Introduction

Nutrition plays profound role in progress of a nation by enhancing physical and mental efficiency of its people and diseases reduction contribute significantly in this process. These issues have drawn the attention of policy makers to prioritize actions for nutritional wellbeing [1]. Besides health nutrition affects functionality of aged people [2]. Older people are vulnerable to under-nutrition as a consequence of biological, physiological, social and psychological changes associated with ageing [3]. Decreasing independence, financial restriction, food anxieties, multiple morbidities, social isolation and widowhood and bereavement jeopardize nutritional status in old age in an interacting manner [4].

In Indian context under nutrition has been viewed as state of being poorly nourished and this has more relevance in old age. Government of India has given due priority to raising nutritional status of Indian population. Considering vulnerability of children and pregnant women initial focus was directed to them. However, it was gradually realized that nutritional status of adolescents and elderly has been far from satisfactory. Adolescent nutrition is currently in the agenda of government. It was assumed that geriatric subjects enjoy prestige in the society and prevailing socio cultural context will take care of nutritional requirement of geriatric subjects. Epidemiological and nutrition transitions have made geriatric population vulnerable in achieving optimum nutritional health because of variety of reasons. Due to emergence of nuclear families and socio economic vulnerability they are at higher risk of Chronic Energy Deficiency [5].

It is difficult to reverse physiological changes (viz., loss of taste sensation, reduced stomach compliance etc) occurring during old age. Therefore, care of geriatric subjects should focus on socio-demographic and socioeconomic issues. There exist direct association between nutritional status and socioeconomic status of individuals. Chronic Energy Deficiency (CED) is common among older persons who live in poverty and this is applicable in adult population as well [6]. Nutritional status in older persons is influenced by their gender, religion, marital status, present employment and family structure[7]. Widowhood without financial protection and living support predisposes to CED. Chronic Energy Deficiency is likely to be more in elderly who are dependent on others than those who are independent. Unfortunately, not much attention has been given to pinpoint factors contributing to CED in urban geriatric subjects of this region of India. Understanding of predictors of CED is prerequisite for planning and execution of initiatives for tackling problem of CED in geriatric subjects on principle of prioritization. In the existing scenario it is worthwhile to pinpoint predictors of chronic energy deficiency in aged subjects.

Materials and Methods

Study design and setting

A community based cross sectional study was conducted in census enumeration wards of a district of eastern Uttar Pradesh. This study was confined to urban component and the study area Varanasi having population of 1597051 which happen to be 43.44% of the entire population of the district [8]. The district has 90 census enumeration wards.

Subjects and sample size

For estimation of sample size prevalence formula was used. With understanding that major underline factor of chronic energy deficiency is socio economic deprivation (SED). The different values used in the formula were SED (40%) [9], Z value (1.96), permissible level of error (5%), design effect (1.5) and non response rate (10%) of estimated sample size. The final sample size was fixed at 616. Simple random sampling procedure was adopted to select 9 out of 90 census enumeration wards of urban Varanasi. For selection of households and family as well as individual's probability proportion to size and lottery methods were applied, respectively. Those who consented for this study were included whereas those who stayed in the area for < 6 months and those with serious mental abnormality were excluded.

Tools and techniques

The tool of the study was proforma. At the outset consent of the subject was obtained using consent form. Socio demographic and economic characteristics of the study subjects were obtained by interview technique and pertinent information was recorded in the proforma.

Assessment of Socio Economic status

For assessment of socioeconomic status Kuppuswamy’s socio economic scale was used [10]. The parameters utilized for this purpose were education and occupation of head of the family and family income. Characterization of socio economic status was done based on total score as upper, upper middle, and lower middle the other two (upper lower and lower) together were used as proxy indicator of socio economic deprivation. Each subject was specifically interviewed for type of ration card possessed by them.

Assessment of Nutritional Status

Anthropometric measurements (weight and height of the subjects) were done as per standard guidelines.[11] For measurement of height anthropometric rod with accuracy of 0.1 cm was used. Body Mass index (BMI) of the subjects was determined by dividing their weight (kg)/ height (m²). A subject with BMI <18.5 kg/m² was considered as victim of CED. BMI range for normal, overweight and obese were 18.5-22.99 kg/m², 23-24.99kg/m² and >25 kg/m², respectively. This stratification is based on World Health Organization criteria (2000) for Asian population.

Ethical Clearance

Institutional Ethical Review Committee, Banaras Hindu University, Varanasi, India was approached for ethical clearance. After getting ethical clearance study was initiated in the urban areas of Varanasi. Bilingual consent form (Hindi and English version) was used to obtain consent of the subjects of the study.

Analysis of Data

IBM Statistical Package (SPSS) version 22.0 was used for data analysis. For statistical association Pearson’s Chi square test was used and cutoff for significance was p<0.05. All significant variables were put in the logistic model. Adjusted Odds Ratios and 95% Confidence Interval were computed to find out predictors of chronic energy deficiency.

