BASELINE FINDINGS OF CARENUTRITION INTERVENTION (RCT) AMONG OLDER CAREGIVERS – RISK OF MALNUTRITION AND INSUFFICIENT PROTEIN INTAKE

S. Kunvik^1,2, R. Valve², K. Salminen¹, M. Salonoja¹, M.H. Suominen³

1. The Social Services and Healthcare Centre of Pori, Finland; 2. Department of Food and Environmental Sciences, University of Helsinki, Finland; 3. Unit of Primary Health Care, Helsinki University Central Hospital, Finland.

Corresponding Author: Susanna Kunvik, The Social Services and Healthcare Centre of Pori, Finland and Department of Food and Environmental Sciences, University of Helsinki, Finland, susanna.kunvik@gmail.com

J Aging Res Clin Practice 2017;6:117-123
Published online May 18, 2017, http://dx.doi.org/10.14283/jarcp.2017.13

Abstract

Objectives: Older caregivers are vulnerable to nutritional problems, but only a few studies have examined their nutrition. The purpose of this study was to determine the associations between nutritional status and nutrient intake among older caregivers. Design: Cross-sectional analysis of baseline data from the CareNutrition randomized controlled trial (RCT). Setting: Community-dwelling caregivers from the Western part of Finland in two different clusters. Participants: A total of 79 caregivers aged ≥65 with normal cognition were recruited for the study, all of whom had officially approved caregiver status by The Social Insurance Institution of Finland. Measurement: Nutritional status was assessed by the Mini Nutritional Assessment (MNA), nutrient intake by a three-day food diary, nutrition-related blood markers by laboratory tests, cognition by the Mini Mental State Examination (MMSE), and other baseline characteristics were also evaluated using validated methods. Results: The majority of the caregivers (79.7%) had a good nutritional status (MNA points >23.5), 19% were at risk of malnutrition (MNA points 17-23.5) and one person (1.3%) already suffered from malnutrition (MNA points <17). The female caregivers were at a higher risk of malnutrition than the males (26.5% vs. 6.7%, p=0.026). Depressive symptoms and medication were associated with decreased nutritional status, and good health-related quality of life with better nutritional status. Mean protein intake was 1.0 g/kg IBW/d and 79.7% of the caregivers (77.6% female, 83.3% male) did not consume the recommended protein intake of 1.2 g/kg IBW/d. Their intake of dietary fibre, folate and vitamin D was also insufficient. Conclusion: Every fifth caregiver was at risk of malnutrition. The females were at a higher risk than the males. Most of the caregivers had insufficient protein intakes. These findings confirm the importance of investigating the nutritional status of older caregivers and indicate a need for preventive nutritional guidance.

Key words: Caregiver, nutrition, nutrient intake.

Introduction

The world’s population is ageing, and as a consequence, the number of older people with disabilities and chronic diseases who need support and assistance will increase (1). Informal caregivers provide valuable services to people with long-term care needs. Europe has approximately 100–125 million caregivers (2). In Finland, about 350 000 caregivers help their relatives or loved ones, and in 2013, roughly 42 500 caregivers received support for informal care from their municipality. Half of these caregivers are ≥65 years old, and every fourth ≥75 years old. More than half are female and the majority take care of their spouses (3, 4).
Informal care is extremely important in the context of an ageing population, the increasing pressures on public finances, and rising life expectancy at older ages (5). Concern has been mounting about the health and welfare of people who provide informal care for family or friends with chronic illnesses. Older caregivers are often under a heavy burden and suffer from health problems themselves (6). They are at an increased risk of stress, depression and other health complications that can increase the risk of nutritional problems (7-10). Many factors increase this risk among older caregivers because ageing is accompanied by numerous cognitive, psychological and social factors, which may expose older people to inadequate nutrition and poorer well-being (11).
Studies have found the prevalence of malnutrition in community-dwelling older people to be 1%–5%, and one in four to be at risk of malnutrition (12, 13). Among older caregivers, the prevalence of malnutrition is around 5%, and about 16%–32% of caregivers are at risk of malnutrition (14, 15). Intake of protein is also low (<1 g/kg/d) among older caregivers (16). Insufficient protein intake may contribute to age-related loss of lean muscle mass, which can in turn lead to impaired physical function (17). This can weaken caregivers’ ability to cope with everyday tasks and the provision of care. To maintain bone mass, muscle mass, and strength, protein intake should be 1.2–1.5 g protein/kg/d (18).
Relatively few studies have assessed the levels of nutritional risk and nutrient intake among community caregivers. Thus, our study aims to examine older (≥65 y) caregivers’ nutritional status and nutrient intake.

Methods

Setting

This cross-sectional study is part of a randomized controlled intervention trial, CareNutrition, which explores the effectiveness of tailored nutritional counselling on protein intake and wellbeing among older caregivers (≥65 y) and people (≥50 y) receiving care. In this cross-sectional study, we focus on older caregivers. The study was approved by the Ethics Committee of the Hospital District of Southwest Finland. Informed consent was obtained from the participants. The trial was registered and described at the Australian New Zealand Clinical Trials Registry, Trial Id: ACTRN12615001254583.

Participants

Caregivers were recruited for the study during nurses’ appointments, by inviting them to attend a caregivers’ well-being and health screening. These screenings were organized in two clusters; Autumn 2015 and Spring 2016. We invited two groups of caregivers; those who received care allowance from the Services for Disabled People (caregivers ≥65 years) and those who received care allowance from the Services for Older People (caregiver ≥40 years, informal carer ≥3 years). These criteria were decided before this study began, and were based on the recommendations of the Finnish Ministry of Social Affairs and Health. All caregivers had a caregiver status officially approved by The Social Insurance Institution of Finland.
If a caregiver showed an interest in the study during the health screening, a nutritionist made a home visit during which they provided oral and written information about the study. Informed consent was obtained from the caregiver if they fulfilled the inclusion criteria (all criteria had to be fulfilled), which were: age of ≥65 during the study year, informed consent, an officially confirmed caregiver status, living at home, and normal cognition (geriatric assessment MMSE points ≤25, if assessment was needed). If the caregiver participated in the study, the data from the nurse’s appointment were used as baseline measurements.
In autumn 2015 and spring 2016, we sent an invitation to a health screening to 368 caregivers, of whom 169 agreed to attend (Figure 1). During the health screening, 92 participants expressed interest in participating in the study. Ten were too young to participate. During the nutritionist’s first visit, a further 13 caregivers were excluded from the study for not meeting the inclusion criteria or declining to participate after the interview. A total of 79 caregivers aged ≥65 were recruited for the study.

Figure 1
Flow chart of participant enrolment

Measurements

Baseline measurements were taken during two different appointments; the nurse’s health screening and the nutritionist’s home visit. The nurse’s appointment was at the health care centre, with a trained nurse, and included several assessments. Cognition was measured by the MMSE (19), activities of daily living (ADL) by the Katz index (20), instrumental activities of daily living (IADL) by the Lawton-Brody questionnaire (21), lower extremity muscle strength by the Five Times Sit to Stand Test (22), depression by the Geriatric Depression Scale (GDS-15) (23), medication by an open question, and harmful alcohol use (alcohol consumption, drinking behaviours, and alcohol-related problems) by the Alcohol Use Disorders Identification Test (AUDIT) (24). An experienced geriatrician reviewed the health screening papers. After the nurse’s appointment, a nutritionist made a home visit. Nutritional status was assessed by the MNA (25), health-related quality of life (HRQoL) by the 15D measure (26), and both-hand grip strength (27) using a Jamar Hydraulic Hand Dynamometer (Jamar Bolingbrook IL 60440-4989). The hand-grip strength of each hand was measured two or three times and the best result from the dominating hand was taken as the result. Nutrient intake was assessed via the three-day food diaries that caregivers returned by mail after the nutritionist’s home visit. We analysed the food diaries using the Finnish National Food Composition Database, Fineli. Ideal bodyweight (IBW) was used to calculate protein intake/kg IBW/d. If the caregivers’ body mass index (BMI) was between 20 kg/m2 and 30 kg/m2, we used the actual BMI. If BMI was under 20 kg/m2, it was adjusted to 20 and if above 30 kg/m2, it was adjusted to 30. Nutrition-related laboratory tests of plasma 25(OH)D vitamin, complete blood count (haemoglobin reported), plasma albumin, and serum prealbumin were conducted in the Satakunta Central Hospital laboratory (SataDiag, Finnish Accreditation Service, standards SFS-EN ISO/IEC 17025:2005, SFS-EN ISO 15189:2013) after the nutritionist’s visit. Haemoglobin was assessed using a photometric system; serum 25(OH)D vitamin levels using a immunoluminometric system (Advia Centaur) that measures both ergocalciferol and cholecalciferol 25-hydroxylated metabolites; plasma albumin using a photometric (bromocrerol purple method) system; and serum prealbumin using a photometric, immunochemical system. Use of vitamin D supplement was assessed via a questionnaire and the food diaries.

