By Odilia I Bermudez, PhD, MPH and Johanna Dwyer, DSc, RD
Older Persons in the Americas
The World Health Organization defines older persons as people over 60 years of age. In Latin America, the projected increase in the older population is from 7.6% of the total population in 1995 to 14.2% in the year 2025, whereas the population less than 15 years of age will decrease substantially from 33.8% to 23.7% in the same period.1 Until recently, the nutritional status of older persons was often considered to be relevant only for a few relatively affluent countries. In fact, almost every country in the Western Hemisphere now has a larger percentage of older persons than it did in 1900, and this percentage is predicted to be even larger in the 21st century.
Nutrition Problems in Elders in the Americas
What factors determine the proportion of older persons in a population? A major factor is the health history of the country's population over the past century, Of particular importance are the impact of public health measures. For example, public health advances, such as those that decreased infant and child mortality from infectious diseases, occurred earlier in Panama and Costa Rica than they did in Guatemala and Bolivia. Thus, a larger proportion of the Panamanian and Costa Rican child population grew to adulthood and had the opportunity to reach old age than in the latter countries. Public health measures have also decreased the sequelae of infectious diseases in later life. The type of nutrition problems in older persons depends on past and current public health efforts, the relative prosperity of the country, distributive justice with respect to economic resources (since this is likely to affect the health of all segments of the population), and the extent to which public resources are used for health and social welfare programmes, especially those involving nutrition.
The current state of the economy and the percentage of the total gross domestic product devoted to health vary dramatically from one country to another within the Americas region. Because older persons are so often economically dependent on others, these factors also affect the proportion of elders at nutritional risk. In some countries, the ageing of the population is taking place in the absence of adequate economic development, and thus necessary economic resources may not be available. Many elders have insufficient income and are poor. They also are highly vulnerable because they have low educational levels, few pension benefits, lack adequate housing, suffer from gender inequalities and are poorly integrated socially. The needs of older persons for social and psychological, as well as economic, support from friends and family, and for funds to ensure economic subsistence are present in the Americas region. A lack in any one of these three domains may be partially ameliorated by enhancements in the other. Strong social and psychological systems in some Latin American countries provides support that money alone cannot buy.
Another factor that is relevant to the nutritional health of older persons is the adequacy of the country's health system and investments in it. In some countries, such as Panama, economic growth is good and spending on health and education are relatively high, equivalent to approximately 12.8% of the gross national product, or 24.4% of all public spending.2 In Costa Rica, in spite of adverse economic conditions over the past decades, spending on health and social welfare programmes continues, cushioning the adverse economic effects to some extent.2 Spending on food and food programs helps to decrease risks of poverty-related malnutrition, but excessive and unbalanced intakes are also problems that must be addressed. Diseases of affluence are endemic in the USA, Canada, Costa Rica, Chile, Argentina, and in some other countries in the Americas region with a history of sound health programs, For example, in Costa Rica, coronary artery disease is a major cause of morbidity and mortality in adults, including older persons.3
Diet Related Diseases in Older Persons
The types of malnutrition evident in elderly persons in the Americas region include undernutrition, vitamin and mineral deficiencies and excesses, obesity, nutritional imbalances, and toxicities such as alcohol abuse. In addition to primary malnutrition caused primarily by poor dietary intake, there is malnutrition secondary to disease. Often the two problems coexist in the same individuals. Both primary and secondary malnutrition require public health interventions, however, the appropriate types of intervention vary. The prevalence of malnutrition problems differs from country to country, but all of the problems are present to some degree in all of the countries. With respect to nutrition and health, the specific needs of older persons must be identified. Much more information on these forms of malnutrition in older persons is required in order to assess national policies and for crafting appropriate interventions that encourage self-care and the continuity and quality of services that are delivered.
FIGURE 1 RISK FACTORS FOR POOR NUTRITIONAL STATUS IN OLDER PERSONS
Nutritional Risks in Older Persons
The risk factors for poor nutritional status of older people are summarized in figure 1. Risk factors for malnutrition are the underlying reasons why people eat less or eat poorly. Individuals having one or more risk factors are more likely to become malnourished. Different risk factors are often linked to each other and they may be more or less common in certain situations.4 The most appropriate interventions depend on the risk profiles of each country.
