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a SEAMEO-TROPMED Regional Center for Community Nutrition, University of Indonesia, Jakarta 10430, Indonesia and b Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ), Eschborn, Germany
 |
ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: • Body mass index • thiamine • Indonesian elderly • micronutrients • anemia
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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).
Population aging is not only occurring in industrialized countries, but
also in developing countries. It is estimated that in the Southeast
Asian region the proportion of individuals older than 60 y will
increase from 5% in 1950 to 11.5% in 2050, equivalent to a four-fold
increase in absolute numbers (Gopalan 1992
).
The aging process is associated with physiological, psychological and
socioeconomic changes leading to nutritional excess, such as obesity,
and deficit, such as micronutrient deficiency, and their related health
outcomes, such as coronary atherosclerosis, diabetes mellitus, certain
cancers and anemia. These changes and outcomes are evidenced from
various studies of elderly people living in industrialized countries
(de Groot et al. 1991,
Hartz et al. 1992,
Kromhout et al. 1990,
Wahlqvist et al. 1995a and b
).
So far, a limited number of studies have been undertaken to observe the
nutritional status of the elderly living in developing countries. The
Western Pacific study (Andrews et al. 1986
) described
sociocultural factors, but not nutritional factors, of free-living,
elderly people living in Fiji, the Republic of Korea, Malaysia and the
Philippines. Recently, Wahlqvist et al. (1995a)
reported the food
habits, lifestyles and health status among the aged in developed and
developing countries. Elderly people living in developing countries
have, up to a certain degree, an inadequate intake of micronutrients,
such as vitamin A, thiamine, riboflavin and vitamin C (Wahlqvist et al. 1995b
). However, for certain micronutrients, intakes are
not reflected in plasma or serum levels. In free-living, middle- to
upper-class, US elderly, 24% of the men and 39% of the women had
vitamin B-12 intakes below three-fourth of the recommended dietary
allowance (RDA)5; most of these people were able to maintain normal levels of serum
vitamin B-12 despite the low intakes (Ahmed 1992
).
Little information is available about nutritional status of the elderly
in Indonesia, but it is expected that inadequate food intake is common
(Horwath 1989
). This was confirmed by a recent study
showing a high prevalence of low body mass index (BMI) (Rabe et al. 1996
) among elderly from Jakarta. A low food intake
increases the risk of micronutrient deficiencies, especially when the
micronutrient density and/or bioavailability in food is low, which is
often the case with diets in developing countries. A factor
complicating nutritional status of the elderly in developing countries
is that many may have had inadequate food intake during much of their
childhood and adult life.
The aim of this study was to investigate the nutrient intake, selected anthropometric and biochemical indicators, and their associations, of noninstitutionalized elderly living in urban Jakarta, Indonesia.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This cross-sectional study was carried out between March and April 1996, in two sub-villages of Johor-Baru sub-district in Central-Jakarta. The Johor-Baru sub-district had a total population of ~108,000 persons and a population density of ~40,000 people/km2. The population of the two sub-villages from which the subjects were selected was ~51,700, of which an estimated 4,400 people were older than 60 y. Environmental sanitation in the study area was poor, with most households having an open drainage system. The majority of households belonged to the low socioeconomic class.
Subjects.
Subjects were randomly selected from a list obtained from the municipality including all inhabitants who were aged from 60 to 75 y. Excluded were those elderly with a serious illness, who were immobile, and who were institutionalized. Furthermore, a cognitive test was conducted among the potential subjects to ensure that they would be able to answer questionnaires. This test consisted of five simple cognitive questions and five questions on food identification, making a total of 10 questions. Subjects were considered eligible for the study if they could provide correct answers to five questions or more. A total of 204 subjects were enrolled in the study. Home visits were undertaken by the interviewers with the assistance of local aides to contact these 204 subjects. All subjects agreed to participate in and successfully completed the study. Written consent was obtained from each subject prior to the commencement of the study.
Questionnaire.