Statistics

The results are presented as means with standard deviation (SD) or as percentages. Statistical differences between groups were determined by T-tests, the Mann Whitney U-test, the Chi Square test or Fisher´s exact test, whichever was appropriate. Associations were analysed by linear regression models (the Enter method) adjusted for age and BMI, and the results are presented as standardized beta coefficients (β). P-values less than 0.05 were considered statistically significant. Statistical analyses were carried out using SPSS version 22.0 (SPSS, Inc., Chicago, IL).

Results

Baseline characteristics

In 2015–2016, 79 older (≥65 y) home-dwelling caregivers – 49 females and 30 males – participated in the study (Table 1). The participation rate was 49.7% of all the 159 caregivers aged ≥65 who attended the health screening. The caregivers’ mean age was 73.7 years, and most of them cared for their spouses. They had good cognition (mean MMSE score 27.4) and had good physical functioning according to their ADL and IADL scores. The mean time in the Five Times Sit to Stand Test was 13.8 seconds. The mean hand-grip strength of the dominating hand was 25.8 kg among the females and 39.0 kg among the males. Most of the caregivers were of normal weight (Mean BMI 28 kg/m2). The mean number of medications was 3.9. Their HRQoL was good (15D score 0.9). According to GDS-15, one in ten (10.1%) suffered from mild or moderate depression. The AUDIT results showed that none of the female caregivers had hazardous alcohol use, but 13.3% (n=4) of the males scored >8 AUDIT points, indicating harmful patterns of alcohol consumption, drinking behaviours or alcohol-related problems.

Table 1
Caregivers’ baseline characteristics and nutritional status (MNA)

Differences between the characteristics of the females and males were tested using the Chi Square test or Fisher´s exact test when appropriate, for categorical variables; the Mann Whitney U-test for non-normally distributed continuous variables and Student’s T-test for normally distributed continuous variables;SD= standard deviation; ICD-10 =International statistical classification of diseases and related health problems (28); MNA= Mini Nutritional Assessment (25); BMI= Body Mass Index: recommended BMI for older people 24–29 kg/m2 (29); MMSE= Minimental State Examination: 24–30 normal cognition, 18.24 mild dementia, 10–18 average dementia, 0-10 severe dementia (19); GDS-15= Geriatric Depression Scale: 0–5 points no depression, 6–10 points mild or moderate depression, 11–15 points severe depression (30); 15D-square= Health-related quality of life square: 0= poor quality of life and 1= good quality of life (26); ADL= Activities of Daily living: 0–6 points, higher score indicating better functioning (20); IADL= Instrumental Activities of Daily Living: 0–8 points, higher score indicating better functioning (21); AUDIT= Alcohol Use Disorders Identification Test: total scores of 8 or more are indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence (24)

Nutritional status

Most of the caregivers (79.7%) had a good nutritional status (MNA points >23.5), 19% were at risk of malnutrition (MNA points 17–23.5) and one person (1.3%) already suffered from malnutrition (MNA points <17). The female caregivers were more likely to be at risk of malnutrition than the males (26.5% vs. 6.7%, p=0.026). The MNA test showed that the females suffered more psychological stress or acute illnesses than the males, but the difference was not quite statistically significant (p=0.056). Among the females, energy intake was associated with nutritional status, but the result was just above statistical significance (p=0.056). Energy intake was higher (1707 kcal/d vs. 1418 kcal/d) among the females who were at risk of malnutrition (MNA <23.5 points).
Nutritional status was negatively associated with depression symptoms (GDS-15, p=0.000, β= -0.487): a higher GDS-15 score indicated a lower MNA score. The number of medications was negatively associated with nutritional status (p=0.000, β= -0.452). The association between good HRQoL and nutritional status (15D score, p=0.026, β=0.336) was positive.

Nutrient intakes

The caregivers’ mean energy intake was 1610 kcal/d (Table 2.). A total of 46.8% had an energy intake of under 1500 kcal/d; 26.7% of the males and 59.2% of the females. The males had a higher energy intake than the females (1798 kcal vs. 1494 kcal, p=0.002). Mean protein intake was 69.2 g/d. Although the males had a higher energy intake, they had less protein calculated as energy (E%) than the females (16.6 E% vs. 18.0 E%, p=0.045). Among the male caregivers, a higher total AUDIT score was associated with lower protein intake g/kg IBW/d (p=0.012, β= -0.454). Greater hand-grip strength was associated with a higher protein intake among the males (p=0.031, β=0.433)

Table 2
Baseline results of caregivers’ nutrient intakes, vitamin D supplement use and nutrition-related laboratory tests

Differences between the characteristics of the females and the males were tested using the Chi Square test or Fisher’s exact test when appropriate for categorical variables, the Mann Whitney U-test for non-normally distributed continuous variables, and Student’s T-test for normally distributed continuous variables. The numbers are presented in means with standard deviation (SD) or percentages. Ideal bodyweight was used to calculate protein intake/ kg/d. If caregivers’ BMI was between 20 and 30 kg/m2, actual BMI was used. If BMI was under 20 kg/m2, it was adjusted to 20, and if above 30 kg/m2, it was adjusted to 30; 1) (31); 2) (32); 3) (33); 4) (34)

For ideal bodyweight (BMI 20–30 kg/m2), the mean protein intake was calculated as 1.0 g/kg IBW/d. A total of 79.7% of the caregivers did not consume the recommended protein intake of 1.2 /kg IBW/d; females 77.6% and male 83.3%.
Dietary fibre (mean 19.8 g), folate (mean 208.1 ug/d) and vitamin D (mean 9.3 ug/d) intake was insufficient. A total of 83.5% did not consume the recommended daily intake of dietary fibre, folate (94.9%) or vitamin D (67.1%).

Laboratory tests

The caregivers’ mean serum 25(OH)D levels were 80.8 nmol/l. A total of 73.4% took a vitamin D supplement. The females were more likely to use supplements than the males (81.6 % vs. 60.0%, p=0.035). The use of a vitamin D supplement was related to serum 25(OH) D levels, as the mean vitamin D status was higher among the caregivers who took a supplement (84.7 nmol/l vs. 69.7 nmol/l, p=0.035). Mean haemoglobin was 138 g/l, plasma albumin 37.6 g/l, and serum prealbumin 0.25 mg/l. The males had higher blood haemoglobin than the females (p=0.002). Haemoglobin levels were positively associated with nutritional status (p=0.031, beta=0.259).

