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Original Article

Prevalence and Correlates of Malnutrition among Elderly in an

Urban Area in Coimbatore
Anil Chankaramangalam Mathew1, Darsana Das2, Saranya Sampath2, M. Vijayakumar3, N. Ramakrishnan4,
S. L. Ravishankar5
1
Professor of Biostatistics, 3PGT, 5Professor, Department of Community Medicine, PSG Institute of Medical Sciences and Research,
4
Medical Officer, PSG Urban Health Training Centre, Coimbatore, Tamil Nadu, 2Trainee Biostatistician, Department of Statistics and
Biostatistics, St. Thomas College, Kottayam, Kerala, India

Abstract
Background: Different studies in India have shown that more than 50% of elderly population of India are suffering from
malnutrition and more than 90% have less than recommended intake. Objectives: The aim of this study is to estimate
the prevalence and correlates of malnutrition among elderly aged 60 years and above in an urban area in Coimbatore
using Mini Nutritional Assessment (MNA). Methods: A cross-sectional study was conducted on 154 households and
190 elderly were interviewed. Nutritional status was assessed using the MNA questionnaire. Results: Mean (standard
deviation) age of the total population (n = 190) was 71.09 (7.93) years and 30% was male. In this population, 37 (19.47%)
was malnourished (MNA <17.0) and 47 (24.73%) were at risk for malnutrition (MNA 17.0–23.5). No significant association
was observed between smoking, current alcohol consumption, higher medication use, higher comorbidity, and use of walk
aid with malnutrition. Among the social factors studied, lower socioeconomic status compared to higher socioeconomic
status (adjusted odds ratio [OR] =5.031, P < 0.001), single/widowed/divorced compared to married (adjusted OR = 3.323,
P < 0.05), and no pension compared to those having pension (adjusted OR = 3.239, P < 0.05) were significantly
associated with malnutrition. Conclusion: The prevalence of malnutrition observed in the aged people is unacceptably
high. The increasing total number of lifestyle, somatic, functional, and social factors was associated with lower MNA
scores. The findings of the present study clearly indicate that malnutrition is a multifactorial condition associated with
sociodemographic, somatic, and functional status. Hence, we recommend that the treatment of malnutrition should be
multifactorial, and the treatment team should be multidisciplinary. Further research is needed to develop appropriate
guidelines for nutritional screening and interventional programs among geriatric population.

Keywords: Elderly, malnutrition, Mini Nutritional Assessment

Introduction health of the elderly will be an important issue defining

The World Health Organization (WHO) has stated that aging
populations will present new challenges to health care. The
Corresponding Author: Dr. Anil Chankaramangalam Mathew,
Department of Community Medicine, PSG Institute of
Medical Sciences and Research, Coimbatore - 641 004,
Tamil Nadu, India.
E-mail: anilpsgmet@gmail.com
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the health status of a population.1 As the number of elderly
increases, so too will their health needs. Multimorbidity
associated with increasing age is common and is found to
be more frequent in resource-poor countries.2 It is therefore
required that health policy addresses this subgroup of the
population as well.1 In India, the elderly (aged 60 years
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DOI: 10.4103/0019-557X.184542 Cite this article as: Mathew AC, Das D, Sampath S, Vijayakumar M,
Ramakrishnan N, Ravishankar SL. Prevalence and correlates of malnutrition
among elderly in an urban area in Coimbatore. Indian J Public Health
PMID: ***
2016;60:112-7.

