© Borgis - New Medicine 4/2010, s. 133-137
*Márta Veresné Bálint, Istvánné Németh, Adrienn Lichthammer, Erzsébet Pálfi, István Szabolcs
Malnutrition and nutrient intake values in the hungarian elderly
Department of Dietetics and Nutrition Sciences, Faculty of Health Sciences, Semmelweis University Budapest, Hungary
Head: prof. dr István Szabolcs
Summary
Introduction. Both obesity and malnutrition are health risks for the elderly, and deficiencies of certain vitamins and minerals also frequently occur.
Aim. The aim of this survey was to assess and analyse nutritional status, occurrence of malnutrition, and the nutrient intake of elderly persons over 55 years of age.
Material and method. Anthropometric data from 327 elderly persons were collected, and the Mini Nutritional Assessment (MNA) questionnaire was used to screen for malnutrition. Nutrient intake was assessed by 24-hour recall, and a nutrient calculator (NutriComp) was also used. The data were analysed using SPSS 15.0 software.
Results. According to MNA a quarter (25.07%) of participants were found to be either malnourished or to be at high risk of it, but ? interestingly ? only 3.98% of those had a subnormal BMI. On the other hand, a third of the subjects (31.19%) were obese (with BMI > 30 kg/m2). Total energy intake in both genders was lower than recommended (8943 kJ for men and 7493 for women versus 10450 kJ recommended). Fat energy and sodium intake were higher, while carbohydrate, calcium, vitamin D, C, folate and dietary fibre intake were lower than recommended. Overall daily fluid consumption, which is important for the elderly, fell below the desirable level.
Conclusions. In the Hungarian elderly, a relatively high risk of malnutrition and imbalance of nutrient intake (sodium excess and insufficiency of fluid, dietary fibre, calcium, vitamin D, and folate) was found and should be corrected.
INTRODUCTION
By 2050 the number of European citizens over 65 years of age is expected to rise by 70%, and the number of octogenarians by 170% ? a serious challenge for the Europe of the 21st century (1). In Hungary in 2009 the proportion of the population over 65 years old was 16.3% (2). Unfortunately, the life expectancy and healthy life span of this age group are lower than the European average.
In old age loss of lean body mass and increase of fat content occur, leading to a slowing down of the metabolism. Due to this and the more inactive lifestyle, there is a decrease in the energy requirement which ? with unchanged appetite ? results in body mass increase. On the other hand, malnutrition caused by poor appetite due to impaired taste and smell, or by difficulties with chewing and swallowing, is also frequent. In addition, disturbed nutrient absorption may lead to deficiencies of certain vitamins (D, B12) and minerals (calcium) (3).
Therefore, the assessment of dietary patterns and nutrient intake in the Hungarian elderly with the aim of proposing and introducing modern, balanced nutrition sustaining health and quality of life is a professional and social responsibility.
AIM
The aim of the survey was to assess and analyse nutritional status, occurrence and risk of malnutrition and obesity, and nutrient intake values for home-living or institutionalized Hungarian persons over 55 years of age, and to identify nutrition-related risks which could hinder ?successful aging?.
MATERIAL AND METHOD
The survey was carried out in 2008-2009 on 327 volunteers over 55 years old, living independently or in institutions of community care. Gender, living status, education and age subgroups are shown in table 1.
Personal and anthropometric data were obtained by a questionnaire containing both open and closed questions. To screen malnutrition, the Mini Nutritional
Assessment (MNA) developed for the elderly was used (4). Nutrient intake was examined by 24-hour recall plus the NutriComp nutrient calculator. Data processing and analyses were done using SPSS 15.0 statistical software.
RESULTS
25.07% of subjects were found to be malnourished or at high risk of malnutrition according to the Mini Nutritional Assessment questionnaire (see table 2). Note that malnutrition was more frequent in the institutionalized versus home-living elderly and in the capital of Hungary versus the countryside.
