Special Article - Malnutrition
Austin J Nutri Food Sci. 2018; 6(4): 1110.
Determinants of Nutritional Status among Geriatric Populations in Kween District, Eastern Uganda
Alphas C, Atuhairwe C, Amongin D and Taremwa MI*
Clarke International University (Formerly, International Health Sciences University), Uganda
*Corresponding author: Ivan Mugisha Taremwa, Institute of Allied Health Sciences, Clarke International University, Kampala, Uganda
Received: November 21, 2018; Accepted: December 12, 2018; Published: December 19, 2018
Abstract
Background: Geriatric persons may exhibit diverse feeding patterns due to age-associated changes. We report the determinants of nutritional status of geriatric population in Kween district, Eastern Uganda.
Methods: A cross-sectional survey was conducted among of 250 adults above 50 years during June 2014 to August 2015. Data was collected using a structured questionnaire, and Chisquare test for association analysis was done to assess factors associated with geriatric nutritional status.
Results: The determinants of geriatric nutritional status were; age, weight, education attained, number of children, declined food intake, neuropsychological problems, and body mass index.
Conclusion: The study results affirm a nutrition gap which necessitates awareness strategies through caregiver nutrition education and health promotion.
Keywords: Geriatric; Determinants; Nutrition status; Uganda
Introduction
Population ageing is a global pattern that describes a life-course trend. It affects all countries, although at varied levels [1], and is a measure of better lifespan and lowered mortality [2]. Despite, the geriatric population is prawn to various challenges, including malnutrition [3,4]. This is due to varied feeding ability as well as ageassociated patterns dictated by factors like financial status, physical and functional changes in relation to physiological and psychological status [5-7]. This leads to nutritional difficulties manifesting with a poor quality of life [4,8-11].
As the poverty levels remain high in sub Saharan Africa [12,13], 64% of Uganda’s geriatric lives below the poverty line; which fosters a high risk of malnutrition [14]. Socio-ecological and geographical aspects further amplify the situation, for example, 84.3% of the population of Kween district depends on subsistence farming. As environmental factors have hindered agronomic yields, there has been a discernible poor quality of life. These combined with rapid population growth, cattle rustling practices among the Karamajong have exacerbated food insecurity. These complex factorial interplays fosters low standards of living, which prompts to poor feeding and quality of life. These may portend the recently launched Sustainable Development Goals (SDGs) that seeks to attain sustainable development in a balanced manner for all aspects of the society, at all ages, with a particular focus on the most vulnerable, which includes older persons [15]. The geriatric population cuts through a section of varied goals, namely: poverty eradication, good health, gender equality, economic growth and decent work, reduced inequalities and sustainable cities.
As part of improved geriatric livelihood, the government of Uganda initiated a Social Assistance Grants for Empowerment (SAGE) support program [16,17], nonetheless, challenges have not seen its countrywide operation and also the costs of living continues to escalate, hence poor quality of life. As major programs have centered on the productive population (under 50 year category), it ought to be known that the geriatric population has in part been neglected. One critical risk of the geriatric population is the risk of malnutrition, which is reportedly high in most part of Uganda [12]. This study explored the geriatric nutritional status and its determinants among the population of Kween district, eastern Uganda.
Materials and Methods
Study design and setting
This was a community based cross sectional study that enrolled the geriatric population aged 50 years and above in all sub-counties of Kween district. Participants were selected using cluster sampling; which involved a random selection of 10 out of 19 parishes in five sub-counties in Kween district. The district is inhabited by Sebei; a sub-tribe of Kalengins that originated from Kenya. It is divided into 3 zones; the upper mountainous zone, the middle and lower zones with a warm weather and plain terrain. Agriculture is the main source of income.
Sample size estimation and enrolment criteria
Using Kish and Leslie formula to estimate the sample size [18], given the prevalence of geriatric malnutrition reported at 33.3% in Mpigi district, Uganda [19] and the allowable error of 5%, we consecutively enrolled a total of 250 geriatric populations.
Data collection tools and management
A structured questionnaire was designed to capture socioeconomic and health related data on the geriatric nutritional status [20-22]. The main outcome measure was assessed using the Body Mass Index (BMI) and Mid-Upper Arm Circumference (MUAC). Weight measurements were taken using a digital scale while putting on light clothing, height was recorded to the nearest 0.1 Centimeter (Cm) and a non-stretch insertion tape was used to measure MUAC. A food-frequency questionnaire was used to determine dietary intake data with focus on the interactive 24-hour recalls [23,24].
