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Heliyon 8 (2022) e08947
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Heliyon
journal homepage: www.cell.com/heliyon
Research article
Assessment of dietary habits, nutritional status and common health
complications of older people living in rural areas of Bangladesh
Arafat Hassan Razon, Md.Imamul Haque, Md.Foyaj Ahmed, Tanvir Ahmad*
Department of Nutrition and Food Technology, Jashore University of Science and Technology, Bangladesh
ARTICLEINFO ABSTRACT
Keywords: Background: Old age is one of the vulnerable and prone stages in terms of health status. So this study aimed to
Malnutrition assess the nutritional status and common health complications of older people.
Nutritional status Methods: Simplified Nutritional Appetite Questionnaire (SNAQ), Anthropometric measurements, Diet History
Dietary knowledge Method, and Mini Nutritional Assessment (MNA) tools were used to measure the nutritional status. Data were
Simplified Nutritional Appetite Questionnaire analyzed by using Statistical Package for Social Science (SPSS) version 16.
(SNAQ) Results: Out of the total 320 elderly participants the mean SD value for the age of male and female was 67.25
6.5 and 67.32 7.7 years respectively. According to BMI classification, it was noticed that with advancing age the
percentage of underweight was also increased such as for 60–75 years old age group the underweight percentage
was 30.0% where for 76 to 85 and >85 years old age group the underweight percentage was 45.0% and 60.0%
respectively. According to the MNA score, 97 elderly respondents were malnourished and a total of 172 re-
spondents had SNAQ scores below 14. This study found a statistically significant (P < 0.05) correlations among
various health complications with nutritional status according to MNA score. In addition 56.6% (OR ¼ 1.24, 95%
CI ¼ .799–1.939), 63.8% (OR ¼ 1.18, 95% CI ¼ .745–1.857) and 64.7% (OR ¼ 1.14, 95% CI ¼ .720–1.804)
respondents had diabetes mellitus, hypertension and cardiovascular disease respectively. The risk of musculo-
skeletal pain (OR ¼ 1.073, 95% CI ¼ .684–1.681), bedsore (OR ¼ 1.884, 95% CI ¼ .903–3.934) and decreased
sense of thirst (OR ¼ 1.278, 95% CI ¼ .821–1.991) were higher among females than males. A little number of the
elderly used to take milk, meat, and fish daily.
Conclusion: During this cross-sectional study, significant correlations among nutritional changes with health
complications were determined. To prevent malnutrition among the elderly a proper health policy as well as
periodical nutritional screening should be conducted.
1. Introduction world population may have age above 60 years. So worldwide it will be
increased from 6.9% to 12% but in Asia 6%–12% [4]. In Bangladesh
It is very important to maintainahealthynutritionalstatusatanyage. people who has age 60 years and above is considered an elderly person
As a result, geriatric nutrition is the nutrition that helps to minimize the [5]. The aging of the population is now a global issue and this is also an
effects of aging and diseases as well as it helps to manage the physical, emerging issue in Bangladesh [6]. It was evident that in Bangladesh the
psychological and psychosocial states of the elderly population [1]. The number of older people aged 60 and above was around 9.41 million in
elderly population may be defined as those populations whose age is 2007 and this increasing tendency of older people was started in
greater than 65 years of age. The elderly can be classified into two types Bangladesh from 1951 [7, 8]. Throughout the world, twenty countries
such as early elderly (between 65 to 74 years of age) and late elderly have the highest elderly population and Bangladesh is one of them. It is
(above 75 years of age) [2]. In developing countries, it is very important predicted that Bangladesh will achieve 44% of the world's elderly pop-
to conduct more research to assess the nutritional status of the aging ulation by 2025 [9]. Among the 160 million population of Bangladesh,
population. To guide community awareness and interventions the in- about7%ofthepopulationhasagedover60yearsanditwillriseto16%
ternational dietary guidelines for older populations are required [3]. It by 2050. The female elderly population is more malnourished than the
has been predicted that from 2000 to 2030 about 550–930 million of male elderly population in Asian countries. But as a whole, both groups
* Corresponding author.
