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Int. J. med. Appl.health. Vol. 1, No.1, 2013

ASSESSMENT OF NUTRITIONAL STATUS OF GERIATRIC POPULATION IN SARGODHA CITY 1

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Abdul Ghani , SarfrazHussain , Muhammad Zubair 1 Department of Medical Nutrition and Dietetics Sargodha Medical College, University of Sargodha, Pakistan 2 Institute of Food Science and Nutrition, University of Sargodha, Pakistan 3 Department of Statistics, University of Sargodha, Pakistan *Address for Correspondence:[email protected] ABSTRACT This study was conducted to assess the nutritional status of geriatric people aged 60 years and above in four Union Councils of Sargodha city. A representative sample of 380 subjects (randomly selected) was studied out of which 209 were males and 171 were females. Nutritional status was evaluated by anthropometric measurements to calculate the body mass index, mid-arm circumference, calf circumference and by data collected through the Mini Nutritional Assessment (MNA). The MNA results revealed that 5.53% of subjects were malnourished and 42.10% were at risk of malnutrition. Malnutrition was more prominent in males (3.16%) as compared to the females (2.37%) of same age group. The prevalence of malnutrition was significantly higher in upper age group of geriatric (80 years and above) population. Age factor was negatively associated with the nutritional status. Mini-nutritional Assessment appears to be a practical and reliable method to assess the nutritional status of elderly people but could not detect yet surplus nutritional problems in elderly. Gender, loss of appetite, development of neuropsychological problems like dementia and depression, etc., dental problems, mode of feeding and level of difficulty in feeding, self-view of health and nutrition status, daily consumption of more than three prescriptions of drugs, daily number of full course meals, body mass index, all correlated significantly (0.05-.001) with MNA screening score. Early identification of malnutrition in the community followed by necessary medical and social interventions could ameliorate the nutritional status of old people and consequently their health and quality of life. Management requires a holistic approach and underlying causes such as chronic illness, depression, medication and social isolation must be treated. Keywords: Nutritional Status, geriatrics, malnutrition, Mini-Nutritional Assessment

satisfy their medical and physiological needs. The disease burden in our elderly is high and some data is available regarding common diseases in the elderly but by and large most numbers are observational. Majority of elderly in Pakistan have a sedentary lifestyle which may play a significant role in immobility disorders, loss of muscle mass and falls, which are common geriatric syndromes. There is little data on depression in the elderly because of the stigma associated to mental illnesses. Dementia may also be presenting later as most elderly patients depend on their families for shopping, transportation and financial interactions leading to a delayed manifestation of functional decline. Nutritional status can be assessed by using Mini Nutritional Assessment (MNA) Questionnaire. To the best of the knowledge of the researcher, there is no study available regarding the assessment of nutritional status of geriatric population using MNA in Pakistan. It is the dire need of the hour to develop medical and social programs for our elderly that help meet their needs at their doorsteps. The objective of this study was to assess the nutritional status of

INTRODUCTION Average life expectancy throughout the world is increasing year by year leading to an overall increase of geriatric population. Goals of improving the quality of life for all, reducing mortality and morbidity rates and increasing the life span are emphasized in all regions of the world. The worldwide rise in the population of elderly people has also made its impact on Pakistan. With limited resources and a poor knowledge of aging and its problems, Pakistan is facing many challenges in the care of its elderly population. Geriatric medicine is not recognized as a separate specialty in Pakistan. Older patients are seen and treated by general practitioners or other doctors of different specialties. There is no comprehensive care. Elderly patients often receive fragmented treatment. No inpatient rehabilitation centers and geriatric wards in the hospital exist for patients with strokes, fractures, and other geriatric disorders. Outpatient physical therapy services are however widely available but use is limited. Our elderly does not receive the desired medical attention which can

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Abdul Ghani ,Sarfraz Hussain , M Zubair

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geriatric population 60 years of age and above. The results are expected to help in designing policies and making plans regarding health care provision for the elderly in Pakistan.

