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 Table of Contents  
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 126-133

Determination of malnutrition and nutritional risks in aged individuals between 65 and 84 years in Turkey

Department of Nutrition and Dietetics, Istanbul Aydin University, Kucukcekmece, Istanbul, Turkey

Date of Submission21-Nov-2021
Date of Decision06-Mar-2022
Date of Acceptance05-Feb-2022
Date of Web Publication27-Jun-2022

Correspondence Address:
Dr. Indrani Kalkan
Department of Nutrition and Dietetics, Istanbul Medipol University, Guney Kampusu, Kavacik, Beykoz, Istanbul 34815
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjhs.bjhs_121_21

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BACKGROUND: Nutritional inadequacy, physical impairments, and degenerative diseases are the main causes of a general deterioration in health and quality of life in aged individuals.
OBJECTIVE: The to determine malnutrition and nutritional risks in Turkish aged individuals by evaluating nutritional status and recording anthropometric measurements.
MATERIALS AND METHODS: Eight hundred and eighty-seven Turkish aged individuals aged between 64 and 85 years participated in the study. Nutritional habits were interrogated by face to face interview method. Anthropometric measurements (body mass index [BMI], waist, hip, and upper-middle arm circumference), nutritional screening index (NSI), and mini nutritional assessment scale (MNA) were used to evaluate nutritional status and malnutrition risk among the participants.
RESULTS: As per MNA, 29.8% of females, 22.1% of males were at malnutrition risk whereas 4.5% of females and 4.3% of males were malnourished. In NSI evaluations, 23.3% of females and 17.1% of males were at medium risk whereas, 12.6% of females and 6.5% of males were in high-risk category. A moderate positive correlation was found between the BMIs of the individuals and upper-middle arm circumferences (P < 0.05). Furthermore, a moderate positive correlation was found between MNA and NSI scores (P < 0.05).
CONCLUSION: It is necessary to evaluate the nutritional and health status of elderly people at a regular basis. Further studies are required for suitable nutritional intervention or recommendations for the aged group.

Keywords: Aged, anthropometry, body mass index, malnutrition, nutritional assessment

How to cite this article:
Durmaz C, Kalkan I. Determination of malnutrition and nutritional risks in aged individuals between 65 and 84 years in Turkey. BLDE Univ J Health Sci 2022;7:126-33

How to cite this URL:
Durmaz C, Kalkan I. Determination of malnutrition and nutritional risks in aged individuals between 65 and 84 years in Turkey. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Aug 15];7:126-33. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/126/348260

Old age comprises the part of life following youth and middle age and embraces a series of physiological and psychological changes related to a general deterioration in health and quality of life. Physiological, psychological, and cognitive changes in an individual related to the genetic makeup and environmental factors may adversely affect his attitudes, behaviors, nutritional priorities lowering the quality of life and increasing the risk of mortality and morbidity.[1] Obesity, cardiovascular diseases, diabetes, digestive and respiratory system diseases, musculoskeletal system diseases, cancer, protein-energy malnutrition, and neuronal diseases are among the major health problems related to nutritional inadequacies, physical impairments, and other degenerative conditions.[1],[2] Nutritional interventions and diet planning leading to appropriate eating habits and balanced nutrition reduces the occurrence of nutritional-related diseases, accelerates the recovery process enabling the elderly to live independently, and increases the quality of life. Malnutrition in aged individuals may be overlooked occasionally but often emerges as a major public health problems in the form of increased hospital admissions, prolonged hospital stays, delays in wound healing, gait disturbances, falls and fractures, infections, and untimely deaths.[3] In this respect, nutritional screening tests performed to detect malnutrition are of great importance in terms of precautionary interventions.[4]

In this study, it was aimed to determine malnutrition and nutritional risks that may arise in aged individuals and use this information to identify individuals at nutritional risk.

  Materials and Methods Top

Study design

The study was conducted in Kucukcekmece, one of the largest counties in Istanbul Turkey, on aged individuals between 65 and 85 years who voluntarily accepted to participate in the study. Based on the aged population of the county, the study sample was calculated to be approximately 875 as per stratified sampling method (confidence level 95%, margin of error 5%). The study sample comprised of 887 individuals (443 females, 444 males) selected on a random basis. Individuals who were seriously handicapped or had a perception problem-dependent were excluded from the study. Care-providers were consulted for participants who had difficulty recalling their food consumption. A questionnaire form conducted on face-to-face basis was used to determine the demographic characteristics and eating habits of the individuals.