© 2016 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow

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Mathew, et al.: The prevalence and correlates of malnutrition
and above) constitutes 7.7% of the total population of
1.20 billion and this number is increasing.3 With national
health policy focusing on maternal health, child health, and
communicable diseases, the health status of the elderly has
not been given due consideration.4 Since nutrition of the
elderly affects immunity5 and functional ability,6,7 it is an
important component of elderly care that warrants further
attention. The magnitude of malnutrition among the elderly
in India is under-reported. The few studies that have been
done showed that more than 50% of the older population
is underweight8 and more than 90% has an energy intake
below the recommended allowance.9
There is no gold standard for estimating malnutrition
among the elderly. Body mass index (BMI;
weight [kg]/height [m2]) predicts disease risk both in
those termed underweight and in those who are obese.
The WHO categorizes underweight as BMI <18.5, normal
18.5–24.9, overweight 25–29.9, obese 30–30.99, and
extreme obesity >40. However, BMI may be unreliable
in the presence of confounding factors such as edema or
ascites, and may not identify significant unintentional
weight loss if used as a single assessment.10-12 Furthermore,
reliable measurement of height can be difficult in
the elderly because of vertebral compression, loss of
muscle tone, and postural changes.10,13 Mini Nutrition
Assessment (MNA) is a widely used international
questionnaire to evaluate the nutritional state of seniors
with high sensitivity (98.9%), specificity (94.3%), and
diagnostic accuracy (97.2%). It closely correlates with
biochemical (albumin, prealbumin, transferrin levels,
and lymphocyte numbers) and anthropometrical markers
(measuring of subcuticular fat and arms circumference)
that were verified by a number of clinical studies on
wide sets of geriatric patients.14-16 However, in India,
only a very few community studies were conducted to
estimate malnutrition among elderly on MNA. In this
study, we aimed to estimate the prevalence and correlates
of malnutrition among elderly aged 60 years and above
in an urban area in Coimbatore using MNA.
Materials and Methods
Study design and population
For this cross-sectional study aiming to investigate the
prevalence and correlates of malnutrition among elderly
population aged 60 years and above, the sample size was
estimated as 113. This is based on an expected correlation
of a number of correlates and MNA score r = 0.30 with
α = 0.05 two-sided and β = 0.10. The urban health center
Indian Journal of Public Health, Volume 60, Issue 2, April-June, 2016
113
of PSG Institute of Medical Sciences and Research has
six areas on which three areas were randomly selected.
The selected areas were HUDCO Colony, AD Colony, and
Pattalamman Kovil Street. The total number of households
on these three areas was 762. In 565 houses, there were no
elderly people and nonresponse was obtained in 43 houses.
Hence, we surveyed 154 households and 190 elderly
were interviewed. They were asked about demographic,
medical history, medication use, and lifestyle. Some of
the responses were obtained from the relatives. All elderly
people aged 60 years and above residents at HUDCO
Colony, AD Colony, and Pattalamman Kovil Street were
included in the study. Those who were too sick, those who
were not present at the time of visit, and those who could
not stand unsupported due to debility were excluded from
this study. Approval for the study was obtained from the
Institutional Human Ethics Committee. Written informed
consent will be obtained from each patient.
Nutritional status
Nutritional status was assessed with the MNA, a validated
questionnaire for older individuals.17 The questionnaire
comprises 18 questions clustered in four sections:
Anthropometric assessment (weight, height, and weight
loss); general assessment (living situation, medicine use,
and mobility); dietary assessment (number of meals, food
and fluid intake, and autonomy of feeding), and subjective
assessment (self-perception of health and nutritional status
and nutritional status). A maximum score of 30 can be
obtained. A score below 17 indicates malnutrition, a score
of 17–23.5 indicates a risk of malnutrition, and a score
of 24 or higher indicates a satisfactory nutritional status.
Factors associated with malnutrition
Possible covariates of malnutrition were classified as
lifestyle, somatic, functional, and social factors.18 Lifestyle
characteristics included smoking and alcohol consumption.
It was assessed by checking whether the aged person was
a current smoker versus never/past smoker or a current
alcohol user versus never/past user. Somatic characteristics
included medication use, comorbidity, and use of walking
aid. The number of drugs was derived either directly from
the elderly people or from the relatives. Medication use was
classified as using ≤3 versus >3. Comorbidity was assessed
by summing the number of underlying chronic diseases
of elderly people. It was classified as having <2 versus ≥2
chronic diseases. The following chronic diseases were
considered: Hypertension, diabetes, and cardiovascular
disease. The use of walking aid was classified as No
versus Yes.18 Functional characteristics included activities
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114 Mathew, et al.: The prevalence and correlates of malnutrition

