Research & Reviews: A Journal of Health Professions

ISSN: 2277-6192 (Online), ISSN: 2348-9537 (Print)

Volume 8, Issue 2
www.stmjournals.com

Risk of Malnutrition and Its Association with Economic

Maintenance in Inpatients Older Adults at a
University-Affiliated Hospital
A.K. Avelar-González1, L.N. Cárdenas-Caro2, P.M. Limón-Torres3, V.R. Toro-Corona3,
K.P. Vázquez-Núñez3, I.M. Suárez-Alvarez3, C.O. Ramos-García4, J.A. Díaz-Ramos2*
1
Department of Gerontology, University of Guadalajara, Mexico
2
Department of Geriatrics, High Specialty Geriatric Care Unit, Civil Hospital of Guadalajara, “Fray Antonio
Alcalde”, Mexico
3
Department of Gerontology, University of Guadalajara, Mexico
4
Departament of nutrition, University of Guadalajara, Mexico

Abstract
The demographic aging has led to an increase in the prevalence of malnutrition. Malnutrition
risk (MR) is considered as a multifactorial condition associated with an increased morbi-
mortality in older adults. The association between MR and socioeconomic factors as the form
of economic maintenance (EM) is not yet clear in aged population. However, an effective
strategy for the diagnosis of MR is the comprehensive geriatric assessment (CGA). The aim of
this study was to determine the prevalence of malnutrition risk and its associations with the
form of economic maintenance in inpatients older adults at a university-affiliated hospital in
Mexico. It is a cross-sectional study in participants aged 60 or older, recruited between
September 2017 and April 2018. Participants underwent a CGA, and diagnosis of
malnutrition risk and EM was obtained. A multivariate logistic regression analysis was
determined to establish the association between the form of economic maintenance and
malnutrition risk. We included 74 subjects; mean age was 73 years (SD=±9), and women
accounted for 48%. This study shows that the prevalence of malnutrition risk is 31% in the
studied population. The hospitalized elderly whose maintenance depends on a government
assistance program or exclusive support of their social networks had an increase in the
probability of malnutrition risk. These results suggest that the EM could have an influence on
the health of the inpatients Mexican older adults.

Keywords: Malnutrition risk, economic maintenance, older adults, food security

*Author for Correspondence E-mail: julio.alberto.diaz.ramos.geriatra@gmail.com

INTRODUCTION classificatory scores [4–7]. Thus the

The worldwide ageing population is increasing,
and it is predicted that by 2050 one in five
people will be aged 60 years or more in
developing countries [1]. This demographic
evolution may be associated with an increase in
the prevalence of Geriatric Syndromes (GS) [2].
This term has commonly been used to indicate
the ‘‘accumulated effect of impairments in
multiple domains’’ that result in negative
outcomes [3]. The diagnostic strategy of GS
with the highest level of evidence is the
performance of the Compressive Geriatrics
Assessment (CGA). This tool includes scales
that assess the physical and mental health,
cognitive performance and functional abilities,
as well as the nutritional status through
malnutrition risk (MR) has been associated with
an increase in morbidity and mortality in the
old age. On the other hand, malnutrition
associates to bad economic situation and food
security (FS) [3, 8, 9].
The National Income - Expenses in
Households Survey reported that the 50% of
older adult’s population had support of
governmental programs, and only the 6% were
pensioners. In 2008, almost the 50% of older
adult economic maintenance (EM) comes from
pensions or retirements, and from the help of
governmental programs [10, 11]. Even the
National Council for the Evaluation of Social
Development Policy reported that only 20%

