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Bioscience Research, 13(1): 43-64, 2016 Available online at www.isisn.org

©Innovative Scientific Information & Services Network Print ISSN: 1811-9506

Online ISSN: 2218-3973

Nutritional assessment of institutionalized elderly in Makkah

region, Saudi Arabia

Hala A.H.Khattab1, 2* and Ebtisam T. Al-Saadoun1 1Food and Nutrition Department, Faculty of Home Economics, King Abdulaziz University, Jeddah, Saudi

Arabia 2Nutrition and Food Science Department, Faculty of Home Economics, Helwan University, Egypt

*Corresponding author

Aging is associated with a decline in physiological functions that can affect nutritional status. The present work aimed to investigate the nutritional status and its related factors among institutionalized elderly. The study was designed as a cross-sectional study in social care homes in Makkah region included 53 subjects aged ≥ 60 years after applied inclusion criteria. Socio-demographic questionnaire, designed especially for older adults and used at all Primary Health Care Centers, Ministry of Health (MOH), Saudi Arabia, was used in this study with some modification. Anthropometric measurements included body weight, height, waist and hip circumferences were assessed. Seven-days estimated dietary intake record (7-DDR) was used to evaluate average intake of macro-and micronutrients (vitamins and minerals) intake and its percentage of dietary reference intake (DRI). It showed that, about quarter of the elderly have a normal anthropometric measurements with normal blood pressure, and majority of them have decline in physical health status. An increase in total energy, protein and carbohydrate, paralleled by a decrease in fiber were recorded relative to DRI. Also, deficiencies in vitamins (A, B6 & D), and minerals (calcium and potassium), accompanied with an increase in sodium were observed relative to DRI. It can be concluded that this study demonstrated that, there was a poor nutritional status among the institutionalized elderly in social care homes. Further research is required to estimate the intervention factors that could prevent or delay the regression in the nutritional status among this vulnerable group and improve their quality of life.

Key words: Elderly; Nutritional assessment; MNA; Physical health; Makkah.

Aging is an irreversible biological process (Joyce et al. 2005; WHO, 2014), and it has been estimated that the number and proportion of older persons are growing in all countries (WHO, 2014). In Saudi Arabia the proportion of the elderly was 4.8% in 2000, in 2012 accounted 7.3%, and it is expected to rise to 8% in 2025 (CDSI, 2012). Mortality rates have declined due to improvement in living standards, hygiene, sanitation and infectious disease prevention. The increases in longevity and the proportion of people over the age of 60 years, is often regarded as a challenge to health systems, as longer lives are commonly associated with a prevalence of disease (United Nations, 2015). Older people are at a greater risk of having unhealthy lifestyles; therefore they

should be targeted through customized health education programs (Farid et al. 2010). Early detection of malnourished residents upon admission to the nursing home would lead to early intervention and reduction in medical-treatment costs as well as reduced complications (Alhamdan, 2004).

Aging health deterioration can be described as a risk factor that leads to prevalence of diseases and loss of functions, which generally increase over time and affect all aspects of human endeavors (Wahl et al. 2009; Inocian et al. 2014). During aging multidimensional processes of physical, psychological and social changes occur (Bowen and Atwood, 2004). It is associated with a decline in a number of physiological functions that

Research Article Communication le

44

can impact nutritional status including a decrease in basal metabolic rate, gastric secretion of digestive juices, changes in the oral cavity and sensory function deficits. Also, the changes in fluid, electrolyte regulation and chronic illness, appear and affect the physical strength and functional ability and vitality (Elmadfa and Meyer, 2008). Therefore, there has been an increasing international awareness of health issues relating to aging populations and there is a great need for preventive, curative and rehabilitative programs in order to introduce high quality of health and care services to elderly in Saudi Arabia (Szucs, 2001; Mohammad and Abd-Elhafez, 2012).

Nutrition is an important determinant of health in older age. Adequate nutrition helps to preventing or delaying the onset of diseases and enhances the quality of their life (Kaiser et al. 2010). Numerous factors could induce malnutrition in the elderly that are often interrelated. There is a growing recognition that age-related physiological changes may predispose to malnutrition in the elderly (Forster and Gariballa, 2005). Elderly are at an increased risk of malnutrition because of insufficient food intake (amount), poor selection of food (quality), reduced desire to eat, decline in food digestion or absorption, compromise in nutritional metabolic pathways, poor dental hygiene, or chronic diseases that are commonly found in elderly (Suominen et al. 2005; Shetty, 2006; Wells and Dumbrell, 2006; De Lima et al. 2012). Many interactions exist between drugs and nutrition as in many instances; drugs and nutrients use similar sites for absorption, and are metabolized and excreted through the same organs (Van Zyl, 2011). Therefore, the present study aimed to assess nutritional status and its related factors, paralleled by evaluation of some biochemical biomarkers in institutionalized elderly subjects in Makkah region.

MATERIALS AND METHODS Subjects and setting

This study was designed as a cross-sectional study that conducted in Makkah region. It included two social care homes in Makkah and Taif cities, Saudi Arabia. It was carried out from September 2014 until January 2015. The populations were of institutionalized elderly at a long-term nursing social care home administered by the Ministry of Social Affairs (MOSA) in Kingdom of Saudi Arabia. The inclusion criteria was subjects aged ≥ 60 years, this age was chosen according to the National Policy for the elderly that classifies individual’s aged 60 (Y) or older as elderly

(Oliveira et al. 2009). The exclusion criteria included subjects who were diagnosed with severe liver or renal diseases; have psychiatric disorders; administering vitamin supplements containing folic acid or vitamin B12 ; taking prescribed drugs known to interfere with folate, vitamin B6 or vitamin B12 metabolism (ex.,

anti‐epileptic drugs); with megaloblastic anemia; have previous gastric surgery and unstable medical conditions, as well as those taking antipsychotic or respiratory diseases medications and those undergoing chemotherapy. All institutionalized elderly included (n =191) of both genders [males (n= 107), and females (n = 84)]. After applying the selection criteria, subjects (n

=53) of all the institutionalized were chosen and submitted in the present study [males n= 28 (52.83%) and females n= 25 (47.17%)].

Ethical approval

The study protocol had been approved by the Ethics Committees (No. HA-02-J-008) from Unit of Biomedical Ethics at Faculty of Medicine, King Abdul-Aziz University, Jeddah, Saudi Arabia. As well, an official permission had been granted to conduct the study in social care homes in Makkah region (Makkah and Taif) by Ministry of Social Affairs (MOSA), Saudi Arabia. All elderly participants in this study were given informed consent form, which contained approval for taking information from the participant´s file, answering complete the questionnaires applied in this study, as well as to taking blood sample for biochemical analysis. The data were collected by the researchers and by trained nurses.