E-mail address: fmtanvir@gmail.com (T. Ahmad).
https://doi.org/10.1016/j.heliyon.2022.e08947
Received 10 September 2021; Received in revised form 9 December 2021; Accepted 9 February 2022
2405-8440/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A.H. Razon et al. Heliyon 8 (2022) e08947
are highly vulnerable to malnutrition [10]. Due to extreme poverty the 2.4. Data collection techniques
majority of older people in Bangladesh are unable to meet their nutri-
tional requirements and this is a common scenario of poor families living ThestudywasconductedfromSeptember2019toFebruary2020and
inbothurbanandruralareas[11,12].Themajorityoftheolderpeoplein data were collected from November 2019 to December 2019 through a
Bangladesh have very poor socio-economic conditions because of simple random sampling method. The study was conducted using the
poverty, wage discrimination, want of essential goods and commodities, direct survey method PAPI (Paper and Pen Personal Interview). The
shelter, and compulsory retirement from the job when the age limit is sample size of this study was calculated through the use of an equation
attained [13]. The nutritional status and food intake pattern of the older [1] and that equation [1] was previously used in a similar study like this
people can be affected by various changes such as physical, psychologi- [4].
cal, social, or health-related changes. Despite these changes, proper N¼Z2 2
nutrition and a healthy lifestyle can only improve the nutritional status pq/d (1)
and quality of life among the elderly population [14]. Several studies Here, Z ¼ 1.96, p ¼ 0.5 (as no study found), q ¼ 0.5 and d ¼ 0.05. Ac-
foundsomemedicalcomplicationsassociatedwitholderpeople.Astudy cording to this equation [1] the sample size was approximately 384 but
foundthatahugenumberofolderpeoplehadmedicalcomplicationslike duetolackoffundingandtimeconstrainonly320sampleswereincluded
cataracts, joint pain, hypertension, diabetes mellitus, etc [15]. To mini- in this study. After calculating the approximate sample size for this study
mize the adverse nutritional outcome it is very important to conduct a the above-mentioned villages were selected purposively because these
nutritional assessment in older people to detect malnutrition. BMI is one villages were situated near Jashore city and it was very easy as well as
of the most popular nutritional assessment tools and it is measured by economical to reach these villages. Then through a simple random
usingtheweightandheightofapersonandisexpressedasKg/m2.Itcan samplingmethod,therequireddatawerecollectedfromtheolderpeople
be used in many nutritional screening programs and it is an appropriate of each village and these villages were visited according to their alpha-
2
identifier of malnutrition. A person having a BMI below 18.5 kg/m is betical order. As this study followed a simple random sampling method
consideredundernourishedormalnourished[16,17].Anothersimplified that's why data were collected randomly from each villages and at the
nutritional screening tool is Mid Upper Arm Circumference (MUAC) and end of the data collection period a total of 320 data were gathered from
whichcanbeusedasanidentifierforthehealthandnutritionalstatusof these villages.An instrument was developed by the researchers to collect
elderly individuals [18, 19, 20]. Among the various nutritional assess- the socio-economic, socio-demographic, anthropometric, and dietary
menttools"MiniNutritional Assessment" (MNA)toolis one of them. The history data. Weight was measured using a digital scale (Soehnle; CMS,
development of the MNA tool was started in 1989 in a meeting of the London,UK)andheightwasmeasuredusingastadiometer(CranleaLtd,
"International Association of geriatrics and Gerontology" (IAGG). Older Birmingham, UK). The questionnaire was prepared in English version
people can be classified as nourished, at risk for malnutrition, or and it was translated into local language (Bengali version) so that the
malnourished through the MNA tool. MNA is performed in a two-step respondents could easily understand all the questions. Before the start of
process to assess the nutritional status. About 10–15 min are required
the interview all the questions were described properly to the re-
to perform a complete MNA [21]. Another nutritional assessment tool is spondents by the interviewers as majority of the study participants were
the "Simplified Nutritional Appetite Questionnaire” (SNAQ). It was
illiterate. An inelastic steel Mid Upper Arm Circumference (MUAC) tape
invented in 2005 by the Council for Nutritional Strategies. It is usually wasusedtomeasuretheMUACofeveryparticipant.Datawerecollected
used to predict weight loss which is a common condition and always a regularly until the targeted sample size was obtained.