Adult equivalent a measure of the household’s calories for its members was determined by scaling the requirements of each individual to those of a reference adult based on age, sex and assumed moderate activity. Data was entered into the EPI-INFO; BMI was calculated as a ratio of weight to height. MUAC less than 19 were considered thin, 19.1-23 were nourished and those above 23 were overweight [25,26]. The MUAC under 21 and calf circumference (CA) below 31 were regarded as thin and under nourished [25].
Ethical approval
We obtained ethical approval from the research and ethics committee of Clarke International University (Formerly, International Health Sciences University). In addition, informed consent was sought from all participants.
Results
We enrolled 250 participants. Of these, 134 (53.6%) were males, participants’ median age was 65.5years (IQR, 61-70). Majority; 178 (71.2%) were 161-180cm in height, and 147 (58.8%) were 51-70Kg in weight. 169 (67.6%) were in a monogamous marriage with almost half of the families 124(49.6%) having 6 or more children. 108 (43.2%) of the respondents lacked formal education and more than three quarters (N=215, 86.0%) were unemployed as shown in (Table 1).
Variables
Frequency N=250 (%)
Malnourished
X2
P-value
Yes
No
Gender/sex
Male
134(53.6%)
8(6.0%)
126(94.0%)
0.316
0.574
Female
116(46.4%)
7(6.0%)
109(94.0%)
Age
50-60
94(37.6%)
5(5.3%)
89(94.7%)
0.289
0.004*
61-70
132(52.8%)
21(15.9%)
111(84.1%)
71-80
24(9.6%)
1(4.2%)
23(95.8%)
81 and above
00 (00%)
00 (0%)
00(0%)
Height/cm
121-140
2(0.8%)
0(0.0%)
2(100.0%)
0.879
0.831
141-160
58(23.2%)
3(5.2%)
55(94.8%)
161-180
178(71.2%)
12(%)6.7
166(93.3%)
181-200
12(4.8%)
0(0.0%)
12(100.0%)
Weight/kg
30-50
69(27.6%)
1(1.4%)
68(98.6%)
12.59
0.003*
51-70
147(58.8%)
12(8.2%)
135(91.8%)
71-90
34(13.6%)
2(5.9%)
32(94.1%)
91 and above
Marital Status
Single Adult
12(4.8%)
1(8.3%)
11(91.7%)
3.479
0.481
Monogamous married
169(67.6%)
9(5.3%)
160(94.7%)
Polygamous married
55(22.0%)
4(7.3%)
51(92.7%)
Separated or Divorced;��
2(0.8%)
0(0.0%)
2(100.0%)
Widowed
12(4.8%)
1(8.3%)
11(91.7%)
Education Attained
No formal education���
108(43.2%)
3(2.8%)
105(97.2%)
15.45
0.004*
Adult education only;
2(0.8%)
0(100.0%)
2(100.0%)
ended in primary
97(38.8%)
7(7.2%)
90(92.8%)
ended in secondary
34(13.6%)
2(5.9%)
32(94.1%)
Tertiary level�
9(3.6%)
3(33.3%)
6(66.7%)
Economic Activity
Unemployed�
215(86.0%)
13(6.0%)
202(94.0%)
4.866
0.182
Salaried employee,
8(3.2%)
2(25.0%)
6(75.0%)
Formal business owner��
14(5.6%)
1(7.1%)
13(92.9%)
Retired with pension
13(5.2%)
1(7.7%)
12(92.3%)
Religion
2.098
0.718
Catholic
88(35.2%)
4(4.5%)
84(95.5%)
Protestant
128(51.2%)
6(4.7%)
122(95.3%)
�Muslim
4(1.6%)
2(50.0%)
2(50.0%)
Pentecostal�
28(11.2%)
2(7.1%)
26(92.9%)
African tradition
2(0.8%)
0(0.0%)
2(100.0%)
Family type
Monogamous
178(71.2%)
9(5.0%)
169(95.0%)
0.354
0.838
Polygamous�
63(25.2%)
4(6.7%)
59(93.7%)
Extended family
9(3.6%)
5(55.6%)
4(44.4%)
Total number of children
2 and below
34(13.6%)
5(14.7%)
29(85.3%)
2-6 children
92(36.8%)
13(14.1%)
79(85.9%)
23.66
0.003*
More than 6
124(49.6%)
19(15.3%)
105(84.7%)
husband and wife/wives all alive
Yes
224(89.6%)
11(4.9%)
213(95.1%)
No
26(10.4%)
9(34.6%)
17(65.4%)
0.714
0.398
IF No, the cause of death
Malaria
12(46.2%)
6(33.3%)
8(66.7%)
Asthma
6(23.1%)
3(50.0%)
3(50.0%)
12.25
0.798
Road traffic accident
3(11.5%)
1(33.3%)
2(66.7%)
Don't know
5(19.2%)
4(60.0%)
2(40.0%)
Table 1: Socio demographic characteristics associated with nutrition status of the elderly.