Anthropometric measurements

An immobile stadiometer fixed on the ground with a sensitivity of 0.1 cm in accordance with international standards was used to determine the height (in meters). A digital scale with 0.5 kg accuracy was used for the measurement of body weight. Body mass index (BMI) was calculated using the standard formula (body weight (kg)/height (m2). For waist and hip circumference measurements a nonflexible measuring tape was used. Waist/hip ratio was calculated by proportioning waist and hip circumference measurements.[5] Appropriate point was determined for upper-middle arm circumference and measurement was recorded by means of a nonflexible measuring tape.[6]

Nutritional assessment tools

Nutritional screening index (NSI) and mini nutritional assessment scale (MNA) were used to evaluate the nutritional risk and malnutrition of individuals.

Nutritional screening index

The “Nutrition Risk Screening” scale, developed by the American Dietetic Association and the National Aging Council-Nutrition Screening Initiative (NSI), is a tool comprising of 10 questions with “yes” or “no” responses that try to bring out the causes leading to inadequate and unbalanced nutrition of the elderly.[7] The questions cover aspects as diet, general, and social assessment of the individual.[5]

Mini nutritional assessment

MNA is a tool recommended by the European Parenteral and Enteral Nutrition Association that enables early screening and detection of the risk of nutritional deficiency in the elderly, living in long-term care units, homes, nursing homes, and hospitals.[8],[9] The sum of 18 questions can provide a maximum score of 30 and a score of 17–23.5 is considered at risk for malnutrition.[9]

Ethical Issues

The study was conducted in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with Helsinki declaration.

Ethical approval was acquired by the Istanbul Aydin University Ethical Committee dated 19.06.2019 (Document No: B.30.AYD.

Statistical analysis

SPSS (Statistical Package for Social Science) PASW 18 Statistical Package Program was used for statistical analysis. The qualitative data in the study were evaluated by calculating the number (S) and percentage (%) values, and the quantitative data by calculating the arithmetic mean (X), standard deviation (S), lower and upper values. Chi-square test was used to compare the means between the two groups. Pearson correlation analysis was used to determine the relationship between anthropometric measurements, MNA, and NSI scales. In all statistical tests, the lowest level of significance was taken as P < 0.05.

  Results Top

In this study, 49.9% were female and 50.1% were male. Of the participants, 12.6% were not able to read or write, 8.6% were literate but had no formal education, 44.9% were primary school, 12.4% secondary school, 12.7% are high school and 8.8% were college graduates. Majority of participants (87.6%) lived with their family and 80.5% stated that they had some kind of health problem. Among the participants who had health problems, 64.4% suffered from cardiovascular diseases and 13.4% had diabetes. When enquired about their diets, 55.8% stated that they did not follow a diet-related to their ailment. Among the participants who did follow a diet (24.7%), 37.4% followed a low fat-low-cholesterol-salt-free diet, 22.8% a salt-free diet, 21.5% a diabetic diet, and 11.9% a low fat-low cholesterol diet. When the BMIs of the individuals were examined, 0.8% were found to be underweight, 21% normal, 40.7% overweight, 23.4% first degree obese, 10.6% second degree obese, 3.5% third degree obese [Table 1].
Table 1: Information on the general characteristics of individuals

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Regarding nutritional habits of individuals, 48.3% consumed 2 meals and 40.4% 3 meals a day, 27.3% 2 snacks a day, 26.4% 3 snacks a day, 20.6% 1 snack a day, and 25.7% did not consume any snacks. Regarding skipping meals, it was found that 39.5% skipped a meal, 39% did not skip any meal, and 21.5% sometimes skipped a meal. Lunch was the most skipped meal (75.6%). On enquiring the reason behind skipping of meals, 36.8% stated that they did not have an appetite or they simply did not want to eat, 28.3% stated that they were not habituated to consume that particular meal. Of the participants, 42.3% prepared their meals themselves, 40.6% stated that their meals were prepared their spouses, 98.6% ate their meals without help, 83.3% ate their meals with their families. 89.3% of the individuals did not have chewing or swallowing difficulties and 76.3% had one or more missing teeth [Table 2].
Table 2: Information on the nutritional habits of individuals

