Nutritional status of older persons in different settings in greater Khartoum.

Salih, Osama A.

Abstract

Nutrition is important to the health and functioning of elderly people. This paper describes the general nutrition situation of the Sudanese older people and estimates those who suffer from under nutrition and outlines the insidious effects of this form of malnutrition. It describes the physiological and practical difficulties elderly people face in achieving good nutrition, and the challenge this poses to health workers in different settings.

The objective was to assess the nutritional status and the risk factors and the nutritional vulnerability of the old people (60 years and above) in different settings in Greater Khartoum. Results indicate the prevalence of malnutrition among elderly in all settings (free living subjects in high and low socioeconomic classes; IDP camps and nursing homes) with varying degrees. The paper discussed the demographic characteristics of the older people in addition to family life, health problems as well as the food habits (number of meals, ability to get and prepare food etc). The paper reflects on the functional abilities of the older persons such as hearing and vision problems, manual dexterity, mobility, coordination and disability with all its forms.

Introduction

Both the number and the proportion of older persons--defined as aged 60 and over are growing in virtually all countries, and worldwide trends are likely to continue unabated (WHO, 2004).

Malnutrition is a highly prevalent problem, particularly in older persons (ENHA, 2005). Moreover, attempts to provide them with adequate nutrition pose many practical problems (Holmes, 2004). Estimates of the prevalence of malnutrition vary across studies, as methods for detection are not standardized and much of malnutrition goes undetected. Prevalence of malnutrition may reach 60% in hospitals and nursing homes (Vellas et al., 2004; Guigoz et al. 1996).

In general, underweight in older persons is associated with increased risk of morbidity and mortality (Persson et al. 2002; Eastwood et al. 2002).The death risk is two to four times higher in malnourished elderly people because malnutrition paves the way to worsening of previous diseases or to additional diseases, mainly infectious diseases

Many studies conducted in European countries and other parts of the world showed that 15% of older adults living in the community were suffering from malnutrition (Hajjar et al, 2004) while Ryan et al, (1992) found higher value of 37-40%.

Studies suggest up to 62-70% of cases of malnutrition go unrecognized in hospitalized patients of all ages (Kelly, 2000; Mowe et al, 1991). This was attributed to the Lack of systematic assessment for malnutrition however, 40% of hospitalized elderly were found malnourished upon admission according to Mc Whiter et al, (1994).

For older persons in nursing homes a prevalence of 60-100% malnutritibn was detected (Stratton, 2005; King et al.2004; Abbasi et al, 1991). Studies showed that up to 10% of nursing home residents lose 5% of their body weight within one month and 10% of their body weight within 6 months of admission to a nursing home (Blaum et al, 1995).

The concept of healthy ageing implies a holistic approach to health with a balance between physical, intellectual, social, emotional and mental well-being. It also aims at decreasing dependency of older persons by emphasizing avoidance of health-damaging habits and practices and adopting regular organized physical activities (Beckingham and Watt, 1999; Sallis et al 1998).

In Sudan, according to UN statistics (2002) elderly population (60+) was 5.5% in year 2000 and with a growth rate of 3.4 is projected to reach 7.9% in 2025.

There have been few studies (up to M.Sc. level) from Sudan which have dealt with age trends in anthropometric characteristic among the elderly individuals. However, to date, there is no detailed study on variation of circumference and skin fold measure by age and gender simultaneously in the elderly.

Research Methodology

This cross-sectional study was characterized as descriptive, with a sample of 265 randomly selected older persons aged from 60 to 80+ years, proportionally stratified by groups from the community (free-living subjects from high and low level classes), older persons living in governmental nursing homes. And Older persons living in two camps for internally displaced (IDP); Campl (Carton Barona, originally from Western Sudan) and Camp2 (Carton Kassala, originally from the Southern Sudan).

A questionnaire was used in an individual interview to obtain information on the socio-demographic characteristics (age, marital and economical status, family organization and income, and educational level), health indicators (subjective perceived health and self-reported health problems, physical activity and disability) and health risk factors.

The measurements of body mass and stature allowed for computing body mass index (BMI), used as a parameter for nutritional status Anthropometric Measurements: Measures for Weight, Heights, Arm span and/or MUAC were used for determining the Body Mass Index (BMI). Cutoff points suggested by Ismail and Manandhar (1998) and The WHO Expert Committee on Physical Growth classifications: mild underweight (BMI = 17.00-18.49 kg/m2), moderate underweight (BMI = 16.00-16.99 kg/m2), and severe underweight (BMI < 16.00 kg/m2). These three groups are considered to be chronically energy deficient. For overweight, the categories are as follows: Grade 1 (BMI = 25.00-29.99 kg/m2), Grade 2 (BMI = 30.00-39.99 kg/m2), and Grade 3 (BMI > 40.00 kg/m2), UN ACC SCN (2000).

