Background: International studies on nursing home residents have demonstrated that undernutrition is a prevalent and serious health issue among this population of older persons. On the other hand, obesity is prevalent among the elderly in Malta. However, to date, there has been no published study on the nutritional status of elderly nursing home residents in Malta. Objective: To assess the nutritional status of Maltese nursing home residents and determine the prevalence of underweight, overweight and obesity. Method: Cross-sectional quantitative survey research was undertaken from 19 Jan to 23 Feb 04 using the full MiniNutritional Assessment (MNA) tool which includes Body Mass Index (BMI) measurement. Subjects: 43 eligible residents (23 females and 19 males) from one female and one male ward of St Vincent de Paul Residence (SVPR). Results: The prevalence of undernutrition was 9.5% and risk of undernutrition was 71.5%. The prevalence of underweight, overweight and obese residents was 7.1%, 35.7% and 26.2% respectively.peer-reviewe

Choon-Huat Koh, Gerald

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28 Malta Medical Journal    Volume 17   Issue 01   March 2005AbstractBackground: International studies on nursing homeresidents have demonstrated that undernutrition is a prevalentand serious health issue among this population of older persons.On the other hand, obesity is prevalent among the elderly inMalta.  However, to date, there has been no published study onthe nutritional status of elderly nursing home residents in Malta.Objective: To assess the nutritional status of Maltesenursing home residents and determine the prevalence ofunderweight, overweight and obesity.Method: Cross-sectional quantitative survey research wasundertaken from 19 Jan to 23 Feb 04 using the full Mini-Nutritional Assessment (MNA) tool which includes Body MassIndex (BMI) measurement.Subjects: 43 eligible residents (23 females and 19 males)from one female and one male ward of St Vincent de PaulResidence (SVPR).Results:  The prevalence of undernutrition was 9.5% andrisk of undernutrition was 71.5%.  The prevalence ofunderweight, overweight and obese residents was 7.1%, 35.7%and 26.2% respectively.Conclusions: Overnutrition, instead of undernutrition, isa nutritional problem among nursing home residents in SVPR.However, a high proportion of residents remain at risk ofundernutrition.  Nutritional assessment is recommended toindividualise diet to resident’s needs.IntroductionMalnutrition is defined as a condition that results from adeficit or excess of nutrients or energy in relation to metabolicand tissue needs.  Hence, malnutrition can be divided into eitherundernutrition or overnutrition. Protein-Energy Undernutrition(PEU), a form of undernutrition, is particularly common amongfrail elderly people in nursing homes and its prevalence in suchsettings is estimated to be 30 – 60%.1 - 3   Overnutrition is theother end of the spectrum of malnutrition with obesity being aconsequence.  Overweight and obesity are major health issuesin Malta, where the prevalence of BMI exceeding the upper limitof normal (ie. >25 kg/m2) for women and men aged above 65years and living in the community is 72.7% and 62.5%respectively.4  Among all the European Union AscensionCountries in Europe in 2004, Malta had the highest incidenceof obesity.5  There has been no previously published data on thenutritional status of older persons in Maltese nursing homesand the prevalence of PEU, overnutrition and obesity isuncertain.The MNA is a semi-quantitative, interviewer-administeredassessment tool that has been validated and shown to beeffective in detecting PEU among older persons in nursinghomes in France and USA.6  The MNA has also been shown topredict morbidity and mortality.  In the SENECA study (alongitudinal Europe-wide multi-centre study on nutrition andhealth in the elderly), Danish subjects determined by the MNAto be at risk of malnutrition or already malnourished hadincreased nutrition-related morbidity and mortality over a five-year follow-up period.7   A copy of the MNA is listed as Figure 1and is available free from the website http://www.mna-elderly.com/clinical-practice.htm.The MNA was redesigned in 1998 to have a screening stageto save time and enhance its usefulness which used 6 keyparameters of its original 18 items.8   A screening score of <11out of a maximum possible score of 14 suggests possibleundernutrition and the rest of the 12 MNA items shouldsubsequently be administered.  