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Regarding anthropometric data of participants, the mean height of females was found to be 157.3 ± 6.97 cm and 170.2 ± 7.34 cm in males. Mean body weight in females was found to be 75.4 ± 13.9 kg and 79.5 ± 13.0 kg in males. Mean BMI in females was calculated to be 30.5 ± 5.84 kg/m2and 27.4 ± 4.12 kg/m2 in males. While the mean waist circumference in females was 102.3 ± 16.0 cm and 101.7 ± 12.7 cm in males, the hip circumference was 111.4 ± 15.0 cm in females and 103.6 ± 11.0 cm in males. The waist/hip circumference ratio was calculated as 0.92 ± 0.102 in females and 0.98 ± 0.103 in males. The upper-middle arm circumference in females was found to be 32.2 ± 5.19 cm and 31.5 ± 5.00 cm in males. It was noted that the mean values of height, BMI, hip circumference, and waist/hip circumference between both genders were significantly different from each other (P < 0.05) [Table 3].
Table 3: Average, standard deviation, minimum and maximum values of the anthropometric measurements of individuals by gender

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On evaluating the MNA and NSI scores of participants; as per MNA scores of females, 65.7% were normal, 29.8% were at malnutrition risk and 4.5% were malnourished. As for males, 73.6% were normal, 22.1% were at malnutrition risk and 4.3% were malnourished. The difference in MNA scores between genders was not significant (P > 0.05). As per NSI scores of females, 64.1% had low risk, 23.3% had medium risk, 12.6% had high risk. On the other hand, 76.4% of males had low risk, 17.1% had medium risk and 6.5% had high risk. Unlike MNA, NSI scores between genders were significantly different from each other (P < 0.05) [Table 4].
Table 4: Information on individuals' Mini Nutritional Assessment Scale and nutritional screening ındex scores by gender

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On investigating the relationship between BMI, upper-middle arm circumference, MNA, and NSI scores of individuals [Table 5]; a moderate positive correlation was found between the upper-middle arm circumference and BMI (r = 0.513, P = 0.000). On the other hand, a weak negative correlation was found between NSI scores and upper-middle arm circumference (r = −136, P = 0.000). In addition, MNA scores exhibited a weak negative correlations with BMI (r = −118, P = 0.000) and upper-middle arm circumference (r = −199, P = 0.000), and a moderate positive correlation with NSI scores (r = 0.401, P = 0.000).
Table 5: Relationship between individuals' anthropometric measurements and their Mini Nutritional Assessment Scale and nutritional screening ındex scores

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  Discussion Top

Factors such as age-related physiological changes, presence of acute and chronic diseases, desolation, economic problems, physical inability to meet personal needs negatively affect the nutritional status of the elderly. Malnutrition state may be further deteriorated by cognitive disorders, socioeconomic conditions, educational status, and side effects of drugs and medicines. In this study, 65% of participants had an education up to primary school level or less. In a study conducted by Yabanci et al.[10] on Turkish elderly individuals above 65 years of age, it was reported that 42.9% of male and 31.3% of female participants were primary school graduates.

In this study, the most reported disease among the participants was cardiovascular diseases (64.4%) followed by diabetes (13.4%) [Table 1]. In Yabanci et al.'s study, however, hypertension was the most reported disease among the 68.8% of participants who complained of suffering from one or more diseases.[10] In another study conducted with elderly individuals by Demir et al., it was reported that 81.5% of individuals living in their own houses and 51.7% living in old age homes complained of one or more health problems. Diabetes was the most reported disease.[11] As per the results of this study, 24.7% of participants with disease followed a diet related to their disease. In Yabanci et al.'s study, it was reported that 31.4% of males and 25.0% of females consumed a diet compatible with their disease.[10]

In multi-center studies conducted in Turkey, chronic diseases commonly encountered among the elderly included hypertension (30.7%), osteoarthritis (13.7%), chronic heart failure (13.7%), diabetes (10.2%), coronary artery disease (9.8%), and osteoporosis (8.2%) respectively.[12]

