Abstract
Objectives
To establish the prevalence of high nutrition risk and associated health and social risk factors for New Zealand Māori and non-Māori in advanced age.
Design
A cross sectional analysis of inception cohorts to LiLACS NZ.
Setting
Bay of Plenty and Lakes region of the North Island, New Zealand.
Participants
255 Māori and 400 non- Māori octogenarians.
Measurements
Nutrition risk was assessed using a validated questionnaire Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN II). Demographic, social, physical and health characteristics were established using an interviewer administered questionnaire. Health related quality of life (HRQOL) was assessed with the SF-12, depressive symptoms using the GDS-15.
Results
Half (49%) of Māori and 38% of non-Māori participants were at high nutrition risk (SCREEN II score <49). Independent risk factors were for Māori younger age (p=0.04), lower education (p=0.03), living alone (p<0.001), depressive symptoms (p=0.01). For non- Māori high nutrition risk was associated with female gender (p=0.005), living alone (p=0.002), a lower physical health related quality of life (p=0.02) and depressive symptoms (p=0.002).
Conclusion
Traditional risk factors apply to both Māori and non-Māori whilst education as indicative of low socioeconomic status is an additional risk factor for Māori. High nutrition risk impacts health related quality of life for non-Māori. Interventions which socially facilitate eating are especially important for women and for Māori to maintain cultural practices and could be initiated by routine screening.
Key words: Aged, Nutrition risk, SCREEN II, New Zealand
Introduction
As with other Organisation for Economic Co-operation and Development OECD countries New Zealand’s (NZ’s) population is ageing. The 85+ age group is the fastest growing population segment in NZ growing from one to six percent of the total population by 2050 (1). Maori are the indigenous people of NZ. Currently few Maori reach 85 years of age (less than 0.2% of the Maori population) (1).
Although life expectancy at birth now lags by seven to eight years for Maori (2) demographic projections (3) suggest that the Maori population is ageing faster than non-Maori, expanding the population of older Maori.
Older people are known to be at disproportionate risk of malnutrition and have an increased risk of developing health problems as a result of inadequate food and nutrition intake (4). The NZ government’s ‘Ageing in Place’ policy (5) highlights the need to understand the factors that could lead to malnutrition among older people who live in the community. There is very little information available about nutritional status of the very old as the National Nutrition Survey data is aggregated over age 55 for Maori and over 70 years for non-Maori.
Nutrition risk screening is a process to identify factors or characteristics related to nutritional status that could lead to malnutrition (6). Nutrition screening tools provide a simple and rapid method to identify those at high nutrition risk. Pathways to nutritional health in older people are complex and multifactorial. Factors related to procurement, preparation and eating may impact nutrition risk. With advanced age, increased functional difficulties, cognitive decline, and increased comorbidities can all lead to malnutrition (7).
No one screening tool can be used as a gold standard for identifying malnutrition (8). The ‘Seniors in the Community: Risk Evaluation for Eating and Nutrition’ SCREENII index determines nutrition risk using four key factors: food intake, physiological, adaptive and functional (9). From an assessment of 21 screening tools used to assess the nutritional status of older adults, SCREENII was the only tool specifically designed for community living older people (10). SCREENII has been validated among older people in Canada against the criterion of a dietitian’s clinical judgement of risk and has high inter-rater and test-retest reliability as well as excellent sensitivity and specificity in detecting malnutrition (11). In NZ SCREENII has been validated for octogenarians with a threshold of 49 (12). This tool was adapted for use in the Maori population (13) and SCREENII has been used in a cohort study of Maori and non-Maori in advanced age at inception. The aim of this paper was establish the prevalence of nutrition risk and to identify health and social factors associated with high nutrition risk in Maori and non-Maori in advanced age.
