Nutrition of older persons in Sudan: a gender perspective.

Salih, Osama A.

Abstract

Whilst traditionally respected, older people in Africa are becoming increasingly marginalized as a result of social change and economic pressure. The family remains the most important social support system for older people, but it is changing. The contribution of the elderly Sudanese (both women and men) to the development of our nation is noticeable. Since women live longer than men in most countries and experience greater financial and cultural constraints, this affects their quality of life as older persons. Nutrition is important during every life stage and the needs continue to change as we age.

After menopause, women have different nutritional needs and meeting them is important to their health. This paper reflects on the gender characteristics of the elderly population in Sudan with regards to factors directly affecting their nutritional status. Information on older adults and high-risk groups within the population of older people are collected through a review of information on the multiple influences (physical, behavioral and socioeconomic) of two groups of elderly living in different socio-economic levels in Khartoum State. Since very little work has been done in searching the needs of this particular group, lessons learned were also viewed. Results indicate high prevalence of malnutrition (under nutrition) among the elderly population, differences between males and females and between the two socio-economic classes were remarkable; 13% and 7% for males and females within the high class compared to 20 and 17% for males and females within the low class. Overweight as a risk to obesity was common to all groups (20-67%), but particularly among oldest women and men in the high socio-economic class (67% and 57% respectively).

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Introduction

The population of older people throughout the world is increasing at a very rapid rate. Women, who currently constitute 55% of the total population of older people, will continue to constitute the majority of the elderly population (HAIb, 2001). African older women contribute in many ways: as income generators; caring for children, the sick or orphaned dependants; teaching younger people, especially by their example of co-operative action; in farming, food production and shelter construction (HAI, 2002).

Since women live longer than men in most countries and experience greater financial and cultural constraints, this affects their quality of life as older persons (Grieco, & Apt, 2001). And whilst traditionally respected, older people in Africa are becoming increasingly marginalized as a result of social change and economic pressure (Kinsella, 1992). Unlike most other countries of the world where older women outnumber men, in Kenya this seems to be the opposite (Kinsella, 1992). This was attributed to the fact that the traditional patterns of family support for the aged have been eroded largely due to migration and changing societal values.

The family remains the most important social support system for older people, but it is changing. Furthermore, during periods of crisis the ability and willingness of the family to support its older members is adversely affected.

Nutrition for Older people:

Older people are generally identified as being a group at particular risk of poor dietary intake and nutritional problems and are thus a high priority target group for nutrition education (MOH MH, 1996).

One of the most prominent changes in body composition with age is the loss of skeletal muscle mass, also referred to as Sarcopenia (Evans & Campbell, 1993). With advancing age, there is also a shift in body composition toward more body fat (from 18 percent at age 18 to 36 percent at age 85 in men; from 33 percent at age 18 to 44 percent at age 85 in women).

A research conducted by Help Age International (HAI, 2004) indicates that Men were taller than women, but no difference was found in body weight. The MUAC (Mid Upper Arm Circumference) was higher (31.4 cm) in urban, compared to rural dwellers (27.5 cm). For men, the mean MUAC was 28.3 cm and for women was 30.5 cm.

The overall prevalence of malnutrition determined by Body Mass Index (BMI <18.5 Kg/m2) was 11.8% and 8% for women and men, respectively. In rural areas a higher prevalence of underweight was found than in urban areas (22.2% versus 17%, respectively). Of older people assessed, 14% were obese (BMI = 30kg/m2), 11% of whom were women, compared to 3% of men.

Irving et al. (1999) indicated a 15 to 20% of definite or possible signs of malnutrition among the individuals studied displayed with significant correlation with the cognitive function and BMI, weight loss and age.

Nutrition is known to play a crucial role in immune function. Inadequate nutritional status may affect the immune response of aging (Krause et al. 1999). This was later confirmed by Ravaglia et al. (2000), whose results strengthen the hypothesis that individual micronutrients may affect the number and function of natural killer (NK) cells in old age. The study also confirms the high prevalence of micronutrient deficiencies in healthy and apparently well-nourished persons aged >/=90 years.

On the other hand, poor vitamin B-12 and folate status may be associated with age-related auditory dysfunction (Houston et al. 1999).

Nutrition for Older Women:

After menopause, women have different nutritional needs and meeting them is important to their health. Calcium, vitamins D and B12 are nutrients older women need more of. Increasing consumption of dairy foods, especially skim or low-fat milk and yogurt, can help with these extra nutrient needs (ADA, 2005).