RRJoHP (2018) 31-36 © STM Journals 2018. All Rights Reserved Page 31
Malnutrition and Economic Maintenance in Elderly
older adults can do pay their expenses; the
remaining live in poverty (46%), while 37%
(2.7 million) are in a situation of moderate
poverty, and 10% live in extreme poverty [12].
The deficit of economic resources involves a
greater risk of food insecurity, because it
limits the access to the quantity and quality of
foods, increasing the probability to develop
malnutrition [13, 14].
The aim of this study is to determine the
prevalence of malnutrition risk and its
association with economic maintenance ways
(EM) in inpatients older adults at a university-
affiliated hospital in Mexico.
MATERIALS AND METHODS
Participants
This cross-sectional study was performed
including 74 participants aged 60 or older,
which were consecutively recruited from a
tertiary care university-affiliated hospital in
Jalisco (a 300-bed teaching hospital in the
west of Mexico) between September 2017 and
April 2018. Eligible participants were invited
to participate in the study and provided written
informed consent. All participants underwent a
CGA, carried out by standardized personnel.
The study protocol was reviewed and
approved by the Hospital Ethics Committee.
Measures
Malnutrition Risk
The nutritional risk was evaluated through the
questionnaire for the detection of malnutrition
in older adults (DNA). The cut-off point of ≥6
indicated the presence of high nutritional risk,
and 0–2 points were considered for low
nutritional risk [5].
Correlations
Social and demographic variables included
age, gender, illiteracy and domestic partner
status. The presence of twelve chronic diseases
including diabetes, hypertension,
dyslipidemia, cancer, myocardial infarction,
stroke, chronic obstructive pulmonary disease,
cirrhosis, osteoarthritis, rheumatoid arthritis,
osteoporosis, and/or chronic kidney disease.
All these comorbidities were summed up in a
score ranging from 0 to 10 [15].
RRJoHP (2018) 31-36 © STM Journals 2018. All Rights Reserved
Díaz-Ramos et al.
The depressive symptoms were assessed using
the version of the 15-item Geriatric Depression
Scale (GDS). A cut-off point of >5 indicated
the presence of depressive symptoms [6].
The family type was evaluated by the familiar
APGAR (Adaptation, Participation, Gradient
of personal resource, Affection, and
Resources). It evaluates five basic functions of
the family. The classification according to the
cutoff point was very functional, moderately
dysfunctional and severely dysfunctional
family [16].
The social resources were evaluated through
the OARS scale (Older Americans Resources
and Services). It is a scale that measures the
impact of services and programs on the
functional status of older persons. The results
were classified according to the cut-off point
as impaired social resources and good social
resources [17].
Economic self-perception was determined by
the question: “how do you describe your
current economic situation?” The options to
choose were the following four: bad, regular,
good, and excellent.
The Economic Maintenance form (EM) was
investigated as an independent variable.
Participants who responded positively to the
question “Have you receive a fixed income
from your current job or your retirement or
pension?” were classified as “Self-managed
Economic Maintenance”. By the other way the
participants who responded positively to the
question “Have you received an inconstant
economic income from family support or a
public social program?” were classified as
“Assistance Economic Maintenance”.
Statistical Analyses
Variables were described using frequencies
and proportions or means and standard
deviations when appropriate. For the
comparison between participants with and
without malnutrition risk, X2 test or student’s t
test were used as appropriate. To develop an
explanatory model, unadjusted logistic
regression analyses were created to identify
the sociodemographic and health correlates of
MR. The choice of independent variables used
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Research & Reviews: A Journal of Health Professions
Volume 8, Issue 2
ISSN: 2277-6192 (Online), ISSN: 2348-9537 (Print)