Methods Socio-demographic and vital signs assessment questionnaire

Questionnaire asking for socio-demographic data. It was developed especially for older adults and used at all Primary Health Care Centers, Ministry of Health (MOH), Saudi Arabia, as the elderly comprehensive clinical file. This questionnaire was applied with some modification. It included: age, nationality, education level, retirement status, marital status, in case caregivers face any problems, medical status and prescribed medication. In addition to general information related to health, including smoking (number of cigarettes smoked/day and duration of smoking), and coffee & tea consumption. A systematic physical exam was used to assess health nutrition-related factors via investigating hearing, vision, mobility status and physical activity, teeth and gum status, and evaluating

45

appetite and weight change during last six months, chewing and swallowing problems and type of diet. Blood pressure (BP) was measured by using a mercury manometer. For elderly participants BP was classified according to blood pressure categories to normal (less than 80/120 mmHg), prehypertension (80-89/120-139 mmHg), high blood pressure (hypertension) stage1 (90-99/140-159 mmHg), hypertension stage2 (100-109/160-179 mmHg) and hypertensive crisis (higher than 110/180 mmHg) (AHA, 2015).

Anthropometric assessment

Anthropometric measurements were recorded by trained experienced nurses; they included body weight, height, waist and hip circumferences. Body weight and height were calculated to the nearest 0.1 kg and 0.1 cm, respectively. They were measured with light clothes and without shoes by using a balance-beam scale for weight and a stadiometer for height. Chair scale was used for elderly who can′t stand. The estimated weight (EW) was calculated for subjects on bed, by using the following: measurements arm circumference (AC), calf circumference (CC), subscapular skinfold (ST), and knee height (KH) in cm. The previous measurements were taken by using a flexible, non-stretchable measuring tape. The estimated weight for each subject was calculated according to Chumlea’s equations (Chumlea et al. 1998). The Chumlea equation for estimated weight (EW):

For men EW = (AC x1.73) + (CC x 0.98) + (ST x 0.37) + (KH x 1.16) - 81.69.

For women EW = (AC x 0 98) + (CC x 1. 27) + (ST x 0. 4) + (KH x 0. 87) - 62.35.

Body mass index (BMI) (kg/m2) was

calculated for each subject (Santos et al. 2004), then classified into four groups (WHO, 2006; NIH, 2015). Waist-hip ratio (WHR) was estimated according to Visscher et al. (2001), using a flexible non-stretchable measuring tape, without any pressure to body surface and measurements were recorded to the nearest 0.1 cm. The value of WHR for each subject was classified according to WHO (2008).

Nutritional assessment questionnaire

The nutritional intake was determined by using: seven-days estimated dietary intake record, by using a validated 7-D dietary record questionnaire (Bingham et al. 1997; Day et al. 2001), to record the estimated actual intake from food and beverages, consumed over 7 consecutive days. The records were written by the researchers or the trainer nurses. All information

of food consumption was conducted by observation, or measuring weight, or estimated standard household measures (e.g. cups and tablespoons) and food model pictures. The obtained data included the meal eaten, and the consumption of additional snacks or beverage. Detailed information including food description, ingredients, preparation method, portion size and the actual quantity eaten, were recorded. The recorded dietary intake for seven days was analyzed, by using the Food Processor Program Software Version 10.12.0.0, for assessment of energy and nutrients intake of elderly participants, with slight modification in food items to be adapted with the food variety of elderly people in the Arab region. The total energy for each subject was calculated according to Lorentz Equations Olivier (WLo) (Bouillanne et al. 2005). The program calculated the average daily intake of macronutrients and micronutrients (vitamins and minerals) for seven days. After inserting the calculated total energy for every subject, all nutrients intake were compared with the estimated average requirement and DRI for the particular age and sex group. The obtained data were represented as the mean dietary intake and percentage of DRI values.

Biochemical analysis

Blood samples were withdrawn after overnight fasting by the trained nurses. The biochemical analysis was performed in the clinical laboratory of the MOH hospital and Alborj laboratories. A total of three laboratories in two cities participated in the biochemical analysis (Makkah, the clinical laboratories in King Abdul-Aziz hospital, and in Taif clinical laboratories at King Faisal hospital, as well in Alborj laboratories in Makkah and Taif). Complete blood count (CBC), vitamin B12 levels, and folate concentrations were analyzed. In addition, serum samples were used to analyze total homocysteine concentrations. All the results of biochemical parameters were classified into: low, normal and high values for all subjects according to the standard values of each lab and kits. The reference range for the biochemical analysis according to the lab was as follows: for CBC (measured by x N-1000 (Sysmex)); white blood cells (WBC) in both male and female (3.80 - 11.00 10

3/cm

3), red blood cells (RBC) in male

(4.60 – 6.08 106/cm

3) and in female (3.80 -5.50

106/ cm

3), hemoglobin (HGB) in male (13.5-18.0

g/dl) and in female (11.5- 15.5 g/dl), and platelet count (PLT) in both male and female (150 - 400 10

3/ cm

3).Vitamin B12 was analyzed by using

human Cobas immunoassay Elecsys Kit with

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reference range for Makkah city laboratory for both male and female (211 - 946 pg/ml) (Barakat and Ekins, 1961), and in Taif city laboratory (240 - 900 pg/ml) (Gutcho and Mansbach, 1977). Folate concentration was evaluated using Human Cobas Immunoassay Elecsys Kit with reference range for both of male and female in Makkah laboratory (4.6- 34.8 ng/ml) (Dunn and Foster, 1973), and in Taif city laboratory (4.60- 18.70 ng/ml) (Gutcho and Mansbach, 1977). Total homocysteine concentration was analyzed using Human Archite immunoassay Elecsys Kit reference range for both male and female (5.46 -16.20 umol/l) (Maiinow,1995). Statistical analysis

All data were analyzed by using the Statistical Package for Social Science (SPSS) version 22. The data were explored for their descriptive statistics (calculation of percentage distributions, frequency distributions and calculations of averages and standard deviation SD), and inferential statistics (Chi-square (ᵪ²). Categorical variables data were described, as frequencies and percentages, while quantitative and results of Food Processor program were represented as mean ± SD. One way ANOVA, followed by L.S.D. test was used to compare between dietary nutrients intake, differences were considered significant if p-value was p < 0.05.

RESULTS General characteristics of the institutionalized elderly

The present results revealed that, the mean age in all subjects was 78.92±12.26, the majority of them were Saudi 92.45%, 43.40% were single, 86.79% were illiterate in equal numbers of both males and females. All females subjects 47.17% were previously non-working, there was a significant difference between males and females in the retirement status (p=0.000). Body mass index (BMI) (Kg/m

2) of elderly participants showed

that, only 13.21% were in normal weight; there was in-significant difference between males and females in BMI. Regarding, waist to hip ratio (WHR) almost half of them 20.75% were in low and 30.19% were in moderate risk, while the rest 32.06% and 16.98%were in very high and high risk, respectively, there was a significant difference between males and females regarding WHR (Table 1).