Obstacles: research in this field of elderly is new in Sudan, and there was no published baseline data on ageing population in Sudan and/or their nutritional status was available. Access was denied for researcher and/or volunteers for security reasons particularly, to older persons living in IDP camps. Unavailability of reference values and/or standards for Sudanese older persons. And variation among older persons with respect to their body measurements, age, sex, tribal and place of origin, previous life style, etc.

Findings and discussion

Age distribution

The majority (60-86%) of the older person's age ranged between 60 to 69 years, while those in the age range of 70 to 79 years were 20 to 29% respectively. Those whose age was above 80 years were relatively few (2 to 18%).

Results for IDPs Camp1 (Barona) showed different pattern of age distribution where, the majority of the older persons (48%) were in the age above 80 years (Table 1).

Socio-economical characteristics of the older persons Marital status

One of the most characteristic features of the older persons in Sudan is the marital status (Table 2). For the free-living older persons, results showed that 71.7% of them were married and 24.2% were widowed. Almost similar results were observed in Camp2 (Carton Kassala) where, 81.2% were married and 13% widowed.

Different results were obtained for the older persons living in the governmental nursing home and those of Camp2. In the nursing home, 43.8% were single; 31.2% divorced and only 25% were married. In Camp2, most of them (69%) were females, who came from the Southern Sudan, 58 % of them were widowed.

Family life

The family life for all older persons under investigation (except those living in the government nursing homes), showed common features (Table 3), i.e. the majority of them were living with families, with caregivers always around. Most of them were responsible for taking care of the young children, doing household activities (such as purchasing food and cooking it for the family). Nearly all of those living in camps have low budget for food and about 60% of them have no job and the rest were doing temporary or marginal jobs.

Food Habits

Number of Meals per day

As shown in table 4, numbers of meals per day taken by the elderly under investigation indicated that, the majority used to have only two meals per day (50% free living; 50% residential homes; 61.1% in Camp1 and 80% in Camp2).

Ability to get and/or prepare food

Of the free living older persons, 60% were found able to get and/or prepare their own food while more than 40% of the elderly living in the IDP camps were not able.

Almost half of the free-living older persons used to eat alone while; those in the camps (81.5%) were lucky to have people around to eat with them.

Rejected foods; food given away to others and/or preferred other types of foods, were problems that seemed to be faced only by the older persons living in the IDP camps.

Only small numbers of older persons were found in need of help with eating, and most of them were in the residential homes (31.3%).

a--Body Mass Index (BMI) for the free-living older persons:

As shown in Table 5, no acute malnutrition (BMI < 16) was found; only 3% were of moderate malnutrition (BMI=16 - 16.99) was found among female subjects. Mild malnutrition was common respectively among 13.3% and 6.7% of males and females of the high socio-economic class, compared to 20 and 16.7% of males and females of the low socio-economic class.

In developing countries there is some evidence that individuals with a BMI below 18.5 kg/m2 show a progressive increase in mortality rates as well as increased risk of illness (Rotimi et al. 1999).

The overall malnutrition among groups of older persons in both classes was found to be 16.7% in males and 15% in females. These results were almost similar to those found in USA, (Ageing Network, 2007) Normal nutritional status (BMI= 18.5 - 24.99) among older persons living in high class was 30% and 26.6% for males and females respectively, compared to 60% and 53.3% for males and females of low class. For both classes the percentage of the normal nutritional status was 45% and 40% for males and females respectively.

Results showed that older persons who's BMI was > 25 (overweight), were more common among females particularly those living in the higher socioeconomic class (56.7% and 66.7% for males and females and 20% and 23.3% for males and females of the lower socio-economic class).

b--Body Mass Index (BMI) for the older persons living in the governmental nursing homes

Results for this group indicated that, 37.5% of the older persons in these nursing homes were acutely malnourished; 25% of them were mildly malnourished; 31% were normal and 6.3% were classified as overweight. Results were in accordance with those obtained by many authors (Stratton et al. 2003; King et al.2004; Abbasi et al, 1991)

c--Body Mass Index (BMI) for the older persons in camp2 (carton Kassala)

BMI results for this group showed that, only 18% of the older persons were of normal nutritional status. Overall malnutrition was very high (4% acute; 17% moderate and 57% mild malnutrition). In addition, 4% were found to be overweight (BMI > 25

Functional Abilities

The most common of the functional abilities (Table 6) was poor strength which amounts to 43% of the free-living older persons; 27.8% of those living in the camps. This result is inline with that of the difficulty in mobility which is also common among 37% and 27.8% for free living elderly and those living in the camps respectively.

Poor coordination and poor manual dexterity were common among 20% of all the older persons under study.

Health problems of the older persons

There were many common health problems found among most of the studied elderly groups (Table 7). The severity of these problems varies from one setting to another. For instance, weak vision was found to be among 21.7% of the free living older persons; 28% of older persons in Camp2; 43.8% of those living in the nursing homes and 50% for those living in Camp l. Dental problems was the second most common health problem among the elderly in Sudan where, 48.3% of the free living older persons; 31% from the nursing homes; 58% from Camp2 and 69.8% of those in Camp 1 complained from this health problem.

