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Malnutrition and obesity among older adults, assessed by Mini Nutritional Assessment and the body mass index, respectively: prevalence and associations with mortality and urinary tract infection
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
2021 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Undernäring och fetma hos äldre enligt Mini Nutritional Assessment och Body Mass Index : förekomst och koppling till mortalitet och urinvägsinfektion (Swedish)
Abstract [en]

INTRODUCTION: Malnutrition and obesity are health concerns among older (aged ≥ 65 years) adults, but the combination of them have not been studied thoroughly nor have they been thoroughly investigated in very old (aged ≥ 85 years) adults. The aims of this thesis were to investigate the prevalence, trends in prevalence and associations with mortality of malnutrition and obesity, assessed by Mini Nutritional Assessment (MNA) and the body mass index (BMI), respectively, and to examine the combined effects of these conditions on mortality. Malnutrition as a risk factor for urinary tract infection (UTI) was also investigated. 

MATERIAL AND METHODS: The studies reported on in papers I and II were conducted with data from the Umeå85+/Gerontological Regional Database study, a population-based study of cohorts of very old adults. Data from all four Swedish cohorts (2000–2002, 2005–2007, 2010–2012 and 2015–2017), and from the 2000–2002 and 2005–2007 Swedish cohorts and a 2005–2006 Finnish cohort, respectively, were used. In the paper I study, trends in the prevalence of malnutrition (by MNA score) and obesity (by BMI) were investigated across cohorts. In the paper II study, the associations of MNA scores and BMI with 5-year mortality were investigated. The study reported on in paper III was conducted with data from the Senior Alert national quality registry; associations of Mini Nutritional Assessment–Short Form (MNA-SF) scores, BMI and 2-year mortality in older adults living in residential care facilities in Sweden were investigated. The study reported on in paper IV was conducted with data from the Frail Older People–Activity and Nutrition and Umeå Dementia and Exercise studies; risk factors for UTI among older adults in residential care facilities were investigated. 

RESULTS: In the paper I study, mean BMI increased between 2000–2002 and 2015–2017 and the prevalence of obesity were 13.4% and 18.3%, respectively; the prevalences of underweight were 7.6% and 3.0%, respectively. Mean MNA scores increased between 2000–2002 and 2010–2012 and were slightly lower in 2015–2017. The prevalence of malnutrition according to MNA scores in the four cohorts were 12.2%, 6.4%, 5.1% and 8.7%, respectively, and the prevalence of at risk thereof were 31.8%–37.2%. In the paper II study, 13.3% of participants were malnourished, and 40.3% at risk thereof according to MNA scores, and malnutrition was more common among women than men. Twenty-five percent of the population had BMIs ≥28.0 kg/m2. Of those with malnutrition according to MNA scores, 17.4% had BMIs ≥ 24.7 kg/m2; of those with good nutritional status according to MNA scores, 13.8% had BMIs < 22.2 kg/m2. Compared to malnutrition according to MNA, lesser mortality was found in individuals with good nutritional status. Compared to individuals with BMI <22.2 kg/m2, lesser mortality was found in those with BMI ≥28.0 kg/m2. In the paper III study, 14.6% of the population was malnourished, and 45.0% at risk of malnutrition according to MNA-SF scores and 16.0% were obese. Compared to individuals with good nutritional status, greater mortality was found in those with malnutrition according to MNA-SF. Mortality was greater among underweight than among normal-weight participants and lesser among participants with obesity, including severe obesity. Higher BMIs were also associated with reduced mortality in subgroups defined by MNA-SF scores. In the paper IV study, malnutrition according to MNA scores was not a risk factor for UTI in the whole sample or in women. In men, the MNA score was associated with UTI in univariate analysis. 

CONCLUSIONS: The results of this thesis highlight the importance of nutritional screening in older adults in residential care facilities and in very old adults, since malnutrition risk was common and associated with greater mortality among these populations. Malnutrition according to MNA was not a clear risk factor for UTI in older adults living in residential care facilities. Time trends indicated an increasing prevalence of obesity whereas no change in nutritional status according to MNA was observed among very old adults, although these trends need further investigation. The results also confirmed that higher BMIs were beneficial for survival in these populations, and in the residential care population this seems to apply also for BMIs reflecting severe obesity. Finally, in the residential care population, regardless of nutritional status according to MNA-SF, higher BMIs were associated with better survival.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2021. , p. 110
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2121
Keywords [en]
Malnutrition, obesity, underweight, Mini Nutritional Assessment, Body Mass Index, older adults, very old, community dwelling, residential care facilities, mortality, urinary tract infection
National Category
Geriatrics
Research subject
Geriatrics; Nutrition
Identifiers
URN: urn:nbn:se:umu:diva-182820ISBN: 978-91-7855-511-6 (print)ISBN: 978-91-7855-512-3 (electronic)OAI: oai:DiVA.org:umu-182820DiVA, id: diva2:1552672
Public defence
2021-06-04, Aula Biologica, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2021-05-12 Created: 2021-05-06 Last updated: 2022-12-04Bibliographically approved
List of papers
1. Prevalence of obesity and malnutrition in four cohorts of very old adults, 2000–2017
Open this publication in new window or tab >>Prevalence of obesity and malnutrition in four cohorts of very old adults, 2000–2017
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2022 (English)In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Springer Link, Vol. 26, no 7, p. 706-713Article in journal (Refereed) Published
Abstract [en]

Objectives: Investigate trends in the prevalence of obesity and malnutrition among very old adults (age ≥ 85 years) between 2000 and 2017.

