FACULTY OF HEALTH SCEINCE

DEPARTEMENT OF PUBLIC HEALTH

UNDERNUTRITION AND ITS ASSOCIATED FACTORS AMONG

ELDERLY PATIENTS ADMITTED TO PUBLIC HOSPITALS OF ILU
ABABORA ZONE, WEST OROMIYA, SOUTHWEST ETHIOPIA, 2024.

BY: EDOSA HABTAMU (BSC)

A THESIS SUBMITTED TO THE FACULTY OF HEALTH SCIENCE

DEPARTMENT OF PUBLIC HEALTH, MATTU UNIVERSITY, IN
PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE
OF MASTER’S IN HUMAN NUTRITION.

AUGUST 2024
MATTU, ETHIOPIA

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UNDERNUTRITION AND ITS ASSOCIATED FACTORS AMONG
ELDERLY PATIENTS ADMITTED TO PUBLIC HOSPITALS OF ILU
ABABORA ZONE, WEST OROMIYA, SOUTHWEST ETHIOPIA, 2024.

BY: EDOSA HABTAMU (BSC)

ADVISOR: DR. EFREM NEGASH (Ph.D, ASSISTANT PROFESSOR OF

HUMAN NUTRITION)

AUGUST 2024
MATTU, ETHIOPIA

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 MATTU UNIVERSITY

SCHOOL OF GRADUATES STUDIES

Approval sheet

This is to certify that the thesis prepared by Mr. EDOSA HABTAMU entitled
“UNDERNUTRITION AND ITS ASSOCIATED FACTORS AMONG ELDERLY
PATIENTS ADMITTED TO PUBLIC HOSPITALS OF ILU ABABORA ZONE, WEST
OROMIYA, SOUTHWEST ETHIOPIA, 2024.” submitted in partial fulfillment of the
requirements for the degree of masters in school of public health in department of human
nutrition and as thesis research advisor, I hereby certify that I have read and evaluated this thesis
prepared under my supervision.

Therefore, I recommend that the student has fulfilled the requirements and hence hereby can
submit the thesis to the department.

_______________________ _____________ ____________

Advisor Signature Date

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 MATTU UNIVERSITY

SCHOOL OF GRADUATE STUDIES

Examiners’ approval sheet

We, the undersigned, members of the board of the examiners of the final open defense
examination we certify that we have read and evaluated his thesis entitled
“UNDERNUTRITION AND ITS ASSOCIATED FACTORS AMONG ELDERLY
PATIENTS ADMITTED TO PUBLIC HOSPITALS OF ILU ABABORA ZONE, WEST
OROMIYA, SOUTHWEST ETHIOPIA, 2024.” prepared by Mr. EDOSA HABTAMU and
examined the candidate. Thus, we recommend that the thesis has been accepted in partial
fulfillment of the requirements of for the degree of Masters in human nutrition field of study.

____________________________________ _________________ ________________

Chairperson Signature Date

_____________________________________ ___________________ ________________

External examiner Signature Date

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Internal examiner Signature Date

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Department Head Signature Date

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College/Institute/Dean Signature Date

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SGS Director Approval Signature Date

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Acknowledgement
First, I want to thank my Lord and savior Jesus Christ for guiding me through this ordeal. Next,
I'd want to express my appreciation to Mattu University, faculty of health Science, and
Department of public health for providing me with this chance of conducting research. Finally, I
would like to express my heartfelt thanks to my advisor and instructor Dr. Efrem Negash,
assistance professor of human nutrition, for his helpful counsel, insightful direction, and
constructive recommendations that aided me in developing my proposal. At last, only in order, I
want to express my gratitude to my study participants and their care givers for their cooperation
in my study.

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Acronym and Abbreviation
ADL-Activity of daily living
AOR- Adjusted Odd Ratio
BMI- Body Mass Index
BSC- Bachelor of Science
CL- Confidence Level
DDSs- Dietary Diversity Scores
FAO- Food and agriculture organization
GDS- Geriatric depression scale
HFIAS- Household Food Insecurity Access Scale
LOS- length of stay
MDR- Multi drug resistance
MKCSH- Mattu Karl Comprehensive Specialized Hospital
MNA-Mini Nutritional assessment
SPSS- Statistical Package for the Social Sciences
UNHCR- United nations high commissions for refuge
VIF- Variance Inflation Factor
WFP- World Food Program
WHO -World Health Organization

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Table of Contents
Acknowledgement...........................................................................................................................3

Acronym and Abbreviation.............................................................................................................4

List of Tables...................................................................................................................................7

List of Figures..................................................................................................................................8

Abstract............................................................................................................................................9

1: INTRODUCTION.....................................................................................................................10

1.1. Background.............................................................................................................................10
1.2 Statement of the problem.........................................................................................................12
1.3 Significance of the study.........................................................................................................14
2. LITERATURE REVIEW..........................................................................................................15

2.1 Magnitude of undernutrition in hospitalized elderly patients..................................................15

2.2. Factors associated with undernutrition...................................................................................18
2.2.1 Sociodemographic Factors............................................................................................18

2.2.2. Clinical characteristics.................................................................................................19

2.2.3.Socioeconomic status....................................................................................................19

2.2.4 Behavioral attributes.....................................................................................................19

2.2.5. Functional status..........................................................................................................19

2.3. Conceptual framework............................................................................................................20

3. OBJECTIVES............................................................................................................................21

3.1. General objective....................................................................................................................21

3.2. Specific objectives..................................................................................................................21
4. METHODS AND MATERIALS..............................................................................................22

4.1. Study area and period.............................................................................................................22

4.2. Study design............................................................................................................................22
4.3. Population...............................................................................................................................22
4.3.1 Source population.........................................................................................................22

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 4.3.2. Study population..........................................................................................................22

4.4. Inclusion and exclusion criteria..............................................................................................22

4.4.1. Inclusion criteria..........................................................................................................22

4.4.2 Exclusion criteria..........................................................................................................22

4.5. Sample size and sampling procedures....................................................................................23

4.5.1. sample size determination............................................................................................23

4.5.2 sampling technique and procedure...............................................................................24

4.6. Study Variables.......................................................................................................................25

4.6.1. Dependent variable......................................................................................................25

4.6.2. Independent variables..................................................................................................25

4.7. Operational definitions...........................................................................................................25

4.8. Data collection tools and procedures......................................................................................26
4.9. Data processing and Analysis.................................................................................................29
4.10. Ethical Consideration............................................................................................................30
4.12. Result dissemination plan.....................................................................................................30
5: RESULTS..................................................................................................................................31

5.1. Basic characteristics of respondents.......................................................................................31

5.2. Nutritional status of the study participants.............................................................................34
5.3. Factors associated with undernutrition in elderly patients.....................................................34
6. DISCUSSION............................................................................................................................36

