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CHAPTER III

METHODOLOGY

The present study entitled 'Nutritional status of the elderly' 'was

designed:-

1) To study the socio-economic and clinical status of the

elderly

2 ) To assess the anthropometric measurements

3) To identify the dietary habits and food consumption

4) To assess the perception of health by the elderly and

5 ) To compare the nutritional status of the elderly in old age

homes and in families

The methods and procedures adopted in the present

investigation are explained in this chapter under the following

sub-headings.

3 .1 Research design

3 .2 Selection of area of study

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3.3 Selection of subjects

3.4 Selection of method and tools for data collection.

3.5 Conduct of the study

3.5.l Pilot study

3 .6 Collection of data.

3.6.1 Socio-economic survey

3.6.2 Personal habits survey

3.6.3 Perception of health and nutritional status.

3 .6.4 Nutritional profile of the subjects

3.6.5 Anthropometric measurements

3.6.6 Biochemical assessment

3.6.7 Clinical assessment

3.5.8 Dietary survey.

3. 7 Developing Nutritional Status Index and

3. 8 Processing and analysis of data

3 .1 Research design

The Research design drawn for the conduct of the study

is descriptive or survey research design where an attempt is made

to describe and explain conditions of the present by collecting

information from many subjects with questionnaires to fully

describe a phenomenon.

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3.2 Selection ofarea ofthe study

In Kerala (2001), 10 per cent of the population is old

and this will be 25 per cent in another quarter of a century. It is

also significant to note that the concentration of the elderly in the

urban areas of Kerala is high compared to the all India figures.

The present study was conducted in the urban areas of

Kollam and Thiruvananthapuram districts where there is a

considerable number of elderly. Among the 52 wards in Kollam

and 86 wards in Thiruvananthapuram district, ten wards each were

selected for the study.

Information on the approximate number of households in

these wards were collected and subsequently, households with

persons above sixty years of age was identified using voters list.

In case the old person was not available, the next house was visited

till the elderly was contacted.

A total of 600 households were selected . Similarly,

twenty old age homes -both governmental and privately run were

identified and twelve were selected based on the accessibility and

willingness of the authorities and elderly inmates. A total number

of 195 elderly above the age of 60 was selected from these old age

homes for the study. The area and wards selected for the study are

presented in Figures I and 2

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• ollamThiruvananthapuram

Figure IArea of Study

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°' ·�

Kera la

� i Kellam district Thiruvananthapuram district

l l Corporation wards

(52) Selected-10

Figure 2

Wards selected from Kollam and Thiruvananthapuram

Corporation wards (86)

Selected-10

Pattom

Palayam

Kowdiar,

3 .3 Selection of subjects &

A sample is any number of per sons or objects

selected to represent the population according to some rule or

plan and any sampling method, to be good and statistically sound

must ensure the representativeness and adequacy of the sample.

(Singh ,2002)

A sample of 800 elderly persons, both male and female

were selected from the two districts by purposive sampling

method. The eligibility for inclusion in the study was, to have

attained the minimum age of 60 years ,as it is the onset of old

age. Hence, purposive sampling method was adopted for

selecting the subjects for the study. In purposive sampling, the

researcher purposely choose subjects who in their opinion are

thought to be relevant to the research study. (en.wikipedia.org)

Elderly subjects were selected from households as well

as from old age homes.

3.4 Selection of method and tools for data collection.

Survey method was used for the collection of data.

Surveys are one of the most frequently employed methods in

social research. Surveys are characterized by the collection of

data from a large or even very large number of people. All

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surveys aim to describe or explain the characteristics or opinions

of population through the use of a representative sample.

(www.nursinglibrary.org)

Accordingly, an interview schedule was formulated for

the collection of data. The interview method of collecting data

involves presentation of oral-verbal stimuli and reply in terms of

oral-verbal responses. ( Kothari, 2008). Data was collected with

the help of a structured questionnaire consisting of predetermined

questions and standardized techniques of recording. Face to face

interview was conducted for collection of data unlike the other

methods, there is a visual interaction component between the

interviewer and the interviewee. More information in greater

depth can be collected through the interview method.

