ARTICLE /ARTICLE
Assessment of the nutritional status of elderly in Western Pyreneans.
Data on 800 indigenous males taking part in the HIPVAL project
Évaluation de l’état nutritionnel des sujets âgés de l’Ouest pyrénéen.
Données collectées sur 800 sujets masculins dans le cadre du Projet HIPVAL
F. Bauduer · J. Salaberria · E. Montoya · B. Oyharçabal
Received: 17 January 2011, Accepted: 26 May 2011
© Société d’anthropologie de Paris et Springer-Verlag France 2011
Abstract Our aim was to assess the nutritional status of elderly males from Western Pyrenees, a particular zone of interest as regards genetics, health and culture. A total of 828 individuals aged 60 or more, indigenous to one of the geographic subdivisions and predominantly living at home, were assessed using the body mass index (BMI), the mini-nutritional assessment (MNA) and a social survey questionnaire. No cases of under-nutrition were detected by the MNA, and 2% of the subjects were classified as“at risk”. These results seemed significantly better than those pub- lished in other international series. A significant percentage of favourable characteristics were found, such as living within a family structure, adequate qualitative and quantita- tive dietary equilibrium, relatively high BMI and a low rate of daily medication. The role of nutrition is of major concern as regards ageing. A favourable profile was observed among these elderly Western Pyreneans.To cite this journal: Bull.
Mém. Soc. Anthropol. Paris 24 (2012).
KeywordsElderly males · Nutrition · BMI · Mini-nutritional assessment · Pyrenees
RésuméNous avons tenté d’évaluer l’état nutritionnel des sujets âgés de sexe masculin de l’Ouest pyrénéen, une zone particulière sur le plan de la génétique, de la santé et de la culture. Un total de 828 individus âgés de plus de 60 ans,
autochtones de l’une des subdivisions géographiques de cette zone et vivant pour la majorité d’entre eux à domicile, ont été testés en utilisant l’indice de masse corporelle, le mini-nutritional assessment (MNA) et un questionnaire social. Aucun cas de malnutrition n’a été détecté par le MNA et 2 % des sujets ont été classés dans la catégorie « à risque de malnutrition ». Ces résultats paraissent significa- tivement meilleurs que ceux publiés antérieurement dans divers échantillons comparables de par le monde. Un pour- centage important de caractéristiques favorables a été retrouvé ici comme le fait de vivre au sein de la structure familiale, un apport alimentaire adéquat sur le plan qualitatif et quantitatif, un indice de masse corporelle relativement élevé et une faible consommation quotidienne de médica- ments. La nutrition joue un rôle majeur dans le processus du vieillissement. Un profil favorable a été observé parmi la population masculine âgée ouest pyrénéenne.Pour citer cette revue : Bull. Mém. Soc. Anthropol. Paris 24 (2012).
Mots clésSujets masculins âgés · Nutrition · Indice de masse corporelle ·Mini-nutritional assessment · Pyrénées
Introduction
The Western Pyrenees are an area of great interest for public health specialists and anthropologists. The area has been occupied continuously by modern humans from the Palaeo- lithic to the present and even during the last glacial maximum, since it was part of the so-called Aquitaine- Cantabrian refuge zone. One of the area’s two main entities is made up of the Basque Provinces, which straddle France and Spain. The Basques are thought to represent the rem- nants of a pre-Neolithic population. They have distinct genetic features (mainly explained by the effects of drift and endogamy) and speak a non-Indo-European language (Euskara) whose origin is still unknown [1,2]. The second
F. Bauduer (*)
Biological Anthropology Unit, Laboratory of Human Genetics, Université Victor Segalen, Bordeaux
e-mail : bauduer.frederic@neuf.fr Department of Clinical Research, Centre hospitalier de la Côte-Basque, F-64100 Bayonne, France
J. Salaberria · E. Montoya · B. Oyharçabal UMR-CNRS IKER, Bayonne, France, for the HIPVAL study network
entity is made up of the surrounding regions where the native tongues are Romanic-derived dialects (especiallyGasconin the French part). Studies in toponymics and historical lin- guistics have suggested that these two parts formed a single cultural entity before the Roman conquest [1]. Interestingly, human longevity within this zone is currently one of the highest in the world [3, 4]. Besides genetic features [2], envi- ronmental characteristics are also important factors that need to be explored to account for this fact, and nutritional habits are likely to play a major role. South-western France has notably been associated with the so-called French paradox, i.e. a low death rate from coronary heart disease despite a high intake of dietary cholesterol and saturated fat [5].
Several hypotheses have been put forward to explain this finding: a low-risk diet (rich in fruit and vegetables), a favourable life-style (regular physical activity, reduced exposure to stress, no smoking) and drinking red wine. Of particular interest is that red wines from South-western France have the world’s highest polyphenol content. These compounds are able to inhibit atherosclerosis (one of the major causes of morbidity and mortality in developed coun- tries) in experimental models [6]. The nutritional character- istics of this population were thus investigated as part of a broad multidisciplinary study on Western Pyreneans, focus- ing on genetics, linguistics, anthropology and public health (especially inherited diseases and ageing). We determined the nutritional status of a sample of elderly indigenous indi- viduals, using a simple and standardized score from geriatric medicine, and compared this status with similar samples from other geographic origins.
