![[Feedback]](/icons/banner/feedbackACT.gif){kind=icon}
![[For Subscribers]](/icons/banner/subscriberACT.gif){kind=icon}
![[Archive]](/icons/banner/archiveACT.gif){kind=icon}
![[Search]](/icons/banner/searchACT.gif){kind=icon}
![[Contents]](/icons/banner/tocACT.gif){kind=icon}
|
|
|
|
|
||
The Epidemiology Research Unit, Tropical Medicine Research Institute, Faculty of Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica; the Department of Nutrition, Schools of Public Health and Medicine; and the Carolina Population Center University of North Carolina, Chapel Hill, NC, 27516
3To whom correspondence should be addressed. E-mail: NZohoori{at}uwimona.edu.jm.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONNutrition and functional statusOther factors affecting...Summary and conclusionsLITERATURE CITED |
|---|
KEY WORDS: • nutrition • functional status • developing countries • elderly
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONNutrition and functional statusOther factors affecting...Summary and conclusionsLITERATURE CITED |
|---|
, with
projections that by 2020, >70% of those 55 y and older will live
in developing countries (2)
. A major concern regarding
this dramatic increase in the numbers and proportions of older adults
is the level of morbidity and associated reductions in functional
ability in the elderly that can ensue. Healthy functioning in old age,
therefore, must become an important goal for populations in developing
countries.
A lengthy discussion of the definition and measurement of functional
status is beyond the scope of this article. Suffice it to say that a
number of scales and instruments exist with varying abilities to detect
impairments (3)
. The more common among these are the
Activities of Daily Living
(ADL)4
, which consists of eating, bathing, transferring, bathing and using the
toilet; the Instrumental Activities of Daily Living (IADL), which
consists of cooking, shopping, managing money, and using the telephone
and public transportation; and a number of physical performance
measures, such as walking, chair stand and balance (3
,4)
.
Similarly, "disability," or "functional impairment," is also
variously defined by different authors, but is commonly considered the
need for assistance or inability to perform one or more ADL or IADL,
depending on the study.
The relationship between nutrition and healthy functioning is as yet
poorly understood. There are a number of major reasons for this. One is
the paucity of databases in which both nutritional and functional
variables are adequately included and measured, whether in developing
or developed countries. In addition, these relationships are likely to
be very complex with many interactions and multiple inputs at each
level. The development of disabilities with aging is the result of
impairments caused by a number of pathological conditions and chronic
diseases. Poor diet and lack of physical activity are two of the most
important known risk factors for development of chronic disease.
Physical activity may also directly affect functional status through
increased muscle mass and blood flow and improved coordination
(5)
. Whether diet and nutritional status also have direct
effects on functional status other than those through chronic diseases
is yet to be determined.
The above-mentioned pathway from diet and physical activity to
disease and disabilities is a biological one, common to all individuals
regardless of socioeconomic and cultural settings. However, there are
many extrinsic risk factors (such as demographic, socioeconomic,
life-setting and cultural factors) that can influence the level and
quality of diet, physical activity and health care and thus the risk of
development of disabilities (6)
. The effects of these
extrinsic factors are likely to be more pronounced in poorer, less
developed countries, and they need to be considered as important risk
factors when looking at nutrition and functional status of the elderly
in these countries. This issue will be dealt with in more detail later
in this article.
|
Nutrition and functional status |
|---|
|
TOPABSTRACTINTRODUCTIONNutrition and functional statusOther factors affecting...Summary and conclusionsLITERATURE CITED |
|---|
A few studies have associated poor nutritional status with functional
impairment. Reports include risks of functional impairment with a BMI
> 30 (7)
, or in the upper quartile (8)
, or
with a BMI of <20 (9)
. Also, a weight gain or loss of
>10 lbs in 6 mo (10)
, loss of >10% in 6 mo
(11)
or loss of even 3% per year (12)
have
been shown to be associated with greater risks of functional
impairment.
