Nutritional Status of Older Persons Presenting in a Primary

Care Clinic in Nigeria

ADEBUSOYE LawrenceUniversity College Hospital

Ibadan, Nigeria

BACKGROUND• Good nutrition is especially important in older

persons because of the physiological changes that occur in the body as people age.1

• Challenging experiences before 60 years – a life of continuing poverty– Deprivation– poor access to health care– a diet poor in quality and quantity.1, 2

BACKGROUND- 2

ASSUMPTIONSUndernutrition

- a rare occurrence in old ageOverweight

- invariable consequence of ageing.2, 3

BMI is the most commonly available tool to assess nutrition in older persons.

OBJECTIVES1. Determine the prevalence of nutritional

problems (undernutrition & overweight).

2. Describe the risk factors contributing to the development of nutritional problems.

3. Determine the association between nutritional problems and morbidities.

THE STUDY SITEUniversity College Hospital, Ibadan, Nigeria.

Largest and oldest Tertiary hospital in Nigeria.

METHODS

• Study design: Cross-sectional study (Family Medicine Department).

• Study Population: 500 newly registered male and female older persons (≥60 years)

• Study period: September 1st to October 30th, 2009.

METHODS- TOOLS

• Mini-Nutritional Assessment (MNAR) tool.5

– 18 questions on dietary history, clinical evaluation and anthropometric measures.

– Used to measure undernutrition– Sensitivity = 96%– Specificity = 98%– PPV = 97%

• MNA score (10 – 30)– Undernutrition- 17.0– At risk of undernutrition- 17.0 – 23.5– Normal - 23.6 – 30.0

METHODS- TOOLS contd

• Body Mass Index (BMI) {weight (kg)/height (m)2}. – Used to measure overweight

• BMI (WHO anthropometric classification)– Underweight < 18.5 kg/m2

– Normal 18.5 - 25.0 kg/m2

– Overweight >25.0 kg/m2

RESULTS• 324 (64.8%) females and 176 (35.2%) males.

Female : Male = 1.8 : 1

• Mean age (SD) = 66.7 (6.6) years; range = 60 to 90 years.

• Median income = U.S. $1.56 daily; range = $0.22 to $24.44

• Average OPD hospital visits in the last one year = 3 (range 1 - 13)

FIGURE 1: UNDERNUTRITION USING MNA TOOL

7.8%

11.8%

80.4%

Undernutrition

At Risk of Undernutri-tion

Normal

Table 1: Significant risk factors for undernutrition

RESPONDENTSn = 39(%)Undernutrition

n = 59(%)At Risk of

Undernutrition

n= 402(%)Normal

N=500(%)Total

EMPLOYMENT STATUS

Engaged in occupation 38(8.5) 38(8.5) 369(83.0) 445 (100.0)Not engaged in occupation 1(1.8) 21(38.2) 33(60.0) 55 (100.0)

χ2 = 42.484 df = 2 p < 0.0001*

FINANCIAL SUPPORT

Self 16(16.7) 10(10.4) 70(72.9) 96(100.0)Others 23 (5.7) 49 (12.1) 332 (82.2) 404(100.0)χ2 = 2.400 df = 2 p = 0.002*

MARITAL STATUS

Married 14(4.6) 35(11.6) 253(83.8) 302(100.0)Not married 25(12.6) 24(12.1) 149(75.3) 198(100.0)χ2 = 10.898 df=2 p < 0.004*

PREVIOUS HOSPITAL ADMISSION

Never 18(4.8) 45(11.9) 314(83.3) 377(100.0)< 60 years 2(4.5) 4(9.1) 38(86.4) 44(100.0)

≥ 60 years 17(26.6) 9(14.1) 38(59.3) 64(100.0)

Can’t remember 2(13.3) 1(6.7) 12(80.0) 15(100.0)χ2 = 39.492 df = 6 p < 0.001*

Table 2: Prevalence of undernutrition and the morbidities

Morbidities n = 39(%)Undernutrition

n = 59(%)At Risk of Undernutrition

n=402(%)Normal

p-value

Hypertension 6(2.2) 29(10.4) 243(87.4) <0.001*

Osteoarthritis 0(0.0) 7(50.0) 7(50.0) <0.001*

Psychosomatic disease

0(0.0) 4(66.7) 2(33.3) <0.001*

Table 3: significant risk factors for overweight

RESPONDENTS n = 24(%)Underweight

n = 219(%)Normal

n = 257(%)Overweight

N=500Total

AGE (YEARS)