Selected information on socioeconomic status, lifestyle and health
status was collected using a precoded questionnaire. Habitual food
intake was assessed using a semiquantitative food frequency
questionnaire. Subjects were asked about 71 food items. Food models and
pictures were used for identification of the foods. Each food had a
corresponding serving portion, and each serving portion had a
corresponding weight. The amount of foods consumed was quantified by
multiplying the daily frequency of consumption by the number of serving
portions consumed and thier corresponding weights. The Indonesian
(Departemen Kesehatan R. I. 1991
) food composition
tables were used to convert foods into nutrients. A European food
composition table (Holland et al. 1993
) was used to
obtain vitamin B-12 and folic acid intakes because information on these
nutrients is not available in the Indonesian food composition tables.
Nutrient analysis was done using the computer program DEMETER 1.5
(Northern Technical Data, Winnipeg). A qualitative question (with yes
or no responses) was used to assess supplement intake.
Anthropometric measurement.
Anthropometric measurements consisted of weight, height, arm span and
skinfolds of biceps, triceps, supra-iliac, and sub-scapula. Between
8.00 and 10.00 h, weight was measured to the nearest 0.1 kg using a
platform model electronic weighing scale (SECA 770 Alpha, Hamburg,
Germany). During the measurement, subjects were wearing a minimum of
clothing for which no correction was made. Stature was measured to the
nearest 0.1 cm using a microtoise (Stanley Mabo, London, UK), with the
subject standing as erect as possible with the back against a wall. Arm
span was measured to the nearest 0.1 cm using a 2-m measuring bar.
Subjects were asked to stand with their backs against the wall, both
arms extended laterally at shoulder level to the maximum with the tip
of the right hand middle finger at the zero mark of the measuring bar.
The reading was made at the point where the tip of the left hand middle
finger touched the opposite side of the bar. Four skinfolds (biceps,
triceps, subscapular and suprailiac) (Durnin and Womersley 1974
) were measured in duplicate at the left-hand side of the
body using a Holtain caliper. All skinfold measurements were made by
the same person, and the mean of the two measurements was taken from
each person.
Biochemical assessment.
Between 800 and 1000 h, after an overnight fast, venous blood (6 mL)
was collected from each subject into tubes containing EDTA. After
collection, the blood specimens were immediately placed in a dark cool
box until they arrived at the laboratory. Hemoglobin and red blood cell
folate concentrations were determined within 2–3 h after blood
collection. Hemoglobin analysis was carried out using the
cyanomethemoglobin method (INACG 1985
). Red blood cell
folate assessment was based on an ion capture assay method using a
commercial kit purchased from Abbott Laboratory (Imx-Folate, Abbott
Park, IL). Thiamine status was determined by measuring the erythrocyte
transketolase (ETK) activity (Brin 1967,
Schouten et al. 1964
). The basal ETK activity and its activity after
adding thiamine pyrophosphate (TPP) were used to calculate the TPP
effect, which is considered to be an indicator for thiamine status. The
coefficient of variation, CV, for basal ETK activity is ~5% for both
within- and between-day analyses. The corresponding values for ETK
activity are ~2 and 4%, respectively (Fidanza, 1991
).
Plasma specimens were obtained by centrifuging the blood samples at
3000 x g for 10 min at room temperature
(25–26°C) within 6 h after blood collection, and
then stored at -20°C until analyzed. Plasma vitamin B-12
was measured by the microparticle enzyme immunoassay method using a
commercial kit (Abbott Laboratory, IMx-B-12, Abbott Park, IL). Retinol
was measured using high pressure liquid chromatography as previously
reported by Bieri et al. (1979)
.
The research proposal was approved by the Ethical Review Committee of
the Regional SEAMEO-TROPMED Center for Community Nutrition at the
University of Indonesia, Jakarta, and conformed to the International
Guidelines for Ethical Review of Epidemiological Studies (CIOMS
1991
)
The following cut-off points were taken to indicate a deficient
situation. Anemia was indicated by hemoglobin values < 120 g/L in
females and <130 g/L in males (WHO 1994
). Low vitamin A
status was indicated by a serum retinol concentration of <0.70
µmol/L. Low thiamine status was indicated by a TPP-induced increase
in ETK activity of >25% (Brin 1967
). Deficient folate
status was indicated by an erythrocyte folate concentration of <368
nmol/L. Vitamin B-12 deficiency was indicated by a serum vitamin B-12
concentration of <148 pmol/L (Herbert 1987
).