6.2 Limitations...............................................................................................................................37

7. Conclusion and recommendations.............................................................................................38

7.1 Conclusion...............................................................................................................................38
7.2 Recommendations...................................................................................................................38
Reference.......................................................................................................................................39

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List of Tables
Table 1 Variables for sample size determination for the second objective...................................15
Table 2 Tentative work plan of study of undernutritionand its associated factors among
hospitalized elderly patients in public hospitals of Ilu Aba Bor zone, southwest Ethiopia,2024..22
Table 3 budget breakdown for study of undernutrition and its associated factors among
hospitalized elderly in public hospitals of Ilu Aba Bor zone, southwest Ethiopia, 2024..............23

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List of Figures
Figure 1 Conceptual Framework for Understanding of factors associated with undernutrition
among elderly patients in public hospitals of Ilu Aba Bor zone, 2024..........................................11

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Abstract
Background: Undernutrition is a common geriatric syndrome affecting approximately half of
the older population with a more pronounced occurrence rate in those who are hospitalized
However, not much is known about the nutritional status of this group of the population and they
are often neglected.
Objective: This study aimed at assessing undernutrition and associated among elderly patients
admitted to public hospitals of Ilu Ababor zone, west Oromia, southwest Ethiopia,2024.
Methods: Institutional-based cross-sectional study design was used among systematically
selected 307 older patients aged above 60 years. The full Mini-Nutritional Assessment (MNA)
tool was employed to assess the nutritional status on admission. The collected data was entered
into Epi-Data version 4.7 and analyzed by using SPSS version 27. All variables with a p-
value<0.25 in the bivariable analysis were taken for multivariable logistic regression for further
analysis and the level of statistical significance was declared at p-value<0. 05.
Multicollinearity was assessed using the Variance Inflation Factor (VIF),whereas model fitness
was evaluated through the Hosmer-Lemeshow test, which indicated a good fit. The association
between variables was measured using the Chi-square test, identifying significant associations
where the p-value was below 0.05.
Results : A total of 307 respondents (100%) were interviewed. About 237 (77.2 %) were found
to be undernourished. Rural residence (AOR = 2.276, 95%CI: 1.057,4.902), poor dietary
diversity (AOR = 3.227, 95%CI: 1.396,7.460), moderate food insecurity (AOR = 5.862, 95%CI:
2.827,12.157) ,old-old (>85 year) age group (AOR = 4.359, 95%CI: 1.330,14.286), being female
(AOR = 2.68, 95%CI: 1.726,6.180), being poorest (AOR = 3.716, 95%CI: 1.019,13.554),
functional impairment(dependent) (AOR = 2.866, 95%CI: 1.066,7.704), were significantly
associated with increased risk of undernutrition.
Conclusion: In the present study, high proportion of undernutrition was identified in older
inpatients. Nutritional support is recommended with special emphasis for those from rural areas,
with financial dependence, and with functional impairment on admission.

Key words : elderly, undernutrition, hospitalized, Ethiopia.

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1: INTRODUCTION
1.1. Background
The dynamics of the world's population demonstrate that the share of the elderly population is
increasing with time (1). In developed nations, elderly populations are classified as individuals
65 years of age and older; while in developing nations, such as Ethiopia, international
organizations define elders as 60 years of age and older (2). It is projected that by 2050, there
will be 2.1 billion persons in this age bracket, a twofold increase in 2020 with two-thirds of
people over 60 worldwide will be residing in low- and middle-income nations. (3). Ethiopia is
likewise going through a demographic shift that is in line with the general tendency of the world
(4).

Undernutrition, is a condition that occurs when the intake of nutrients and energy is insufficient
to meet an individual's needs for maintaining good health and proper bodily functions, owing to
insufficient food intake or impaired absorption resulting in impaired physical and mental
function which exacerbates the clinical course of disease (5). Based on the prevalence of
undernutrition, the evaluation of world hunger in 2022 indicates that undernutrition remained
significantly higher than pre-covid pandemic levels. In 2022, 9.2 percent of the world's
population experienced chronic hunger, which is up from 7.9 percent in 2019 (6).

Common in this population, undernutrition is a well-known geriatric condition with a

complicated etiology that seriously impairs quality of life and health consequences (7).
Undernourishment, sarcopenia, and frailty are common concomitant comorbidities in elderly
patients with hip fractures (8,9). According to reports, up to 81% of older persons suffer from
undernutrition; however, prevalence estimates differ greatly depending on the population, the
healthcare context, and the assessment tool utilized (10–12) . In addition, a high proportion of
older adults are at risk of undernutrition, with estimates ranging between 27% in community or
outpatients and 50% in all other healthcare settings (11).

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Undernutrition in older adults is a multifaceted, complex condition that is currently only partially
understood (7). A Reduced food intake, a contributing factor to undernutrition, is frequently
linked to a decline in taste and smell perception, which causes anorexia, also known as anorexia
of aging (14), but can also be brought on by poor oral health, trouble digesting and swallowing
food, adverse drug reactions, cognitive decline, social isolation and depression.

A number of acute illnesses, such as infections and surgery, frequently coexist with chronic
illnesses, such as heart failure, respiratory disorders, cancer, and renal failure. These illnesses
raise energy requirements and hasten undernutrition in elderly individuals who are already at
risk. Other environmental factors, such as meal quality, meal ambience, and the standard of
medical and nutritional treatment, which are particularly relevant in hospitals and care homes
may also affect dietary intake and contribute to undernutrition (7).

One of the hallmarks of undernutrition is the loss of body protein as a result of inadequate
protein intake or increased demand in sickness which is followed by a compromised immune
system and muscle mass loss, all of which significantly enhance the morbidity associated with
undernutrition (15). Undernutrition in hospitals is linked to a higher risk of complications
following surgery, extended stays in the hospital, and nosocomial infections (16,17).

Undernutrition causes diseases to heal more slowly and requires longer convalescence times. It
come as no surprise that patients who are undernourished spend far longer time in the hospital,
have a higher likelihood of unscheduled readmissions, and use more health resources overall.
These repercussions ultimately raise the financial strain on the health care system in addition to
adding to the cost for the affected individuals (18).

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 1.2 Statement of the problem
Undernutrition is frequent in many illnesses and is particularly common among hospital admitted
patients, elderly people in institutions, and those with chronic conditions (19). Elderly
hospitalized patients are more frequently undernourished than younger patients, highlighting the
critical need for targeted nutritional screening, assessment, and intervention protocols
specifically tailored to address the unique requirements of the elderly (11).