The questionnaire contained the following schedules:

1. Schedule for socio-economic survey

2. Schedule for personal habits survey

3. Schedule for perception of health

4. Anthropometric measurement and biochemical estimation

schedule

5. Clinical examination schedule (2)

6. Dietary survey schedule

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Data regarding socio-economic status, personal habits

and dietary habits and perception of health was collected through

direct interview method. Clinical and biochemical assessment

was done with the help of a well trained clinician.

Anthropometric measurements were recorded , biochemical and

clinical assessment done and dietary survey was conducted by 24

hour recall method. The interview schedule and questionnaire are

presented in Appendix 1.

3.5 Conduct of the study.

Pilot study.

A pilot study is a small scale preliminary study

conducted before the main research in order to check the

feasibility or to improve the design of the research.

( Haralambos and Holbom,2000)

The reliability and validity of the tools for data

collection was tested through a pilot study. The pilot study was

executed among seventy five elderly subjects from house holds

in Kollam district and twenty five elderly subjects from an old

age home in Thiruvananthapuram district.

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Details regarding the socio-economic status, personal

habits and perception of health and nutritional status were

gathered through direct personal interview. Anthropometric

data were collected using standard techniques. Clinical

assessment and biochemical test were conducted with the help

of a clinician. Information regarding the food habits and

consumption was collected using the dietary survey schedule.

The pre-test revealed that certain questions were

irrelevant and repeated. Suitable modifications were made in

the questionnaire and design of the study accordingly.

3.6 Collection of data

Data was collected through direct personal

interview using the framed questionnaire.

3.6 .1 Socio-economic survey

Socioeconomic status (SES) 1s an economic and

sociological combined total measure of a person's work

experience and of an individual's or family's economic and social

position relative to others, based on income, education, and

occupation. When analyzing a family's SES, the household

income earners' education and occupation are examined, as well

as combined income, versus with an individual, when their own

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attributes are assessed.( NCES, 2008). Income and socio­

economic status can influence nutritional status of individuals.

Since elderly are a more vulnerable group to nutritional

deficiencies, socio-economic status could have a special

relevance on nutrition of elderly people. (Gattas et al, 1999)

The socio-economic survey was conducted to elicit

information on the following dimensions

a) Personal profile

b) Economic status and

c) Social status of the subjects

Data regarding age, sex, religion, marital status, income and

their source, place of stay, employment status and social

participation were collected through direct interview method.

These formed the dependent variables for the study.

(i) Age - The age of the subjects was assessed as the number of

completed years of life. Elderly men and women of the age of

sixty and above were selected for the study.

(ii) Religion - The religion to which the elderly subjects

belonged - whether Hindu, Christian or Muslim was ascertained.

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(iii) Marital status - The status of the subjects whether married

or unmarried, divorced or widowed.

(iv) Source of income - It refers to the source of monthly

income earned by the elderly subjects, being from pension,

business, current employment, from children or as interest or

profit from land or building.

(v) Place of stay - Place of stay refers to the mode of stay by the

elderly subjects whether with family or in old age home.

(vi) Employment status - The employment status of the

subjects was ascertained to find out if they were employed or

unemployed, in government or private sectors earlier and also

in the present.

(vii) Social participation -Social participation was

operationalized as the social experience gained by the elderly

subjects by participating in formal or informal organizations

either as a member or an office bearer. (Jaimy, 2001)

3.6.2. Survey of personal habits

Information on personal habits was collected to see if

any of these habits have influenced the dietary habits and

nutritional status of the subjects. Personal habits assessed in this

study includes the habit of smoking, liquor consumption, tobacco

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chewing, physical exercise and habit of prayer. The information

was collected by personal interview technique, using the

standardized questionnaire given in Appendix II

3 .6.3 Perception of health and nutritional status

A structured questionnaire was administered to

understand the perception about health and nutritional status by

the elderly. (Appendix Ill)

3.6.4 Nutritional profile of the subjects

Assessment of nutritional status of community is one of

the first steps in the formulation of any public health strategy to

combat malnutrition. The principal aim of such an assessment is

to determine the type, magnitude and distribution of malnutrition

in different geographical areas, to identify the at-risk groups and

to determine the contributory factors. (Stookey, 2001 )

The assessment of nutritional status can be summarized

by 'ABCD' - anthropometric measurements, biochemical tests,

clinical indicators and dietary assessment. ( www.answers.com)

3. 6. 5 Anthropometric measurements

Nutritional anthropometry is the measurement of human

body at various ages and levels of nutritional status.

