Nutritional status and its associated factors of elderly population living in old age homes of Kathmandu Metropolitan City

Nutrition plays an important role in the overall well-being of human beings more so in the elderly. Elderly living at old age homes have a different nutritional status as compared to those living with their families. Thus, this study was conducted to assess the nutritional status of the elderly living in old age homes of Kathmandu Metropolitan City (KMC). A descriptive cross-sectional study was carried among 133 elderly residing in all six old age homes of KMC by using Nepali-translated Nestle’s Mini Nutritional Assessment Tool (MNA). Further collected information was analyzed using chi square test. Regarding nutritional status, 30.8% of the participants had normal nutritional status, whereas 52.7% were at risk of malnutrition and 16.5% were malnourished. Lifestyle related factors such as smoking and physical activity were found to be the factors affecting the nutritional status of elderly people. Significant association was seen between nutritional status and age (p =0.001) and past occupation (p =0.021). A significant proportion of elderly people living in old age homes are at risk of malnutrition or are malnourished.


INTRODUCTION
Advancements in public health and medical care have contributed to the significant reduction in infant and childhood mortality rates during the first half of the 20th century.With increased longevity in adults, there is now a larger population of individuals aged 60 and above in developed countries. 1The global population of people aged 60 or above will increase from 900 million to 2 billion by 2050, thereby making up a larger percentage of the total population, moving from 12.0% to 22.0%. 2 The aging of the world's population has brought significant attention to the matter of elderly care. 3trition influences the overall well-being of all humans, not to mention its role in the elderly population. 4Malnutrition ranges from severe undernutrition to overweight and obesity.In 2016, there was an increase in the number of people worldwide who are chronically undernourished, estimated to be 815 million, up from 777 million in 2015. 5Elderly are particularly vulnerable to malnutrition, especially among the elderly living in the community in care homes. 6The prevalence of malnutrition as rated by the Mini Nutritional Assessment short form (MNA-SF) among the elderly reported 0-8% for living in the community and 0-74% for those who are hospitalized or living in institutions. 7e aging process is often accompanied by various changes that can pose challenges in meeting nutritional needs.These changes can be classified into categories: physical/ physiological and psychosocial. 8The elderly population may experience malnourishment due to several factors, including a decrease in food consumption resulting from a decline in physical activity and resting metabolic rate that occurs as part of the aging process, 9 underlying medical conditions, gender (with women being at a greater risk), and economic vulnerability. 10dernutrition, particularly in the elderly population, is a prevalent public health concern that can lead to increased mortality rates and economic challenges, particularly in developing countries. 11utritionally inadequate diets can contribute to chronic and acute diseases and accelerate the development of degenerative diseases such as cardiovascular and cerebrovascular disease, diabetes, osteoporosis, and cancer associated with aging. 12The recent increase in the prevalence of undernourished people is of great concern and poses a significant challenge to international commitments to end hunger by 2030. 5However, it is known that 85.0% of chronic disease and disability in older adults can be prevented or mitigated with proper nutrition. 13cross-sectional study conducted on 237 senior citizens living in old age homes in Kathmandu Metropolitan City showed 15.5% of them were malnourished and 61.0% at risk of malnutrition as per MNA scores.14 Similarly, another study conducted in rural areas of Nepal, revealed 38.7% had normal nutritional status, 49.7 were at risk of malnutrition, and 11.6% were malnourished.15 This has shown that the higher proportion of malnourished elderly individuals found among those who stayed in the old age homes as compared to people who live in their own houses.16 Recognizing and addressing the nutritional requirements of elderly individual is essential in fostering optimal aging and enhancing their overall status.17 Thus, this study was carried out to assess the nutritional status and its associated factors among elderly people living in old age homes of Kathmandu Metropolitan City.