Discussion

In this study, most of the older (≥65 y) caregivers had a good nutritional status, according to the MNA. However, every fifth was at risk of malnutrition, and this risk was more likely among the females. Depressive symptoms and medication were associated with decreased nutritional status, and good HRQoL with better nutritional status. The food diaries showed that most of the caregivers had an insufficient protein intake. Intakes of dietary fibre, folate and vitamin D were also low. Among the males, a higher AUDIT score was associated with a lower protein intake, and greater hand-grip strength with a higher protein intake.
The prevalence of nutritional risk among caregivers in this study is in line with that of previous studies, which have found 16%–30% of older caregivers to be at risk of malnutrition (14, 35). This result is interesting, since although the physical performance of the caregivers in our study was good (IADL, ADL), every fifth caregiver was still at risk of malnutrition. Ageing is also accompanied by many cognitive, psychological, and social factors, which may expose older people to inadequate nutrition (11). In this study, depressive symptoms and medication were associated with decreased nutritional status. This result is expected, as depression is believed to be the most common cause of nutritional problems among older people, and the use of medication can affect nutritional status in many ways (36). Caregivers’ good HRQoL was associated with better nutritional status. Previous studies have also found a relationship between HRQoL and the risk of malnutrition (37). Caregivers are greatly exposed to depression and poor mental health, which can increase the risk of inadequate nutrition (8, 9, 38).
The MNA revealed that the female caregivers were more likely to be at risk of malnutrition than the males, as has been found in other studies examining nutrition among older people (39, 40). In this study, the result is not explained by a lower energy intake among the females, because the energy intake of females who were at risk of malnutrition was higher. The MNA showed that the females had more psychological stress or acute illnesses than the males, but the differences were not quite statistically significant. The results still indicate, however, that these gender differences may be explained by psychological factors. Only a few studies have investigated the nutritional status of older caregivers, which indicates the need for further research and more systematic assessments.
In this study, the caregivers’ protein intake was lower (1.0 g/kg IBW/d) than is recommended in Finland; 1.2–1.4 g/kg/d (31). Approximately 80% of the caregivers did not consume the recommended intake of 1.2 g/kg/d, which is a concern. The male caregivers consumed less protein than the female caregivers when calculated as energy, but their protein E% was still in line with the recommendations in Finland; 15–20 E% (31). Adequate protein intake is known to play an important role in the immune system, bone mass density, muscle function, strength, and the management of sarcopenia (17, 41, 42). It is estimated that an intake of 1,2 to 1.6 g/kg BW/d may be required for older people to preserve muscle mass (18, 43). In this study, greater hand-grip strength was associated with a higher protein intake. Adequate protein intake is important for older caregivers, since they need to stay in relatively good physical shape to be able to take care of another person. Increasing protein intake may help maintain muscle strength and help prevent mobility impairment (44). There is a need for preventive nutritional guidance that specifically focuses on increasing the protein intake of older caregivers.
Among the males, a higher AUDIT score was associated with a lower protein intake. AUDIT is a screening tool for alcohol consumption, drinking behaviour, and alcohol-related problems (24). Our result was analysed using the overall AUDIT score, which may not be the proper way to use this test, as the result is usually classified into different risk categories. Moreover, the moderate alcohol consumption in this population meant that we were unable to obtain the same result when alcohol consumption was categorized as 0–7 and >8 AUDIT points. However, the result is still interesting, because it is known that alcohol consumption is related to eating habits (45). Harmful alcohol consumption among older people may accompany nutritional problems, as it replaces the consumption of foods with superior nutritional value (46).
The caregivers had a poor intake of folate and dietary fibre, as found in previous studies among older caregivers (16). These findings indicate a low intake of fruits, vegetables and whole grain products. Stress can affect eating habits and may be shown in the consumption of vegetables. A study by Shaffer et al. (47) found that cancer-related stress was associated with a low consumption of vegetables among cancer-patients and their caregivers. Nutritional guidance can help increase the use of products rich in fibre and vitamins (48). The average vitamin D intake from food was below the recommended level. Still, the caregivers’ mean plasma 25-OH-vitamin D levels were good (80.8 nmol/l) in comparison to the results from the UK National Diet and Nutrition Survey 2008–2012, in which the year-round mean plasma 25(OH)D concentration was 42.5 nmol/l among >65-year-old females (49). The use of vitamin D supplements was related to higher plasma 25-OH-vitamin D levels, which highlights the clinical value of vitamin D supplements among the older population.
The strength of our study is that it provides information regarding the nutritional status and nutrient intake of older caregivers, information that is generally lacking. We used validated methods to assess their nutritional status. The MNA has been validated for older adults (25, 50) and has been used in large populations (51). We also obtained information on caregivers’ nutrient intakes and 25(OH)D levels, which are not usually reported.
Nevertheless, our study has some potential limitations. Due to its cross-sectional nature, causal relationships cannot be drawn from the results. Because of the specifity of our recruitment, the number of participants was small and the study population was selected. This weakens the generalizability of our results to other older caregivers. Selection bias is also possible because the participants were in good physical shape and were keen to participate. This may indicate that they were more health conscious than the average elderly population, and the study results may be more optimistic than in reality. The study population consisted of both females and males, which improved the sample. Some other limitations are related to the measurements. Nutrient intake was studied using three-day food diaries, which can affect the results through over- or under-reporting. This time may not be long enough to show the actual food intake over a longer period. However, we performed check calls to confirm the amounts and types of foods consumed, and it is still noteworthy that the participants had fairly stable food habits, as older people usually do.
Nutritional well-being is a fundamental component of health, physical functioning and quality of life (52). Older caregivers have shown to be prone to malnutrition (16) so they need special support for their nutritional wellbeing.

Conclusion

Our results showed that most of the older (≥65 y) caregivers had good nutritional status, but that one in five was still at risk of malnutrition, especially among the females. Depressive symptoms and medication were associated with decreased nutritional status, and good HRQoL with better nutritional status. A total of 79.7% of the caregivers had a lower protein intake than that recommended. The intake of dietary fibre, folate and vitamin D were also low. Among the males, a greater AUDIT score was associated with a lower protein intake, and greater hand-grip strength with a higher protein intake. These results highlight the need for systematic nutritional assessment among older caregivers and the importance of preventive nutritional guidance. Further studies are required to obtain more information about older caregivers’ nutritional statuses and nutrient intake.

Funding/Support: This study received funding from the National Institute for Health and Welfare (THL) in Finland. The funders played no role in the design, analysis or interpretation of the data or in writing, reporting or deciding whether to submit this article for publication. The authors are independent researchers and are not associated with the funders.

Conflict of interest: The authors declare that they have no conflicts of interest directly relevant to this report. However, Dr Suominen reports co-operating professionally with Nutricia Medical and Verman.

Ethical standards: The Ethics Committee of the Hospital District of Southwest Finland approved the study and participants provided written informed consent.