Methods
We conducted a cross-sectional study using data from the baseline assessment of Life and Living to Advanced Age a cohort study in New Zealand (LiLACS NZ) a longitudinal study of the very old in New Zealand (14). The study was initiated in 2010 and recruited 937 octogenarians living in one North Island region, including rural and urban areas. The recruitment procedures and response rate have been reported earlier (15). At inception, the sample consisted of 421 Maori aged between 80 and 90 and 516 non-Maori aged 85. Both Maori and non-Maori are similar in gender profile with just over half being female. In brief, participants were identified from the electoral roll, health care databases and extensive family and personal networks and were recruited by personal invitation from the general practitioner or community contact. Eligibility criteria were Maori born between 1 January 1920 and 31 Dec 1930; non-Maori born between 1 January and 31 December 1925 living within the defined regional boundaries of the Bay of Plenty and Lakes District Health Boards (excluding the Taupo region of the Lakes District Health Board). Recruitment occurred between March 2010 and April 2011. Younger Maori participants were recruited as the gap in life expectancy between Maori and non-Maori was 8.2 years for men and 8.8 years for women (16). The study was approved by the Northern X Regional Ethics Committee (NXT 09/09/088) in 2009 and all study participants provided written informed consent.
Measures
The socio-demographic data (residential care, living arrangement, difficulty getting to the shops, driving a car, occupational status) were obtained through a standardised questionnaire administered during a face-to-face interview. Life satisfaction was ascertained using the question “All things considered, how satisfied are you with your life as a whole these days?” The NZ Deprivation (NZ Dep) index obtained from the Ministry of Health was used as an indication of socio-economic deprivation. The index was constructed from geo-coded addresses and included eight dimensions of material and social deprivation reflecting lacks of income, employment, communication, transport, support, education qualifications, home ownership and living space (17).
A Physical Activity Scale for the Elderly (PASE), validated in community living older adults (18) was used to assess physical activity. PASE consists of ten items used to identify leisure, household and occupational related activity, and the duration of each activity over a one-week period.
Muscle strength was assessed by measuring grip strength using a Takei digital handgrip dynamometer-Grip D. The average of three readings from the strongest hand was used for the data analysis (19).
The Modified Mini Mental State Examination (3MS) was used to determine cognitive impairment (20). The SF-12 (21) was used to provide a view of health related quality of life of the participants based on their perceived experience, knowledge and awareness of their personal, physical, mental and emotional status. The scale presents two summary scores: physical and mental health related QOL. The maximum score is 100; any score lower than 40 indicative of perception of poor health and above 60 indicative of perception of reasonable and better health.
Depression was assessed by the 15 item Geriatric Depression Scale (GDS-15) (22). The GDS-15 is a reliable and valid self-rating depression screening scale developed specifically for the elderly (23). Scores range from 1-15 and correlate with depressive symptoms. A higher score indicates more depressive symptoms. A cut off of 5 or more is considered to indicate significant depressive symptoms and is associated with moderate and major depression (24).
Functional status was assessed with the Nottingham Extended Activities of Daily Living (NEADL) (25) which is a measure of independence in physical function, initially designed for community-dwellers with stroke. The NEADL asks whether the older person ‘does’ a range of activities ‘on their own, on their own with difficulty, with help, or not at all’. There are 22-items covering four domains: mobility, in the kitchen, domestic tasks and leisure activities. A higher score indicates a higher level of function.
Health behaviours smoking and alcohol intake were ascertained by self-report: myocardial infarction, stroke, was ascertained through a combination of self-report, general practitioner medical record review and hospitalisation discharge record review (26).
Nutrition risk was determined using the 14-item SCREENII questionnaire (11). SCREENII provides information on weight change, food intake and risk factors for food intake (meal frequency, diet restriction, appetite, chewing and swallowing difficulties, meal replacement, eating alone, meal preparation and shopping difficulties). Items are scored and summed with the total score ranging from 0 to 64.
The assessment tools described above were used in the feasibility study for Maori and non-Maori and feedback from the participants indicated the tools gave a reasonable indication of their state of wellbeing therefore they have been used in this wider cohort study (27).
Statistical analysis
Descriptive analyses were completed for demographic, social, physical and health data. The sample was categorised into two groups; high nutrition risk (SCREENII <49) and moderate or low nutrition risk (SCREENII <49). Maori and non-Maori were analysed separately due to the sampling difference related to age, because the prevalence differed between ethnicities and to enable ethnic specific interpretation of the findings.