bent at 90 angles (Anonymous, 1997). Mid upper arm circumference was measured as the circumference of the right upper arm in the middle. The body mass index (BMI) was calculated from an individual's weight in kilogram divided by the square of the height in meters. Nutritional status of geriatric population was accessed by using mini nutritional assessment which is an instrument designed for elderly people (Guigozet al1996). MNA is a rapid and simple tool with high sensitivity (96%) and specificity (98%) to determine nutritional status of elderly persons (Gazzottet al 1997; Compan, 1999; Rubenstein, 1999). Data Collection and Statistical Test: Data was collected from the subjects aged 60 years and above at their homes. The data thus, collected was analyzed using a statistical packages for social sciences and the results were tabulated. For testing of homogeneity in the response of males and females, Pearson Chi-Square test was applied. SPSS version 20 was used to find that bivariate relation in responses. P-Value from 0.05-0.001 was taken in the testing.

MATERIALS AND METHODS Research Design: This study was cross sectional and nutritional status assessment was done by using 18 items (30 points) Mini Nutritional assessment (MNA). MNA scale includes questions regarding appetite, mobility, acute and chronic illness, medication history, dietary history, anthropometric measurements (Body Mass Index, Mid Upper Arm Circumference and Mid-Calf Circumference etc). Research Instruments and Types: Standard mini nutritional assessment questionnaire was the research instrument used in this study. Population: In the present study, Nutritional Status of geriatric population of age 60 and above was assessed. This study was conducted in four selected Union Councils (Satellite Town, Factory Area, Tariq Abad and Block No. 25) of Sargodha city (Punjab, Pakistan). The total population of Sargodha city is 1,023,000 and the population of our selected UC’s is 200,000 (Anonymous, 2010). The total geriatric population in the four Union Councils is 12,000 (6% of general population) (Saniya et al2010). Sample and Sampling Techniques: In the study, two stage sampling scheme was used. At first stage, four Union Councils were selected at random out of 22 Union Councils in Sargodha city. In the second stage, stratified random sampling with equal allocation was used and selected 400 individuals randomly aged 60 years and above, 100 from each Union Council. Data was collected by home visits along with the team of researcher after taking the consent of the individuals. 380 subjects participated in this study. Research Instruments and Types: Standard mini nutritional assessment questionnaire was the research instrument used in this study (attached as Appendix-A). All anthropometric measurements were taken in duplicate by trained interviewers and an average of two measurements was calculated. Weight of subjects was recorded on a calibrated scale to the nearest 100 gram. Height was recorded using a stadiometer. Calf circumference was measured to the nearest 0.5 cm at the largest circumference of the calf with the knee and ankle

RESULTS The Table 1 reveals that in the total sample of 380 people, 160 subjects (42.10%) were at risk of malnutrition (MNA score between 17 and 23.5 points). 21 subjects (5.53%) were malnourished. Their MNA score was less than 17 points. 199 subjects (52.37%) were well-nourished. Their MNA score was above 24 points.Table 2 reveals that 88 males (23.16%) and 72 females (18.95%) were at risk of malnutrition. 3.16% males and 2.37% females were suffering from malnutrition. Males were predominant and had poor nutritional status as compared to females of same age group The results are significant at P-value 0.05-0.001 (Table 3). Table 4 reveals that among the 60-70 years subgroup, there were 93 males (54.71%) and 77 females (45.29%). In age subgroup of 70-80 years, there were 80 males (55.17%) and 65 females (44.83%) and in the age subgroup of 80 years and above, males were 36 (55.38%) and females were 29 (44.62%). Thus, total males in all age subgroups were 209 (55%) and females were 171 (45%).The results are significant at P-value 0.05-0.001 (Table 5).

