Dietary Diversity and Nutritional Status: An Association Among the Elderly

Background: Old age and nutrition have become a Global challenge. Inadequate dietary intake arises mostly as a result of physiological changes which contribute to malnutrition. Studies conducted in India focused mainly on the Nutritional Status of Infants and Pregnant women, leaving out this important age group which is also vulnerable to malnutrition. The focus of this study was to find out the dietary diversity and its association with nutritional status among the rural elderly


INTRODUCTION
Globally, the prevalence of the elderly population aged more than 60 years has increased gradually over the past few decades.In India, it accounts for 6.8 percent of the total population as per the population pyramid. 1 India and other countries are experiencing an increasing elderly population as a result of the decline in fertility and mortality rates.Old age and nutrition have become a Global challenge.Malnutrition among the elderly often goes unrecognized.Inadequate dietary intake arises due to physiological changes, lack of financial support, stressful life events, and improper access to food, which contribute to malnutrition. 2 Dietary Diversity is the number of food groups consumed by the individual over a reference period. 3It reflects the concept that increasing the variety of food groups in the diet helps to ensure the intake of adequate nutrients which is essential to maintain proper health status. 4 It is a key component of health, fitness, and overall wellness and helps to reduce the risk of major diseases like Diabetes, Hypertension, Metabolic syndrome, Stroke, and Cancer.Dietary diversity is usually affected by various factors like age, sex, physical and mental health, and social and macroenvironment.Studies conducted in India have shown a strong association between Dietary diversity and nutrient adequacy. 5,6though there are previous studies evaluating the factors of dietary diversity and nutritional status, most of them have focussed on children, and pregnant and lactating women unrecognizing the elderly age group which is most vulnerable to malnutrition because of inadequate food intake, poor nutrient absorption, illnesses that cause increased nutrient requirement, lack of proper care.Malnutrition and unintentional weight loss among the elderly contribute to reduced physical and cognitive functional status, increased hospitalizations, progressive decline in health, and increased mortality. 7Nutritional assessment should be a routine point of care for all elderly persons so that malnutrition can be recognized at an early stage and appropriate preventive measures can be taken.The focus of this study was to assess the dietary diversity among the elderly and its association with nutritional status and awareness in the study population about nutritional deficiencies.The objectives were to find out the dietary diversity and prevalence of malnutrition among the elderly and to find out the association between dietary diversity and nutritional status among them in the rural areas of the Chengalpattu district.

METHODOLOGY
Study setting: This study was carried out in a rural field practicing area of a tertiary care teaching hospital in Chengalpattu district, Tamil Nadu.The field practice area includes 12 villages from 2 blocks among the 8 blocks of Chengalpattu district, namely Thiruporur and Thirukazhukundram block.The total population of 12 villages was 42425 among which elderly people aged 60 years and above were listed and the samples were selected for the study.

Study design and Target population:
This study was a community-based cross-sectional study carried out among Elderly people residing in a study setting.The inclusion criteria were elderly people above 60 years of age who are permanent residents of the study setting.People with acute illness and discharged from the hospital, previously diagnosed chronic illnesses, and patients with neuropsychiatric disorders were excluded from the study.
Sample size determination and Sampling procedure: Geoffrey Maila et al in their study among the elderly in rural South Africa found low dietary diversity among 64.4% of participants (5) .Considering its prevalence, with a 95% confidence interval, allowable error of 7%, and non-response rate of 10%, the sample size was estimated to be around 200.The study was conducted in Chengalpattu district of Tamil Nadu and the sampling method followed was multistage random sampling.Among 8 blocks, 2 blocks were selected by lottery method.The blocks selected were the Thiruporur and Thirukazhukundram blocks.These two blocks contain several villages among which 12 villages that come under the field practice area of tertiary care hospital were selected.The 12 villages include Mahabalipuram, Kokilamedu, Poonjeri, Kadumpadi, Manamai, Kunnathur, Nallur, Perumaleri, Karanai, Kunnapattu, Kuzhipanthandalam, Payyanur covering a population of 42425.Among these, 5642 elderly above 60 years were listed.These 12 villages were considered as 12 clusters and 17 participants from each cluster were selected by simple random sampling to obtain a sample size of 200.

