Assessing Nutritional Vulnerability in Older People in Developing Countries

By Suraiya Ismail, PhD

The majority of poor older people in developing countries enter old age after a lifetime of poverty and deprivation, a diet that is inadequate in quantity and quality, and a lifetime of disease and poor access to health care, Until recently, we have assumed that older people represented only a small proportion of the populations of developing countries, and that they were adequately cared for within extended families. These assumptions must be challenged. The twentieth century has seen an unprecedented transition from high birth and death rates to low fertility and mortality, In 1950, there were about 200 million people over 60 years; by 2025 there will be 1.2 billion, of whom nearly 70% will live in developing countries. For most of these older people retirement is not an option. Poverty, lack of pension retirement, deaths of younger adults from AIDS, and rural to urban migration of younger people are among the factors that compel older people to continue working. Adequate nutrition, healthy ageing and the ability to function independently are thus essential components to preserve a minimum quality of life.

In 1992, the London School of Hygiene and Tropical Medicine, in collaboration with HelpAge International, began a programme of research on the nutrition of older adults in developing countries (see book review p50). The objectives of the programme were to test simple anthropometric measures of nutritional status, assess functional ability, and examine the risk factors of nutritional vulnerability. Fieldwork was undertaken in three sites: urban slum areas of Mumbai, India, Rwandan refugees in a camp in Tanzania, and rural communities in Lilongwe, Malawi.^1-3 The samples (n=1335 for India; 828 refugees; n=296 for Malawi) consisted of men and women aged 50 - 96 years.

All studies gathered data on age, a wide range of anthropometric measurements and functional ability (self-reported and physical performance tests), using slightly modified versions of standard techniques used in studies from Europe and North America. Clinical examinations were performed by nurses in Tanzania and Malawi and by doctors in India (where haemoglobin levels were also measured). Information on potential social and economic risk factors of nutritional vulnerability was obtained by interview, and in Tanzania and India, in depth case studies were conducted on sub-samples. Analyses examined the relationship between nutritional status and functional ability and the determinants of nutritional vulnerability.

Measuring the height of older people presents a number of problems. Spinal curvatures (kyphosis) can be common, leading to inaccurate height measurements. Yet by omitting individuals whose height cannot be measured accurately, one could be excluding those with poorest nutritional status, especially among the very old. We found that 15% of the Indian sample, 17% of the Malawi sample, and 5% of the refugee sample had spinal curvatures, and the prevalence increased with age. Long bone measures (armspan, halfspan (demispan or hemispan), and knee height) have been proposed as proxies for height. These long bone measures are strongly correlated with height, but the relationship differs significantly between different ethnic groups. In Caucasian populations, armspan for example is almost equal to height, but is considerably longer than height among African populations. We therefore established the regression equations between armspan and height for each sample separately, using data from non-kyphotic individuals, and used these equations to estimate height from armspan in those with kyphosis.

Mid upper arm circumference (MUAC) has recently emerged in the literature as a potential screening tool for poor nutritional status. James et al.⁴ analyzed its usefulness in adults, and calculated cutoffs equivalent to body mass index (BMI) and cutoffs for chronic energy deficiency (CED), using a range of data sets from developing countries. Accurate MUAC measurements in older people can be problematic, but with good training we achieved a high reliability (99% error free). We found that a MUAC cut off of 21.7 cm had a sensitivity of nearly 86% in relation to the BMI cutoff of 16 kg/m². We have therefore proposed it as an alternative to BMI as part of a screening tool in the acute phase of an emergency. WHO states that conventional BMI cutoffs for defining CED may not be appropriate for older people 70 years and over, because of age-related changes in body composition.⁵ In the absence of alternatives, we used the conventional values, but feel strongly that research is needed on this subject. Table 1 shows the prevalence of undernutrition by sex in the three studies.^1,6,7

In all three studies, the prevalence of undernutrition increased with age among women. This was most marked in India where it rose to nearly 60% among women over 70 years. The relatively low prevalence of undernutrition in the refugee population is probably because the study was conducted in the post-emergency phase: the sample represented those who had successfully reached the camp and survived a year in exile. In India, where haemoglobin levels were measured, the prevalence of anaemia was high, using WHO criteria for anaemia: 38% among men (<13g/dl) and 52% among women (<12g/dl). Among women over 70 years, the prevalence rose to 70%. In both men and women, the prevalence of anaemia was highest among those with severe malnutrition (BMI<16kg/m²). We found that nutritional status was indeed related to functional ability. The strongest relationship was with handgrip strength, a measure of the strength of the upper limb. But undernutrition was also found to be associated with higher risks of impairments in psychomotor speed and coordination, mobility, and the ability to carry out activities of daily living independently, even after controlling for age, sex and disease.