Univariate statistics assessed each risk factor (Table 2). A balance of socioeconomic status (SES), functional and health, variables were selected from knowledge of the literature. SES: Gender, marital status, education, living situation, occupation, deprivation index and pension; functional: difficulty getting to the shops, driving a car; health: smoking and alcohol usage, functional status (NEADL), depression (GDS-15), physical activity, cognition. Health related QOL and life-satisfaction were selected to gauge potential associations related to patient oriented outcomes.
Table 2.
Māori and non-Māori participant characteristics by nutrition risk status
| High Nutrition Risk | Low Nutrition Risk | Total | P value | |
|---|---|---|---|---|
| SCREEN II <49 | SCREEN II ≥49 | |||
| Māori participants | n (%) | n (%) | n (%) | |
| Prevalence of nutrition risk | 126 (49%) | 129 (51%) | n 255 | |
| Gender Men | 42 (33) | 58 (45) | 100 (39) | 0.6 |
| Women | 84 (67) | 71 (55) | 155 (61) | |
| Marital status Married/Partnered | 28 (22) | 54 (42) | 82 (32) | 0.007 |
| Widowed | 91 (72) | 65 (51) | 156 (61) | |
| Divorced/Separated | 6 (5) | 6 (5) | 12 (5) | |
| Never married | 1 (1) | 3 (2) | 4 (2) | |
| Education Primary | 48 (39) | 25 (20) | 73 (29) | 0.005 |
| Secondary | 65 (52) | 76 (60) | 141 (56) | |
| Tertiary | 11 (9) | 26 (20) | 37 (15) | |
| Smoking Current | 13 (11) | 19 (15) | 32 (13) | 0.58 |
| Former | 52 (42) | 58 (53) | 110 (44) | |
| Never | 58 (47) | 52 (40) | 110 (44) | |
| Alcohol Never | 64 (52) | 56 (43) | 120 (47) | 0.238 |
| Occasional (monthly) | 41 (33) | 36 (28) | 77 (30) | |
| Less 2 times/week | 19 (15) | 37 (29) | 56 (22) | |
| SF-12 Physical Health Score | 41.1 (11.1) | 45.3 (10.9) | 43.4 (11.3) | 0.0034 |
| SF-12 Mental Health Score | 52.2 (10) | 54.7 (7) | 53.4 (8.7) | 0.0279 |
| GDS-15 Depression Score | 3.2 (2.5) | 2 (1.7) | 2.6 (2.2) | 0.0001 |
| Living situation alone | 66 (52%) | 40 (31%) | 106 (42%) | 0.0011 |
| with spouse only | 23 (18%) | 45 (35%) | 68 (27%) | |
| with others | 37 (29%) | 44 (34%) | 81 (32%) | |
| Difficulty getting to shops No | 99 (80%) | 113 (90%) | 212 (85%) | 0.0445 |
| Yes | 24 (20%) | 13 (10%) | 37 (15%) | |
| Pension only income No | 65 (52%) | 68 (54%) | 133 (53%) | 0.7548 |
| Yes | 60 (48%) | 58 (46%) | 118 (47%) | |
| Non-Māori participants | n (%) | n (%) | n (%) | |
| Prevalence of nutrition risk | 153 (38%) | 247 (62%) | 400 | |
| Gender Men | 50 (33) | 138 (56) | 188 (47) | <0.001 |
| Women | 103 (67) | 109 (44) | 212 (53) | |
| Marital status Married/Partnered | 45 (30) | 131 (53) | 176 (44) | <0.001 |
| Widowed | 91 (60) | 96 (39) | 187 (47) | |
| Divorced/Separated | 12 (8) | 12 (5) | 24 (6) | |
| Never married | 4 (3) | 7 (3) | 11 (3) | |
| Education Primary | 25 (17) | 37 (15) | 62 (16) | 0.656 |
| Secondary | 86 (57) | 136 (56) | 222 (56) | |
| Tertiary | 39 (26) | 72 (29) | 111(28) | 0.198 |
| Smoking Current | 10 (7) | 9 (3) | 19 (5) | |
| Former | 60 (39) | 108 (44) | 168 (42) | |
| Never | 83 (54) | 130 (53) | 213 (53) | |
| Alcohol Never | 53 (35) | 52 (21) | 105 (26) | 0.025 |