We have shown similar results in our studies in Russia, based on data
from the Russia Longitudinal Monitoring Survey (RLMS). In this survey,
among a nationally representative sample of 2,500 individuals over
55 y or age (see ref. 13
for more details on the
RLMS), in multivariate logistic regression models, after adjusting for
a number of chronic diseases and socioeconomic factors, a weight loss
of >3 kg was significantly associated with an 87% higher risk of
having a disability (defined in these analysis as needing assistance
in, or being unable to perform, any one of the five ADL) 2 y later
(Fig. 1
). In this sample, we also found a marked dimorphism between sexes, with
diabetes, anemia and weight gain being significant risk factors for
subsequent disability among males, but not females; the only risk
factor that was significant for both males and females was weight loss
(Fig. 2
).
|
|
. Cross-sectional
analysis of our data from the 1997 China Health and Nutrition Survey
(containing some 2,000 individuals over age 55 y) indicate that
among this sample, there is no contemporaneous association between BMI
and ADL disability (Fig. 3
). However, for IADL, these data indicate that there is a significant
trend of increasing disability (again defined as needing assistance
with, or being unable to perform, any one IADL) with decreasing BMI,
and that chronic protein energy malnutrition (BMI < 18.6) is
significantly associated with IADL disability.
|
,16)
, points to the coexistence of
states of over- and undernutrition in many parts of the developing
world and the emerging problem of increasing prevalence of chronic
diseases in these countries. At the same time, physical activity levels
are on the decline (17)
. As these populations age, we can
expect a mix of both undernourished and overweight older individuals,
with resulting higher prevalences of disabilities in these populations. |
Other factors affecting nutrition and function in developing countries |
|---|
|
TOPABSTRACTINTRODUCTIONNutrition and functional statusOther factors affecting...Summary and conclusionsLITERATURE CITED |
|---|
poses a special problem for the elderly in these
societies. Whereas the demographic transition in developed countries
proceeded at a slow enough pace to allow the development of health,
economic and social infrastructures to provide for the care of the
emerging older population, the rapidity of the transition in developing
countries precludes a similar development of services and attitudes.
This condition, combined with varying cultural attitudes toward and
expectations of the elderly (see Levkoff et al. [18
] for
a more detailed review of these factors), is likely to put the older
person at particular risk of lack of nutritional and other forms of
support from both the family and the state. Demographic change.
There is general agreement among researchers that the declining birth
rates that accompany population aging in many developing countries will
result in fewer future caregivers for the elderly (19
,20)
.
While currently, in most countries, the trend of having fewer children
poses greater insecurity for the elderly in terms of care and economic
well-being, few attempts have been made to assess the impact of
this decreasing fertility on family care for the elderly, and
indications are that it varies among countries (18)
. In
China, for example, the one-child policy puts at risk the informal
social security system of the family, particularly if the one child is
a girl (21)
. Increasing numbers of elderly, therefore,
face the prospect of either living alone or being in the culturally
undesirable position of living with their daughter’s family, with
potential for social insecurity and psychological stress. In the U.S.,
eating alone has been shown to be associated with poorer nutritional
status and functional limitations (22)
, and in developing
countries with fewer economic resources and services, the result is
likely to be more severe.
Health care and economics.
As populations in developing countries age, they are likely to go
through two stages with respect to prevalence of disability. Initially,
with the emergence of chronic diseases, it is likely that there will
not be as much disability as in developed countries, because income and
health care standards will not support frail elderly for too long and
many disabled elderly will likely die rather than survive with their
diseases into older age, as shown in Taiwan (23)
. However,
as more health technology reaches populations and their standard of
living improves, more frail elderly are likely to survive for longer
periods of time (24)
. A number of studies have shown that
in traditional societies, frail elderly are less respected and less
valued than healthier elders and are subject to poor and
death-hastening treatment (25
,26)
. This results in
poor nutritional and instrumental support with consequent declines in
health and function.
National economies in many developing countries are unable to provide
the elderly with social services and nutritional support, as does the
Elderly Nutrition Program in the U.S. (27)
. Therefore, the
elderly must depend on their own savings and familial ties for old age
security. However, the processes of economic change, and a shift from
rural agricultural economies to industrialization, has reduced the
value of agricultural land and products, often owned by older
individuals in poorer countries (28)
. In rural
communities, which are disproportionately older in most of Africa, Asia
and Latin America (20
,29)
, social status and financial
security of older individuals often depend on agricultural land and
cattle (25)
. The resulting diminished status of the
elderly in these traditional societies has been shown in a number of
countries (25
,30
,31)
.
Migration, urbanization and education.
Migration and urbanization continue to grow most rapidly in low and
middle income countries, particularly in Latin America and the
Caribbean (18)
. A number of factors can operate here to
affect the security, nutritional status and health of older persons in
developing countries. First, urban migration of younger members of the
family in search of higher education and income leaves the elderly
prone to loneliness and lack of support. Second, higher educational
status achieved by younger members of the family leads to a situation
in which less educated elders are less valued and less respected
(25)
, which has psychological, social and economic
repercussions (32)
. Third, in situations in which the
migrant is an older person, the shift to an unfamiliar and seemingly
hostile urban environment leads to greater social isolation
(33)
and is thought by some authors to lead to poorer
mental and physical health (34)
.