The screening stage is onlyrecommended for elderly populations with a low prevalence ofOvernutrition Among Older Personsin a Maltese Nursing HomeOriginal ArticleGerald Choon-Huat KohKeywordsMNA (Mini Nutritional Assessment), undernutrition,overnutrition, malnutrition, body-mass index, obesity, nursinghome, older persons.Sources of Research Funding / SupportManuscript based on research for a dissertation submitted forDiploma in Gerontology and Geriatrics which was funded by aMerck Institute of Ageing and Health Fellowship grant.Informed ConsentInformed verbal consent was obtained from all participants priorto entry into study.  The study did not pose any health risk toparticipants.Gerald Choon-Huat KohFellow, College of Family Physicians (Singapore)European Institute of Gerontology, University of Malta.Email: dr_gerald_koh@hotmail.comMalta Medical Journal    Volume 17   Issue 01   March 2005 29undernutrition and since the prevalence among Maltese nursinghome residents was uncertain, the full MNA was used for thisstudy.Participants and MethodsSt Vincent de Paul Residence (SVPR) was chosen as thestudy population.  SVPR is a government-run nursing homeinstitution with a bed complement of 1050 beds.  It providesnursing home and respite care and offers medical, nursing,physiotherapy, occupational therapy, speech therapy, podology,dental and ophthalmic services.9One female general ward (44 beds) and one male generalward (36 beds) in SVPR were selected.   From each ward, allresidents who satisfied the following inclusion criteria wereinvited to participate in the study:1. 65 years old or above.2. Able to give informed verbal consent.3. No limb amputations (because it invalidates BMImeasurement)4. Eating meals orally.5. Stays in residence >90% of the time.The two wards selected were only general wards and thestudy excluded wards caring for residents with severebehavioural and psychological symptoms of dementia (eg.agitation, wandering), populations known to be at high risk ofundernutrition.To reduce inter-assessor variability, the MNA was onlyadministered by the investigator.  Height was measured usinga calibrated, non-stretchable tape attached to a vertical pointand weight was measured using a calibrated digital weighingchair.  Guidelines on how to administer the MNA (described inthe MNA User Guide 10) were closely followed.  A Maltesetranslation of the MNA was created to standardize the phrasingof questions (Table 1).  It should be noted that the MNA hasbeen validated with English and French speaking elderly butnot with Maltese speaking elderly.  Subtle nuances of questions(especially Items A, B, O and P) in the English version may havebeen lost in the Maltese translation.  The study did not poseany health risk to participants.  As part of the consent process,subjects were informed that they had been selected for a studyand the purpose of the study explained to them.  The studyincluded residents with dementia but omitted those whoseconsent was not informed or whose relatives were not availableto provide surrogate consent.  The MNA can be used withdemented persons (provided their answers are checked foraccuracy with nursing staff or caregiver) and has been used inresearch with Alzheimer’s dementia patients.11ResultsOut of a total of 80 residents from both wards, only 42satisfied the inclusion criteria and were enrolled into the study.The reasons for exclusion of residents from participating in thestudy are tabulated in Table 2.The characteristics of the study population are presented inTable 3.  SPSS statistical software (version 10.0) was used foranalysis.  The Student t-distribution was used for calculatingconfidence intervals and testing differences in means betweengenders.  There was no significant difference in age betweengenders (t = 0.54 at 0.05 level of significance).  The height andweight of males were significantly higher than females whichare expected as males are generally taller and heavier.  However,Table 1:  Maltese translation of MNA questions which participants are asked directly30 Malta Medical Journal    Volume 17   Issue 01   March 2005the BMI scores for female subjects were significantly higher thanmales (t = 2.17 at 0.05 level of significance) and the MNA scorefor female subjects were significantly lower than males (t = 4.01at 0.05 level of significance), using independent samples t-test.The BMI score correlated positively and significantly with MNAscores (simple linear regression, F = 10.62, p = 0.02).The prevalence of undernutrition in the sample was 9.5%while nearly three-quarters of residents were at risk ofundernutrition (71.5%).  