BMI values in the range of 23–27 kg/m2 for elderly have been recommended in terms of functional capacity and cognitive level. However, for those above the age of 75, slightly higher BMI (26–28 kg/m2) is favorable in terms of reducing the risk of malnutrition and sarcopenia and a low BMI is associated with a decrease in functional strength and increased mortality.[13] Elderly individuals with BMI in the range of mild obesity have been shown to preserve sufficient nutrient stores that is required to cope better with acute effects of the diseases and a faster recovery.[14] In a nutritional screening study conducted in 76-year-old age homes in Germany, it was reported that 30.3% of the 5521 elderly were overweight and 15.1% were obese.[15] In this study, it was found that 40.7% of individuals were overweight and 23.4% were first degree obese. In another study conducted by Kaya et al.[16] on Turkish elderly above 65 years of age, 39.6% were found to be overweight and 23.1% were in the first degree obese category. BMI is a simple technique in evaluating nutritional status, but it should be kept in mind that the intersection points used in the elderly are different as compared to normal adults.[17]

In order for the elderly to have adequate and balanced nutrition as well as prevent malnutrition and obesity, eating in less quantity, frequent meals, and consuming healthy snacks may be recommended. On investigating the daily eating habits of the participants in this study, 48.3% were found to consume two meals and 26.4% snacked thrice in a day. Lunch was the most commonly skipped meal (75.6%) due to lack of appetite. On the other hand, in another study conducted by Hoca et al., it was reported that 91.8% of the elderly consumed three meals in a day, 23.3% did not consume any snacks, and 11% had a poor appetite.[18]

In this study, although 89.3% of the individuals did not have chewing and swallowing difficulties, 76.3% had had some tooth loss. However, in a study conducted by Ekici et al., on elderly individuals living in an old age home in Istanbul, it was reported that 27.4% of the elderly individuals had difficulty in chewing or swallowing due to tooth loss or related problems. The dental status of elderly individuals has been reported to have a profound effect on nutritional status.[19]

Anthropometric measurements are important components in evaluating the nutritional status of the elderly in clinical and epidemiological studies. Furthermore, BMI is used to evaluate protein-energy malnutrition and obesity and shows a good correlation with total body fat.[6] In the elderly, there is a decrease in subcutaneous adipose tissue in limbs and an increase in intra-abdominal subcutaneous adipose tissue. The body fat, which is 25% in men at the age of 40–45, reaches 38% at the age of 60–65 and remains constant afterward. In women, body fat reaches an average of 30% at the age of 40–49 and increases to 43% at the age of 55–59, and remains constant thereafter.[6] In this study, mean BMI in females and males were calculated as 30.5 ± 5.84 kg/m2 and 27.4 ± 4.12 kg/m2 respectively [Table 3]. In a study conducted by Savas et al.[20] on elderly individuals over the age of 64, the mean BMI of the individuals was found to be 27.1 ± 4.7 kg/m2 whereas in the study by Hoca et al.[18] it was reported as 29.81 ± 4.68 kg/m2 in men and 32.39 ± 5.85 kg/m2 in women.

Fat accumulation around the abdomen is an important risk factor for obesity and cardiovascular diseases. Waist and hip circumference as well as waist/hip circumference ratio is significant in this context. Waist circumference not exceeding 88 cm in females, 102 cm in males, and waist/hip ratio lower than 0.85 for females and 0.90 for males are considered as cut-off points. In this study, mean waist circumference in females was 102.3 ± 16.0 cm and 101.7 ± 12.7 cm in males. The waist/hip circumference ratio was calculated as 0.92 ± 0.102 in females and 0.98 ± 0.103 in males [Table 3]. In a study conducted by Kablan et al., on Turkish elderly individuals,[21] mean waist circumference. In Hoca et al.'s study, the average waist/hip ratio was 1.01 ± 0.07 in men and 0.91 ± 0.07 in women.[18] Although the anthropometric values of the participants were higher than recommended levels, similarities were found between other studies performed on Turkish elderly population.

