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Assessment of nutrient intake and associated factors in an Indian elderly population.

Introduction

India is a 'mature' community and, with the population above 60 years increasing steadily, by the turn of the century it will become an 'ageing' society |1~. The percentage of persons aged above 60 years in India has risen from 5% in 1931 to 6.5% in 1981 and in 2000 is expected to increase to about 7.4%. Concern for nutrition of elderly people has grown considerably in Western countries. In India, even though the percentage of elderly population is increasing steadily, less attention has been paid so far to the nutritional aspects in the elderly.

Macleod and her colleagues have carried out dietary studies in the UK on elderly people, and their studies indicate apparently inadequate nutrient and energy intake among those individuals |2~. Elderly people are at risk of poor nutrition for a number of reasons including economic pressures, poor dentition, reduced mobility, depression, loneliness, ageing tissues and inadequate food consumption |3~.

In view of these facts, a study was planned with the objective of assessing the relationship between nutrient intake and the education, economic and social factors in the elderly people of India.

Methods

Four hundred and twenty subjects over the age of 60 years were selected from urban and rural populations for the study. The urban subjects were selected from Madras city and the rural from Melmaruvathur village which is 91 km away from Madras. The village is situated on a plain and the main occupation is agriculture. The housing is mainly thatched huts.

The elderly subjects were identified from the voters list and each individual was assigned a number. The required number of subjects was selected without bias using Tippet's sampling table.

With the help of a qualified dietician the dietary pattern, socio-economic profile and nutritional knowledge of the selected subjects were assessed, with an interview schedule summarized in the Appendix. The interview was carried out in the subjects' houses. The measurements of height and weight of all the subjects were recorded. Three day dietary recall data were collected by showing the subjects standardized measuring cups and spoons. From these weights the raw equivalent of the cooked food consumed was computed and the nutritive value of the raw foods consumed was determined using the Food Composition Table which gives the nutritive value of commonly consumed food items |4~. The nutrient intake of the subjects was compared with the Recommended Dietary Allowance for Indians given by the Indian Council of Medical Research |4~.

Results

Of the 420 subjects, 163 were women and 257 men. In India the male population outnumbers the female population. The age range of the subjects in this study was 60-84 years (mean age 65 years). Fifty-seven per cent belonged to the urban community and 43% the rural. The literacy status of the sample is presented in Table I. Most (59.6%) of the elderly men were literate compared with 26.4% of the women. The economic status (Table II) showed that 46.7% belonged to the low income group and 41.2% belonged to the middle income group. The types of families to which the subjects belong are shown in Table III. The traditional joint family system was observed in 37%, nuclear family in 24% and couples living alone in 20.5%.

Among the men, 85.6% were engaged in sedentary work, while 14.4% were engaged in moderate work. Of the 163 women 83.4% were engaged in sedentary work and 16.6% were engaged in moderate work.

Analysis of the meal patterns showed that 76.4% were non-vegetarian and the rest vegetarian. When considering the meal pattern, 82.9% had three meals per day, 13.8% had two meals per day and 3.3% had one meal per day. Their diet was mainly cereal-based. Rice was consumed daily by 95.5% of the subjects. Pulses (63%), vegetables (79.5%), milk and milk products (76.6%), sugar and jaggery (71.9%) and unsaturated fats (81.4%) were consumed daily. Roots and tubers, egg, sea foods, flesh foods, nuts and fruits were rarely present in their diet, as shown in Table IV.
Table I. Literacy status of the group studied
                       Men (n = 257)      Women (n = 163)
Literacy status         No.     %         No.     %
Primary                 62      24.1      32     19.6
Middle School           59      23.0       8      5.0
High School             21       8.2       2      1.2
Graduate                11       4.3       1      0.6
Uneducated             104      40.4     120     73.6
Table II. Monthly income levels of the selected elderly
subjects
                                              No. (%)
Income range                                  (n=420)
Below Rs 1000/-                            196 (46.7)
RS 1000/- to Rs 2000/-                     173 (41.2)
Above Rs 2000/-                             51 (12.1)
Table III. Type of family of the subjects
                                             No. (%)
Type of family                               (n=42)
Subject living alone                        48 (11.4)
Couple living alone                         86 (20.5)
Nuclear family                             101 (24.0)
Joint family                               156 (37.0)
Living with sons/daughters and relatives     28 (6.7)
Living in homes                               1 (0.2)


