J Med Allied Sci 2019; 9(1):32-35 DOI: 10.5455/jmas.7814

Short Communication

High prevalence of malnutrition and anemia among elderly at old age homes in Kerala, India

B. A. Renjini1, Arun Raj2, V. K. Krishnendu2, Midhun Rajiv2, S. Divyamol3, P. S. Rakesh1


1Amrita Urban Health Centre, Department of Community Medicine & Public Health, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India.

2Department of Community Medicine & Public Health, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India.

3Department of Geriatrics, Amrita Institute of Medical Sciences, Amrita University, Kochi, Kerala, India.

Corresponding author: Dr. P. S. Rakesh, Assiatant Professor, Amrita Urban Health Centre, Department of Community Medicine & Public Health, Amrita Institute of Medical Sciences, Amrita University, Kochi-682041, Kerala, India.

Phone: +91-9495537333 Email: rakeshrenjini@gmail.com


There are limited data available regarding the problem of anemia and malnutrition in the elderly care homes in India. The current study analyzed comprehensive health check-up data of 104 elderly inmates belonging to five old age homes in Kochi city. Hemoglobin was estimated using HemoCue® Hb 201 System. Anemia status was decided as per WHO guidelines; less than 12 g/dl for women and less than 13 g/dl for men. Among them, 28.3% (13/46) of males and 20.7% (12/58) had Body Mass Index less than 18.5. Mean hemoglobin was 11.28 (SD 1.88, 95% CI 10.95-11.60) ranging from 6.2g/dl to 16.40g/dl. Prevalence of anemia was 73.9% (34/46) among males and 77.6% (45/58) among females (p 0.417).  Prevalence of malnutrition and anemia among elderly in old age home at Kochi were high and warrants urgent attention from the side of policy makers, primary health care providers, researchers and civil society.

Keywords: Anemia, Elderly, Malnutrition, Old age homes

Running title: Anemia among elderly at old age homes


Epidemiologic and demographic transition coupled with improvements in health has resulted in a steady increase in proportion of elderly [above 60 years] in India from 5.3 in 1951 to 8% in 20111. Kerala, a state in southern India, which has good indicators of health and social development, seems to be aging fast with proportion of elderly forming 12.6% of the total population2. The age structure has resulted in a new set of problems in the society with direct and indirect effects. As per official figures, there are 565 old-age homes in Kerala accommodating 10,500 persons.

Globally, anemia is the most common nutritional problem and one of the leading causes of disability3. Most common cause of anemia is iron deficiency. Anemia is common in older people4. While there are numerous studies conducted on anemia in other age groups, limited studies have been conducted to address anemia among the elderly in India. Majority of studies on anemia have been targeted toward children and pregnant women. Limited studies done among elderly in India have also shown the prevalence of anemia to be high in elderly5,6.

Malnutrition among elderly is imposing a huge challenge to the health sector as well as care providers. Amrita Urban Health Centre is involved in providing primary health care to the old age homes in Kochi Corporation as per the request from Corporation authorities. We conducted a comprehensive medical check-up including screening for malnutrition and anemia among the inmates of old age homes in Kochi corporation area during March 2018. Data pertaining to nutritional status and anemia among elderly people at old age homes in Kochi are presented here.

Materials and methods

Six old age homes were registered in Kochi Corporation under Social Justice department of Government of Kerala. The comprehensive screening program was done under stewardship of Kochi Municipal Corporation and with official support of District Social Justice Department. Medical team included lady medical officer, medical interns, social workers and field workers from Amrita School of Medicine.  Examination included general examination, filling a history cum clinical sheet, screening for diabetes using GRBS, hypertension screening, screening for chronic respiratory diseases, hemoglobin estimation and screening for TB for all inmates. 

Hemoglobin was estimated using HemoCue® Hb 201 System7. The HemoCue photometer has been widely used for estimation of hemoglobin in recent years because it is portable, requires only a small sample of capillary blood, is relatively simple to use, does not require electricity, and gives immediate, digitally displayed results. Hemoglobin determined by the HemoCue method is found to be comparable to the values determined by both the Cyanmethemoglobin and automated hematology analyser (Sysmex KX-21N) methods8-10.

The HemoCue instrument has inbuilt internal self-test that verifies the analyzer each time when it is turned on and every two hours after that. Quality Control has been made sure by testing the function of the HemoCue photometer on a daily basis by measuring the control cuvette (Serial no: 0214-003 071) and a standard of known concentration.

The data was entered in Microsoft Excel and was analyzed using SPSS 16 for Microsoft windows. Anemia status was decided as per WHO guidelines; less than 12 g/dl for women and less than 13 g/dl for men. Severe anemia was hemoglobin less than 8g/dl and moderate anemia was hemoglobin between 8.1 and 10g/dl11. Descriptive statistics including frequencies and percentages were done. The study has got approval from Institutional Ethics Committee.


157 inmates were examined. 24 of them were bedridden and so itself did not undergo the complete examination process. Age of 29 inmates was less than 60. Data of 104 inmates including 46 males and 58 females whose ages were more than 60 years were compiled.