of daily life (ADL) and instrumental ADL (IADL). ADL
was assessed by asking if the elderly people were able to
dress or wash himself independently or not. IADL was
assessed by asking the elderly people were able to do the
shopping and cleaning the household independently or not.
Both ADL and IADL were classified as independent versus
not independent. Social factors included socioeconomic
status, education, marital status, pension, and living
alone. Socioeconomic status was classified on the
basis of modified Prasad’s classification (August 2014)
according to which the five classes are: Class I (>5770
per capita income), Class II (2890–5770 per capita
income), Class III (1730–2890 per capita income),
Class IV (870–1730 per capita income), and Class V (<870
per capita income). It was classified as Classes I, II, III
versus Classes IV and V. Education was classified as
schooling up to 12th versus college and above. Marital
status was classified as married versus single/widowed/
divorced. Pension and living alone were assessed as Yes
versus No.
Other variables
Height was measured with a measuring tape (Wellknown
Syndicate. Tirupur, Tamil Nadu, India) measured to the
nearest centimeter (cm) and weight was assessed by a
digital weighing machine to the nearest kilogram (kg).
BMI was calculated as weight in kg by the square of
height in meters (kg/m2).
number of covariates (0–2, 3–5, 6–7) and compared
using Kruskal–Wallis test. Statistical analysis was
performed with SPSS software (19) IBM, New York,
USA.
Results
Mean (standard deviation) age of the total population
(n = 190) was 71.09 (7.93) years and 30% was male.
In this population, 37 (19.47%) was malnourished
(MNA <17.0) and 47 (24.73%) were at risk for
malnutrition (MNA 17.0-23.5) [Figure 1]. No
significant association was observed between neither
smoking nor current alcohol consumption with
malnutrition [Table 1].
Among the somatic characteristics studied, no significant
association was observed between higher medication use
and malnutrition. No significant association was observed
between higher comorbidity and malnutrition. Similarly,
no significant association was observed between use of
walk aid and malnutrition. Findings were presented in
Table 1.
Table 1: Lifestyle, somatic, and functional characteristics
associated with malnutrition
Different parameters n Malnourished, Unadjusted Adjusted for
n (%) OR (P) age and sex
Lifestyle characteristics
Smokers

Statistical analysis Never/past 179 34 (19.0) 1 1

Current smokers 11 3 (27.3) 1.599 (0.504) 1.554 (0.611)
Characteristics in the elderly were calculated for the Alcohol
nutritional status categories (malnourished: MNA <17.0, Never/past 185 35 (18.9) 1 1
at risk of malnutrition: 17.0–23.5, and normal Current consumers 5 2 (40) 2.857 (0.260) 2.953 (0.308)
nutritional status: >23.5). Logistic regression analysis Somatic characteristics
was performed to assess the independent association Medication use
≤3 152 32 (21.1) 1 1
of the covariates with the presence of malnutrition.
>3 38 5 (13.2) 0.568 (0.277) 0.594 (0.409)
Somatic, functional, social, and lifestyle characteristics Comorbidity
were separately included as covariates in the model. <2 161 33 (20.5) 1 1
Regression analysis was adjusted for age and sex. To ≥2 29 4 (13.8) 0.621 (0.405) 0.724 (0.648)
assess the independent association of the covariates Use of walk aid
with the presence of malnutrition, all covariates for No 186 35 (18.8) 1 1
Yes 4 2 (50) 4.314 (0.151) 5.716 (0.107)
malnutrition (somatic, functional, social, and lifestyle)
Functional
were included in one logistic regression model using characteristics
backward elimination. Hosmer and Lemeshow test and ADL independent
Omnibus Chi-square statistic were performed to test the Yes 107 17 (15.9) 1 1
No 83 20 (24.1) 1.681 (0.159) 0.219 (0.165)
goodness of fit of the model. In addition, Nagelkerke
IADL independent
R2 and Cox and Snell R2 as well as classification table Yes 127 17 (13.4) 1 1
of the models were also computed. Finally, all somatic, No 63 20 (31.7) 3.010 (0.003) 12.789 (0.018)*
functional, and social correlates were summed, and *P<0.05, IADL = Instrumental activities of daily life, OR = Odds ratio, ADL = Activities
median MNA score was calculated for categories of of daily life