The prevalence of malnutrition was 6.0% (N=15). This varied across a continuum of mild moderate and severe. In addition, there was a varied feeding pattern as 112(44.8%) had two meals a day. Further, majority (N=210, 84.0%) of the respondents had MUAC of 22cm or more, and 153 participants (61.2%) had calf-circumference of 31 or more, as presented in (Table 1).
Chisquare test for association analysis indicated the determinants of geriatric nutritional as: the number of drug prescribed (X2=1.059, CI=95%, p=0.000), numbers of meals taken (X2=2.741, CI=95%, p=0.002), mode of feeding (X2=16.069, CI=95%, p=0.000), and thoughts about nutrition (X2=16.421, CI=95%, p=0.001) as given in (Table 2).
Variables
Frequency N=250(%)
Malnourished
X2
P-value
Yes
No
Declined food intake
Severe loss of appetite
29(11.6%)
1(3.4%)
28(96.6%)
20.9
0.000*
Moderate loss of appetite
173(71.2%)
6(3.5%)
167(96.5%)
No loss of appetite
48(19.2%)
8(%16.7)
40(83.3%)
Weight loss(3 months)
Weight loss greater than 3 kg�
66(26.4%)
0(0.0%)
66(100.0%)
5.55
0.136
Does not know
110(44.0%)
5(4.5%)
105(95.5%)
Weight loss between 1 and 3 kg
66(26.4%)
9(13.6%)
57(86.4%)
No weight loss
8(3.2%)
1(12.5%)
7(87.5%)
Mobility
Bed or chair bound
5(2.0%)
0(0.00%)
5(100.0%)
0.15
0.697
Able to get out of bed/or wheelchair
245(98.0%)
15(6.1%)
230(93.9%)
Suffered psychological stress
2.55
0.111
Yes
147(58.8%)
10(6.7%)
137(93.3%)
No
103(41.2%)
7(6.8%)
96(93.2%)
Neuropsychological problems
Severe dementia or depression
10(4.0%)
0(0.0%)
10(100.0%)
20.1
0.000*
Dementia
175(70.0%)
7(4.0%)
168(96.0%)
No Psychological problems
65(26.0%)
8(12.3%)
57(87.7%)
Body mass Index
BMI less than 19
82(32.8%)
1(1.2%)
81(98.8%)
10.9
0.001*
BMI 19 to less than 21
64(25.6%)
0(0.0%)
64(100.0%)
BMI 21 to less than 23
48(19.2%)
6(12.5%)
42(87.5%)
BMI 23 and greater
56(22.4%)
8(14.3%)
48(85.7%)
Mid-arm circumference
0.35
0.841
MAC Less than 21
10(4.0%)
0(0.0%)
10(100.0%)
MAC 21 to 22
30(12.0%)
3(10.0%)
27(90.0%)
MAC 22 or more
210(84.0%)
12(5.7%)
198(94.3%)
Calf-circumference
0.37
0.425
CC less than 31
97(38.8%)
3(3.1%)
94(96.9%)
CC 31 or more
153(61.2%)
12(7.8%)
141(92.2%)
Table 2: Screening of geriatric respondents.
Assessment of the 24-Hour dietary recall for respondent indicated that 40% (N=100) of the respondents reported taking only breakfast and supper in a day. The major foods consumed were posho, matooke and sweet potatoes, as shown in (Table 3).
