pshtfctwc7

3

ppotea

3d

pcid

NHANES, Korea National Health and Nutrition Examination Survey; SD, standard da P value from t test.

ercent of energy from protein and fat. In women, the traditionalietary pattern (67.2%) and modified traditional dietary pattern32.8%) were identified by cluster analysis. The traditional dietaryattern received 71% of energy solely from white rice and con-umption of white rice, and kimchi in this pattern was significantlyigher, compared with the modified traditional pattern. In contrast,he modified traditional dietary pattern received 35% of energyrom white rice, and consumption of most food groups was signifi-antly higher, compared with the traditional pattern. With respecto nutrients, women in the traditional dietary pattern, comparedith the modified traditional dietary pattern, showed a signifi-

antly higher percentage of energy from carbohydrate (more than5% of energy) but lower percent of energy from protein and fat.

.2. Population characteristics by dietary patterns

Among men, those in the modified traditional pattern, com-ared with the traditional, had higher household income, lowerercentage residing in a rural area, and lower prevalence of anginar myocardial infarction (Table 2). Women with modified tradi-ional dietary pattern, compared with the traditional, had higherducation and household income, and tended to reside in an urbanrea.

.3. Association between dietary patterns and functionalisability

In men, there was a significant association between dietary

atterns and ADL disability (Table 3). Even after adjusting foronfounders, compared with the traditional pattern, the mod-fied traditional pattern showed a lower likelihood of ADLisability (OR = 0.17, 95% CI: 0.05–0.56). There was, however, no

ion.

significant association between dietary patterns and IADL disabil-ity. In women, there were significant associations between dietarypatterns and disability. Compared with the traditional pattern, themodified traditional pattern showed a lower likelihood of ADL(OR = 0.45, 95% CI: 0.23–0.90) and IADL disability (OR = 0.45, 95%CI: 0.28–0.72).

4. Discussion

Dietary patterns were significantly associated with functionaldisability in the current study among older Korean adults.The modified traditional dietary pattern showed a lower riskof ADL but not IADL disability than the traditional dietarypattern in men. Also, the modified traditional dietary patternshowed a lower risk of both ADL and IADL disability than the tradi-tional dietary pattern in women. To our knowledge, the currentstudy is the first to investigate the association between dietarypatterns and functional disability among the older population inKorea.

There are only few studies that have examined the associationbetween dietary patterns and functional disability. Older Frenchwomen with the highest Mediterranean diet adherence had a 50%relative risk reduction of incident disability than those in the low-est Mediterranean diet category [8]. In the NHANES, among olderAmericans, compared with those who had HEI-2005 scores in thelowest quartile, those who had HEI-scores in the highest quartilewere at a significantly lower risk of disability [9].

In this study, both older men and women adopting modified tra-ditional dietary pattern showed carbohydrate (65–68% of energy),protein (16–17% of energy), and fat (16–18% of energy) intakethat met the recommendations of the dietary reference intakes for

J. Kim et al. / Maturitas 76 (2013) 160– 164 163

Table 2Population characteristics by dietary patterns of respondents aged ≥65 years, 2005 KNHANES.

Men (n = 327) Women (n = 460)

Modifiedtraditional(n = 136)

Traditional(n = 191)

P-valuea Traditional(n = 309)

Modifiedtraditional(n = 151)

P-valuea

Age (year) (%)65–74 76.5 80.2 0.493 64.8 75.7 0.083≥75 23.5 19.8 35.2 24.3

Marital status (%)Not marriedb 11.3 14.0 0.556 64.8 67.5 0.585Married 88.7 86.0 35.2 32.5

Education level (%)<Elementary school 12.9 14.4 0.745 60.3 29.9 <0.001≥Elementary school 87.1 85.6 39.7 70.1

Household income (10,000 won/month) (%)<50 13.0 28.5 0.002 36.3 25.6 0.04050–99 25.8 28.6 23.1 19.3≥100 61.2 42.9 40.6 55.1

Region (%)Rural 27.1 46.1 0.010 49.1 19.2 <0.001City 28.2 15.1 21.5 32.8Metropolitan 44.7 38.8 29.4 48.0

