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ABSTRACT
Objective:
Assessment of the nutritional status of the
institutionalised elderly in Nigeria.
Methods: Elderly patients' nutritional
status was assessed using a structured questionnaire,
anthropometric measurements and direct weighing
of food intake.
Results: Socio-demographic characteristics
showed that 52% of patients were male (48% female),
with ages ranging from 60 to 80 years. Twenty-four
percent of patients had no formal education, while
32% had primary education. BMI measurements showed
that the majority of patients were of normal weight,
while only 20% of the females were overweight.
Food consumption patterns confirmed that roots
and tubers such as cassava (gari) and yam (yam
flour) were in moderate consumption, i.e., eaten
at least once a week. Cereal-based foods such
as fermented corn (ogi) were frequently consumed,
as a majority of patients ate the fermented cereal
ogi daily. Calorie intake among males and females
ranged from 2534 to 2637 kcal/day and 2414 to
2558kcal/day, respectively. The mean protein intake
was 87.3 g/day for male patients and 89.6 g/day
for female patients.
Conclusion: While the energy and protein
intake was adequate according to the recommended
dietary allowance (RDA), the micronutrient intake
was found to be lower than the RDA. On the whole,
the diets were low in fruits and vegetables. It
is essential for elderly people to eat foods that
contain high levels of antioxidants and micronutrients.
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INTRODUCTION
The majority of the elderly
in developing countries enter old age after a lifetime
of poverty, deprivation, disease, poor access to health
care and an inadequate diet in terms of both quantity
and quality. (1, 2, 3) Until recently, it has been assumed
that older people represent only a small proportion
of the population in developing countries and that they
are adequately cared for by their extended families
(4). In many communities of Africa, there are elderly
people who require caregivers, either in homes or institutions,
as they are unable to adequately take care of themselves.
Ensuring adequate nutrition and health care of the elderly
requires support and assistance from the community,
local and national governments, civil and religious
groups and NGOs. For example, the Ministry of Health,
Ministry of Social Affairs, NGOs and religious groups
provide social security to the elderly in both Egypt
and South Africa (1,5). Retired people in Egypt also
have some price exemptions for transportation and are
included in the public health insurance system. Subsidies
and credits for retired people can be obtained through
Nasser Bank, and some special aid is occasionally distributed
to them as well. (6,7). In Nigeria, only the local government
runs institutionalised homes because many Nigerians
believe that the extended family should care for the
elderly. Recently, social scientists have observed that
some elderly Nigerians do not get the same level of
care from their families and extended relatives compared
with previous generations (4). Elderly women in Nigeria
were observed to be carrying out domestic tasks into
extremely old age (4,8). Weakness, arthritis and failing
vision were the chief health problems among these women;
all of these illnesses require proper care (9,10).
In order to prolong the life of the elderly in Africa
and improve their quality of life, more information
is required about the nutrition, care and health of
this population. Adequate and appropriate nutrition
is essential to the well-being of the elderly. Poor
nutrition is exacerbated by poverty, isolation, misdistribution
of food, and poor eating habits, including those due
to dental problems. For the elderly to stay healthy,
extra care must be given, including constant surveillance
and follow up of their nutrition status. Constant nutrition
assessment will help maximise Quality of life and assist
in the formation of social and health care policy for
the elderly in Africa, especially in Nigeria.
Methodology
Area of study
This study was carried out in the old people's home
in Yaba, Lagos, located in an industrialised and highly
populated area of Lagos City, Nigeria. The home was
established in 1927 by religious bodies and later handed
over to the Lagos Municipal Council in 1937. In 1982,
the Lagos State Government, under the Ministry of Social
Welfare and Sport Development, took over the management
of the facility and was still managing it at the time
of the study.
Subjects
All participants were residents at the home, were at
least 60 years of age and were able to give informed
consent to join the study. All procedures were approved
by the Research Committee of the Department of Nutrition
and Dietetics at the University of Agriculture, Abeokuta,
Nigeria as well as the management of the old people's
home. A total of twenty-five residents, the entire population
registered as full residents at the time of the study,
consented to participate.
Data collection
Demographic information was collected using a structured
household questionnaire, and non-demographic information
was collected via an interview.
Anthropometrics
Anthropometric data were collected according to the
procedures outlined by the WHO in 1989. Height (without
bent curvature) was measured with a locally manufactured
stadiometer, and weight was measured with a sensitive
Anderson bathroom scale (in 100g/kg). Mid-upper arm
circumference was taken with non-stretch tape, and arm
span was measured with a meter ruler from the tip of
longest finger on the right hand to the longest finger
on the left hand (11,12).
Direct weighing method
A direct weighing method was used to measure food consumption
daily for three days. At mealtimes each day, food was
weighed using a Salter scale. The name of each food
item was entered, in the local language, on a coded
record form. At each visit, subjects were asked to recall
what other foods they had eaten that were not recorded.