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Mathew, et al.: The prevalence and correlates of malnutrition 115

Table 2: Social factors associated with malnutrition

120
Social factors n Malnourished, Unadjusted Adjusted
100 106 n (%) OR (P) OR (P)
No. of study participants

Socioeconomic status
80 Classes I, II, III 138 15 (10.9) 1 1
Classes IV and V 52 22 (42.3) 6.013 (0.000) 5.031 (0.000)
60
Education
College and above 29 1 (3.4) 1 1
40 47
37 Schooling up to 12th 161 36 (22.4) 8.064 (0.044) 3.037 (0.311)
20 Marital status
Married 96 13 (13.5) 1 1
0 Single/widowed/ 94 24 (25.5) 2.189 (0.040) 3.323 (0.022)
Malnourished At risk of malnutrition Normal nutritional Status divorced
Figure 1: Distribution of the study participants according to malnutrition assembled
Pension
by Mini Nutritional Assessment Yes 68 6 (8.8) 1 1
No 122 31 (25.4) 3.520 (0.008) 3.239 (0.029)
Among the functional characteristics studied, IADL Living alone
No 178 35 (19.7) 1 1
dependent was significantly associated with malnutrition Yes 12 2 (16.7) 0.817 (0.800) 0.944 (0.948)
even after adjusting for age and sex (adjusted odds OR = Odds ratio
ratio [OR] =12.789, P < 0.05). Findings were presented
in Table 1. Table 3: Factors associated with malnutrition in the multivariate
regression analysis
Among the social factors studied, lower socioeconomic Variables Adjusted OR P 95% CI
status compared to higher socioeconomic status (adjusted IADL independent
OR = 5.031, P < 0.001), single/widowed/divorced Yes 1 0.005 1.432-7.587
No 3.296
compared to married (adjusted OR = 3.323, P < 0.05), and
Socioeconomic status
no pension compared to those having pension (adjusted Classes I, II, III 1 0.000 2.194-11.144
OR = 3.239, P < 0.05) were significantly associated with Classes IV and V 4.945
malnutrition [Table 2]. In the multivariate analysis also, Marital status
the same variables were found to be statistically significant Married 1 0.049 1.001-5.399
with malnutrition and the model was found fit well by Single/widowed/divorced 2.325
Pension
Hosmer–Lemeshow statistic (P = 0.613) [Table 3]. The
Yes 1 0.043 1.035-7.731
model explained between 17.9% (Cox and Snell R2) and No 2.829
28.6% (Nagelkerke R2) of variance in the dependent IADL = Instrumental activities of daily life, OR = Odds ratio, CI = Confidence interval
variables studied and correctly classified 83.7% of cases.
Table 4: Mini Nutritional Assessment score for categories of
Furthermore, increasing total number of lifestyle, total number of covariates
somatic, functional, and social factors was associated Total number of covariates (lifestyle, MNA score P
somatic, functional, or social characteristics) median value
with lower MNA scores (P < 0.001) [Table 4].
0-2 26 <0.001
3-5 23.50
Discussion 6-7 16.50
Kruskal–Wallis Chi-square statistic=34.856. MNA = Mini Nutritional Assessment
The present study among 190 geriatric populations
indicates a high prevalence of malnutrition (19.47%). urban elderly (11% and vs. 62% and 2% and 36%,
Poor functional status measured through IADL, poor respectively).19 In another study at Vellore, 14% were
socioeconomic status, living as single/widowed/divorced, malnourished and 49% were at risk of malnourishment.
and no pension was independently associated with Compared with these results, our population shows
malnutrition. There were only a few studies conducted in slightly higher rates of malnutrition.
India using the MNA questionnaire to assess malnutrition.
Only such study was done in Western Rajasthan and In our study, statistically significant association was
showed a prevalence of malnourishment and risk of found between poor socioeconomic status in general and
malnourishment among rural elderly compared with malnutrition. We also observed a significant association