Results

General characteristics

Out of 616 geriatric subjects 63.6% belonged to 60-69 years whereas, 28.1% subjects were 70-79 years and rest (8.3%) were from > 80 years. Nearly 13 out of 20 (64.6%) subjects were living with their spouse, whereas 35.4% were without spouse. In case of 82.6% subject’s religion was Hindu; 51.6% belonged to Other Backward Caste followed by Others (32.5%) and rest were from Scheduled Caste/Scheduled Tribe (15.9%) caste categories. Subjects belonging to joint/three generation families were 70.4%; 29.6% subjects were from nuclear family. As much as 16.9% subjects were self engaged in income generation activities, whereas, 17.9% subjects were unemployed. Nearly four out of ten subjects were illiterate and 33.4% subjects had educational status as high school and above. As per Kuppuswamy classification 41.9% subjects were in socioeconomically disadvantaged position whereas, 25.3% subjects were from upper middle class. Subjects belonging to upper lower and lower middle were 35.2% and 26.0%, respectively. Out of 616 subjects in this study, 598 (97.1%) were provided card and of these 85 (14.2%) were below poverty line.

Associates of Chronic Energy Deficiency

Out of 616 subjects' anthropometric measurements of 4 subjects were not recorded because of their bending position hence nutritional status of 612 subjects was assessed. As per World Health Organization Asian classification 44.8% subjects were victim of CED whereas, 16.2% subjects were either overweight or obese. Nearly 4 out of 10 (39.1%) subjects classified as normal. In this study association of nutritional status of subjects with socio-demographic variables have been done to find out the influencing factors of CED in geriatric subjects. There existed significant (p<0.01) association of nutritional status with age, marital status, religion and occupation of the subjects (Table 1). However, nutritional status of study subjects was not significantly (p>0.05) influenced by caste, gender, size and type of family.

Extent of CED was 36.2% in 60-69, 56.1 %in 70-79 and 74.5% in > 80 years age group. None of the subjects > 80 years were either overweight or obese; whereas 21.7% participants were from 60-69 years and 8.1% subjects belonging to 70-79 years age group were either overweight or obese. CED was maximum (55.6%) in widower, and this was least (40.3%) in married subjects; half of the widowed subjects had CED. As much as 20.7% married, 8.9% widower and 7.1% widowed subjects were either overweight or obese. Extent of CED was 40.9% in Hindu and 63.2% in Muslim subjects, whereas overweight/obesity was present in 17.6% Hindu and 9.4% in Muslim subjects. Extent of Chronic Energy Deficiency was maximum (66.7%) in unskilled subjects whereas prevalence of overweight/obesity was maximum (33.3%) in retired subjects and nil in unskilled workers. CED was maximum in SC/ST (53.1%), subjects from joint family (49.2%) and having family size > 6 (47.6%), whereas overweight/obesity was maximum in others caste category (19.7%), subjects from nuclear family (20.4%) and having family size 3 to 6 (19.7%). Nutritional status of participants was significantly influenced (p<0.01) by their education. Extent of CED in subjects with educational status just literate and below was 50.6% whereas, this was 53.1%, 41.7%, 33.3%, 31.0% and 21.9% in participants having educational status as 5^th standard (primary) and 8^th standard (Middle) secondary, senior secondary and graduate and above, respectively. Prevalence of overweight/obesity was maximum (40.6%) in subjects with educational status as graduate and above and this was least (11.6%) in illlterate and  just literate subjects (Figure 1).

Figure 1: Educational and nutritional status of study subjects (N=612)

Nutritional status of the participants was significantly influenced by socioeconomic status and type of card (Table 2). Extent of CED was least (26.2%) in upper SES; whereas 56.4%, upper lower plus lower, 43.0% lower middle and 32.3% upper middle SES subjects were victim of CED. Prevalence of overweight and obesity was maximum (40.5%) in upper SES and this was least in upper lower plus lower SES (7.8%). CED was maximum (66.2%) in subjects with white card and this was least in those without card (38.9%).