Anthropometry has been accepted as one of the most important

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tools for the assessment of nutritional status of the population and

to monitor the growth and health of the individual.

(Gorstein et.al,1994)

Nutritional anthropometry was adopted in the present

study because the pattern of growth and physical fitness of an

individual, though genetically determined are profoundly

influenced by diet as explained by Gai, (1996).

ICMR (1994) , reported that in field studies, to assess

the nutritional status, heavy reliance must be placed in the

measurement of external morphology of the body. Hence, height,

weight ,waist and hip measurements and mid-upper arm

circumference were recorded using standard techniques and the

corresponding Body Mass Index and Waist Hip ratio were

computed.

(i) Measurement of Height

The height or the total length of an individual is

influenced both by genetic and environmental factors. It is the

most sensitive means of evaluating the overall well being of

an individual. (Smita and Underwood, 1991 ). It is considered

as an index of chronic or long duration malnutrition.

(Srilakshmi,2003)

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The elderly subjects were asked to stand against a wall

with bare foot and heels, buttocks, shoulders and the back of

head touching the wall. The head was held comfortably erect

with the arms hanging freely at the sides in a natural manner.

The height was measured using a non-stretchable

measuring tape. A scale was placed perpendicular to the wall

and a mark was made on the wall after which the height of

the subject was measured using the measuring tape.

(ii) Measurement of weight

Body weight is the most widely used sensitive and

simple, reproducible anthropometric measurement. It

indicates the body mass and is a composite of all body

constituents like water, mineral, fat, protein and bone. It

reflects the recent nutrition. (Srilakshmi,2003).

In the present study, weight of the elderly was

recorded using a bathroom scale. The weighing scale was

adjusted to zero before taking each measurement. The subjects

were asked to stand on the weighing scale, barefooted, without

touching anything, knees not bent, head straight and looking

forward. The readings were carefully viewed and recorded

nearest to 0.5 kg.

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Plate 1. Measurement of height

Plate 2. Measurement of Weight

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Plate 3. Measurement of waist and hip

Plate 4. Measurement of mid upper arm circumference

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(iii) Measurement of Body Mass Index - BMI can be used

to grade chronic energy deficiency and is regarded as a good

indicator of nutritional status. The Body Mass Index of the

elderly subjects was computed by dividing the weight in

kilograms by the square of the height in metres.

Body Mass Index = Weight (k�)Height (m )

( Park and Park, 2000)

( iv) Measurement of Mid-Upper Arm Circumference

MUAC is the most useful, practical method for

assessing muscle mass, as this region is easily accessible and

measurement requires only a flexible fibre glass tape. (Gopaldas

and Sheshadri, 1987).Mid upper arm circumference of the

subjects were measured to the nearest 0.1cm with a tape placing

gently but firmly round the limb to avoid compression of the soft

tissue. The mid-point of the left arm in the hanging position was

taken.

(v) Measurement of Waist and hip circumferences -

According to Boyle et al (1993), the waist

circumference should be taken at the narrowest circumference

between the ribs and hip.

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Mahan (2000) stated that hip circumference is defined as

the largest circumference between waist and knees.

The waist and hip circumferences were accurately

measured and the Waist-Hip ratio was computed by the formula

Waist Hip Ratio = Waist circumference (cm)Hip circumference ( cm)

(NIN,1999) Y

3.6.6 Biochemical assessment

Under biochemical assessment , the blood haemoglobin

level was estimated for all the subjects.

Assessment of haemoglobin 1s one of the most

important tools for assessing the nutritional status of a

population. Hb level is a useful index of the overall state of

nutrition irrespective of its significance in anaemia. The

Haemoglobin level of the subjects were estimated through

'Cyanmethaemoglobin' method. (NIN, 2003)

The procedure is presented in Appendix VIII

3.6.7 Clinical assessment

Clinical examination is stated to be one of the most

essential and simplest tool used in the evaluation of nutritional

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status. It is a part of nutritional assessment through which direct

information on signs and symptoms of dietary deficiency could

be observed.