In addition to the changes in nutrition, weight changes seem to coincide with menopause. This increase may be a function of a slowing metabolism or decreased energy expenditure. The findings of Kigutha, et al. (1998) indicate the need to review the levels of energy expenditure in older people as the current recommended levels are too low to meet energy needs of active older people.

WHO (2007) considered women are at greater risk because their bone loss accelerates after menopause. Osteoporosis and associated fractures are a major cause of illness, disability and death, and are a huge medical expense. It is estimated that the annual number of hip fractures worldwide will rise from 1.7 million in 1990 to around 6.3 million by 2050. Women suffer 80% of hip fractures; their lifetime risk for osteoporotic fractures is at least 30%, and probably closer to 40%. In contrast, the risk is only 13% for men (WHO, 2007). The relationship between the socioeconomic status and quality of living is well established. However, van Rossum et al. (2000) in their study of the Dutch elderly people indicated the socioeconomic differences in dietary intake although these differences were small; the findings support the role of diet in the explanation of socioeconomic inequalities in cardiovascular health. The relationships between the quantity and type of foods or nutrients consumed, and nutrient status, are complex. However, Bates et al. (1999) indicate the gender differences in food choices, in energy and nutrient intakes and in nutritional blood status indices in older British people, especially those aged 65-79 years

Methodology:

This cross-sectional, descriptive study was undertaken between 2005-2006 to assess the nutritional status, the functional ability and the dietary intake profile of older people in two different socio-economic settings in Khartoum State. Equal numbers (150) of both older women and men (total of 300 subjects) were randomly selected from two different localities; AlRiyadh (high class), and ALGieraf (medium to low class). Training workshop was conducted for the data collectors on how to interview elderly people and on taking anthropometric measurements. Anthropometric Measurements: Measurements for Weight, Heights, and Arm span and/or MUAC were used for determining the Body Mass Index (BMI). Cut-off points as suggested by Ismail and Manandhar (1998) and the WHO Expert Committee on Physical Growth classifications (1995): 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).

Results and Discussion:

Age Characteristics of the elderly in Sudan (World and National Statistics).

Statistics show that the elderly population in Sudan representing 5.5% (year 2000) and projected to grow up to 8% an 14.4% in years 2025 and 2050 Table 1). The published statistics of the Sudan Central Puire of Statistics (2003) stated that the elderly population (60+) for the whole Sudan is 3.94% (4.11% for the North and 3.08% for the South). It is very clear (table 1) that the number of elderly population (60+) in Sudan has tripled during the period 1950-2000 (from 185,900 to 627000) and the number is projected to increase 5 times by 2050. Through all years, women outnumbered men and that is true across all age groups. In the year 2000, the age group (60-64) was representing the higher percentage (37%) of the total elderly population; 27% for the age group 65-69; 18% for the age group 70-74 and 10.7% for the age group 75-79. The same pattern was observed in year 1950 and 1975 with observed phenomenon of reduction in the percentage of the age group 60-64 from 39.2% in 1975 to 36.9% in 2000 and is projected to decrease up to 30.8% in 2050. The oldest old groups (80+) were representing 5% and 5.5% of the total elderly population in year 1950 and 1975 respectively. In year 2000 this group showed a remarked increase to 7% and is also projected to 9% and 11% in 2025 and 2050. in the coming future, projections showed that there will be a reduction in the population (60-64 years) parallel with increase in the population group 70+.

Adapted from: World Population Ageing 1950-2050. Population Division, DESA, United Nations

Nutritional status as measured by the body mass index (BMI): The overall prevalence of malnutrition determined by Body Mass Index (BMI <18.5 Kg/m2) was 13 and 7% for males and females within the high class compared to 20 and 17% for males and females within the low class. Fanou et al. (2004) found overall prevalence of malnutrition among Benin older persons 11.8% and 8% for women and men, respectively. In rural areas a higher prevalence of underweight was found than in urban areas (22.2% versus 17%, respectively). Sibetcheu and Nankap (2004) found the prevalence of 5.5% underweight (BMI<18.5) among older Cameron persons (7.7% among men and 4.2% for women). InNairobi, more men (32.6%) than women (12.8%) were underweight and a similar trend was found in Machakos 32.3% and 24.7% respectively (Wagah et al. 2004).