serious event in older people [22]. As older people are very much
vulnerable to nutritional deficiency diseases so this study has utilized 2.5. Variables
various nutritional assessment tools to assess the nutritional status and
common health complications among the elderly population of a rural The socio-demographic features (such as age, sex, educational level,
area in Jashore, Bangladesh. occupation, marital status, monthly family income level, family type),
2. Materials and methods morbidity related characteristics (visual impairment, hearing problem,
musculoskeletal pain, bedsore, food allergy, sense of thirst, dental pros-
2.1. Study design thesis, diabetes mellitus, hypertension, cardiovascular disease), physical
status related characteristics (neuropsychological status, mobility state,
A cross-sectional study was conducted to describe the nutritional digestive problem, loss of weight), anthropometric measurements
status and common health complications among elderly individuals (60 (height, weight, body mass index, mid-upper arm circumference), mini
years old or older) living in rural areas of jashore city under randomly nutritional assessment score (MNA), simplified nutritional appetite
selected villages such as Islampur, Dogachia, Shamnagar, Belermath, questionnaire (SNAQ) and dietary history and habits of elderly (milk
Kamlapur, Jogahati, Saziali, Abdulpur, and Vogolpur. intake, legumes, and egg, meat and fish, fruits and vegetables, meals,
fluid intake, drug intake) were assessed to investigate the research
objective. As majority of study participants lived in joint family that's
2.2. Population why study data were collected from the care givers (son, daughter and
wife) of older people who had dementia. During appetite measurements
The study was carried out through the inclusion of individuals aged of patients with mild dementia, opinions of the patients were prioritized
60 years or older that lived in the above-mentioned villages. Moreover, over the opinions of their caregivers, but for patients with severe de-
320 elderly individuals were included in this study. mentiaopinionsofthecaregivers,wereprioritizedoverthepatient'sown
estimation.
2.3. Eligibility criterias
2.6. Dietary and anthropometric measurements
Those eligible to participate in the study were individuals of both
sexes, aged 60 years living in rural areas under the above-mentioned Dietary intake was assessed by the diet history method [23]. This
villages of Jashore city who agreed to participate in the research. The method was used for the analysis of food intake habits by the partici-
exclusion criteria comprised: those who disagreed to give consent; geri- pants. The participants were asked about their food consumption habits
atric individuals who were not willing to give an interview; seriously ill throughout the day in different periods. The food consumption pattern
people and <60 years old people. was obtained by asking questions on the frequency of daily intake of
2
A.H. Razon et al. Heliyon 8 (2022) e08947
certain food groups, and fluids such as legumes and egg, meat and fish, MUACwasmeasuredtwiceforeachparticipant and their average value
fruits and vegetables, milk and other fluids. Participants were also asked was recorded as the final MUAC. The MUAC measurement procedure
about their medication. The questionnaire included an estimate of the described in the pocket guide to nutrition and diet therapy, 1993, and a
daily consumption (yes or no) of milk, legumes and egg, meat and fish, pocket guide to clinical nutrition was followed in this study [27, 28].
fruits and vegetables, drugs, as well as the approximate number of meals
(2 meals or 3 meals) per day and a total cup of fluid intake (<3 cups, 3–5
cups, and >5 cups) per day. And the dietary intake was analyzed by sex 2.7. Nutritional assessment tools
and age.