Upper middle arm circumference is a good indicator of skeletal muscle protein mass and is used to detect lean body tissue. The upper-middle arm circumference below the 10th percentile or below 25.7 cm in men and 25.5 cm in women is a very sensitive indicator of malnutrition and sarcopenia. Kablan et al.[21] reported the value as 30.04 ± 4.88 cm in men and 29.05 ± 3.97 cm in women. In Hoca et al.'s study, the values were reported as 28.16 ± 2.67 cm in men and 28.76 ± 3.54 cm in women.[18] In this study, the upper-middle arm circumference was found to be 31.5 ± 5.00 in males and 32.2 ± 5.19 in females [Table 3]. The values were found to be similar to those obtained in other studies. Gender differences in terms of height, BMI, hip circumference, and waist/hip circumference were found to significant (P < 0.05).

MNA screening includes physical, mental health of an individual as well as the dietary aspects enabling the detection of malnutrition at an early stage.[9] As per 2002 ESPEN (European Society of Clinical Nutrition and Metabolism) recommendations and guidelines, all individuals over the age of 65 should be screened routinely from a nutritional perspective.[8] Within the framework of the decision taken by the European Parliament in 2007, obesity and malnutrition were accepted as the most important public health problem and the issue was included in the official political agenda of the European Union in 2008. The year 2009 was declared as the year of war against malnutrition by ESPEN. These data stresses on the importance of nutritional screening the elderly, both living in the community and receiving institutional care, in terms of malnutrition.[22]

In a study done by Çevik et al.[22] evaluating the nutritional status of the elderly who receive home healthcare services, it was found that 33.1% of 178 individuals had malnutrition, 39.3% were at risk of malnutrition and 27.5% had no nutritional problem. In another study conducted by Bektas et al.[23] on elderly Turkish individuals, it was reported that 28.7% of males had a risk of malnutrition and 11.9% were malnourished. On the other hand, 41.2% of females had a risk of malnutrition, and 18.8% were malnourished.

The level of education and desolation were also found to play a role in the nutritional status of individuals. In the study conducted by Feldblum et al.[24] on elderly individuals with a mean age of 75.2 ± 5.8 years, it was stated that 12 years or less of education was a risk factor for malnutrition. It was determined that 89.6% of those who received education for <12 years were either malnourished or at a risk for malnutrition. In this study, where the education level was also found to be quite low, 29.8% of females were at a risk of malnutrition and 4.5% were malnourished whereas, 22.1% of males were at a risk of malnutrition and 4.3% were malnourished. No significant difference between genders was noted for MNA scores.

Sinnett et al.[25] conducted a study with NSI on 924 elderly people half of whom were living alone and found that 74% of the individuals had high, 19% of them moderate and 7% of them had low risk of malnutrition. Küçükerdönmez et al.[5] in their study, compared MNA and NSI scores of participants and reported 35.7% of the individuals to be at high nutritional risk, 38.9% at moderate and 25.4% at low nutritional risk as per NSI scores. As per MNA scores, they defined 7.8% of participants as malnourished, 76% at malnutrition risk, and 16.2% at no nutritional risk. In this study, as per NSI scores of participants, 64.1% of females were at low risk, 23.3% at medium risk and 12.6% at high risk. On the other hand, 76.4% of males were at low risk, 17.1% at medium risk and 6,5% at high risk. No significant difference between genders was found with respect to NSI scores. In a cross-sectional study examining the relationship between nutritional status and anthropometric measurements of elderly individuals, a significant and positive correlation was found between BMI and upper-middle arm circumference and MNA.[5] In this study however, there was a low negative correlation between BMI (r = −118, P = 0.000) and upper-middle arm circumference (r = −199, P = 0.000) and MNA scores, and a positive medium level correlation (r = 0.401, P = 0.000) between MNA and NSI scores [Table 5].

Physiological changes and chronic diseases are a common feature in the elderly population, affecting their nutritional and health status. This is a significant public health concern since the ratio of elderly population to total population is increasing progressively in the country as well as globally. While evaluating the nutritional status of the elderly, it is necessary to use several nutritional screening methods together instead of a particular one. Such screening programs must be conducted on a routine basis and for better evaluation of results further studies must be performed for suitable nutritional intervention or recommendations for the aged group.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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