These foods were usually in-between meals, such as snacks,
as most of the elderly hardly eat outside the home.
An equivalent portion of the snack was then purchased
and weighed, and the data were recorded on the respondent's
coded form. Food intake was converted to nutrient intake
using food composition tables, and these values were
entered into the computer. Using Microsoft Excel, the
average energy and nutrients per day were calculated
for each respondent.
Results
The demographic characteristics
and other non-demographic variables of the elderly are
presented in
Table 1.
Table 1: Demographic characteristics
of the elderly
Of the 25 individuals studied, 52% were male, while
48% were female. Their ages ranged from 60 to 80 years.
In terms of marital status, 24% were married, 48% were
either divorced or separated, and 28% were widowed.
About a third of the elderly had no children, 60% had
between two and six living children and the rest had
more than seven. Twenty-four percent of participants
had no formal education, 32% had primary education,
and 12% had tertiary education. Their previous occupations
were civil servants (44%), traders (24%) and farmers/artisans
(32%). The health status revealed a low morbidity rate,
as 72% visited the hospital occasionally for aliments
such as body pain (25%), eye problems (14%) and arthritis
(14%), while 20% had no ailments and therefore had not
visited the hospital for years. The recreational activities
listed by the participants included singing (13%), dancing
(17%), leisure walking (14%) and watching television/listening
to the radio (27%). Other activities listed were indoor
games and reading.
Dietary patterns, food habits and nutrient intake.
The dietary patterns, food habits and nutrient intakes
of the elderly Yorubas in the institutionalised home
were observed to be similar to those in non-institutionalised
homes. Ninety percent of the elderly ate twice daily,
and the source of these foods was most often from the
institution's cafeteria. Food consumption patterns confirmed
that roots and tubers such as cassava (gari) and yam
(yam flour) were consumed at least once a week (moderate
consumption). Cereal-based foods such as fermented corn
(Ogi) were consumed daily by a majority of patients.
Apart from fish, animal product consumption was low.
The mean energy intake among the elderly was adequate
for the recommended dietary allowance (RDA) (Table 2).
Protein intake was 87 g/day for males and 89 g/day for
females. Mean fat intake was slightly lower than the
RDA in both male and female participants (Table 2).
Table 2: Mean intake of energy
and macronutrients in the elderly per day
Table 3: Daily mean intake
of vitamins and minerals by elderly
Table 3 shows the vitamin and mineral intake of the
participants. Iron and calcium were consumed generously,
meeting the RDA. However, vitamin intake, especially
that of biotin, vitamin A and vitamin B6, was very low,
as none of the subjects reached 50% of the RDA. The
mineral dietary intake was very high and mainly derived
from plant sources.
Table 4: Mean body
mass index of the respondents
ANTHROPOMETRIC MEASUREMENTS
Body mass index measurements demonstrated that many
of the elderly had a normal body habitus, as only 20%
of the female participants were overweight.
DISCUSSION
This nutritional assessment of the institutionalised
elderly in Nigeria has demonstrated the need to promote
a healthy lifestyle in this population. BMI measurements
showed that this group of elderly people had a normal
nutritional status despite an energy intake above the
RDA. The need for elderly to reduce their dietary intake
has been a topic of discussion among nutritionists.
Many studies have associated lower energy intake with
body decomposition, including decreases in metabolic
factors such as DNA repair, plasma glucose, insulin
sensitivity and healthy lifespan (13,14).
The elderly Yorubas had inadequate vitamin intake, well
below the RDA according to the Food and Agriculture
Organization (15). The poor intake of vitamin B may
be due primarily to consumption of roots and tubers
with little consumption of legumes (such as cooked beans).
Some elderly have food preferences that cause them to
avoid certain foods, and the decrease in their ability
to taste, smell, and even swallow may decrease their
appetite. The low intake of vitamins is not limited
to the Yoruba elderly. Recent studies in developed countries
have revealed that the vitamin intake in the elderly
population is below the RDA, putting this population
at risk for vitamin deficiencies as well. The FAO/WHO
(16) and National Research Council (17) have both recommended
that adults and the elderly maintain an adequate intake
of thiamin, pyridoxine, biotin and vitamin A. Contrary
to the commonly held belief that B6 is only important
in infants, recent studies have demonstrated the importance
of vitamin B6 in the elderly (18), as it plays a role
in metabolic reactions including nucleic acid biosynthesis,
lipid metabolism, and neurotransmitter release.
