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 assessing malnutrition in older people in developing countries. After five years of this study some of the results were presented at a symposium held at LSHTM at the end of September. The symposium advocated for greater attention to be paid by development and emergency organisations to the nutritional and related needs of older people.

The research concentrated on finding a simple but effective way of using anthropometric measurements to assess the nutritional status of older people. It examined the relationship between nutritional status and functional ability (the ability to perform basic activities of daily life without support). Vulnerability factors associated with risk of malnutrition in the elderly were also examined. The study took place in three sites, an urban slum in Bombay, a rural population in Malawi and a refugee population in Karagwe region of Tanzania. The elderly were defined as those over 50 years of age.

Nutritional status was measured using various indices like MUAC (mid upper arm circumference) and BMI (wt/ht² )but substituting armspan (the distance between the tips of the middle fingers when both arms are held out) for height where there was curvature of the spine (kyphosis). One difficulty with using BMI to assess nutritional status of the elderly is that accurate height measurement is necessary, yet curvature of the spine confounds accurate measurement. In one of the study populations the percentage of the elderly with kyphosis was 17%.

The main findings of the study were as follows:

• Levels of malnutrition using standard BMI cut-off (substituting armspan for height where necessary) points were high in all three sites. For example, in the Bombay site using a cut-off of 17.5 kg/m2(severe malnutrition), the prevalence of underweight was 46.8% among younger adults and 57.1% among older adults. The proportion of undernutrition rose with age.
• Estimations of muscle area using MUAC and triceps skinfold thickness found that there was a declining trend in muscle area with age for all three study populations and that in the African populations there was no significant difference between the sexes while there were large gender differences for the Bombay slum population.
• In the Bombay study haemoglobin levels were assessed and it was found that 38% of older men and 52% of older women have anaemia (< 13 gms/dl for men and 12 gm/dl for women) and that prevalence increases with age
• Functional ability as measured by self reported activities of daily living (ADL), assessed mobility, self reported health, and physical performance tests like handgrip strength, manual dexterity, speed and co-ordination and flexibility, were related to undernutrition independently of age, sex and health status in all three sites.
• All levels of undernutrition significantly increase the risk of having some level of functional ability impairment (even mild and moderate malnutrition).
• A number of vulnerability factors were associated with undernutrition. These include, income earning opportunities/income, physical impairment, social isolation, living alone or having to care for younger children, socio-economic determinants like illiteracy, alcohol consumption and smoking in men, self-reported poor health in women, impaired memory.

One of the main conclusions from the study is that prevention of malnutrition is critical in protecting functional ability of the elderly.

A handbook arising out of this study, to assist organisations or individuals wishing to measure nutritional status or assess vulnerability in the elderly is currently at draft stage. The first three chapters have largely been written. These explain methods of assessing nutritional status in the elderly, e.g. MUAC, BMI using armspan, height or demispan. BMI nutritional status charts using all these anthropometric measures are provided. Further chapters are to be written on ways of assessing vulnerability in the elderly and on appropriate interventions to deal with nutritional risk and problems in the elderly.

A report of the symposium can be obtained from Kate Gregory at Help Age International, 67-74 Saffron Hill, London EC1N 8QX. Tel No +44 171 404 7201, E-Mail helpage@dial.pipex.com