Latin American countries reports demonstrate the magnitude of undernutrition as high as 60% at
the time of admission (20). In France while fifty percent of hospitalized elderly are
undernourished, 40% are hospitalized for the consequences of undernutrition (21). With a
prevalence that ranges from 16% to 78% and all of its severe repercussions, the issue of
undernutrition among hospitalized seniors in Asia further highlights the scope of the problem
and the attention it demands (22). In Algeria 37.2% of hospitalized elderly patients are a victim
of undernutrition while 51.2% of patients were at risk of undernutrition (23). In our country,
alarmingly 81% of hospitalized elderly patients are undernourished. The problem even
pronounced in the fact that in only two of the patients that undernutrition was reported in hospital
(10).

Remarkably 49% of undernourished patients who stay in the hospital for longer than a week
either maintain their prior nutritional status or see it deteriorate, with roughly 33% of patients
who had a stable nutritional status before admission experiences undernutrition while in the
hospital setting (24). Due to the increased morbidity, undernourished patients experience a
significantly prolonged treatment duration, reduction in quality of life, functional alterations in
immune defense, a reduction in overall muscle strength, especially in pulmonary ventilation,
delayed recovery from surgery (21,25–28).

Undernutrition has a detrimental effect on hospital length of stay (LOS) and is linked to
increased expenses and a higher risk of complications. It is demonstrated that LOS in people who
are undernourished can rise by 40–70% (29–31). Conversely, a higher LOS is linked to a
worsening of nutritional status while a patient is in the hospital (32).

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Furthermore, undernutrition is associated with elevated risk of acute renal injury, stroke, septic
shock, intubation (33) and is an independent predictor of non-ventilator hospital-acquired
pneumonia (34). The undernourished elderly patients face a twofold increased risk of developing
multidrug-resistant (MDR) infections (35) and undernutrition is associated with significantly
increased risk for all-cause mortality (36).

Every year, around $147 billion is spent on disease related undernutrition. Nutrition interventions
to prevent undernutrition results in substantial cost savings on average of over $3,800 per patient
(37). Increased length of stay (LOS) costs additional $26.7 billion annually. A further $3.4
billion is spent on medications for treating infectious problems resulting from undernutrition
(38). When compared to well-nourished elderly, undernourished elderly patients spend more
than twice as much on average annual total health cost (39).

Age, gender, and the existence of one or more comorbidities (19,40), area of residence (10,40),
functional autonomy, financial reliance (10), food insecurity (41), dietary diversity (42), marital
status (43,44), educational status, smoking (44) are the factors associated with undernutrition.

Data shows that 40% of medical/surgical staff and 58% of nursing staff are not able to diagnose
undernutrition (45) and nutritional care is inadequate, and prevention measures are often not
acquired (46). Despite Ethiopia's demographic changes, no targeted old-age policies or
interventions are in place to address the health and nutritional issues that the elderlies face (47).
There also no nationally adopted guideline for the management of acute malnutrition in this age
group and no mandate to include them in screening for acute malnutrition (48).

There is limited literature to boldly quantify the magnitude of undernutrition and its correlates
among hospitalizedamong hospitalized elderly in Ethiopia including the study area. The study
conducted at Jima university medical center is a single center study and used a small sample size
with convenience sampling method (10). The study conducted at university of Gondar Hospital,
Northwest Ethiopia also utilized convenience sampling and used fifty years and above to define
elderlies ,whichelderlies, which is not standard used to define elderly populations (49). So, this
study was conducted to fill the knowledge gaps regarding undernutrition and its correlates in the

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hospitalized elderly. Therefore, the purpose of this study was to determine the magnitude of
undernutrition and the factors affecting it among elderly patients in public hospitals in Ilu Aba
Bor zone.

1.3 Significance of the study

Understanding the magnitude and contributing factors of undernutrition is crucial since it is a
sensitive and serious problem for older patients in hospitals. By presenting solid data regarding
the magnitude and correlates of undernutrition in elderly patients, this study can guide the
creation of focused policies and initiatives for Ministry of Health and regional Health Burrous
meant to enhance the nutritional care provided to this susceptible group being made available in
systematic reviews and meta-analysis.

The study's recommendations can also greatly assist hospitals, nurses, by improving their
comprehension of undernutrition in elderly patients and directing evidence-based clinical
practice. This study will have a significant positive impact on patients and caregivers themselves
by raising awareness of the value of healthy nutrition for senior citizens and enabling them to
actively participate in their own health and wellbeing by making informed decisions about their
dietary habits and way of lifestyles.

The findings of this study will also contribute to the existing body of knowledge by providing
valuable insights into the magnitude, risk factors of undernutrition among the hospitalized
elderly population. Building on these findings, future researchers might explore more particular
facets of undernutrition, including how it affects health outcomes, quality of life, and patterns of
healthcare expenditures.

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2. LITERATURE REVIEW
2.1 Magnitude of undernutrition in hospitalized elderly patients
A multinational evaluation of undernutrition in older adults from twelve countries using the Mini
Nutrition Assessment (MNA) reported that undernutrition was prevalent in 38.7% of hospitalized
participants, 13.8% in nursing home and 5.8% in community setting (50). An American study
evaluating elderly patients hospitalized to surgical and medical intensive care units (ICUs) at a
major academic medical center revealed that up to 34% of the cohort had undernutrition (51).

A systematic review and meta-analysis of 223 study samples from 24 European countries and
583,972 older adults revealed that Pooled prevalence rates of undernutrition across all nations of
Europe were 28.0% ,17.5%, and 8.5%, for the hospital, residential care and community settings
respectively. In the same study, prevalence rates were higher in adults aged greater than 80years,
in women and in patients with one or multiple comorbidities (19).

Systematic review conducted using 66 studies including 29,474 patients in 12 Latin American
countries reported prevalence of disease-related undernutrition within the range of 40%-60% at
the time of admission, with an increase in prevalence with increasing duration of hospitalization.
Disease-related undernutrition having a consequence of an increase in infectious and non-
infectious clinical complications, length of hospital stays, and costs (20). Another systematic
review of studies conducted in Asia demonstrated that the prevalence of undernutrition including
the risk of undernutrition among hospitalized seniors ranged from 16% to 78% (22).

According to study conducted on 389 inpatients in two departments of Internal medicine, Hue
University of Medicine and Pharmacy Hospital in Vietnam, the prevalence of undernutrition
among elderly inpatients was found to be 35.0 % (52). According to A multicenter, cross-
sectional study conducted in 12 hospitals in northern Italy medical and surgical wards using the
full Mini Nutritional Assessment, 21.4% of hospitalized elderly are found to be undernourished
(45).

According to one study conducted in France the prevalence of undernutrition was found to be 4-
10% in elderly people living at home, 15-38% in those living in institutions while fifty percent of

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hospitalized elderly are undernourished and 40% are hospitalized for the consequences of
undernutrition (21). Analytical cross-sectional study involving 150 elderly hospitalized patients,
recruited from surgical and medical departments of governmental hospitals in the Gaza Strip,
Palestine found out that the prevalence of undernutrition to be 52.7% (53).

