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Nutritional status of older persons presenting in a primary care clinic

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					  Nutritional Status of Older 
Persons Presenting in a Primary 
     Care Clinic in Nigeria

    ADEBUSOYE Lawrence
     University 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
ASSUMPTIONS
vUndernutrition
  - a rare occurrence in old age
vOverweight
  - invariable consequence of ageing.2, 3
vBMI is the most commonly available tool to
 assess nutrition in older persons.
             OBJECTIVES
1. 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 SITE
 University 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
          Sales, 7.8%
                        11.8%
          0.00%
                            Undernutrition


                            At Risk of Undern


                            Normal




80.4%
  Table 1: Significant risk factors for undernutrition
                           n = 39(%)            n = 59(%)      n= 402(%)    N=500(%)
RESPONDENTS                Undernutrition       At Risk of     Normal       Total
                                              Undernutrition
EMPLOYMENT STATUS
Engaged in occupation      38(8.5)          38(8.5)            369(83.0)    445 (100.0)
Not engaged in             1(1.8)           21(38.2)           33(60.0)     55 (100.0)
occupation
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(%)        n = 59(%)        n=402(%)    p-value
                 Undernutrition   At Risk of       Normal
                                  Undernutrition

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    0(0.0)           4(66.7)          2(33.3)     <0.001*
disease
         Table 3: significant risk factors for overweight

RESPONDENTS               n = 24(%)       n = 219(%)   n = 257(%)   N=500
                          Underweight     Normal       Overweight   Total

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

  vellas & Sieber 2009 hospital              39.0%                           47.0%                 14.0%




vellas & Sieber 2009 community    6.0%            32.0%                            62.0%




            Izawaa 2005, Japan     8.9%                   51.2%                            39.9%




       Zarina 2006, Bangladesh            26.0%                           62.0%                     12.0%




            Nzegwu et al, 2010     9.0%                           75.0%                            16.0%




          Adebusoye et al, 2009    7.8% 11.8%                              80.4%



                                  0%              20%         40%           60%            80%             100%

                        Undernutrition      At Risk of Undernutrition      Normal
                CONCLUSION
1. 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
                    REFERENCES
1. 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
                        n = 39(%)          n = 59(%)      n= 402(%)    N=500(%)
RESPONDENTS             Undernutrition     At Risk of     Normal       Total
                                         Undernutrition
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
                           n = 39(%)           n = 59(%)      n= 402(%)    N=500(%)
RESPONDENTS                Undernutrition      At Risk of     Normal       Total
                                             Undernutrition
EMPLOYMENT STATUS
Engaged in occupation      38(8.5)          38(8.5)           369(83.0)    445 (100.0)
Not engaged in             1(1.8)           21(38.2)          33(60.0)     55 (100.0)
occupation
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
                               n = 39(%)        n = 59(%)        n= 402(%)   N=500(%)
RESPONDENTS                    Undernutrition   At Risk of       Normal      Total
                                                Undernutrition

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
                           n = 39(%)             n = 59(%)        n= 402(%)   N=500(%)
 RESPONDENTS               Undernutrition        At risk of       Normal      Total
                                                 Undernutrition
 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 undernutrition
Presenting complaints                     Undernutrition n = 39(%)   Total N = 500 (%)
Digestive domain
Problem 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 Domain
Forgetfulness                                      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 Domain
Financial 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)

				
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