Health status of the institutionalized elderly

The current results revealed that, 86.79% of all participants are suffering from diseases, there

was a significant difference (p = 0.035) between males and females in the presence of diseases, majority of all elderly 84.90% are suffering from 1-3 diseases. Almost half 27 (50.93%) of all subjects have normal BP, 23 (43.41%) of the subjects have pre-hypertension, while there are an equal numbers 1of both males and females in hypertension stage 1, and only 1(1.89%) male in hypertension stage 2, there is a significant difference between males and females in BP (p=0.005). Regarding elderly receiving medication the data showed that, about three quarters of elderly have been taking prescribed drugs 79.25% of all subjects, most of them have been taking from 1-3 drugs/day, there is in-significant difference between males and females in receiving prescribed drugs and in number of drugs taking. The surgical history in elderly residents at social care in Makkah region showed that, in total subjects there are 44 subjects have no surgical history. Concerning if caregivers facing problems with elderly, the results showed that, 50.94% of elderly causes problems for caregivers, there is a significant difference between males and females in causing problems for caregivers (Table 2). Physical status and nutrition related factors of the institutionalized elderly

In mobility status it showed that, 77.36% of elderly are incapable of walking, more than half of elderly 56.60% are weak in hearing, 13.20% are blind, 24.53% have bad gum and teeth health, 41.51% have problems in chewing the food, and 28.30% have swallowing problems, there are no significant differences between males and females in all previous physical status. About 37.74% have change in appetite during the last 6 months, 69.81% have change in weight, there are significant differences between males and females in appetite and weight change during the last 6 months. Three quarters of elderly (71.70%) have been consuming special diet; the most type was low-sodium and soft diet. Concerning consumption of tea and coffee, the data revealed that, majority of elderly 49 (92.45%) consume tea, most of them 81.13% consume from 1-3 cups/day, there is in-significant difference between male and female in tea consumption. 71.70% consume coffee, the majority of elderly consume from (1-3) cups coffee/ day. All females subjects 25 are non-smokers, while only 5 males subjects were smokers, there is a significant difference between males and females in coffee consumption and smoking (Tables 3 and 4).

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Table 1: Demographic characteristics of the institutionalized elderly.

Characteristics All participants 53(100%)

Male 28(52.83)

Female 25 (47.17)

P-value*

Age (Y)

78.92 ± 12.26 a 78.86 ± 12.11

a 79 ± 12.67

a

60-74 21 (39.62)

11 (20.75)

10 (18.87)

75-89 20( 37.73 ) 11 (20.75)

9 (16.98)

0.962

90-105 12 (22.65 ) 6 (11.32) 6 (11.32)

Nationality

Saudi 49 (92.45)

26 (49.05)

23 (43.40)

Non-Saudi 3 (5.66) 1(1.89) 2 (3.77)

0.509

Unknown 1(1.89) 1(1.89) -

Marital status Single 23 (43.40)

16 (30.19)

7 (13.21)

Married 5 (9.43) 1 (1.89)

4(7.55)

Divorced 6 (11.32)

4 (7.55)

2 (3.77)

0.065

Widow 18 (33.96)

6 (11.32)

12 (22.64)

Unknown 1 (1.89) 1 (1.89) -

Education level

Illiterate 46 (86.79)

23 (43.40) 23 (43.40)

Read & write

3 (5.66)

1 (1.89)

2 (3.77)

Elementary

3 (5.66) 3 (5.66)

-

Secondary & High school

-

-

-

0.243

University

1 (1.89)

1 (1.89)

-

Postgraduate & Unknown - - -

Retirement status Previously working

14 (26.42)

14 (26.42) -

Non-working previously

37 (69.81)

12 (22.64)

25 (47.17)

0.000*

Unknown 2 (3.77) 2 (3.77) -

BMI (Kg/m2)

Under weight

12 (22.64)

8 (15.09) 4 (7.55)

Normal weight 14 (26.42)

7 (13.21)

7 (13.21)

Over weight

14 (26.42)

8 (15.09)

6 (11.32) 0.54

Obese 13 (24.53)

5 (9.43) 8 (15.09)

WHR

Low 11 (20.75) 11 (20.75)

-

Moderate 16 (30.19) 11 (20.75)

5 (9.43) 0.000*

High

9 (16.98)

1 (1.89)

8 (15.09)

Very high 17 (32.06)

5 (9.43) 12 (22.65)

BMI: Body Mass Index. WHR: Waist to Hip Ratio. Data are expressed as frequency N (percent of total number, n=53). a Values expressed as mean ±SD.

*Significant difference between males and the corresponding females (Chi-square). Body mass index (BMI) classification according to WHO (2014) Waist to hip ratio (WHR) classification according to WHO (2012).

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Table 2: Health status of the institutionalized elderly.

Health status All participants 53(100%)

Male 28(52.83)

Female 25 (47.17)

P-value*

Presences of diseases

Free from diseases

7 (13.21) 1 (1.89)

6 (11.32)

0.035*

Suffering from diseases

46 (86.79)

27 (50.94)

19 (35.85)

Number of diseases#

1.77 ± 1.14

a

1.96 ± 0.84

a

1.56 ± 1.39

a

< 1

7 (13.21)

1 (1.89)

6 (11.32)

1-3 45 (84.90)

27 (50.94)

18 (33.96)

0.045*

4-6 1 (1.89) - 1 (1.89)

Blood pressure (BP) (mmHg)+

Normal BP

27 (50.93)

8 (15.09)

19 (35.85)

Pre hypertension

23 (43.41)

18 (33.96) 5 (9.43)

Hypertension stage 1

2 (3.77)

1 (1.89)

1 (1.89) 0.005*

Hypertension stage 2

- - -

Hypertension crisis 1 (1.89)

1 (1.89)

-

Medication

Used prescribed drugs

42 (79.25)

24(45.28)

18(33.96)

0.219

Non- use any drugs 11 (20.75) 4 (7.55) 7 (13.21)

Surgical history

Yes 9 (16.98)

23 (43.40) 4 (7.55)

0.857

No 44 (83.02) 5 (9.43)

21 (39.62)

Caregivers facing problems

Yes 27 (50.94)

6 (11.32)

21 (39.62)

0.000*

No 26 (49.06) 22 (41.51) 4 (7.55)

Data are expressed as frequency N (percent of total number, n=53). a Values expressed as mean ± SD.

*Significant difference between males and the corresponding females (Chi-square). # Elderly may suffer from more than one disease and take more than one drug.

+Blood pressure categories according to AHA (2015).

