Malnutrition and its determinants among older adults people in Addis Ababa, Ethiopia

Old age is defined as people aged 65 years or above [1]. In fact ageing is an irreversible biological phenomenon [2]. Particularly, older adults are highly vulnerable to malnutrition [3]. Globaly, about 13–78% of the older adults are suffering from malnutrition [4] . If it is not prevented or treated in time, it could increase morbidity and mortality rates, thus becoming a problem of great personal, family and socio-health significance [5].

So far, malnutrition in older adults remains under detected, under-treated, under-resourced and leads to further weight loss, increased infections and delay in recovery from illness as well as increased hospital admissions and length of stay [6]. Obviously, malnutrition is multi-factorial, it could be due to inadequate food intake, illness or both that causes increased nutrient loss, poor nutrient absorption or both [7]. Previous studies have shown that socio-cultural, health and socio-economic characteristics are main significant determinants of malnutrition [8, 9]. High odds of malnutrition has been documented among female, older age [10], unmarried [11], illiterate [12], low income [13], and living alone [12] older adults. Moreover, reduction of income and physical in capability in older adults increases vulnerability to food insecurity, which in turn predisposes to malnutrition [8]. Geographic and psychosocial concerns, can also affect dietary behaviors and nutritional status [9].

Population aging is an emerging challenge in Africa [14]. Despite the increasing number of older adults, there has been little effort to fulfill their health and nutritional needs, and therefore they seek a great attention in Ethiopia [15, 16]. Ethiopia has been implementing policy, program and strategies such as; Food and Nutrition program (FNP), Immunization and Health Sector Transformation Plan i.e. focusing to improve children, adolescents and maternal health and nutrition [17‐19]. However, malnutrition among older adults is underdetected and neglected area because the entire problem related with aging considered as fate of aging. Also literatures are scarce in Ethiopia; there is a limited information in the current study area among older adults using Min nutritional assessment (MNA) tool recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) and fitted for Ethiopian older adults [20, 21]. Investigating the prevalence and determinants of malnutrition in a disadvantaged segment of population is of a crucial importance to develop strategies to address the problem and provide holistic support for the older adults. Therefore, this study was aimed to assess prevalence of malnutrition and its associated factor among older adults in Addis Ababa, Ethiopia.

Malnutrition is a significant public health problem especially, in resource-limited setting like Ethiopia where food insecurity prevail [3, 4, 25]. However, malnutrition in vulnerable groups such as older adults have usually been ignored [26, 27]. Our study is the one to focus on malnutrition of older adults and has a crucial importance to develop strategies to address malnutrition and provide holistic support for the older adults. This finding show that more than one-fourth (26.6%) of the older adults were malnourished. Moreover, depression, occupation, wealth index and age were independent predictors of malnutrition. The current finding was consistent with local studies from Debre Markos town, Northwest Ethiopia (22.7%) [28] and Hawassa city, Southern Ethiopia (28.3%) [21].

However, the current finding was higher than local finding reported from Aykele town, Amhara region, Ethiopia (17.6%). The discrepancy might be due to the difference of nutritional assessment methods, the former study assessed nutritional status based on Body Mass Index (BMI); whereas the current study assessed nutritional status based on Mini nutritional assessment which is a better way to identify nutritional disorder in older adults [24, 29]. Since BMI does not take into account the structure of the body or the percentage and distribution of adipose tissue, both of which change as a person ages [30] and also does not reflect changes that may occur due to sarcopenia (loss of skeletal muscle mass) or decrease in stature (osteoporosis, degenerative changes in the vertebrae and vertebral discs thinning) [31]. Thus, BMI is masking important weight changes and resulting in the failure to recognize malnutrition in time [24]. This implies that MNA is a better proxy than BMI to determine the nutritional status of older adults [29]. Similarly, a higher prevalence of malnutrition was reported in this study compared to previous studies reported from South Africa (5.5%) [32],Sire Lanka (13.6%) [33] and Brazil (18.8%) [34]. This might be due to the difference in the living standards and socioeconomic status like economic power of the older adults. The present study was done among older adults living in low income country compared to the earlier studies. This could explain lower food purchasing power of older adults, which in turn results in the consumption of undiversified food items, and limit their dietary intakes. Low dietary intake may increase the risk of malnutrition. Also, cultural difference including religious differences among older adults could be another possible reason.

The result the adjusted analysis demonstrated that the odds of malnutrition were higher among oldest old (aged 75 years old or above) older adults as compared to young old (aged 65–74 years old). This finding was confirmed by a local studies done in Debre Markose [28] and Gondar [23], Ethiopia which states that oldest old were more likely to be malnourished than young old people. Obviously, increased age puts older adults in a catabolic state i.e. body decomposition [35]. The risk of malnutrition is higher as their functional status is deteriorated possibly because of age increases and chronic co-morbidities such as respiratory disease, arteritis, and dementia. Impaired mobility and co-morbidities are known to impair appetite thereby food intake of the older adults [36].

This study also illustrated that depression was significantly associated with higher likelihood of malnutrition. Also, higher odds of malnutrition were reported among depressed older adults from studies done in South Africa, India and Netherland [2, 32, 37]. This might be due to depression negatively influences the appetite, food in-take and reduced energy in-take, and this can lead to weight loss and increase the risk of malnutrition [38].

The likelihood of malnutrition was increased by 1.94 folds among older adults in the poor wealth category. This finding is congruent with the study done in Northwest Ethiopia [23] and Northern Italy [13]. Thus, in poor households food consumption is reduced because of economic reasons, this may severely impact the physical and health status of the individual [39]. Particularly, older adults with poor socio-economic status might not afford nutrient dense and protein rich food, as a result cereal-based monotonous diet is common in this group of people which again diminishes their body ability and increases the risk of fat and fat-free loss [8, 13].

Finally, this paper showed increased odds of malnutrition among daily laborer and guard older adults compared to merchant (self employed) older adults. The adverse effect of unemployment on malnutrition mainly operates through its impact on the household economic deprivation. Similarly, most of the older adults in Ethiopia are not empowered compared to the non- older adults, which indirectly influence their economic power to purchase nutritious food.

Limitation: This study addressed an important public health concern, malnutrition. However, the cross-sectional nature of this study could not show the causal relationship between the response and explanatory variables. Hence, the study included samples from community; the findings may not be generalizable to those who did live in humanitarian organization like Mekedonia. Moreover, the study is not free from recall bias as the measurement of dietary issues was relied on memory, nevertheless efforts, such as training of data collectors and supervisors and appropriate probing techniques were used to minimize this bias. Finally, self-reported nature of the questionnaire also limits the external validity of the study.

This study illustrated that considerably high proportion of older adults were malnourished in Addis Ababa. Socio-economic characteristics (wealth index and occupation) and depression were significantly associated with malnutrition. Therefore, nutritional and social support activities are essential for older adults, particularly of those who are socio-economically disadvantaged and advanced age. In addition, regular nutritional screening and management as well as behavioral interventions should be strengthened as a pillar component of therapeutic interventions. At last, specific nutritional requirements, at later stages of life is changing, and with the population aged over 65 years increasing in low-income countries like Ethiopia, the research in this field is likely to increase further.