Design, Setting, Participants, Measurements: A study with data from the Umeå 85+/Gerontological regional database population-based cohort study of very old adults in northern Sweden. Every 5 years from 2000–2002 to 2015–2017, comprehensive assessments of participants were performed during home visits (N=1602). Body mass index (BMI) classified participants as underweight (<18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (≥30.0 kg/m2). Mini Nutritional Assessment (MNA) scores classified participants as malnourished (0 to <17), at risk of malnutrition (17–23.5), and having good nutritional status (24–30). Prevalence and trends were examined using analysis of variance and chi-squared tests, including subgroup analyses of nursing home residents.

Results: Between 2000–2002 and 2015–2017, the mean BMI increased from 24.8± 4.7 to 26.0± 4.7 kg/m2. The prevalence of obesity and underweight were 13.4% and 7.6%, respectively, in 2000–2002 and 18.3% and 3.0%, respectively, in 2015–2017. The mean MNA score increased between 2000–2002 and 2010–2012 (from 23.2± 4.7 to 24.2± 3.6), and had decreased (to 23.3± 4.2) by 2015–2017. The prevalence of malnutrition was 12.2%, 5.1%, and 8.7% in 2000–2002, 2010–2012, and 2015–2017, respectively. Subgroup analyses revealed similar BMI and MNA score patterns among nursing home residents.

Conclusions: Among very old adults, the mean BMI and prevalence of obesity seemed to increase between 2000–2002 and 2015–2017. Meanwhile, the nutritional status (according to MNA scores) seemed to improve between 2000–2002 and 2010–2012, it declined by 2015–2017.

Place, publisher, year, edition, pages
Springer, 2022
Keywords
Body mass index, malnutrition, Mini Nutritional Assessment, obesity, very old adult
National Category
Geriatrics Nursing
Identifiers
urn:nbn:se:umu:diva-182795 (URN)10.1007/s12603-022-1820-x (DOI)000824821500002 ()35842761 (PubMedID)2-s2.0-85133502496 (Scopus ID)
Funder
Swedish Research Council, K2014-99X-22610-01-6Umeå UniversityVästerbotten County Council
Note

Originally included in thesis in manuscript form. 

Available from: 2021-05-04 Created: 2021-05-04 Last updated: 2023-09-05Bibliographically approved
2. Body Mass Index, Mini Nutritional Assessment, and their Association with Five-Year Mortality in Very Old People
Open this publication in new window or tab >>Body Mass Index, Mini Nutritional Assessment, and their Association with Five-Year Mortality in Very Old People
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2015 (English)In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 19, no 4, p. 461-467Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: to investigate the prevalence of malnutrition and the association between Body Mass Index (BMI), Mini Nutritional Assessment (MNA) and five-year mortality in a representative population of very old (>85 years) people.

DESIGN: A prospective cohort study.

SETTING: A population-based study of very old people in northern Sweden and western Finland, living in institutional care or in the community.

PARTICIPANTS: Out of 1195 potential participants, 832 were included (mean age 90.2±4.6 years).

MEASUREMENTS: Nutritional status was assessed using BMI and MNA and the association of those two variables with five-year mortality was analyzed.

RESULTS: The mean BMI value for the whole population was 25.1±4.5 kg/m2, with no difference between genders (P=0.938). The mean MNA score was 22.5±4.6 for the whole sample, and it was lower for women than for men (P<0.001). Thirteen percent were malnourished (MNA<17) and 40.3% at risk of malnutrition (MNA 17-23.5) according to MNA. Also, 34.8% of those with a MNA score <17 still had a BMI value ≥22.2 kg/m2. A BMI value <22.2 kg/m2 and a MNA score<17 were associated with lower survival. The association with mortality seemed to be J-shaped for BMI, and linear for MNA.

CONCLUSIONS: Malnutrition according to MNA was common, but a substantial portion of those with a low MNA score still had a high BMI value, and vice versa. The association with mortality appeared to be J-shaped for BMI, and linear for MNA. The MNA seems to be a good measurement of malnutrition in very old people, and BMI might be misleading and could underestimate the prevalence of malnutrition, especially in women.