Diabetes mellitus (%) 13.3 15.0 0.708 13.4 20.8 0.093Hypertension (%) 38.4 33.8 0.494 41.8 53.8 0.067Stroke (%) 6.3 7.0 0.842 7.2 6.1 0.717Angina or myocardial infarction (%) 2.4 14.6 <0.001 4.6 4.8 0.906Arthritis (%) 16.5 21.4 0.302 58.7 66.3 0.192Body mass index (kg/m2) (%)

<25.0 73.5 68.8 0.457 66.5 63.1 0.530≥25.0 26.5 31.2 33.5 36.9Body weight (kg), mean (SD) 62.0 (9.5) 63.0 (10.0) 0.456 53.0 (8.7) 54.9 (8.6) 0.083

Smoking (%)Never 18.1 15.7 0.178 81.3 88.4 0.252Former 56.9 47.3 9.7 6.0Current 25.0 36.9 9.0 5.6

Alcohol drinking (%)Never 13.5 8.7 0.346 46.1 39.0 0.450Former 18.7 25.3 16.9 20.9Current 67.8 66.1 37.0 40.0

Physical activity (%)Sedentary 49.7 57.9 0.380 76.8 76.7 0.855Low level 10.4 11.2 7.4 5.9Recommended levelc 39.9 30.8 15.8 17.4

KNHANES, Korea National Health and Nutrition Examination Survey; SD, standard deviation.ariabl

ity ae

Kt7ud

TO

K

i

a P value from t test for continuous variables and chi-square test for categorical vb Single, widowed, divorced, or separated.c ≥150 min/week of moderate-intensity and/or ≥75 min/week of vigorous-intens

oreans (KDRIs) [17], within the acceptable macronutrient dis-

ribution ranges (AMDR) in adults (carbohydrate 55–70%, protein–20%, and fat 15–25%). Also, the consumption of fruits, dairy prod-cts, and legumes was higher in this pattern than the traditionalietary pattern. In contrast, both older men and women adopting

able 3dds ratio (OR) with 95% confidence interval (CI) for functional disability by dietary patte

Men (n = 327)

Modified traditional (n = 136)versus traditional (n = 191)

P-val

ADL disabilityCrude 0.19 (0.08–0.48) 0.00Model 1b 0.17 (0.07–0.44) <0.00Model 2c 0.17 (0.05–0.56) 0.00

IADL disabilityCrude 0.66 (0.36–1.19) 0.16Model 1b 0.59 (0.32–1.10) 0.09Model 2c 0.96 (0.48–1.92) 0.90

NHANES, Korea National Health and Nutrition Examination Survey; ADL, activities of daa P value from logistic regression analysis.b Adjusted for age.c Adjusted for age, marital status, education level, household income, region, diabetes m

ndex, smoking, alcohol drinking, physical activity, and energy intake.

es.

robic physical activity [15].

traditional dietary pattern had more than two thirds of its percent

daily energy intake solely from white rice, with the proportion ofcarbohydrate intake comprising more than 75% of energy, above theKDRIs [17]. As derived patterns are unique to each study popula-tion and influenced by culture, it is difficult to compare the results of

rns of respondents aged ≥65 years, 2005 KNHANES.

Women (n = 460)

uea Modified traditional (n = 151)versus traditional (n = 309)

P-valuea

1 0.40 (0.20–0.80) 0.0101 0.42 (0.21–0.86) 0.0174 0.45 (0.23–0.90) 0.024

3 0.37 (0.24–0.56) <0.0016 0.39 (0.26–0.58) <0.0012 0.45 (0.28–0.72) 0.001

ily living; IADL, instrumental ADL.

ellitus, hypertension, stroke, angina or myocardial infarction, arthritis, body mass

1 ritas 7

dsr

ettocorfb[a

attiDcptfais

tuvscihsi

ddwstdta

C

saidvtphivs

C

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

64 J. Kim et al. / Matu

ietary pattern studies. However, previous studies and the currenttudy suggest that a better quality diet is associated with reducedisk of disability.