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Table I: Distribution of subjects (total) and their nutritional status as per MNA score

%

Subjects

%

Malnutrition Subjects

%

%

380

100

Percent

Female

Percent

Male

Percent

Female

Percent

Male

Percent

Female

Percent

Male

199 52.37 160 42.10 21 5.53 Table:2 Distribution of subjects (male and female) and their nutritional status Well Nourished At Risk of malnutrition Malnutrition

Total

Percent

Subjects

At Risk of malnutrition

Total

Well-Nourished

109 28.68 90 23.68 88 23.16 72 18.95 12 3.16 9 2.37 380 100 Table: 3 Analyses of variance for distribution of subjects according to gender in different age subgroups Chi-Square Tests Pearson Chi-Square Value

df

P-value

122.380 2 0.000*** Results are significant at (0.05-0.001), where *=0.05,**=0.01 and ***=0.001. Table: 4 Distribution of subjects according to gender in different age subgroups Age Subgroup Male Percent Female Percent Total Percent 60-70 93 54.71 77 45.29 170 44.74 70-80 80 55.17 65 44.83 145 38.15 80 and above 36 55.38 29 44.62 65 17.11 Total 209 55 171 45 380 100 Table: 5 Analyses of variance for distribution of subjects according to their nutritional status of all age subgroups Chi-Square Tests Pearson Chi-Square Value df P-value Well nourished 63.815 2 0.000*** At Risk of malnutrition 53.094 4 0.000*** Malnutrition 11.700 4 0.020* Results are significant at (0.05-0.001), where *=0.05,**=0.01 and ***=0.001.

Percent

Female

Percent

Male

Percent

Female

Percent

Male

Percent

Female

Percent

58

34.12

50

29.41

33

19.41

25

14.71

2

1.18

2

70-80

39

26.90

32

22.07

37

25.52

31

21.38

4

2.76

2

80 & 12 above Total 109 Grand Total

18.46

8

12.31

18

27.69

16

24.62

6

9.23

5

28.68

90 199

23.68 52.37

88

23.16

72 160

18.95 42.10

12

3.16

9 21

1.1 8 1.3 8 7.6 9 2.37 5.5 3

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Percent

Male

60-70

Total

Age Subgroup

Table :6 Distribution of subjects according to their nutritional status of all age subgroups Well Nourished At Risk of malnutrition Malnutrition

170

100

145

100

65

100

380 380

100 100


Table. 6 revealed the status of nutrition in all age subgroups under study. In the subgroups of age 6070 years 58 males (34.12%) and 50 females (29.41%) were well nourished. 33 males (19.41%) and 25 female (14.71%) were at the risk of malnutrition. 2 male (1.18%) and 2 female (1.18%) were found to be suffering from malnutrition. In the age subgroup of 70-80 years, 39 males (26.90%) and 32 females (26.90%) and 32 females (22.07%) were well nourished. 37 males (25.52%) and 31 females (21.38%) were found at risk of malnutrition. 4 males (2.76%) and 2 females (1.38%) were found to be above, 12 males (18.46%) and 8 females (12.31%) were well nourished. 18 males (22.69%) and 16 females (24.62%) were at risk of malnutrition. In same age subgroup, 6 males (9.23%) and 5 females (7.69%) were found to be suffering from malnutrition. DISCUSSION

age group is moredependent, less mobile and was suffering from different type of diseases like Hypertension, Diabetes Mellitus, Ischemic Heart Disease, Acid Peptic Disease, Dementia, Dental Problems and difficulties in intake of diet. Furthermore, this group was most isolated as compared to 60-70 years of age group. Physical immobility and social isolation further aggravates the problem. Sarah et al. (2005) conducted a cross-sectional study with the aim to measure the effect, if any of age, on nutritional status in elderly people. After adjusting for disability and co-mobility, age alone had a significant and independent effect on important anthropometric and biochemical nutritional assessment variables. They concluded that increasing age was independently associated with poor nutritional status. Baweja (2008) reported that as the age increases, malnutrition and risk of malnutrition increases. Similar trends of declining nutritional status with increasing age were present in study by Soiniet al (2004). In the present study, malnutrition was prominent in the males (23.16%) as compared to females (18.95%) of the same age group as per score of MNA. This factor was more prominent in at risk group of nutritional status. This observation was in accordance with Iftikharet al (2011), who reported in their cross sectional study that malnutrition was common in apparently healthy Pakistani men. Geriatric medicine is not recognized as a separate specialty in Pakistan. Older patients are seen and treated by general practitioners or other doctors of different specialties. There is no comprehensive care. Elderly patients often receive fragmented treatment. No inpatient rehabilitation centers and geriatric wards in the hospital exist for patients with strokes, fractures, and other geriatric disorders. Outpatient physical therapy services are however widely available but use is limited. Our elderly does not receive the desired medical attention which can satisfy their medical and physiological needs. The disease burden in our elderly is high and some data is available regarding common diseases in the elderly but by and large most numbers are observational. Majority of elderly in Pakistan have a sedentary lifestyle which may play a significant role in immobility disorders, loss of muscle mass and falls, which are common geriatric syndromes. There is little data on depression in the elderly because of the stigma associated to mental illnesses. Dementia may also be presenting later as most elderly patients depend on their families for shopping,

