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 Table of Contents  
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 64-68

Malnutrition in elderly pilgrims attending kumbh festival 2019: A cross-sectional study

1 Department of Geriatrics, Armed Forces Medical College, Pune, Maharashtra, India
2 Commandant, 7AFH, Kanpur, Uttar Pradesh, India
3 O/o DGMS (Army), New Delhi, India
4 Central Air Command, Prayagraj, Uttar Pradesh, India

Date of Submission21-Oct-2020
Date of Decision23-Dec-2020
Date of Acceptance26-Dec-2020
Date of Web Publication01-Apr-2022

Correspondence Address:
Col (Dr) Vivek Aggarwal
Department of Geriatrics, Armed Forces Medical College, Pune - 411 040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_154_20

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Background and Objectives: Geriatric population is at increased risk of malnutrition which in turn leads to decreased immunity, sarcopenia, frailty and poor clinical outcomes. This study was planned to study the prevalence of malnutrition in the elderly people (>60 yrs) attending Kumbh Mahotsava. The objectives of the study were to see the association of malnutrition with socioeconomic status, gender, age and geriatric syndromes. Methods: Cross sectional observational study in elderly more than 60 years attending Kumbh Festival. Nutritional assessment was done using Mini Nutritional Assessment (MNA) questionnaire. Socioeconomic status was assessed using the modified Kuppuswamy score. Anthropometric data like body mass index (BMI), calf circumference, and upper mid-arm circumference were measured. All the above data points were integrated into a web application and the socioeconomic and nutritional score were calculated automatically. Based on nutritional assessment nutritional advice was given by a short message service and verbal counseling. Prevalence of malnutrition and its association with socioeconomic status, gender, age and geriatric syndromes were analysed. Results: Total 219 elderly were included in the study. Mean age was 68.5 years. Around 70% (152/219) were either malnourished or at risk of malnutrition. Nutritional status was significantly associated with modified Kuppuswamy socioeconomic status (P = < 0.001). There was a significant association between nutritional status and presence of geriatric syndromes in form of having a falls (P= 0.010), leaking of urine (P= <0.001) and forgetfulness (P < 0.01). Conclusion: Around 70% (152/219) of the elderly were either malnourished or at risk of malnutrition with significant ssociation with socioeconomic status and geriatric syndromes. This study shows the importance of screening our geriatric population for malnutrition.

Keywords: Elderly, Kumbh, malnutrition, mini nutritional assessment

How to cite this article:
Aggarwal V, Sashindran V K, Dudeja P, Prashant P, Sarkar N, Vasdev V, Singhal A. Malnutrition in elderly pilgrims attending kumbh festival 2019: A cross-sectional study. J Mar Med Soc 2022;24, Suppl S1:64-8

How to cite this URL:
Aggarwal V, Sashindran V K, Dudeja P, Prashant P, Sarkar N, Vasdev V, Singhal A. Malnutrition in elderly pilgrims attending kumbh festival 2019: A cross-sectional study. J Mar Med Soc [serial online] 2022 [cited 2022 Aug 18];24, Suppl S1:64-8. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/64/342376

  Introduction Top

Increased life expectancy and decreasing fertility rate have globally led to accelerated aging of populations.[1] India is in a phase of demographic transition and the population is aging at a very rapid pace.[2] The geriatric population is the fastest-growing segment of the population in our country.[3] Increasing life expectancy also increases the chances of malnutrition.[4] This increased risk of malnutrition may be due to a number of factors such as poverty, isolation, loneliness, inability to procure or prepare food, poor awareness and knowledge about balanced nutrition, decreased appetite, polypharmacy, multiple comorbidities, and physiological and psychosocial changes.[5],[6],[7],[8] Poor nutrition is a very important risk factor for infections, decreased immunity, sarcopenia, falls, poor clinical outcomes, and mortality. Nutrition also impacts response to therapy and the duration of hospital stay in the elderly population.[9] Thus, screening for malnutrition in older adults is very important to reduce morbidity, disability, and mortality.[10] Poor nutrition in the elderly impedes their independence and quality of life.[11] Assessment of malnutrition in the elderly is complex as body mass index (BMI) is not a reliable indicator.[12] Serum albumin alone as a marker of nutrition in the elderly is not proven.[13] Multiple tools are used in the elderly to assess nutritional status. These include the Mini Nutritional Assessment (MNA), Geriatric Nutrition Risk Index, and Malnutrition Universal Screening Tool.[14] MNA tool is simple, noninvasive, and therefore the most extensively used tool to assess nutrition in the elderly.[15],[16] The modified Kuppuswamy scale is one of the most commonly used tools to measure socioeconomic status in both urban and rural settings. It was devised by Kuppuswamy in 1976 and later on was modified to determine the socioeconomic status of the family and not an individual. The components of the Modified Kuppuswamy score are education and occupation of the head of the family along with the monthly income of the family. The score ranges from 3 to 29 and classifies the population into five different socioeconomic groups.[17]