References

1.   Torres MJ, Dorigny B, Kuhn M, Berr C, Barberger-Gateau P, Letenneur L Nutritional status in community-dwelling elderly in France in urban and rural areas. PLoS One 2014;9:e105137. doi: 10.1371/journal.pone.0105137.
2.   European Foundation for the Improvement of Living and Working Conditions, 2009. Second European Quality of Life Survey. Overview. Luxembourg: Office for Official Publications of the European Communities. http://www.eurofound.europa.eu/pubdocs/2009/02/en/2/EF0902EN.pdf. Accessed 26 January 2017.
3.   Finnish Ministry of Social Affairs and Health, 2014. National informal care development programme, final report. https://www.julkari.fi/bitstream/handle/10024/116146/URN_ISBN_978-952-00-3483-2.pdf?sequence=1. Accessed 26 January 2017.
4.   The Central Association of Carers in Finland, 2015. Am I a Carer? First-Hand Guide to Informal Care. https://www.omaishoitajat.fi/sites/omaishoitaja.asiakas.fi/files/ensiopas_EN_low_3.pdf. Accessed 26 January 2017.
5.   Robards J, Vlachantoni A, Evandrou M, Falkingham J. Informal caring in England and Wales–Stability and transition between 2001 and 2011. Adv Life Course Res 2015;24:21-33. doi: 10.1016/j.alcr.2015.04.003.
6.   Doran T, Drever F, Whitehead M. Health of young and elderly informal carers. BMJ 2003;327:1388. doi: 10.1136/bmj.327.7428.1388.
7.   Schulz R, Martire LM. Family caregiving of persons with dementia: prevalence, health effects, and support strategies. Am J Geriatr Psychiatry 2004;12:240-249.
8.   Sorensen S, Pinquart M, Duberstein P. How effective are interventions with caregivers? An updated meta-analysis. Gerontologist 2002;42:356-372.
9.   Aggarwal B, Liao M, Christian A, Mosca L. Influence of caregiving on lifestyle and psychosocial risk factors among family members of patients hospitalized with cardiovascular disease. J Gen Intern Med 2009;24:93-98. doi: 10.1007/s11606-008-0852-1.
10.   Alzheimer’s Disease International, 2010. World Alzheimer Report. The global economic impact of dementia. http://www.alz.co.uk/research/files/WorldAlzheimerReport2010.pdf. Accessed 6 January 2017.
11.   Suominen MH et al. Working Group Report, State Nutrition Council, Nutrition Recommendations for Elderly. Edita Prima, Helsinki 2010
12.   Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment. Clin Geriatr Med 2002;18:737-757.
13.   Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature–What does it tell us? J Nutr Health Aging 2006;10:466-85; discussion 485-7.
14.   Suominen MH, Puranen T, Jyväkorpi S. Ravitsemus muistisairaan kodissa. Loppuraportti. Suomen Muistiasiantuntijat ry 2013.
15.   Rullier L, Lagarde A, Bouisson J, Bergua V, Torres M, Barberger-Gateau P. Psychosocial correlates of nutritional status of family caregivers of persons with dementia. Int Psychogeriatr 2014;26:105-113. doi: 10.1017/S1041610213001579.
16.   Puranen T. Intervening nutrition among community-dwelling individuals with Alzheimer’s disease and their spouses. University of Helsinki, Faculty of Medicine, 2015.
17.   Wolfe RR. The role of dietary protein in optimizing muscle mass, function and health outcomes in older individuals. Br J Nutr 2012;108 Suppl 2:S88-93. doi: 10.1017/S0007114512002590.
18.   Pedersen AN, Cederholm T. Health effects of protein intake in healthy elderly populations: a systematic literature review. Food Nutr Res 2014;58:10.3402/fnr.v58.23364. doi: 10.3402/fnr.v58.23364.
19.   Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198. doi: 0022-3956(75)90026-6.
20.   Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of Illness in the Aged. the Index of Adl: a Standardized Measure of Biological and Psychosocial Function. JAMA 1963;185:914-919
21.   Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179-186
22.   Bohannon RW. Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders. Percept Mot Skills 2006;103:215-222. doi: 10.2466/pms.103.1.215-222.
23.   Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, Leirer VO. Development and validation of a geriatric depression screening scale. J Psychiatr Res 1983;17:37-49
24.   Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption–II. Addiction 1993;88:791-804
25.   Vellas B, Guigoz Y, Garry PJ, Nourhashemi F, Bennahum D, Lauque S, Albarede JL . The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116-122. doi: S0899-9007(98)00171-3.
26.   Sintonen H. The 15D instrument of health-related quality of life: properties and applications. Ann Med 2001;33:328-336
27.   Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, Cooper C, Sayer AA. A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach. Age Ageing 2011;40:423-429. doi: 10.1093/ageing/afr051.
28.   World Health Organization, 2016. International statistical classification of diseases and related health problems. Available: http://apps.who.int/classifications/icd10/browse/Content/statichtml/ICD10Volume2_en_2016.pdf?ua=1&ua=1. Accessed 14 February 2017
29.   Beck AM, Ovesen L. At which body mass index and degree of weight loss should hospitalized elderly patients be considered at nutritional risk? Clin Nutr 1998;17:195-198. doi: S0261-5614(98)80058-7.
30.   Friedman B, Heisel MJ, Delavan RL. Psychometric properties of the 15-item geriatric depression scale in functionally impaired, cognitively intact, community-dwelling elderly primary care patients. J Am Geriatr Soc 2005;53:1570-1576. doi: JGS53461.
31.   Finnish Nutrition Recommendations. National Nutrition Council. Health from food – The Finnish Dietary Guidelines, 2014.
32.   Nordic Council of Ministers, Nordic Council of Minister, 2012. Nordic Nutrition Recommendations http://dx.doi.org/10.6027/Nord2014-002.
33.   Satakunta Central Hospital laboratory Satadiag, 2017. Research manual. Satahttp://webohjekirja.mylabservices.fi/SataDiag/?fp=1. Assessed 7.2.2017.
34.   Rustad P, Felding P, Franzson L, Kairisto V, Lahti A, Martensson A, Hyltoft Petersen P, Simonsson P, Steensland H, Uldall A. The Nordic Reference Interval Project 2000: recommended reference intervals for 25 common biochemical properties. Scand J Clin Lab Invest 2004;64:271-284. doi: 10.1080/00365510410006324.
35.   Rullier L, Lagarde A, Bouisson J, Bergua V, Barberger-Gateau P. Nutritional status of community-dwelling older people with dementia: associations with individual and family caregivers’ characteristics. Int J Geriatr Psychiatry 2013;28:580-588. doi: 10.1002/gps.3862.
36.   John BK, Bullock M, Brenner L, McGaw C, Scolapio JS. Nutrition in the elderly. Frequently asked questions. Am J Gastroenterol 2013;108:1252-66; quiz 1267. doi: 10.1038/ajg.2013.125.
37.   Jimenez-Redondo S, Beltran de Miguel B, Gavidia Banegas J, Guzman Mercedes L, Gomez-Pavon J, Cuadrado Vives C. Influence of nutritional status on health-related quality of life of non-institutionalized older people. J Nutr Health Aging 2014;18:359-364. doi: 10.1007/s12603-013-0416-x.
38.   Hiel L, Beenackers MA, Renders CM, Robroek SJ, Burdorf A, Croezen S. Providing personal informal care to older European adults: should we care about the caregivers’ health? Prev Med 2015;70:64-68. doi: 10.1016/j.ypmed.2014.10.028.
39.   Cuervo M, Garcia A, Ansorena D, Sanchez-Villegas A, Martinez-Gonzalez M, Astiasaran I, Martinez J. Nutritional assessment interpretation on 22,007 Spanish community-dwelling elders through the Mini Nutritional Assessment test. Public Health Nutr 2009;12:82-90. doi: 10.1017/S136898000800195X.
40.   Wham CA, McLean C, Teh R, Moyes S, Peri K, Kerse N. The BRIGHT Trial: what are the factors associated with nutrition risk? J Nutr Health Aging 2014;18:692-697. doi: 10.1007/s12603-014-0032-4.
41.   Morley JE, Argiles JM, Evans WJ, Bhasin S, Cella D, Deutz NE, Doehner W, Fearon KC, Ferrucci L, Hellerstein MK et al. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc 2010;11:391-396. doi: 10.1016/j.jamda.2010.04.014.
42.   Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, Phillips S, Sieber C, Stehle P, Teta D et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc 2013;14:542-559. doi: 10.1016/j.jamda.2013.05.021.
43.   Lancha AH,Jr, Zanella R,Jr, Tanabe SG, Andriamihaja M, Blachier F. Dietary protein supplementation in the elderly for limiting muscle mass loss. Amino Acids 2017;49:33-47. doi: 10.1007/s00726-016-2355-4.
44.   McLean RR, Mangano KM, Hannan MT, Kiel DP, Sahni S. Dietary Protein Intake Is Protective Against Loss of Grip Strength Among Older Adults in the Framingham Offspring Cohort. J Gerontol A Biol Sci Med Sci 2016;71:356-361. doi: 10.1093/gerona/glv184.
45.   Kesse E, Clavel-Chapelon F, Slimani N, van Liere M, E3N Group. Do eating habits differ according to alcohol consumption? Results of a study of the French cohort of the European Prospective Investigation into Cancer and Nutrition (E3N-EPIC). Am J Clin Nutr 2001;74:322-327.
46.   Satre DD, Sterling SA, Mackin RS, Weisner C. Patterns of alcohol and drug use among depressed older adults seeking outpatient psychiatric services. Am J Geriatr Psychiatry 2011;19:695-703. doi: 10.1097/JGP.0b013e3181f17f0a.
47.   Shaffer KM, Kim Y, Llabre MM, Carver CS. Dyadic associations between cancer-related stress and fruit and vegetable consumption among colorectal cancer patients and their family caregivers. J Behav Med 2016;39:75-84. doi: 10.1007/s10865-015-9665-y.
48.   Jyväkorpi S et al. Nutrition education and cooking classes improve diet quality, nutrient intake, and psychological well-being of home-dwelling older people—a pilot study.” J Aging Res Clin 2014;3:120-124
49.   Bates B, Lennox A, Prentice A, et al, 2014. London: Public Health England, Food Standards Agency National Diet and Nutrition Survey Results from Years 1, 2, 3 and 4 (combined) of the Rolling Programme (2008/2009–2011/2012)
50.   Vellas B, Villars H, Abellan G, Soto ME, Rolland Y, Guigoz Y, Morley JE, Chumlea W, Salva A, Rubenstein LZ et al. Overview of the MNA–Its history and challenges. J Nutr Health Aging 2006;10:456-63; discussion 463-5
51.   Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony PS, Charlton KE, Maggio M et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc 2010;58:1734-1738. doi: 10.1111/j.1532-5415.2010.03016.x.
52.   Phillips MB, Foley AL, Barnard R, Isenring EA, Miller MD. Nutritional screening in community-dwelling older adults: a systematic literature review. Asia Pac J Clin Nutr 2010;19:440-449