Mean age was 71.5 years. 15 of them reported that they belonged to other states. 60 % were females.  Among them 27 (17.2%) had a diagnosed psychiatric illness and 05 (3.2%) had epilepsy. Chronic Respiratory Disease was present among 10.5% (11/104) and diabetes was present among 13.4% (14/104) inmates.

Mean hemoglobin was 11.28 (SD 1.88, 95% CI 10.95-11.60) ranging from 6.2 g/dl to 16.40 g/dl. Prevalence of anemia was 73.9% (34/46) among males and 77.6% (45/58) among females (p 0.417).  Hemoglobin status by severity of anemia was shown in Table 1. Most of the males had mild anemia while females had moderate anemia.

Table 1: Anemia status of the elderly individuals at old age homes (N=104)


Anemia status



Severe anemia

Moderate anemia

Mild anemia

No anemia



1 (2.2%)

4 (8.7%)

29 (63%)

12 (26.1%)



2 (3.4%)

19 (32.8%)

24 (41.4%)

13 (22.4%)



3 (2.9%)

23 (22.1%)

53 (51%)

25 (24%)


Chi square: 9.36, p=0.024

Table 2: Distribution of Body Mass Index of elderly individuals at old age homes (N=104)


Body Mass Index (kg/m2)






13 (28.2%)

26 (56.5%)

7 (15.2%)



12 (20.6%)

37 (63.7%)

9 (15.5%)







Chi square: 1.02, p=0.598

Among them, 28.3% (13/46) of males and 20.7% (12/58) had Body Mass Index less than 18.5. However, no association between gender and BMI could be obtained. Details were shown in Table 2. BMI and hemoglobin status did not show any statistically significant correlation (r 0.16 p 0.091).


This demographic change has obvious implications for family and society. It may impact definitely on healthcare provision; as longer life does not necessarily equate to more years of good health. It is important to highlight common medical problems in elderly people, especially if their burden and negative impact are not generally recognized. The current data suggest that malnutrition and anemia are alarmingly high in old age homes in Kochi.

Malnutrition can lead to decline in immunity making an individual vulnerable to infections, delayed wound healing, and muscle weakness, which can lead to falls and fractures. Nutritional status of the elderly may further deteriorate as malnutrition itself can lead to further disinterest in eating. Malnutrition at older age group is multifactorial and determined by various social, physiological, and psychological changes that occur with aging, social isolation, financial instability and food insecurity. However, malnutrition in older individuals is still not recognized, leading to deprived nutrition, long periods of hospitalization, increased cost of health care and morbidity and diminished quality of life. Although we have many policies made for the elderly like National Policy for Older persons 1999, Maintenance and Welfare of Parents and Senior Citizens Act, 2007, National Programme for Health care of the Elderly, 2010 and National Policy for Senior Citizens, 2011, none of these legislations have not well addressed the nutritional needs of the elderly.

Anemia is a major risk factor that is associated with a variety of adverse outcomes in elderly, including hospitalization, disability, and mortality12-14. In general, hemoglobin levels are lower in elderly than in younger people. It is not clear whether this fall in hemoglobin in elderly is a feature of normal ageing, or whether it is always pathological, even in absence of underlying conditions. There has been debate about the use cut of values and whether the current cut off values should be used to define anemia in elderly, but there is no acceptable alternative definition of anemia in this age group.

Prevalence of undernutrition in elderly at old age homes in our study was more than those obtained from the community-based studies from urban areas of Coimbatore (19%), rural Vellore (14%) and Assam (15%)15-17. A community based study from Kerala reported the prevalence of undernutrition among elderly as only 11%18. Our results are consistent with studies done at old age homes supporting the observation that malnutrition is more common at old age homes19. The differences might also be due to the methodology as most of the studies have assessed malnutrition not based on Body Mass Index. In the presence of edema or ascites, which is common among the elderly, BMI alone may not provide a good assessment of malnutrition20. Also due of vertebral compression, changes in the posture and weakening of muscle tome, measurement of height may be challenging in elderly21.

Data on malnutrition among elderly living in institutions like old age homes is crucial to provide importance to as the number of elderly in old age homes is increasing more frequently than before. The need for obtaining the data mainly is to determine the extent to which this issue has currently become a burden to our population as well as to determine the need of more effective nutritional care policies and health services to be undertaken for this population in terms of old age homes. This will improve the outcome by avoiding progressive degradation of the nutritional status of such individuals besides providing them with a continuum of care.

The current study compiled the data from a comprehensive health check up and did not look at the factors associated with anemia among them. Bedridden patients were excluded; however including them will only increase the prevalence of malnutrition and anemia. Sub group analysis could not be performed due to lower sample size. Whether generalisable to all old age homes in Kerala could not be stated. Despite these limitations the findings have got greater public health significance. Directions for future research includes answering i) to what extent anemia in the elderly is the result of pre-existing disorders, ii) to what extent it predetermines potential subsequent morbidity, and iii) to what extent public health interventions could make a change

To summarize, prevalence of malnutrition and anemia was alarmingly higher among elderly at the old age homes in Kochi city. Malnutrition and anemia among elderly in old age home needs urgent attention from the side of policy makers, primary health care providers, researchers and civil society.

Acknowledgments: None

Conflict of interest: None


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