| Occasional (monthly) | 41 (27) | 67 (27) | 108 (27) | |
| >2 times/week | 59 (39) | 128 (52) | 187 (47) | |
| SF-12 Physical Health Score | 37.7 (12.1) | 43.5 (11.5) | 41.3 (12) | <.0001 |
| SF-12 Mental Health Score | 54.3 (9.4) | 55.5 (7.6) | 55.1 (8.3) | 0.1717 |
| GDS-15 Depression Score | 2.9 (2.4) | 1.7 (1.5) | 2.2 (2) | <.0001 |
| Living situation alone | 94 (61%) | 99 (40%) | 193 (48%) | <.0001 |
| with spouse only | 35 (23%) | 119 (48%) | 154 (39%) | |
| with others | 24 (16%) | 29 (12%) | 53 (13%) | |
| Difficulty getting to shops No | 122 (83%) | 238 (97%) | 360 (92%) | <.0001 |
| Yes | 25 (17%) | 8 (3%) | 33 (8%) | |
| Pension only income No | 97 (63%) | 184 (75%) | 281 (70%) | 0.0158 |
| Yes | 56 (37%) | 62 (25%) | 118 (30%) |
All variables significantly associated (p<0.05) with a SCREENII score <49 were included in a final logistic regression model for both Māori (Table 3) and non-Māori (Table 4). The final logistic regression models were adjusted for health (SF-12 Physical and Mental Health Scores), GDS-15 depression score and socioeconomic factors (education, pension only income). Statistical analyses were performed with SAS version 9.2 (SAS Institute Inc., Cary, NC).
Table 3.
Factors associated with high nutrition risk (SCREEN II <49) for Māori participants using multiple logistic regression, adjusting for all other variables in the model
| Variables | Observed Odds Ratio | Adjusted Odds Ratio | 95% CI | P value | ||
|---|---|---|---|---|---|---|
| Gender, | M vs F | 0.78 1 | 1.29 1 | 0.70 | 2.41 | 0.42 |
| Age | 0.89 | 0.79 | 0.99 | 0.04 | ||
| Education | Primary | 2.21 | 3.41 | 1.35 | 8.62 | 0.03 |
| Secondary | 1.55 | 1.70 | 0.75 | 3.83 | ||
| Tertiary | 1 | 1 | ||||
| Living situation | Alone vs Others | 1.36 | 2.85 | 1.34 | 6.05 | <0.001 |
| Spouse vs Others | 0.74 | 0.66 | 0.31 | 1.43 | ||
| Alone vs Spouse | 1.84 | 4.10 | 1.90 | 8.84 | ||
| SF-12 PHC | 0.973 | 0.944 | 1.003 | 0.08 | ||
| SF-12 MHC | 0.967 | 0.927 | 1.008 | 0.11 | ||
| GDS-15 | 1.30 | 1.06 | 1.60 | 0.01 |
Table 4.
| Variables | Observed Odds Ratio | Adjusted Odds Ratio | 95% CI | P values | ||
|---|---|---|---|---|---|---|
| Gender | M vs F | 0.55 1 | 0.49 1 | 0.30 | 0.81 | 0.005 |
| Living situation | Alone vs Others | 1.08 | 1.85 | 0.87 | 3.95 | 0.002 |
| Spouse vs Others | 0.5 | 0.74 | 0.33 | 1.65 | ||
| Alone vs Spouse | 2.14 | 2.41 | 1.42 | 4.08 | ||
| Difficulty getting to shops | No vs Yes | 0.04 1 | 0.49 | 0.19 | 1.28 | 0.14 |
| Pension only | No | 0.73 | 0.66 | 0.40 | 1.09 | 0.10 |
| income | vs Yes | 1 | ||||
| SF-12 PHC | 0.976 | 0.957 | 0.996 | 0.02 | ||
| GDS-15 | 1.24 | 1.08 | 1.43 | 0.002 |
Results
From a total of 766 Māori identified as eligible, aged 80 to 90 years, 421 participated (55%) and of 870 non-Māori identified as eligible, aged 85 years, 516 participated (59%). Hence the overall response rate was 57%. All participants completed core information and 60% of Māori participants and 77% of non-Māori participants completed comprehensive interviews which included the measures for this paper.