NUTRIENT INTAKE AND NUTRITIONAL STATUS OF THE AGED IN LOW INCOME AREAS OF SOUTHWEST, NIGERIA

W.A.O. Afolabi, I.O. Olayiwola, S.A. Sanni, O. Oyawoye

Department of Nutrition and Dietetics, College of Food Science and Human Ecology, Federal University of Agriculture, Abeokuta Ogun State Nigeria

Corresponding Author: W.A.O. Afolabi, Department of Nutrition and Dietetics, College of Food Science and Human Ecology, Federal University of Agriculture, Abeokuta Ogun State Nigeria, Email: afolabiwao@yahoo.com, Mobile: +234 803 475 0655

Abstract

Objective: The study was carried out to assess the nutrient intake and nutritional status of free living and non-institutionalized elderly Nigerian men and women residing in low income areas. Design, Setting and Participants: The study was cross sectional involving 140 (58-99 years) apparently healthy elderly subjects randomly selected across four low income urban and rural areas of southwest Nigeria. Measurements: Data on socio economic characteristics and dietary intake (24-hour recall) were obtained with a structured questionnaire while anthropometric data were measured and nutritional status indices were classified using WHO standards. Nutrient intake data was compared to DRI while other data were analyzed using Statistical Package for Social Sciences version 16.0. Results: Majority (84.3%) of the respondents were married and illiterate (80%). Most popular occupation were farming (47%) and trading (35.7%). Half of the respondents earn ≤ NGN1, 000 (≤US$6) and only 27% earn ≥ N6000 (US$37) monthly. The mean weight, height and arm circumference for men were 59.7 ± 6.50kg, 1.61±10.564m and 27.5 ± 9.24 cm respectively while that for women were 56.3 ± 5.72 kg, 1.57 ± 4.37m and 27.0 ± 5.22cm respectively. The mean daily energy (1805.2Kcal) and protein (23g) intake of women were significantly (p<0.05) lower than that of men (2044Kcal and 27.7g respectively). Intake of protein, calcium, riboflavin, niacin and vitamin C for both men and women were below DRI while iron, phosphorus, thiamine and energy intakes were adequate. Prevalence of underweight was low (2.9%) in this study while that overweight (pre obesity) was high (20% for men and 22.8% for women). Weight and BMI are significantly influenced by energy intake of the men (r=0.439, p=0.008); (r=0.352,p=0.038) and not women (r=0.229,p=0.186; r=0.320,p=0.06 respectively) while arm circumference was significantly (p<0.05) influenced by protein intake of both men and women (r=0.333,p=0.04 and r=0.404,p=0.02) respectively. Conclusion: This study has established a less than adequate intake of protein and some micronutrients among the elderly population as well as a high prevalence of overweight which coexists with underweight. There is need for a functional policy on the care of the aged in Nigeria in order to improve their nutrition, health and general wellbeing.

Key words: Nigerian, elderly, nutritional status, nutrient intake.

Introduction

Malnutrition is a great hazard to which the aged appears to be more vulnerable than the younger age groups due to problems relating to ignorance on appropriate food choices, loneliness, social isolation which often times lead to depression, apathy, lack of appetite, physical disabilities, cardiovascular problems and poverty among others. According to World Health Organisation (WHO) (1) the elderly are defined as persons above the age of 60 years with women comprising a majority of this population. The elderly population in the recent decade especially in Africa and other developing countries appear to be increasing (2-6). Govender (7) noted that the elderly are the gemstones of any society that are often ignored. Their care and wellbeing especially in rural communities depend largely on their children, relatives and sometimes government resources. This places a huge financial burden on their caregivers with a consequent lack in adequately providing for the nutritional and health needs of the aged in their care. Inadequate household food security, war and famine, and the indirect impact of HIV infection and AIDS among others have been documented as important determinants of poor nutritional status of elderly Africans (2).All these increases in the cost of living affects to a great extent dietary intakes and nutritional status of not only the general populace, but the often neglected elderly population. Furthermore, the vulnerability of the aged being far greater than that of the younger population shows the need for continuous monitoring of the aged with a view to identifying the extent of malnutrition among them in Nigeria. Several studies (8-10) have documented poor nutritional status among the aged. Similarly, previous studies (5, 7,11,) have documented that the energy and nutrient intakes of the elderly were low compared to recommended dietary allowances. Older people are at nutritional risk, not only because of impaired digestion, absorption or utilization of nutrients associated with chronic disease or drug–nutrient interactions, but also due to an interaction between physiological, psychological and socioeconomic factors (11). In addition, it is evident that the elderly in developing countries will be vulnerable to health related predicaments associated with very low income, inadequate food intakes, poor food patterns, under-nutrition, over-nutrition, chronic illness and diseases (12, 13, 7).

In many developing countries including Nigeria, there is a dearth of information as well as epidemiological data on the nutritional status of the aged since studies regarding the nutrient intakes of these groups are limited and isolated. Studies on children particularly infants and preschool children appears to be more common than studies on the aged who are equally as vulnerable as young children to changes in social and economic conditions. In view of this, this study was carried out to assess the dietary habit, nutrient intake and nutritional status of the elderly who resides in low income areas of Ibadan in Southwest of Nigeria. It is expected that the study will further bridge the information gap and promote the care of the aged population.

Methodology

Study area

The study was carried out in Ibadan located in South West Nigeria. Ibadan is the capital of Oyo State and the third largest metropolitan area in Nigeria apart from Kano and Lagos. It has a population of 1,338,659 according to Nigeria Census (14). Ibadan metropolitan area is made up of eleven Local Government Areas with 5 in the urban area of the city and 6 in the peri-urban area of the city. However, Ibadan is inhabited by several ethnic groups in Nigeria but the Yorubas are the predominant ethnic group and are of middle and low socio economic class. Ibadan has a population pyramid similar to the national population pyramid of Nigeria hence was judged to have similar proportion of elderly put at 2.7% (15). According to the 2006 Census figure the population of Ibadan South East was 266,046 and Egbeda (319,388) respectively (16).