Kumbh Mahotsav is the biggest gathering of humankind on earth and attracts people from all over the country. The elderly, flock to this event, hoping to ensure salvation for their souls.[18] The population in Kumbh Mela is likely to be heterogeneous as people from all over the country come on pilgrimage. This can, therefore, be taken as a representative sample of India as a whole. The present study was done during Kumbh Mahotsav 2019 with the aim of determining the prevalence of malnutrition in elderly people (>60 years of age). The objectives of the study were to see the association of malnutrition with socioeconomic status, gender, age, and geriatric syndromes.

  Materials and Methods Top

This was a cross-sectional observational study conducted on elderly pilgrims attending the Maha Kumbh festival 2019 at Prayagraj. Data were recorded between January 27, 2019 and February 10, 2019. A large eye camp with a capacity to screen 3000–5000 elderly patients for ophthalmologic morbidity was the setting for our study. With the permission of the organizers, we set up a medical camp inside their facility. All sequential willing patients >60 years of age attending this eye camp (Netra Kumbh) were included in the study. A web application was created to capture the demographic and socioeconomic data. Nutritional assessment was done using the MNA questionnaire which comprises of four sections and a total of 18 questions for anthropometric assessment (height, weight, and weight loss); general assessment (living conditions, use of more than three prescription medicines, and mobility); dietary assessment (number of meals, fluid, intake of protein and milk products, and autonomy of feeding); and lastly, the individual's perception of one's own health and nutritional status. The maximum score of the MNA tool is 30. A score of <17 is suggestive of malnutrition, while a score between 17 and 23.5 indicates “at risk of malnutrition.” A score of 24 or higher is a marker of a satisfactory nutritional status.

History of comorbidities and geriatric syndromes was recorded. Calf and upper mid-arm circumference and BMI were measured. All the above data points were integrated into a web application which could be used on a mobile or a tablet and data were captured automatically. At the end of the assessment, MNA score and modified Kuppuswamy score were calculated automatically by the web application to assess the nutritional status and socioeconomic status of the elderly. Based on the nutrition score, an automated nutritional advice was generated by the application which could be messaged as short message service on the individual's mobile number. Immediate nutritional counseling was also done verbally. The concept of balanced diet was promoted. This covered frequency, quality, and quantity of recommended food to be taken by elderly people. The questions of the web application were administered by a trained geriatric physician in Hindi and English depending on the educational status of the participant. The association between socioeconomic status, age, gender, and geriatric syndromes was studied with nutritional assessment as assessed by the MNA tool.

Data were collated and analyzed in IBM statistics SPSS software Version 22.0 (IBM Corp, Armonk, NY, USA). Informed consent of the individuals was obtained. The sample size was calculated based on the prevalence of malnutrition as 19% with alpha of 0.05 and precision of 5%. The computed number was 120. On each day, approximately 20 patients were assessed. Using systematic sampling, patients were selected and interviewed till the final sample size was achieved. The study was approved by the Institutional Ethical Committee.

