|Year : 2023 | Volume
| Issue : 1 | Page : 36-41
Nutritional status and food environment of the elderly population residing in tea gardens of a block of Darjeeling District, West Bengal, India
Kunal Singh Sullar1, Pallabi Dasgupta1, Kaushik Ishore2
1 Department of Community Medicine, North Bengal Medical College, Darjeeling, West Bengal, India
2 Department of Community Medicine, MJN Medical College, Coochbehar, West Bengal, India
|Date of Submission||17-Dec-2022|
|Date of Decision||03-Jan-2023|
|Date of Acceptance||04-Jan-2023|
|Date of Web Publication||17-Mar-2023|
Department of Community Medicine, North Bengal Medical College, Sushrutanagar, Darjeeling - 734 012, West Bengal
Source of Support: None, Conflict of Interest: None
Objectives: In India, poverty, illiteracy, and difficult terrains make the tea garden elderly population more vulnerable to malnutrition. The food environment shows the interface through which consumers interact with their food system. Hence, the present study was done to assess the nutrition status and identify the sociodemographic and food environmental factors affecting the nutritional status of the elderly population residing in tea gardens of Naxalbari block, Darjeeling district, West Bengal, India. Materials and Methods: A community-based cross-sectional study was conducted in all tea gardens of Naxalbari block, Darjeeling, from March 2022 to September 2022, among older people aged 60 years and above selected by simple random sampling. Using the predesigned, pretested questionnaire, the Mini Nutritional Assessment tool for nutritional assessment and the elderly population's perceived food environment was determined based on five points Likert's scale. Perceived food environment clusters were identified using a two-stage cluster analysis. Binary logistic regression was used to determine predictors of nutritional status. Results: Out of the 294 study participants, the majority of 190 (64.6%) of the older people were at the risk of malnutrition, 18 (6.1%) malnourished, and 86 (29.3%) had normal nutritional status. Binary logistics regression showed older people who were illiterate (adjusted odds ratio [AOR] 14.864; 95% confidence interval [CI]; 4.311–51.457) and not working (AOR 3.775; 95% CI; 1.753–8.128) had significantly higher odds of being undernourished. Older people who perceived a favorable food environment (AOR 0.408; 95% CI; 0.214–0.775) had significantly lesser odds of being undernourished. Conclusion: Tea garden older population is at higher risk of malnutrition. Illiteracy, working status, and perceived favorable food environment plays important role in altering the nutritional status of the elderly. Prior interventions such as awareness regarding food nutrition and developing elderly friendly food environment are needed.
Keywords: Elderly, environment, food, India, mini nutritional assessment
|How to cite this article:|
Sullar KS, Dasgupta P, Ishore K. Nutritional status and food environment of the elderly population residing in tea gardens of a block of Darjeeling District, West Bengal, India. J Indian Acad Geriatr 2023;19:36-41
|How to cite this URL:|
Sullar KS, Dasgupta P, Ishore K. Nutritional status and food environment of the elderly population residing in tea gardens of a block of Darjeeling District, West Bengal, India. J Indian Acad Geriatr [serial online] 2023 [cited 2023 Mar 22];19:36-41. Available from: http://www.jiag.com/text.asp?2023/19/1/36/371908
| Introduction|| |
During the last two decades, all over the world, “population aging” is becoming a major concern for policymakers, for both developed and developing countries. In India, 8.6% of the people are aged 60 and above, compared to 7.7% in 2001 (census 2011) which is increasing. Aging is a serious problem which is associated with various physiological changes and needs, which makes the elderly population vulnerable to malnutrition. Malnutrition is both a serious and common health problem among the elderly population. Malnutrition is a state of imbalance in energy, protein, and other entities of nutrition. Malnutrition in the elderly population is always underdiagnosed. The increase in the prevalence of malnutrition among the elderly population is having a negative impact on this population's health and quality of life. In India, the magnitude of malnutrition among the older population is underreported. Various studies have shown that more than 50% of the elderly population is underweight. In the present time, among all undernourished and obese people in low-and middle-income countries roughly half of them and quarter of them live in India, respectively. Most undernourished Indians reside in rural areas.