Participants who completed the comprehensive questionnaire were more independent in mobility (93 vs 79% p value <0.0001) and less likely to be living in residential care (3 vs 20% p value <0.0001). Table 1 provides an overview of the social, physical and health characteristics of the Māori and non-Māori participants
Table 1.
| Māori Participants n (%) | Non-Māori Participants n (%) | ||
|---|---|---|---|
| Age (SD) | 82.3 (2.6) | 84.6 (0.5) | |
| Gender | Men | 100 (39.2) | 188 (47.0) |
| Women | 155(60.8) | 212 (53.0) | |
| Residential care | 2 (0.8) | 20 (5.0) | |
| Living arrangement | Living alone | 106 (42) | 193 (48) |
| Living with spouse only | 68 (27) | 154 (39) | |
| Living with others | 81 (32) | 53 (13) | |
| Life Satisfaction | Dissatisfied / Neither nor | 16 (6) | 42 (11) |
| Satisfied | 238 (94) | 349 (89) | |
| Difficulty getting to shops | No | 212 (85) | 360 (92) |
| Yes | 37 (15) | 33 (8) | |
| Drives a car | No | 105 (41) | 111 (28) |
| Yes | 148 (58) | 289 (72) | |
| Occupation | * Professionals | 109 (43) | 200 (50) |
| Technicians | 45 (18) | 86 (22) | |
| Clerks | 101 (40) | 114 (29) | |
| Deprivation Index (Low) | Deprivation Quintile 1 | 6 (2) | 25 (6) |
| Deprivation Quintile 2 | 30 (12) | 75 (19) | |
| Deprivation Quintile 3 | 41 (16) | 101 (25) | |
| Deprivation Quintile 4 | 57 (22) | 127 (32) | |
| (High) | Deprivation Quintile 5 | 121 (47) | 72 (18) |
| Pension plus other income | 133 (53) | 280 (70) | |
| Pension only income | 118 (47) | 118 (30) | |
| Physical Median (range) | |||
| PASE score | 111 (81.6) | 98.9 (66) | |
| Grip strength, Kg | 24.4 (8.1) | 24.3 (8.1) | |
| Health Mean(SD) | |||
| Cognition (3MS) | 86.2(14.1) | 90.9 (9.8) | |
| SF-12 Physical Health Score | 43.4 (11.3) | 41.3 (12) | |
| SF-12 Mental Health Score | 53.4 (8.7) | 55.1 (8.3) | |
| Depression (GDS) | 2.6 (2.2) | 2.2 (2) | |
| GDS score of 5 and above | 38 (15%) | 42 (11%) | |
| Activity (NEADL) | 17.2 (4.6) | 17.6 (4) | |
| MI (by self-report) | 40 (15.9) | 57 (14.3) | |
| Stroke (by self-report) | 15 (6.1) | 19 (4.8) | |
| High nutrition risk SCREEN II <49 | 126 (49.4) | 153 (38.3) |
PASE, Physical Activity Scale for the Elderly, higher score means more activity; 3MS, Modified mental test score, cognitive screen, high score means better cognitive function; NEADL, Nottingham Extended Activity of Daily Living Scale, higher score means better function; MI, myocardial infarction; SCREENII, Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II;
Professional:-Legislators, Administrators, Professionals, Agricultural and Fishery Workers; Technicians:-Technicians, Associate Professionals and Trades Workers; Non-technical:-Clerks, Service Workers, Sales Workers, Plant/Machine Operators, Assemblers, Elementary Workers
Māori participants
Of the 421 Māori participants, 255 (100 men) completed the comprehensive interview including the SCREENII questionnaire. The mean age was 82.8 (SD 2.6) years. Physical health related QOL was moderately low with a mean score of 43.4(SD 11.3), mental health-related QOL was moderately high with mean scores above 50 and 38 (15%) had significant depressive symptoms. Thirteen percent of Māori participants were current smokers and 17% consumed alcohol more than twice a week (Table 2).
Nutrition risk
Forty-nine percent of the Māori participants were at high nutrition risk (SCREEN II score <49). The mean SCREENII score was 48±6 (range 21-60; out of maximum score 64). Information on the Māori participants’ lifestyle characteristics by nutrition risk status is provided in Table 2. There were more widows and widowers in the high nutrition risk group (SCREENII score <49) compared to the low nutrition risk group (SCREENII score ≥49), p=0.007. Those at high nutrition risk had a lower level of education than those at low nutrition risk, p=0.005.