Material and methods
This study is part of theHIPVALproject (Histoire des popu- lations et variation linguistique, i.e.Population history and linguistic variation) conducted from February 2005 to Sep- tember 2006 under the auspices of the National Centre for Scientific Research (Centre National de la Recherche Scien- tifique[CNRS]) under the European project on“The Origin of Man, Language and Languages”. Its aim is to explore the genetics, culture, anthropology and public health of the Western Pyrenean population.
Subjects
The study subjects were males aged 60 years or more who were living independently at home or in retirement homes.
The concomitant assessment of mitochondrial DNA and Y chromosome from blood specimens explains why our sam- ple is composed only of male individuals. The participants were randomly recruited on the basis of their indigenous
origin in one of the geographic zones studied. (Their indige- nous origin was confirmed by the surnames and birth places of each individual and of their parents and grandparents, as recorded in the registry offices.) The individuals studied belonged to the Western Pyrenean geographic zones shown in Figure 1, which straddle France (northern part) and Spain (southern part) and are defined by current or historical administrative subdivisions. These zones centred around the Basque area* and included neighbouring non-Basque regions, i.e. in France, the Provinces of Labourd*, Basse Navarre*, Soule* and Béarn (Pyrénées Atlantiquesdéparte- ment), the Provinces of Bigorre (Hautes Pyrénéesdéparte- ment) and Chalosse (south-eastern part of the Landes département), and in Spain, the Provinces of Guipuzcoa*, Biscay* and Alava* (Basque Autonomous Community or Euskadi), the Autonomous Community of Navarra*, the north-western part of the Autonomous Community of Aragon, the eastern part of the Autonomous Community of Cantabria, the northern zone of the Province of Rioja, and the northern zone of the Province of Burgos. Most of the individuals were from villages of less than 5000 inhabitants, often located in isolated rural zones or valleys, except for those living in the cities of Bilbao (Biscay), Vitoria (Alava), Pau (Bearn) and Logroño (Rioja).
The exclusion criteria were acute or end-stage diseases (i.e. conditions modifying the usual health and nutritional status) or severe cognitive impairment (i.e. inability to understand and answer questions).
Methods
The survey was performed using a printed questionnaire and physical measurements. The nutritional investigation was adapted from the mini-nutritional assessment (MNA) test, which includes simple measurements and short questions (mean duration of about 15 minutes) [7,8]. This test consists of 18 items divided into four sections: (1) anthropometric data (weight, height and weight loss), (2) questions on diet (number of meals, food and fluid intake and autonomy of feeding), (3) an overall assessment (lifestyle, medication and mobility) and (4) a subjective assessment (self- perception of nutrition and health). The subjects were classi- fied as well nourished (MNA score > 24), at risk of malnu- trition (MNA score between 17 and 23.5) or malnourished (MNA score < 17). The full MNA form is available on http://www.mna-elderly.com/practice/forms/MNA_english.
pdf. This method has been validated through three seminal studies performed by the Centre for Internal Medicine and Clinical Gerontology in Toulouse (France), the Clinical Nutrition Program at the University of New Mexico in
* Basque territories
Albuquerque (USA) and the Nestlé Research Centre in Lau- sanne (Switzerland), involving more than 600 subjects aged more than 60 years [7]. Regarding the detection of malnutri- tion in different clinical settings, sensitivity was reported as 96%, specificity as 98% and predictive value as 97% as compared to the nutritional status assessed using anthropo- metric, biochemical and dietary parameters [9]. In 2006, a review of the literature found more than 35,000 elderly sub- jects who had been screened using the MNA [10]. We had already used this test with patients hospitalized for blood dis- orders [11]. MNA scores were calculated for the entire sample and also for the subgroup of individuals aged more than 75 years. In addition to the MNA, our questionnaire also included the following: exact number of medications per day, size of family, type of residence (i.e. suite of rooms, individual home, farm or retirement home) and weekly meat and fish consumption.
Body weight was measured to the nearest 0.5 kg with a balance beam scale, and height was measured to the nearest 0.5 cm. Body mass index (BMI) was calculated using the classic formula weight/(height)2 (kg/m2), and the subjects were classified according to the World Health Organization
(WHO) categories. Our BMI profile was interpreted in the light of the subclasses from various published series consid- ered to be associated with optimal health status [12–14].
Statistical analysis
The data collected were analysed using Microsoft Excel® software. Statistical Mann–Whitney and chi-squared tests were performed to compare anthropometric and nutritional characteristics. Our MNA scores were compared with those obtained from various similar international samples includ- ing free-living individuals of both sexes aged more than 60 years. Given that the older series from our literature review included individuals older than 75 years [15], we decided to perform a subgroup analysis of this category of subjects in order to avoid any age-related bias. The signifi- cance level was set atp< 0.05.
