Open access Original research

BMJ Open: first published as 10.1136/bmjopen-2022-062845 on 24 January 2023. Downloaded from http://bmjopen.bmj.com/ on September 30, 2023 by guest. Protected by copyright.
Undernutrition and associated factors
among older adults in Ethiopia:
systematic review and meta-­analysis
Hiwot Yisak ‍ ‍,1 Melkamu Aderajew Zemene ‍ ‍,1 Getachew Arage ‍ ‍,2,3
Agmasie Tigabu Demelash,4 Denekew Tenaw Anley ‍ ‍,1 Amien Ewunetei,5
Melkalem Mamuye Azanaw ‍ ‍1

To cite: Yisak H, Zemene MA, ABSTRACT

Arage G, et al. Undernutrition Objective Undernutrition contributes to decreased STRENGTHS AND LIMITATIONS OF THIS STUDY
and associated factors among physical and cognitive functional status, higher healthcare ⇒ The study was registered in PROSPERO.
older adults in Ethiopia: ⇒ The quality of each original study was assessed
consumption, premature institutionalisation and increased
systematic review and using the Newcastle Ottawa Scale, a three-­part ap-
mortality. So, the objective of this study was to determine
meta-­analysis. BMJ Open
the pooled prevalence and factors associated with proach, for observational studies quality assessment
2023;13:e062845. doi:10.1136/
bmjopen-2022-062845 undernutrition among older adults in Ethiopia. and the Grading of Recommendations, Assessment,
Design Systematic review and meta-­analysis was used. Development, and Evaluations checklist.
► Prepublication history for ⇒ Coming to the limitation only eight studies were eli-
Articles that presented original data on undernutrition
this paper is available online. gible for the study.
using body mass index (BMI) were included. We made
To view these files, please visit ⇒ The present systematic review was about observa-
an inclusive literature search from PubMed, Medline
the journal online (http://dx.doi.​
and Google Scholar. The I2 test was used to examine the tional studies, mainly cross-­sectional.
org/10.1136/bmjopen-2022-​
heterogeneity of the studies considered in this meta-­ ⇒ From the total included studies, only a few studies
062845).
analysis. Stata software V.14 and METANDI command were evaluated place of residence, dietary diversity and
Received 14 March 2022 used. meal frequency.
Accepted 13 January 2023 Setting Studies conducted in Ethiopia were included.
Participants Eight independent studies were eligible and
enrolled for final analysis.
Outcome Prevalence and determinants of undernutrition. over in 2015, with forecasts that this number
A selection of publications, data extraction and reported will nearly double to 22% (2 billion people)
© Author(s) (or their results for the review was designed according to the by 2050.1
employer(s)) 2023. Re-­use Preferred Reporting Items for Systematic Reviews and Chronic diseases and disabilities are
permitted under CC BY-­NC. No Meta-­Analyses (PRISMA) guidelines. becoming a public health challenge as the
commercial re-­use. See rights Results A total of eight unique studies were enrolled for
and permissions. Published by
world’s population ages, particularly in devel-
final analysis. The pooled prevalence of undernutrition was oping nations where the healthcare system is
BMJ.
20.53% (95% CI 17.39% to 23.67%). The study revealed
1
Department of Public Health, underdeveloped and resources are scarce.2
that males had lesser odds of being undernutrition
College of Health sciences,
with AOR 0.17 (95% CI 0.15 to 0.20). Older adults in
Furthermore, the older adult population in
Debre Tabor University, Debre developing countries is expanding at a faster
Tabor, Ethiopia
the age range of 65–74 years were less likely to be
2 undernourished as compared with those whose age rate than in developed countries.3 This rapid
Department of Pediatrics and
Child Health Nursing, Debre was above 85 years with Adjusted Odds Ratio (AOR) 022 demographic shift leaves these countries with
Tabor University, Debre Tabor, (95% CI 0.22 to 0.25). Older adults who were depressed insufficient time to construct their health,
Ethiopia had higher odds of undernutrition as compared with economic and social infrastructures to deal
3
Department of Nutrition and their counterparts with AOR 1.27 (95% CI 1.19 to 1.37). with the ageing population. Another issue
Dietetics, Jimma University However, older adults from households with poor wealth is that in developing countries, population
College of Public Health and indexes were two times more likely to be undernourished
Medical Sciences, Jimma, ageing is accompanied by persistent poverty.4
as compared with those who were from rich households.
Ethiopia Healthy diets and exercise are frequently
4 Conclusion The burden of undernutrition in Ethiopia is
Department of Adult Health
significant. The limitation of the current study was that emphasised in nutrition to reduce the chance
Nursing,College of Heath of acquiring lifestyle diseases such as cancer,
sciences, Debre Tabor University, all included studies were observational, mainly cross-­
Debre Tabor, Ethiopia sectional. diabetes and cardiovascular disease. However,
5
Department of as people get older, their nutritional objec-
pharmacy,College of Health tives shift to fulfilling greater nutrient needs
sciences, Debre Tabor University, INTRODUCTION while consuming less energy and preventing
Debre Tabor, Ethiopia
According to a factsheet released by the lean muscle loss.5 6
Correspondence to WHO, around 12% of the global population In older adults, undernutrition is a common
Hiwot Yisak; ​hyisak@​yahoo.​com (900 million people) was aged 60 years or and dangerous condition. Undernutrition