Mobility problems and difficulties in movement as a result of certain disease and/or ageing process (joint's pain, osteoporosis, gout, etc.) were common specially among older persons living in the residential homes (43.8%); in Camp1 (27.8%); and 37.5% for the free living older persons.

Diabetes and hypertension were less common among older persons particularly those living in the IDP camps (originally from the Western and Southern tribes). The highest percentages of those having diabetes and hypertension (15.8% and 17.5% respectively) were from the free living respondents.

Other health problems such as, loss of appetite, constipation, as well as the different types of infections (skin infections, acute respiratory tract infection and GIT infections), were more common among the elderly living in the IDP camps.

References

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Osama A. Salih (Nutrition Center for Training and Research (NCTR), Ahfad University for Women)

Table No 1. Age distribution of older persons

Age in Community Community Total
Years A B (A +B) %
 (high class) (low class)
 % %

60-69 80 38 86
70-79 20 20 32
>80 -- 2 2

Age in Nursing Campl Camp2
Years homes % %
 %

60-69 62.5 13.9 60
70-79 18.8 29.6 29
>80 18.8 48.2 11

Table No 2. Marital status

Marital Community A Community B Total
status (high class) (low class) (A +B)
 % % %

Single 0 8.3 4.2
Married 76.7 66.7 71.7
Divorced 0 0 0
Widowed 23.3 0 24.2

Marital Nursing Camp1 Camp2
status homes % %
 %

Single 43.8 0 2
Married 25 81.4 13
Divorced 31.2 5.6 2
Widowed 0 13 58

Table No 3. Family Life

Family Life Total (A+B) Camp1
 % %

Live alone 5 13
Care givers 89 94.4
Looking after grandchildren 39 61.1
Doing household activities 59 41.7
Children far away 66 30.6
Low budget for food -- 82.4
Dept -- 64.8
Buying food for family -- 41.7
No job -- 68.5

Table No 4. Food Habits

Food Habits Total (A +B)% Camp1

Able to get and prepare food 66 57.4
Three meals per day 50 38.9
Eating alone 51 18.5
Do not like food 9 58.3
Reject food -- 58.3
Prefer other food -- 58.3
Give food to others -- 66.7
Needs help with eating 12 17.6

Nutritional Status Assessed Using the Body Mass Index (BMI)

Table No 5. Body Mass Index (BMI) of older persons

BMI Nutritional Community Community
 Status A B
 (high class) (low class)
 % %

 Malnutrition M F M F
<16 Acute 0 0 0 0
16-16.99 Moderate 0 0 0 6.7
17- 18.49 Mild 13.3 6.7 20 16.7
18.5-24.99 Normal 30 26.6 60 53.3
>25 Overweight 56.7 66.7 20 23.3

BMI Nutritional Total Nursing Camp2
 Status (A + B) homes %
 % %

 Malnutrition M F M + F M + F
<16 Acute 0 0 37.5 4
16-16.99 Moderate 0 3.3 -- 17
17- 18.49 Mild 16.7 11.7 25 57
18.5-24.99 Normal 45 40 31.3 18
>25 Overweight 38.3 45 6.3 4

M = male, F = female

Table No 6. Functional ability

Functional ability Total
 (A + B)% Camp1%

Needs help with eating 12 17.6
Poor strength 43 27.8
Poor manual dexterity 18 23.1
Poor coordination 21 23.1
Disability 12 11.1
Injuries 22 20.4
Mobility 37 27.8
Less exposure to sunlight 15 26

Table No 7. Different Types of Health Problems by Different Settings
of Older Persons

Health Community A Community B Total
Problems (high class) (low class) (A + B)
 % % %

Weak vision 6.7 36.7 21.7
Hearing 5 -- 2.5
Dental 36.7 60 48.3
Mobility 38.3 26.7 32.5
Disability -- 6.6 6.7
Blood pressure 15 16.7 15.8
Diabetes 15 10 17.5
Loss of appetite 6.7 -- 3.3
GIT -- -- 21
Constipation -- -- 31
Osteoporosis -- -- 9
Infection/Fever -- -- 25
ARI -- -- --
Skin infections -- -- --
Joints pain -- -- --
CHD -- -- 15

Health Nursing Camp1 Camp2
Problems Homes % %
 %

Weak vision 43.8 50 28
Hearing -- 3.3 2
Dental 31.3 69.8 58
Mobility 43.8 29.8 --
Disability -- 26.9 --
Blood pressure 12.5 3.3 3
Diabetes 31.3 5 1
Loss of appetite -- 29.6 61
GIT -- 4 10
Constipation -- 33.3 29
Osteoporosis -- --
Infection/Fever -- 46.3 --
ARI -- 15.7 10
Skin infections -- 32.4 --
Joints pain -- 77.8 36
CHD -- 1.6 --