Nutritional status was assessed using anthropometric measures TheMiniNutritional Assessment (MNA)toolwasusedtoidentifythe
including weight and height to calculate body mass index (BMI). The nutritional status of the study population. This tool is recognized as a
anthropometric measurements and body composition estimates were gold standard in geriatric nutrition [29]. This tool has a sensitivity of
done in the morning. The weight and height of the participants were 96% and a specificity of 98% [30]. MNA has 18 items such as anthro-
measured at their homes. Weight was measured twice to the closest 0.1 pometric measurements, dietary questionnaires, global health and social
kg with light clothing on and without shoes by digital scale placed on a assessment, and subjective assessment of health and nutrition [31]. The
flat surface. The average of the two measurements was used in the total MNAscorerangesfrom0to30.TheMNAscore24recognizesthe
analysis. Stadiometer was used to measure the height of the respondents elderly participants as good nutritional status, the score between 17 to
withoutshoesandheight(tothenearest0.1cm)wasmeasuredtwicefor 23.5 means at risk of malnutrition, and MNA score less than 17 recog-
each respondent. The average of the measurement was used in the nizes protein caloric malnutrition [32].
analysis. The weight and height of each respondent were measured on SNAQ is another nutritional assessment tool that was used in this
their empty stomach and the respondents did not perform any stretching study. The SNAQtoolwasusedinthisstudybecauseitisestablishedasa
exercises before giving the measurements. BMI was calculated as weight morereliabletoolforsubjects60yearsandaboveage.SNAQtoolconsists
2 of appetite, hunger, and sensory perception questionnaire [33]. SNAQ
(kg)/height (m ). Here in this study, Asian BMI cut-offs were used to
definethe nutritional status of the study participants. So based on Asian contains 4 questions and these questions were asked to the study par-
BMI cut-offs, the nutritional status was defined as underweight (<18.5 ticipants during the interview. Eachquestionconsistsoffiveoptionssuch
2 2 2 as A, B, C, D, and E. Answers were scored based on the following nu-
kgm ), normal (18.5–22.9 kgm ), overweight (23–24.9 kgm ), pre-
2 2 mericalscale:A¼1,B¼2,C¼3,D¼4,andE¼5.ThetotalSNAQscore
obese (25–29.9 kgm ), and obese (30 kgm )[24]. For participants
whowerechair or bedridden as well as had curved spines, their height, was calculated by adding the scores for each question. The range of the
total SNAQscoreis4–20.TheSNAQscore<14meansasignificantriskof
and weight could not be measured through the height and weight scale.
So their knee height (KH) was used to calculate their actual height. The weight loss >5% within 6 months with a sensitivity of 81.5% and a
kneeheightwasmeasuredontheleftlegofeachparticipantandasimple specificity of 76.4% [34].
measuring tape was used to estimate the knee height. The knee height
measurementwastakentwiceforeachparticipantandtheaverageofthe 2.8. Ethical approval and consent to participate
measurementwasusedtomeasuretheheightofthechairorbedriddenas
wellascurvedspinepatients.Thefollowingequations[2,3]wereusedto The Ethical Review Committee, Faculty of Biological Science and
measure the height of the immobilized respondents [25]: Technology, Jashore University of Science and Technology Jashore,
Height (cm) ¼ [2.03 KH (cm)] – [0.04 Age (years)] þ 64.19 (men) (2) Bangladesh gave the ethical approval to conduct this study. The study
Height (cm) ¼ [1.83 KH (cm)] – [0.24 Age (years)] þ 84.88 (women) (3) participants were reassured by the researchers that their names would
notberecordedandmentionedinthisstudy.Anopportunitywasgivento
To measure the weight of immobilized respondents the following the respondents to ask any question regarding this study and they could
anthropometricmeasureswerecollectedtwicefromeachrespondentand leaveorstoptheinterviewatanymomenttheywished.Writteninformed
the average of each anthropometric measure was used to calculate the consentofeachoftheparticipantswasobtainedbeforedatacollectionby
weight of the immobilized participants. Calf circumference (CC), knee explaining the purpose and methods of the study, risks, and benefits of
height (KH), arm circumference (AC) were measured by using an in- participation in the study.