A high carbohydrate diet may increase the risk of glucose intol-rance and insulin resistance. Park et al. [18], based on data fromhe 2005 KNHANES, reported an increased risk of diabetes melli-us in Korean women consuming diet rich in carbohydrates (>70%f energy). In a recent meta-analysis, high levels of white riceonsumption were associated with a significantly increased riskf type 2 diabetes [19]. High carbohydrate intake through whiteice may increase insulin resistance, which is a major risk factoror sarcopenia [20] and metabolic abnormalities, including dia-etes mellitus [21], which in turn may lead to functional disability22,23]. Further studies are needed to elucidate the detailed mech-nisms.

Moreover, a high consumption of fruits in both men and women,nd of dairy products and legumes in women in the modifiedraditional dietary pattern may contribute to a reduced risk of func-ional disability. In a cohort study, intakes of dairy and fruit werenversely associated with risk of disability in ADL and IADL [5].airy products may reduce the risk of functional disability asso-iated with osteoporosis [24]. Antioxidants found in fruits mayrevent free radical damage and, thus, decrease the risk of func-ional decline [25]. In a cross-sectional study, older women withrequent consumption of legumes and soy products demonstrated

reduced risk of IADL disability [26]. Soy components, such assoflavones, may positively affect muscle mass, acting as phytoe-trogens [27].

In interpreting the results of this study, several limitations needo be considered. First, one day 24-h dietary recall might not eval-ate usual intake because it cannot be corrected for day-to-dayariation of participants in food consumption. Second, it is pos-ible that there was residual confounding. Other covariates notonsidered in this study, such as depressive symptoms, cognitivempairment, and other unknown risk or protective factors, couldave affected the relationship. Finally, this was a cross-sectionaltudy so that caution should be exercised in making any causalnferences.

In conclusion, we found that the Korean modified traditionalietary pattern was associated with a decreased risk of ADLisability in older men and ADL/IADL disability in older womenhen compared with the traditional dietary pattern. Our findings

uggest that the modified traditional dietary pattern, meetinghe current Korean diet recommendations, may play a role in theisablement process in late life. Longitudinal studies are warrantedo better understand the relationship between dietary patternsnd disability.

ontributors

J. Kim participated in the conceptualization and design of thetudy, data analysis, interpretation of data, writing of the paper,nd have seen and approved the final version. Y. Lee participatedn the conceptualization and design of the study, interpretation ofata, writing of the paper, and have seen and approved the finalersion. S.Y. Lee participated in the design of the study, interpreta-ion of data, and have seen and approved the final version. Y.O. Kimarticipated in the design of the study, interpretation of data, andave seen and approved the final version. Y-S. Chung participated

n the interpretation of data and have seen and approved the finalersion. S.B. Park participated in the interpretation of data and haveeen and approved the final version.

ompeting interest

The authors declare no conflict of interest.

[

[

6 (2013) 160– 164

Funding

This work was supported by the Basic Science Research Pro-gram through the National Research Foundation of Korea (NRF),funded by the Ministry of Education, Science and Technology (No.2012R1A1B3002939). The sponsor of the study did not have rolesin study design; data collection, analysis, and interpretation; orwriting of the report.

References

[1] Statistics Korea Population projections, http://kosis.kr/nsikor/view/stat10.do,2012.

[2] Guralnik JM, Fried LP, Salive ME. Disability as a public health outcome in theaging population. Annual Review of Public Health 1996;17:25–46.

[3] Rowe JW, Kahn RL. Successful aging. Gerontologist 1997;37:433–40.[4] Milaneschi Y, Tanaka T, Ferrucci L. Nutritional determinants of mobility. Cur-

rent Opinion in Clinical Nutrition and Metabolic Care 2010;13:625–9.[5] Houston DK, Stevens J, Cai J, Haines PS. Dairy, fruit, and vegetable intakes and

functional limitations and disability in a biracial cohort: the atherosclerosis riskin Communities Study. American Journal of Clinical Nutrition 2005;81:515–22.

[6] Vercambre MN, Boutron-Ruault MC, Ritchie K, Clavel-Chapelon F, Berr C. Long-term association of food and nutrient intakes with cognitive and functionaldecline: a 13-year follow-up study of elderly French women. British Journal ofNutrition 2009;102:419–27.