The weight of 43.8% of the sample was below the ideal weight, whereas obesity was observed only in 9.3%. The caloric intake of 92.6% of men and 94.4% of women was less than the recommended daily allowance (1760 kcal and 1350 kcal, respectively). The average daily TABULAR DATA OMITTED TABULAR DATA OMITTED TABULAR DATA OMITTED intake of calories in the study was 1191 kcal for men and 928 kcal for women. Deficient protein intake was observed in 95% men and 98.7% women, as judged against the Recommended Allowance given by the Indian Council of Medical Research. Calcium intake was adequate in 57.2% of men and 40% of women. Iron was lower than the Recommended Dietary Allowance in 86% and 90% of men and women, respectively.

Vitamin A intake was found to be less than the recommended allowance (2400 |mu~g) in 91.5% of the sample. Vitamin C intake was deficient in 70.8% and 79.5% of elderly men and women, respectively. The average intake in the study was 30 mg/day. The dietary intake of thiamine, riboflavin and niacin was low in 88.7%, 94.2% and 97.5% of the elderly subjects, respectively. Table VI summarizes the daily nutrient intake of the sample. Only 5.5% of men and 4.5 % of women had any knowledge about daily nutrient requirements.
                          Yes     (%)      No      (%)
Foodstuffs               Illit.   Lit.    Illit.   Lit.
Egg                       31       49      10       10
Dhal                      34       54       7        5
Fish and Poultry          31       50      10        9
Milk                      34       52       7        7
Ragi                      34       52       7        7
Groundnuts                31       50      10        9


With regard to the various cooking methods for cereals and vegetables, the water absorption method was adopted by 21% and 24% while the nutritionally less desirable water straining method was adopted by 79% and 76% for cereals and vegetables, respectively. Boiled water was preferred for drinking by only 35%, while 62.5% of the subjects used unboiled water for drinking and 2.5% used filtered water.

When posed the question as to which foodstuffs among a presented list they considered to be nutritious, the answers from illiterate and literate respondents were as shown in Table VII. By |X.sup.2~ test there was no significant difference between literates and illiterates regarding the knowledge of nutritive value of foodstuffs.

Discussion

This study showed that most of the elderly subjects were under weight (43.8%) and this may be attributed to low intake of calories and proteins. The prevalence of obesity was low (9.3%). Energy intake and energy expenditure by elderly people are usually assumed to be much lower than in the young or middle-aged |5~. The low caloric intake of 92.6% of men and 94.4% women in this study may be due to habitual intake of a high carbohydrate diet lacking in protein and fat. The caloric intake of elderly people has uniformly been found to be inadequate |6~. This view is in line with the Household Food Consumption Survey of the US Department of Agriculture, which demonstrated that, as age increased, the mean caloric and nutrient intake decreased |7~.

The Dietary Allowances Committee of the National Academy of Sciences of the USA has recommended a protein intake of 0.8 g/kg body weight for their elderly population |8~. Nitrogen balance studies carried out on elderly subjects in the UK has calculated that protein requirement is about 0.6 g/kg body weight per day |9~. The Indian Council of Medical Research has recommended 1 g of protein per kg body weight for Indian elderly people |4~. Only 8.3% of the subjects in this study ingested recommended dietary allowances of protein (1 g/kg).

Except for calcium, the intake of all nutrients was low in this study. Socio-economic factors such as poverty, illiteracy, lack of nutritional knowledge, and unfavourable domestic circumstances may have affected nutritional status. The calcium intake was adequate in 50.5% of subjects, which may be attributed to sufficient intake of calcium-rich foods such as ragi and green leafy vegetables. Ragi is a cereal which is commonly consumed in South India and is a rich source of calcium; 100 g of ragi contains 344 mg of calcium, whereas the same amounts of wheat and rice contain 41 mg and 9 mg calcium, respectively.

Higher education and higher income were the factors related to a more adequate diet in the Gothenburg studies in elderly men |10~. In a study carried out by Colucci et al., financial problems, educational level/background and home facilities were found to be relevant socio-economic factors |11~. But in the present study the educational status of the elderly subjects does not correlate directly with their nutrient intake. Although 47% of the subjects were literate, more than 80% of the subjects were on low nutrient intake.

Economic pressure plays an important role in determining dietary adequacy |12~. Insufficient income is the chief factor that limits dietary adequacy, which has also been observed in our study, as 88% of our subjects belong to low and middle income groups |13~.