Forced displacement, widowhood and psychological factors.
Generally, psychological factors assume greater significance in the
nutritional and functional profiles of older persons as factors such as
loneliness, bereavement and depression become more prevalent
(35
,36)
. Widowhood (especially late in life) and forced
displacement (due to political conflicts or natural disasters) lead to
psychological insults from which it is difficult to recover, and which
have profound nutritional and health consequences. In traditional
societies, as in Asia and Africa, widowhood, more frequently
experienced by women, is an economically and socially vulnerable time
of life with greater rates of depression and malnutrition. Wars and
famines can act against the elderly as a form of forced triage
phenomena, whereby the old and the frail are either left behind or not
cared for, in favor of the younger and more fit majority
(37)
. Even when included in relief efforts, older
individuals are less likely to adapt to new environments and situations
and are more likely to feel the negative consequences of leaving a
familiar home environment (33
,37)
.
|
Summary and conclusions |
|---|
|
TOPABSTRACTINTRODUCTIONNutrition and functional statusOther factors affecting...Summary and conclusionsLITERATURE CITED |
|---|
|
FOOTNOTES |
|---|
2 Supported in part by a grant from the National
Institutes of Health (K01-AG00702).
4 Abbreviations used: ADL, Activities of Daily
Living; IADL, Instrumental Activities of Daily Living; RLMS, Russia
Longitudinal Monitoring Survey.
|
LITERATURE CITED |
|---|
|
TOPABSTRACTINTRODUCTIONNutrition and functional statusOther factors affecting...Summary and conclusionsLITERATURE CITED |
|---|
1. Kinsella K. (1993) Population aging in Africa. Changing Population Age Structure. Demographic and Economic Consequences and Implications 1993:391-398 United Nations Economic Commission for Europe Geneva, Switzerland. .
2. Kinsella K. & Suzman R. (1992) Demographic dimensions of population aging in developing countries. Am. J. Hum. Biol. 4:3-8.
3. Rozzini R., Frisoni G. B., Bianchetti A., Zanetti O & Trabucchi M. (1993) Physical Performance Test and Activities of Daily Living scales in the assessment of health status in elderly people. JAGS 41:1109-1113.
4. Gill T., Williams C. & Tinetti M. E. (1995) Assessing risk for the onset of functional dependence among older adults: the role of physical performance. JAGS 43:603-609.
5. Evans W. J. (1999) Exercise training guidelines for the elderly. Med. Sci. Sports Exerc. 31:12-17.[Medline]
6. Verbrugge L. M. & Jette A. M. (1994) The disablement process. Soc Sci Med 38:1-14.
7. Marshall J. A., Lopez T. K., Shetterly S. M., Morgenstern N. E., Baer K., Swenson C., Baron A., Baxter J. & Hamman R. F. (1999) Indicators of nutritional risk in a rural elderly Hispanic and non-Hispanic white population: San Luis Valley Health and Aging Study. J. Am. Diet. Assoc. 99:315-322.[Medline]
8. Fried L. P., Ettinger W. H., Lind B., Newman A. B. & Gardin J. (1994) Physical disability in older adults: a physiological approach. Cardiovascular Health Study Research Group. J. Clin. Epidemiol. 47:747-760.
9. Ho S. C., Woo J., Yuen Y. K., Sham A. & Chan S. G. (1997) Predictors of mobility decline: the Hong Kong old-old study. J. Gerontol. A. Biol. Sci. Med. Sci. 52:M356-M362.[Abstract]
10.
Jensen G. L., Kita K., Fish J., Heydt D. & Frey C. (1997) Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges. Am. J. Clin. Nutr. 66:819-828.
11. Covinsky K. E., Martin G. E., Beyth R. J., Justice A. C., Sehgal A. R. & Landefeld C. S. (1999) The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients. JAGS 47:532-538.
12. Tully C. L. & Snowdon D. A. (1995) Weight change and physical function in older women: findings from the Nun Study. JAGS 43:1394-1397.
13.
Zohoori N. (1997) Recent patterns of alcohol consumption in the Russian elderly, 1992–1996. Am. J. Clin. Nutr. 66:810-814.