Only 7.1% of the study population wasunderweight but 35.7% were overweight and 26.2% were obese.DiscussionThe prevalence of undernutrition in the sample was only9.5% whereas published data on undernutrition among nursinghome residents in other countries is estimated to be 30% to60%.  There are many possible reasons why the prevalence ofundernutrition in the study was low.  The menu for residentswas highly adequate for protein, fruits and vegetables.  This issupported by a 100% response rate for the full score for selectedconsumption markers for protein intake (Item K of MNA) and95.2% response rate for adequate consumption of fruit andFigure 1:  The Mini-Nutritional Assessment (MNA) Form(available from website http://www.mna-elderly.com/clinical-practice.htm)Malta Medical Journal    Volume 17   Issue 01   March 2005 31vegetables (Item L of MNA).  Residents with dementia severeenough to preclude informed consent made up 44.7% ofresidents who were excluded from the study.  This group ofelderly is at higher risk of undernutrition and their exclusioncould have lowered the prevalence of undernutrition in the studypopulation.  The high functional status of SVPR residents isanother possible contributing factor to the low prevalence ofundernutrition as only 14.3% were either bed or chair bound (ItemC of MNA).   When compared to a study by Yap et al where 48%of Singaporean nursing home residents were non-ambulant orbedridden, the prevalence of undernutrition was correspondinglyhigher at 22%.12   The final sample of 42 participants may be toosmall to represent a 1050 bedded institution.  It must also benoted that including residents from other nursing homes wouldhave provided more information for comparison because nursinghomes are heterogeneous and the study nursing home is anunusually large residential institution.The high prevalence of obesity among subjects may have“protected” residents from undernutrition because of greaterinitial nutritional reserve.  The prevalence of BMI exceedingthe upper limit of normal was 73.9% for females and 47.3% formales.  The BMI for female elderly residents may have beenunfairly high because females experience loss in height frompost-menopausal osteoporotic vertebral fractures and heightmeasured may be lower than the true height.  Nevertheless, itappears that undernutrition is not as large a problem in Maltesenursing homes as overnutrition.  Obesity has its associatedmorbidity such as coronary heart disease, diabetes,Female Ward Male WardTotal no. of residents 44 36Reasons for exclusionYounger than 65 years 2 5Unable to give consent because of dementia 13 4Unable to give consent because resident was deaf and illiterate 3 1Unable to give consent because resident was too ill 0 1Refused consent 1 2Has lower limb amputations 1 1On non-oral feeding 1 0In ward < 90% of the time 0 3Total no. of residents excluded 21 17Total no. of study participants 23 19Table 2:  Reasons for exclusion of residents from studyFemales Males AllMean value (95% Confidence Interval)Age (years) 83.0 (80.2 – 85.8) 81.9 (78.9– 84.9) 82.5 (80.5 – 84.5)Height (m) 1.46 (1.44 – 1.49) 1.65 (1.60 – 1.70) 1.55 (1.51 – 1.59)Weight (kg) 60.1 (55.1 – 65.1) 68.0 (62.8 – 73.2) 63.7 (60.1 – 67.3)Number (and %) of subjects by BMI (kg/m2)Underweight (< 20) 2 (8.7%) 1 (5.3%) 3 (7.1%)Normal (20 – 24.9) 4 (17.4%) 9 (47.4%) 13 (31.0%)Overweight (25 – 30) 8 (34.8%) 7 (36.8%) 15 (35.7%)Obese (>30) 9 (39.1%) 2 (10.5%) 11 (26.2%)Number (and %) of subjects by MNA ScoreNormal (24 - 30) 6 (26.1%) 2 (10.5%) 8 (19.0%)At Risk of Undernutrition (17 – 23.5) 14 (60.9%) 16 (84.2%) 30 (71.5%)Undernourished (0 – 16.5) 3 (13.0%) 1 (5.3%) 4 (9.5%)Table 3:  Characteristics of study population32 Malta Medical Journal    Volume 17   Issue 01   March 2005osteoarthritis, disability and breast cancer in postmenopausalwomen.13   In dependent residents who require assistance inambulation and ADLs, obesity increases physical demands onnursing care staff and increases difficulty in utilizing exerciseas a weight-loss tool.  The SENECA study has confirmed thepresence of obesity in community-living elderly men and womenin Malta and it appears that this extends to elderly nursing homeresidents. With increasing numbers of older persons and obesitybecoming an increasingly common health problem in Europe,the nutritional status of nursing home residents may changefrom undernutrition to overnutrition.   