Tea production is a major revenue earner followed by tourism and it provides employment to more than half the population of Darjeeling district, West Bengal. There are various factors such as poor socioeconomic status, illiteracy, overcrowded, and unhygienic conditions in residential areas that make the tea garden population vulnerable to various communicable diseases and malnutrition. In recent years, the Food and Agriculture Organization has focused on food environments in dealing with malnutrition in low- and middle-income countries like India. The food environment shows the interface through which consumers interact with his/her food system. The food choices of consumers are influenced by multiple factors such as what food items are available, accessible, and affordable in their food environment. This food environment is categorized under two domains, namely the external domain which is related to the food system and the personal domain includes household and individual livelihood systems. This concept links the wider food system with household and individual livelihoods. The concept of the food environment is shown in [Figure 1]. In India, presently food environments are in the middle of far-reaching changes that are impacting health and nutrition outcomes for living rural populations. Although there are many studies depicting the burden of malnutrition in the elderly population across Indian, the relationship between food environment and nutritional status in this region is still unavailable. Focusing on the tea gardens of Darjeeling district, the elderly population is vulnerable to malnutrition because of their aging along with the location of living.
In this backdrop, the present study was planned with the objective of assessing the nutritional status of the elderly population residing in tea gardens in a block, Darjeeling district, West Bengal, and to identify the sociodemographic and food environmental factors affecting their nutritional status.
| Materials and Methods|| |
Study design, study area, and study subjects
A community-based descriptive study with cross-sectional design was conducted for 7 months from March 2022 to September 2022 in the tea gardens of Naxalbari block, Darjeeling district, West Bengal, India. Darjeeling is the North most district of West Bengal in Eastern India in the foothills of the Himalayas. The study participants were older persons aged 60 years or more residing in the study area for more than 1 year. The respondents were the selected older person or their primary caregivers.
Sample size was estimated using the formula for descriptive study (proportion as parameter of study), considering a 95% level of confidence, 10% relative precision, and anticipated proportion of undernutrition in the rural elderly population of West Bengal as 60%, and taking 15% as nonresponse, the final sample was 294.
All 12 tea gardens in Naxalbari block (according to data provided by local tea gardens' association) were included in the study. Prior list of older people was prepared beforehand with the help of respective field workers (ASHA workers) in each tea garden. By applying simple random sampling (without replacement), 25 older persons were selected from each tea garden to achieve desired sample size. If two or more older persons were present in the same household, only one eligible person was selected randomly. Unwilling individuals, seriously ill, those withdrawn from study, or individuals unavailable even after three home visits were considered nonresponders. Nonresponders among the selected 25 individuals in each tea garden were replaced from the sampling frame of older persons in the same tea garden. Finally, 294 participants were included in the study after exclusion.
Data were collected by interviewing the older persons, taking anthropometric measurements (weight in kg, height in cm, mid-arm circumference in cm, and calf circumference in cm) using standard guidelines, and reviewing relevant medical records/prescriptions. A predesigned, pretested interview schedule consists of sociodemographic characteristics, statements regarding the perceived food environment, and Mini Nutritional Assessment (MNA) tool was used.
Sociodemographic characteristics included age (in completed years), sex (male/female), education status (illiterate/literate), current marital status (living with spouse/not living with spouse), working status (working/not working), caregiver (self/others), and social assistance.
The perceived food environment was determined based on 5-point Likert scale by composing statements related to two domains of the food environment: external and personal domains. External domain comprised statements related to the availability of food items, the opening of food shops, the location of food shops, and nutritional information. Personal domain comprised statements related to distance to acquire food items, food cost, time spend in preparing food, people's view toward food, and acceptability to available food. Five responses were assessed for each statement “strongly disagree, disagree (D), neutral (N), agree (A), and strongly agree.”
The nutritional status of the elderly was assessed using the MNA tool, a validated questionnaire for rapid assessment of the nutritional status of older people and it comprises 18 questions. It consists of two parts screening and assessment having items related to the past 3 months medical history and anthropometric measurements. Each item has a specific score as per response. Its total assessment score was 30 points (maximum). According to the score obtained using the MNA tool, nutritional status was categorized as normal nutritional status (24–30 points), at risk of malnutrition (17–23.5 points), and malnourished (<17 points).
Descriptive statistics such as mean, standard deviation, and percentage were used. Analytical statistic was done using the Chi-square test. Two-stage cluster analysis was performed among the sample to analyze the perceived food environment. Before the cluster analysis, collinearity among variables and the adequacy of sample size were examined. Using log-likelihood distance measure, a two-cluster solution was retained. Individuals perceived food environment statements' responses in Likert's scale were used in cluster analysis. Cluster of older people responding favorably to the statements of higher predictor importance was labeled as “favorable food environment” and others as “unfavorable environment.” For this study, “favorable food environment” was conceptually defined as those perceiving to have supportive food environment and other “unfavorable food environment” as unsupportive food environment.