Until recently, little was done in the United States and Canada to identify elders at risk. Today, a number of efforts are underway to screen and identify elders at risk of malnutrition. The Nutrition Screening Initiative is one such example.5 It focuses on the determinants for undernutrition that are listed in Box 1 which are somewhat similar for all countries, yet probably vary with respect to relevance and prevalence. Thus, while some determinants may be country- or population-specific, others are universally associated with malnutrition. For example, the Nutrition Screening Initiative determinant checklist did not predict risk of malnutrition in older persons living in the Netherlands, although it did predict risk satisfactorily in the United States. Perhaps this was because social circumstances and the health and social service systems for elders differ markedly between the two countries. Similarly, it is reasonable to expect that adaptations will be needed in checklists for Latin America, especially in poor countries and rural areas, where life circumstances and the infrastructure of health services are very different from those of affluent, urban, highly industrialized societies. Therefore, it is important to develop and/or validate systems for identifying determinants in each country and setting. Some risks are also setting-specific: those for individuals who are living in the community differ from those of persons in institutions or long term care facilities.
Appropriate Interventions
The most appropriate ways and means for intervening and ameliorating the nutritional problems of older persons differ, but the general principles are the same for all countries. Many of the chronic degenerative diseases of older persons such as cardiovascular disease, diabetes, obesity, osteoporosis and anaemias due to iron, folic acid and vitamin B12 deficiency have preventable causes, including nutritional causes. Many of the measures to prevent or control these conditions depend upon both enhanced dietary intakes and more physically active lifestyles. Appropriate physical activity (both aerobic and strength types of exercise) is a desirable health-producing behaviour in older persons. In addition, health care, social support, food assistance, and other interventions are also often appropriate. Not all malnutrition in older persons can be prevented, but it should be treated or ameliorated.
One recent review of intervention strategies from HelpAge International4 is also useful for crafting interventions in the Americas. It suggests that persons should be classified by severity of the malnutrition problem prior to selecting an appropriate intervention(s). For example, this might involve improving the diets of older people, physical functional abilities, food availability, or reducing the social and emotional risk factors of nutritional vulnerability. There is a general need to insure that all older persons have a sound diet. Each country's food-based dietary guidelines should be generally appropriate and modified slightly for older persons, if needed. Simple self-feeding aids (e.g., specially bent eating utensils for arthritic sufferers) may improve physical activity and ability, and small gardens or small income generating programs may increase food availability.
Future Directions
The ultimate goal is to implement prevention oriented programs for elders and to increase the years of healthy life elders enjoy in all countries. High priority areas for action include: preventing the age-associated chronic degenerative diseases that have nutritional implications in their causation and treatment; eliminating vaccine-preventable diseases of elders such as influenza and pneumonia that adversely impact nutritional status; eradicating poverty-related undernutrition and malnutrition in elders; and instituting interventions to ameliorate loneliness and depression. Also, there is an urgent need for training health and social science professionals in the Americas to prevent, recognize, and improve the nutritional status of older persons. Health and social service infrastructures must be developed to serve the nutrition and health needs of the growing population of older persons. Advocacy efforts by elders for elders and by others are also needed.
An avalanche of older persons will overwhelm the unprepared in the 21st century. Decision-makers and leaders in nutrition in all countries in the Americas must plan now to ensure that their older population is well nourished and food secure. They must pay attention to adequate, humane, equitable, and timely integrated services, including nutrition, for older persons. Some general goals and policy recommendations for nutrition programs are provided in the United Nations International Plan of Action in Ageing6 and summarized in Box 2. Country-specific plans, which involve the health, agriculture, education, and social welfare sectors are also needed.
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Box 1 Determinants for Undernutrition in Elders Disease |
References
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Box 2 Recommendations for Nutrition of Older
Persons: Adequate, appropriate and sufficient nutrition is essential to the well being of the elderly. Poor nutrition is exacerbated by poverty, isolation, maldistribution of food, and poor eating habits, including those due to dental problems. Therefore special attention should be paid to: à Improvement of the availability of sufficient foodstuffs to the elderly through appropriate schemes and encouraging the aged in rural areas to play an active role in food production Source: International Plan of Action on Ageing III
Recommendations/or Action, (a) Health and Nutrition Recommendation 12. UN
Div. Social Policy and Development
http://www.un.org/esa/socdev/ageipaa3.htm |