Nutritional status of geriatric population aged 60 years and above was assessed using Mini Nutritional Assessment (MNA) Questionnaire. All the subjects above 60 years were divided into three age subgroups as per convenience of the researcher. The study was conducted in four Union Councils of Sargodha city spreading on an area of 4 sq. km. There were 380 persons aged 60 years and above who were interviewed at their homes. Age subgroup of 60-70 years (44.74%) was in majority and the results obtained have been discussed in the light of available literature as under. In the present study, 5.53% subjects were suffering from malnutrition and 42.10% subjects were at risk of malnutrition as assessed with MNA. Similar results (5.8%) in older people living in community were reported in Germany (Kaiser et al 2010), (7.1%) in community dwelling elderly in India (Bawejaet al2008), (6.5%) in elderly living at their homes in Turkey (Ozgeet al2005). These results of present study (prevalence of malnutrition) differ from study of Beck and Ovesen (1998), which was conducted in a mixed population and the prevalence of malnutrition was 5-40%. The results of present study also differ from the results of the study of Rita et al. (2011) who conducted a cross sectional study in the elderly living in the community in Brazil and the prevalence of malnutrition was 1.3%. It was observed in this study that malnutrition was most common in upper geriatric age group (80 years & above males (9.23%) and females (7.69%)) as compared to lower geriatric age group (60-70 years age subgroup 1.18 % each males and females). This

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transportation and financial interactions leading to a delayed manifestation of functional decline. Good nutrition and a balanced diet can be beneficial for the elderly in many ways. Provision of good nutrition prevents many nutritional health problems; improve the management of some existence diseases; fastens recovery from many illnesses; increases mental, physical and social well-being. It may be difficult for some older persons to get enough food, especially if they are, dependant, poor, unable to drive and go outside. For an older person, a request for help may be equated to a loss of independence. Many eligible older people are missing meals and are poorly nourished simply because they don’t know of available resources to help them. Irregular meal patterns and weight loss, often caused by difficulties in preparing food (when they are living alone) are warning signs that malnutrition may be developing. Nasir (2008) reported that despite severe socioeconomic pressures, Pakistani society has stood for high value, respect and dignity of human life. Being the Pakistani, we regard old age as a mark of wisdom, esteem and faithfulness. This is due to the strong ties that exist in the joint family system strengthened by religious values dignifying the status of geriatric group of society. The constitution of Pakistan declares promotion of social and economic well-being of the elderly people as one of its main objectives. It is the duty of the state to provide basic necessities of life for those citizens who are unable to earn livelihood on account of sickness, infirmity or unemployment. Pakistan is heavily indebted as a result of world-wide economic recession and the process of globalization. The issue such as income security, housing and medical care for elderly have assumed increased importance.