Binary logistic regression was done to find predictors of nutritional status among older persons. Where, at risk of malnutrition and malnourished were categorized as “undernutrition” and other was “normal nutrition” status, (Undernutrition [=1] and Normal [=0]) were the dichotomous-dependent variables. Sociodemographic variables such as age, sex, education status, current marital status, current working status, caregiver, social assistance, and perceived food environment were independent variables. Analysis was done after addressing multicollinearity among independent variables. Analysis of the data was performed using IBM SPSS version 20, Armonk, New York, USA, IBM Corp. P < 0.05 was considered statistically significant.
The ethical approval was obtained from Institutional Ethics Committee, North Bengal Medical College, Darjeeling. After getting the necessary approval from authorities, data were collected after taking informed consent from the selected participants maintaining privacy, confidentiality, and anonymity.
| Results|| |
A total of 294 older persons aged 60 and above were interviewed from all 12 tea gardens of Naxalbari block. The mean age of participants was 66.1 ± 4.9 years (range: 60–86 years) and the majority belonged to the age group of 60–75 years 282 (95.9%). Majority were females 210 (71.4%), illiterate 272 (92.5%), not living with spouse 170 (57.8%), currently not working 253 (86.1%), taking care by themselves 161 (54.8%), and 107 (36.4%) of older people do not receive any social assistance provided by the government.
Among 294 older people, the majority 208 (70.7%) were undernourished, (190 [64.6%] of them were at the risk of malnutrition, 18 [6.1%] were malnourished), and 86 (29.3%) were having normal nutritional status as per MNA score [Table 1].
|Table 1: Association of sociodemographic variables and nutritional status (n=294)|
Click here to view
Proportion of older people who were at risk of malnutrition was significantly higher among females 153 (72.9%) (P = 0.000), who were illiterate 186 (68.4%) (P = 0.000), not living with spouse 122 (71.8%) (P = 0.010), currently not working 171 (67.6%) (P = 0.001), and not taking care by themselves 87 (65.4%) (P = 0.042). Proportion of older people who were malnourished was significantly higher among who were illiterate 18 (6.6%) (P = 0.000), currently not working 18 (7.1%) (P = 0.001), and not taking care by themselves 15 (11.3%) (P = 0.042). Proportion of older people who were having normal nutritional status was significantly higher among male 37 (44.0%) (P = 0.000), literate 18 (81.8%) (P = 0.000), living with spouse 47 (37.9%) (P = 0.010), currently working 22 (53.7%) (P = 0.001), and taking care of themselves 55 (34.2%) [P = 0.042, [Table 1]].
Perceived food environment
Regarding the external domain of the food environment, the majority of the older people agreed that all food items were always available in their area 180 (61.3%) and food items shops open frequently 172 (58.6%). Most of them have neutral responses regarding the nutritional information of food items before purchasing 138 (46.9%) [Table 2].
Regarding the internal domain of the food environment, the majority of the older people agreed that the costs of food items were very high in their area 184 (62.6%), they must spend long time to prepare food 115 (39.1%), the food items available were as per their choice 214 (72.8), and most were satisfied with the food they consumed 200 (68.0%). Most of them disagreed that they must travel very far from home to buy or acquire food items 117 (60.3%) and that cost of travel to buy food items was high 148 (50.3%) [Table 2].
Cluster analysis among participants regarding their responses to perceived food environment statements revealed that more than half 189 (64.3%) of the older people had “favorable food environment” and other was “unfavorable food environment” 105 (35.7%) [Figure 2]. Most important predictors for clusters were the statements “food items always available in the area” followed by “Cost of travel to buy food items is high” followed by “Food items shops open frequently in the area.” The quality of clusters was fair.
Predictors of nutritional status among the elderly
Using the binary logistics regression model, older people who were illiterate (adjusted odds ratio [AOR] 14.864; 95% confidence interval [CI]; 4.311–51.457) and not working (3.775; 1.753–8.128) had significantly higher odds of being undernourished. Older people who perceived their food environment as favorable (0.408; 0.214–0.775) had significantly lesser odds of being undernourished [Table 3].
The model here explained between 19.4% (Cox and Snell R2) and 27.7% (Nagelkerke R2) of the variance in nutritional status, correctly classifying 76.9% of cases (Hosmer–Lemeshow test Chi-square, 16.3; P = 0.038).
| Discussion|| |
Nutritional status of the elderly
Our study reported that among 294 older people, the majority 208 (70.7%) were undernourished, (190 [64.6%] of them were at the risk of malnutrition, and 18 [6.1%] were malnourished). Our finding is consistent with other community-based studies conducted among elderly population in India. In Manipur, 20.8% were malnourished and 49.2% at risk of malnourished, Assam 15% malnourished and 55% were at risk of malnutrition, Tamil Nadu 14% were malnourished and 49% risk of malnourishment, and Rajasthan 11.6% malnourished while 46% at risk of malnutrition. In Nepal, 24% were malnourished and 65% were at risk of malnutrition. West Bengal showed 29.4% elderly had malnutrition and 60.4% were at risk of malnutrition.