60 – 64 9(4.0) 85(37.9) 130(58.1) 224(100.0)

65 – 69 5(5.1) 50(50.5) 44(44.4) 99(100.0)

70 –74 4(3.7) 52(44.7) 53(48.6) 109(100.0)

75 – 79 3(8.1) 13(35.1) 21(56.8) 37(100.0)

≥ 80 3(9.7) 19(61.3) 9(29.0) 31(100.0)

χ2 = 15.154 df = 8 p = 0.050*

GENDER

Male 7(4.0) 93(52.8) 76(43.2) 176(100.0)

Female 17(5.2) 126(38.9) 181(55.9) 324(100.0)

χ2 = 9.020 df = 2 p = 0.011*

LOGISTIC REGRESSION ANALYSIS (Undernutrition):

• Hospital admission after the age of 60 years – (OR=2.105, CI=1.479-2.996)

• Having hypertension– (OR=8.197, CI=3.270-20.833).

• Not being in marriage – (OR=1.355, CI=1.075–1.708)

• CORRELATION ANALYSIS (PEARSON’S): Positive association between BMI and MNA scores (r=0.152, p <0.0001).

MNA categories across care settings

Adebusoye et al, 2009

Nzegwu et al, 2010

Zarina 2006, Bangladesh

Izawaa 2005, Japan

vellas & Sieber 2009 community

vellas & Sieber 2009 hospital

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

7.8%

9.0%

26.0%

8.9%

6.0%

39.0%

11.8%

75.0%

62.0%

51.2%

32.0%

47.0%

80.4%

16.0%

12.0%

39.9%

62.0%

14.0%

Undernutrition At Risk of Undernutrition Normal

CONCLUSION1. High prevalence of nutritional problems in this study

underscores the need for intervention in the older population.

2. The MNAR tool is an easy, simple and fast tool that could assess the nutritional status of older persons especially in primary care setting at first-contact.

3. Older persons need to be comprehensively examined as most of the predisposing factors to nutritional problems can be easily identified and treated.

THANK YOU

REFERENCES1. Charlton KE, Rose D. Nutrition among older adults in Africa:

the situation at the beginning of the millennium. J Nutr. 2001; 131:2424S–8S.

2. Evans C. Malnutrition in the elderly: a multifactorial failure to thrive. The Permanente Journal. 2005; 9:3.

3. Hajjar RR, Karmel HK, Denson K. Malnutrition in aging. The Internet J Geriatr Gerontol. 2004; 1:1.

4. National Population Commission of Nigeria. National and states population and housing tables. 2006 population and housing census of the Federal Republic of Nigeria. 2009. Accessed at www.population.gov.ng on 14 February 2011.

REFERENCES- 2

5. Nestle nutrition institute. Mini Nutritional Assessment (MNA). Nestle´, 1994, Revision 2006. N67200 12=99 10M. Accessed at http://www.mna-elderly.com/ forms/MNA_english.pdf on 13 April 2009.

6. World Health Organization expert committee on physical status 1995: the use and interpretation of anthropometry physical status. Technical Report Series no. 854. Geneva: World Health Organization.

7. Vellas B, Sieber C. The MNA revisited : what does the data tell us? Scientific Symposium Proceeding XIXth IAGG World Congress of Gerontology and Geriatrics. Monday, 6 July 2009 Paris, France.

TABLE 1: Demographic characteristics and undernutrition

RESPONDENTSn = 39(%)Undernutrition

n = 59(%)At Risk of

Undernutrition

n= 402(%)Normal

N=500(%)Total

AGE GROUP (YEARS)

< 75 37 (8.5) 50 (11.6) 345 (79.9) 432 (100.0)

≥ 75 2 (2.9) 9 (13.2) 57 (83.9) 68 (100.0)

χ2 = 2.634 df=2 p = 0.268

GENDER

Female 25(7.7) 36(11.1) 263(81.2) 324(100.0)

Male 14(8.0) 23(13.0) 139(79.0) 176(100.0)

χ2 = 0.447 df=2 p = 0.800

MARITAL STATUS

Married 14(4.6) 35(11.6) 253(83.8) 302(100.0)

Not married 25(12.6) 24(12.1) 149(75.3) 198(100.0)

χ2 = 10.898 df=2 p < 0.004*

NUMBER OF CHILDREN

< 4 13 (11.3) 14 (12.2) 88 (76.5) 115 (100.0)

≥4 26 (6.8) 45 (11.7) 314 (81.5) 385 (100.0)