Ethics
The study was approved by the ethics committee of Bordeaux B in accordance with current French law on Fig. 1 Geographical origins of the individuals studied.France: Pyrénées Atlantiquesdepartment, including the Basque Provinces of Labourd* (1) (N = 65), Basse-Navarre* (2) (N = 61), Soule* (3) (N = 55) and the Province of Bearn (4) (N = 56); Hautes Pyrénées département: Province of Bigorre (5) (N = 40); south-eastern part of the Landesdépartement: Province of Chalosse (6) (N = 54).Spain:
Basque Autonomous Community* (or Euskadi) including the Provinces of Guipuzcoa (7) (N = 108), Biscay (8) (N = 85), Alava (9) Autonomous Community of Navarra* (10) (N = 158); north-western part of the Autonomous Community of Aragon (11) (N = 26); east- ern part of the Autonomous Community of Cantabria (12) (N = 19); northern zone of the Province of Rioja (13) (N = 28), Province of Burgos (14) (N = 23). *: Basque territories; the thick line shows the border between France and Spain /Origines géographiques des individus étudiés
biomedical research. All the participants signed a written prior informed consent document before taking part in the study.
Results
Geographical distribution of the individuals studied
The study sample included 828 men. Their geographical distribution is given in Figure 1.
Social characteristics
The age of the participants ranged from 60 to 97 years (mean, 70.7 years). About 753 to 827 subjects were eligible for assessment depending on the different data collected.
About half of the free-living individuals lived with one fam- ily member (wife, sibling, child or parent), and only 12.2%
lived alone. Five per cent lived in retirement homes. Only 4% of the subjects were dependent. Psychiatric problems were very rarely encountered (<4%). The mean number of medications per day was 1.87 (range, 0–10). Residence types were as follows: own home (52.55%), suite of rooms (28.14%), farm (14.32%) and retirement homes (4.98%) (Table 1).
Anthropometric measurements
Mean values for height and weight were 170.86 ± 6.16 cm (range, 154.0–189.0) and 80.42 ± 10.85 kg (range, 53.0– 119.0), respectively. Mean BMI was 27.57 ± 3.44 kg/m2 (range, 19.84–41.91). Because of some missing data on weight or height (especially for the two participants older than 95), BMI scores were available for 812 of the 828 indi- viduals. The distribution of BMI subcategories according to the WHO classification was as follows: normoweight (18.5–25), 191 individuals (23.52%); overweight (25–30), 441 (54.31%); type 1 obesity (30–35), 153 (18.84%); type 2 (35–40), 25 (3.07%); type 3 (>40), 2; underweight, 0 (Fig. 2). BMI values were quite stable up to 75 years of age and declined steadily thereafter (Table 2). BMI of 187 subjects (23.03%) was in the range of 27–29 kg/m2, and these individuals were thought to be associated with the lowest risk of mortality within 15 years after age 70 [13]. In a study performed in 2002 on an elderly population in South-west France [14], a BMI between 23 and 27 kg/m2 (corresponding to 38 individuals out of 80, i.e. 47.5%) was associated with optimum conservation of autonomy in daily life during the next 5-year period, and 39.90% of our entire sample (324 individuals) were within this range. However, another study has found that the best BMI of individuals
older than 60 is above 27 kg/m2[12], in which 430 subjects (52.95%) were above this threshold.
Nutritional characteristics
Nutritional categories according to the MNA scores were determined for 812 individuals (Table 3). No cases of undernutrition were found (MNA < 17); eighteen subjects (2.18%) were at risk of undernutrition (MNA between 17 and 23.5), and the remaining individuals were considered as well nourished (97.82%) (MNA > 23.5). The mean MNA score was 27.64 ± 1.42. In the category at risk of undernutri- tion, there was an over-representation of older subjects (mean age, 79.17 ± 11.08 years, with five individuals more than 90 years old; p< 0.0001), individuals living in retire- ment homes (38.88%; p< 0.001) and individuals with medication overuse (mean daily number, 4.92 ± 1.55;
p< 0.001). There was no particular geographic pattern in the distribution of individuals with the lowest MNA values (pvalue, n.s.). When only subjects of more than 75 years were considered (N = 205, or about 25% of the total sam- ple), ten cases were classified as being at risk of under- nutrition (4.88%). Consumption of fruit and vegetables at least twice a day was found in about 90% of cases. The mean weekly intake of meat was 4.53 (0–14), and fish 2.53 (0–10). There were only two vegetarians. Daily consump- tion of dairy products was found in about 90% of the sub- jects. In more than two-thirds of cases, hydration was observed to be at levels considered satisfactory, i.e. more than 5 cups a day. The results of the nutritional and general health self-assessments were highly positive (Tables 1 and 2).
When comparing the proportion of well-nourished indivi- duals (MNA > 23.5) found in our sample with other similar international samples, we found marked differences in favour of the Western Pyrenean population and even in our subgroup of men older than 75 years (with the exception of the Israeli sample,p= 0.08) (Table 4).
Discussion
The proportion of elderly individuals in developed countries has been steadily increasing in recent decades. In France for instance, the ratio of people older than 60 years in 2000 was about one to five (20%), as against 2–3% before the indus- trial revolution [16]. It should be pointed out that there is no universal definition for“elderly”. International organisations such as the United Nations (UN) [17] or the WHO [18] have proposed a definition as more than 60 years of age. We there- fore decided to use this criterion for our study.