Variables
Frequency
Malnourished
X2
p-value
Yes
No
Time/Meal
0.75
0.085
Breakfast, lunch & super
70(28.0%)
10(14.3%)
60(85.7%)
Breakfast & lunch
45(18.0%)
8(17.8%)
37(82.2%)
Breakfast & supper
100(40.0%)
14(14.0%)
86(86.0%)
Lunch & super
35(14.0%)
5(14.3%)
30(85.7%)
method of preparation
Boiled
248(99.2%)
15(6.1%)
233(93.9%)
0.06
0.97
Steamed
1(0.4%)
0(0.0%)
1(100.0%)
Shallow fried
1(0.4%)
0(0.0%)
1(100.0%)
Description of the food
Fresh
233(93.2%)
15(6.4%)
218(93.6%)
0.1
0.756
Dry
17(6.8%)
3(17.6%)
14(82.4%)
Three most important staples
Posho/matooke/sweet potatoes
183(73.2%)
6(3.3%)
177(96.7%)
Posho/irish/rice
39(15.6%)
1(2.6%)
38(97.4%)
1.72
0.632
Posho/chapati/rice
12(4.8%)
0(0.0%)
12(100.0%)
Posho/cassava/matooke
16(6.4%)
1(6.2%)
15(93.8%)
Three most important relishes
beans/green/g-nuts
71(28.4%)
5(7.0%)
66(93.0%)
beans/green/egg
98(39.2%)
2(2.0%)
96(98.0%)
3.28
0.351
beans/green/simsim
6(2.4%)
0(0.0%)
6(100.0%)
beans/green/meat
75(30.0%)
8(10.7%)
67(89.3%)
Table 3: 24 hour’s dietary recall by respondents associated with nutrition status of the elderly.
Food security index indicated that in the six past months, most of the respondents (N=202, 80.8%) had food supply run out, 191(91.2%) were forced to skip meals because the food was not enough. The variables; skipping of meals (X2=21.584, CI=95%, p=0.000) and having insufficient foods (X2=30.75, CI=95%, p=0.000) were significantly associated with malnutrition, as given in (Table 4).
Variables
Frequency
Malnourished
X2
P-value
Yes
No
In the past month, how often has your food supply run out before you were able to get more food from either your garden or the market?
�Never
25(10.0%)
3(12.0%)
22(88.0%)
Sometimes
202(80.8%)
12(5.9%)
190(94.1%)
3.203
0.202
Often
23(9.2%)
2(4.3%)
21(95.7%)
In the past month, how often have you had to borrow money for food in order to ensure that your household eats enough?
Never
35(14.0%)
5(14.3%)
30(85.7%)
Sometimes
187(74.8%)
10(5.3%)
177(94.7%)
5.648
0.059
Often
28(11.2%)
0(0.0%)
28(100.0%)
In the past month, how often have you had to limit the amount that you yourself ate in order to make sure that the other members of the household eat enough food?�
Never
23(9.2%)
3(13.0%)
20(87.0%)
Sometimes
202(80.8%)
12(5.0%)
190(95.0%)
12.77
0.004
Often
25(10.0%)
1(4.0%)
24(96.0%)
In the past month, how often have you or your children been forced to skip meals because the food is not enough?
Never
37(14.8%)
3(8.1%)
34(91.9%)
Sometimes
191(91.2%)
12(6.3%)
179(93.7%)
21.58
0
Often
22(8.8%)
0(0.0%)
22(100.0%)
In the past month, have you worried that you yourself is not getting an adequate diet?
Yes��
�No��
207(%82.8)
14(6.8%)
193(93.2%)
0.059
0.807
43(17.2%)
1(2.3%)
42(97.7%)
In the past month, have you worried that the children or other members of the household are not getting an adequate diet?
Yes�
214(85.6%)
8(3.7%)
206(96.3%)
No
36(14.4%)
4(11.1%)
32(88.9%)
1.068
0.301
In the past month, have you had to reduce your household size to reduce food costs?
Yes�
177(70.8%)
11(6.2%)
166(93.8%)
No
73(29.2%)
4(5.5%)
69(94.5%)
2.49
0.076
In the past month, have you had to sell some of your non-productive household assets to buy food?
Yes�
191(76.4%)
12(6.3%)
179(93.7%)
No
59(23.6%)
3(5.1%)
56(94.9%)
0.531
0.025
In the past month, how often have you or your children been forced to go for a whole day without eating because the food is not enough?
Never
Sometimes
38(15.2%)
5(13.2%)
33(86.8%)
4.659
0.097
Often
197(78.8%)
9(4.6%)
188(95.4%)
15(6.0%)
1(6.7%)
14(93.3%)
In the past month, how often has the food for your household been insufficient?
Never�
24(9.6%)
2(8.3%)
22(91.7%)
Sometimes�
205(82.0%)
15(7.3%)
190(92.7%)
30.747
0.000
Often
21(8.4%)
0(0.0%)
21(100.0%)
Table 4: Assessment of food security index associated with nutrition status of the elderly.