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Table 3: Physical status among the institutionalized elderly.

Physical status All participants 53(100%)

Male 28(52.83)

Female 25 (47.17)

P-value*

Mobility

Yes 12 (22.64)

8 (15.09)

4 (7.55)

0.224 No 41 (77.36) 20 (37.74) 21 (39.62)

Hearing

Normal

19 (35.85)

9 (16.98)

10 (18.87)

Weak

30 (56.60)

17 (32.08) 13 (24.53)

0.812

Blind 4 (7.55) 2 (3.77) 2 (3.77)

Vision

Normal

23 (43.40)

12 (22.64)

11 (20.75)

Weak

23 (43.40)

11 (20.75)

12 (22.64)

0.547

Blind 7 (13.20) 5 (9.43) 2 (3.77)

Teeth and gum

Good 18 (33.96)

7 (13.21)

11(20.75)

Weak 22 (41.51)

14 (26.41)

8 (15.09)

0.295 Bad 13 (24.53) 7 (13.21) 6 (11.32)

Chewing problems

Yes 22 (41.51)

12 (42.857)

10 (18.87)

0.833

No 31 (58.49) 16 (30.21) 15 (28.30)

Swallowing problems s

Yes 15 (28.30)

10 (18.87)

5 (9.43)

0.205

No 38 (71.70) 18 (33.96) 20 (37.74)

Appetite change #

Yes 30 (56.60)

10 (18.87)

20 (37.74)

0.001*

No 23 (43.40) 18 (33.96) 5 (9.43)

Weight change#

Yes 37 (69.81) 14 (26.42 )

23 (43.40 )

0.001*

No 16 (30.19) 14 (26.42 ) 2 (3.77) # During the last 6 months.

Data are expressed as frequency N (percent of total number, n=53). *Significant difference between males and the corresponding females (Chi-square).

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Table 4: Type of diet and nutrition related factors of the institutionalized elderly.

Type of diet and nutrition related factors

All participants 53(100%)

Male 28(52.83)

Female 25 (47.17)

P-value*

Type of diet

Regular diet

15 (28.30)

6 (11.32)

9 (16.98)

0.192 Special diet

38 (71.70)

22 (41.51) 16 (30.12)

Liquid diet

2 (3.77)

1 (1.89)

1(1.89)

0.726

Soft diet

16 (30.12)

11 (20.75)

5 (9.43)

0.109 Low-sodium diet

23 (43.40)

15 (28.30)

8 (15.09)

0.096 Low- protein diet - -

-

-

Calorie restricted diet 11 (20.75)

2 (3.77)

9 (16.98)

0.011*

Low-fat diet

10 (18.87)

8 (15.09)

2 (3.77)

0.057 Low-cholesterol diet

9 (16.98)

7 (13.21) 2 (3.77) 0.099 Fiber-restricted diet

1 (1.89)

1 (1.89)

-

0.528 High-fiber diet 13 (24.53)

9 (16.98) 4 (7.55) 0.148

Tea drinkers

No 4 (7.55)

1 (1.89)

3 (5.66)

0.246 Yes 49 (92.45)

27 (50.94)

22 (41.51)

Number of cups/day

1-3 43 (81.13) 22 (41.50)

21 (39.62)

4-6 4 (7.55)

4 (7.55)

-

0.18

7-10 2 (3.77) 1 (1.89) 1 (1.89)

Coffee drinkers

No 15 (28.30)

12 (22.64) 3 (5.66)

0.01*

Yes 38 (71.70)

16 (30.19) 22 (41.51)

Number of cups/day

1-3 37 (96.81)

15 (28.30)

22 (41.51)

0.02*

4-6 1 (1.89) 1 (1.89) -

Smoking

No 48 (90.56)

23 (43.40)

25 (47.17)

0.026*

Yes 5 (9.43)

5 (9.43)

Number of cigarettes/day

1-5 3(5.66)

3(5.66)

-

6-10 1 (1.89)

1 (1.89)

-

11-15 -

-

- 0.18*

16-20 1 (1.89) 1(1.89) -

Data are expressed as frequency N (percent of total number, n=53). *Significant difference between males and the corresponding females (Chi-square).

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Biochemical analysis The biochemical analyses of the elderly

participants are illustrated in Table 5. The results revealed that, there are 58.49% of all subjects have high level of homocystiene. In vitamin B12 26.41% of all subjects have low vitamin B12 level. Almost all elderly (96.23%) have normal folate level, while equal numbers 1 (1.89%) of both males and females has low folate level. Regarding CBC parameters for elderly it revealed that, almost all elderly have normal WBC 94.34% and only 5.66% of females have a low count of WBC. While in RBC it was clear that, 67.93% of all subjects have a normal count, 15 (28.30%) at low count, there are equal numbers 1 (1.89%) of both male and female have a high level of RBC. In regard to HGB level, it showed that, half of the sample 26 (49.06%) have low level, while the majority 43 (81.132%) of all subjects have a normal level of PLT, and 8 (15.09%) have low count 5 (9.43%) of them were females subjects. There are an insignificant differences between males and females elderly in all tested biochemical parameters, expect there is a significant difference between males and females elderly in vitamin B12 level (p =0.004).

Nutritional status of the institutionalized elderly Seven-days dietary intake record:

Macronutrients dietary intake of the institutionalized elderly as average and percentage of DRI is illustrated in Tables 6 and 7. The analysis of daily food intake for 7-days record indicated that, the average of total daily calorie intake is (2038.37±446.50 K.cal) in all participants, which represent 151.65% as percentage from DRI. Both males and females showed elevation in total energy intake recorded 133.49 % and 171.98 %, respectively as percentage of DRI, respectively. Protein intake considered high in male and female than the requirements, its amount recorded 91.61±21.48 g in males and 73.72 ± 16.89 g in females, with percentage of DRI account 210.61% and 238.42%, respectively, protein caloric contribution with 17.11% and 15.34% for males and females, respectively. The same trend has been shown in carbohydrate intake, the intake of carbohydrate increased than DRI, it represent 191.57% for females and 140.33 % for males. Carbohydrate caloric contribution with 57.46 % and 61.43% for male and female, respectively. The average fat intake amount 61.12±14.58 and 50.90 ±13.69 g with percentage 121.62% and 147.25% for males and females, respectively, it contributes 25.68% and 23.83% from total caloric consumed for males

and females, respectively. Dietary fiber intake is in the acceptable intake level as the percentage of DRI in all elderly. There are significant differences between males and females in the average daily dietary intake of protein and fiber, as well as in percentage of DRI in total energy, carbohydrate intake, fiber and fat.