Acknowledgement

We wish to thank Roussel Scientific Institute, India for providing financial support to this study.

References

1. Mansharamani GG. Aging--its magnitude. Proc Int Conf Geriatr Med Gerontol Geriatric Society of India, New Delhi: 1988;20-3.

2. Macleod CC. Dietary intake of older people. Nutrition (Lond) 1970;24:24-9.

3. Thomas A, Bunker VW, Hinks LJ, Sodha N, Mulee MA, Clayton BE. Energy, protein, zinc and copper status of twenty-one elderly inpatients: analysed dietary intake and biochemical indices. BrJNutr 1988;59:181.

4. Gopalan C, Sastri RBV, Balasubramanian SC. Nutritive value of Indian foods. National Institute of Nutrition, Indian Council of Medical Research. Hyderabad: 1989;47-94.

5. Durvin JVGA. Energy intake, energy expenditure, and body composition in the elderly. In: Chandra RK, ed. Nutrition, immunity, and illness in the elderly. Proceedings of the International Conference on Nutrition. Oxford: Pergamon Press. 1985;19.

6. Kohrs MB, O'Hanlon P, Krause G, Nordstron J. The Title VII-- Nutrition Program for Elderly: II. Relationship of socio-economic factors to one day's nutrient intake.JAm Diet Assoc 1979;75:537-42.

7. Household Food Consumption Survey, Food and Nutrient intake of individuals in the United States--Spring. Washington D.C.: Department of Agriculture, Agriculture Research Service Report, 1965.

8. Dietary Allowances Committee and Food and Nutrition Board. Recommended dietary allowances. Washington D.C.: National Academy of Sciences, 1974; Edition 8.

9. Munre HN. In: Carlson LA, ed. Nutrition in old age. Stockholm: Almqvist & Wiksell, 1972.

10. Steen B, Isaksson B, Svanborg A. Intake of energy and nutrients and meal habits in 70 year old males and females in Gothenburg, Sweden: a population study. Acta Med Scand 1977;(suppl 611):39-86.

11. Guthrie HA. Introductory nutrition. 6th edn. St Louis and Toronto: Times Mirror/Mosby College Publishing, 1986;593-602.

12. Robinson CH, Lawler MR. Normal and therapeutic nutrition. 16th edn. New Delhi: Oxford and IBN Publishing Co. Pvt. Ltd., 1982;383,387.

13. Colucci RA, Bell SJ, Blackburn GL. Nutritional problems of institutionalized and free-living elderly. Compr Ther 1987;13:20-8.

Appendix

Interview Schedule

Name, address, sex, age, data urban/rural residence Education (primary school, middle school, high school, graduate, uneducated)

Occupation, nature of regular work (sedentary, moderate, heavy)

Economic status (retired, working, pensioner)

Income (annual, monthly, weekly, daily for each member of family unit)

Family status (joint family, nuclear family, couple living alone, single)

Smoking (yes/no, number of cigarettes per day, regularly, occasionally)

Alcohol, tobacco, betel (yes/no, regularly, occasionally)

Three-day dietary recall (early morning, breakfast, lunch, tea, dinner, bedtime)

Preferred food items (daily, alternate days, weekly, occasionally, never): rice, wheat, ragi, pulses, roots and tubers, other vegetables, greens, eggs, seafoods, meat, fruits, milk and milk products, nuts, sugar and jaggery, fat (hydrogenated), cooking oil (unsaturated)

Preferred preparations (bland, hot and spicy, sweets, fried foods, salty foods)

Preference for food form (liquid, semi-solid, soft, solid, crunchy)

Place of consumption (only house, only outside, both) Knowledge of nutrition

Cooking methods for cereal and vegetables (water absorption, water strained, other)

Washing of vegetables (before cutting, after cutting)

Vegetable size (large, small); peeling (yes, no) Knowledge of daily allowances (yes, no)

Drinking water (boiled, unboiled, filtered)

Foods considered nutritious by the subject (egg, dhal, fish, milk, ragi, groundnuts, others-specify)
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Author:Natarajan, V.S.; Ravindran, Shanthi; Sivashanmugam; Thyagarajan; Kailashi, Karthik; Krishnaswamy, B.
Publication:Age and Ageing
Date:Mar 1, 1993
Words:2197
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