In a multivariable logistic regression model (Table 3), factors that were independently associated with high nutrition risk were younger age (p=0.04), a lower education level (p=0.03), living alone (p<0.001) and higher depressive symptoms (p=0.01). NZ deprivation index was not significantly related to nutrition risk in this analysis.
Non-Māori participants
There were 516 non-Māori participants and 400 (188 men) completed the interview mean age 84.6 (SD 0.5) years.
Physical health related QOL was moderately low with a mean score of 41.3 (SD 12) and mental health-related QOL was moderately high with mean scores above 50.
There were 42 (11%) of non-Māori participants who had significant depressive symptoms. Five percent were current smokers and 37% consumed alcohol more than twice a week (Table 2).
Nutrition risk
Thirty-eight percent of the non-Māori participants were at high nutrition risk (SCREEN II score <49) less prevalent than Māori (p = 0.01) controlling for gender. The mean SCREENII score was 50±6 (range 20-63; out of maximum score 64).
Table 2 reports the demographic and lifestyle characteristics of the non-Māori participants by nutrition risk status. There were more women at high nutrition risk (SCREENII score <49) compared to the men, p=<0.0001. More widowed and single non-Māori participants were at high nutrition risk compared to those who were married or partnered, p=<0.0001. Those non-Māori who never consumed alcohol tended to be at high nutrition risk compared to those who drank but less than four times a week (p=0.025).
In a multivariable logistic regression model (Table 4) factors independently associated with high nutrition risk were female gender (p=0.005), living alone (p=0.002), a lower physical health related QOL (p=0.02) and higher depressive symptomatology (p=0.002).
Discussion
We found half (49%) of Māori and 38% of non-Māori LiLACS NZ participants were at high nutrition risk as determined by SCREENII. As the sample that completed the full questionnaire was more independent than those who did not, this is likely to underestimate nutrition risk. We know that the overall sample has a similar age profile for Māori and slightly underrepresents women (28) and this would also suggest an underestimation is possible. A comparable prevalence of high nutrition risk using SCREENII has been reported in Canada, 39% (mean age 79 years) (29); in NZ; 31% of community living older people mean age 80 years and 82 years respectively (30, 31) and in 52% of the participants in the feasibility study for LILACS NZ (32). Similarly using SCREENII high nutrition risk was found in 30% of community living non-Māori and 63% of Māori, mean age 74 years (33) and supports our finding that nutrition risk is higher in Māori. Food (kai) has important cultural significance for Māori. The displacement of traditional foods valued and frequently used by older Māori (34) may impact on food choice and nutritional quality. The SCREENII tool has not been validated for Māori and process evaluation of the feasibility study indicated several items of the screening tool were interpreted differently for Māori and non- Māori (13). Accordingly the tool was adapted with clearer instructions. These factors need to be considered when interpreting the results; however this is novel information for this indigenous population.
For Māori participants independent risk factors associated with high nutrition risk included younger age and a lower level of education. Functional limitations may impact more on nutrition risk status than chronological age (35). Indeed disability affects 24% of Māori compared to 18% of non-Māori aged over 65 years (3) and may adversely affect meal preparation and consumption (36). Māori participants with only a primary level of education were three times more likely to be at high nutrition risk than those with a tertiary education. Lower education is an important indicator of socioeconomic status and has previously been linked to high nutrition risk (38). Older Māori are more disadvantaged than older non-Māori 7cross all socio-economic indicators including education (38). Nearly half of our Māori participants lived in the highest quintile of socioeconomic deprivation. Older single Māori, mostly women, have the least material wellbeing (39) which may lead to low food security (40). The picture of health for Māori is a reflection of their life course and the effects of social, economic and cultural deprivation from the ongoing process of colonisation and globalisation.