Discussion
There are few published studies on geriatric nutrition. In this study, majority of the respondents were between 61-70 years, which suggests a probable longer-life that may give hopes to many. We too found a statistical association in the risk of geriatric malnutrition with increase in age. This agrees with previous findings [4,20,27,28], and is ascribed to systemic deteriorations and body changes [19,28,29]. Also, being in a monogamous marriage had a nutritional significance, similar to previous findings [3,27-30]. This is explained by the fact that marriage is a socio-cultural phenomenon that is associated with improved support and motivation to cook, eat and find solutions together [31,32]. As majority of the participants reportedly did not attain, or had low education, it could be one of the promoters of malnutrition. This vividly concurs with previous findings [8,20,21], in which it was urged that one can tell the utilization of education and health services from education and health status. As most participants were uneducated, it confirms the likelihood of poor economic status as earlier indicated that educational status possibly could reflect the outcome of household economic welfare, and determines the nutritional and health status of individuals [13,22]. We also found that majority of the households had more than 6 children which could be due to early marriages and child bearing to late reproductive age; a feature that agrees with earlier reports which indicated that every increase in family size causes decrease per capita food and nutritional availability, and reduces the nutritional and health quality thus risk to malnutrition [2,12]. There were 44.8% who could have two full meals in a day and this could be because most people reported that they go to the garden and find it hard coming midway to cook food or could be a way of economizing the available food or also due to food insufficiency as a number of them reported running short of food at one point in time which therefore has a nutritional significance [4,11,32]. Relatedly, 74.5% had at least one serving of dairy products a day and 66.0% consumed two or more servings of fruits or vegetables daily which could be because of easy accessibility. Interestingly, nearly all participants (96.4%) were able to feed without any problem which had a nutritional significance, and it contravenes a previous report [7], in which it was reported that despite the question of inadequacy, swallowing problems due to old age may also pause challenges in feeding and increases the risk of geriatric malnutrition. Further, 55.6% of the participants acknowledged not knowing whether they were healthy or not which had an association with one’s nutritional status given the fact that most didn’t bother taking weights, a feature attributed to lack of awareness [13].
On the food security context, most respondents (N=187, 74.8%) reported to have sometimes run out of food supply in the past six months before they could get more from either their gardens or the market. A big number of respondents (N=191, 91.2%) agreed to sometimes having limited amount to eat in order to make sure that the other members of the household got what to eat. This is ascribed to poverty, and the fact that most respondents were unemployed; a fact in agreement with earlier report that “food insecurity” exists every time the accessibility of nutritiously adequate, safe foods or the capacity of acquiring individually and socially satisfactory foods in suitable ways is restricted or uncertain [3]. The study also found out that 207 respondents (82.8%) or their children sometimes skipped meals because the food was not enough, 214 respondents (85.6%) worried that they were not getting an adequate diet.
Conclusion
Based on our results, age, weight, number of children, frequency of meals, availability of a sufficient supply of food, decline in weight, BMI, psychological and neurological problems, full meals a person takes, prescription drugs a person takes, mode of feeding and whether they had a radio, oxen cart, bicycle, cow/s, sheep and chicken had nutritional significance. Of importance also was whether the respondents had clean drinking water, a latrine, and source of light, how often they limited the food they ate, skipped meals or had insufficient food in the previous six months. The study further confirms that level of formal education attained is an important determinant of employment, utilization of health and educational services. To this, we make the following propositions; 1) there is need to supplement with fruits and vegetables; 2) the government together with stakeholders ought to launch collective approach of sensitizing and educating the masses about the importance of elderly care; 3) the social assistance grants for empowerment which is covering only 15 districts in Uganda ought to be extended to Kween and the amount increased from the current 25,000 Uganda Shs per month to ensure adequate financial support of these senior citizens; 4) the feeding program ought to target the elderly more since they are the ones with poor nutritional status; 5) Food Based Approaches (FBAs), which include food production, dietary diversification and food fortification, are sustainable strategies for improving the micronutrient status of the elderly population.
Ethics Approval and Consent to Participate
We received ethical approval from Clarke International University (Formerly, International Health Sciences University) Research Ethics Committee (REC). All respondents provided written informed consent after receiving detailed description of the study. Eligible participants were consented in privacy and no incentives were given. Anonymity of the respondents was ensured at all stages of data analysis.
Acknowledgement
The authors express our utmost gratitude to our respondents who voluntarily responded to our questionnaire. We are grateful to research assistants for the field support.
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