Statistical analysis.
The concentrations of plasma vitamin B-12, red blood cell folate and stimulated ETK activity did not resemble a normal distribution. Normalization was obtained after performing log transformation procedures for vitamin B-12 and folate, and a square root transformation for ETK. Differences in concentration of biochemical indicators between subgroups were investigated using unpaired t-tests. Analysis of determinants of micronutrient status was carried out using stepwise multiple regression, with transformed values if necessary. BMI, age, nutrient intake and dummy variables for sex, smoking, and usage of vitamin or mineral supplements were included as possible determinants.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Habitual daily dietary intake of selected nutrients was assessed by the
semi-quantitative food frequency questionnaire. The median energy
intake was lower than the recommended intake. The median intake of
thiamine was less than half of the recommended daily intake of 1.2 mg.
The median iron intake of males and females was higher than that of the
basal iron requirement of 9–10 mg/d, assuming an intermediate
bioavailability of the dietary iron becuase of the relatively high
vitamin C intake. The median intakes of vitamins A and B-12 for both
men and women were higher than the recommended intakes, but the median
folate intake of the men was lower than the recommended intake
(Table 2). Energy intake was weakly but significantly correlated with BMI
(r = 0.231, P = 0.001) and the sum of
skinfolds (r = 0.157, P = 0.02).
Subjects with BMI < 18.5 kg/m2 had mean energy intake
of 1306 ± 374 kcal (5459 ± 1563 kJ), whereas subjects with
BMI 
18.5 kg/m2 had mean energy intake of 1417 ± 502 kcal (5923 ± 2098 kJ).
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Lindenbaum et al. 1994
).
Using this cut-off point, the prevalence of vitamin B-12 deficiency was
32.4% in the whole population, with 33.3 and 31.5% for men and women,
respectively. Red blood cell folate concentration was correlated with
serum vitamin B-12 concentration (r = 0.2472,
P < 0.001). Other biochemical variables were not
significantly correlated with each other.
|
Variation in ETK activity (transformed values) was partly explained by the dietary thiamine intake (r = 0.176, P = 0.012). Variation in plasma retinol concentration was explained (r = 0.379, P < 0.001) by the dietary vitamin A intake (P = 0.001), sex (P = 0.03) and BMI (P = 0.002).
To investigate possible determinants of hemoglobin concentration, plasma retinol, vitamin B-12 and folate intakes were also added in the model. The model showed that hemoglobin concentration (r = 0.394, P = 0.001) was determined by sex (P < 0.001) and vitamin B-12 intake (P = 0.003). Dietary folate intake and erythrocyte folate concentration explained the variation in B-12 concentration (r = 0.77, P < 0.001). The determinants of erythrocyte folate concentration were sex (P = 0.003), BMI (P = 0.006) and plasma vitamin B-12 concentration (P < 0.001, r = 0.372). No significant differences in erythrocyte folate were found between smokers and non-smokers.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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). The average age of the
investigated subjects was 66 y, which is higher than the life
expectancy. Therefore the subjects can be considered as elderly in the
Indonesian context.
In the present study, nutritional status was assessed by anthropometric
and biochemical indicators, as well as by the intake of selected
nutrients. Although no specific studies were undertaken in the
Indonesian elderly to test the validity of food intake assessed by the
food frequency questionnaire, we decided to adopt this method because
it was recommended and applied by other two cross-cultural studies in
elderly populations (Gross 1997,
Wahlqvist et al. 1995a
).
By using different indicators, we classified a large part of the
investigated subjects as being malnourished. The overall prevalence of
chronic energy deficiency, as indicated by a BMI < 18.5
kg/m2 (James et al. 1988
), was 26.6%. Low
BMI values in the Asian elderly population were also reported in the
IUNS Study (Roche 1995
). The BMI values of elderly men
and women in the present study were not different from the Chinese
elderly men and women, aged 70–79 y, living in rural Tianjin and were
similar to BMI values of the Guatemalan elderly (King et al. 1997
).