Observational, retrospective study conducted in the community hospital of Loreto

(Ancona) which studied frequency of undernutrition after introducing the Mini Nutritional
Assessment found out that the prevalence of undernutrition among elderly patients to be 70%
(54). According to a study conducted in Colombia using a descriptive analysis of selected data
from 7 consecutive, annual, and cross-sectional nutritionDay samples including a total of 7,994
adult patients in 248 units in the country, the magnitude of undernutrition in Colombia was 38%
(55).

A large retrospective and observational cohort study that included 43,415 consecutive elderly
patients admitted at Guangdong Provincial People's Hospital in Guangdong, China, found that
48.19% of the cohort was undernourished (36). A Retrospective cohort study conducted in
Netherlands, Leeuwarden Medical Centre, all patients of elective acute geriatric unit,
undernutrition was present in 24.5% of patients (56).

Another study of cross-sectional nature conducted in King Abdul-Aziz University Hospital,

Jeddah, Saudi Arabia which evaluated the nutritional status of hospitalized elderly patients using
short form of Mini Nutritional Assessment (MNA-SF) on a total of 248 hospitalized patients
revealed that a total of 76.6% patients were either undernourished or at risk of undernutrition
(57).

Another cross-sectional study in old people over 65 years living in public nursing homes in
Mexico City which evaluated malnutrition-sarcopenia syndrome in 212 institutionalized elders
demonstrated that the prevalence of undernutrition was of 32.2% in females and of 17.5% in
males making the overall prevalence to be 27.85 (58). A study done on 311 elderlies in Sri Lanka
demonstrated that the Prevalence of undernutrition was 30 % (59).

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A cross-sectional study conducted in six large hospitals of Tehran University of Medical
Sciences on 451 hospitalized elderlies aged over 65 years found that the prevalence of
undernutrition was 27.3% and a total of 30.8% elderly patients were at risk of undernutrition
(60). According to study conducted on 235 elderly patients at a tertiary care public teaching
hospital in India, it was found that 46.4% of patients were undernourished while 50.2% the
patients are at risk of undernutrition (61).

According to study done at Royal Melbourne Hospital in Australia which assessed prevalence,
the coexistence of, and the association between undernutrition and sarcopenia in geriatric
inpatients found that 51% of the patients were undernourished (62). Research conducted in
Brazil on 2613 hospitalized elderly patients in a public hospital in São Paulo, 47.26% of the
population were at nutritional risk and 37.3% undernutrition (63).

An observational, descriptive, cross-sectional study conducted on 300 patients who are older
than 65 years admitted to the internal medicine ward at the "Hospital de Urgencia Asistencia
Pública" in Chile assessing nutritional status using the Mini Nutritional Status tool found out that
42.7% % of patients were undernourished (64).

Another systematic review and meta-analysis of Nutritional status and associated factors of older
persons in sub-Saharan Africa found undernutrition with prevalence ranging from 3.2 to 30.4%
(65). Another cross-sectional study from Algeria on hospitalized elderly patients in the Internal
Medicine Service of the University Hospital of Sidi Bel Abbes, the score of MNA screening
showed that 51.2% of patients were at risk of undernutrition while 37.2% of them are
undernourished (23).
Another study done in hospital settings in Burkina Faso on total of 222 inpatients revealed that
the prevalence of undernourishment was found to be 25.2% which increased to 31.0% during
hospitalization (66). Research conducted in Hospital Family Medicine Clinic (FMC) of Aminu
Kano Teaching hospital, Kano in Northwestern Nigeria, employing Cross-sectional Study on

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348 elderly patients using the Mini Nutritional assessment the prevalence of undernutrition was
found to be 25.3% (67).

In another study conducted in community setting among 423 study subjects of old age in Debre
Markos town employing Mini Nutritional Assessment Short-Form (MNA-SF) screening tool the
prevalence of under nutrition among study participants was found to be 22.7% (43). Another
Research of cross-sectional design, done on 337 elderly adults enrolled at Public Servants Social
Security Agency in Harar, eastern Ethiopia using The Mini Nutritional Assessment Tool Short
Form found that he magnitude of undernutrition was 16.6% and 45.1% were at risk of
undernutrition (41).

Another study conducted in Womberma district, West Gojjam Zone, Amhara Region, revealed
that the prevalence of undernutrition among older community dwellers was 14.6% (42). In
another study conducted in Jima university Medical Center on 157 elderly patients using the full
mini-nutritional assessment (MNA) it was found that 81% of the subjects were undernourished
while 17% of them were at risk for undernutrition (10). According to a community-based study
conducted in Ilu Aba Bor Zone on 645 community dwellers, employing MNA it was
demonstrated that 48.1% of elderly people were undernourished (68).

2.2. Factors associated with undernutrition

2.2.1 Sociodemographic Factors
According to systematic review conducted on six longitudinal studies from different countries to
identify the determinants of undernutrition, increasing age, being unmarried/separated/divorced,
predicted undernutrition (69). An observational cross-sectional study conducted at a major
tertiary teaching hospital medical and surgical unit in Beirut city over a period of seven months
period on patients aged 60 and over found out that, low level of education and higher age, was
significantly associated with hospital elderly undernutrition (16). According to a study done on
patients with type 2 diabetes mellitus in a Nigerian tertiary hospital, male gender was significant
predictors of undernutrition (70). According to a cross sectional study conducted in Womberma
district, West Gojjam Zone, it was found that poor dietary diversity was associated with
increased risk of elderly undernutrition (42).

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2.2.2. Clinical characteristics
A retrospective study conducted at the First Hospital of Lanzhou University in China, on total of
365 elderly Chinese inpatients found that the following factors were linked to undernutrition in
hospitalized elderly: presence of chronic disease comorbidity, depression (71). Iranian
researchers’ study of senior patients in the six hospitals connected to Tehran University of
Medical Sciences also found that increased comorbid diseases, presence of psychological
conditions are factors associated with undernutrition (60). Another Research conducted on
Lebanese patients in Centre Hospitalier Universitaire Notre Dame de Secours hospital revealed
that previous hospitalization, low body-mass index are determinants of undernutrition (72).

2.2.3.Socioeconomic status
Study conducted in Jima university Medical Center on 157 elderly patients, self-reported
financial dependency was found to be independent predictors of undernutrition in admitted
elderly patients (10). A community based cross-sectional study conducted at Sodo Zuriya district
on 578 elderlies indicated that having monthly income less than $20 were factors positively
associated with undernutrition (44).
2.2.4 Behavioral attributes
According to a certain community-based cross-sectional study conducted in Ilu Aba Bor Zone
on total of 645 elders, smoking and alcohol consumption are demonstrated to be associated
factors in elderly undernutrition (68).
2.2.5. Functional status
According to a prospective observational cohort study conducted in Copenhagen University
Hospital, Denmark, Limitations in functional ability was found to be associated with elderly
undernutrition (73). Another study of cross-sectional nature conducted in twelve hospitals in the
North of Italy, it was demonstrated that impaired autonomy was associated with undernutrition in
hospitalized elderly patients (45).