Table 1. Data of examined subjects (N = 327).
| | N | % |
| Gender | men | 91 | 27.8 |
| women | 236 | 72.2 |
| Residence | Budapest | 145 | 44.3 |
| country | 182 | 55.7 |
| Institutionalized or home-living | institutionalized | 116 | 35.5 |
| home-living elderly | 211 | 64.5 |
| Education | higher educated | 118 | 36.1 |
| secondary or lower educated | 209 | 63.9 |
| Age (years) | 55-65* | 62 | 19.0 |
| 65-75 | 142 | 43.4 |
| 75-85 | 106 | 32.4 |
| 85 ł | 17 | 5.2 |
*Late middle age
Table 2. Evaluation of the Mini Nutritional Assessment (MNA) (N = 327).
| | Normal nutritional status1 (by screening) | Normal nutritional
status2 (by total score) | At risk of
malnutrition3 (by total score) | Malnourished4 (by total score) |
| N | % | N | % | N | % | N | % |
| Institutionalized or home-living | institutionalized | 65 | 56.03 | 1 | 0.86 | 37 | *31.90 | 13 | 11.21 |
| home-living elderly | 177 | 83.89 | 2 | 0.95 | 24 | 11.37 | 8 | 3.79 |
| Age (years) | 55-65 | 45 | 72.58 | . | 0.00 | 13 | 20.97 | 4 | 6.45 |
| 65-75 | 113 | 79.58 | 3 | 2.11 | 16 | 11.27 | 10 | 7.04 |
| 75-85 | 77 | 72.64 | . | 0.00 | 26 | 24.53 | 3 | 2.83 |
| 85 ł | 7 | 41.18 | . | 0.00 | 6 | 35.29 | 4 | 23.53 |
| Residence | Budapest | 101 | 69.66 | 1 | 0.69 | 31 | 21.38 | 12 | **8.28 |
| country | 141 | 77.47 | 2 | 1.10 | 30 | 16.48 | 9 | 4.95 |
| Total | 242 | 74.01 | 3 | 0.92 | 61 | 18.65 | | 6.42 |
1. > 12 points: normal ? not at risk ? no need to complete assessment
2. > 23.5 points: (screening assessment points) ? normal
3. 17-23.5 points: (screening assessment points) ? at risk of malnutrition
4. < 17 points: (screening assessment points) ? malnourished
*p < 0.001 versus home-living elderly
**p = 0.014 versus countryside
Based on the body mass index (BMI) (tab. 3 and 4) only 3.98% of participants were found to be malnourished
(BMI < 20 kg/m2), which reflects significant divergence from the MNA results. As MNA was developed to study the elderly age group, its results may be more appropriate to be taken into account. There was no gender-related difference in the BMI distribution but 31.19% of the investigated elderly subjects were found to be obese (BMI > 30 kg/m2),
which occurred more frequently in the age group of
65-75 years than in younger or more advanced age.
Table 3. Distribution of BMI by gender (N = 327).
| | N | Min | Max | Mean | Median | Std |
| BMI (kg/m2) | Gender | men | 91 | 14.69 | 40.27 | 27.15 | 26.57 | 4.67 |
| women | 236 | 14.52 | 56.51 | 28.31 | 27.99 | 6.03 |
Table 4. Distribution of BMI by age (N = 327).
|
BMI
| Age (years) | Total |
| 55-65 | 65-75 | 75-85 | 85 ? |
| < 20 | N (%) | 6 (1.83) | 5 (1.53) | 1 (0.31) | 1 (0.31) | 13 (3.98) |
| 20-30 | N (%) | 38 (11.62) | 86 (26.30) | 77 (23.55) | 11 (3.36) | 212 (64.83) |
| > 30 | N (%) | 18 (5.50) | *51 (15.60) | 28 (8.56) | 5 (1.53) | 102 (31.19) |
| Total | N (%) | 62 (18.96) | 142 (43.43) | 106 (32.42) | 17 (5.20) | 327 (100.00) |
*p = 0.038 versus other subgroups
The analysis of nutrient intake values (tab. 5) showed that total energy intake in the elderly is lower than recommended and lower in females than males. On the other hand, the fat energy % was higher than recommended, without a gender-related difference. Elderly people with a higher education level had a more favourable distribution of fatty acid intake (not shown in the tables).