χ2 = 2.648 df=2 p = 0.266

TABLE 2: Economic status and undernutrition

RESPONDENTSn = 39(%)Undernutrition

n = 59(%)At Risk of

Undernutrition

n= 402(%)Normal

N=500(%)Total

EMPLOYMENT STATUS

Engaged in occupation 38(8.5) 38(8.5) 369(83.0) 445 (100.0)

Not engaged in occupation

1(1.8) 21(38.2) 33(60.0) 55 (100.0)

χ2 = 42.484 df = 2 p < 0.0001*

INCOME

Above the poverty line 10(3.4) 35(11.9) 248(84.7) 293(100.0)

Below the poverty line 29(16.4) 20(11.3) 128(72.3) 177(100.0)

Don’t Know 0(0.0) 4(13.3) 26(86.7) 30(100.0)χ2 = 6.968 df = 4 p = 0.138

FINANCIAL SUPPORT

Self 16(16.7) 10(10.4) 70(72.9) 96(100.0)

Others 23 (5.7) 49 (12.1) 332 (82.2) 404(100.0)

χ2 = 2.400 df = 2 p = 0.002*

TABLE 3: Social characteristics and undernutrition

RESPONDENTSn = 39(%)Undernutrition

n = 59(%)At Risk of Undernutrition

n= 402(%)Normal

N=500(%)Total

LIVING ARRANGEMENT

Alone 2(4.0) 4(8.0) 44(88.0) 50(100.0)

With others 37(8.2) 55(12.2) 358(79.6) 450(100.0)

χ2 = 2.107 df = 2 p = 0.349

SOCIAL SUPPORT

Children/ grandchildren 18(7.4) 24(9.9) 200(82.6) 242(100.0)

Self 14(9.5) 21(14.3) 112(76.2) 147(100.0)

Spouse 5(6.4) 9(11.5) 64(82.1) 78(100.0)

Other relatives 2(6.1) 5(15.2) 26(78.8) 33(100.0)

χ2 = 3.250 df = 6 p = 0.777

WHO PREPARES YOUR MEALS?

Self 26(13.5) 26(13.5) 140(73.0) 192(100.0)

Children/ grandchildren 7(4.2) 17(10.2) 142(85.6) 166(100.0)

Spouse 5(3.9) 14(11.0) 108(85.1) 127(100.0)

Other relatives 1(6.7) 2(13.3) 12(80.0) 15(100.0)

χ2 = 3.758 df = 6 p = 0.709

Table 4: Hospital care utilization and undernutrition

RESPONDENTSn = 39(%)Undernutrition

n = 59(%)At risk of Undernutrition

n= 402(%)Normal

N=500(%)Total

PREVIOUS HOSPITAL ADMISSION

Never 18(4.8) 45(11.9) 314(83.3) 377(100.0)

< 60 years 2(4.5) 4(9.1) 38(86.4) 44(100.0)

≥ 60 years 17(26.6) 9(14.1) 38(59.3) 64(100.0)

Can’t remember 2(13.3) 1(6.7) 12(80.0) 15(100.0)

χ2 = 39.492 df = 6 p < 0.001*

NUMBER OF OUTPATIENTS HOSPITAL VISITS IN THE PREVIOUS YEAR

1 – 3 31(9.0) 38(11.0) 276(80.0) 345(100.0)

≥ 4 8(5.2) 21(13.5) 126(81.3) 155(100.0)

χ2 = 2.609 df = 2 p = 0.271

Table 5: presenting complaints and undernutritionPresenting complaints Undernutrition n = 39(%) Total N = 500 (%)

Digestive domainProblem with mouth, teeth and tongue 34(9.9) 345(100.0)

Constipation 5(4.0) 125(100.0)

Swallowing problems 7(6.9) 102(100.0)

Abdominal pain/discomfort 7(13.0) 54(100.0)

Diarrhoea 6(11.5) 52(100.0)

Vomiting 4(11.1) 36(100.0)

Bleeding from the Anus 2(7.7) 26(100.0)

Mental DomainForgetfulness 31(8.7) 357(100.0)

Feeling of anxiety/ Nervousness 18(6.0) 299(100.0)

Insomnia 23(8.1) 284(100.0)

Depression 16(7.8) 205(100.0)

Alcohol abuse 1(11.1) 9(100.0)

Social DomainFinancial problems 25(7.5) 334(100.0)

Welfare problems 8(5.5) 145(100.0)

Housing problems 10(7.4) 136(100.0)

Socio-cultural problems 5(10.4) 48(100.0)

Access to health care facility problems 1(10.0) 10(100.0)