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 2.3. Conceptual framework
This conceptual framework is developed by reviewing different literatures
(74,62,75,16,73,22,71).

Behavioral attributes
Socio-demographic
 Alcohol consumption Socio-economic status
 Age
 Tobacco smoking  Wealth index
 Sex
 Marital status
 Educational level
 Residence
Elderly
Undernutrition
Food insecurity
Clinical characters Dietary diversity score
 Chronic disease
Comorbidity
 Previous Functional autonomy
hospitalization in one
year
 Depression

Figure 1 Conceptual Framework for Understanding of factors associated with

undernutrition among elderly patients admitted to public hospitals of Ilu Aba Bor zone,
2024.

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3. OBJECTIVES
3.1. General objective
To assess the magnitude of undernutrition and its associated factors among elderly patients
admitted to public hospitals of Ilu Aba Bor zone from June 15 - July 15,2024
3.2. Specific objectives
 To determine the magnitude of undernutrition among admitted elderly patients admitted to
public hospitals of Ilu Aba Bor zone from June 15 - July 15,2024
 To identify factors associated with undernutrition among elderly patients admitted to public
hospitals of Ilu Aba Bor zone from June 15 - July 15,2024.

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4. METHODS AND MATERIALS
4.1. Study area and period
The study was conducted from June 15 - July 15,2024 G.C in Mattu Karl Comprehensive
Specialized Hospital and Darimu General Hospital which are located in Ilu Aba Bor Zone. Ilu
Aba Bora Zone is found 600 Km to the southwest of Addis Ababa. The zone has two public
hospitals which are Mattu Karl Comprehensive Specialized Hospital which is located in Mattu
town and Darimu General hospital which is located in Darimu town. Mattu Karl Comprehensive
Specialized hospital has a total of 261 health professionals and 148 administrative workers and
has been providing health care services for more than 4,000,000 populations in its surrounding
area. It gives services under different specialties like gynecology, surgery, internal medicine,
ophthalmology, ICU and critical care, pediatrics, and neonatal care with total capacity of 289
beds. The hospital has an average admission of 421 elderly patients on monthly basis (74).
Darimu general hospital has a total of 102 health professionals and 98 administrative workers
providing healthcare services to more than 470,000 populations in its catchment area with total
capacity of 80 beds with average admission of 209 elderly patients on a monthly basis which is
increased exponentially during the study period due to malaria endemic during the study period
(75).
4.2. Study design
Facility based quantitative cross-sectional study design was conducted.
4.3. Population
4.3.1 Source population
All elderly patients admitted to public hospitals of Ilu Aba Bor zone were source population.
4.3.2. Study population
Selected elderly patients admitted to public hospitals in Ilu Aba Bor zone hours from June 15 -
July 15,2024.
4.4. Inclusion and exclusion criteria
4.4.1. Inclusion criteria
Elderly Patients who provided written consent, residents of Ilu Aba Bora zone for at least 6
months, admitted within 24-48 hours were included.

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4.4.2 Exclusion criteria
Elderly Patients with cognitive impairment or psychiatric disorders and those receiving
enteral/parenteral nutrition and edematous patients were excluded.
4.5. Sample size and sampling procedures
4.5.1. sample size determination
The total number of sample size required for this study was calculated based on the specific
objectives.
For first specific objective:
The sample size was calculated by using single proportion population formula using a study
done at Jimma medical center, Jimma, with magnitude of undernutrition 81% with 95% level of
confidence, and 5% margin of error (10). The sample size used in this study, adding 30 % non-
response rate, 307.
Sample size estimate using the following assumption would be: -
n = (Z α/2)2 P (1-P) = (1.96)2 0.81(1-0.81) = 236.4
d2 0.052
Where n is sample size, Z is standard normal distribution corresponding to significance level at α
= 0.05, d is margin of error assumed to be 5% and P is proportion of undernourished hospitalized
elderly.
For the second specific objective:
The sample size was calculated using Epi Info version 7.2.6.0, based on different studies, by
taking educational status and presence of chronic comorbidity, depression, area of residence,
household income and dietary diversity variables, which are associated with elderly
undernutrition with the given parameters in the table.

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Table 1 Variables for sample size determination for the second objective.

% outcome

% outcome

Total sample
in unexposed

in exposed

to exposed

of
(unexposed

confidence

Reference
Variables

Odd ratio

Power
group

group

Level
Ratio

size
Residence 9.9% 25.2% 1 3.06 95% 80% 192 (76)
area
Chronic 7.3% 25.8% 1 4.41 95% 80% 128 (41)
comorbidity
Educational 9.4 % 9% 1 3.93 95% 80% 126 (41)
status
Depression 3.9% 22.4% 1 7.11 95% 80% 104 (76)

House hold 2.8% 50% 1 34.7 95% 80% 26 (77)

income
Dietary 12.9% 75.6% 1 20.9 95% 80% 18 (77)
diversity

4.5.2 sampling technique and procedure

Systematic random sequential sampling method was used to select study subjects meeting the
inclusion criteria using average 630 patients monthly admissions to the hospitals as a sampling
frame.
4.6. Study Variables
4.6.1. Dependent variable
Undernutrition
4.6.2. Independent variables
 Sociodemographic characters (age, sex, residence area, marital status, educational level etc.)
 Behavioral characteristics (alcohol drinking, cigarette smoking)
 Wealth index

26 | P a g e
 Clinical characteristics of the patient (chronic disease comorbidity, Previous hospitalization
in one year)
 Neuropsychological condition (depression/dementia)
 Food insecurity
 Dietary diversity score
 Functional status
4.7. Operational definitions
Undernutrition: a respondent having score of less than 17 points in Mini Nutritional Assessment
scoring (MNA) (78).
Older adults: Those individuals aged 60 years old and above (2).
Depression: present in elderly patients with score of five and above for test answers on the
Geriatrics Depression Scale (79).
Demi-span: the distance measured from the middle of the sternal notch to the tip of the middle
finger in the coronal plane (80).
Functional status : refers to individuals functional autonomy as dependent, If scored 2 points or
less Partially dependent between 3 and 5 points, Fully independent, if the patient scored 6 points
on the Katz ADL score (81).
Dietary diversity score: It refers to food groups consumed from total of 16 food groups during
the 24 hours before the survey. It was classified as; Poor when the DDS is<3, medium when the
DDS is between 4–5 and High when the DDS is>6 (82).
Comorbidity: Any distinct additional entity that has existed or may occur during the clinical
course of a patient who has the index disease under study (83).