14. Manandhar M. C. (1995) Functional ability and nutritional status of free-living elderly people. Proceedings of the Nutrition Society 54:677-691.[Medline]
15. Drewnowski A. (2000) Nutrition transition and global dietary trends. Nutrition 16:486-487.[Medline]
16. Popkin B. M. (1998) The nutrition transition and its health implications in lower-income countries. Public Health Nutr 1:5-21.[Medline]
17. Popkin B. M. (1994) The nutrition transition in low-income countries: an emerging crisis. Nutr. Rev. 52:285-298.[Medline]
18. Levkoff S. E., MacArthur I. W. & Bucknall J. (1995) Elderly mental health in the developing world. Soc. Sci. Med. 41:983-1003.
19. Kendig H., Hashimoto A. & Coppard L. (1992) Family support to the elderly in international perspective. Kendig H. Hashimoto A. Coppard L. eds. Family Support for the Elderly: The International Experience 1992:293-308 Oxford U. Press Oxford, UK. .
20. Kinsella K. (1988) Aging in the Third World 1988:79 International Population Reports Series P. U.S. Bureau of the Census, Washington, DC. .
21. Tu E. J., Liang J. & Li S. (1989) Mortality decline and Chinese family structure: implications for old age support. J. Gerontol. B Psychol. Sci. Soc. Sci. 44:S157-S168.
22. Jensen G. L., Kita K., Fish J., Heydt D. & Frey C. (1997) Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges. Am. J. Clin. Nutr. 66:819-828.
23. Tu E. J. & Chen K. (1994) Changes in active life expectancy in Taiwan: compression or expansion?. Soc. Sci. Med 39:1657-1665.
24. Logue B. J. (1990) Modernization and the status of the frail elderly: perspectives on continuity and change. J. Cross-Cult. Gerontol. 5:345-374.
25. Guillette E. A. (1990) Change and continuity for older Tswana. J. Cross-Cult. Gerontol. 5:191-204.
26. Glascock A. P. & Fineman S. L. (1981) Social asset or social burden: treatment of the aged in non-industrial societies. Fry C. L. eds. Aging, Culture and Health 1981:13-31 J. F. Bergin Publishers New York. .
27. Zohoori N. (2001) Nutrition and older adults. Lesnoff-Caravaglia G. eds. Aging and Public Health 2001:29-47 Charles Thomas Publishers Springfield, IL. .
28. Osako M. (1982) Increase of elderly poor in developing nations: the implications of dependency theory and modernization theory for the aging of world population. Sokolovsky J. eds. Studies in Third World Societies: Aging and the Aged in the Third World. Publication 22–23 1982:85-113 Department of Anthropology, College of William and Mary Williamsburg, VA .
29. Kinsella K. (1992) Population aging in Africa: the case of Zimbabwe. Changing Population Age structures: Demographic and Economic Consequences and Implications 1992:391-398 United Nations Population Fund Geneva. .
30. Gallin R. S. (1994) The intersection of class and age: mother-in-law daughter-in-law relations in rural Taiwan. J. Cross-Cult. Gerontol. 9:127-140.
31. Gaffrey R. A. (1992) Family care of the elderly in Northeast Thailand: changing patterns. J. Cross-Cult. Gerontol. 7:105-116.
32. Twumasi P. A. (1987) Ageing and problems of old age in Africa: a study in social change and a model for its solutions. Levi L. eds. Society, Stress and Disease: Old Age 5:94-100 Oxford University Press Oxford, UK .
33. Beiser M., Turner J. & Ganesan S. (1989) Catastrophic stress and factors affecting its consequences among Southeast Asian refugees. Soc. Sci. Med. 28:183-195.
34. Sainsbury P. (1987) Psychosocial factors in developed and developing countries with regard to age and aging. Levi L. eds. Society, Stress and Disease: Old Age 5:74-84 Oxford University Press Oxford, UK .
35. Briley M. E. (1994) Food preferences of the elderly. Nutr. Rev. 52:S21-S23.[Medline]
36. Walker D. & Beauchene R. E. (1991) The relationship of loneliness, social isolation, and physical health to dietary adequacy of independently living elderly. J. Am. Diet. Assoc. 91:300-304.[Medline]
37. Godfrey N. & Kalache A. (1989) Health needs of older adults displaced to Sudan by war and famine: questioning current targeting practices in health relief. Soc. Sci. Med. 28:707-713.
This article has been cited by other articles:
|
|
 |
|
  T. Ferdous, T. Cederholm, A. Razzaque, A. Wahlin, and Z. Nahar Kabir Nutritional status and self-reported and performance-based evaluation of physical function of elderly persons in rural Bangladesh Scand J Public Health, July 1, 2009; 37(5): 518 - 524. [Abstract] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