Cholesterol intake was adequate, but the most advanced age group showed a significant surplus (p = 0.038).
Carbohydrate rate was lower than recommended for the age groups, but it is beneficial that the quantity of added sugar did not exceed the allowed limit. Interestingly, those in community care had higher sugar consumption (p = 0.012) than people living in their own homes.
In both genders the consumption of dietary fibre was lower than recommended (tab. 5).
Table 5. Distribution of energy and macronutrient consumption by gender (based on 24-hour recall) (N = 137).
| | N | Min | Max | Mean | Median | Std | 1Recommended nutrient values |
| Energy (kJ) | m | 41 | 4534.08 | 17791.69 | 8943.21 | 8452.36 | 3150.048 | 10450 |
| w | 96 | 2042.64 | 19575.44 | *7493.71 | 7130.87 | 2828.539 |
| Protein 2(E%) | m | 41 | 6.62 | 21.46 | 15.31 | 15.03 | 3.342 | 13 |
| w | 96 | 6.58 | 26.41 | 14.71 | 14.10 | 3.318 |
| Fat (E%) | m | 41 | 4.01 | 45.91 | 31.74 | 32.07 | 9.894 | 30 |
| w | 96 | 15.10 | 81.91 | 35.39 | 33.53 | 10.034 |
| 3SFA (E%) | m | 41 | 0.59 | 17.55 | 9.27 | 9.15 | 3.831 | 10 |
| w | 96 | 4.18 | 28.71 | 10.93 | 10.12 | 4.034 |
| 4MUFA (E%) | m | 41 | 0.54 | 18.53 | 10.13 | 9.41 | 4.437 | 12 |
| w | 96 | 3.48 | 35.73 | 11.29 | 9.98 | 4.649 |
| 5PUFA (E%) | m | 41 | 0.36 | 13.44 | 7.78 | 8.16 | 3.271 | 6-8 |
| w | 96 | 1.25 | 15.16 | 8.20 | 8.24 | 2.821 |
| n6/n3 | m | 41 | 5.55 | 62.82 | 31.73 | 31.15 | 16.535 | 40-50 |
| w | 96 | 4.01 | 308.37 | 31.18 | 27.13 | 32.065 |
| Cholesterol (mg) | m | 41 | 61.98 | 673.06 | 286.92 | 249.30 | 158.936 | < 300 |
| w | 96 | 33.71 | 807.20 | 247.08 | 204.74 | 147.898 |
| Carbohydrates (E%) | m | 41 | 32.11 | 81.94 | 50.64 | 48.68 | 11.192 | 57 |
| w | 96 | 11.12 | 71.97 | 49.38 | 50.62 | 9.788 |
| Added sugar (E%) | m | 41 | 0.00 | 50.49 | 7.03 | 4.62 | 8.353 | < 10 |
| w | 96 | 0.00 | 29.52 | 5.76 | 4.91 | 5.009 |
| Dietary Fibre (g) | m | 41 | 7.17 | 44.95 | 21.16 | 20.28 | 7.536 | ł 25 |
| w | 96 | 4.51 | 42.39 | 21.00 | 20.08 | 7.265 |
1. Recommended energy and nutrient intake for over 60 year-olds ? Source: Rodler I. (ed): Hungarian Nutrient Data Bank, Medicina Könyvkiadó Rt., Budapest, 2005
2. %E = % of total energy;
3. SFA = saturated fatty acid;
4. MUFA = monounsaturated fatty acid;
5. PUFA = polyunsaturated fatty acid.
*p = 0.012 versus men
As for micronutrients (tab. 6), the survey showed that sodium intake surpassed the recommended rate in both sexes but was higher in men than women (p = 0.006) and in the subgroup of elderly with lower education (p = 0.045). Calcium and vitamin D intake was significantly lower than needed but those in community care had higher values (p = 0.032). Iron intake was acceptable. Vitamin B12 consumption of women did not reach the recommended value while for men and for the home-living elderly the intake was acceptable (p = 0.002). Vitamin C consumption was less than recommended, but higher in the subgroup of home-living elderly (p < 0.001). Folate intake was well below the recommended value (tab. 6).
