|Year : 2021 | Volume
| Issue : 2 | Page : 127-133
Functional correlates of malnutrition among older patients in a primary care clinic in Northern, Nigeria: A cross-sectional study
Abdulgafar Lekan Olawumi1, Bukar Alhaji Grema1, Abdullahi Kabir Suleiman1, Yakubu Sule Omeiza2, Godpower Chinedu Michael1
1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Clinical Services and Training, National Orthopedic Hospital, Kano, Nigeria
|Date of Submission||11-Apr-2021|
|Date of Decision||29-Aug-2021|
|Date of Acceptance||21-Sep-2021|
|Date of Web Publication||10-Dec-2021|
Dr. Abdulgafar Lekan Olawumi
Department of Family Medicine, Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Context: Nutritional and functional impairments are assumed to be inevitable consequences of aging and they attract little attention in the primary care setting. Aim: To determine the association between malnutrition and functional status of the elderly to advocate for their routine screening in the primary care clinics and similar settings. Settings and Design: A cross-sectional descriptive study involving 352 patients of age ≥60 years who presented at the Family Medicine Clinic. Methods and Materials: The nutritional status was assessed using the Mini Nutritional Assessment tool, whereas functional capacity was assessed using Katz and Lawton index for the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), respectively. Statistical Analysis: Chi-square test and logistic regression analysis were used to determine associations between variables and nutritional status, and determinants of nutritional status, respectively. Results: The mean age of respondents was 67.9 ± 7.6 (60–95) years; 215 (61.1%) were women. The prevalence of malnutrition was 25.9% and of risk of malnutrition 53.1%. Advancing age (odds ratio [OR] = 4.93, 95% confidence interval [CI] =1.42–1.71, P ≤ 0.001), low monthly income (OR = 9.29, 95% CI = 0.20–43.50, P = 0.005) and being functionally dependent (OR = 14.706, 95% CI = 1.26–3.35, P = 0.03 for ADL; OR = 17.51, 95% CI = 5.07–37.31, P = 0.004 for IADL) were the determinants of malnutrition in the elderly patients. Conclusion: The prevalence of malnutrition and those of at-risk of malnutrition was high. Advancing age, low income, and functional dependence were the independent correlates.
Keywords: Elderly patients, functional status, malnutrition, primary care and Northern Nigeria
|How to cite this article:|
Olawumi AL, Grema BA, Suleiman AK, Omeiza YS, Michael GC. Functional correlates of malnutrition among older patients in a primary care clinic in Northern, Nigeria: A cross-sectional study. Niger J Basic Clin Sci 2021;18:127-33
|How to cite this URL:|
Olawumi AL, Grema BA, Suleiman AK, Omeiza YS, Michael GC. Functional correlates of malnutrition among older patients in a primary care clinic in Northern, Nigeria: A cross-sectional study. Niger J Basic Clin Sci [serial online] 2021 [cited 2022 Dec 9];18:127-33. Available from: https://www.njbcs.net/text.asp?2021/18/2/127/332171
| Introduction|| |
The proportion of older persons is stretching the world's population distribution with a slightly steep to the developing countries. By 2025, the number of older population is expected to reach more than 1.2 billion, with about 840 million of these in developing countries. As of 2006, Nigeria had a populace of 140 million with 5% comprising the older age group, and this is expected to be doubled by 2025.,
The age-related physiologic, psychosocial, and economic changes, could lead to an inevitable deterioration in the degree of their efficiency, functionality, and nutritional state. Malnutrition, “defined as a state of deficiency, excess or imbalance of energy, protein, and other nutrients,” could lead to adverse effects on body forms, function, and clinical outcome.,
The lack of family and financial support, and inadequate access to food especially among elderly people in developing countries account for the high prevalence of malnutrition in them. A prevalence of 6.5% for malnutrition was reported among the elderly population in Norway. Also, a prevalence of 42% has been reported in Ilorin, Northcentral Nigeria as against the global estimate of 22.8%., Given the socioeconomic hardships of older Africans such as poverty, illiteracy, lack of quality food, and potable water, it is not surprising that this group may be at a higher nutritional risk. Surprisingly, “most nutritional intervention programs in most African countries are directed toward infants, young children, adolescents, pregnant women, and lactating mothers”.