New research highlights the importance of the B vitamins
in the prevention of vascular disease. Several studies
have shown that low concentrations of folate, vitamin
B12 and vitamin B6 are related to an increased homocysteine
concentration, which has been linked to an increased
risk of heart disease, stroke and other vascular pathologies
(1). Homocysteine is an amino acid that is an intermediate
product of protein metabolism. The breakdown of homocysteine
to cysteine requires cystathionine beta synthase, a
vitamin B6-dependent enzyme, and remethylation to methionine
requires a vitamin B12-dependent enzyme with folate
as a cofactor. The most common cause of homocysteine
accumulation is a deficiency of folate, vitamin B12
or vitamin B6. The relationships between these nutrients
and homocysteine concentrations have been noted in several
studies and were clearly demonstrated in the Framingham
Heart Study cohort (1,19,20;).
Although there was no specific investigation of the
elderly in the Framingham Heart Study, 29% of patients
aged 67-96 years had high homocysteine concentrations
(>14 ?mol/L), of which 64% were attributed to low
vitamin B status. Assuming that increased vitamin B
levels lead to elevated homocysteine levels, vitamin
B intake is very important for the overall health of
the elderly population. In the Framingham study, dietary
sources of vitamin B6 such as bananas, avocado, beef,
poultry, fish, green leafy vegetables and whole grains
were consumed only once a week.
Generally, the supply of the vitamin B complex also
depends on the individual's activity level. If the energy
intake is low (<8.368 MJ/day), the diet may not provide
the recommended daily intake of vitamins and minerals.
This situation is particularly relevant to the elderly,
who generally are inactive and have decreased lean body
mass and energy intake (15). Therefore, the diet of
the elderly population should be adequate in both quality
and quantity, especially regarding vitamin and mineral
intake. For example, while only a small amount of vitamin
A is required, this vitamin is essential for normal
visual acuity, epithelial cellular integrity, immune
function and gene transcription (21). Dietary vitamin
A is normally provided by preformed retinol (mainly
as retinyl ester) and pro-vitamin A carotenoids. In
this study, the carotenoid was converted to a retinol
equivalent, accounting for the low intake relative to
the RDA (22).
The dietary calcium intake among the elderly was mainly
derived from plants and exceeded 100% of the RDA. This
intake pattern was similar to that seen by Oguntona
et al. (23) in a dietary assessment of the elderly in
a rural Nigerian community. Dietary calcium of plant
origin has not been implicated in either hypercalcaemia
or ailments due to poor bioavailability (24,25). Calcium
intake in this study fell within the intake range of
most countries as reported in the National Health and
Nutrition Examination Survey (477 to 895 mg; (24). Higher
calcium intake in these elderly individuals was positively
correlated with a higher health status score (r=0.23,
p<0.05). These results confirm the findings of Delmas
and Fraser (24), who demonstrated that calcium intake
is important for bone health in the elderly, helping
to reduce hip and spine fractures.
Conclusions and Recommendations
While the institutionalised elderly in Lagos are not
deficient in energy, their diet does not provide adequate
amounts of B vitamins, especially B6, biotin, thiamin
and riboflavin. In addition to a monotonous diet, the
majority of the elderly do not receive an adequate amount
of physical activity.
Food intake should contain ample amounts of vitamins
and minerals. For example, whole grains such as unpolished
rice and enriched fortified maize (ogi) are preferred
to refined grain products since the former provide adequate
amounts of the B vitamins. As cereals comprise the bulk
of the diet of elderly people, the inadequacy of refined
grain products puts many of the elderly at risk for
malnutrition. For the institutionalised elderly to maintain
a healthy BMI, fat and oil intake must be regulated.
Fats, oils and sweets should be used sparingly. Older
adults need approximately 1,600 calories per day. Proper
nutrition should be combined with physical activity
or exercise to maintain a healthy weight, prevent mobility
problems, and decrease the risk of heart disease, arthritis,
cancer and other health problems. The elderly should
choose fruits and vegetables that are deeply coloured
in order to obtain sufficient amounts of vitamin A,
folate and antioxidants. Emphasis should also be placed
on low-fat dairy products to provide adequate amounts
of calcium and vitamin D. Within the nutrient-rich meat,
poultry, fish, dried beans, eggs and nuts food group,
variety is important, with individual choices being
made according to availability, affordability, chewability,
physiological status, individual preference and ease
of preparation. Consumption of foods high in dietary
fibre should be stressed, and the fluid intake of elderly
people should be monitored closely as their thirst sensation
is decreased.
The institutionalised elderly should be encouraged to
eat together and must be informed about their nutritional
needs, especially where they differ from other age groups.
Caregivers and nurses must properly convey nutritional
messages to the elderly and allow them to help plan
meals. The health and nutritional status of the elderly
must be monitored before admission to a home as well
as during their stay. The entire staff caring for the
elderly in institutions must be trained in the nutritional
needs of the elderly residents and have nutrition qualifications
commensurate with their job. All members of the community
involved in providing services to older people, whether
they are domiciliary care workers, social workers, or
informal caregivers, should also be educated on the
unique dietary needs of the elderly. Such widespread
education will improve both the length and quality of
life of the elderly population.
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