Study period: The study duration was from Sep
Study tool: A semi-structured questionnaire obtained from the Food and Agricultural Organisation 7 for measuring the Individual Dietary Diversity Score (IDDS) was used in the study.The questionnaire consists of the following sections.Section 1 had questions related to the sociodemographic profile of the participant.
Section 2 was the dietary diversity questionnaire based on 14 food groups consumed by each participant 7 days before the day of the interview.In addition to the 24 hours, a 7-day reference period was used as a valid timeframe for dietary recall.Respondents who consumed a specific food group were given a score of 1 and who never consumed the notified food group were given a score of 0. To calculate Dietary Diversity Score (DDS), the number of food groups consumed by individual respondents was summed over the 7-day recall period. 8Currently, as there are no established cut-off values for the number of food groups to indicate Inadequate and Adequate dietary diversity for the Elderly, the mean dietary diversity score was used as the cut-off.Based on this, participants with DDS less than 7 were considered to have Inadequate dietary diversity and those who had DDS 7 and above as Adequate dietary diversity.Section 3 consisted of questions modified from the Mini Nutritional Assessment tool 9 to assess the Nutritional status of the participants and it also included other age-related perceived health statuses like Ocular morbidities, Hard of hearing, Tooth loss, Insomnia, and Falls.Section 4 included Anthropometric measurements like weight, height, BMI, Waist circumference, Hip circumference, Waist-hip ratio, Mid-Upper arm circumference, Body Adiposity Index, and Calf circumference that were classified based on WHO standards for assessing nutritional status. 11,12ta collection: After obtaining Institutional Ethical Committee approval (IHEC-I/1228/22) participants were selected based on inclusion and exclusion criteria.Informed consent was obtained from the participants, the questionnaire was explained and the responses were filled out using the interview method.The dietary diversity was calculated as per the guidelines of the Food and Agricultural Organization based on the Individual Dietary Diversity Score.Anthropometric measurements such as Weight, Height, Waist Circumference, Hip Circumference, Mid Upper Arm Circumference, and Calf Circumference were measured using a digital weighing scale, Stadiometer, and a measuring tape.Waist-hip ratio, Body Adiposity Index, and BMI were computed using standardized formulas.

Statistical analysis:
The collected data were entered into Microsoft Office Excel and analyzed using Statistical Package for Social Sciences (SPSS) version 21.Relevant frequency distribution was calculated and tabulated.The continuous variables were expressed in mean and standard deviation.Categorical variables were presented as percentages and compared using the Chi-square test and Fisher's exact test.A pvalue of <0.05 was considered significant and the independent variables were dichotomized and subjected to the bivariate logistic regression model.The outcome is reported as an adjusted odds ratio with 95% CI.