Study Design

This study was cross sectional and descriptive in nature and involved apparently healthy free living non institutionalized elderly Nigerians residing in low income areas of Oyo state Nigeria.

Sample size and Sampling procedure

A multistage sampling technique was used for the research. First stage involved purposive selection of the three local government areas. Then using classification criteria for low income, high population density areas (17-21). The identification of the low income areas was further limited to an area within the selected areas that had majority (over 60%) of its housing structure as urban slums (no decent roofing and houses built with mud) and with little or no access to basic facilities such as clinics, schools, and water and toilet facilities. An estimated 2.7% of the total population of each of the local government areas was assumed to be aged. Household listing was conducted for all the households with at least one aged male or female within the defined low income areas. Participants in the study were then selected systematically from a list of pre listed households using a sampling interval of five. Then one hundred and thirty two households were randomly selected where at most two participants were selected from a household.

A total of 140 free living and non-institutionalized and willing aged persons participated in the study. They were selected from the five identified low income urban communities (Aliwo, Gbenla, Kobomoje, Oke Paadi) and a rural community (Osegere) in the outskirts of Ibadan. The study comprised of both males and female in the ratio 1:1. The elderly start up age in this study was reduced to 58 years due to lower life expectancy for men and women in Nigeria compared to other developed countries (22) and the fact that most of the participants have no record of age or birth certificate and the ages were based on estimates using historical events. The Criteria for selection were based on the fact that the subject must be resident in the area and not a visitor, then he/she must have lived in the area for not less than 3-5 years prior to the study.

Ethical Approval and Consent

This study was approved by the ethical review and research committee of the College of Food Science and Human Ecology, Federal University of Agriculture, Abeokuta, Ogun state, Nigeria (Ref 2011/COLFHEC/043). The subjects were also duly informed and verbal consent of the participants and their children was obtained before they were allowed to participate in the study.

Method of Data Collection

A structured pretested interviewer administered questionnaire was used to obtain information in this study. The questionnaire contained sections seeking the following information

i. Socio demographic and economic data

ii. Dietary recall (24-hour)

iii. Anthropometric data

Dietary recall

With the aid of 24-hour dietary recall format, the respondents were asked to recall all foods and drinks including in-between meals consumed within the previous 24 hours. The source, time of consumption and estimated cost of each meal was also obtained. Other caregivers within the households especially children of the aged assisted in providing information on portion sizes and food description were confirmed with the aid of food models and household measures and were converted to grams using weighing scales before leaving the households. The nutrient intakes of the individual subjects were then calculated using a combination of Food Composition tables compiled by FAO (15) and Oguntona and Akinyele (24).

Anthropometric data

Anthropometric measurement collected includes weight, height and upper arm circumference. The weight of the subjects was measured while standing with both arms by the side and with only light clothing on. The pointer of the weighing scale (Hanson model) was adjusted to zero before each weighing and was recorded to the nearest 0.1kg

In measuring the height of the respondents, a locally constructed but standardized height meter was placed behind the heels of each subject and the height was measured while each individual was standing with the head fixed against the height meter and the level just above the hair was marked and recorded to the nearest 0.1cm.

The upper arm circumference was recorded as a measure to reflect protein and fat intake adequacy. The mid upper arm circumference was taken using WHO procedures (23). This was measured using a non stretchable tape measure. The measurement was taken in centimeters with the non elastic tape measure placed firmly on the left mid upper arm, at the mid-point between the acromion process of the scapular and the olecranon process of the ulna bone and compared to standards by Jellife, (25).

The body mass index of the aged were calculated as weight of each individual in kg divided by the square of the height in metres, values were then compared to WHO (26) reference standards.

Method of Data Analysis

Statistical Package for Social Sciences Software (27) was used to analyze data obtained from questionnaire and represented as frequencies, percentages, means and Standard deviations. linear regression analyses (Bivariate) were also carried out to establish relationships and measure the effect of variations between variables after adjusting for age (protein and energy intakes were used as the dependent variables). Level of significance was defined at 95% confidence interval (p<0.05). Adequacy of nutrient intakes was compared with Dietary Reference intakes (DRI) (28).

Results

The socio economic and demographic characteristics of respondents are presented in table 1. Most (84.3%) of the respondents were married while about 16% were widowed. Less than 20% of the respondents were educated and their major occupation was farming (47.1%) and trading (35.7%). Half of the respondents earn a monthly income ≤1000NGN (<US$6). Fifty four percent of the houses were constructed with cement but most (52.9%) of these houses had no toilet facilities and defecation is usually done in and around the houses in the urban low income areas and surrounding bushes in the rural area. Water is usually (100%) sourced from a community stand pipe in the urban low income areas and a river located close to the rural community. Table 2 shows information on the mean anthropometric indices of the respondents. The men had slightly higher weight (59.6kg), height (161.4cm) and arm circumference (27.5cm) compared to the women (56.3kg, 156.7cm, and 27.0cm respectively). The body mass index of the women was slightly higher (22.97kg/m2) than that of the men (22.77kg/m2).

Table 1 Socio Demographic and Economic Characteristics of Aged in Low income areas of Ibadan

*Multiple response

The usual feeding frequency per day for all the respondents was three times with breakfast customarily being consumed between 7:00-8:00 am, lunch at 1:30-2:30 pm and dinner between 7:30pm and 8:30 pm daily. The food of choice of these group of people for breakfast was ‘hot maize porridge or pap’ (eko) served with moinmoin (steamed bean pudding) or Akara (fried bean paste). During lunch, amala (prepared from yam flour)/ lafun (cassava based) is preferred with either Ewedu (Cochorus olitorus), okro, vegetable-melon soup, bean soup (Gbegiri) and stew served with or without meat or fish while either eko/agidi and Akara or mashed beans and stew are the usual meals for dinner. Breakfast and dinner are usually purchased from food vendors by most (80.3% and 87.1%) of the respondents while lunch is mostly prepared at home (76.5%). The cost of breakfast and dinner for majority (94%) of the aged in this study ranges NGN 100-150 per individual. Snacks or between meals is not common among this population and fruits are only consumed when they are in season.

Table 2 Mean anthropometric indices of aged in low income areas of Ibadan by sex

Table 3 Mid Upper Arm Circumference Evaluation of the Aged in Southwest Nigeria

Table 4 Nutritional Status of the aged in low income areas by BMI

About 74% of the women were within the normal range of BMI, 20% were overweight while 5.7% were underweight. Among the men, however, about 87% had healthy BMI range, 8.6% were overweight while only 2.9% were found to be underweight. Nutrient intake analysis shown in Table 5 indicated that the mean intake of energy (2044 Kcal/day) carbohydrate (388.3g), protein (27.7g) and fat (42.2g) for men was significantly (p<0.05) higher than that

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of the women. Similarly intakes of micronutrients including phosphorus, iron, thiamine, riboflavin niacin and Vitamin C were higher among the men than the women except for the intake of calcium which was higher in the women than men. In terms of recommended daily intakes, the intakes of energy and phosphorus were adequate for men while intakes of iron, carbohydrate and thiamine were far above the recommended intakes and the intakes of protein, fat, calcium, riboflavin, niacin and Vitamin C were below the DRI for the men. Among the women, the higher intake of calcium compared to the men did not translate into adequate intake as they consumed it in amounts far below recommended intakes. However, the intakes of energy and phosphorus among the women were adequate while that of carbohydrate, iron, and thiamine were above the recommended amounts, and the intakes of protein, fat, riboflavin, niacin and vitamin C were below the recommended intakes. Energy intake was observed to significantly increase with BMI (r=0.352, p=0.038) (table 7) among the men, this accounts for about 10% increase in BMI while 90% is accounted for by other factors. Similarly, energy intake also increased with weight and arm circumference. Linear regression coefficients of determination (adjusted R2) after adjusting for age indicates that energy intake influences almost 17% increase in weight for the men while it accounts for only 11.7% variation in arm circumference. Age did not influence either energy or protein intakes among the men and women. Furthermore, protein intakes were also significantly (p<0.05) associated with variations in weight, BMI and arm circumference for men accounting for approximately 25% and 16% variation in weight and BMI and only 9% for arm circumference of men. Among the women no significant relationship exists between energy intake, weight, and BMI and arm circumference. However, their arm circumference, weight and BMI were significantly influenced by their protein intake. Their protein intake similarly accounted for 13.2%, 12.7% and 13.8% variations in weight, BMI, and arm circumference respectively.