Predictors of Chronic Energy Deficiency

The logistic regression analysis was done to pinpoint predictors of Chronic Energy Deficiency in geriatric subjects (Table 3). This analysis eliminated the influence of marital and occupational status obtained in bivariate analysis. However, Adjusted Odds Ratio was 1.39 (95% CI: 0.78-2.46) for widower and 1.02 (95% CI: 0.60-1.73) for widowed subjects. In comparison to service plus retired plus self employed subjects AOR for CED was 1.69 (0.77-3.72) for skilled/unskilled workers and 1.47 (0.83-2.61) for unemployed subjects though it is not significant at 5% level. On the basis of logistic regression analysis significant AOR was obtained for age, religion, literacy status, socio economic status and type of card. AOR for under nutrition was 4.05 (95% CI: 1.52- 10.77) in > 80 years and 2.20 (95%CI: 1.4-3.43) in 70-79 years age group. In comparison to Hindu, Muslim subjects had significantly higher AOR (2.16; 95%CI: 1.31-3.56) for CED. Logistic analysis revealed that when subjects having educational status intermediate and above were considered as reference significantly (p<0.05) higher AOR for CED prevailed for illiterate and just literate (AOR 2.53; 95% CI: 1.10-5.81) and primary plus middle (AOR 2.42; 95%CI 1.08-5.44). Subjects belonging to upper plus upper middle and lower middle categories had significantly (p <0.05) less AOR for CED than subjects from lower socio economic status (AOR 1.74; 95%CI: 1.02-2.96). AOR for CED in subjects with white and Red/Pink ration card was 1.79 (95%CI: 1.03-3.11).

Discussion

Several physiological functions can alter nutritional wellbeing of aged persons resulting in reduced Body Mass Index. It was observed in this study that with progressing age there was decline in subjects with normal Body Mass Index and increasing trend of CED; seven out of twenty from the age group 60-69 years have been victim of CED; in contrast to this, three out of four subjects > 80 years had CED. In conformity of the present study several workers also observed higher prevalence of under nutrition with advancing age [7,13,14]. Half of widowed, 11 out of 20 widower, and 4 out of 10 married subjects of this study had CED, these findings are consistent with the scenario presented in studies conducted in South India [7,15]. Adversities of nutritional status in single, widowed and divorced subjects may be due to lower economic and social support. In consonance with finding of present study religion-wise difference in nutritional status has been also observed in a study conducted on urban and rural geriatric subjects [7]. In contrast to findings regarding similar nutritional status of male and female subjects of present study there are several evidences substantiated gender as a predictor of nutritional status [14,16,17]. Though in the present study gender was not found significantly associated with nutritional status however, higher percentage of geriatric female is in category of obesity/obese than male was observed. It could be attributed to the fact that females particularly after middle age tend to live sedentary life style while male subjects have to continue working because of economic constraints which make them active to lead a normal health status. In female the low levels of estrogens and progesterone after menopause result into overweight/obesity and their risk factors [16]. Variations in nutritional status of geriatric subjects observed in different studies may be due to difference in tools and criteria, geographical context and their demographics. Contrary to present observation significant association between nutritional status and type of family has been reported from a study conducted in South India [7]. Although CED was more in subjects form large family size (>6) the association between nutritional status and family size have not been significant at 95% level. In the present study extent of CED was highest in SC/ST caste. However, nutritional status of subjects was not significantly different in different caste categories. Living alone was not considered for bivariate analysis in this study. However, finding of a study from Iran revealed that under nutrition has been significantly more frequent in the older people living alone before nursing home placement [18].

In conformity with the finding of present study significant linkage between literacy and nutritional status, has been observed in Indian studies conducted in Karnataka[7]; Rajasthan[19] and Eastern Uttar Pradesh [13]. Finding of significant association of occupation with nutritional status is consistent with the observations made by other workers as well[7,19].

Socio Economic Status (SES) has been considered as an important predictor of nutritional status. Irrespective of parameter adopted for SES it has been observed that if a subject was at lower level of SES there was more prevalence of CED whereas reverse trend was observed for obesity/overweight; with increasing socio economic status lower prevalence of CED has been reported by several workers [7,15,19,20]. Subjects having lower per capita income have more adversities for nutritional status [13]. If geriatric subjects are dependent on others, chances of nutritional adversities are more [7,20]. A study conducted in Coimbatore observed that geriatric subjects without access to pension had more under-nutrition than those having pension. It has been observed that with increasing number of lifestyle, somatic, functional and social factors there had been lower Mini Nutritional Assessment (MNA) Scores of subjects [15].

In consonance with the findings of the present study in logistic model, increasing age has been identified as risk for under nutrition by other workers [4,21,22]. Marital status as single/widowed/divorced than married has higher odds of under nutrition [4,15,22,23]. However, significant association between marital status and nutritional status observed in the present study in bivariate analysis was not substantiated by the logistic model. Besides the present study lower income or socio economic status in reality or in perceived form have been identified as predictor of under nutrition by several workers [15,22,23,24]. No pension to those having pension has been identified as predictor of malnutrition [15]. Higher Adjusted Odd Ratios in older geriatrics belonging to Muslim religion, having educational status as illiterate, just literate, primary plus middle and subjects from lower socio economic status call for focused and targeted interventions for improving nutritional status of geriatric population.

Conclusion

Subjects in higher age, from Muslim religion, having educational status less than intermediate, lower and lower upper socio economic status and with white/pink ration card had higher risk for CED. It is imperative that targeted and focused strategies giving considerations to these risk factors can give optimum dividend in terms of improvement of nutritional status of geriatric population.

Acknowledgement

Authors would like to acknowledge all subjects for their participation and corporation for this study.

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