Further, functional status, “which is the ability to perform tasks necessary to live independently in the community” is adversely affected in the older population. The changes associated with normal aging, and the associated health problems and functional decline could place the elderly population on a cascade of treatment-associated complications and subsequent malnutrition.,
Nutritional and functional deficiencies relating to the elderly are commonly overlooked by primary care physicians and other healthcare workers in our setting because of the assumption that “they are inevitable consequences of aging and disease, and that interventions in correcting these deficiencies have limited effect”. In addition, many physicians often lack the ability to assess or detect nutritional and functional status in the elderly due to insufficient knowledge and awareness. All these could result in a delay or omission of appropriate interventions which could have reduced the suffering of the older persons from the consequences of nutritional and functional impairments.
A community-based cross-sectional study by Danielewicz et al. in Southern Brazil reported a significant interdependent relationship between nutritional status and functional status among the studied elderly. Also, a systemic review on the risk factors for malnutrition in older adults by Fávaro-Moreira et al. in the USA reported a general health decline including physical and functional status as one of the significant risk factors for malnutrition in the older population.
Despite all these burdens and associated problems, there is a paucity of studies in this important area in Nigeria. This study is therefore aimed at providing information on the relationship between the nutritional status and functional capacity among the older population to advocate for routine nutritional and functional status screening for older people attending primary care clinics and similar settings, and it could also serve as a basis for further studies.
| Subjects and Methods|| |
The descriptive cross-sectional was study conducted in a Family Medicine Clinic (FMC) in Kano; which is the largest commercial center in Northern Nigeria. The hospital has 20 clinical departments with a 600-beds capacity and serves as a referral center to the neighboring states. The FMC is the primary care unit of the hospital, where all patients except emergency pass-through for assessment, treatment, and referral of necessary cases to other sub-specialty departments and units of the hospital. According to the hospital records, about 250 patients have attended on a daily basis of which the older patients constitute up to 10%.
The study population comprised male and female patients of age 60 years and above who presented at the clinic over 12 weeks (November 1, 2017–January 24, 2018).
Consenting older male and female patients attending the FMC of the hospital during the study period were recruited. However, critically ill older patients and those with major neuropsychiatric illnesses such as schizophrenia and mood disorders were excluded from the study because they might not cooperate with the research team.
A sample size of 374 was estimated using the Fischer's formula n = Zα2pq/d2 where n = minimum sample size, Zα = standard normal deviate corresponding to a 5% level of significance (1.96), p = 42% (prevalence rate of malnutrition among older patients in UITH Ilorin, Nigeria).
q = 1 − p (58%), and d = level of precision which was set as 5%. The hospital record revealed an average of 25 older patients seen daily in the Family Medicine Clinic (FMC) therefore, the sampling frame was 2,100 (25 × 7 × 12). This formula ns = n/1+ (n/N) was then used to adjust the sample size to 352 (for population <10,000 with 90% response rate).
A systematic random sampling method was used to recruit 352 older patients attending the hospital, within the sampling frame of 2,100 and a sample interval of 6 (2100/352). At the registration of each clinic day, a trained research assistant identified all elderly patients who had completed registration for possible recruitment. On the first day, the first respondent was chosen through balloting thereafter, every sixth older patient was recruited if he or she fulfilled the inclusion criteria. A minimum of four respondents was recruited each day and an average of 29 respondents were recruited each week until the sample size of 352 was obtained.
A pretested, interviewer-administered semistructured questionnaire was administered to the participant by the researcher or a trained research assistant; who was a resident in the Department of Family Medicine. Respondents' folder was serialized with numbers written on them to avoid repetition. Information was verified from the patients' files or caregivers whenever necessary. The sociodemographic characteristics which included gender, marital status, ethnicity, religion, literacy level, living condition, and occupation were assessed with closed-ended questions while age and monthly income were assessed with open-ended questions. Age was determined by the direct recall, age at marriage, age at birth of a first child, or in relation to historical events.
The nutritional status was assessed with the Mini Nutritional Assessment tool which has 18 items. These include anthropometric measurements, dietary history, clinical assessment of lifestyle habits, medication, mobility, neuropsychological problems, and self-perception of nutrition and health. The assessment score was graded as malnutrition <17, at risk of malnutrition 17–23.5, and well-nourished 23.6–30.,
The anthropometric examinations included height, weight, mid-arm circumference, and calf circumference (CC). The height and weight were measured using a stadiometer and weighing scale manufactured by Seca Corporation® (Germany), and the measurements were made to the nearest 0.1 cm and 0.1 kg, respectively. In older patients with spinal curvatures or wheelchair-bound, the half arm span was used to estimate the height, which is the distance from the midline at the sternal notch to the tip of the middle finger. Height was then calculated by doubling the half arm span.