elastic steel measuring tapeandsubscapularskinfoldthickness(SST)was
measured through a Lange skinfold caliper (Beta Technology Inc, USA). 2.9. Data quality control
After estimating these anthropometric measures the following equations
[4, 5] wereusedtoestimatetheweightofimmobilizedrespondents[26]: Atrainingregardingthestudyobjectiveanddatacollectiontoolswas
Weight (kg) ¼ [0.98 CC (cm)] þ [1.16 KH (cm)] þ [1.73 AC (cm)] þ undertakenduringthestudy. Informationaboutessential technical skills
[0.37 SST (mm)] – 81.69 (men) (4) required to collect anthropometric measurements, diet history, simpli-
fied nutritional appetite, and MNA also comprised part of the training.
Weight (kg) ¼ [1.27 CC (cm)] þ [0.87 KH (cm)] þ [0.98 AC (cm)] þ During this study, proper checking and supervision of the data for con-
[0.4 SST (mm)] – 62.35 (women) (5)
sistency and completeness were carried out.
MUACtapewasusedtomeasurethemid-upperarmcircumferenceof 2.10. Statistical analysis
the participants. To measure the MUAC of each respondents the MUAC
tapewhichwasprovidedbyACF(ActionContrelaFaim)Bangladeshwas The collected data were analyzed by using SPSS (Statistical Package
used in this study. The participants were asked to bend their non- for the Social Sciences) version 16 (SPSS Inc., Chicago, USA). Proper
dominant arm at a right angle with the palm up. The distance between parametric and nonparametric analysis was performed. Parametric
the acromial surface of the scapula and the olecranon process of the analysis was performed for continuous variables and nonparametric
elbow on the back of the arm was measured. The midpoint of that dis- analysis was performed for categorical variables. Continuous variables
tance was pointed with a pen and the participants were asked to let the werepresentedasmeanstandarddeviation(SD)whereapplicableand
arm hang loosely by his/her side. After that, the MUAC tape was posi- categorical variables were expressed as the number and the percentage.
tioned at the midpoint on the upper arm and tightened snugly. The Chi-square test and odds ratio (OR) with 95% confidence intervals (CIs)
measurement was recorded in centimeters (cm) to the nearest 0.05 cm. were also performed. P < 0.05 was considered statistically significant.
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A.H. Razon et al. Heliyon 8 (2022) e08947
3. Results
Table1.Socio-demographicandSocio-economicprofileoftherespondents(N¼
320). 3.1. Study population
Characteristics Male Characteristics Female
Age in year Age in year The present study involved 320 participants. Demographic charac-
Mean SD 67.25 6.5 Mean SD 67.32 7.7 teristics of the study participants are presented in Table 1. Most of the
N% N% participantsweremale(53.4%)andtheir mean (SD) age was approxi-
Male sex 171 53.4 Female sex 149 46.6 mately 68 (6.5) years. In addition, the majority of the study participants
Marital status Marital status lived in a joint family which was almost 61% and 57% for males and
Married 127 74.3 Married 93 62.4 females respectively. Regarding educational background most of the re-
Widow 44 25.7 Widow 56 37.6 spondents were illiterate and the percentage of illiteracy among women
Family type Family type (65.8%) was significantly higher than that among men (57.9%). In
Nuclear 67 39.2 Nuclear 64 43.0 addition, a high proportion of the study participants were farmers where
Joint 104 60.8 Joint 85 57.0 62.0% and 66.4% of male and female respondents respectively had
Educational Educational level monthly family income between 1 to 5000 taka.
level
Illiterate 99 57.9 Illiterate 98 65.8 3.2. The dietary habit of the respondents
Primary 45 26.3 Primary 41 27.5
Secondary 20 11.7 Secondary 7 4.7 Table2summarizestheparticipant'sdietaryhabitsaccordingtotheir
College/University 7 4.1 College/University 3 2.0 sex and age group. The participants were categorized according to their
sex(maleorfemale)andagegroupintheyear(60–75,76–85,and>85).