Table 5 Average Daily Nutrient intake of the Aged in Low income Areas of Nigeria

*Statistically significant at 95%CI

Table 6 Mean daily Energy and protein intake of the respondents by Income

NGN- Nigerian naira

Table 7 Food habit of the Low income aged in Ibadan

Discussion

This present study assessed the nutrient intake and nutritional status of free living, non-institutionalized elderly men and women in some low income urban and rural communities in Southwest Nigeria. More than half of the participants in this study were less than 68 years, this may be partly due to poor survival capacities among this population entrenched in the extent of poverty in the country, this suggests that only a very few proportion of elderly Nigerians live till age 80 years and above. The women were older compared to the men in this study. The men were taller than the women and this is similar to the findings among the elderly in Asaba, Delta state in South-South (29) Nigeria as well as in southwest Nigeria (30). However, the men weighed more than the women contrary to the reports of Odenigbo et al. (29) among similar populations but different ethnic group. We observed a significantly decreasing pattern of height and arm circumference with age among the women compared to the men who had these trends increasing with age but not statistically significant. This may be due to the fact that majority of the men were still engaged in farming and reasonably engaged in a vocation involving regular muscular exercise. A similar trend was also reported among elderly Nigerians (29). Among the elderly population in this study, height, arm circumference and weight increased with BMI. Body weight also decreased with age among the women, this finding is similar to that of Suraih et al., (31) which reported that decline in body weight among women was greater than that of the men this may be associated with reduction in body water and muscle mass (6, 32) as well as social, health care, personal morbidity, availability and accessibility issues. Similar to the findings of Seong et al.(6), we found that the BMI of men decreased with age; this should not be interpreted as due to the ageing process but selective survival, they further affirmed that people with lower BMI tend to survive with increasing age thus shifting the BMI distribution of survivors downwards (33). The mid upper arm circumference (MUAC) were measured to reflect risk of malnutrition in this study, MUAC has been documented to be a more sensitive index than BMI in revealing under-nutrition among the elderly (2, 34). We observed that the arm circumference of the elderly in this study was strongly related to their BMI. Although majority of the elderly in this study appeared to have MUAC ≥ 80th percentile, the fact that a low proportion of under-nutrition exists among them still emphasizes the need for close monitoring and care of the aged. The level of under-nutrition in this study (using <22cm for women and 23cm for men as cutoff points) by MUAC was 4.3% while by BMI it was 5.7%. Mid upper arm circumference has been shown to be influenced by protein and fat intakes of individuals. In general, the nutrient intakes of both men and women in this study were low compared to DRI except for the intakes of energy for the women. The pattern of dietary intake of the elderly in this study supports the findings of a similar study in Ibadan southwest Nigeria (35) where the dishes were mostly dominated by cassava products (eba and amala), cereals (rice), legumes by beans (Akara or moi moi) and tubers (yam eaten boiled or pounded). The foods consumed by the elderly in this study were mostly from plant based sources and animal based foods are only consumed when they have economic access to it. This may be majorly responsible for the low protein and very high carbohydrate intakes among them. Intake of energy and protein appeared to increase with income in the study. Low intakes of protein results in malnutrition and thus increases susceptibility to infections whilst infection is recognized to have a synergistic relationship with malnutrition (26). Fruits are consumed in lesser amounts compared to vegetables; they (fruits) are consumed only when they are in season while the reason for increased green vegetable consumption among the study group may be adduced to the fact that many south western Nigerian based dishes are often consumed with green vegetables (36). Corchorus. olitorus is usually recommended for pregnant women and nursing mothers due to its richness in iron (36-39). This may be responsible for the very high iron intakes among the subjects in this study. Reports of many studies (3, 5, 39) suggest that older adults tend to have poor nutrient intakes. Although, energy and carbohydrate were the major macronutrients consumed in adequate amount in this study, protein and fat intake were low. Despite that the energy intake in this study exceeded 6.3MJ (1500Kcal) which was argued to imply difficulty in meeting requirements for vitamins and minerals (40) , the inability to meet the requirements for some vitamins and calcium in this study suggests that adequacy in energy intake does not imply adequate intakes of micronutrients. Ngatia et al. (41) documented very high carbohydrate intake among the elderly in Kenya, a similar study on the elderly in Zimbabwe (42) and India (43) documented very low protein intakes. Another study in south-south (44) and rural southwestern regions of Nigeria (45) documented very low intakes of thiamin, riboflavin and niacin among elderly populations; this is similar to the findings of this study where the intake of riboflavin and niacin were low.

Table 8 Relationship between Anthropometric Variables and Nutrient Intakes of the aged Men

*statistically significant at 95% confidence interval; p(All variables were adjusted for age.)

Table 9 Relationship between Anthropometric Variables and nutrient intakes of aged women

*statistically significant at 95% confidence interval; p(All variables were adjusted for age.)

In conclusion, this study has shown that the nutrient intake of the elderly is inadequate especially in protein and micronutrients which is a consequence of low intake of food of animal origin and fruits. The study also confirmed that mid upper arm circumference is a better index for assessment of under-nutrition among the elderly and is influenced strongly by their protein and energy intake. There is a heightened need to adequately improve their intakes through promoting appropriate dietary practices and increasing their access to food through community support.

Ethical Standards: This study was approved by the ethical review and research committee of the College of Food Science and Human Ecology, Federal university of Agriculture, Abeokuta, Ogun state, Nigeria (Ref 2011/COLFHEC/043) and all methods used comply with the research and ethical laws of the Federal Republic of Nigeria.

Conflicts of Interest: There was no funding received for this research. All authors declared no conflict of interest.

References

1. World Health Organisation. 2010a. Definition of an older or elderly person (online). Available http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html (Accessed 15 April 2014)

2. Charlton Karen E. and Rose Donald 2001Nutrition among Older Adults in Africa: the Situation at the Beginning of the Millenium J. Nutr. 2001;vol. 131 no. 9 2424S-2428S

3. Olayiwola LM, Adeleye A, Jiboye AD. “Effect of Socio-cultural factors on Housing quality in Osogbo, Nigeria”. International Symposium on Construction in Developing Economies: New issues and challenges. Santiago, Chile. 2006;January, 18-29.

4. National Population Commission. Statistical Information for the Nation. Federal Office of Statistics, Abuja, 1998.

5. Tucker K.L, Dallal G.E, Rush D. Dietary patterns of elderly Boston area residents defined by cluster analysis. J.Am Diet Assoc 1992;92(12):1487-1491

6. Seong Ting Chen, Hooi Jiun Ngoh & Sakinah Harith. Prevalence of Malnutrition among Institutionalized Elderly People in Northern Peninsular Malaysia: Gender, Ethnicity and Age-specific Sains Malaysiana 2012;41(1) (141–148

7. Govender. Analysis of The Nutritional Status And Dietary Intake Data Of a group Of Elderly At A Day And Frail Care Centre In Verulam. Theses of Master of Technology Department of Food and Nutrition Consumer Science Faculty of Applied Sciences at the Durban University of Durban, South Africa, 2011.

