Elsevier

Nutrition

Volume 21, Issues 11–12, November–December 2005, Pages 1100-1106
Nutrition

Applied nutritional investigation
Geographical inequalities in nutrient status and risk of malnutrition among English people aged 65 y and older

https://doi.org/10.1016/j.nut.2005.03.005Get rights and content

Abstract

Objective

Geographical inequalities in health continue to be a problem within developed countries. This study investigated whether there were north-south geographical inequalities among older people living in England with respect to risk of protein-energy malnutrition and status of nutrients, particularly those derived from fruit and vegetables.

Methods

A secondary analysis of data collected prospectively by the National Diet and Nutrition Survey of people aged 65 y and older was undertaken to assess geographical prevalence of risk of protein-energy malnutrition (1155 subjects) and nutrient status (881 to 1046 subjects).

Results

A north-south gradient was found in risk of protein-energy malnutrition (19.4%, 12.3%, and 11.2% in the northern, central, and southern regions, respectively; P = 0.013, P for trend = 0.002). This was accompanied by a north-south gradient in the status of vitamin C (30, 38, and 46 μmol/L in the respective regions, P < 0.001), which was associated with deficiency (<11 μmol/L) in a third of subjects in the northern region, a range of carotenoids (P = 0.023 to <0.001), vitamin D (P < 0.001), and selenium (P < 0.001). These inequalities were accompanied by gradients in indices of health status and socioeconomic status, which could account only partly for the “geographical” inequalities. Circulating vitamin C and carotenoid concentrations were related to the intake of fruit and vegetables.

Conclusions

This study suggests there is a north-south divide in the risk of protein-energy malnutrition and a range of nutrients, which have been implicated in the development of common chronic diseases.

Introduction

Greater prosperity and improvements in health in the United Kingdom and other developed countries do not appear to have decreased inequalities in income, mortality, and outcome of disease [1], [2]. In the United Kingdom there is evidence that several inequalities between people and places have increased [1]. Further, the map of regional standardized mortality in England [3] still reflects its historical past, with lower life expectancy in the poorer industrial and rural northern areas of England than in the richer rural and suburban southern areas of England. However, it is surprising how little attention has been directed toward nutritional inequalities between geographical regions [4], given that nutrition has an important role to play in the development and financial cost of a variety of diseases or conditions, including ischemic heart disease, stroke, hypertension, obesity, and certain types of cancer [5].

A survey of nutritional status of people 65 y and older living in the United Kingdom [6] raised concern about the high frequency of some vitamin and other nutrient deficiencies among older people (10% to 30%), especially those due to inadequate consumption of fruit and vegetables, which have been implicated in the etiology of cardiovascular and malignant conditions [5], [6], [7]. In the European Union it has been estimated that low fruit and vegetable consumption contributes to 3.5% of the overall burden of disease [8]. Information about the geographical distribution of nutrient status and intake of fruit and vegetables may help identify and target regions that are at particular risk. An assessment of geographical distribution of protein-energy malnutrition [9] may also help target areas at particular risk, especially if they coincide with those that have poor nutrient status. Therefore, the primary aim of this study was to assess whether or not there is a major north-south divide in England with respect to protein-energy malnutrition and the status of individual nutrients, especially those related to fruit and vegetable consumption. A secondary aim was to assess the extent to which the “geographical” variation could be attributed to socioeconomic status.

Section snippets

Materials and methods

This study was based on a secondary analysis of data collected from the National Diet and Nutrition Survey of people 65 y and older [6]. Eighty areas were sampled within the United Kingdom after obtaining ethical approval from each local National Health Service ethics committee and consent from each subject. The subjects were living freely within the community or in residential accommodation [6]. Of the 2172 free-living subjects who were selected for the main survey (eligible sample), 75%

Results

Malnutrition risk was found to be greater in the northern region of England than in the central (58% higher) and southern (73% higher) regions (Table 1). The prevalence increased with age and was greater in institutionalized than in free-living subjects (Table 1). When adjusted for age, gender, and domicile, there was little change in the regional prevalence of malnutrition (medium + high risk), which remained greater in the northern region than in the rest of England (odds ratio 1.826, 95%

Discussion

This study involving people aged 65 y and older has shown that there is a strong north-south gradient in England (worse in the north) with respect to risk of protein-energy malnutrition and status of several nutrients that are mostly derived from fruit and vegetables. These generally affected vitamins and carotenoids rather than minerals or trace elements. The most striking nutrient inequalities between geographical regions related to carotenoids and vitamin C, which are antioxidant nutrients

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