Menu ENN Search

Letter on older people, nutrition and emergencies, by Yvonne Grellety and Michael Golden (with response by Vanessa Tilstone)

Dear Editor,

We refer to the Article by Vanessa Tilstone "Older people, Nutrition and emergencies in Ethiopia" (issue number 14, November 2001). We agree that the welfare of the elderly in emergencies has received much less attention than is necessary. The result is a dearth of field expertise upon which to draw and almost no data upon which to base judgements. There clearly needs to be a lot of research in this area. HelpAge is to be congratulated for initiating both research and debate on how to recognise and appropriately help the vulnerable elderly in emergency situations.

The cut-off points for definition of severe and moderate malnutrition in childhood are based upon over 50 years of data analysis (from the initial paper by Gomez published in the 1950's). The mass of data from around the world, for this age group, clearly shows relationships between the definitions of the grades of malnutrition and the risk of death. Severe malnutrition means that the child has a high risk of death from malnutrition. No relationships have been established for the elderly in terms of risk of death or even other adverse outcomes. This is an area where data is desperately needed to inform the debate so that meaningful opinions can be reached.

The use of the term "severe malnutrition" itself carries the connotation of the person being at high risk of death and should only be used when this is the case. This should not be an arbitrary decision, or even one based upon fulfilling some sort of quota of patients needed to justify a programme at field level, but upon the real risk and needs of this section of the population.

In the absence of a body of outcome data, there is no basis for the choice of any particular cut-off point, which will either divert the limited resources available in an emergency away from, or to, the elderly. Steve Collins comes closest to this with his analysis of outcome in relatively small numbers of adults (not the elderly) of particular ethnic groups. Collin's cut-off points are rejected by HelpAge; the basis for this rejection is unclear. Nevertheless, it is probable that very small numbers of elderly would be selected by Collins' criterion.

HelpAge therefore chose a criterion said to be based upon a personal communication from myself (Yvonne Grellety). In this I have been totally misrepresented. I have no data upon which to base such a judgement. I have therefore never advocated any cut-off point for either BMI or MUAC for definition of malnutrition in the elderly. We did not use the quoted cut-off point for selection of either adults or the elderly in Rwanda. Incidentally, I was with UNICEF in Ethiopia and not ACF. My main concern is to avoid confusion at field level and consequently ask the readership of Field Exchange to ignore all quotations ascribed to myself in this article.

Nevertheless, we agree that in the absence of meaningful data some reasonable cut-off point should be chosen pragmatically, on an experimental basis, for inclusion of the elderly in programs. The onus is then for the agency to determine the outcome of the elderly, both those included and particularly those excluded by that criterion, in order to build up a body of knowledge and experience with which to refine the criteria and definitions whilst not ignoring the humanitarian needs of this section of the community. Any particular cut-off point cannot be justified post hoc by quoting an incorrect personal communication that the readers cannot verify.

In case study 1, given the demography of Ethiopia, we are astonished that the ratio of age groups admitted was 1 pregnant/lactating mothers, 4.5 children and 14 elderly. Were resources in that programme really being distributed according to need? This case study seems to show how the selection of an inappropriate criterion for "malnutrition" in one age group can lead to real problems with resource allocation at field level.

Yvonne Grellety, Michael Golden

 

Dear Editor,

I received a copy of the letter from Yvonne Grellety and am grateful that she has reemphasised the need to do more research to define and measure malnutrition among older people.

I apologise sincerely for misquoting her in any way. What was written was based on my understanding of the recommendations she gave to HelpAge when she very kindly advised us on our programmes in Ethiopia while working for UNICEF there. As stated in the article, we were not happy with the MUAC cut off points suggested by Steve Collins nor HelpAge cutoffs, based on our nutrition survey results using the MUAC, and therefore we used those suggested by Yvonne on an experimental basis, based on what we understood was ACFs practical experience in Rwanda.

The fact that the number of older people registered in case study 1 was higher than the other groups may have a number of causes, including: the prioritisation of certain members of the family for food, the fact that supplementary feeding programmes for children had been carried out since 1999, and probably most significantly because older people may have been more actively recruited in the programme.

These issues need to be further explored and the understanding shared and I hope that this will be done, along with more comprehensive international and longitudinal studies of elderly malnutrition in order to help a group of people so often overlooked in emergency situations.

Vanessa Tilstone

More like this

FEX: Older people, nutrition and emergencies in Ethiopia

By Vanessa Tilstone Vanessa Tilstone has worked for HelpAge International in Ethiopia for the last 3 years as the Country Programme Director and has worked previously in...