Ageing is characterised by biological and social changes including sarcopenia, osteoporosis, digestive disturbances, dental problems, changes in glucose tolerance, total water
Table 1 Socio-demographic and lifestyle profile of the participants (N refers to the number of subjects eligible for assessment) / Profil sociodémographique et style de vie des participants (N correspond au nombre de sujets évaluables)
Parameter Subgroups Percentage/(number)
of individuals
WHO-PS (N = 827)
0 (normal) 95.04% (786)
1 (slightly decreased autonomy) 3.63% (30) 2 (less than 50% of the day in bed) 1.21% (10) 3 (more than 50% of the day in bed) 0.12% (1)
4 (bedridden) 0% (0)
Residency type (N = 803)
Suite of rooms 28.14% (226)
Own home 52.55% (422)
Farm 14.32% (115)
Retirement home 4.98% (40)
Size of family (N = 753, individuals in retirement homes excluded)
Living alone 12.21% (92)
Two people (couple) 52.85% (398)
Three people 21.64% (163)
Four people 6.90% (52)
Five people 3.58% (27)
Six people 2.12% (16)
Seven people 0.66% (5)
Independence when living at home (N = 826)
Yes 95.88% (792)
No 4.12% (34)
Neuropsychiatric problem (N = 826)
None 96.49% (797)
Slight depression 3.39% (28)
Severe depression 0.12% (1)
Number of medications (N = 807)
0 26.64% (215)
1 25.53% (206)
2 17.47% (141)
3 11.03% (89)
4 10.29% (83)
5 4.83% (39)
6 2.35% (19)
7 0.50% (4)
8 0.74% (6)
9 0.37% (3)
10 0.25% (2)
Health status self-assessment in comparison with other people of the same age (N = 826)
Not as good 2.30% (19)
As good 34.38% (284)
Better 60.78% (502)
No opinion 2.54% (21)
decrease, feelings of thirst and isolation, depression and the loss of social and family relationships [19]. Many studies suggest that nutritional status plays a significant role in age- ing. Unfortunately, there is evidence of a relatively high prevalence of malnutrition in elderly populations. Studies from the 1990s have estimated the prevalence of under- nutrition in free-living older people as between 5% and 8%
[20,21]. The EURO-NUT report published more than 20 years ago [22] observed under-nutrition in France in 350,000 to 500,000 elderly free-living individuals.
The MNA is the first nutritional screening instrument for older individuals that has been properly validated [23]. This was done by comparison with a full set of anthropometric, clinical, biological and dietary parameters considered as the gold standard for nutrition assessments [7]. The first aim was to assess the risk of malnutrition in order to allow early inter- vention when needed. The procedure involves single mea- surements and short questions and can be performed in about 10 to 15 minutes per person. MNA has been widely used
with elderly people living in the community, as shown by Guigoz [10], who found 23 studies of 14,149 individuals in this context. In the meta-analysis, which covers various populations across the world, the prevalence of under- nutrition was 2 ± 0.1% (range, 0–8%), and the risk of mal- nutrition was 24 ± 0.4% (range, 8–76%). The nutritional profile of our sample from the Western Pyrenees seems markedly favourable compared with data from other popula- tions worldwide (Table 4). This may be explained in several ways. First, the possibility of selection bias must be consid- ered. We acknowledge that our sample has a lower mean age than in the majority of the published series. However, even when considering only the older part of our sample (indivi- duals older than 75), their nutritional characteristics were still significantly better (Table 4). In France in 1990, 15.4%
and 3.6% of men older than 65 lived, respectively, alone at home or in retirement homes (INSEE national census 1990).
This distribution resembles that of our sample. According to a survey conducted under the auspices of the Basque Fig. 2 Distribution of BMI subcategories (N= 812) /Distribution des sous-catégories d’indice de masse corporelle (n = 812)
Table 2 Distribution of BMI according to age subcategories /Distribution de l’indice de masse corporelle selon les tranches d’âges
Age categories N BMI: mean (range) Percentage of BMI > 25
60–64 177 27.61 (19.84–39.32) 79.0%
65–69 219 28.13 (21.35–41.91) 80.6%
70–74 188 27.61 (21.30–40.12) 78.2%
75–79 149 27.31 (20.70–38.10) 70.4%
80–84 65 26.39 (20.28–36.33) 60.0%
85–89 20 26.15 (22.22–32.03) 55.0%
90–94 6 25.81 (20.54–31.14) 50.0%
95–99 2 Not eligible for assessmenta -
aExact height impossible to determine because of spine deformities.