Perceived food environment
The food environment perceived by older people plays a vital role in their nutritional status. The majority of elderly with favorable food environments have less prevalence of malnutrition and risk of malnutrition. However, it is seen that the majority of them 138 (46.9%) have no response for the nutritional information regarding food items before purchasing. This might be due to illiteracy, they were not aware of nutritional information regarding food items before purchasing. Most of them 115 (39.1%) agree that they have to spend long time to prepare food, as they were still practicing the traditional way of cooking food on wood fire. Majority of them 184 (62.6%) acknowledged the high cost of food items in their area. These tea gardens are situated in the out skirts of the city, only few distributors/shops were present in the area, they were mostly available, and they might be overcharging them.
Predictors of nutritional status among the elderly
In this study, older people who were illiterate and not working had significantly higher odds of being undernourished. In a study in Tamil Nadu, schooling was not found to be significantly associated with lower MNA scores. Similar findings to our study were present in Bangladesh, nonformal education (odds ratio 6.5; 95% CI 1.3–32.1) was observed among the malnourished respondents, and in West Bengal and Delhi, illiterate older adults were more undernourished., This could be because the intake of food or choices all depends on wisdom. There might be a possibility that those older people who were not working were incapable to meet their living which leads to the risk of malnutrition.
This study is the first of its kind to be conducted regarding the food environment in tea gardens among older people in West Bengal, India. However, due to the nature and sensitivity of this issue, there is a possibility of a social desirability bias.
| Conclusion|| |
The elderly population residing in tea gardens is at higher risk of malnutrition. There might be high proportion of older people with deficient protein–energy intake without obvious clinical signs of malnutrition. It is essential to develop elderly friendly food environment in difficult terrains such as tea gardens with available and accessible low-cost nutritious food items and fuel subsidies. Literacy is crucial for generating awareness regarding food and its nutritional values. Moreover, routine nutritional assessment should be done at primary health centers, so that early identification those at risk of developing malnutrition and timely intervention can be done.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Joymati O, Ningombam M, Rajkumari B, Gangmei A. Assessment of nutritional status among elderly population in a rural area in Manipur: community-based cross-sectional study. International journal of community medicine and public health 2018;5:3125-9.
Shivraj M, Singh VB, Meena BL, Singh K, Neelam M, Sharma D, et al.
Study of nutritional status in elderly in Indian population. Int J Curr Res 2014;6:10253-7.
Kutikuppala A, Mathur N, Prakash TG. Nutritional status of elderly people using mini nutritional assessment tool in an Urban Slum of Hyderabad. Int J Med Sci Public Health 2018;7:885-9.
Ghosh A, Dasgupta A, Paul B, Sembiah S, Biswas B, Mallik N. Screening for malnutrition among the elderly with MNA scale: a clinic based study in a rural area of West Bengal. Journal of Contemporary Medical Research 2017;4:1978-82.
Medhi GK, Hazarika NC, Shah B, Mahanta J. Study of health problems and nutritional status of tea garden population of Assam. Indian J Med Sci 2006;60:496-505.
] [Full text]
Biswas S, Biswas S. Nutritional status assessment of elderly people in a rural area of West Bengal, India. Int J Adv Sci Technol 2020;29:3164-70.
Agarwalla R, Saikia AM, Baruah R. Assessment of the nutritional status of the elderly and its correlates. J Family Community Med 2015;22:39-43.
Vedantam A, Subramanian V, Rao NV, John KR. Malnutrition in free-living elderly in rural South India: Prevalence and risk factors. Public Health Nutr 2010;13:1328-32.
Ghimire S, Baral BK, Callahan K. Nutritional assessment of community-dwelling older adults in rural Nepal. PLoS One 2017;12:e0172052.
Lahiri S, Biswas A, Santra S, Lahiri SK. Assessment of nutritional status among elderly population in a rural area of West Bengal, India. Int J Med Sci Public Health 2015;4:569-72.
Rahman KM, Khalequzzaman M, Khan FA, Rayna SE, Samin S, Hasan M, et al.
Factors associated with the nutritional status of the older population in a selected area of Dhaka, Bangladesh. BMC Geriatr 2021;21:161.
Vaish K, Patra S, Chhabra P. Nutritional status among elderly: A community-based cross-sectional study. Indian J Public Health 2020;64:266-70.
] [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]