Table 6. Distribution of micronutrients, alcohol, caffeine, and fluid consumption by gender (based on 24-hour recall)
(N = 137).
| | N | Min | Max | Mean | Median | Std | 1Recommended nutrient values |
| Na (mg) | m | 41 | 1758.66 | 9828.71 | *4866.33 | 4554.62 | 1950.468 | Ł 2000 |
| w | 96 | 500.33 | 10071.29 | 3860.88 | 3687.12 | 1506.822 |
| Ca (mg) | m | 41 | 160.95 | 1778.35 | 587.37 | 559.72 | 338.423 | 1000 |
| w | 96 | 95.09 | 1625.39 | 589.65 | 543.01 | 290.484 |
| Mg (mg) | m | 41 | 116.75 | 585.90 | 322.36 | 305.36 | 119.506 | 350 |
| w | 96 | 110.87 | 695.29 | 315.20 | 303.49 | 108.052 | 300 |
| Fe (mg) | m | 41 | 3.21 | 16.88 | 9.20 | 9.35 | 3.262 | 10 |
| w | 96 | 1.86 | 20.99 | 7.79 | 7.15 | 3.123 | 8 |
| Vitamin B12 (?g) | m | 41 | 0.33 | 11.06 | **2.23 | 1.98 | 1.745 | 2.0 |
| w | 96 | 0.00 | 5.85 | 1.67 | 1.59 | 0.922 |
| Vitamin C (mg) | m | 41 | 4.29 | 368.98 | 78.88 | 40.99 | 83.286 | 90 |
| w | 96 | 2.75 | 436.79 | 85.06 | 64.35 | 71.588 |
| Vitamin D (?g) | m | 41 | 0.16 | 8.60 | 1.58 | 1.31 | 1.384 | 5 |
| w | 96 | 0.00 | 9.97 | 1.52 | 1.26 | 1.211 | 6 |
| Folate (?g) | m | 41 | 44.85 | 297.84 | 123.52 | 102.25 | 59.358 | 200 |
| w | 96 | 9.91 | 354.91 | 115.31 | 104.02 | 61.600 |
| Alcohol (g) | m | 41 | 0.00 | 180.00 | ***6.53 | 0.00 | 28.895 | - |
| w | 96 | 0.00 | 84.00 | 0.88 | 0.00 | 8.573 |
| Caffeine (mg) | m | 41 | 0.00 | 300.00 | 31.38 | 0.00 | 58.848 | - |
| w | 96 | 0.00 | 640.00 | 43.83 | 16.00 | 83.920 |
| Fluid (g) | m | 41 | 243.58 | 4030.03 | 1240.53 | 1010.58 | 738.652 | 1500 |
| w | 96 | 302.80 | 11145.85 | 1263.87 | 1009.73 | 1208.988 |
1. Recommended micronutrient intake for over 60 year-olds ? Source: Rodler I. (ed): Hungarian Nutrient Data Bank,
Medicina Könyvkiadó Rt., Budapest, 2005
*p=0.006 versus women
**p=0.030 versus women
***p=0.004 versus women
Alcohol consumption was well below the tolerable level but was correlated with gender and education. Men, and people with higher education (p = 0.013) drank more. The overall fluid consumption was less than desirable (tab. 6).
DISCUSSION
The Seneca study (5) and the Ageing Nutrition Project (6) are probably the most important cross-sectional comparative European studies to investigate nutrition in the elderly, but a longitudinal study has not been carried out so far. Regarding Hungary, three cross-sectional surveys of all age groups have been performed between 1985 and 2003 (7-10).