Yisak H, et al. BMJ Open 2023;13:e062845. doi:10.1136/bmjopen-2022-062845 1

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contributes significantly to morbidity and mortality in for the review was designed according to the Preferred
older adults today, without a doubt.7 Reporting Items for Systematic Reviews and Meta-­Analyses
The number of existing geriatric disorders had a (PRISMA guidelines. Throughout the comprehensive
positive association with the probability of undernutri- literature search, the following search terms were used:
tion. Poor nutritional status was linked to depression, ‘Undernutrition OR Nutritional Deficiency OR Undernu-
dementia, functional dependency and various comorbid- trition OR malnourishment OR undernourishment OR
ities.8 Undernutrition and poor nutritional status in the cachexia OR Low BMI OR nutritional status OR starvation
older population are major concerns. Undernutrition AND Aged OR Older adults OR older adults OR geriat-
and accidental weight loss contribute to health decline, rics OR advanced years AND Ethiopia’. Furthermore, we
decreased physical and cognitive functional status, higher checked the reference lists of published studies to iden-
healthcare consumption, premature institutionalisation tify additional articles. The identification and selection
and increased mortality.9 of the papers in all the researched databases were made
Weight loss in older persons is frequently accompanied independently by three researchers (HY, MAZ and ATD),
by a decrease in muscle mass, which can harm functional respecting the eligibility criteria and without the use of
status. The advancement to undernutrition is mostly filters. Then, the duplications between the databases were
treacherous and often unnoticed. Undernutrition in eliminated. Next, a refinement was performed to select
older people is linked to problems and early death.10 On studies regarding the theme addressed, by reading the
the other side, they are overweight and obese due to a titles and abstracts. In the event of disagreement between
lack of mobility and a sedentary lifestyle.11 the investigators, the study was re-­ evaluated, and the
In Ethiopia, there is an underlying respect for older doubts obtained in the process of applying the eligibility
people in Ethiopia where family and community support criteria were discussed until a consensus was reached
systems are relatively strong. However, a significant among the members.
number of older people have no family and community
support, mainly due to the death of relatives or separation
Eligibility criteria
caused by famine, war, disease and displacement and the
The eligibility criteria used were: articles that presented
weakening of family and community support structures.12
original data on prevalence and determinants of under-
In 1973, during the Imperial regime, almost 3 million
nutrition using body mass index (BMI) <18.5 among
Ethiopians were affected by food shortages, and total
older adults in Ethiopia. The study included all studies
excess mortality in the country hovered at around 250
done so far in Ethiopia. All available and eligible studies
000.13 Elderlies of the current study were below the age
were observational cross-­sectional studies. The selected
of 15 years during that time. Even though they were survi-
language of publication was English. We excluded studies
vors of the famine, the famine may have a consequence to
that used secondary data, reviews of reviews and those
their current nutritional status during old age.
studies that did not report the outcome of interest.
Undernutrition in older adults may be reduced if
the overall prevalence and determinant factors were
addressed. So, the objective of this study is to see the Selection and identification of studies
prevalence and determinants of undernutrition among All studies identified through different databases were
older adults in Ethiopia. There are many original types combined, exported and managed using COVIDENCE
of research on elderly undernutrition, and this system- software. All duplicated studies were removed, and the full
atic review and meta-­analysis evaluates and summarises text of the articles was searched manually using Endnote
the findings of all relevant individual studies in Ethiopia software. A total of 581 studies were identified from the
on elderly malnutrition, thereby making the available literature search. Of these studies, 13 articles of dupli-
evidence more accessible to decision makers. cate records were identified and removed. A total of 510
articles were excluded after reviewing the titles, and 47
articles were excluded after reviewing abstracts because
MATERIALS AND METHODS they were irrelevant. After assessing the full texts of the
Study protocol registration remaining 11 articles were left, three additional articles
The protocol in this study was registered in the Interna- were excluded because of the following: poor quality and
tional Prospective Register of Systematic Reviews (PROS- articles do not report outcome interest. Therefore, a total
PERO) database and can be accessed with a protocol of eight unique studies were eligible and enrolled for
number CRD42021254805. final analysis (figure 1).
The selected studies were: (1), Abate et al 2020 from
Search strategy Addis Ababa14; (2) Abdu et al, 2020 from Eastern Ethi-
We made an inclusive literature search conducted from opia15; (3) Legesse et al 2019 Aykel town, Ethiopia16; (4)
October 2021 to November 2021 from PubMed, Medline Wassie et al 2014 Northwest Ethiopia,17; (5)Wondiye et al
and Google Scholar, in parallel using search strings from Wolaita Sodo, Ethiopia,18; (6) Mezemir et al19 2020
adapted to the requirements of each database. A selec- from Debre Birhan Ethiopia; (7) Adhana et al 2019 from
tion of publications, data extraction and reported results Debre Markos20; and (8) Yisak et al 2021 from South