FEX: Methods for Assessing Malnutrition in Older People

A Summary of Initial Findings In the first edition of Field Exchange we reported on an ongoing research project by Helpage and the LSHTM which was developing methods for...

FEX: Comment on: Including infants in nutrition surveys

Experiences of ACF in Kabul city By Michael Golden, Department of Medicine and Therapeutics, University of Aberdeen, AB25 2ZD, Scotland. Perinatal mortality and birth-weight...

FEX: Anthropometric cut-off points for older children and adolescents in Syria

By Paluku Bahwere View this article as a pdf Paluku Bahwere is a paediatrician with over 25 years of experience in operational research and programming in the fields of...

en-net: Urgent: Weight for Height Z-scores: Unisex Z-score table used in West African countries vs. calculated Z score values

In the 2011 Guidelines for THE INTEGRATED MANAGEMENT OF SEVERE ACUTE MALNUTRITION published by ACF, Annex 4 depicts a Weight-for-Height table. This same table has been adopted...

en-net: Treatment of SAM in older people through outpatient

Treating older people (-=60 year old) with uncomplicated SAM with RUTF at home as out patients: which doses should we use? Some recommend 100kcal/kg/day. Should it be...

FEX: Concordance between weight-for-height z-score (WHZ) and mid-upper arm circumference (MUAC) for the detection of wasting among children in Bangladesh host communities

View this article as a pdf Lisez cet article en français ici By Md. Lalan Miah, Dr. Md. Khalilur Rahman, Dr. Md. Abdul Alim and Bijoy Sarker Md. Lalan Miah is the...

en-net: Only MUAC for admission and discharge?

There has been a discussion about the use of ONLY MUAC as an admission and discharge criteria (http://www.en-net.org/question/468.aspx). Although I understand the challenge in...

en-net: Nutritional status and vulnerability of older adults/older people (aged 50 +)

Happy New Year to En-net colleagues, I have recently been contracted by HelpAge International (in partnership with NutritionWorks) to write a module on nutrition in older...

en-net: Low mid-upper arm circumference identifies children with a high risk of death who should be the priority target for treatment

BMC Nutrition just published a comment that we wrote about a paper published a few months ago by Grellety and Golden. The link to the original...

FEX: Death of children with SAM diagnosed by WHZ or MUAC: Who are we missing?

Summary of presentation1 View this article as a pdf By Michael H. Golden and Emmanuel Grellety Michael Golden is a retired professor of medicine with 45 years' experience of...

en-net: MUAC vs W/H

I understand that MUAC has gender and age bias, identifying more girls and younger children with acute malnutrition. Has any work been done to show if MUAC only criteria were...

FEX: NGOnut discussion summaries - cassava poisoning, and HIV and breastfeeding

The following are edited summaries of e-mail correspondence from the NGO Nutrition Association (NGO Nut) which may be of interest to readers. The NGO Nut was recently set up...

en-net: MUAC cut off points for school aged children

Dear All, I would like to ask, where I can find literature for MUAC cut off points for school aged children (6 years old up to 15 years). I am looking for MUAC cut off point...

en-net: WFH versus MUAC

I would like experts input in this regard. I wish Mark Myatt to be one of the respondent of my question. Much has been said about the discrepancy of MUAC and WFH in some...

FEX: An Ongoing Omission: Adolescent and Adult Malnutrition in Famine Situations

By Peter Salama and Steve Collins. (December '98) A boy sits under a tree awaiting a distribution by the UN World Food Programme in the southern village Acum Cum. The food is...

FEX: Comparison of Weight-for-Height Based Indices for Assessing the Risk of Death

Summary of Published Paper Mortality rates among children with severe malnutrition vary considerably between different treatment centres. This variation is due to differences...

FEX: Letter on background to 1999 WHO guidelines on malnutrition, by Mike Golden

Dear ENN, Further to your article on the technical debate regarding the management of severe malnutrition, I wish to offer some contextual information to the development of...

en-net: Nutritional recommendations children > 5 yrs, adolescent, adults, elderly..

I am currently working with a protocol to be used in treatment of SAM. Some questions raised, and I hope some of you will be able to answer them. First question is about the...

en-net: What is the cut off point for child bearing age women to decide acute malnutrition based on MUAC?

We are planning to do nutrition assessment among child bearing age women using MUAC only. As far I know, MUAC less than 21cm (some where may be 22cm,23cm) is used as cut off...

Close

Reference this page

Yvonne Grellety, Michael Golden (). Letter on older people, nutrition and emergencies, by Yvonne Grellety and Michael Golden (with response by Vanessa Tilstone). Field Exchange 15, April 2002. p9. www.ennonline.net/fex/15/lettersyvonne

(ENN_3573)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.