MATERIALS AND METHODS
This was a descriptive cross-sectional study conducted at old age homes in Kathmandu Metropolitan City from June to September 2022.All old age homes registered in Kathmandu Metropolitan City was included in the study, namely; Samaj Kalyan Kendra Sangh, Nishaya Sewa Sadan, Satpryash, Bouddha Briddha Ashram, Dhumbarahi Lion Briddhashram and Shree Janak Baba Aashrit Mandir.There were 99, 37, 8, 7, 6, and 5 elderly individuals of 60 years and above in the listed old age homes, respectively.Of the total 162 elderly people, 133 were eligible owing to the inclusion criteria.To be specific, elderly people with disabilities, inabilities to listen and respond and those residing for less than 3 months in the old age homes, were not included in the study.Thus, it was a complete enumeration of elderly residing in all the old age homes.Data was collected using a semi-structure questionnaire.The technique of face-to-face interview was carried out with each participant in selected old age homes in Kathmandu Metropolitan City.Additional data was collected using the structured questionnaire known as Nestle's Mini Nutritional Assessment Tool (MNA), and the tool demonstrated 96.0% sensitivity and 98.0% specificity in various institutional study.It consisted of 18 items and was translated from English to Nepali.The tool consists up of four components: anthropometric, general, dietary, and subjective.Cumulative scores range from 0 to 30.For the assessment of nutritional status, the cumulative score was categorized into three types: 1.An MNA score of less than 17 indicates malnutrition, 2. Scores between 17and 23.5 indicate the subject is at risk of malnutrition, and 3. Any score of 24 or higher is considered normal nutritional status. 18 anthropometric assessments, height was measured using a stadiometer.The measurements were taken without any footwear, with the participant standing on a flat surface, placing their feet together with their knees straight, and facing the interviewer.The recorded height was in centimeters.The weight was measured using a digital weighing scale placed on a flat surface.The measurement was taken with the participant wearing minimal clothes and no footwear, and it was recorded in kilograms.The Body Mass Index (BMI) was calculated by dividing the weight in kilograms by height in meters squared.Furthermore, Mid Upper Arm Circumference (MUAC) and calf circumference were measured using a non-stretchable measuring tape, with the measurement recorded to the nearest 0.1cm.
To ensure the liability of information, pretesting was done in the 10.0% of the participants with similar characteristics as the study population.An old age home, Dyomma Old Age of Bhaktapur was the selected site and necessary corrections in lagging area were made.Complete enumeration performed enhances reliability.
The collected data were analyzed using SPSS-17, and chi-square test was applied to measure the association between two categorical variables: dependent and independent variables.Ethical considerations were taken into account, with permission obtained from the Institutional Review Committee (IRC) of Nobel College (IRC: 38/022/023).Informed consent was taken from each old age home and from each participant for interview and assessment.All information was kept confidential i.e., respondent's privacy was highly maintained.

RESULTS
Table 1 shows the distribution of respondents according to their socio-demographic characteristics lifestyle, health related factors and anthropometric measurements of the  the participants, (72.2%) didn't take more than three prescription drugs per day.Likewise, 10.5% had pressure sores.It was also observed that more than half of the respondents, (55.6%) viewed themselves as having no nutritional problem.Similarly, 37.6% of them considered their health status good in comparison with other people of the same age.Nine out of ten (90.2%) consumed three meals per day.The results showed that 6.8% of the participants consumed meat, fish, or poultry every day.Likewise, 92.5% of them consumed two or more servings of fruit or vegetables per day.In addition, 63.9% of participants consumed more than three cups of fluid per day.The study also showed slightly more than seven out of ten (70.7%) of the participants self-fed without any problem.
Fig. 1 shows the nutritional status of the respondents according to the MNA score.
Regarding nutritional status, 30.8% of the participants had normal nutritional status, whereas 52.7% were at risk of malnutrition and 16.5% were malnourished.
Table 3 shows that the proportion of elderly people at risk or malnutrition or malnourished are more in the age group of 80 years and above (89.1%)than in the age group of 70-79 (65.4%) and in the age group of 60-69 (48.6%).In order to measure the association between age and nutritional status, the chisquare test was applied.The test showed a highly significant association between age and nutritional status (p =0.001).In this study, a significant association was observed between past occupation of participants and nutritional status (p =0.021).The test showed a statistically significant association between smoking status and nutritional status (p =0.031).In this study, a significant association was found between physical activity and nutritional status (p =0.004).Furthermore, a statistically significant association was found between consumption of two or more servings of legumes or eggs, mode of feeding and nutritional status (p =0.045 and 0.004, respectively).