Table 1.
Prevalence of undernutrition (BMI)

	% Men < 18.5 kg/m2	% Women < 18.5 kg/m2
India (Mumbai slum area)	35.0	35.0
Rwandan Refugees	19.5	13.1
Malawi (rural Lilongwe)	36.1	27.0

Case studies of Rwandan refugees showed that older people in camps face special problems. Not only have they suffered bereavement and trauma, they find it particularly difficult to adjust to an unfamiliar environment. They experience great difficulty coping with the general rations distributed in the camp: the ration is monotonous and unfamiliar or difficult to chew. They suffered also from lack of respect from younger family members and reduced social status, partly at least because they no longer had an inheritance to pass on to their children. Such transformations in traditional roles and cultural patterns are common not only in refugee camps but also in conditions of severe economic stress.

In summary, then, our results show that there is a high prevalence of malnutrition in older adults in the three developing countries in this sample, and that it is highest among the very old. While we can be sure that poor functional ability, and hence the ability to live an independent life, is associated with poor nutritional status, our cross-sectional studies do not allow us to infer cause and effect. For that, a more elaborate longitudinal study design is needed. Information from our interviews also tells us that most of our older adults are occupied in activities that contribute substantially to the family income.

Research is urgently needed in a wide range of areas. We need more studies of the kind we have undertaken, to begin to assess the magnitude of the problem and to refine techniques for the anthropometric assessment of nutritional status. We know little about the micronutrient status of older people in developing countries. The appropriateness of conventional BMI cutoffs for the older elderly need to be assessed. Nutrient requirements for elderly people are mostly extrapolated from younger adults in developed countries, and assume the reduction in energy expenditure associated with retirement. These requirements may not be correct for poor older people in developing countries. There are also age-related changes that can lead to reduced or altered food intake. Interventions that address these problems need to be developed and tested. Pieterse (1999) proposes a screening tool for use in emergencies which needs to be tested, in particular, the validity of the MUAC cutoffs it uses.² Therapeutic and supplementary feeding programmes for use in emergencies should also be investigated. Indeed there is almost no experience of nutrition interventions for older persons; we have little or no idea of what works, nor do we even know if their nutritional status can be improved or if such improvement would lead to better functional ability.

The challenge facing the handful of nutritionists working with older people in developing countries is enormous. Most nutritionists have no experience of working with older people, nor have they been trained to understand their special needs and problems, food-related or otherwise. In an effort to address this in the Africa region, HelpAge International, in collaboration with the London School of Hygiene and Tropical Medicine and with funding from the UK's Department for International Development, has launched a programme of training and advocacy aimed in the first instance at nutritionists and then at staff of NGOs. Above all, we hope to change attitudes: older people are not "burdens' or 'problems' in need of charity. They are active members of society, contributing daily to their families, their communities and their countries. Investing in older people is investing in ourselves.

References

1.	Manandhar MC (1999) Undernutrition and impaired functional ability amongst elderly slum dwellers in Mumbai, India. PhD Thesis, University of London.
2.	Pieterse SG (1999) Nutritional vulnerability of older refugees. PhD Thesis, University of London.
3.	Chilima DM (1998) Nutritional status and functional ability of older people in rural Malawi. PhD Thesis, University of London.
4.	James WPT, Mascie-Taylor GCN, Norgan NG, Bistrian BR, Shetty PS, Ferro-Luzzi A (1994) The value of arm circumference measurements in assessing chronic energy deficiency in third world adults. Eur J Cli. Nutr 48:883-894.
5.	World Health Organisation (1995) Physical status: the Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. Technical Report Series No. 854, Geneva.
6.	Pieterse S, Manandhar M, Ismail S (1998) The nutritional status of older Rwandan refugees. Public Health Nutrition 1:259-264.
7.	Chilima DM and Ismail SJ (1998) Anthropometric characteristics of older people in rural Malawi. Eur J Clin Nutr 52:643-649.

Acknowledgements HelpAge International, the Department for International Development (UK) and the Association of Commonwealth Universities provided most of the funding for the three studies described. None of these organizations is responsible for the content of this article.

Dr Suraiya Ismail is Head of the Public Health Nutrition Unit at the London School of Hygiene and Tropical Medicine, 49/51 Bedford Square, London WC1B 3DP, UK; tel +44 171 299 4696; fax +44 171 299 4666; email: s.ismail@Ishtm.ac.uk

TRANSITIONS Nutrition Transition - encompasses changes in dietary intake, physical activity and body composition; specifically refers to a shift to diets high in total fat, sugar and refined grains; and includes a more sedentary lifestyle and increased of tobacco products. Epidemiological Transition - refers to a shift away from the high prevalence of infectious disease and malnutrition as causes of mortality to a high prevalence of chronic and degenerative diseases (hypertension, cardiovascular disease, and diabetes) - conditions made worse by the nutrition transition. Countries in Transition - refers to a shift in economic conditions associated with countries experiencing a change in political philosophy or structure - may lead to a nutrition transition. UN in Transition - "We should bring the Organization closer to the people." (Kofi Annan, 18 Dec 96, GA/9212)