[7] Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology.Current Opinion in Lipidology 2002;13:3–9.

[8] Féart C, Pérès K, Samieri C, Letenneur L, Dartigues JF, Barberger-Gateau P.Adherence to a Mediterranean diet and onset of disability in older persons.European Journal of Epidemiology 2011;26:747–56.

[9] Xu B, Houston D, Locher JL, Zizza C. The association between Healthy Eat-ing Index-2005 scores and disability among older Americans. Age and Ageing2012;41:365–71.

10] Kim S, Moon S, Popkin BM. The nutrition transition in South Korea. The Amer-ican Journal of Clinical Nutrition 2000;71:44–53.

11] Villegas R, Liu S, Gao YT, Yang G, Li H, Zheng W, et al. Prospective study of dietarycarbohydrates, glycemic index, glycemic load, and incidence of type 2 dia-betes mellitus in middle-aged Chinese women. Archives of Internal Medicine2007;167:2310–6.

12] Ministry of Health and Welfare, Korea Institute for Health and Social Affairs.The Third Korea National Health and Nutrition Examination Survey (KNHANESIII), 2005: Summary. Seoul. Ministry of Health and Welfare, Korea Institute forHealth and Social Affairs; 2006.

13] National Rural Living Science Institute, Rural Development Administration.Food composition table. 6th revision Gyeonggi-do: National Rural Living Sci-ence Institute, Rural Development Administration; 2001.

14] Song Y, Joung H. A traditional Korean dietary pattern and metabolicsyndrome abnormalities. Nutrition, Metabolism & Cardiovascular Diseases2012;22:456–62.

15] WHO. Global recommendations on physical activity for health. Geneva: WHOPress; 2010.

16] Newman AB, Brach JS. Gender gap in longevity and disability in older persons.Epidemiologic Reviews 2001;23:343–50.

17] Korean Nutrition Society. Dietary reference intakes for Koreans. Seoul: KookjinPress; 2005.

18] Park SH, Lee KS, Park HY. Dietary carbohydrate intake is associated with car-diovascular disease risk in Korean: analysis of the third Korea National Healthand Nutrition Examination Survey (KNHANES III). International Journal of Car-diology 2010;139:234–40.

19] Hu EA, Pan A, Malik V, Sun Q. White rice consumption and risk of type 2diabetes: meta-analysis and systematic review. BMJ 2012;344:e1454.

20] Guillet C, Boirie Y. Insulin resistance: a contributing factor to age-related musclemass loss? Diabetes and Metabolism 2005;31(Spec No 2), 5S20-26.

21] Reaven G. Metabolic syndrome: pathophysiology and implications for manage-ment of cardiovascular disease. Circulation 2002;106:286–8.

22] Janssen I, Heymsfield SB, Ross R. Low relative skeletal muscle mass (sarcope-nia) in older persons is associated with functional impairment and physicaldisability. Journal of the American Geriatrics Society 2002;50:889–96.

23] Wu JH, Haan MN, Liang J, Ghosh D, Gonzalez HM, Herman WH. Dia-betes as a predictor of change in functional status among older MexicanAmericans: a population-based cohort study. Diabetes Care 2003;26:314–9.

24] Heaney RP. Calcium, dairy products and osteoporosis. Journal of the AmericanCollege of Nutrition 2000;19(Suppl. 2):S83–99.

25] Cesari M, Pahor M, Bartali B, Cherubini A, Penninx BW, Williams GR,et al. Antioxidants and physical performance in elderly persons: the Invec-chiare in Chianti (InCHIANTI) study. American Journal of Clinical Nutrition2004;79:289–94.

26] Kim J, Lee Y, Lee SY. Legumes and soy products consumption and functionaldisability in older women. Maturitas 2011;69:268–72.

27] Lemoine S, Granier P, Tiffoche C, Rannou-Bekono F, Thieulant ML, DelamarcheP. Estrogen receptor alpha mRNA in human skeletal muscles. Medicine andScience in Sports and Exercise 2003;35:439–43.