in the univariate analyses was based on the The multivariate logistic regression model
review of literature and clinical judgment. showed that the use of EM maintained a
Wald tests were used to eliminate from every significant association with MR, even after
model, those variables judged not significant adjustment to sex, partner status, literacy, and
at the 10% level and then the variables economic self-perception (OR=5, CI 95% 1.1–
considered significantly associated with MR. 24, P=0.03).
In the next step, variables that were
statistically significant were included in Table 1: Prevalence of Malnutrition Risk per
multivariate regression models with additional Sociodemographic and Clinical
adjustment for age, sex and comorbid. All Characteristics.
statistical tests were performed using 95% Malnutrition Risk
confidence intervals (CI). Statistical analyses No Yes
Variable
were conducted using Stata statistical package % %
for Windows® (Stata Corp., Texas, IL., v. 14) Sex
obtained by being part of the National Female 25 75*
Postgraduate Program of quality of Male 52 48
CONACYT. Marital Status
Married 39 61
Widowhood 21 79
RESULTS Economic Self-Perception (Bad)
Mean of age was 73 (SD=±9; range 60 to 92) Yes 22 78
and 48% of participants were women. Table 1 No 46 54
shows the socio-demographic and health- Social Resource (Deteriorated)
related characteristics of participants. 37% Yes 30 70
were classified severely dysfunctional; 15% of No 43 57
the participants reported illiteracy. Married Economic Maintenance
partner status was present in 53% of Assistance 29 71*
participants. Self-management 65 35
Delirium
Depressive symptoms were present in 37% of Yes 14 86
participants. The mean in the DNA was 3.5 No 40 60
(SD±2.5). 31% of participants were classified Falls
as high nutritional risk. 14% of participants Yes 38 62
No 37 63
were classified with delirium.
Depression
Yes 17 83*
Participants with MR diagnosis were more No 53 47
likely to be female, to have depression and to Functional Family
have Assistance Economic Maintenance Yes 25 75
(p<0.05). Nevertheless, the comparison No 43 57
between groups showed no differences *P<0.005.
regarding marital status, economic self-
perception, and social resources. 38% of Table 2: Univariate Regression Logistic
participants reported deteriorated social Analyses of Malnutrition Risk.
resources. Bad economic situation were Variable OR
reported by 33%. The frequencies of economic (95% IC) P
Economic Self-perception 3.16
maintenance form (67%) and self-management (0.65–15.3) 0.15
(30%). 71% of elders that reported Assistance Economic Maintenance 5.8
Economic Maintenance, presented elevated (0.09–1.2) 0.05
nutritional risk. Sex 5.2
(1.13–2.4) 0.34
Marital status 0.34
The univariate logistic regression analysis (0.054–2.1) 0.25
showed that assistance economic maintenance Literacy 0.175
was associated with MR (P=0.05) (Table 2). (0.021–1.43) 0.105