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Figure 1 Flow diagram depicting the selection process for articles included in this review and meta-­analysis.

Gondar Zone, Ethiopia.21 A detailed description of decrease the quality of the evidence, it is deducted from 1
selected studies is indicated in table 1. to 2 points, according to the magnitude of the factor. The
presence of factors that increase the quality of evidence
Evaluation of study quality
adds an initial score of 1–2 points. After the final sum,
The Grading of Recommendations, Assessment, Devel-
the studies were classified as low (<2 points) and good
opment, and Evaluations method was used to evaluate
quality (>2 points); we did not identify publication bias
the quality of studies included in the review. This instru-
ment assesses factors that may diminish (risk of bias, and selective reporting of studies. Studies with >2 points
inconsistency of results, inaccuracy, indirect evidence were included in the review.
and publication bias) or increase (magnitude of effect The quality of each original study was assessed using the
and decrease of confounders). Since all of the reviewed Newcastle Ottawa Scale, a three-­part approach, for obser-
articles are observational studies, the score starts with low vational studies quality assessment.22 The tool is made up
quality (2 points). Then, for each present factor that can of three main components. The methodological quality

Table 1 Summary of included studies to assess the prevalence and associated factors of undernutrition among older adults
in Ethiopia, 2021
Study Study Sample Response Prevalence Quality
S.no Author name year design Region size rate (%) (%) score
1 Abate et al 2020 CBCS Addis 682 97 26.6 8
Ababa
2 Abdu et al 2019 CBCS Harari 630 93.4 15.7 7
3 Legesse M, Abebe Z, 2018 CBCS Amhara 921 96.8 17.6 7
Woldie H
4 Wassie et al 2013 CBCS Amhara 757 100 21.9 7
5 Wondiye et al 2017 CBCS SNNP 578 95.8 17.1 8
6 Mezemir et al 2020 CBCS Amhara 347 98.3 21.2 6
7 ZK Adhana 2015 CBCS Amhara 423 100 22.7 8
8 Hiwot Yisak et al 2020 CBCS Amhara 300 96.6 27.6 6
prevalences of under nutrition
CBCS, community-­based cross-­sectional study; SNNP, Southern Nations Nationalities and People.