For both socio-economical classes, elderly females with Mild Malnutrition were higher than males. The only cases of Moderate Malnutrition (7%) were found among females of low socio economic

High percent of the older persons (67%) of females and 57% of males in the high economic class were obese, compared to 20 and 23% for males and females in the low economic class. This was similar to that obtained by Sibetcheu and Nankap (2004); 23.3% of men and 16.5% women were obese with BMI > 30 kg. The values obtained by Fanou et al. (2004) were lower i.e. 14% obese, 11% of them were women, compared to 3% men.

Socio-economic characteristics Age:

The study showed that for the age group 60-69 years, the percent of females (67%) in the low-income class was higher than male (60%) in the same group, while, the opposite was true in the high-income class (87% male oppose to 73% females).

In the age group 70-79 years, females (27%) out numbered the males (13%) in the high-income class while in the low-income class they were the same (33%) but higher than the percent of both males and females of the high income class. For the age above 80 years only 7% were found among the males of the low income class.

Marital Status:

None of the respondents were found single except 17% of the males in the low-income class. Married males of the high-income class (87%) were higher than the males (67%) in low-income class. While the percent of married women in both classes was the same (667%) widowed females in both classes (33%) were higher than the males.

Income:

Results indicated that, all men in the high-income group were economically independent, compared to 66.6% of the females in the same group. In the low-income group it was observed that the dependency level among males was more than females. Fanou et al. (2004) reported that the rate of dependency is higher in towns than in the rural areas (32.4% as opposed to 24.2% respectively) and is also more noticeable among older men.

Health Problems:

Regarding health conditions in the month prior to the assessments, the difficulty in mobility was more common among females in high and low socio-economical classes (43% & 33% respectively), compared to males (33% & 20% respectively).

Males were more prone to weak vision than the females particularly in the high-income group (13%) and 40% among males of low economic class. While none of the females in the high economic class reported poor eye sight 33% of their counterpart in the low class reported it. Results obtained showed similar results where thirty-seven percent reported having poor eye sight, more so those in urban areas (39%) than in rural areas (35.9%).

For men, 23% and 20% of both classes (high and low respectively) reported having diabetes compared to women (10% & 17%) for high and low classes respectively. Seventeen percent of both sex of the low economic class and males of the high class had self-reported hypertension. Only 13% females among the high economic class self-reported hypertension compared to males (17%) of the same class. Studies of Fanou et al. (2004) showed that 22% of the older people had self-reported hypertension, with a higher prevalence among urban compared to rural residents (25.7% versus 17%, respectively), while 4.1% of men and women reported that they had diabetes.

Problems with Food Intake:

Regarding the food habits among elderly, results showed that the majority the elderly under investigation used to have only two meals per day (50% of both classes; loss of appetite was found only in the females of the high-income class (13%); chronic diseases that affect the food intake were more common among males of the high-income class (33%) and the females of the low class (13%).

Total blindness and disability that directly affect food intake of older persons were much higher in females of both classes (10% & 13% for high and low classes respectively) than the males.

Lessons learned:

There were many lessons learned from this study, and we believe they will be of much help for further research in this particular field;

* Living in a family does not mean that old persons are not nutritionally vulnerable. They could feel lonely, isolated and depressed. There is no special food prepared for them. Family members and caregivers as well as the older people themselves were not nutritionally educated.

* More than 75% of the older people (both sex) were the head of household.

* Many factors contribute to the nutritional status of the elderly and that anthropometrics measurements alone are not enough to correctly assess the nutritional status of the elderly.

* Both the previous nutritional status and life style are crucial for the present nutritional status of the elderly.

* Much of the information has been transferred during these studies to older people and their caregivers, during anthropometrical measurements and interviews, data collectors and volunteers; university staff and students.

References

ADA (2005). American Dietetic Association. http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/home_4244_ENU_HTML.htm

Bates, C.J; Prentice A; Finch, S. (1999). Gender Differences in Food and Nutrient Intakes and Status Indices from the National Diet and Nutrition Survey of People Aged 65 Years and Over. Eur J Clin Nutr. 53(9):694-699.

Daniel Sibetcheu and Martin Nankap (2004). Assessment of Nutritional Status and Socio-economic Vulnerability of Older People in Bangoua, Western Province. In HelpAge International (2004). Summary of research findings on the nutritional status and risk factors for vulnerability of older people in Africa

Evans, W.J; Campbell, W.W. (1993). Sarcopenia and Age-related Changes in Body Composition and Functional Capacity. J Nutr, 123: 465-68.