Employment Employment
Business 14 8.2 Business 17 11.4 Almost 75% male and 70% female respondents ate legumes and eggs
Salary 3 1.8 Salary 3 2.0 daily as well as 97.1% male and 99.3% female respondents ate fruits and
Farming 105 61.4 Farming 84 56.4 vegetables daily. However, the intake of milk, meat, and fish was
Labour 20 11.7 Labour 21 14.1 significantlyloweramongbothmalesandfemales.Theestimatedperday
Nocash income 26 15.2 Nocash income 22 14.8 drug intake for participants (n ¼ 290) aged between 60-75 years was
Noanswer 3 1.8 Noanswer 2 1.3 58.3% and approximately 94% of respondents who had an age between
Family income monthly Family income monthly 60-75 years took three meals a day. The fluid intake pattern was signif-
1-5000 taka 106 62.0 1-5000 taka 99 66.4 icantly lower with the increasing age of the respondents.
5001-15000 taka 37 21.6 5001-15000 taka 23 15.4
>15000 taka 2 1.2 >15000 taka 5 3.4 3.3. Nutritional status among participants of different age groups
Don't know 26 15.2 Don't know 22 14.8
SD ¼ Standard deviation. According to BMI classification (Asian cut-off), only 2 (20.0%) re-
spondentsbelongedtothenormalweightthathadageabove85years.It
Table 2. Dietary habit of the participants (N ¼ 320).
Eating habit/day Gender (N ¼ 320) Age group (Year) (N ¼ 320)
Male (n ¼ 171) Female (n ¼ 149) 60-75 (n ¼ 290) 76-85 (n ¼ 20) >85(n¼10)
Milk intake
Yes 48 (28.1%) 42 (28.2%) 83 (28.6%) 4 (20.0%) 3 (30%)
NO 123 (71.9%) 107 (71.8%) 207 (71.4%) 16 (80.0%) 7 (70%)
Legumes and Egg
Yes 127 (74.3%) 103 (69.1%) 213 (73.4%) 10 (50.0%) 7 (70.0%)
No 44 (25.7%) 46 (30.9%) 77 (26.6%) 10 (50.0%) 3 (30.0%)
Meat and Fish
Yes 67 (39.2%) 38 (25.5%) 96 (33.1%) 5 (25.0%) 4 (40.0%)
No 104 (60.8%) 111 (74.5%) 194 (66.9%) 15 (75.0%) 6 (60.0%)
Fruits and Vegetables
Yes 166 (97.1%) 148 (99.3%) 287 (99.0%) 18 (90.0%) 9 (90.0%)
No 5 (2.9%) 1 (.7%) 3 (1.0%) 2 (10.0%) 1 (10.0%)
Drug intake
Yes 110 (64.3%) 82 (55.0%) 169 (58.3%) 15 (75.0%) 8 (80.0%)
No 61 (35.7%) 67 (45.0%) 121 (41.7%) 5 (25.0%) 2 (20.0%)
Meals
2 meals 18 (10.5%) 4 (2.7%) 19 (6.6%) 2 (10.0%) 1 (10.0%)
3 meals 153 (89.5%) 145 (97.3%) 271 (93.4%) 18 (90.0%) 9 (90.0%)
Fluid intake
<3cups 11 (6.5%) 16 (10.7%) 13 (4.5%) 9 (45.0%) 5 (50.0%)
3-5 cups 77 (45.0%) 53 (35.6%) 123 (42.4%) 5 (25.0%) 2 (20.0%)
>5cups 83 (48.5%) 80 (53.7%) 154 (53.1%) 6 (30.0%) 3 (30.0%)
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