Table 3 Nutritional data (N refers to the number of subjects eligible for assessment) / Données nutritionnelles (N correspond au nombre de sujets évaluables)
Parameter Subgroups Percentage / (number) of individuals
Number of meals (N = 820)
1 0.24% (2)
2 5.60% (46)
3 91.70% (752)
4 1.09% (9)
5 0.60% (5)
6 0.73% (6)*
*: related to diabetes Fruit or vegetables≥twice a day (N = 826)
Yes 90.44% (747)
No 9.56% (79)
Daily oral hydration expressed in number of cups (N = 826)
Less than 3 3.15% (26)
Between 3 and 5 25.79% (213)
More than 5 71.06% (587)
Daily consumption of dairy products (N = 826)
Yes 89.71% (741)
No 10.29% (85)
Weekly meat consumption (N = 825)
0 or less than once a week 0.24% (2)**
**: one vegetarian
1 3.03% (25)
2 11.63% (96)
3 23.87% (197)
4 16.48% (136)
5 14.18% (117)
6 9.21% (76)
7 16.60% (137)
8 1.09% (9)
9 0.12% (1)
10 2.18% (18)
11 0.24% (2)
12 0.85% (7)
13 0.85% (7)
14 0.24% (2)***
***meat at every meal Weekly fish consumption (N = 825)
0 1.94% (16)
0.5 (once every 2 weeks) 2.30% (19)
1 20.24% (167)
1.5 0.36% (3)
2 34.66% (286)
2.5 0.12% (1)
3 21.45% (177)
4 8.60% (71)
5 4.85% (40)
(Continued on next page)
government’s department of health (2002), only 6.0% of men older than 65 assessed their own health as poor or very poor, with 19.2% prevalence of functional incapacity.
We obtained similar results here, suggesting again that our sample is representative of the elderly population as a whole in this area. We also acknowledge that this sample is com- posed of only males, who are known to have a better nutri- tional status [24–27]. However, when only the male subjects included in the various published series listed in Table 4 are considered, our conclusions remain valid (data not shown).
We therefore believe that our results are indeed indicative of a better nutritional and general health status in this popu- lation. This finding is important given that life expectancy at birth in our study population is one of the highest in the world, with values as follows in the different zones: in the French part [3]: Pyrénées-Atlantiques, 77.0 years for men (84.0 for women); Landes, 77.7 for men (84.0 for women);
Hautes-Pyrénées, 77.1 for men (84.4 for women) (France, 76.8 and 83.7); in the Spanish part [4]: Euskadi, 80.75 years (77.2 and 84.2); Rioja, 81.18 years; Navarra, 81.51 years (men, 78.46); Aragon, 80.50 years; Cantabria, 80.85 years (Spain, 80.23 years). Interestingly, the low cardiovascular mortality found in this region is thought to be related to wine and a particular diet [5]. Food consumption patterns in the older community of the Basque country have been found satisfactory, especially regarding fish, vegetables and fruit [28]. We confirm this finding here. The relatively high frequency of the C677T mutation of the methylenetetrahy- drofolate reductase gene found in the Basque population may be considered as a surrogate indicator of high folic acid content in food [29]. A broad prospective study con- ducted with 521,000 subjects from ten European countries has revealed that high fibre intake and fish consumption are protective against colorectal cancer, a major cause of malignancy-related death [30].
Family status, health status, economic position and sup- port from relatives and neighbours are also important factors for successful ageing. In this rural zone, households are often multigenerational, especially in the Basque area, including grandparents, parents and children. This correlates with the
old (i.e. pre-Roman) Western Pyrenean legal system regard- ing inheritance and securing family homes through succes- sive generations [31]. In our sample, the relative rarity of individuals living alone, which is usually associated with a poor nutritional profile, is also an important factor in accounting for our positive results. This finding contrasts with that from a comparable study from Finland, where 66% of the individuals lived alone at home [15]. Self- neglect, often disregarded as a harmless peculiarity of advanced age, represents an independent risk factor for pre- mature death. Again, elderly people neglecting themselves usually live alone [32]. Among those living in retirement homes, a significant negative correlation was found between the number of drugs taken and MNA score (age had no influ- ence) [33]. Also to be noted is the very low mean number of medications per person and per day in our sample (1.87;
range, 0–10). This compares favourably with data obtained from a French study [34] on 150 individuals with a mean age of 79.8 years (4.4; range, 0–14). In our zone, there is an ancestral dairy farming background. We confirm here that sustained consumption of diary products parallels a high per- centage of lactase persistence in the adult population [35].
The mean BMI was about 27.6 kg/m2in our sample. This was higher than the values from similar age- and sex- matched neighbouring populations: 26.2 in Toulouse, South-western France [7]; 24 in Dordogne, South-western France [14] but slightly lower than the 28 kg/m2found in Southern Finland [15]. About two-thirds of our participants were in the overweight or type 1 obesity categories accord- ing to the WHO classification. An association has been found between BMI and morbidity and mortality [36]. Nev- ertheless, reference ranges have been established from healthy adult samples and rarely from older individuals [37]. Dey et al. [13] considered that the lowest risk for 15-year mortality beyond the age of 70 was 27 to 29 kg/m2 for males. In the study by Deschamps et al. [14], a BMI between 23 and 27 kg/m2was associated with optimum con- servation of autonomy in daily life during the next 5 years.