RRJoHP (2018) 31-36 © STM Journals 2018. All Rights Reserved Page 33
Malnutrition and Economic Maintenance in Elderly
DISCUSSION
The assessment of the nutritional status of the
elderly population, as well as the risk factors
for malnutrition, should be a main concern in
health care systems, since malnutrition risk
and malnutrition have a clear association with
poor health outcomes during and after
hospitalization, such as higher length of stay
and readmission rate, respectively, increased
mortality, morbidity and higher costs for
health services [18]. The results of the present
study showed an association between
economic maintenance and high nutritional
risk diagnosis in hospitalized adults of
60 years or more (P=0.03). In 2013, Contreras
et al., found a similar association was found
between malnutrition with a lack of economic
resources and social support [19].
The findings of the present study are similar to
the results of other investigations in similar
populations. For example, in Spain and Latin
America, the prevalence of malnutrition ranges
from 29 to 60% [19, 20]. A cross-sectional
study including760 northern Mexican non-
sheltered adults of 60 years old or more,
showed an association between MR and living
alone (OR=1.762. CI 1.307–2.376, p=0.001)
[21]. The present study showed a non-
significant tendency between the risk of
malnutrition and widowhood.
A 2013 review summarizes studies assessing
protein-energy malnutrition in elderly
population; concluding that the etiology of
malnutrition multifactorial including
physiological, social and economic factors,
identifying lack of access to food for multiple
causes (financial constraints, isolation),
decreased ingestion (oral health problems,
anorexia, depression) and those related with
nutrient absorption (polypharmacy, food
intolerance, malabsorption) [22]. Thus, the
malnutrition etiology in older adult is not due
to a single factor, but not to several, including
social and economic aspects that can influence
the nutritional status [7, 14, 22]. The poor
availability of resources and the isolation
impairs the consumption of foods, and
consequently, the nutritional status can be
diminished [23]. In another study, the
consumption of dairy meats had a significant
association (p<0.05) with the economic
maintenance [24].
RRJoHP (2018) 31-36 © STM Journals 2018. All Rights Reserved
Díaz-Ramos et al.
The organization for Economic Cooperation
and Development explains that 39% of people
aged over 65 receive a pension, while 40%
must continue working, while the 50% of the
population reported not fixed income [25–27].
According to the National Survey of Financial
Inclusion, about 10% of the population earns
less than 75 US$ per month, while 17% barely
earn between 75 and 150 US$ [27]. The
numbers in Mexico on pensioned and retired
seniors present a discrepancy between men
and women, since only 9% of women are
included in this classification, while of men it
is 25%, and the assistance social programs are
the first source of income for people aged 80
and over (for 71.0% of women and 67.1% of
men) [26]. In the present study, the 38% of
participants reported deteriorated social
resources, and the percentage of older adults
with self-managed support was only 30%.
Although our study did not evaluate FS, the
risk of malnutrition was not different in the
groups with dysfunctional families,
deteriorated social resources and poor
economic self-perception, unlike findings from
other studies [9]. In 2014, Rivera-Márquez
found that 67% of the homes reported lack of
FS. The same work showed an association
between alimentary insecurity in the home and
low weight of the elderly [28]. In the present
study, logistic regression analyses showed a
statistically significant association between
EM and MR (P=0.03).
The Mexican federal program of economic
support for older adults began in 2007 and in
2014, it had a beneficiary population of 5.10
million people over 65 (60% women) whose
main action consists of a monetary support of
27 US$ per month (administered bimonthly)
[26]. In December 2015, a large group of
program beneficiaries denounced that they had
not received the payment corresponding to the
last two months of the year. Local government
authorities commented that the delay was at
national level due to the closure of fiscal years
by the Ministry of Finance [29–33].
The results in the present study show that the
hospitalized older adults whose economic
maintenance depends on a government
assistance program or the exclusive support of
their social networks, had an increase in the
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Research & Reviews: A Journal of Health Professions
Volume 8, Issue 2
ISSN: 2277-6192 (Online), ISSN: 2348-9537 (Print)
probability of malnutrition risk. In our best
knowledge, our work is one of the first to
describe the association between exclusive
economic factors and the risk of malnutrition
in hospitalized elderly population in Mexico.
Thus, the exclusive economic maintenance
could represent a factor of risk for malnutrition
risk in the people over 60 years.
Our study has several limitations. This is a
cross-sectional design and is not possible to
know the direction of the associations found.
Patients were recruited consecutively to
participate in the study in a University-
Affiliated Hospital, thus the sample was
consisted of individuals with heterogeneous
characteristics (e.g. poor self-care levels, lack
of food security).
The main strengths of our study are MR
screening, which was done with standardized
CGA, and our analysis considers covariates.
However, these results must be replicated in a
more extensive cohort with a longitudinal
approach.
CONCLUSION
This study shows that the prevalence of
malnutrition risk is 30% in the studied
population. The form of economic
maintenance had a significant association in
the dependent variable (MR). The presence of
inadequate MR and its potential negative
effects are some of the challenges of this time
in which lack of FS security has become an
extended social problem. The results of the
present study suggest the importance of
monitoring other economic covariates that
potentially could have an impact on health
status of the hospitalized elderly population in
order to improve outcomes and diminish
malnutrition-associated complications.
ACKNOWLEDGEMENTS
The corresponding author is particularly
grateful to Claudia Fraga Avila, specialist in
geriatric nutrition for her unconditional
support for this research.
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Cite this Article
Avelar-González AK, Cárdenas-Caro LN,
Díaz-Ramos JA et al. Risk of Malnutrition
and Its Association with Economic
Maintenance in Inpatients Older Adults at
a University-Affiliated Hospital. Research
& Reviews: A Journal of Health
Professions. 2018; 8(2): 31–36p.
Page 36