Further researchinvolving a larger sample size and other Maltese nursing homesis needed to fully elucidate the extent of this problem.The finding of a high proportion of elderly residents at highrisk of undernutrition seems to contradict the finding of a highprevalence of overweight and obesity.  Many residents wereassessed to be at risk of undernutrition because of theirconcurrent medical problems, evidenced by the high positiveresponse to MNA questions on recent psychological stress oracute disease (Item D = 45.2%), neuropsychological problems(Item E = 54.8%) and taking more than 3 prescription drugs aday (Item H = 73.7%).  It appears that while the residents are atrisk of undernutrition, their current nutritional status is over-compensated.  A possible reason could be the caloric value ofthe diet provided may be too high for the low activity level ofresidents, many of whom are functionally impaired.  Given theheterogeneity of medical problems and nutritional needs ofolder persons, individual nutritional assessment and tailoringof diet provided is needed.Four out of the six items in the screening stage retained theirclose correlation with the final MNA score [Item A (p = 0.028),B (p = 0.014), E (p = 0.008) and F (p = 0.002)].  With the lowprevalence of undernutrition in study nursing home, validity ofthe screening stage of MNA is expected.  Thus, nutritionalscreening using the 2 stages of the MNA is appropriate in SVPR.ConclusionThe prevalence of undernutrition among older persons in aMaltese nursing home is estimated to be 9.5% and theprevalence of risk of undernutrition is 71.5%.  The prevalenceof underweight, overweight and obese residents is 7.1%, 35.7%and 26.2% respectively.  Overnutrition appears to be moreprevalent than undernutrition among older persons in Maltesenursing homes.  This may be related to the high prevalence ofobesity in Malta.  However, many older persons remain at riskof undernutrition and individualisation of diet to nutritionalneed is recommended.AcknowledgementI thank Ms Maria Ellul who provided critical review of thestudy proposal.References1. Rudman D, Feller AG. “Protein-calorie undernutrition in thenursing home”.  J Am Geriatr Soc 1989;37(2):173-83.2. Rudman D, Arora VD, Feller AG, Nagraj HS, Lalitha PY, CaindecNP. “Epidemiology of Malnutrition in Nursing Homes”. In:Morley JE, Glick Z, Rubenstein LZ, editors.  Geriatric Nutrition: aComprehensive Review. 1st Edition. New York: Raven Press; 1990.p. 325-32.3. Pinchcofsky-Devin GD, Kaminski MV Jr.  Incidence of protein-calorie malnutrition in the nursing home population.  J Am CollNutr 1997;6:109-12.4. National Statistics Office (Malta).  Malta Lifestyle Survey. 2003.p. 37.5. International Obesity Task Force and European Association forthe Study on Obesity Task Force. Obesity in Europe: A Case forAction. 2002. p 6.6. Guigoz Y, Vellas B, Garry PJ. Mini Nutritional Assessment: Apractical assessment tool for grading the nutritional status ofelderly patients. In: Vellas BJ, Guigoz Y, Garry PJ, Albarede JL,editors. Facts and Research in Gerontology (Suppl: Nutrition). 2nded. Europe: Serdi Publisher; 1994. p. 15-59.7. De Groot LC,†Beck AM†, Schroll M, Van Staveren WA. Evaluatingthe Determine Your Nutritional Health†Checklist and the MiniNutritional Assessment as tools to identify nutritional problemsin elderly Europeans. Eur J Clin Nutr, 1998;52:877-83.8. Rubenstein LZ. “Development of a short version of the MiniNutritional Assessment”. In: Vellas B, Garry PJ, Guigoz Y,editors. Mini Nutritional Assessment (MNA): Research andpractice in elderly. NestlÈ Clinical and performance NutritionWorkshop series, Vol 1. Philadelphia: Lippincott-Raven; 1998. p.101-111.9. Ministry of Health (The Elderly and Community Care). SaintVincent de Paul Residence. (cited 25 Dec 04). Available fromURL http://www.health.gov.mt/service/svpr.htm.10. Nestlè Nutrition. A Guide to Completing the Mini NutritionalAssessment.  (cited 2003, Nov 3. Available from URL http://www.mna-elderly.com/clinical-practice.htm.11. RiviËre S, Lauque S, Vellas B. Health promotion programme:nutrition and Alzheimer’s disease. J Nutr Health Aging1998;2(2):101-6.12. 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Overnutrition among older persons in a Maltese nursing home

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Overnutrition among older persons in a Maltese nursing home

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