8. Sanya E O, Kolo P M, Adekeye A, Ameh O I, Olanrewaju T O. Nutritional status of elderly people managed in a Nigerian tertiary hospital. Ann Afr Med [serial online] 2013 [cited 2014 Apr 15];12:140-1. Available from: http://www.annalsafrmed.org/text.asp? 2013/12/2/140/112416

9. Olayiwola IO1, Ketiku AO. Socio-demographic and Nutritional Assessment of the Elderly Yorubas in Nigeria. Asia Pac J Clin Nutr.;2006;15(1):95-101

10. Fadupin G.T. Social Support, Environmental Condition and Nutritional Status of the Elderly in Ibadan. Nigerian Journal of Nutritional Sciences, 2012;Vol 31, No 1., 2012

11. Charlton K E, Bourne Lesley T, Steyn Krisela and Laubscher Jacoba A. Poor nutritional status in older black South Africans Asia Pacific J Clin Nutr 2001;10(1): 31–38

12. World Health Organisation. 2009. Nutrition for older persons (online). Available http://www.who.int/nutrition/topics/ageing/en/index.html (Accessed 15 April 2014).

13. Oldewage-Theron, W.H., Dicks, E.G., Napier, C.E. and Rutengwe, R. Situation analysis of an informal settlement in the Vaal Triangle. Development Sothern Africa. 2005;22 (1): 13–26.

14. NPC. National Population Commission, Provisional Census Figure of the 2006 National Census for Oyo State, Nigeria 2006.

15. Food and Agricultural Organisation (1968) Food Composition Table for use in Africa. Available on http://www.fao.org/docrep/003/x6877e/x6877e00.htm accessed 13th April, 2013.

16. Abumere S. Residential Differentiation in Ibadan: Some Sketches of an Explanation. In Filani M.O.; Akintola F.O.; and Ikporukpo C.O. (eds). Ibadan Region, Rex Charles Publication Ibadan, 1994;pp.72-84

17. Asiyanbola, R.A., and Filani, M.O. An Exploratory Analysis of the Determinants of Women’s Involvement in Housing Delivery in Nigeria. Research for Development. Published by the Nigerian Institute of Social and Economic Research, Ibadan, Nigeria. 2007;23( 1 and 2): 119-143

18. Ayeni, B. The Metropolitan Area of Ibadan, Its Growth and Structure. In: M.O. Filani, F.O. Akintola and C.O. Ikporukpo. Ibadan Region, Rex Charles Publication, Ibadan. 1994;p.34.

19. NISER. Socio-economic Survey of Ibadan City. Report of a Survey Commission by the Ibadan Metropolitan Planning Authority (IMPA), NISER, Ibadan. 1988;43pp

20. Okuneye, P., Adebayo, K., Opeolu, B. and Baddru, F. Analysis of the Interplay of Migration and Urban Expansion on Health and environment: the case of Lagos, Nigeria. 2007;28pp

21. Oyo State Government (2011) Detailed Information of the 33 Local Governments in Brief. http://www.oyostate.gov.ng/ministries-departments-and-agencies/local government-and-chieftaincy-matters/detailed-information-of-the-33-local-governments-in-brief/

22. WHO. Adults 60 years of age and older. In: physical status: the use and interpretation of anthropometry. Report of a WHO Expert committee, technical report series 1995;no. 854, ch. 9, Geneva:

23. Oguntona, E.B. and I.O. Akinyele. Nutrient Composting of Commonly Eaten Foods in Nigeria: Raw, Processed and Prepared. 1st Edn., Food Basket Foundation Publication Series, Ibadan, 1995.

24. Jelliffe D.B. The Assessment of Nutritional Status of the Community. WHO Monograph series 1966;No 53.

25. WHO. 2000 Turning the tide of malnutrition: responding to the challenge of the 21st century. Geneva: WHO, (WHO/NHD/00.7)

26. SPSS for windows. Release 16.0.0 SPSS Inc Standard Version.

27. Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes Series, National Academy Press 2002. Available at www.nap.edu

28. Odenigbo U.M., Odenigbo C.U. and O.C. Oguejiofor. Nutritional Status of Elderly in Asaba, Delta State, Nigeria Pakistan Journal of Nutrition 2010;9 (5): 416-418,

29. Oguntona, C.R.B. and O. Kuku. Anthropometric survey of the elderly in south-western Nigeria. Ann. Human Biol., 2000;27: 257-262.

30. Suriah, A.R., Zalifah M.K., Zainorni, M.J., Shafawi, S., Mimie Suraya, S., Zarina N. & Wan Zainuddin W.A. Anthropometric measurements of the elderly. Malaysian Journal of Nutrition 1998;4: 55-63.

31. Nair, K.S. Aging muscle. American Journal of Clinical Nutrition 81(5): 953-963.

32. Lim TO, Ding LM, Zaki M, Suleiman AB, Fatimah S, Siti S, Tahir A & Maimunah AH. Distribution of body weight, height and body mass index in a national sample of Malaysian adults. Med J Mal 2000;55(1):108-128.

33. Ismail, S. & Manandhar, M. Anthropometric characteristics of older people in rural Malawi. Better nutrition for older people: assessment and Action HelpAge International and London School of Hygiene and Tropical Medicine London, UK, 1999.

34. Aromolaran, A.B. “The Nigeria Nutritional Problem: A case study of Ibadan and Selected Villages”. M.Sc thesis, University of Ibadan, Ibadan, Nigeria, 1987.

35. Yekeen, T.A., Akintaro, O.I., Akinboro, A. and Azeez, M.A. (2013) Evaluation of cytogenotoxic and nutrient composition of three commonly consumed vegetables in South-Western Nigeria. The Free Library, http://www.thefreelibrary.com/Evaluation of cytogenotoxic and nutrient composition of three…-a0354661287 (Accessed April 30 2014)

36. Oyedele DJ, Asonugho C and OO Awotoye. Heavy metals in soil and accumulated by edible vegetable after phosphate fertilizer application. J. Environ. Agric. Food Chem. 2006;5(4): 1446-1453

37. Olaiya C and J Adebisi. Phyto-evaluation of the nutritional values of ten green leafy vegetables in South -Western Nigeria. The Internet Journal of Nutrition and Wellness. Volume 9 Number 2, 2009.

38. Mehta Pallavi., Patel Krishna, Chauhan Komal. Assessment of Diet, Nutrition & Disease Profile of Elderly Females Residing in Rural Setting of Vadodara. Helpage India-Research & Development Journal 2011;Vol. 17 No.1pg 5-14

39. Parfitt AM, Gallagher JC, Heaney RP, Johnston CC, Neer R, Whedon GD. Vitamin D and bone health in the elderly. Am J ClinNutr 1982;36: 1014–1031.

40. Ngatia, E.M., Gathece l.W., Macigo F.G., Mulli T.K Mutara L.N., and Wagaiyu E.G. Nutritional And Oral Health Status of an Elderly Population In Nairobi East African Medical Journal 2008;Vol. 85 No. 8

41. Allain T. J., Wilson A.., Alfred Z., Gomo R., Donald J. Adamchak. Jonathon A. Matenga. Diet and nutritional status in elderly Zimbabweans Age and Ageing 1997;26: 463-470

42. Natarajan VS, Ravindran S, Sivashanmugam, Thyagarajan, Kailish K, Krishnaswamy B et al. Assessment of nutrient intake and associated factors in an Indian elderly population. Age Ageing; 1993;22: 103-8.

43. Nnanyelugo D. O., Kubiangha L. O. & U. O. Akpanyung. Food intakes and pattern of consumption among elderly Nigerians with a low income. Ecology of Food and Nutrition Volume 8, Issue 2, 1979; pages 79-86 DOI:10.1080/03670244.1979.9990548

44. Oguntona Clara R. B., Kuku Y. Olabisi & Addo Adenike A. Dietary Survey of Rural Elderly in Nigeria Journal of Nutrition For the Elderly Volume 18, Issue 1, 1999; pages 1-14 DOI:10.1300/J052v18n01_01