Concerning the micronutrients vitamins as shown in Tables 6 and 7, the data revealed that, there is a decrease in retinol (Vit. A), pyridoxine (Vit. B6), calciferol (Vit. D), alpha-tocopherol (Vit. E), and folate the average intake was 413.84±155.00 g, 1.02±0.23 mg, 90.72±60.88 mg, 2.32±1.11 mg and 317.41±85.61 µg, respectively, which represent 51.38±17.94, 63.81±13.91, 13.72±6.88, 15.63±7.25 and 79.36±21.40, respectively of DRI. In minerals there is a decrease in calcium and potassium intake and the average intake are 572.73±139.53 and 2083.41±465.80 mg, respectively, with percentage of DRI represented 49.10±12.12 and 44.33±9.91%, respectively in all elderly, while the average intake of sodium is 3102.26±868.32 mg, which represent 251.71± 70.80 % as percentage of DRI in all elderly. DISCUSSION

Aging is a period of progressive decline in physical, cognitive and psychosocial functioning, consequently a growing healthcare burden on the society (Jeste et al. 2013). The older population is rapidly growing throughout the world, the increasing number of the older people which accompanied by declining functions in the human body, induced many difficulties to provide different health and social services for monitoring, reducing health hazards and maintaining good quality life for them (WHO,2011). Many of the oldest-old lose their ability to live independently because of the limited mobility, frailty, or other declines in physical or cognitive functioning. Many required some form of long term care, which can include home nursing, community care and assisted living, residential care, and long-stay hospitals (WHO, 2011). The loss of functional status and the related high level of dependence are the main cause of admission to long-term care services (Quinn et al. 2011).

Aging and demographic characteristics

The present study results revealed that, majority of older people were in the first two categories of age group (60-74 and 75-89Y) with mean age (78.92±12.26). This finding matched with the definition of elderly in Saudi Arabia, in which 60 years and above refers to older adults

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Table 5: Biochemical analyses of the institutionalized elderly.

Biochemical parameters All participants 53(100%)

Male 28(52.83)

Female 25 (47.17)

P-value*

Homocysteine (µmol/L)

Normal 22 (41.5) 2

14 (26.41)

8 (15.09)

0.184

High 31 (58.49)

14 (26.42)

17 (32.08)

Vitamin B12 (pg/mL)

Low 14 (26.42)

12 (22.64)

2 (3.77)

0.004*

Normal 39 (73.58) 16 (30.19) 23 (43.4)

Folic acid (ng/mL)

Low 2 (3.77)

1 (1.89)

1(1.89)

0.126

Normal 51 (96.23) 27 (50.94) 24 (45.28)

WBC (103/cm

3)

Low 3 (5.66)

-

3 (5.66)

0.059

Normal 50 (94.34) 28 (52.83) 22 (41.51)

RBC (106/cm

3)

Low 15 (28.30)

10 (18.87)

5 (9.43)

Normal 36 (67.93)

17 (32.07)

19 (35.85)

0.446 High 2 (3.77) 1 (1.89) 1 (1.89)

HGB (g/dl)

Low 26 (49.06)

15 (28.30)

11(20.75)

0.487

Normal 27 (50.94) 13 (24.53) 14 (26.42)

PLT(103/cm

3)

Low 8 (15.09)

3 (5.66)

5 (9.43)

Normal 43 (81.13)

24 (45.28)

19 (35.85)

0.633

High 2 (3.77) 1 (1.89) 1 (1.89)

WBC: White Blood Cells. RBC: Red Blood Cells. HGB: Hemoglobin. PLT: Platelet Count. Data are expressed as frequency N (percent of total number, n=53). *Significant difference between male and the corresponding female (Chi-square). Low, normal and high of all biochemical tests were assessed according to the standard for analysis as described in the procedure for each lab.

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Table 6: Average daily dietary intake for the institutionalized elderly.

Average daily dietary intake All participants ( N = 53)

Male ( N = 28)

Female ( N = 25)

Macronutrients

Total energy (K.cal)

2038.37 ± 446.50

2142.00 ± 458.42

1922.30 ±411.07 Protein (g)

83.17 ± 21.27

91.61± 21.48

73.72± 16.89 **

Carbohydrate (g)

301.82 ± 72.95

307.71± 67.09

295.23± 79.87 Fiber (g)

16.30 ± 6.43

15.52± 4.27

17.17± 8.22 Fat (g)

56.30 ±14.95

61.12± 14.58

50.90± 13.69 *

Cholesterol (mg) 183.02 ± 75.97 192.96± 84.85 171.88± 64.50

Micronutrients – Vitamins

Retinol (A) (µg)

413.84 ± 155.00

461.74 ± 165.74

360.19±124.41*

Thiamin (B1) mg)

1.36 ± 0.32

1.47± 0.30

1.24± 0.31 **

Riboflavin (B2) (mg)

1.24 ± 0.22

1.31± 0.21

1.16± 0.20 *

Niacin (B3) (mg)

20.73 ± 5.73

23.01 ± 4.82

18.18± 5.68**

Pyridoxine (B6) (mg)

1.02 ± 0.23

1.08 ± 0.20

0.96± 0.24

Cobalamin (B12) (µg)

2.16 ± 0.61

2.13± 0.68

2.20 ± 0.53 Ascorbic acid (C) (mg)

90.72 ± 60.88

122.71± 64.38

54.90± 28.92 ***

Calciferol (D) (µg)

2.55 ± 1.33

2.45 ± 1.14

2.66 ± 1.54 Alpha-tocopherol (E) (mg)

2.32 ± 1.11

2.24 ± 1.31

2.42± 0.84 Folate (µg) 317.41 ± 85.61 331.17± 63.25 302.01± 104.46

Micronutrients – Minerals

Calcium (mg) 572.73 ± 139.53

576.51±122.45

568.49 ±158.99 Iron (mg) 12.84 ± 3.94

12.63 ± 4.47

13.07 ± 3.31 Phosphorus (mg) 875.22 ± 163.03

908.80 ±172.94

837.61 ± 145.43

Potassium (mg) 2083.41 ± 465.80

2167.14 ±343.24

1989.63 ±565.88 Sodium (mg) 3102.26 ± 868.32 3182.90 ±1012.84 3011.95 ± 680.76

Each value represents as (mean ± SD). Significant difference between male and the corresponding female at

*p<0.05, ** p< 0.01 and *** p< 0.001.

Total energy was estimated for each subject according to Lorentz equations (WLo).

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Table 7: Nutrient intakes as a percentage of daily dietary intake (DRI) for the institutionalized elderly.