RESULTS
Demographic and socio-economic characteristics: Out of 200 participants, the majority were females (52.5%) and 47.5% were males.The mean age of the participants was 70±5.7 years.A total of 66.5% of respondents were married while almost 33.5% were single due to divorce or the spouse's death.More than half of the respondents (56.5%) had no formal education while 56.5% of participants were unskilled workers.Most participants, 33%, belonged to the Upper lower class of socio-economic status as per the modified BG Prasad scale (Feb 2022) 10 57 % of respondents have comorbidities.Table 1 shows the distribution of baseline characteristics of participants.
Dietary Diversity: Food groups like Cereals, Vitamin A-rich vegetables, Green leafy vegetables, and eggs were found to be highly consumed by 100%, 90%, 82%, and 80% of the respondents respectively.Also, Seafood (mostly fish), Flesh meat, Roots and Tubers, and Milk products were found to be commonly consumed by 74.5%, 59%, 58%, and 46% of respondents respectively while few of the respondents do consume fruits (24%), Organ meat (11.5%),Nuts and legumes (5%), Oil and Fat (4%).Further analysis revealed that the mean dietary diversity score was 7.2±1.8.The minimum DDS was 4 while the maximum was 12. Currently, as there are no established cut-off values to classify dietary diversity as low or high, the mean score was used as a cut-off for Adequate and Inadequate dietary intake.Based on this, 37% of respondents have Inadequate dietary diversity, while 63% consume diverse diets.A significant association was observed between dietary diversity scores and socio-demographic characteristics like marital status (p = 0.045), educational status (p = 0.002), Type of house (p = 0.001), and Socioeconomic status (p = 0.000) indicating that adequate diversity is observed among participants who are married, residing in the pucca house with better educational level and belonging to upper socio-economic status.
Table 2 shows the association between the sociodemographic characteristics and dietary diversity of respondents.
Nutritional status: The nutrition assessment component of the study revealed that 21.5% of respondents were undernourished as character- rized by the WHO BMI [11] cut-off value of less than 18.5, 60% of participants were in normal weight while 18.5% were overweight.Being Underweight was more prevalent in men (57%, n=25) than in women (43%, n=18).The study assessed Waist circumference (WC) and Waistto-hip ratio (WHR) as per WHO cut-off points 12 for both men and women and found that the majority of women (71%) were at risk of developing Central Obesity compared to men (29%).

DISCUSSION
The study explored the association between dietary diversity scores and nutritional status among older persons.The findings on food consumption revealed that many participants consumed mostly carbohydrate food sources and vegetables whereas Vitamin A-rich foods, and protein-rich food were consumed in lesser quantities.Their diet typically consisted of Rice and green leafy vegetables.This agrees with the study conducted in rural Zambia on dietary diversity among the Elderly by Geofrey Maila et al. 5 It was also observed that most of the vegetables that were consumed at the time of the study were seasonal and rain-fed.
Most participants consuming vegetable foods may be attributed to the availability and affordability of vegetables during the study.Low consumption of organ meat, legumes and nuts, milk, and milk products, and moderate consumption of eggs and fish may be a result of the low socioeconomic status of participants, as they could not afford to purchase foods that they did not produce.This finding concurs with that of other researchers 13,14 that poor households subsist on monotonous staple-based diets and lack access to nutritious food such as vegetables, fruits, and animal source foods.It can further be stated that the high rice and maize consumption observed was a result of these being stapled foods for the local community.The nutritional status of respondents was measured using the Anthropometry method.Based on Body Mass Index, more than half of the respondents (60%) had an acceptable Nutritional status while some (18.5%) were Overweight and Obese.However, being Underweight (21.5%) was more prevalent among men compared to women which is contrary to studies conducted on nutritional status among the elderly by Thouhidur Rahman et al and Patra S et al which state that females are vulnerable to malnutrition. 15,16This can be attributed to the fact that most of the male participants in the study setting were living independently and experienced depressive symptoms which tend to lose their appetite, refuse to eat, and experience weight loss. 17ist circumference and Waist-Hip Ratio among study participants indicated that most of the women were at risk of developing Central obesity compared to men which are in accordance with the study conducted in India among Older adults by Banerjee, S. et al 18 .This indicates that the elderly in the study area must be duly taken care of to reduce the prevalence of malnutrition among them by targeting the dietary intervention program thereby improving the quality of life of the rural elderly.However, recall bias could not be eliminated because the participant's replies to questions about dietary diversity relied on their memory and capacity to recall the specific food groups correctly.The study could not assess the seasonal variation of dietary diversity among the study participants.

CONCLUSION
The present study found out that most study participants were consuming a diverse diet and those subjects with better dietary diversity scores had their Body Mass Index in the normal range.Thus, the study revealed a statistically significant association between dietary diversity and nutritional status among older persons suggesting that adequate dietary diversity can contribute to the attainment of optimum nutritional status.Nutritional intervention should focus on older people with lower wealth and educational levels and who live in rural areas which might help to increase dietary diversity in the elderly.It also recommends the existing public health guidelines that encourage people to consume all major food groups including fruits, vegetables, and dairy products as a part of their regular Balanced diet.