Grieco, M. & Apt, N. (2001). Development and the Ageing of Populations: Global Overview by Experts on Ageing in Africa. United Nations Economic and Social Affairs Department.

HelpAge International (2001a). Addressing the Nutritional Needs of Older Persons in Emergency Situations in Africa: Ideas for Action.

HelpAge International (2001b). Research and Information on Ageing in Africa: An Annotated Bibliography. Africa Regional Development Centre.

HelpAge International (2002). Older People in Disasters and Humanitarian Crises: Guidelines for best practice

HelpAge International (2004). Summary of Research Findings on the Nutritional Status and Risk Factors for Vulnerability of Older People in Africa

Kigutha, H. (1998). Elderly Under Nutritional Stress: A Seasonal Study on Food Consumption and Nutritional Status in Kenya. The International Journal of Food Sciences and Nutrition, Vol. 49, pp. 423-433.

Houston, D.K; Johnson, M.A; Nozza, R.J; Gunter, E.W; Shea, K.J; Cutler, G.M; Edmonds, J.T (1999). Age-Related Hearing Loss, Vitamin B-12, and Folate in Elderly Women. Am J Clin Nutr. 69(3):564-571.

Ismail, S. and Manandhar, M. (1999). Better Nutrition for Older People: Assessment and Action. London. HelpAge International and London School of Hygiene and Tropical Medicine.

Kinsella, K. (1992). Aging Trends in Kenya. Journal of Cross-Cultural Gerontology, Vol. 7(3); 259-268.

MOH MH, (1996). Food and Nutrition Guidelines for Healthy Older People: Wellington, Ministry of Health Report, Manatu Hauora, New Zealand.

Krause, D; Mastro, A.M; Handte, G; Smiciklas-Wright, H; Miles, M.P, Ahluwalia, N. (1999). Immune Function Did Not Decline with Aging in Apparently Healthy, Well-Nourished Women. Mech Ageing Dev. 7;112(1):43-57. From Medscape Ob/Gyn & Women's Health (Posted 06/18/2002)

Margaret Wagah; Sophie Ochola; Jane Omalla (2004). Nutritional Risk Factor Analysis Amongst Older Persons in Nairobi and Machakos Districts. In HelpAge International Summary of research findings on the nutritional status and risk factors for vulnerability of older people in Africa

Nadia, L.M.; Fanou,1; Romain, A.M.; Dossa, Eric-Alain (2004). Assessment of the Nutritional Status and Risk Factors Facing Older People in Urban (Cotonou) and Rural (Dangbo and Akrop-Misserete) areas. In: HelpAge International (2004). Summary of research findings on the nutritional status and risk factors for vulnerability of older people in Africa

Irving, G.F.; Olsson, B.A.; Cederholm, T. (1999). Nutritional and Cognitive Status in Elderly Subjects Living in Service Flats, and the Effect of Nutrition Education on Personnel. Gerontology, 45(4): 187-194.

Ravaglia, G.; Forti, P.; Maioli, F. (2000). Effect of Micronutrient Status on Natural Killer Cell Immune Function in Healthy Free-Living Subjects Aged >/=90 Years Am J Clin Nutr. Feb;71 (2):590-598.

World Health Organization WHO, (2007). http://www.who.int/nutrition/topics/ageing/en/index.html

World Health Organization (WHO) (1995): Expert Committee on Physical Status: The use and interpretation of anthropometric physical status. WHO

Van Rossum, C.T.; van de Mheen, H; Witteman, J.C.; Grobbee, E.; Mackenbach, J.P. (2000). Education and Nutrient Intake in Dutch Elderly People. The Rotterdam Study Eur J Clin Nutr. 54(2): 159-165.

Osama A. Salih, Associate Professor of Biochemistry and Nutritional Sciences (Nutrition Center for Training and Research (NCTR), Ahfad University for Women-Sudan).

Table 1. Distribution of elderly by age groups and gender through
the years 1950, 1975, and 2000, and the projection for year
2025 and 2050.