Nutrients intakes as % of DRI

All participants ( N = 53)

Male ( N = 28)

Female ( N = 25)

Macronutrients

Total Energy 151.65 ± 48.17 133.49± 38.73 171.98± 50.25**

Protein 223.73 ± 76.75 210.61± 71.95 238.42± 80.71

Carbohydrate 164.5 ± 58.79 140.33± 44.61 191.57± 61.68 **

Fiber 87.57 ± 43.68 69.93± 28.46 107.32± 49.52**

Fat 133.71 ± 45.21 121.62± 33.97 147.25± 52.63 *

Cholesterol 61.01 ± 25.32 64.32± 28.28 57.29± 21.50

Micronutrients – Vitamins

Retinol (A) 51.38 ± 17.94 51.30± 18.42 51.46± 17.77

Thiamin (B1) 117.78 ± 26.74 122.46± 24.93 112.54± 28.21

Riboflavin (B2) 103.05 ± 17.42 100.61± 16.39 105.79± 18.44

Niacin (B3) 137.24 ± 35.78 143.80± 30.14 129.88± 40.57

Pyridoxine (B6) 63.81 ± 13.91 63.56± 11.89 64.08 ± 16.12

Cobalamin (B12) 90.18 ± 25.24 88.86± 28.10 91.67± 22.08

Ascorbic acid (C) 106.56 ± 66.00 136.34± 71.54 73.20± 38.56 **

Calciferol (D) 13.72 ± 6.88 13.20 ± 5.69 14.30 ± 8.09

Alpha-tocopherol (E) 15.63 ± 7.25 15.19± 8.55 16.12± 5.59

Folate 79.36 ± 21.40 82.80 ± 15.81 75.50 ± 26.12

Micronutrients – Minerals

Calcium 49.10 ± 12.12 50.65 ±11.03 47.37 ±13.25

Iron 156.21 ± 36.25 149.78 ±30.23 163.41 ±41.43

Phosphorus 125.13 ± 23.21 130.01±24.52 119.66 ±20.78

Potassium 44.33 ± 9.91 46.11±7.30 42.33 ±12.04

Sodium 251.71 ± 70.80 256.79 ± 80.88 246.01±58.62

DRI: Dietary Recommended Intake Each value represents as (mean ± SD). Significant difference between male and the corresponding female at

*p<0.05, ** p< 0.01 and *** p< 0.001.

as it is considered as retirement age (Almadani, 2005). In 2015 WHO defined those over 60 years of age as "older people ", age of 60 or 65, roughly equivalent to retirement ages in most developed countries “beginning of old age” (WHO,2015). Moreover, this is compatible with the studies conducted on aging by Amr et al. (2014) and Aboelfetoh et al. (2015), who studied aging people between 60 to 87 years of age with mean (71±5.8 Y). Regarding the marital status, the majority of our studied population were without partner and only 5 (9.43%) were married. According to the Ministry of Social Affairs, 90% of the elderly residing in these centers either have no relatives, divorced, widowed or have no shelter and only few of them have relatives (MOSA, 2014). It is

taking place alongside other broad social trends that affect the lives of older people. Marital status is commonly viewed as a risk factor for depression in the elderly (Steunenberg et al. 2006).

The majority of the subjects in this study were illiterate, this result consistent with the findings of Amr et al. (2014) and Aboelfetoh et al. (2015). Saudi Arabia Public Pension Agency Annual Report (MEP, 2006) most of the elderly more than three fourth were illiterate. The percentage of illiterate elderly was found to be more than half of the studied population, and only 2% of the elderly have done study till graduation or post-graduation (Shraddha et al. 2012), which is in keeping with the current results whereas the percentage of the

55

graduation in our sample was 1.89%. This may be explained as the educational opportunities were scarce by the time of their childhood and youth. These results showed that, about one quarter of the elderly subjects were previously working and all of them were males, while all female, subjects were non-working and there was a significant difference between males and females. These results are matched with Abusaaq (2015), who mentioned that, elderly people aged 60 or more tend to work less with low productive, due to retirement or illness. This finding may be due to the culture of Saudi society, where most of the women were not working till recent time.

Anthropometric measurements are good indicators for elderly nutritional status (Ahmed et al. 2012). Based on BMI and WHR results, the present findings showed that, only one quarter of all the subjects were in normal weight, with a significant difference between males and females in WHR. These findings fit with the previous studies of Elmadfa and Meyer (2008); Mokdad et al. (2009) and Mckay et al. (2006) and Ng et al. (2011). Moreover, earlier studies in KSA indicated an increasing trend in the prevalence of obesity in the studied elderly sample with average of 20 to above 35%; ranging from 13.1% among men and 26.6% among women (Alnozha et al. 2005; Alothaimeen et al. 2007). This may be partly due to their disabilities, sedentary lifestyles and lack of regular physical activity, also fat mass tends to increase with age, while muscle mass tends to decrease (Kim et al. 2015).

Unhealthy weight from the causes of illness and decrease quality of life, this explained why most elderly in the present study have diseases. Elevated BMI was the leading risk factor for disability-adjusted life years in the Kingdom of Saudi Arabia (IHME, 2013). Memish et al. (2014) mentioned that, obesity is a major risk factor for illness and death in KSA especially among high risk groups as older people. At the same time, a low BMI or underweight has been found to have a negative impact on health-related quality of life and associated with an increased risk of mortality among nursing home residents aged 65 and over (Crogan and Pasvogel, 2003; Hausman et al. 2011). The prevalence rates of obesity and some features of metabolic syndrome in elderly more than 60 years were higher among Saudi Arabian women than that among men (Alnozha et al. 2005). Over the last twenty years, Saudi Arabia has witnessed major socioeconomic development leading to a significant change in its standard of living and lifestyle. The transformation of the society has also resulted in changes in dietary

habits and related social practices. This has been compounded by a lack of exercise of the society (Almodeer et al. 2013).

Effect of aging on health status

Co-morbidity is common in elderly persons and is associated with more rapid declines in health status (Fillenbaum, 2000). The majority of our institutionalized aging people suffered from diseases by account of 86.79%, most of them were males, and at the same time most of our subjects (84.90 %) were suffering from 1-3 diseases, with a significant difference among males and females regarding suffering from chronic diseases. The obtained results are consistent with Almodeer et al. (2013); Joshi

et al.

(2003); Ghabrah and Qadi (2005) and Hassan (2015). This result may be explained by Joshi et al. (2003), who mentioned that, the age was among the factors which predict increased morbidity. Moreover, WHO in collaboration with Ministry of Health in Saudi Arabia from a national survey indicated that, chronic diseases are more prevalent in aging men than in women (WHOSTEP, 2005).

Ageing is a degenerative process that is characterized by reduced physiological functions and increased risk of diseases and death (Lee and Wei, 2012). Health deterioration can be described by risk factors that lead to diseases and conditions which cause loss of functions, these factors are dependent on the environmental context. The presence of certain risk factors indicate greater likelihood damage of health and can result in disability and diseases prevalence in elderly population, which generally increased over time (Christensen et al. 2011).

