By Suraiya Ismail and Mary Manandhar
Book Review by Noel W Solomons, MD, Scientific
Center for Studies of Sensory Impairment, Ageing and Metabolism (CeSSIAM)
Guatemala City, Guatemala
A superb combination of institutions with unique - and in this instance, complementary - interests and talents, HelpAge International (a private, charitable agency for developing country elders) and the London School of Hygiene and Tropical Medicine (an institution heralded for both its basic and applied health investigation in the tropics) have collaborated to place onto center stage as a health concern the increasing number of persons surviving into old age. The process of the formation of this new self-instructive guide and manual, Better Nutrition for Older People Assessment and Action, was ideal. Samples of destitute elders were measured in India, Tanzania and Malawi to provide the basic experience and information. It was then pre-tested in three additional countries: the Philippines in Asia, Ethiopia in Africa, and Grenada in the Caribbean. The authors and their sponsors are up-front about their intent and interest: "In this handbook, we are concerned only with undernutrition so we use the word malnutrition to mean undernutrition only."
All of this care and forethought has led to a 79-page manual with a laminated-plastic cover, and A-4 paper size divided into six chapters: 1. Background to Nutritional Assessment; 2. Anthropometric Measurements; 3. Assessing Nutritional Status from Anthropometric Measurements; 4. Assessing Nutritional Vulnerability 5. Interventions - A Brief Overview; and 6. Conclusion. A bibliography is included, in addition to ten appendices (including a Glossary of Terms). There are four diagrams and nine numbered tables distributed throughout the text. Many more diagrammatic silhouettes and unnumbered tables are included as well. The design and editing of the book are more than admirable, achieving a clarity of presentation and a simplicity of language that is right on target for the presumptive audience of non-titled (empirical or apprenticed) community health workers in developing countries. The treatment of gender issues is explicitly politically correct and the casual illustrations (silhouette figures) represent women in Hindu saris, elders with African features and garb, and persons in western dress, allowing any reader to identify personally. This is not a casual offering, but a crafted product - although not a finished product. The authors state in their concluding chapter: "As more information becomes available we will update this handbook. Please help by giving your comments about it and telling us about your experiences of malnutrition in older people and the design of suitable interventions." This honesty and humility on the author's part is even more ingratiating than the high quality of the work itself.
The subtitle of the book is Assessment and Action. The second and third chapters constitute a handbook for diagnostic "assessment" of nutritional status as defined by reference standards of body composition. The measurements are height, weight, armspan (or its proxy measurement of the hemispan or "halfspan") and mid-upper-arm circumference (MUAC). Armspan is the horizontal distance between the fingertip of the longest digit on one hand to the corresponding point on the other hand, with the subject assuming a "crucifix" position with the arms extended laterally. If range of motion in the shoulder, elbow or wrist excludes this posture, or there is a unilateral amputation, a hemispan (termed "halfspan" by these authors) is measured on one side with the distance from the center of the sternum to the tip of the one hand constituting the index. Its value is doubled to estimate the full span for individuals so measured. It has been established in cadaveric studies and living persons that the armspan has a strong correspondence to the maximal stature achieved in early adulthood, with the advantage that it does not "shrink" as does the standing height with advancing age. The derivative, interpretative indices for nutritional classification are Quetlet's body mass index (BMI) and MUAC, each applied to normative standards for older persons. The didactic instructions are so effectively written that one could credibly believe that a basic level professional could learn to perform accurate and precise measurement simply with the written directions and the self-assessment exercises.
The Appendix 5 consists of three "BMI Charts": multicolored, nomogram-based graphs in which a subject's BMI value can be easily determined; moreover, the nutritional classification is included in the colour coding. The criteria used in Appendix 5: Chart 1 are those of James and Ralph (1992) in which severe undernutrition of <16 kg/m2 is the red area of the upper right diagonal field, 16 to 16.9 kg/m2 is the yellow area of moderate undernutrition, and 17 to 18.5 kg/m2 is mild undernutrition, signified by a blue band. A broader green area encompassing 18.5 to 24.9 kg/m2 represents adequate nutrition, and in the extreme lower left field shaded in purple includes those who are overweight at >25 kg/m2. In keeping to its focus on undernutrition, this manual did not include an area for obesity, defined as BMI >30 kg/m2, nor for extreme or morbid obesity, defined as >40 kg/m2.