For non-Māori high nutrition risk was associated with being female and a lower physical health related QOL. Gender differences in nutrition risk among older people are multifaceted. Older women are also more likely than men to report poorer health and have multiple chronic diseases (41) which can escalate age related muscle loss and result in poor physical function (42). Other researchers have found older women to be at greater nutrition risk especially those who are socially isolated and have difficulty accessing food due to transport difficulties (43). Our study did not find an association between ‘difficulty getting to the shops’ and nutrition risk. This may be due to strong family support. This generation, who have lived through the post war depression may also practice home gardening as a method of food procurement and are also likely to use various food preservation techniques.
Health related QOL (using the EuroQoL-5D pain/discomfort dimension) has previously been related to nutrition risk in community living women aged over 80 years in Spain (44). Among these older women dietary assessment indicated health related QOL was negatively associated with energy, protein and the intake of other nutrients.
For both Māori and non- Māori high nutrition risk was associated with living alone or marital status. The impact of living alone on nutrition risk status is well established (45., 46., 47.). Generally older women are more likely than men to be widowed and live alone and are especially vulnerable to nutrition risk (48). Mealtime companionship is a better predictor of caloric intake than marital status (49). Our findings reinforce that every opportunity needs to be taken to encourage older people to eat meals with others.
Depressive symptoms were associated with high nutrition risk for non-Māori which agree with other studies (50, 51) Depression has an impact on appetite, food intake and physical capacity (50). For Māori, self-identification whilst living with a supportive whānau (extended family) community is seen to have positive influence providing a sense of connection with others, with cultural heritage, and with the environment (52). LiLACS NZ baseline analyses show that participation in cultural activities is associated with higher QOL (53) and may explain in part the lesser association between depression and nutrition risk for Māori compared with the strong association observed for non-Māori.
Screening for nutrition risk can act as a preventative health measure especially for this older age group. Good nutrition is a modifiable factor which may help to prevent health problems and increase QOL. Improvement in nutrition status could allow for greater health expenditure to be directed at keeping older people well. Nutrition risk can be easily identified in community dwelling populations and this study shows older women living alone are a particularly vulnerable group. Locally developed intervention trials are needed which acknowledge diversity to test sustainable food based strategies.
Limitations include the use of the SF-12 for Māori as health has a broader perspective for Māori (54). Indigenous specific measures need to be developed by indigenous peoples. The participation rate for LiLACs NZ was less than 60% and then the comprehensive interview was completed by two thirds of Māori and three quarters of non-Māori. Those completing the core questions only were more likely to be living in residential care and have higher likelihood of disability in ADLs. Thus generalisability of these findings to all people in advanced age may be questioned. High nutrition risk may be underestimated as those who fully participated were more able hence the prevalence reported can be considered ‘at least’ 38% of non-Māori at age 85 and 49% of Māori octogenarians.
In conclusion, this is the first study to report the prevalence of nutrition risk in Māori and non-Māori octogenarians. Whilst traditional risk factors such as living alone and depression apply to both Māori and non-Māori low education is an additional risk factor for Māori. Although life experience may redress for Māori the limited access to educational opportunities they had in their childhood and early adult life, unequal opportunity to education impacts nutrition risk. Effort is needed to engage relevant community and whanau (family) support to ensure older Māori have food security and cultural practices are met. For non-Māori women high nutrition risk impacts physical health related QOL. Routine screening is a simple measure to identify those at high nutrition risk and need of nutrition support. Interventions to encourage older people to eat together with others is an important preventative strategy especially for older women who are widowed or live alone and who are an easily identifiable group
Acknowledgements
We acknowledge the Health Research Council of New Zealand and Ngā Pae o te Māramatanga for funding the baseline recruitment of LiLACS NZ. Betty McPherson advised nutrition assessment for Māori and with Hone and Florence Kameta assisted with translation of the interview. We thank the organisations contracted to conduct the LiLACS NZ study in the communities of origin: Western Bay of Plenty PHO, Ngā Matāpuna Oranga Kaupapa Māori PHO, Rotorua Area Primary Health Services, Te Korowai Aroha Trust and Te Rununga o Ngati Pikiao, Te Rununga o Ngati Awa Research and Archives Trust, Te Rununga o Ngati Iripuaia and Te Whānau a Apanui Community Health Centre. We acknowledge the support of the Ministry of Health for manuscript production and we thank all participants and their whanau for participation.
Conflict of Interest
None.
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