Food insecure: participant who answered affirmatively to two or more questions on the food
insecurity access scale and otherwise secure. (84).
Household: individuals that sleep under the same roof and take meals together at least four
days a week (84).
Alcohol: an intoxicating substance, the active ingredient in drinks consumed and any locally
available drink which has stimulant effect (85).
Alcohol use: Participants, who have used at least one of the alcoholic drinks locally available for
nonmedical purposes in the past 12 months (86).

27 | P a g e
Smoker : older patients who used one or more smoked tobacco products on a daily or non-daily
basis (87).

4.8. Data collection tools and procedures

Data collection tool: The MNA tool, adopted from the Nestle Nutrition Institute., which has 18
items, of anthropometric measurements, dietary history, clinical assessment of lifestyle habits,
medication, mobility, neuropsychological problems, and self-perception of nutrition and health
status was administered for older adults to asses nutritional status after the English questionnaire
was translated into Afan oromo and Amharic.

The dietary diversity scores (DDSs) of participants were measured using the 24-hour recall
method. This is the most popular method because it is less prone to recall bias and is less
cumbersome for respondents. Participants were asked to list what food groups they had
consumed in the past 24 hours of the survey. Sixteen food groups were used to compute the DDS
of study subjects. It comprises cereals, roots and tubers, legumes and nuts, dairy products, fresh
foods (meat, fish, poultry, and organ meats), eggs, vitamin A-rich fruits and vegetables, other
fruits and vegetables, oils and fats, sweets, and condiments. Finally, the score was classified as;
"poor" (when the DDS is<3), "medium" (when the DDS is between 4–5), and "high" (when the
DDS is >6) (82).

The household food insecurity status of the participants were assessed using the Household Food
Insecurity Access Scale(Scale (HFIAS) developed by the Food and Nutrition Technical
Assistance project( FANTAproject (FANTA III3). It consisted nine questions regarding food
insecurity, with three possible responses including never, rarely, sometimes, or often and a total
score of 27. Each of the questions was asked using a 4-week recall period. First, the respondents
were asked an occurrence question about whether the condition in the question happened at all in
the past 4 weeks (yes or no). Then, if the respondent answers “yes” to the occurrence question, a
frequency-of-occurrence question was asked to determine whether the condition happened rarely
(once or twice), sometimes (3–10 times), or often (more than 10 times) during the preceding 4
weeks. Finally, the score was calculated and categorized into four categories: food secure, mild

28 | P a g e
food insecure access, moderately food insecure access status and severely food insecure access
status (84).

Functional status of the subjects was assessed using Katz index of Activity of Daily
Living(ADL) in six daily living functions of eating, dressing, bathing, transferring, continence,
and toileting, each of which is assigned a score of 1 or 0. Accordingly, patients was categorized
as independent (full function), partially dependent (moderate impairment), or dependent (severe
functional impairment) if they scored 6, 3–5, and 2 or less points, respectively (81).

Geriatric Depression scale (GDS), which is comprised of 15 items, was used to objectively
assess the psychological condition of older patients on admission. Each question in GDS has two
alternative responses, either yes or no, and the patients were categorized as having no
psychological problem (0–4), mild depression/dementia (5–9), or severe depression/dementia
(10–15) (79).

Wealth index: The wealth index was constructed by evaluating household assets, dwelling
characteristics, access to basic services, and agricultural and livestock holdings via the
Household Survey Questionnaire. Through principal components analysis (PCA), each item
received a weight or factor score, subsequently standardized to attain a mean of zero and a
standard deviation of one. These standardized scores were then used to categorize households
into five wealth quantiles of poorest, poor, medium, rich and richest (88).
Personnel
The team was comprised of two supervisors, four data collectors, and one principal investigator.
Data collectors and supervisors were selected carefully and they had good knowledge of the local
language.
Procedure
The data was collected at the hospital settings using a questionnaire by interviewing older adults
who are admitted to the hospitals. Before the data collection, the respondents were informed
about the purpose of the study. The data collectors give the consent paper to the respondents who
can read and write, and then they mark the response in the appropriate box with their signature.
For those who cannot read and write, the data collectors read the consent and provide them with

29 | P a g e
a place to put their signatures. After written consent was obtained and documented, the data
collection was carried out. To ensure confidentiality, personal identifiers such as names were not
used during data collection.

Anthropometric measurements: Weight measurement. The study participants were weighted a

using a digital scale SECA model 874(SECA GmbH & Co. KG, Hamburg, Germany). The scale
was calibrated for accuracy with the use of a known weight before each measuring session and
set at zero on a flat surface. The older adults were asked to stand on the scales upright and with
minimum clothing and no shoes. The weight measurements were read where the needle stopped
wobbling. This procedure of reading and recording the weight was repeated twice and the
average weight was recorded.
Height measurement: The study participant stood with his or her back against the measuring
board, heels, buttocks, shoulders, and head touching a flat, upright sliding headpiece. The
participants’ legs were placed together, making the knees and ankles touch each other. The
height was recorded to the nearest 0.1 cm.. For those who could not stand, Demi-span was
measured as the distance from the middle of the sternal notch to the tip of the middle finger in
the coronal plane and height is then calculated from a standard formula developed for Ethiopian
population (80);
Height=79.93+1.05(demi span) −6.12(sex);
Where;
sex=1 for females & 0 for males.

The mid upper arm circumference. The older adults were asked to bend their non-dominant arms
at the elbow at a right angle with the palm up. The distance between the acromial surface of the
scapula and the olecranon process of the elbow on the back of the arm was measured. The mid-
point between the two was marked with a pen. They asked to let their arms hang loosely by their
sides. Then the tape measure is positioned at the mid-point of the upper arm. Pinching was
avoided and the measurements were recorded to the nearest 0.1 centimeters.

The calf circumference. The calf circumference measurements were taken from the older adults
with the tape between the ankle and knee in a sitting position with the left leg. They asked to roll

30 | P a g e
up their trousers to uncover the calf. A measuring tape was wrapped around the calf at the widest
part and the measurement was noted to the nearest 0.1cm. The calf circumference measurements
were taken with their knees bent at a 90° angle.

Body Mass Index (BMI). Was calculated as body weight in kilograms divided by the square of
height in meters.

4.9. Data processing and Analysis

A training of one day was given to data collectors and supervisors. The weight scale was
validated by using standardized weight before the actual weighing of each study participant.
Moreover, the quality of the data was assured through careful translation and pretesting of the
questionnaires. During the data collection at the end of each day, the team supervisors reviewed
all questionnaires for completeness and inconsistency and ensured that missing information was
added while still in the hospital.