challenge to the economy and social planning of the nation in coming years of which the Government is fully aware. Financial and Technical Assistance by international donors (like IMF and World Bank etc) can assist us in achieving the goals set for welfare of elderly (Nasir, 2008). To the best of the knowledge of the researcher, there is no study available regarding the assessment of nutritional status of geriatric population using MNA in Pakistan. It is the dire need of the hour to develop medical and social programs for our elderly that help meet their needs at their doorsteps. Such programs should also provide caregiver education, training and facilities to family members caring for their older relatives. This need was also highlighted by one study that surveyed local communities. Some interest in geriatric health has recently been generated in the medical community. Articles citing the health problems of the elderly have been published. These have highlighted some medical and social problems faced by our elderly. In addition some media (both print and other) has also focused their attention towards the elders in our society. At the end, however, we expect that efforts will be made for the improvement of medical care of our elderly population with the help of related knowledge and skill building of our medical professionals. This can be achieved by increasing health awareness of our public and allowing better access to appropriate preventive and medical care for our elderly. The present study was conducted only in four Union Councils of Sargodha city and may not be representative of elderly population of Pakistan. In order to accomplish the abovementioned tasks, further studies are needed in larger population from different geographical areas of Pakistan to reflect a representative sample with individuals from different socio-cultural background. Medical and social programs should be devised for our elderly to help meet their needs in the comfort of their homes. Health education should be given to the caregivers about nutrition and its principles i.e., dietetics. Emphasis should be given on print and electronic media to focus their attention towards the elders in our society. Geriatric should be taught at Undergraduate and Postgraduate level especially in public sector educational institutions. All the medical students should recognize for the teaching and learning geriatrics so that all Doctors are trained to understand the need of our elderly patients. All the paramedical health care providers like Dispensers, Nurses, Hospital Pharmacists, Physiotherapy Assistants, etc. should receive the Medical Training

WHO declared 2010 “Health for All” and one of their goal is to pay attention on elderly health (Krinke, 2005). Government of Pakistan views second world assembly on aging as an opportunity to identify gaps for re-designing strategies and to assess the progress made so far in achieving the desired goals and actions to fully support made by this Assembly at Madrid. But due to severe economic constraints, Pakistan is facing many difficulties to launch any developmental program. These problems has aggravated due to decrease in Pakistan exports after th 11 September 2009 developments. Therefore, it is very difficult to allocate resources for social development, thus, increasing dependence on international financial assistance. Aging will pose a

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of the common medical problems in old age people. Public awareness towards the needs of elderly should be enhanced through Radio, Television, Internet, Free Seminars, etc. at hospital and Universities via patient and family education. Community education programs should be initiated to help families understand common geriatric illnesses like dental problems, Diabetes Mellitus, Obesity, Fractures, Eye diseases and Hypertension etc. All the elders should be encouraged to take part in part-time teaching and in charity work so that the healthy elders may contribute towards society. Elders helping elders could be another low cost feasible programme. To develop a program on the line of World Health Organization (WHO); vision for the health of the elderly that encourages community participation and focuses on the combined role of Government, Institutional and Community Participation. Old age benefit schemes should be strengthened. Supply of medicines on rebates could be a useful step for the reduction of hardships. Modern science has shown the way to grow old with grace and good health and as a useful member of the society. The elderly must remain active, promote and improve friendships, see their prayers regularly, recite the Holy Quran, have positive thinking, take balanced diet, have adequate rest and realize their limitations. CONCLUSIONS