Appendix 5 Charts 2 and 3 are based on classifying individuals when stature cannot be assessed and either armspan or halfspan is the measurement for the horizontal axis. The former is labelled for application in Asians, excluding Chinese; the latter is labelled for application in Africans. No further explanation is given to the user. A careful inspection of the intersection of the classificatory shaded zones on the Charts 2 and 3 (armspan) have quite distinct margins as compared to Chart 1, which is based on standing height. The boundary BMI values for the gradient from severely-undernourished to overweight for the Asian elders are 14.6; 15.6; 17.1; and 23.6 kg/m2 and 14.0; 15.0; 16.6; and 22.9 kg/m2 for the African elders when armspan comprises the horizontal value. One can only assume to know the rationale for the difference in the BMI criteria using span. We assume armspan was not equal to height in any ethnic group, and was different between the Africans and the non-Chinese Asians, and that the authors mobilized robust data to make the proportional conversions. However, were the conversions made based on young adults or the older persons themselves? This answer would make a major difference in the classification of nutritional status.
The armspan is a useful surrogate for height when a person cannot stand, or assume a suitable posture on the stadiometer. The armspan, based as it is on the length of long bones, remains constant throughout life, whereas stature decreases due to senescent toss of height by the combination of compression of the intervertebral disk spaces and any osteoporotic compression of the vertebrae themselves. As such, the use of measured stature will overestimate the "true" (height-loss adjusted) BMI, but armspan can be used itself as a height-loss adjustment. In the opinion of this reviewer, the index of "BMA" (BMI from armspan) should be the routine index for comparative analysis across populations and across adult age groups, but the normalization should be a relation to the BMI of a person at the peak of his or her adult height. It is a promising step that the manual introduces users to the concept and measurement of armspan and halfspan.
The most serious technical flaw in the manual has to do with issues of measurement precision, based on the tolerance for agreement of replicate measurements. These are found in Chapter 3 as a self-assessment exercise on p35. Let me first assert that with proper thermometer instrumentation, the change from 0 to 1°C is equally measured as that from 99 to 100ºC. In a curious departure, the authors demand a reproducibility within 1.0 cm for duplicate measurements of armspan but only 0.5 cm for halfspan. This is the logical equivalent of imposing a 0.5 cm tolerance on one's stadiometer measurement for a person who is 1 meter tall and a 1.0 cm tolerance for someone who is 2 m tall. It is the same metric tape* whether applied extended from mid-sternum to one fingertip or stretched across the body from fingertip to fingertip. As one doubles the halfspan value to estimate the full span for use with Charts 2 or 3 of Appendix 5, this introduces yet another, intrinsic error in measurement based on the propagation-of-error principle, i.e. summation or multiplication of discrete measurements compounds the additional error. In fact, the legitimate tolerance for duplicate estimates for armspan derived from hemispan should be greater than that for armspan measured directly. Users of this manual may become discouraged with their inability to repeat sequential halfspan measurements within a 0.5 cm difference of one another!
The "action" component comes in the fifth chapter entitled "Interventions - A Brief Overview." It addresses the issue of "how you can promote better nutrition amongst the older people that you work with." Perhaps these six pages are too brief, both in narration and its consideration as well. The action components of the handbook are based more on "common sense", bordering at times on platitudes, and for the arena of the settlement house social worker, rather than on any serious analysis of the prognostic and actuarial considerations of malnourished older persons living in conditions of poverty. There is nothing "macro" about the scale of considerations for what to do once the diagnostic assessment of a population has been made using the manual. There is nothing strategic for policies or programmes; nothing that would seek an entry point for actions taken at the level of the society as a whole that contains the elders as a segment nor at the level of the aged as a subgroup. Rather, it presents merely a tactical and situational approach. The plan of action is almost like "cherry picking" in which one identifies the individuals based on an implicit assumption.
That the nidus for action represents almost a "settlement-house social worker" outlook is not surprising given the nature of a HelpAge International, but it is hardly what we have come to expect from the London School! Also, the explicitly one-tailed interest in "undernutrition" will introduce critical blind spots when anything other than individual "curative" nutritional measures are considered. The recommendations for intervention are thin even for a book not aimed at the trained dietician. They derive from the paradigm of poverty and deprivation, and see diet, and constraints on intake, as the principal modifiers of body composition of the elders. To some extent, for a slum in Calcutta or a hamlet on the slopes of the Andes, they might be more right than wrong. Western gerontology treats underweight from its non-community-based focus of nursing care facilities and tertiary hospitals. In this context, recent (unintentional) weight loss and cumulative weight loss of greater than 10% of maximal adulthood weight (often jocularly called "the dwindles" in geriatric circles) have dire adverse prognostic consequences, predicting the demise of the older person in relatively short order. This poor prognosis holds whether or not dietary interventions are imposed. In the West, malignancy, dementia or some other irreversible process is most often the basis of the geriatric undernutrition receiving notoriety. Geriatricians are much less intervention-minded in the sense of an optimism about the reversibility of weight lost than are Drs Ismail and Manadhar. They might be right - I might be overall academic.