However, another study has found that the best BMI after 60 years of age is above 27 kg/m2[12]. This view contrasts Table 3(Continued)
Parameter Subgroups Percentage / (number) of individuals
6 1.09% (9)
7 3.76% (31)
8 0.12% (1)
9 0% (0)
10 0.48% (4)
Nutritional self assessment (N = 826)
Unsatisfactory 0.48% (4)
Satisfactory 99.52% (822)
Table 4 MNA scores for other samples including free-living elderly individuals compared with our Western Pyrenean sample / Scores MNA de divers échantillons d’individus âgés vivant à domicile comparés à notre échantillon ouest pyrénéen
Place N Well-nourished At risk
of malnutrition
Undernourished Age (years) Sex
References
Western Pyrenees ¶ (France/Spain)
812 205
97.8%
95.1%
2.2%
4.9%
0%
0%
71* / M
> 75 / M
This study This study USA (Albuquerque) 330 81.2%
p < 0.0001 p< 0.0001
18.2% 0.6% 77*
M + F
[7]
Poland (Warsaw) 102 83%
p < 0.0001 p = 0.005
16% 1% 75*
M + F
[47]
Iran 1962 42.7%
p < 0.0001 p< 0.0001
45.3% 12.0% > 60
M + F
[26]
Brazil 42 69%
p < 0.0001 p = 0.0005
31% 0% 71*
M + F
[48]
Israel (Jerusalem) 463 91%
p < 0.0001 p = 0.08 (n.s)
8% 1% > 70
M + F
[49]
Greece 502 69%
p < 0.0001 p < 0.0001
28% 3% 74*
M + F
[50]
Estonia (Tallinn) 51 69%
p < 0.0001 p < 0.0001
28% 3% 51-97**
M + F
[51]
China (Shangai) 115 79%
p < 0.0001 p = 0.0002
19% 2% 68*
M + F
[52]
Sweden 128 83%
p < 0.0001 p : 0.004
17% 0% 70-75**
M + F
[53]
Bangladesh 457 12%
p < 0.0001 p< 0.0001
62% 26% 69*
M + F
[54]
Finland § 178 49%
p < 0.0001 p< 0.0001
48% 3% > 75
M + F
[15]
Denmark # 94 62%
p < 0.0001 p< 0.0001
38% 0% > 65
M + F
[55]
Spain
(entire country)
22007 71.3%
p < 0.0001 p< 0.0001
25.4% 4.3% ≥65
M + F
[27]
* mean, ** range, § home-care patients, # individuals from a clinic of a general practitioner, ¶ including some subjects living in retire- ment homes. Thepvalue refers to the comparison, using the chi-square test, of the proportion of well-nourished individuals found in our entire Pyrenean sample (in bold) and our subgroup of individuals over 75 (in italics) with the other populations mentioned.
with the findings obtained by Heiat et al. [38], suggesting that above this threshold, significant increased mortality from all causes and cardiovascular reasons is observed among individuals aged 65 to 74 years. In any case, BMI criteria for obesity should be higher in the elderly than in younger people [13,39,40]. Importantly, overweight is an established risk factor for reduced survival in younger sub- jects but not in older subjects [41]. Recently, a longitudinal U.S. study of a cohort of more than 5000 individuals aged 65 and more showed that being overweight or obese was rarely associated with an increase in mortality or morbidity compared to normal weight, but could, on the contrary, sometimes be correlated with better outcomes [40]. Similar conclusions were drawn in a study from Japan of 697 80 year olds persons [42]. There is no generally agreed explanation for this fact, but it has been noted, for instance, that older people with a higher BMI have a better survival rate in cases of acute illness [43]. In addition, Arterburn et al. [44] have shown that, regarding heath-related quality of life among U.S. veterans, the optimal BMI was probably above the so- called normal upper limit. According to various studies per- formed in European populations, the BMI usually peaks between 60 and 65 years of age and thereafter gradually decreases at an average rate of 0 to 0.65 kg/year [45]. This tendency, which seems to occur about 15 years later in our population (Table 2), could perhaps indicate a slower rate of ageing. Our results support the absence of a reverse relation- ship between a relatively high BMI and survival in the elderly population, as previously suggested by others [13,40,46]. BMI also needs to be interpreted according to each population, given the high variability of physical anthropometric characteristics across the world. In our pop- ulation, the high BMI scores are more related to skeletal and lean mass than to real fatness (data not shown). This point will be explored further using skinfold and impedance measurements.
Using the MNA score and other markers from biological anthropology, the nutritional profile of these elderly males from the Western Pyrenees seems significantly better than that of other comparable populations worldwide. These highly favourable findings suggest that nutrition (including dietary but also social parameters) could be a key point in explaining the “successful ageing” picture seen in this population.
AcknowledgementsThe members of the HIPVAL project network are Bernard Oyharçabal (general manager), Frédé- ric Bauduer (biological anthropology), Jasone Salaberria and Estibalitz Montoya (selection of individuals and linguistics), David Comas and Lluis Quintana-Murci (molecular genet- ics) and Pierre Darlu (patronymics). David Basterot and Tristan Carrère worked as laboratory technicians for the con- ditioning of biological samples.
This study was made possible by grants from the Centre National de la Recherche Scientifique, Conseil des élus du Pays Basque, Conseil Régional d’Aquitaine, Conseil Gén- éral des Pyrénées-Atlantiques and the Sang 64 Association.
