The impact of a nutrition and physical activity intervention programme on frailty syndrome in elderly citizens in Lesotho
Turkson, Rose Kokui Dufe
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The number of elderly in the world is steadily increasing. Although a large number of studies have reported on the impact of nutrition and physical activity interventions in preventing, postponing or even reversing frailty in the elderly from developed countries, the evidence from developed countries is lacking. The main aim of the study was to determine the impact of a nutrition and physical activity intervention on indicators of frailty and malnutrition in the elderly in Lesotho. The baseline phase of the study investigated levels of frailty, malnutrition and associated factors (socio-demography, reported health, dietary diversity and levels of physical activity) amongst a baseline of elderly in Maseru, Lesotho. The baseline was followed by the intervention phase to assess the impact of a fermented milk and physical activity intervention on indicators of frailty and malnutrition in the elderly in Lesotho. This baseline study had a cross-sectional design. The elderly (N=300) aged 65 years and older were recruited from 16 communities in urban Maseru. A questionnaire was administered to acquire information on socio-demography, reported health and individual dietary diversity. The Physical Activity Scale for the Elderly (PASE) was used to measure levels of physical activity, while the Rockwood frailty scale was applied to assess the degree of frailty and the Mini Nutritional Assessment (MNA) was used to determine nutritional status. In terms of frailty, 26.2% of participants were classified as fit; 52.4% as fit but bladder incontinent, 9.7% as pre-frail and 11.7% as frail. There was no significant difference between the prevalence of frailty in men and women (p=0.68). In terms of nutritional status, more than half (66.0%) of participants were at risk of malnutrition, while 19.4% were malnourished. More than forty percent (43.1%) of participants were unemployed and almost half (46.3%) reported a household income of R500 or less. Most (81.3%) resided in brick/concrete dwellings, 61% used pit toilets and 51.3% had access to electricity at their homes. Gas was the most common fuel used for cooking (44.1%). The most prevalent reported symptom was joint pain (59.7%). Loss of appetite (54%), involuntary weight loss (46.6%) and swelling of the feet (44.5%) were also common. More than half (63.2%), of participants were diagnosed with high blood pressure, and 36% suffered from heart disease/ heart related diseases. Almost all (90.7%) of the participants were members of a local church. Feelings of sadness and depression were reported by 47%. Almost 60% (57.1%) reported using medication regularly, and 7.2% had been hospitalised during the previous 12 months. Individual Dietary Diversity Score (IDDS) showed that more than half of participants (53.5%) had low levels of dietary diversity, consuming mostly starchy staples (97.3%). Frequency of consumption of meat and dairy was low (38% and less than 1% respectively). The median PASE score of 106.1, (range 87.2-122.8) fell below the recommendation of >120. Compared to the fit group, participants that were pre-frail or frail were more likely to use paraffin as fuel for cooking (p=0.02), less likely to go out (p=0.01), more likely to experience breathlessness with usual exercise (p<0.01) and wheezing or coughing (p=0.03). A significantly higher percentage of elderly in the frail group (13%) had been diagnosed with stroke as compared to the fit group (5.0%) (p=0.04). Diagnoses of lung disease such as asthma was significantly higher in the frail group (22.0%) than in the fit group (10.3%) (p=0.02). A significantly higher percentage that were well-nourished according to the MNA used electricity for cooking (39.6%) compared to participants (23%) that were malnourished and at risk of malnutrition combined [95% CI -30.2%; -3.5%]. A significantly higher percentage of well-nourished respondents used flush toilets compared to those that were malnourished and at risk of malnutrition [95% CI -30.8%; -7.7%]. Perceived poor health status and nutritional problems were significantly (positively) associated with malnutrition [95% CI 19.3%; 36.0%] and [95% CI 22.2%; 37.8%] respectively. A significantly higher percentage (9.5%) of respondents that were malnourished had cognitive impairment/depression compared to those that were well-nourished (0%) [95% CI 2.6%; 13.9%]. For the intervention phase of the study a pre-test–post-test study design was applied in four urban constituencies (16 communities) in the Maseru District. After completion of the baseline study 120 of the 300 participants that were classified as pre-frail, frail and/or malnourished were selected to participate in the intervention phase of the study. Information about socio-demography, reported health, IDDS, MNA PASE and frailty (Rockwood scale) was collected in these participants before and after the three month interventions. The 120 participants were divided into three groups of 40 each. Group 1 received the fermented milk and exercise intervention; Group 2 received only the fermented milk intervention and Group 3 comprised the control group. The interventions were delivered over a 12 week period. In Groups 1 the physical activity intervention consisted of sessions lasting for 1 hour a day on three days a week. After the exercise session the fermented milk was given to participants. In Groups 2 the fermented milk was delivered to participants every second day. As far as the intervention sample was concerned, about two thirds were female, with a median age of between 74.4-76.1 years (range 64.3-94 years). More than 60% were widowed and had a low literacy level (primary school). More than 80% lived in brick or concrete houses and used pit latrines. As found I the baseline phase of the study, chest pain, loss of appetite and joint pain were the most commonly experienced symptoms, while hypertension and heart disease were the most commonly diagnosed conditions. More than 85% of participants regularly attended church. Major sources of stress included crop or business failure and major intra family conflict. More than 70% of participants in the intervention groups had cared for people infected with HIV/AIDS at some time. Before intervention, more than 70% of all participants fell in the low dietary diversity score category (70.7% in the both group, 82.2% in the milk group and 70.2% in the control group). Only 4.9% of participants in the both group, 17.8% of those in the milk group and 12.8% in the control group were classified as well-nourished according to the NMA score. Before intervention the median PASE score of all was 113.3 in the both group, 102.9 in the milk group and 103.7 in the control group, indicating a low level of physical activity. In terms of the frailty score, 12.5% of the participants in the both group, 28.9% of those in the milk group and 28.9% in the control group were categorised as pre-frail and frail. After three weeks of intervention, no significant improvements in any of the indicators of frailty or malnutrition were observed in any of the groups. In conclusion, a large percentage of elderly participants included in this study were characterised by poverty, ill health, low dietary diversity, malnutrition and risk of frailty. Frailty and malnutrition were associated with a lower socio-economic situation, lower mobility and higher risk of symptoms and disease. It is probable that the amount of fermented milk that was provided was not enough to impact on measures of frailty and malnutrition in participants. The socio-economic and food security situation of the elderly in Lesotho resulted in sharing of the food supplement. These findings further confirm the role of socio economic status and perceived health on nutritional status, and the need for routine screening thereof in the elderly to ensure timely diagnoses and management of malnutrition. Important differences between developed and developing countries, such as those related to socio-economic status, caregiving responsibilities of the elderly and food insecurity, complicate the situation of the elderly in developing countries. Research related to the unique nutrition situation and development, implementation and evaluation of relevant nutrition interventions in African countries are urgently required.