In this study, the prevalence of clinical signs and

symptoms among the subjects due to dietary deficiencies or

excess were assessed for all the subjects. The presence and

absence of deficiency symptoms, which is an index of nutritional

status was assessed with the help of a qualified physician using

the standard proforma .(NIN,1986). (Appendix V, VI)

�.

The symptoms was recorded as those;

* who did not have the symptom,

* those who had, but did not see a doctor and

* those who had the symptom and did consult a doctor

during the previous month of the survey .

3.6.8. Dietary survey - The value of nutritional assessment is

greatly enhanced when it is supplemented by an assessment of

food consumption. The diet survey constitutes the information

regarding the source of food stuffs, existing food use frequency,

dietary habits, food preference, food expenditure pattern, food

consumption pattern etc.

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In the dietary recall method, the subjects were asked to

recall the actual food consumed by them the previous day. In this

method, a set of 'standardized' cups suited to the local conditions

were used following the standard procedure. (Thimmayamma

and Rao, 2003).

An account of the raw ingredients used for each of the

preparations was obtained from the cooked food. The individuals

interviewed were asked a systematic series of questions to ensure

recollection and description of all the foods and drinks consumed

in the 24 hours before the interview with emphasis on the food

consumption meal-by-meal. From these weights the raw

equivalent of the cooked food consumed was computed and the

nutritive value of the raw foods consumed was determined using

the Food Composition Table which gives the nutritive value of

commonly consumed food items.

The nutrient intake of the subjects was compared with

the Recommended Dietary Allowance for Indians given by the

Indian Council of Medical Research. The proforma used for

dietary survey is given in Appendix VII

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3. 6 Developing Nutritional Status Index

Nutritional Status Index is an indicator of social well

being of a community. (Srinath , 1998) The NSI was computed

using the formula developed by K��n��-�-_S ��-�--�-�r�-����(1993).ln the present study, Body Mass Index, blood

Haemoglobin level and nutrient intake ( protein and calorie )

were taken into consideration for computing the NSI. Nutritional

Status Index was computed for all the 800 elderly.

NSI = L Wj Xjjj=]

i = 1,2,3 .. ... n

j = 1,2,3 .... k

n = 800 (number of subjects)

k = number of variables

Accordingly nutritional status was classified as:-

Mean- standard deviation = Low

Between mean ± standard deviation = Medium

Mean + standard deviation = High.

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3. 8 Processing and analysis of data

The data, after collection was processed

,tabulated and analysed in accordance with the outlines laid

down at the time of developing the research plan. After editing

and coding, the data was classified and tabulated according to

certain characteristics.

According to Koul (1992), analysis of data means

studying the organized material in order to discover inherent

facts. The data was analysed from different angles as possible

to explore new findings.

Data analysis was done using the Statistical Package for

Social Sciences (SPSS) of Windows version 10.0 program for

all variables

(i) The Mean and Percentages were used for finding out the

frequency distributions.

(ii) Pearson's chi-square (x:) test is the best-known of several chi-

square tests - statistical procedures whose results are evaluated

by reference to the chi-square distribution. Chi square tests were

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administered to find out the significance of NSI and socio­

economic variables.

(iii) Correlation is the most widely used method of measuring

the degree of relationship between two variables. Correlation

was used to measure the relationship between NSI and other

variables.

(iv) The z-test and t-test , along with an independent sample

test were also done to assess whether the means of two groups

are statistically different from each other.

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Kol/am district ,I.

Corporation warda(52)

[1 O selected]

Figure 3

RESEARCH DESIGN

j Selection of Area

Kera la

Thlruvananthapuram district ,I.

Corporation wards(86)

[10 selected] (Thangassery west.Beach north, Thamarakulam, Mundakkal west, Thekkevila, Pattathanam,Thevally, Pallithottam,Kadappakada,Asramom.)

( Nalanchira, Kesavadasapuram, Pattern, Ulloor, Petta, Palayam Kannammoola, Nanthencode, Kowdiar, Vazhuthacaud)

Selection of subjects (N=BOO)

Socio-economic background Personal habits

Perception of health and nutrition

Nutrltlonal1 Assessment

J, J; :i; .j. Anthropometry Biochemical Analysis Clinical examination Dietary and nutrient intake

* BMI *MUAC*WHR

* Hb

l I Developing NSI

Statistical Analysis

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