We thank all the volunteers who kindly agreed to participate in the study. We are also grateful to many contributors for their valuable help with the recruitment of individuals, and to Bénédicte Dubroca for her contribution to the statistical analyses.
References
1. Cavalli-Sforza LL, Menozzi P, Piazza A (1994) The history and geography of human genes, Princeton University Press, Prince- ton, 413 p
2. Bauduer F, Feingold J, Lacombe D (2005) The Basques: review of population genetics and Mendelian disorders. Hum Biol 77:609–627
3. Institut national de la statistique et des études économiques (2004) Espérance de vie à la naissance par département. http://
www.insee.fr
4. Instituto Nacional de Estadistica (INE) (2005) http://www.lne.es 5. Ferrieres J (2004) The French paradox: lessons for other coun-
tries. Heart 90:107–11
6. Corder R, Mullen W, Khan NQ, et al (2006) Red wine procyani- dins and vascular health. Nature 444:566
7. Guigoz Y, Vellas B, Garry PJ (1994) Mini-nutritional assessment:
a practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol Suppl 2:15–59
8. Bauer JM, Kaiser MJ, Anthony P, et al (2008) The mini-nutritional assessment–its history, today’s practice and future perspectives.
Nutr Clin Pract 23:388–96
9. Dwyer J (1994) Strategies to detect and prevent malnutrition in the elderly: the Nutritional Screening Initiative. Nutr Today 29:14–24
10. Guigoz Y (2006) The mini-nutritional assessment (MNA). Review of the literature–what does it tell us? J Nutr Health Aging 10:
466–5
11. Bauduer F, Scribans C, Dubernet E, Capdupuy C (2003) Evalua- tion of the nutritional status of patients over 60-year admitted in a hematology department using the mini-nutritional assessment (MNA). A single centre study of 120 cases. J Nutr Health Aging 7:179–82
12. Wynn A, Wynn M. (1995) What is a desirable weight for the elderly? Geriatric Medicine July issue:18
13. Dey DK, Rothenberg E, Sundh V, et al (2001) Body mass index, weight change and mortality in the elderly. A 15 y longitudinal population study of 70 y olds. Eur J Clin Nutr 55:482–92 14. Deschamps V, Astier X, Ferry M, et al (2002) Nutritional status
of healthy elderly persons living in Dordogne, France, and rela- tion with mortality and cognitive or functional decline. Eur J Clin Nutr 56:305–12
15. Soini H, Routasalo P, Lagström H (2004) Characteristics of the mini-nutritional assessment in elderly home-care patients. Eur J Clin Nutr 58:64–70
16. Brutel C (2002) La population de la France métropolitaine en 2050: un vieillissement inéluctable. Economie et Statistique 355–6
17. United Nations (1991) The world ageing situation 1991, Centre for Social and Humanitarian Affairs, Vienna, New York, 132 p
18. World Health Organisation (1995) Physical status: the use and interpretation of anthropometry. Report of a WHO expert com- mittee. Technical Report Series 854. World Health Organisation, Geneva, 460 p
19. Ferry M, Alix E, Borcker P, et al (2002) Nutrition de la personne âgée. 2ndédition. Masson, Paris, 327 p
20. Cederholm C, Hellerstrom K (1992) Nutritional status in recently hospitalized and free-living elderly subjects. Gerontology 38:
105–10
21. Löwik MR, Schrijver J, Odink J, et al (1990) Nutrition and aging:
nutrition of“apparently healthy”elderly (Dutch nutrition surveil- lance system). J Am Coll Nutr 9:18–27
22. de Groot LC, Van Staveren WA (1988) Nutrition and the elderly.
A European collaborative study in cooperation with the World Health Organization Special Programme for Research on Aging (WHO-SPRA) and the International Union of Nutritional Science (IUNS) Committee on Nutrition Manuel of Operations. Euronut Report 11. Wageningen, The Netherlands
23. Vellas B, Villars H, Abellan G, et al (2006) Overview of the MNA-its history and challenges. J Nutr Health Aging 10:456–63 24. Tsai AC, Chang JMC, Lin H, et al (2004) Assessment of the nutri- tional risk of > 53-year-old men and women in Taiwan. Public Health Nutr 7:69–76
25. Castel H, Shahar D, Harman-Boehm I (2006) Gender differences in factors associated with nutritional status of older patients.