Age (years) 1950 1975 2000 2025 2050
 Population (thousands)

60-64 185.9% 298.5 627.0 1370.6 2822.9
 (37.9%) (39.2%) (36.9%) (35.1%) (30.8%)
Female 95.2 157.1 326.5 702.3 1433.5
Male 90.7 141.5 300.5 668.2 1389.4
65-69 138.2 213.3 461.3 1023.7 2328.5
 (28%) (28%) (27%) (26%) (25.4%)
Female 71.7 114.2 244.0 531.7 1198.0
Male 66.5 99.1 217.3 492.0 1130.5
70-74 92.4 134.6 310.6 694.9 1764.6
 (18.7%) (17.7%) (18.3%) (17.8%) (19.3%)
Female 49.0 73.3 167.1 366.7 922.9
Male 43.4 61.3 143.5 328.2 841.7
75-79 50.3 72.7 181.9 463.1 1218.1
 (10%) (9.5%) 10.7)% 11.9%) 13.3)%
Female 26.9 40.2 100.3 249.8 650.2
Male 23.4 32.5 81.7 213.3 467.9
80-84 84.1 235.6 663.0
 (4.9%) (6%) (7.2%)
Female 47.7 130.2 362.1
Male 36.4 105.5 300.9
85-89 26.7 87.7 270.3
 (l.6%) (2.3%) (3%)
Female 15.8 50.1 151.8
Male 10.9 37.6 118.4
90-94 25.10 42.30 5.4 21.3 73.2
 (0.32%) (0.55%) (0.8%)
Female (5%0 (5.5%) 3.4 12.9 42.8
Male 13.5 F 24.8 F 2.0 8.4 30.3
95-99 11.6 M 17.5 M 0.6 3.0 11.1
 (0.04%) (0.08%) (0.12%)
Female 0.4 2.0 7.0
Male 0.2 1.0 4.0
100+ 0.0 0.2 1.0
 (0.0%) (0.005%) (0.01%)
Female 0.0 0.2 0.7
Male 0.0 0.1 0.3
Nations.

Table 2. The nutritional status of older persons assessed by the Body
Mass Index (BMI)

Nutritional BMI High socio-economic Class
Status Males (%) Females (%)
Acute -16 0 0
Moderate 16-16.99 0 0
Mild 17- 18.49 13.0 7.0
Normal 18.5-24.99 30.0 27.0
Overweight 25 57.0 67.0

Nutritional BMI Low socio-economic Class
Status Males (%) Females (%)
Acute <16 0 0
Moderate 16-16.99 0 7.0
Mild 17- 18.49 20 17.0
Normal 18.5-24.99 60.0 53.0
Overweight >25 20.0 23.0

Table 3. General Characteristics of the Elderly people in different
socio-economic classes

Age High socio-economic Class
 Males (%) Females (%)
(Years)
60-69 87.0 73.0
70-79 13.0 27.0
80 0 0
Marital Status High socio-economic Class
 Males (%) Females (%)
Single 0.0 0.0
Married 87.0 67.0
Divorced 0.0 0.0
Widowed 13.0 33.0
Income High socio-economic Class
 Males (%) Females (%)
Independent 100 67.00
Dependent 0.00 33.00
Health Problems High socio-economic Class
 Males (%) Females (%)
Poor Eye Sight 13.00 0.00
Deafness 10.00 0.00
Hypertension 17.00 13.00
Diabetes 20.00 10.00
Poor Mobility 33.00 43.00
Food Intake High socio-economic Class
Problems Males (%) Females (%)
Dental problems 33.00 40.00
Loss of appetite 0.00 13.00
Chronic diseases 33.00 20.00
Total blindness/ 3.00 10.00
disability

Age Low socio-economic Class
 Males (%) Females (%)
(Years)
60-69 60.0 67.0
70-79 33.0 33.0
80 7.00 0.00
Marital Status Low socio-economic Class
 Males (%) Females (%)
Single 16.7 0.0
Married 66.6 66.6
Divorced 0.0 0.0
Widowed 17.0 33.0
Income Low socio-economic Class
 Males (%) Females (%)
Independent 67.00 77.00
Dependent 33.00 23.00
Health Problems Low socio-economic Class
 Males (%) Females (%)
Poor Eye Sight 40.00 33.00
Deafness 0.00 0.00
Hypertension 17.00 17.00
Diabetes 23.00 17.00
Poor Mobility 20.00 33.00
Food Intake Low socio-economic Class
Problems Males (%) Females (%)
Dental problems 67.00 53.00
Loss of appetite 0.00 0.00
Chronic diseases 17.o 33.o
Total blindness/ 0.00 13.00
disability