The collected data was were entered into EPI DATA version 4.7 and exported to SPSS version
27 for cleaning and analysis. The outcome variable undernutrition was categorized based on the
overall sum score of each subject by using the full MNA score (out of 30) and calculated using
the compute command in SPSS. Descriptive statistics were employed and the findings were
presented in the form of tables, charts, and graphs. The associations between dependent and
independent variables were assessed and their strength was presented using an adjusted odds
ratio at 95% confidence intervals.

Binary logistic regression was used to assess the association between outcome and explanatory
variables. Variables with a p-value<0.25 in a bivariable analysis were fitted into the
multivariable analysis to show the independent relationship between dependent and independent
variables. Both the crude odds ratio (COR) and the adjusted odds ratio (AOR) with the
corresponding 95% confidence interval (CI) were calculated to show the strength of the
association. A p-value of 0.05 was used to determine if the association was statistically
significant. The association between each categorical covariate and the outcome variable was

31 | P a g e
tested by using a chi-square test. A principal Component Analysis was done to construct the
household wealth index by asking all assets they have while Household food insecurity access
status was calculated using if and do commands in SPSS. The goodness of fit of the model was
checked by using the Hosmer and Lemeshow test with a p-value of .569.

4.10. Ethical Consideration

Ethical consideration
The study was conducted after obtaining ethical clearance from Mattu University, Research
Ethics Committee. A formal permission letter was obtained from MKCSH. Written consent was
also obtained from the study subjects prior to data collection. The confidentiality of the
information was respected throughout the data collection process. Information was given to
participants about the voluntary basis of participation. Furthermore, to ensure participants’
confidentiality, names or personal identifiers were not included in the written questionnaires.

5: RESULTS
5.1. Socio-demographic characters of elderly patients in MKCSH,2024.
In this particular study, a total of 307 respondents were investigated with response rate of 100 %.
The mean age of the participants was 75.11 years with standard deviation of 8.5 years, and most

of them (56.4%) were men and from rural residency (59.3%), and 39.7% of them are in the
lowest wealth quantiles Regarding religion, a total of 142 (46.3%) and 94(30.6%) were followers
of Islam and orthodox Christianity respectively. More over 27.4% of the subjects are above the
age of 85 years (Table 2).

Variables Category Frequency(n) Percentage (%)

Sex of the patient Male 173 56.4

Female 134 43.6

32 | P a g e
 Marital status Single 162 52.8
Married 145 47.2

Educational status No formal education 140 45.6

Formal education 167 54.4

Age category Young old 121 39.4

Middle old 102 33.2
Old old 84 27.4

Percentile group of Poorest 63 20.5

wealth Poor 59 19.2
Medium 60 19.5
Rich 62 20.2
Richest 63 20.5

Urban 125 40.3

Rural 182 59.7

Table 2. Sociodemographic characteristics of elderly patients treated at MKCSH, southwest

Ethiopia, July 2024.
Variables Category Frequency(n) Percentage (%)

Sex of the patient Male 173 56.4

Female 134 43.6

Marital status Single 162 52.8

Married 145 47.2

Educational status No formal education 140 45.6

Formal education 167 54.4

Age category Young old 121 39.4

Middle old 102 33.2
Old old 84 27.4

Percentile group of Poorest 63 20.5

wealth Wealth status Poor 59 19.2
Medium 60 19.5

33 | P a g e
 Rich 62 20.2
Richest 63 20.5

Urban 125 40.3

Residence Rural 182 59.7

5.2. Nutritional related, behavioral and clinical related factors of the study participants at
MKCSH,2024.
Majority (43.3%) of the study subjects have poor dietary diversity score while almost two-third
(64.2%) of them are moderately food insecure. Moreover, more thanmore than half of the study
subjects have history of hospitalization in previous one year (55.7%) while a little less than two-
thirds (63.5%) of the respondents have chronic comorbid diseases. On assessing the activities of
daily living using the Katz score, 68.1% of the participants had impairment in their functional
autonomy. Moreover, a total of 307 respondents were screened for their depression status, out of
this 118 (38.4%) of respondents were positive for geriatric depression, while more than half, 189
(61.6%) had no depression for the geriatric depression screening tool. (Table 3)
.
Table 3 Nutritional related, behavioral and clinical related factors of the study participants at
MKCSH,2024.

Variables Category Frequency(n) Percentage (%)

Dietary diversity Poor 133 43.3
score Medium 103 33.6
High 71 23.1
Household food Food secure 53 17.3
security access Mildly food insecure 46 15.0

34 | P a g e
 Moderately food 197 64.2
insecure
Severely food 11 3.6
insecure
Alcohol consumption Yes 48 15.6
No 259 84.4
Cigarette smoking Yes 34 11.1
No 273 88.9
Khat chewing history Yes 42 13.4
No 266 86.6
Functional autonomy Dependent 100 32.6
Partially dependent 109 35.5
Independent 98 31.9
Psychological Depressed 118 38.4
condition Not depressed 189 61.6
Presence of Yes 195 63.5
comorbidity No 112 36.5
Previous Yes 171 55.7
hospitalization No 136 44.3

5.3. Nutritional status of the study participants

The prevalence of undernutrition among hospitalized elderly patients (aged above 60 years), was
found to be 77.2% based on validated MNA screening tool.

5.4. Factors associated with undernutrition in elderly patients

In binary logistic regression, factors such as age group, sex, being rural, dietary diversity score,
depression, functional status, alcohol consumption, smoking, wealth index, comorbidity were
found to be associated with undernutrition.

In the multivariable logistic regression, being female [AOR (95% CI): 2.680(1.726,6.180)],
being 85 years or older [AOR (95% CI): 4.359(1.330,14.286)], residing in rural areas [AOR
(95% CI): 2.276(1.057,4.902)], having moderately food insecure access status [AOR (95% CI):
5.862(2.827,12.157)], a poor dietary diversity score [AOR (95% CI): 3.227(1.396,7.460)], being
depressed [AOR (95% CI): 4.110(1.727,9.777)], living with one or more chronic comorbid
diseases [AOR (95% CI): 2.628(1.283,5.384)], being dependent in activities of daily living
[AOR (95% CI): 2.866(1.066,7.704)], and being in the poorest wealth quantiles [AOR (95% CI):

35 | P a g e
 3.716(1.019,13.554)] were all significantly associated with increased likelihood of undernutrition
in elderly patients (Table4).