  Results Top

A total of 219 elderly were included in the study and analyzed for nutritional status. The mean age was 68.5 years. Fifteen subjects were more than 80 years of age. Males constituted 68.4% (150/219) and females constituted 31.6% (69/219). Fifty-three elderly belonged to Kuppuswamy socioeconomic status I or II, whereas 166 belonged to Kuppuswamy socioeconomic status III, IV, or V. Around seventy percent (152/219) of the elderly were either malnourished or at “risk of malnutrition” and only 30.5% (67/219) had a satisfactory nutritional status as per MNA tool. Poor nutritional status was significantly associated with Kuppuswamy socioeconomic status (p = <0.001). Gender did not influence nutritional status significantly (P = 0.31). People more than 80 years of age did not differ from the other elderly as far as nutritional status was concerned (P = 0.13), However, if we were to only consider absolute numbers, 13 out of 15 elderly above 80 years were either malnourished or at risk of malnutrition. Details are shown in [Table 1]. Although malnutrition was seen to significantly correlated with the educational status of the study population (P < 0.001), the Pearson's correlation coefficient was only 0.523 suggesting a very week correlation [Table 2].
Table 1: Correlates of malnutrition in elderly

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Table 2: Correlation between educational status and malnutrition in the geriatric population attending Kumbh festival

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It was noted that 28.7% (63/219) elderly were on more than three prescription drugs. Only 6.3% (14/219) gave history of suffering from acute illness or psychological stress in the last 3 months. Almost 70% (152/219) had only 2 meals/day. Almost one-third of the elderly denied consuming any milk products. BMI of more than 23 was noted in 52% (114/219). The BMI was <19 kg/m2 in about 10% (23/219) and in 16.8% (37/219), the BMI ranged between 19 and 21 kg/m2. Mid-arm circumference was >22 cm in 56.2% (123/219) and was <21 cm in 8.2% (19/219). In all others, it was between 21 and 22 cm. As per the MNA tool, a mid-arm circumference of above 22 cm is considered normal and between 21 and 22 cm is considered borderline abnormal. Almost one-fourth (55/219) had calf circumference of <31 cm (normal value as per MNA tool is >31 cm). Educational status revealed that 18.3% (40/219) were illiterate, whereas 21.9% (48/219) had graduation and/or postgraduation degrees. One-third of the elderly did only elementary occupations and had no fixed source of income, 15% (33/219) were farmers, and 5% (11/219) had handicraft-related work.

Among the geriatric syndromes, falls, leakage of urine, and forgetfulness were the most common. 22/24 subjects with history of >1 fall in the past year and 130/195 without history of falls were malnourished or at risk for malnutrition (P = 0.010). 52/62 subjects who had leaked urine in the past month and 100/157 who gave no history of urinary incontinence were malnourished or at risk for malnutrition (P < 0.001). 43/49 subjects with history of forgetfulness and 111/170 without history of forgetfulness were malnourished or at risk for malnutrition (P < 0.01). Details are shown in [Table 3].
Table 3: Geriatric syndromes associated with malnutrition

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  Discussion Top

In a recent study from South India, 76.7% of the elderly had impaired nutritional status with 17.9% being malnourished and 58.8% at risk of malnutrition.[19] In another study done from urban Maharashtra, the prevalence of malnutrition and “at risk of malnutrition” was 50.7%.[14] In our study, 69.04% of the elderly were either malnourished or “at risk of malnutrition.” Similar findings were noted in a recent Sri Lankan study where almost two-third of the elderly patients were either malnourished or at risk of malnutrition.[20]

This nutritional deficiency increases with advancing age due to multiple factors including reduced appetite, comorbidities, and polypharmacy.[21] However, in our study, the advanced age of more than 80 years was not seen to be significantly associated with malnutrition with P value of 0.13, though 13 out of the15 oldest subjects in our study were either malnourished or were at risk of malnutrition. The small number of this subset may be due to their inability to undertake such a strenuous pilgrimage. Female gender is considered to be a risk factor of malnutrition as seen in the studies done by Aggarwala R and Domini LM et al.[6],[22] However, in our study, there was no significant association noted between female gender and malnutrition. This may be due to the fact that more than two-third (150/219) of subjects in our study were males. Socioeconomic status plays a very important role in the nutritional status of the elderly as lower socioeconomic status predisposes to undernutrition.[6] Similar findings were noted in a study done by Hoogendijk et al. where socioeconomic status was an important determinant of the nutritional status of the elderly population.[23] In our study also, the socioeconomic status, as determined by Modified Kuppuswamy socioeconomic status, was significantly associated with nutritional status with those from lower socioeconomic strata being more prone to malnutrition. Educational status in our study was seen to be associated with malnutrition, but that correlation coefficient was only 0.523 suggesting a very week correlation.