J Am Coll Nutr 25:128–34
26. Aliabadi M, Kimiagar M, Ghayour-Mobarhan M, et al (2008) Prevalence of malnutrition in free living elderly people in Iran: a cross-sectional study. Asia Pac J Clin Nutr 17:285–289 27. Cuervo M, Garcia A, Ansorena D, et al (2009) Nutritional assess-
ment interpretation on 22007 Spanish community-dwelling elders through the Mini Nutritional Assessment test. Public Health Nutr Apr 12:82–90
28. Aranceta J, Rodrigo Perez C, Eguileor I, et al (1998) Food con- sumption patterns in the adult population of the Basque Country (EINUT-I). Public Health Nutr 1:185–92
29. Bauduer F, Lacombe D (2005) Factor V Leiden, prothrombin 20210A, methylenetetrahydrofolate reductase (MTHFR) 677T and population genetics. Mol Genet Metabol 86:91–9
30. Gonzalez CA (2006) The European perspective investigation into cancer and nutrition (EPIC). Public Health Nutr 9:124–6 31. Lafourcade M (1983) Le particularisme juridique. In: Haritschel-
har J (ed) Etre Basque. Privat, Toulouse, 493 p
32. Lachs MS, Williams CS, O’Brien S, et al (1998) The mortality of elder mistreatment. J Am Med Assoc 280:428–32
33. Griep MI, Mets TF, Collys K, et al (2000). Risk of malnutrition in retirement homes elderly persons measured by the “mini- nutritional assessment”. J Gerontol Med Sci 55A:M57–M63 34. Ferry M, Hininger-Favier I, Sidobre B, Mathey MF (2001) Food
and fluid intake of the SENECA population residing in Romans, France. J Nutr Health Aging 5:235–7
35. Enattah NS, Jensen TGK, Nielsen M, et al (2008) Independent introduction of two lactase-persistence alleles into human popula- tions reflects different history of adaptation to milk culture. Am J Hum Genet 82:57–72
36. de Onis M, Habicht J (1996) Anthropometric reference data for international use: recommendations from a World Health Organi- sation Expert Committee. Am J Clin Nutr 64:650–8
37. Lehmann AB, Bassey EJ, Morgan K, Dallosso HM (1991) Nor- mal values for weight, skeletal size and body mass indices in 890 men and women aged over 65 years. Clin Nutr 10:18–22
38. Heiat A, Vaccarino V, Krumholz H (2001) An evidence based assessment of federal guidelines for overweight and obesity as they apply to elderly persons. Arch Intern Med 161:194–203 39. Andres R, Elahi D, Tobin JD, et al (1985) Impact of age on
weight goals. Ann Intern Med 103:1030–3
40. Diehr P, O’Meara ES, Fitzpatrick A, et al (2008) Weight, mortal- ity, years of healthy life, and active life expectancy in older adults. J Am Geriatr Soc 56:76–83
41. Stevens J, Cai J, Pamuk ER, et al (1998) The effect of age on the association between body mass index and mortality. N Engl J Med 338:1–7
42. Takata Y, Ausai T, Soh I, et al (2007) Association between body mass index and mortality in an 80-year-old population. J Am Geriatr Soc 55:913–7
43. Potter J, Klipstein K, Reilly JJ, Roberts M (1995) The nutritional status and clinical course of acute admissions to a geriatric unit.
Age and Ageing 24:131–6
44. Arterburn DE, McDonell MB, Hedrick SC, et al (2004) Associa- tion of body weight with condition-specific quality of life in male veterans. Am J Med 117:738–46
45. Lehmann AB, Bassey EJ (1996) Longitudinal weight changes over four years and associated factors in 629 men and women aged over 65. Eur J Clin Nutr 50:6–11
46. Stevens J, Plankey MW, Williamson DF, et al (1998) The body mass index-mortality relationship in white and African American women. Obes Res 6:268–77
47. Chartewska J, Chabros E, Rogalska-Niedzwiedz M, et al (1999) Mininutritional assessment in elderly people living at home in Warsaw. Nestle Nutrition Workshop Series Clinical Perform Programme 1:161
48. Delacorte RR, Moriguti JC, Matos FD, et al (2004) Mini- nutritional assessment score and the risk for undernutrition in free-living older persons. J Nutr Health Aging 8:531–4 49. Maaravi Y, Berry EM, Ginsberg G, et al (2000) Nutrition and
quality of life in the aged: the Jerusalem 70-year old longitudinal study. Aging (Milan) 12:173–9
50. Spatharakis GC, Asimakopoulou FA, Koustagianni Z, et al (2002) Assessment of the nutritional risk in community-dweling elderly in Greece using the Mini Nutritional Assessment scale.
J Nutr Health Aging 6(suppl):19
51. Saava M, Kisper-Hint IR (2002) Nutritional assessment of elderly people in nursing house and at home in Tallinn. J Nutr Health Aging 6:93–5
52. Fei XF, Cheng QM, Shi YM, Cao WX (2004) Evaluation of the nutritional conditions in community retired residents by nutri- tional assessment questionnaire and anthropometry. Chin J Clin Rehabil 8:4364–5
53. Eriksson BG, Dey DK, Hessler RM, et al (2005) Relationship between MNA and SF-36 in a free-living elderly population aged 70 to 75. J Nutr Health Aging 9:212–20
54. Kabir ZN, Ferdous T, Cederholm T, et al (2006) Mini-nutritional assessment of rural elderly people in Bangladesh: the impact of demographic, socio-economic and health factors. Public Health Nutr 9:968–74
55. Beck AM, Ovesen L, Schroll M (2001) A six months’prospec- tive follow-up of 65 + -y-old patients form general practice clas- sified according to nutritional risk by the Mini Nutritional Assessment. Eur J Clin Nutr 55:1028–33