The CC and the mid-arm circumference were measured with a fiber-glass tape rule and the measurement was recorded to the nearest 0.1 cm.
The functional status which included the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) were assessed with the Katz and Lawtons indexes, respectively. The Katz index assessed six functions, with scores 5–6 indicating full function, 3–4 indicating moderate impairment, and ≤2 indicating severe functional impairment. The Lawtons index assessed eight functions. To avoid gender bias, scores 0–5 for women and 0–3 for men were classified as dependent, and 6–8 for women and 4–5 for men were considered as independent.
Ethical approval was obtained from the Research Ethical Committee of the hospital (no. NHREC/21/08/2008/AKTH/EC/1842). Adequate education preceded an informed written consent from each participant. Confidentiality was ensured by not writing the names of participants on questionnaires. Participants discovered to have nutritional problems during the study were provided with adequate counseling and care as appropriate.
Data were collated, coded, and analyzed by using the Statistical Package for Social Sciences version 20 software. Absolute numbers and simple percentages were used to describe categorical variables. Similarly, quantitative variables were described using measures of central tendency (mean) and dispersion (range, SD) as appropriate. The qualitative variables were expressed as proportions. The Chi-square test was used to assess the significance of associations between categorical variables. A P value of ≤ 0.05 was considered statistically significant. Variables that were significant in bivariate analysis were subjected to logistic regression.
| Results|| |
A total of 352 respondents (100% response rate) completed the study. Their ages ranged from 60 to 95 years with mean age of 67.88 (SD ± 7.62) years. As shown in [Table 1], most (78.1%) of the respondents belonged to the young–old (60–74 years) group whereas 17.3% and 4.6% belonged to middle–old (75–84 years) and old–old (≥85 years) groups, respectively. The patients were predominantly women (61.1%), and of Hausa tribe (58.8%) and Muslims (94%). Most (63.6%) of them were widowed in polygamous family settings. Most (73.5%) of them had no formal education and earned below ₦10,000 (28USD) per month [Table 1].
As shown in [Table 2]; 21.0% of respondents had normal nutrition while 53.1% were at risk of malnutrition and 25.9% were malnourished. Thus, the prevalence of malnutrition in the study was 25.9%.
[Table 3] shows that 15.3% and 6.3% of respondents were moderately and severely dependent on ADL, respectively. This resulted in a prevalence of 21.6% for functional dependence on ADL. Impairment in urinary continence was common to all respondents who were dependent on ADL. Similarly, 12.2% of men and 20.2% of women were functionally dependent on IADL, to give a prevalence of 32.4% for functional dependence on IADL.
[Table 4] shows statistically significant associations between malnutrition and advancing age (FE = 46.243, P < 0.001), marital status (FE = 15.678, P = 0.001), tribe (FE = 19.200, P = 0.008), educational level (χ2 = 21.772, P = 0.005), occupation (FE = 44.157, P < 0.001), monthly income (χ2 = 58.496, P < 0.001), and family type (χ2 = 10.186, P = 0.007). [Table 5] shows statistically significant association between ADL and nutritional status of the participants (FE = 66.967, P < 0.001). Similar association was also found with the IADL (χ2 = 74.771, P < 0.001). This means that functional status is associated with the nutritional status of the participants.
Logistic regression of the associated factors with nutritional status in [Table 6] revealed that advancing age (odds ratio [OR] = 4.934, 95% confidence interval [CI] =1.423–1.710, P < 0.001), low monthly income (OR = 9.289, 95% CI = 0.199–43.498, P = 0.005) and functional dependence in ADL (OR = 14.706, 95% CI = 1.263–3.349, P = 0.032) and IADL (OR = 17.510, 95% CI = 5.067–37.309, P = 0.004) were the predictors of malnutrition among the older population in this study.
|Table 6: Multiple logistic regression analysis of the factors associated with malnutrition|
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| Discussion|| |
The demographic transition toward an increasing proportion of senior citizens in the world is a thing of concern because of the associated risk of malnutrition and functional decline in them probably because of the effects of aging., This cross-sectional, hospital-based study was designed to determine the prevalence of malnutrition, and the association between functional capacity and the nutritional status of the older population.