DISCUSSION
Using the MNA tool, 30.8% of the respondents had normal nutritional status, 16.5% of them were malnourished with an additional 52.7% at risk of malnutrition in this study.This finding similar to the study conducted in old age homes of Kathmandu: 15.5 % of the elderly were malnourished and 61% were at risk of malnutrition. 14These findings indicate a significant prevalence of malnutrition among older individuals in Nepal.Other studies using the MNA tool conducted in different parts of South Asia suggest a similarly high prevalence of malnutrition among the elderly.Two studies conducted in India found prevalence of malnutrition at 15.0% and 14.0%.However, both had at least 30.0% of the population in the normal nutritional status range which is slightly higher than the current study. 19,20In contrast, a study conducted in Bangladesh in 2006 10 revealed 26.0% prevalence of malnutrition and 62.0% at risk of malnutrition.
Present study shows the association between age and nutritional status of participants.
Older age was associated with the lower MNA scores in our population.Similar findings has been observed in some previous studies as individuals age, their nutritional status appears to deteriorate. 21,22In addition, a statistically significant association was observed between past occupation of the participants and nutritional status (p =0.021) in the present study.Similarly, an association between past occupation and nutritional status was observed in the studies conducted in Nepal. 23tritional status was significantly associated with the smoking status (p =0.031).This is similar to the study conducted in Pyuthan District of Nepal 24 and southern Brazil. 25The association between smoking and nutritional status can be attributed to various impacts that smoking has on altering metabolic regulation and thyroid gland. 26Those at risk of malnutrition or malnourished were seen in higher proportion among those who did not perform any physical activity (91.2%).A significant association was found between physical activity and nutritional status in this study (p =0.004).This findings is consistent with the study conducted in Morang district. 27his can be explained by the fact that lack of physical activity can lead to lifestyle disease including both physical and mental health problems.It is well documented that physical inactivity, or a decreased physical activity level is an underlying mechanism of sarcopenia 28 and therefore, promotion of physical activity with nutrition intervention could be important for improving the well-being of elderly's.
This study shows that mode of feeding was significantly associated with nutritional status, which is similar with the study conducted at Gokarneshwor Municipality in Kathmandu. 29 this study, no significant association was observed between educational level and nutritional status.The proportion of malnourished/ at risk was higher among the illiterate participants than literate participants which is consistent with the study conducted in India 30 and Iran, 31 which indicate that the nutritional levels of elderly people are influenced by their literacy levels.
The study reveals a significant proportion of elderly individuals are at risk of malnutrition or being malnourished while living in old ages.Furthermore, nutritional status of elderly was significantly associated with explanatory variables: age (p =0.001), past occupation (p =0.021), smoking status (p =0.031), physical activity (p =0.004), two or more servings of legumes or eggs (p =0.045) and mode of feeding (p =0.004).These findings emphasize the importance of regularly monitoring the nutritional and health status of elderly people residing in such facilities.By implementing timely interventions, the nutritional well-being and quality of life for elderly individuals can be greatly improved.

Table 1 :
Socio-demographic, lifestyle, health related factors and anthropometric measurements of the participants (n = 133) .With a mean age of 74.82 years and 8.764 SD, 27.1 % belonged to the age group 60-69 years, 39.8% to the age group 70-79 years, and 33.1% to the age group 80 and above.Female participants were dominant as they were almost eight out of ten (78.9%).
participantsfifth of the participants (78.9%) didn't know about their weight loss.Similarly, 69.2% of participants, were able to go outside the old age homes.A significant proportion (62.4%) didn't suffer from psychological stress.This study also showed that 9.0% were reported to have mild dementia.Almost three-quarters of

Table 3 : Association between demographic, lifestyle health's related factors and general assessment with nutritional status
(*) variables are significantly associated.