Hypertension is the second leading risk for death worldwide. World Health Organization reported that, disturbance in blood pressure (BP) are responsible for 62% of cerebrovascular disease and 49% of ischemic heart disease (IHD) (WHO, 2009). The present study showed that about half of our elderly participants have hypertension; there was a significant difference among males and females. These results are in agreement with Alnozha et al. (2007) and Ibrahim et al. (2013). Blood pressure from moderate or severe hypertension among elderly showed an upward trend by advancing age (WHO, 2011). This may be attributed to sedentary lifestyles and lack of regular physical activity among institutionalized elderly.

Multi-morbidity and chronic conditions are fairly common among older adults (Salive, 2013), which may have an impact on the treatment drugs

56

(Lee et al. 2008). The number of prescriptions ranged from 1-3 drugs in 54.72% and 24.53% of the institutionalized elderly used more than 3 drugs /day. The obtained results are consistent with Aboelfetoh et al. (2015); Hassan (2015) and Elmadbouly and Abd Elhafez (2012). Moreover poly-pharmacy was even more common in institutionalized elderly than among the community-dwellers (Ramage-Morin, 2009). The high prevalence of diseases among the elderly in our study 86.79% explains the high percentage of medicines use. The present findings showed that, 83.02% of our elderly participants had no surgical history, while only 16.98% of the subjects have a surgical history most of them were males. The obtained results are in accordance with Hassan (2015) who found that, about quarter of his elderly subjects had history of previous operations. A caregiver refers to anyone who routinely helps others who are limited by chronic conditions (Tennstedt, 1999). The burden of care is higher among institutionalized older adults, as these individuals are often managing a wide range of physical and cognitive disorders (Ersek and Carpenter, 2013). About one half of our elderly participants caused problems to their caregivers; most of them were females.

Effect of aging on physical status

Older adults who are able to maintain their mobility and overall functional independence are likely to feel more secure and a better general sense of wellbeing (Davis et al. 2015). Therefore, impaired mobility is a major concern for older adults and is associated with greater risk for disability, institutionalization and death (Rosano et al. 2008). An increase in chronic disease can cause problems in mobility among the elderly population, and this explains the high percentage 77.36% of our participants who had mobility impairment. The obtained results may be explained by the loss of strength in aging. In addition, the capacity of muscle to function as an energy source may be limited in the elderly (IHME, 2013). Hearing and vision deficits are common in older populations, these impairments increase with age (Fisher et al. 2014). Older people with hearing loss recorded greater difficulties with activities than did people without sensory problems. Hearing impairment in our participants was observed as equally percent in both males and females, where 7.55% of the total sample was deaf. Our results agree with Shraddha et al. (2012) and John and Vincent (2004). The prevalence of visual dysfunction increases rapidly with age. Aged with visual

impairment is more likely to have multiple co-morbidities (Court et al. 2014). Vision status results in the present study showed that, 43.40% of our institutionalized elderly had a weak vision, while 13.20% were blind; this was compatible with Alshaaln et al. (2011).

Aging oral health is frequently poor (Zuluaga et al. 2012), and this supports the findings of this study as the prevalence of disorders in the teeth and gum status among the elderly subjects was more than two-third. This finding agrees with Shraddha et al. (2012) and Hassan (2015). Age-related changes in swallowing and related diseases are predisposing factors for dysphagia (Sura et al. 2012). Swallow maintains a functional ability to propel food safely and efficiently (Daggett et al. 2006). Results regarding the chewing and swallowing status in the present study revealed that, about half have chewing problems, and more than one quarter had swallowing problems. These findings are agreement with those obtained by Aboelfetoh et al. (2015) and Ghabrah and Qadi (2005).

Aging process changes the body composition and nutritional status as one gets older, at the same time the body becomes more susceptible to diseases and diet becomes significantly imbalance than in earlier years (Ebersole et al. 2005). The sense of taste and smell deteriorate with age, which makes food not enjoyable, therefore with increasing age appetite declines and food consumption declines. Healthy older people are less hungry and are fuller before meals, consume smaller meals, eat more slowly, and become satiated after meals more rapidly than younger people (Ahmed and Haboubi, 2010). Regarding appetite change in the institutionalized elderly, the present results showed that, more than half had changed in their appetite during the last six months ago and most of them were females. These findings are in agreement with Aboelfetoh et al. (2015) and Ibrahim et al. (2013), these results may be attributed to normal physiological changes associated with aging which affect food intake (Westenhoefer, 2005), gastrointestinal changes occur with age that affect oral intake, as greater satiation after a meal and a delay in gastric emptying in older people, esophageal motility and atrophic gastritis (Refai and Seidner, 1999), and dental problems (including poorly-fitting dentures) (Morais et al. 2003). Weight loss is an important risk factor in the elderly (Bilbao et al. 2002), with aging body fat increases and fat-free mass decreases because of the loss of skeletal muscle. The causes of increased fat are multifactorial; it may be

57

attributed to reduced physical activity, reduced growth hormone secretion, diminished sex hormones, decreased resting metabolic rate, and poor dietary food intake (Ahmed and Haboubi, 2010). Regarding weight change during the last six months in our institutionalized elderly we found that 69.81% had changed in weight, most of them were females.

Epidemiologic studies have been associated tea consumption with a wide variety of health benefits, such as the prevention of cardiovascular diseases (Sumpio et al. 2006), and cancer (Sun et al. 2006). Coffee is one of the most commonly consumed beverages around the world, there is a significant positive trend between coffee intake and cognitive performance (Panagiotakos et al. 2007). Regarding tea and coffee consumption, our findings showed that, the majority of the study populations 92.45% and 71.70% were tea and coffee drinkers, respectively. The obtained results are in agreement with Arab et al. (2011). The increased percentage of tea consumption may be due to tea preference as favorite source of caffeine among elderly subjects. Smoking remains a strong risk factor for premature mortality at older age (Gellert et al. 2012). Concerning smoking status among our elderly participants in the present study, the findings revealed that, the majority of them were non-smokers, all females were non-smokers. These findings come in line those of Hassan (2015) and Nazemi et al. (2015) who revealed that, the majority of the elderly in their studies were non-smokers accounting 79.1% and 81.2%, respectively. All of our older female’s subjects were non-smokers, which may be due to customs and traditions in Saudi Arabia.