Recently, Rabe et al. (1996)
studied 69 elderly subjects, aged 60–69,
living in a low-income area in Central Jakarta. They found that ~30%
of the subjects were considered chronically energy deficient. However,
the BMI values presented in our study are higher than those reported
for a group of institutionalized elderly Indonesian individuals
(18.2 ± 2.4 kg/m2 for males and 18.2 ± 3.8
kg/m2 for females) (Oenzil 1995
). The fact
that the BMI values had substantial degrees of agreement with skinfold
measures of fatness in the present study has supported the previous
findings (Iswarawanti et al. 1996,
Rabe et al. 1996
).
The assessed food consumption indicated that only the median intakes of
energy and thiamine were less than the recommended daily intake. The
low intake of energy correlated positively with BMI and with fat mass.
The intakes of the other vitamins were assessed as being relatively
favorable. The median vitamin A intake seemed to be adequate and
exceeded the US revised RDAs of 1000 µg retinol equivalent (RE) for
males and 800 µg RE for females for people aged 51 y
(National Research Council 1989
). About 8% of the males
and 14% of the females had vitamin A intakes below two-thirds of the
recommended dietary intake (RDI). In the SENECA study, >50% of the
European elderly in three towns were identified as having vitamin A
intakes below the lowest European RDI, which are 700 µg for males and
600 µg for females (Euronut SENECA Investigators 1991a and b
).
The adequacy of vitamin A intakes in this population was generally
reflected in the relatively high plasma retinol concentrations, and a
weak, but significant, correlation existed between plasma retinol and
vitamin A intake. However, the subjects who had an intake of >400 RE
had an average plasma retinol concentration of 1.23 µmol/L,
indicating that assessed low intake was a poor predictor of biochemical
status. A similar lack of agreement between assessed vitamin A intake
and plasma retinol concentration was also reported for the European
elderly. Results of the SENECA study revealed that there was nil
prevalence of biochemical vitamin A deficiency despite the application
of lower cut-off for plasma retinol concentration (<0.35 mol/L) to
define high risk of vitamin A deficiency (Euronut SENECA Investigators
1996a
).
This study showed that the median thiamine intake of the elderly was
about 50 and 45% of the RDI for males and the females, respectively.
About 93% of the men and 80% of the women had thiamine intakes below
two-thirds of the RDI. These values are particularly high in comparison
with other elderly nutrition studies. In the IUNS study
(Wahlqvist et al. 1995b
) the Asian elderly, who were
mostly Chinese and Japanese, were similar to the Greeks in Melbourne,
with 10–20% not achieving the RDA. It is plausible that the Chinese
and Japanese elderly obtain thiamine by consuming large quantities of
rice. However, the Indonesian elderly were not able to satisfy their
thiamine requirements despite rice being a staple food. Most Indonesian
people, nowadays, consume machine-milled rice, which is distributed by
the Indonesian government. The polished rice has a lower thiamine
content than the unpolished rice (0.134 mg/100 g rice vs. 0.320 mg/100
g rice, respectively) (Djoenaidi 1991
). In the SENECA
study, about 20% of the men and 30% of the women were not achieving
the lowest European RDA for thiamine (0.8 mg/d for men and 0.7 mg/d for
women) (Euronut SENECA Investigators 1991b
).
The low intake of thiamine in our study was confirmed by a high
prevalence of the subjects having ETK > 25%, ~42% in the men
and 32% in the women. These values are much higher than a Boston
survey (Sokoll and Morrow 1992
) where ~15% of the
elderly subjects had marginal thiamine status, and 2–5% were
deficient. Using a clinical indicator, Djoenaidi (1991)
reported that
the incidence of beriberi polyneuropathy in young adults was ~4% of
total admissions in the Neurological Department at the Dr. Soetomo
Hospital in Surabaya.
The median vitamin B-12 intake of the subjects was higher than the USA
RDA (National Research Council 1989
) (2 µg for men and
1.6 µg for women). About 2% of the men and 3% of the women had
dietary vitamin B-12 intakes below two-thirds of RDI. Using 148 pmol/L
as a cut-off-point, ~3% of the male subjects and 12% of the female
subjects in this study were considered to have vitamin B-12 deficiency.