In this study, the prevalence of malnutrition and at risk of malnutrition were 25.9% and 53.1%, respectively. Also, the prevalence of functional dependence in ADL was 21.6% and IADL was 32.4%. The study reported a strong association between malnutrition and advancing age, low monthly income, and functional dependence in ADL and IADL.
The prevalence of malnutrition and at risk of malnutrition in this study was similar to that reported by Ferdous et al. in Bangladesh; where 26% were reported to be malnourished and 55% were at risk. Our findings were comparable to 22.8% prevalence of malnutrition reported in a multinational study and 20.8% reported in other studies in Bangladesh and India., The similarities between our findings and that of Bangladesh and India could be because we share similar socioeconomic characteristics of developing countries such as high disease burden, high illiteracy level, poor housing, and income. However, the result of this study is lower than the 29.1% prevalence reported by Oliviera et al. among the hospitalized older patients in Brazil with a smaller proportion of 37.1% were at-risk. This could be because nutritional status deteriorates as dependency and care needs grow; following a sequence from community living, to the nursing home, and then hospital. This can also be corroborated by the report of Milne et al. that more than 55% of older people admitted to the hospital have pre-existing evidence of malnutrition. Besides, a lower prevalence of malnutrition and the at-risk group were reported in Turkey (13% and 31%) and South Africa (5.5% and 43.4%)., This is because Turkey is a developed country with high income and literacy levels. However, a significantly lower prevalence of malnutrition in a developing country like South Africa could also be because the study was done in the community where older people lived autonomously with limited dependence compared to those visiting the hospital due to chronic diseases and different levels of functional dependency. Similarly, a cross-sectional study conducted at the GOPC of University College Hospital Ibadan, Southwestern, Nigeria reported a significantly lower prevalence of 7.8% for malnutrition and 11.8% for the at risk. This could be attributed to the higher socioeconomic status of older patients in Ibadan compared to those in Kano, which will enhance frequent hospital visits, keeping to follow-up and consequently better health awareness and outcome.
The strong relationship between advancing age and malnutrition identified in this study was also observed in many similar studies.,,,, This could be due to the physiologic and pathologic changes associated with advancing age. These changes could result in the development of comorbid conditions, functional impairment, feeding problems, and consequently malnutrition. Also, the strong association between malnutrition and low income or financial dependency is consistent with the findings from other similar studies.,,,,, This could be because intake and even choices of foods largely depend on the purchasing power. A strong association between functional capacity and nutritional status has been reported in several studies.,,,, This study showed that those older groups who had functional impairment (by ADL) were at least 14 times more likely to be malnourished while those older groups who had functional impairment (by IADL) were at least 17 times more likely to be malnourished. This could be because lack of functional autonomy to look after oneself, communicate, prepare and eat foods, and even meet other needs, could predispose the older people to nutritional compromise which could also predispose them to multiple comorbidities which could later contribute to the overall functional impairment, thus creating a vicious cycle., For these reasons, periodic nutritional and functional screening may be recommended for older patients especially women and those at an advanced age to comprehensively examine, identify and treat predisposing factors of malnutrition and functional impairment in them. Also, the physicians and caregivers of the older population should not only concentrate on the chronic illnesses of the older people, but also pay more attention to promoting improvements in their nutritional adequacy, functional independence by harnessing adequate social, and financial support for them.
Among the limitations in this study was that biochemical and hematologic parameters of nutritional status were not assessed and recall bias could not be eliminated. Also, the finding is limited to urban outpatient settings. A descriptive study of this type cannot establish causality between functional dependence and malnutrition, thus a longitudinal study is required to test and confirm these findings. Despite the aforementioned limitations, the data generated from this study may contribute to scientific evidence on this subject and form the basis for advocacy toward screening for malnutrition and functional dependence among the older population in our clinic and similar primary care settings. Also, interventions to reduce malnutrition may require improved surveillance in primary care using age, monthly income, and functional dependence as important risk factors.
We acknowledge the role of the research assistants and the department's secretarial staff in making this study a reality.
Financial support and sponsorship
The study was solely funded by the authors.
Conflicts of interest
There are no conflicts of interest.
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