Malnutrition has been associated with geriatric syndromes as seen in a study done by Saka et al. showed a strong correlation between malnutrition and geriatric syndromes (P < 0.001). They found that as many as 62% of their subjects with >4 geriatric syndromes had low MNA scores. In people with >6 geriatric syndromes, 80 had low MNA scores.[24],[25] In a study from Taiwan, it was noted the odds risk for fall in elderly with malnutrition or at risk of malnutrition was 1.73 in a study from Taiwan.[26] Dementia has also been shown to be associated with malnutrition with an odds ratio of 2.72 and P value of 0.010.[21] Similar findings were seen in another dementia progression study where malnutrition was associated with 3–4-time hazard for developing dementia.[27] Saka et al. found that 63% of patients with (77/123) with low MMSE score and 36% of subjects with normal MMSE score had low MNA scores (P < 0.0001).[24] Malnutrition has also been seen to be associated with urinary incontinence in a study done by van Bokhorst-de van der Schueren et al.[7] Our findings mirror those of these studies. Malnutrition is today considered a major geriatric syndrome.[28],[29]

Despite almost 2/3 of our subjects being classified as undernourished or at risk for malnutrition, the anthropometric assessments did not conform to this trend. Only 10% had a BMI of <19 kg/m2 and 52% were overweight. Sarcopenia seems to be a bigger problem with mid-arm circumference being <22 cm and calf circumference being <31 cm in about 60% and 25% of the study population, respectively. A study from South India showed that mid-arm circumference and calf circumference can be used as a marker of undernutrition by community workers with mid-arm circumference being better than calf circumference. Both mid-arm circumference and calf circumference had good correlation with BMI.[24]

Almost 70% of the elderly in our study were barely able to manage 2 meals/day and almost one-third did not consume any dairy or milk products. Moreover, most of the elderly consumed a diet which was not adequately balanced. In a country where milk and milk product consumption is so prevalent, this finding is contrary.

This study shows that malnutrition in the elderly is a major cause for concern. Awareness is lacking both among doctors and lay public. Poverty and lack of livelihood both affect food choices. In a country with such a rich dietary tradition and culture, the lack of diversity in food consumption is a matter of concern. This is mainly due to ignorance. In a systemic review of dietary patterns in the Indian population, 11 different dietary patterns were identified with majority of the dietary pattern having increase carbohydrate and fat intake with vegetarian predominance.[30] A study from Taiwan found that dietary attitudes in the elderly are often governed by tradition and religious beliefs.[31] This study emphasizes the importance of educating the elderly about diet and nutrition. Another good example of dietary education impacting the longevity of the elderly comes from Japan. The Ministry of Agriculture, Forestry, and Fisheries of Japan developed a Japanese Food Guide Spinning Top in 2005 and vigorously popularized it. This was basically to educate people about the quantity and balance of food components in daily diet. In their prospective cohort study, Kurotani et al. found that good adherence to these Japanese dietary guidelines led to decreased mortality from cardiovascular disease, especially cerebrovascular disease.[32] The strength of the study is that it looked at a heterogeneous population from all over the country. Bias due to geographical and regional variation was thus eliminated. The limitation of the study is that only the physically active and less infirm people would attend the Maha Kumbh festival. Another limitation of the study was that the geriatric population constituted only a small subset of the population coming to the eye camp and the findings of this study cannot be generalized to the whole geriatric population. Our study may not, therefore, be truly representative of the whole geriatric population of the country. Never the less this study gives us insight into the nutritional status of the elderly population in our country and can be a starting point to assess the nutritional status of our elderly population on a larger scale in the community using the web application designed for this study.

  Conclusion Top

Seventy percent (152/219) of the elderly were either malnourished or at risk of malnutrition. Poor nutritional status was significantly associated with a lower Kuppuswamy socioeconomic status and presence of geriatric syndromes. This study shows the importance of screening our geriatric population for malnutrition. A focus on their nutrition will help keep them healthy and prevent morbidity.

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  [Table 1], [Table 2], [Table 3]


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