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of each article was the focus of the first component, authors. I2 test statistics of <50%, 50%–75% and >75%
which was rated on a scale of one to five stars. The study’s were declared as low, moderate and high heterogeneity,
comparability is evaluated in the second part, which has a respectively.23 Based on this, this study revealed that there
possible two-­star rating. The results and statistical analysis was no variation across studies (I2=0.00% and p<0.001).
of each original research were the emphases of the third The pooled prevalence of undernutrition (BMI less than
component, which was graded out of three stars. The two 18.5 kg/m2) among older adults in Ethiopia was 20.53%
reviewers’ disagreements were resolved through discus- (95% CI 17.39%, 23.67%) (figure 2).
sion. High-­quality articles were those rated on a scale of
6 out of 10. Associated factors of undernutrition among older adults
All eight studies were included in the analysis of asso-
Statistical analysis
ciated factors for undernutrition. Ten associated factors
By dividing the number of positive subjects in all studies
of undernutrition among older adults in Ethiopia were
by the total number of study participants, the prevalence
included in the analysis. The pooled OR ranges from
of undernutrition was estimated. The I2 test was used to
0.15 to 13.07. The studies included the meta-­ analysis
examine the heterogeneity of the studies considered in
effect model with a 95% CI. Heterogeneity was observed
this meta-­analysis. The degree of diversity in each research
among studies for sex, age and depression. Sex, age,
is referred to as heterogeneity. Based on the I2 value
depression status (which was assessed by geriatric depres-
less than 50%, 50%–75% and above >75%, the studies’
sion score) and wealth index were found to be statically
heterogeneity was characterised as low, moderate and
significant factors of undernutrition among older adults.
high, respectively. Stata software (V.14, STATA Corp) was
(table 2).
used to conduct the meta-­analysis; METANDI command
The study revealed that males had lesser odds of being
was used, and p<0.05 was regarded statistically significant.
undernutrition as compared with females with AOR 0.17
Patient and public involvement (95% CI 0.15 to 0.20). Older adults in the age range of
There is no public and patient involvement. 65–74 years (young-­old) were less likely to be undernutri-
tion as compared with those whose age was above 85 years
(old-­old) with AOR 022 (0.22 to 0.25). Older adults who
RESULTS were depressed had higher odds of undernutrition as
Prevalence of undernutrition among older adults compared with their counterparts with AOR 1.27 (1.19 to
In the estimation of the pooled prevalence of undernutri- 1.37). However, older adults from households with poor
tion, a total of 4628 older adults from eight studies were wealth index had two (AOR 1.90; 95% CI 1.08 to 3.32)
included. I2 test statistics were used to check the hetero- times more likely to be undernutrition as compared with
geneity of the studies after a detailed examination by the those who were from rich.

Figure 2 The pooled prevalence of undernutrition with its 95% CI among older adults in Ethiopia, 2021.

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Table 2 Summary of meta-­analysis for associated factors of undernutrition among older adults in Ethiopia, 2021