Table 4: Multivariable logistic regression analysis output of factors associated with

undernutrition among the older patients in MKCSH, South West, Ethiopia,2024.
Variable Undernutrition COR (95% CI) AOR (95% CI)
Yes No .
Age group 60-85 159(71.3%) 64 (28.7%) 1 1
>85 years 78(92.9%) 6 (7.1%) 5.233(2.171,12.610 4.359(1.330,14.286)**

Residency Urban 82 (65.6%) 43 (34.4%) 1 1

Rural 155(85.2%) 27(14.8%) 3.010(1.736,5.221) 2.276(1.057,4.902)*
Presence of comorbidity No 71(63.4%) 41(36.6%) 1 1
Yes 166(85.1%) 29 (14.9%) 3.305(1.906,5.734) 2.628(1.283,5.384)**
Sex Male 121(69.9%) 52(30.1%) 1 1
Female 116(86.6%) 18 (13.4%) 2.770(1.530,5.013) 2.680(1.726,6.180)***
Poorest wealth status No 183(73.8%) 65(26.2%) 1 1
Yes 54 (91.5%) 5 (8.5%) 5.469(1.911,15.649) 3.716(1.019,13.554)**
Low dietary diversity score No 120(69.0%) 54(31.0%) 1 1

36 | P a g e
 Yes 117(88.0%) 16(12.0%) 3.291(1.782,6.076) 3.227(1.396,7.460)***
Moderately food insecure No 61(55.5%) 49(44.5%) 1 1
Yes 176(89.3%) 21(10.7%) 6.732(3.738,12.125) 5.862(2.827,12.157)***
Dependent No 145(70.0%) 62(30.0%) 1 1
Yes 92(92.0%) 8(8.0%) 4.917(2.251,10.741 2.866(1.066,7.704)**
Depression No 130(68.8%) 59(31.2%) 1 1
Yes 107(90.7%) 11(9.3%) 4.415(2.208,8.825) 4.110(1.727,9.777)***
Smoking No 207(75.8%) 66(24,2%) 1
Yes 30(88.2%) 4(11.8) 2.391(.813,7.038) 2.280(.497,10.472)
Alcohol drinking No 203(78.4) 56(21.6%) 1 1
Yes 34(70.8%) 14(29.2%) .670(.336,1.335) .658(.259,2.217)
Khat chewing No 201(75.6) 65(24.4%) 1 1
Yes 36(87.8) 5(12.2%) 2.328(.877,6.181) 1.602(.443,5.792)

6. DISCUSSION

This study was intended to estimate the magnitude of undernutrition and identify the associated
factors of undernutrition among older patients in hospital setting. According to this, the overall
prevalence of undernutrition was found to be 77.2% (95% CI: 72.48--81.92). We found that
female sex, rural residency, Oldest Old age group, depression, dietary diversity score, household
food insecurity access status, impairment in activity of daily living, poorest wealth-status were
significantly associated with undernutrition.

The prevalence of undernutrition in this study was in line with studies done in Jimma zone
(77.8 %), Jimma university medical center (81%), and review of studies conducted in Asia (16%
to 78%) and is comparable with study conducted in Loreto (70%) (10,22,54,89) . However, it
was higher than the studies conducted in India (46.4%), Mexico (32.2), Netherlands (24.5),
Nigeria (25.3%), and China (48.19%) (36,56,58,61,67). This could be attributed to potential
differences in the study participants’ characteristics due to variation in a socio-economic status,

37 | P a g e
and low level of literacy. Evidence also shows that medical comorbidity, physical impairments
(90,91) affects nutritional status in elderly people which is also observed in our study.

This study revealed that undernutrition was higher among female elderlies than males. Females
were four times more likely to be undernourished than males. This is comparable to studies
conducted in Debre Markos, jimma, mettu towns of Ethiopia (10,43,68). The reason could be
that older females has higher likelihood to encounter adverse economic and social circumstances
in old age and continue to care for their families while receiving less care for themselves are
assumed to increase the risk of malnutrition in women. In addition to this, repeated pregnancies,
high workload, cultural beliefs, gender discrimination and low social freedom to access income-
generating activities may influence women’s nutritional status (92).

Age 85 years and above and between 75–84 years was found to be a significant factor of
undernutrition. This finding was similar to a study done in Debre Markos, Jimma, Ethiopia
(10,43). This could be because as age increases, body composition also changes, and there could
be a loss of fat and muscle which results in undernutrition. This is scientifically supported that as
age increases, the vulnerability to undernutrition also increases due to the natural aging process
accompanied by physiological and functional changes. Acute and chronic illness with poor
prognosis can impact nutritional status and cause inadequate nutrition resulting in undernutrition
(93,94).

Another important finding in this study was depression, which showed a significant association
with undernutrition among older adults. Not being involved actively in work would make them
less active and at risk for undernutrition. Depression could change eating behaviors and,
influences people’s appetite and food intake, which could lead to an increased risk of
undernutrition. This finding is supported by reports from womberma districts of west Gojjam
zone, Harergie, Ethiopia, which illustrated a significant relationship between depression and
undernutrition (42,95).

Food insecurity also increases the risk for malnutrition (48), which is also observed in our study
where older patients who were moderately food insecure had a nine-fold increased risk for

38 | P a g e
undernutrition as compared to their counterparts. This finding is consistent with other similar
studies (96,97). Another finding in this study was dietary diversity score, which showed
significant association with undernutrition among older adults, in which older patients with poor
dietary diversity score are with three-fold increased risk for undernutrition, which is also
supported by study in womberma district of Amhara region (42). However previous
hospitalization in one-year, alcohol consumption, and tobacco smoking was not found to be
associated with undernutrition in elderly patients.

6.2 Limitations
The cross-sectional nature of the survey makes it difficult for causal association cannot be
assessed; and a single 24-hour recall of dietary data might not reflect the usual intake of
participants to measure the dietary diversity score and could not also rule out the possibility of
response bias where some respondents may not actually answer some questions truthfully, which
may distort study results.

7. Conclusion and recommendations

7.1 Conclusion
The overall prevalence of undernutrition in the public hospitals of Ilu Aba bor zone was high and
factors including sex, rural residency, oldest-old age, food insecurity, low dietary diversity,
lowest wealth quantiles, and depression were significantly associated with undernutrition. The
government should give special attention and support to female older adults. Nutritional
supplementation, care and support should be given to oldest-old age groups, low socioeconomic
status and those with depression. Nutritional counseling programs should be strengthened to
improve dietary diversity. The community should utilize local existing food sources and increase
crop diversity to enhance dietary diversity.

39 | P a g e
 7.2 Recommendations
Based on the finding obtained the following recommendation were forwarded.

The hospital should implement gender-specific nutritional programs for female older
adults, alongside targeted support, supplements, and dietary counseling for the oldest-old
and patients with depression, while strengthening hospital-based nutritional counseling
and screening services.
The regional health bureau should incorporate older adults' nutrition into national surveys
like DHS, develop national guidelines to standardize hospital-based nutritional
interventions, and advocate for financial aid or food voucher programs for low-income
older adults.
Community & Agriculture Departments should promote local food production and crop
diversity to enhance dietary diversity, and organize community-based food banks for
vulnerable groups.

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