I would argue, however, that the nature of low weight in free-living elders in abject situations is not known. Even paranoids have real enemies; even older paupers in low-income Third World setting may have real organic illness causing their wasting. Obviously, if adequate food is a scarcity then sophisticated high-tech medical and surgical intervention is much more out of reach. The intellectual caution would not be overly locked into poor accessibility, availability, or acceptability as the universal cause of underweight, and the practical consequence is not to be overly optimistic that the weight loss one detects is reversible. One must consider the process of "sarcopenia" i.e., that inexorable loss of muscle mass associated with senescence; to "recover" one's former weight is to replace muscle weight with fat mass, a challenge to weakened limb strength and a potential metabolic liability. Moreover, one must also raise the heretical question of the extent to which low weight in deprived elders might represent an adapted state, or even be adaptive. That is, the organism has reached a stable equilibrium with his or her surroundings, and other "set-points" brought on by higher caloric consumption would be meta-stable at best and fatally disruptive at worst. Hence, we come to a final caveat concerning the potential hazards of refeeding. For acute refeeding of persons in the "red zone" coordinates of the BMI charts, patience and caution is more prudent than aggressive haste.
The manual was based on multicentric work carried out in India, Tanzania and Malawi and it has gone on the road in Ethiopia, Grenada and the Philippines for pilot testing; the question arises now as to whether or not it is ready for "prime time." In an arena of virtual total abandonment of the older segment in developing country populations, this handbook is much, much better than the nothing that preceded it. It is clear enough, concise enough, and self-instructive enough to attain its goal of empowering health technicians to make an accurate assessment of the body composition of individuals or groups of older persons. The technical flaws are minor and amenable to correction. I do, however, have a few suggestions for the authors. In the diagnostic domain, this manual could be - and should be - pressed into service in another, opportunistic and "academic" endeavour, namely as a survey instrument. How valuable it would be if Better Nutrition for Older People were taken up by undergraduate and masters degree candidates in Latin America, Asia and Africa! A proliferation of mini-surveys using this instrument could be the beginning of stitching together a quilted tapestry of the state of the poor older-aged residents across the tropics. This should be a two-tailed application in which the question of "excess" would not be a pariah.
With respect to the advocacy for action component, it is only human and humane that one takes the nutritional assessment beyond the point of archival statistics or curiosity to some benefits and betterment for the subjects surveyed. In fact, to date, the world has chosen to deal with its scant population of older persons by omission; as their numbers burgeon, they can be invisible no longer. But rapidly, the world needs to get beyond the notion of individual charity for elders to some considerations at the population-wide public health level. And, for the sake of the short term goal of benefits outweighing risks, and from the long term value of preventing debility of senescence and preserving function, we must admit that we really know too little about the nature and causes of low weight in the developing world's destitute elders. That is, we know too little to chalk it all up exclusively to dietary determinism. Simplicity in diagnosis does not always find its counterpart in simplicity of remedy. Both individual action to refeed underweight elders and mass action to feed aged populations at apparent risk are multi-edged swords. The call for advocacy in this manual brings its users face-to-face with the rock of neglect and inaction, and the hard-place of the consequences of imprudent and overzealous intervention. Fortunately, the "loose-leaf spirit of the authors' intention to maintain permanent revision is such that any legitimate concerns of critics and skeptics can rapidly be incorporated in the generations of the ground-breaking manual to come.
* The manual recommends the use of a flexible metric tape for the determination of span and hemispan. In this reviewer's experience, a rigid metric bar - rather than a flexible tape - produces the most consistent, reproducible and accurate measurements as it forces consistent abduction for the subject to have his or her arms parallel to the ground and perpendicular to the spinal axis, and limits flexion and extension of the sagittal plane.ISBN: 1 872590 40 3 (1999) p79 £7.00 (US$11.55) plus shipping £2 (US $3.30) International Money Orders or cheques drawn on a UK bank accepted. HelpAge International, 67-74 Saffron Hill, London EC1N 8QX, UK
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