No. of Heterogeneity
S.no Factors studies AOR (95% CI) P value Q value P value I2 (%)
1 Sex (male) 5 0.17 (0.15 to 0.20) <0.001 116.35 <0.001 96.6
Sex (female) 1 1 1 1 1
2 Age (old-­old) (>85) 1 1 1 1 1
Young old (65-­74) 5 0.22 (0.20 to 0.25) <0.001 63.6 <0.001 92.1
Middle old (75-­84) 4 1.63 (0.78 to 3.40) 0.195 0.78 0.855 0.0
3 Depression (yes) 3 1.27 (1.19 to 1.37) <0.001 12.42 0.002 83.9
Depression (no) 1 1 1 1 1
4 Wealth index (rich) 1 1 1 1 1
Poor 5 1.90 (1.08 to 3.32 0.025 0.19 0.996 0.0
Middle 5 1.13 (0.77 to 1.66) 0.517 3.54 0.316 15.3
5 Marital status (not married) 3 1.79 (0.82 to 3.90) 0.143 0.43 0.807 0.0
Marital status (married) 1 1 1 1 1
6 Educational status (no 4 2.00 (0.98 to 4.05) 0.055 0.20 0.977 0.0
education)
Educational status (with 1 1 1 1 1
education)
7 Residence (rural) 2 2.10 (0.70 to 6.30) 0.183 0.06 0.807 0.0
Residence (urban) 1 1 1 1 1
8 DDS (good)
DDS (middle) 2 1.16 (0.79 to 1.69) 0.446 0.06 0.804 0.0
DDS (poor) 2 4.28 (0.43 to 13.07) 0.217 0.03 0.871 0.0
9 Meal frequency (≤2) 2 1.46 (0.82 to 2.56) 0.196 0.34 0.559 0.0
Meal frequency (>2) 1 1 1 1 1
10 Declined food intake (yes) 2 2.17 (0.44 to 10.66) 0.338 0.10 0.757 0.0
Declined food intake (no) 1 1 1 1 1
Young-­old=65–74 years, middle-­old=75–84 years, old-­old= ≥85 years.
factors associated with under nutrition
DDS, dietary diversity score; I2 (tau-­square), estimated variance of the observed effect size; Q-­value, implies study variability.

Publication bias in Ethiopia, older adults are suffering from many chal-
The presence of a small study effect was checked by using lenges including poverty, deteriorated health and ener-
funnel plots and Egger’s test from the log-­odds scale of vation, shrinkage of assets, financial hardship, rejection
the proportion for a better property of meta-­analysis of and scorn by youth, disrespect, abuse and limited social
a proportion. SE is dependent on the value of log odds services.25 It was predicted that the prevalence of under-
and the underlying proportion. Thus, a study in which weight in sub-­ Saharan Africa is expected to be up to
r(cases) out of n(sample size) patients were observed to 26
6%–48%. A systematic review in Africa found a lower
have an event, gives a proportion of r/n. The associated pooled prevalence of undernutrition, which was 19.9%,
log odds is ln(r/(n-­r)) with an SE of sqrt(1 /r+1/(n-­r)).24 which is comparable with the current study, but the prev-
Hence, the funnel plot showed asymmetric distribution, alence of the current study was lower than the Central
and the Egger’s test was 0.967; both results revealed that
African Republic (CAR) (33.4%).27 Another study from
there was no publication bias (figure 3).
the CAR and the Republic of Congo) reported that the
prevalence of undernutrition was 19.2%, which is compa-
DISCUSSION rable with the current result.28 A study from Nigeria found
The pooled prevalence of undernutrition from a total of a lower prevalence (7.8%).29
4628 older adults from eight studies among older adults The results of this study found that older adults who
in Ethiopia is 20.53% (95% CI 17.39% to 23.67%). This were depressed had higher odds of undernutrition as
indicates that undernutrition is a significant public health compared with their counterparts with AOR 1.27 (1.19 to
problem among older adults. This might be because, 1.37). This might be because depression leads to appetite

Yisak H, et al. BMJ Open 2023;13:e062845. doi:10.1136/bmjopen-2022-062845 5

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Figure 3 Funnel plot and Egger’s test to assess publication bias for undernutrition among older adults in Ethiopia,2021.