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116 Mathew, et al.: The prevalence and correlates of malnutrition
between malnutrition and those who do not have a
pension. High prevalence of malnutrition among elders
in poor socioeconomic status was reported in some
earlier studies.8,9 This could be attributed to the fact that
socioeconomic conditions influence dietary choices and
eating patterns thereby affecting the nutritional status. We
also observed that those who are living alone were having
higher rates of malnutrition. This may also attribute to the
practical difficulties that influence their dietary choices
and eating patterns.
Many studies reported a strong association between
lifestyle factors particularly smoking and alcoholism
with malnutrition. However, in our study, we could not
observe any significant association between lifestyle
factors and malnutrition.
Our findings that the MNA score was lower in patients
with multiple burdens of somatic, functional, or social
characteristics provides further evidence that malnutrition
could be regarded as a geriatric syndrome, next to
already established geriatric syndromes such as falls,
incontinence, pressure sores, and delirium. A geriatric
syndrome refers to one symptom or a complex of
symptoms with high prevalence in geriatric populations
resulting from multiple risk factors and leading to
decreased functioning.
We observed that malnutrition is associated with several
adverse clinical outcomes. 20-22 Since malnutrition is
mostly thought to be modifiable, it is important to develop
and implement adequate interventions to prevent,
diagnose, and treat malnutrition. Early identification of
malnutrition is a first step. The MNA fulfills many criteria
for both screening and diagnostic measures.23 Protein and
energy supplementation was considered as an effective
intervention strategy not only to increase height24 but also
to improve functional characteristics.25,26 However, the
findings from our study clearly indicate that intervention
should preferably target not only the nutritional status
but also underlying problems in the somatic, social, and
functional domain.
Our study has several strengths. We have used a validated
questionnaire to elicit the prevalence of malnutrition. The
availability of a complete and extensive dataset is another
strength of the study. However, our study has some
limitations. This is a cross-sectional study and hence
could not establish cause–effect relationship. Second,
our data collection was dependent on the response of
Indian Journal of Public Health, Volume 60, Issue 2, April-June, 2016
individual person and their relatives. This could have led
to both under and over reporting of comorbidity.
Conclusion
The prevalence of malnutrition observed in the aged
people is unacceptably high. The increasing total
number of lifestyle, somatic, functional, and social
factors was associated with lower MNA scores. The
findings of the present study clearly indicate that
malnutrition is a multifactorial condition associated with
sociodemographic, somatic, and functional status. Hence,
we recommend that the treatment of malnutrition should
be multifactorial, and the treatment team should be
multidisciplinary. Further research is needed to develop
appropriate guidelines for nutritional screening and
interventional programs among geriatric population.
Acknowledgments
The authors are extremely thankful to Dr. S. Ramalingam,
Principal, PSG Institute of Medical Sciences and
Research for permitting us to do this study. We are
grateful to Dr. Thomas V. Chacko, Professor and Head
of Department of Community Medicine, PSG Institute of
Medical Sciences and Research, for his constant support
and encouragement for the successful completion of the
study. We would like to express our deep and sincere
gratitude to Dr. Y. S. Sivan, Associate Professor Social
Science Research and Ms. Ashraf, Assistant Professor in
Physiotherapy for their valuable guidance in the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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