Biochemical alteration with aging

Elevated homocysteine is recognized as a sensitive marker for folate and vitamin B12 deficiency (Ansari et al. 2014). Biochemical analysis results of the institutionalized elderly in the present study showed that, more than one half have hyperhomocysteine and most of them were females. Low levels of vitamin B12 were found in more than quarter of the institutionalized elderly. The obtained results are compatible with Alharbi et al. (2012). On the other hand, most of the elderly in the present study had a normal levels of folic acid and vitamin B12 this could be explained by supplementation of these vitamins before starting this study, where elderly are at high risk for low B- vitamin status, due to lower vitamin bioavailability, atrophic gastritis or gastric hypoacidity (Suominen et al. 2005). Regarding red blood cell (RBC) and hemoglobin (HGB) values in

the present study, the results indicated that, 28.30% and 49.06 % had low level of RBC and HGB, respectively, most of them were males. This finding is similar to the results of the previous studies reported by Alsaeed (2011). The prevalence of anemia increases with advancing age and exceeds (Steensma and Tefferi, 2007).

Nutritional status of institutionalized elderly

Nutritional status plays an important role in the quality of elderly health. Elderly population is at risk of undernutrition due to physical and functional decline. There are different causes of nutritional risks like physiological causes including diseases, intake of medicines, disabilities like walking, hearing, optical, economical causes as reduction of income, low purchasing capacity, social causes as isolation, getting less importance and attention from family members, psychological causes including depression, loneliness and insecurity (Saha et al. 2014). The 7-DDR was selected as the reference method capturing the participant’s habitual eating patterns over seven days. The macronutrients for the institutionalized elderly in the present study showed that, the total energy, carbohydrate intake in all participants was increased than DRI. The same trend in elevated total energy and carbohydrate intake among elderly was recorded by Kim et al. (2015) and Trabal et al. (2014).

High energy consumption among our participants may be explained by eating rice as a common traditional food among the Saudi elderly population, and increased consumption of dates, cookies, cakes and sugary snacks. The people of Saudi Arabia are very traditional and eat the same foods they have eaten; the basic ingredients are the same. Fava beans, wheat, rice, yoghurt, dates and chicken are staple foods for all Saudis. Rice consumption was served mostly two times in lunch and dinner (Adam et al. 2014). Regarding protein intake among the institutionalized elderly in the present study, it accounted 223.73 of DRI. These results are in agreement with those reported by Kim et al. (2015), Gray-Donald et al. (2013) and Valenzuela et al. (2013). The interpretation of high protein consumption among the subjects of the present study may be due to eating large amounts of dietary protein sources during their meals. An excess protein intake may affect calcium excretion, skeletal mass, bone health and it may induce osteoporosis (Sellmeyer et al. 2001). Animal protein intake was about two-thirds of total protein intake among elderly in this study. This finding agrees with Tur et al. (2005), who reported that, the animal protein intake was

58

two-third of total protein intake among his studied elderly persons. This dietary protein imbalance may increase the risk of osteoporosis and fracture among this elderly population.

Regarding total fat and cholesterol intake the results in the present study showed that, institutionalized elderly consumed a high fat diet than they need (133.71% of DRI), but the amount of cholesterol was within the normal range. These findings agree with Trabal et al. (2014) and Su et al. (2015). The explanations for high fat intake of our elderly participants may be due to the high consumption of whole milk and milk products, and the un-healthy cooking method which used high quantities of oils and fatty meats. Noteworthy, due to Westernization of the Saudi Arabian diet, the increased intakes of high level of fat have become much more common in the daily dietary pattern (Abahussain et al. 1999).

Dietary fiber has a protective effect against much co-morbidity among older people. Fiber intake in the present study showed that there was a decrease in dietary fiber among our elderly subjects. The same manner was found in the study by Kjeldby et al. (2013). Explanation of low fiber intake may be due to low intake of whole grains, bran, fruits and vegetables, as a result of chewing and dental problems. Moreover, the dietary pattern in the Middle Eastern region, including Saudi Arabia, has been documented with a lower consumption of fruits, vegetables and an increased consumption of animal products and refined foods in the usual diet (Al-Hazzaa et al. 2011).

Concerning micronutrients intake the results showed that, there were deficiency in most vitamins among the elderly participants, especially retinol (51.38% of DRI), Pyridoxine vitamin B6 (63.81% of DRI) and severe deficiency in calciferol vitamin D (13.72% of DRI) and alpha-tocopherol vitamin E (15.63% of DRI). Concerning minerals intake, there were remarkable deficiency in calcium (49.10% of DRI) and potassium (44.33% of DRI), while sodium intake exceed than the DRI recommendations, in which it reached (251.71% of DRI). The obtained results are consistent with Alassaf and Alnumair (2007) and Washi and Ageib (2010).

There is a variety of reasons why elderly are at high risk for deficiencies in some vitamins and minerals, including higher prevalence of drug intake and lower vitamin bioavailability, especially because of atrophic gastritis or gastric hypoacidity (Selhub, 2002). Deficiency of vitamin A was found especially among malnourished elderly, abnormal visual adaptation to darkness, dry skin and

decreased resistance to infections are among the first signs of vitamin A deficiency (Russell and Suter, 2001), which was shown in the present study. Vitamin B12 deficiency is caused by intrinsic factor deficiency (Carmel, 2000), hypochlorhydria (Stabler, 2000), or malabsorption arising from bacterial overgrowth syndrome (Clarke et al. 2004). Kjeldby et al. (2013) found that, elderly people in nursing homes are at risk of vitamin B6 deficiency because they consume poor dietary sources of vitamin B6. Deficiency of vitamin D may be attributed to a lack of sun exposure and low intake of dietary sources or fortified food with vitamin D. While vitamin E deficiency may be explained by reduction of the dietary sources. The decreased intake of these vitamins could be linked to an unhealthier dietary pattern and lower consumption of antioxidants dietary sources like fruit and vegetables (Aldaghri et al. 2013). Moreover, Ruiz-López et al. (2003) reported that, inadequate micronutrients intake in the elderly may contribute to the development of malnutrition in this population. From reason of calcium deficiency the negative effect of caffeine on calcium absorption (Alothman et al. 2012), implicating caffeine-containing beverages as a risk factor for osteoporosis especially in populations consuming substantially less than optimal calcium intakes (Heaney, 2002). Potassium and blood pressure hypothesis is that high potassium intake may have beneficial effect on lowering blood pressure (Sacks et al. 2012). The average sodium intakes were also very high, 2-3 folds in comparison with DRI. This is consistent with and explained by the present results where about half of elderly have hypertension. CONCLUSION It can be concluded that the assessment of nutritional status, as a part of screening protocols, is necessary to identify malnutrition, which is a potential cause or an aggravation of morbidity and mortality. High prevalence rates of malnutrition could be expected more among subjects living in an institution because of their need of help or care. These findings may indicate unhealthy dietary habits that may be attributed to the elderly adults′ low possibilities of choosing healthy food. Therefore, elderly population need especial needs of care services to maintain high level quality of life due to the physiological changes in this period of life. The obtained results revealed that, there was a poor nutritional status in the institutionalized elderly especially in micronutrients such as vitamin A, D, E, and calcium.

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