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REFERENCES Anonymous.1988. Survey of Elderly, A Case Study of Lahore District, Lahore (M/S Ideal Consultancy Agency, Arbi, Ghulam Shabbir). Pakistan, Special Education and Social Welfare Division. Anonymous 1990. Survey of Elderly, A Case Study of Islamabad (Draft), Islamabad. Pakistan, Special Education and Social Welfare Division. Anonymous 1997. Obesity: preventing and managing the global epidemic. Report on consulting meeting. World Health Organization. Anonymous 2001. Federal Bureau of Statistics. Pakistan Demographic Survey. Anonymous 2003. Sex and Age Distribution of World Population. Volume II.Department of Economic and Social Affairs, Population Division, ST/ESA/SER.A/180, New York, USA. World Population Prospects, The 2002 Revision. Anonymous 2003. World Population Prospects. Calculated on the basis of UN. Baweja, S., H. Agarwal, A. Mathur, J.R.Haldiyaa, and A. Mathur, 2008. Assessment of Nutritional Status and Related Risk Factors in Community Dwelling Edlerly in Western Rajasthan. Journal of the Indian Academy of Geriatrics, 5-13. Beck, A.M., L. Ovesen, and M. Osler, 1999. The mini nutritional assessment (MNA) and the determine your health checklist (NSI checklist) Compan, B., A. Dicastri, J.M.Plaze, and F. ArnaudBattandier, 1999.Epidemiological study of malnutrition in elderly patients in acute, subacute and long-term care using the MNA.Journal of Nutrition Health Aging, 3:14651. Iftikhar, A., L. Anis, P. Graham, and P. Parvez, P. 2011. Relationship between anthropometric variables and nutrient intake in apparently healthy male elderly individuals: A study from Pakistan. Nutrition Journal.10:111. Kaiser, M.J., J.M. Bauer, C.Ramsch, W.Uter, Y. Guigoz, Y., T. Cederholm, D.R. Thomas, P.S. Anthony,

The prevalence of malnutrition (by MNA) is significantly higher in upper age group of geriatric (80 years and above) population. Age factor is negatively associated with the nutritional status. Mini Nutritional Assessment (MNA) appears to be a practical and reliable method to assess the nutritional status of elderly people. Management of malnutrition in the elderly population requires the involvement of multiple disciplines for its diagnosis and treatment. Recommendations Necessary Steps should be taken for the 1.

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more sensitive so that MNA can be applied in a better way in the community. Merger of nutritional management with clinical practice and establishment of geriatric wards in the hospitals. In the light of the growing number of elderly in Pakistan there many peoples who will be malnourished, so additional studies must be carried out to assess these and other alternative solutions.

Enrichment of the food with specific micronutrients including iron, iodine , vitamin B6, E and long term provision of β carotene Assessment of nutritional status of the elderly population in the community using simple tools. Modification of MNA including its validity and reliability testing and comparing to other nutritional status indicators that are

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K.E. Charlton, M. Maggio, A.C. Tsai, B.Vellas, and C.C. Sieber, (2010). Frequenc of malnutrition in older adults: A multinational perspective using the mini nutritional assessment. Journal of Geriatric Society, 9:1734-8. Krinke, U.N. 2005.Nutrition and the elderly. In: Brown J.E. Nutrition through the life cycle 2nd Edition. Belmot CA; Thomson Wadsworth.420-41. Nasir, S. 2008. The situation of elderly population in Pakistan: Problems and Prospects. PJSE. Available on http://www.specialsedu.com/2011/01/situatio n-of-elderly-population-in. html th Assessed on 2012 August 10 . Nasir, Z.M. and S.M. Ali, 2000.Labor Market Participation of the Elderly. The Pakistan Development Review, 4: 1075-1086. Ozge, K., K. Eda, R.Neslisah, and P. Gulden, 2005.Assessment and evaluation of the nutritional status of the elderly using two different instruments. Saudi Med J, 10:1611-16. Rita, S.V.R., I.D.R. Maria, and C.B. Mary, 2011.Malnutrition and associated variables in an elderly population of Criciuma SC. Rev. Assoc. Med. Bras.1. Saniya, R. and A. Gohar, 2010. Ageing in Pakistan A new challenge. Ageing International, 1-5. Sarah, F. and G. Salah, 2005. Age as a determinant of nutritional status: A cross sectional study. Nutritional Journal, 4:28. Soini, H., P. Routasalo, and H. Lagstrom,2004.Characteristic of the mininutritional assessment in elderly home care patients.European Journal of Clinical Nutrition, 58:64-70. Rubenstein, L.Z. 1999. Comprehensive geriatric assessment (CGA) and the MNA: the overview of CGA, nutritional assessment and development of a shortened version of the mini-nutritional assessment. In: Vellas B., Garry P.J. and Guigoz Y. (1999). Mini nutritional assessment: research and practice in elderly. Nestle clinical and performance nutrition workshop series. Basel: Karger, 1:101-106.

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