Place, publisher, year, edition, pages
Paris: Springer, 2015
Keywords
MNA, BMI, very old, five-year mortality
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-101459 (URN)10.1007/s12603-015-0443-x (DOI)000352705800012 ()25809811 (PubMedID)2-s2.0-84939650109 (Scopus ID)
Available from: 2015-03-31 Created: 2015-03-31 Last updated: 2023-03-24Bibliographically approved
3. Obesity may increase survival, regardless of nutritional status: a Swedish cohort study in nursing homes
Open this publication in new window or tab >>Obesity may increase survival, regardless of nutritional status: a Swedish cohort study in nursing homes
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2022 (English)In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 22, no 1, article id 655Article in journal (Refereed) Published
Abstract [en]

Background: To investigate the associations between the body mass index (BMI), Mini Nutritional Assessment-Short Form (MNA-SF) scores, and 2-year mortality.

Methods: A nationwide cohort study using data from a national quality register of older (age ≥ 65 years) nursing home residents (N = 47,686). Individuals were categorized according to BMI as underweight (< 18.5 kg/m2), normal-weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (class I, 30.0-34.9 kg/m2; class II, 35.0-39.9 kg/m2; class III, ≥ 40.0 kg/m2). Participants' nutritional status were categorized as good (MNA-SF score 12-14), at risk of malnutrition (MNA-SF score 8-11), or malnutrition (MNA-SF score 0-7). Associations with mortality were analysed using Cox proportional-hazards models.

Results: At baseline, 16.0% had obesity, and 14.6% were malnourished. During 2 years of follow-up, 23,335 (48.9%) individuals died. Compared with normal-weight individuals, mortality was greater among underweight individuals [hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.55-1.69] and lesser among individuals with class I (HR 0.63, 95% CI 0.60-0.66), class II (HR 0.62, 95% CI 0.56-0.68), and class III (HR 0.80, 95% CI 0.69-0.94) obesity. Compared with individuals with good nutritional status, mortality was increased for those with malnutrition (HR 2.98,95% CI 2.87-3.10). Lower mortality among obese individuals was also seen in subgroups defined according to MNA-SF scores.

Conclusions: Among older nursing home residents, obesity, including severe obesity, was associated with lower 2-year mortality. Higher BMIs were associated with better survival, regardless of nutritional status according to MNA-SF.

Place, publisher, year, edition, pages
BioMed Central, 2022
Keywords
Mortality, Nutritional status, Obesity, Older nursing home residents
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-182792 (URN)10.1186/s12877-022-03356-1 (DOI)000838662600003 ()35948885 (PubMedID)2-s2.0-85135815690 (Scopus ID)
Funder
Swedish Research Council, K2014-99X-22610-01-6Västerbotten County Council
Note

Originally included in thesis in manuscript form. 

Available from: 2021-05-04 Created: 2021-05-04 Last updated: 2022-09-09Bibliographically approved
4. Is malnutrition a risk factor for incident urinary tract infection among older people in residential care facilities?
Open this publication in new window or tab >>Is malnutrition a risk factor for incident urinary tract infection among older people in residential care facilities?
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2018 (English)In: Journal of Nursing Home Research, ISSN 2496-0799, Vol. 4, p. 49-55Article in journal (Refereed) Published
Abstract [en]

Background: Malnutrition and urinary tract infections (UTI) are common among older people living in residential care facilities.

Objectives: To determine whether malnutrition is a risk factor for incident urinary tract infection in people aged ≥65 years living in residential care facilities.

Design, Setting, and Participants: A prospective cohort study of people living in residential care facilities in northern Sweden (N=373). Data from the Frail Older People-Activity and Nutrition and Umeå Dementia and Exercise studies were used.

Measurements: Malnutrition was assessed using the Mini Nutritional Assessment (MNA). Risk factors for UTI were explored using univariate and multivariate Cox proportional hazard regression analyses. Maximum follow-up time was 9 months.

Results: The incidence of UTI was 460/1000 person-years; 85/276=30.8% of women and 16/97=16.5% of men contracted UTIs. History of UTI (hazard ratio [HR] 2.804, 95% confidence interval [CI] 1.824–4.311), heart failure (HR 2.101, 95% CI 1.368–3.225), hypertension (HR 1.656, 95% CI 1.095–2.504), and low Mini-Mental State Examination (MMSE) score (HR 0.937, 95% CI 0.892–0.985) were associated independently with higher risk of incident UTI in multivariate analyses. Malnutrition was not associated with UTI in the whole sample or in women; MNA score was associated with UTI in men in univariate analysis (HR 0.841, 95% CI 0.750–0.944).

Conclusion: The incidence of UTI was high in residential care facilities and individuals with histories of UTI, heart failure, hypertension, or cognitive impairment were more likely to be affected. Malnutrition was not a risk factor for UTI in the whole sample or in women, but may constitute a risk for UTI among men.

Keywords
Malnutrition, urinary tract infection, residential care, older people
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-179154 (URN)10.14283/jnhrs.2018.10 (DOI)
Available from: 2021-01-26 Created: 2021-01-26 Last updated: 2022-01-03Bibliographically approved

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