In the IUNS study (Wahlqvist et al. 1995b
), a different
cut-off-point, ie 111 pmol/L, was used. With this cut-off, 2–8% of
the assessed elderly populations (Spata Greeks, Melbourne Greeks,
Swedes and Anglo-Celtics) had vitamin B-12 deficiency. In the SENECA
study, 2.7% of the elderly subjects had low plasma vitamin B-12
concentrations (<111 pmol/L) (Euronut SENECA Investigators 1991a
).
This value increased to 7.3% in the SENECA's follow-up study (SENECA
Investigators 1996a
). There is growing evidence to indicate that in the
elderly with vitamin B-12 deficiency, neuropsychiatric and metabolic
abnormalities may precede megaloblastic anemia (Allen et al. 1993,
Lindenbaum et al. 1988
). Using a metabolic
study, Lindenbaum et al. (1994)
demonstrated that the cut-off-point of
<148 pmol/L to define vitamin B-12 deficiency in the elderly was too
low. They proposed that a serum vitamin B-12 concentration < 258
pmol/L is a better cut-off for suspecting vitamin B-12 deficiency. We
found that 32.4% of the subjects would be deficient when using this
cut-off. In the Framingham study, the prevalence of vitamin B-12
deficiency among the elderly was 40.5% (Lindenbaum et al. 1994
).
The median folate intake of the subjects in this study was lower than
the USA RDA (National Research Council 1989
) of 200 µg
for males and 180 µg for females, and ~20% of males and females
had folate intakes below two-thirds of the RDI. This value is about
three times that found in the Boston survey (Sahyoun 1992
).
In spite of the low intakes, only 5% of the men and 1% of the women
had RBC folate below 368 nmol/L. In the IUNS study, the mean plasma
folate concentration in the Caucasian elderly was above the minimum
cut-off of 6.8 nmol/L. Folate status appeared to be good in most of the
four assessed elderly populations (Spata Greeks, Melbourne Greeks,
Swedes, and Anglo-Celtics), with <5% having values below this cut off
(Wahlqvist et al. 1995b
). Similarly, in the SENECA
study, folate status was good in all individuals in all centers.
No subjects were at risk of folate deficiency with blood concentrations
below 6.8 nmol/L (Euronut SENECA Investigators 1991a
).
The prevalence of folate deficiency increased from 0 to 0.3% among the
elderly subjects in the SENECA follow-up study (SENECA
Investigators 1996a
).
It can be concluded that malnutrition was quite common among the
investigated population, which stresses the need for specific
interventions. Irrespective of the assumptions made in the nutrient
analyses, it was clear that the Indonesian elderly had less favorable
thiamine status than their counterparts living in developed countries.
Moreover, dietary thiamine intakes of this population group were not as
good as their Asian counterparts, namely Chinese and Japanese. To what
extent the thiamine status of this population causes any clinical signs
and symptoms would await more comprehensive clinical studies. Using the
cut-off proposed by Lindenbaum et al. (1994)
, the prevalence of vitamin
B-12 deficiency in this study does not differ much from the other
available studies, and the eventual consequences of a deficient status
would need to be further investigated. Anemia was prevalent among the
Indonesian elderly, and although the hemoglobin concentration was
associated with vitamin B-12 intake, no observation was made with
respect to the type of anemia in this study. It would be of interest to
observe the association between vitamin B-12 and folate status and
their endpoints in this population in the near future as far as
megaloblastic anemia and other metabolic abnormalities are concerned.
Micronutrient supplementation would be a possibility to improve the micronutrient status of the elderly. The composition of the supplement would, however, need to reflect the deficient status of thiamine and vitamin B-12, and it would need to be investigated whether supplementation with iron would improve hemoglobin concentration.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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1 Presented in part at the 16th International
Congress of Nutrition, July 30, 1997, Montréal, Canada.
2 Supported by P. T. Bayer Indonesia Tbk.
3 The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked ''advertisement'' in accordance with 18 USC section 1734 solely to indicate this fact.
4 Abbreviations used: BMI, body mass index; ETK,
erythrocyte transketolase; RDA, recommended dietary allowance; RE,
retinol equivalent; RDI, recommended dietary intake; TPP, thiamine
pyrophosphate.
Manuscript received June 21, 1998. Initial review completed September 3, 1998. Revision accepted November 5, 1998.
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