and weight changes that result in undernutrition, and The current study revealed that females had higher
poor nutrition predisposes old individuals to psychiatric odds of being undernutrition as compared with males with
upset (depression, agitation and irritability).30 A study AOR 5.88 (95% CI 5.00 to 6.66). This might be because, in
from Brazil on undernutrition and depression among Ethiopia, women, the old-­old, those lacking formal educa-
community-­dwelling older adult people found that nutri- tion and those with lower incomes reported significantly
tional deficit presented a significant association with lower quality of life in the physical, psychological and
depression (OR=4.38; 95% CI 2.23 to 8.64; p<0.001).31 social domains.36 A systematic review and meta-­analysis of
Similarly, a study from southern Brazil stated that depres- undernutrition and risk of undernutrition among older
sion was positively associated with the risk of undernutri- adults (≥60 years) in India reported that the prevalence
tion OR 2.4 (95% CI 0.79 to 7.38).32 A population-­based of undernutrition was higher among females (16.67%).37
study on the association between undernutrition and The multidimensional background of undernutrition
depression in older adult people in Razavi Khorasan also among rural older individuals in Bangladesh investigated
concluded that there is a significant statistical difference that the female gender (p<0.05) was independently asso-
between the prevalence of undernutrition in depressed ciated with poor nutritional status.38 Another systematic
and non-­ depressed individuals (p=0.047).33 Another review and meta-­analysis found a higher risk of undernu-
study that was conducted in Bangladesh found that being trition among females than males (OR=1.45 (95% CI 1.27
malnourished (OR: 4.05, 95% CI 2.79 to 5.87) and people to 1.66); p<0.00001).39
at risk of undernutrition (OR: 1.67, 95% CI 1.24 to 2.24) The current study found that older adults from house-
had a significantly higher risk of suffering from depres- holds with poor wealth index had two (AOR 1.90; 95% CI
sion.34 Similarly, a multicentre, cross-­sectional study from 1.08 to 3.32) times more likely to be undernutrition as
Turkey discovered that depression score (OR=95% CI compared with those who were from rich. This might be
1.104 to 3.051; p=0.02) was independently associated with because rich individuals use healthcare services, hygiene
undernutrition.35 and sanitation services in addition to having better access

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to balanced food as compared with the poor. By doing have agreed on the journal to which the article has been submitted and agree to be
this, the immediate cause of undernutrition (inadequate accountable for all aspects of the work.
dietary intake) can be averted. In agreement with this, Funding The authors did not receive any specific grant for this research
a systematic review and meta-­ analysis of observational Competing interests None declared.
studies on social and economic factors and undernutri- Patient and public involvement Patients and/or the public were not involved in
tion or the risk of undernutrition in older adults indi- the design, or conduct, or reporting, or dissemination plans of this research.
cated that low-­income level (OR: 2.69; 95% CI 2.35 to Patient consent for publication Not applicable.
3.08; p<0.001).40 Another study on social and economic Ethics approval Not applicable.
correlates of undernutrition in the Polish older adult Provenance and peer review Not commissioned; externally peer reviewed.
population indicated that self-­reported poverty was an
Data availability statement Data are available on reasonable request. In the
independent correlate of undernutrition.41 The assess- manuscript, all the data are available.
ment of the multidimensional background of under- Open access This is an open access article distributed in accordance with the
nutrition among rural older individuals in Bangladesh Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
reported that having no income (p<0.01), being illiterate permits others to distribute, remix, adapt, build upon this work non-­commercially,
(p<0.01) and not receiving regular financial support and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
(p<0.05) were also independently associated with poor is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
nutritional status.38
Additionally, a cross-­sectional survey in South Africa ORCID iDs
reported that a significantly higher percentage of partic- Hiwot Yisak http://orcid.org/0000-0003-2922-289X
Melkamu Aderajew Zemene http://orcid.org/0000-0003-1150-6333
ipants from the lower socioeconomic area were found to Getachew Arage http://orcid.org/0000-0003-4155-3237
be at risk of undernutrition than those from the higher Denekew Tenaw Anley http://orcid.org/0000-0002-5612-6943
socioeconomic area (74.2% vs 37.1%) (95% CI 19.8% to Melkalem Mamuye Azanaw http://orcid.org/0000-0002-2897-8903
51.4%). Participants from the higher socioeconomic area
consumed significantly more fluid and protein-­rich foods
than their counterparts.42
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