We investigated only the elderly subpopulation, but in more detail than before. First, we also assessed life mode (residence, level of education), and found significant associations with the nutritional status (24-hour recall): Fat energy % and salt intake were lower in the more educated elderly persons but alcohol consumption was higher. Vitamin B12 and C intake of the home-living elderly was higher but sugar and vitamin D intake were lower versus the subgroup in community care. Additionally to BMI detailed anthropometric data were obtained (not shown in this paper). Malnutrition was assessed by MNA and BMI as well. We found ? as a new finding
? that there is a discrepancy between the two methods.
We believe that MNA validated for the elderly is more informative and should be the method of choice.
It is not surprising that beside malnutrition obesity (BMI > 30 kg/m2) is also common in the elderly, especially in the age group 65-75, being less frequent in younger and older age groups.
CONCLUSION
We conclude that characteristics of nutrition patterns in the elderly should be carefully evaluated to be able to identify nutrition related risks, which inhibit ?successful aging? (11). As the study suggests, we must pay greater care to the optimal intake of macro- and micronutrients, which may be imbalanced, excessive (as in the case of sodium) or insufficient (e.g. dietary fibre, calcium, vitamin D, folate, fluid) in the diet of the elderly. Modern, balanced ?elderly specific? diets would greatly contribute to maintenance of good health (12-14).
Piśmiennictwo
1. The Public Health Portal of the European Union ? Elderly
http://ec.europa.eu/health-eu/my_health/elderly/index_en.htm ? 2010-07-21. 2. People by age classes ? Proportion of population aged 65-79, ? 80 years ? Share of total population (%) http://epp.eurostat.ec.europa.eu/tgm/refreshTableAction.do?tab=table&plugin=1&pcode=tps00010&language=en ? 2010-07-23. 3. Elmadfa I, Meyer AL: Body Composition, Changing Physiological Functions and Nutrient Requirements of the Elderly. Ann Nutr Metab 2008; 52(Suppl 1): 2-5. 4. Kondrup J et al.: ESPEN guidelines for nutrition screening 2002. Clinical Nutrition 2003; 22(4): 415-421. 5. Haveman-Nies A, de Groot LC, van Staveren WA: Dietary quality, lifestyle factors and healthy ageing in Europe: the SENECA study. Age Ageing 2003; 32(4): 427-34. 6. Lesser S et al.: for the AgeingNutrition Group 1: Nutritional Situation of the Elderly in Eastern/Baltic and Central/Western Europe ? The AgeingNutrition Project. Ann Nutr Metab 2008; 52(Suppl 1): 62-71. 7. Bíró Gy (ed.): Az elsô magyarországi reprezentatív táplálkozási vizsgálat (1985-1988). Budapest, OÉTI; 1992. 8. Bíró Gy, Antal M, Zajkás G: A magyarországi lakosság egy csoportjának táplálkozási vizsgálata 1992-1994 között. Népegészségügy 1996; 77: 3-13.
9. Rodler I et al.: Táplálkozási Vizsgálat Magyarországon, 2003-2004. Orvosi Hetilap 2005; 146(34): 1781-1789. 10. Bíró L et al.: Táplálkozási Vizsgálat Magyarországon, 2003-2004, Mikro-tápanyagok: ásványi sók. Orvosi Hetilap 2007; 148(15): 703-708. 11. Rurik I: Idôskorúak táplálkozás-egészségügyi vizsgálatának családorvosi vonatkozásai. LAM 2005; 15(12): 913-919. 12. Fabian E, Elmadfa I: Nutritional situation of the elderly in the European Union: data of the European Nutrition and Health Report (2004). Ann Nutr Metab 2008; 52(Suppl 1): 57-61. 13. Pavlovic M et al.: Challenges in harmonizing energy and nutrient recommendations in Europe. Ann Nutr Metab 2007; 51: 108-114. 14. Cuervo M: Food consumption analysis in Spanish elderly based upon the Mini Nutritional Assessment test. Ann Nutr Metab 2008; 52: 299-307.
