J Nutr Health Aging

Volume 19, Number 4, 2015

SOCIAL AND ECONOMIC CORRELATES OF MALNUTRITION IN POLISH

ELDERLY POPULATION: THE RESULTS OF POLSENIOR STUDY
R. KRZYMIŃSKA-SIEMASZKO1, M. MOSSAKOWSKA2, A. SKALSKA3, A. KLICH-RĄCZKA3,
S. TOBIS4, A. SZYBALSKA2, M. CYLKOWSKA-NOWAK5, M. OLSZANECKA-GLINIANOWICZ6,
J. CHUDEK6, K. WIECZOROWSKA-TOBIS1
1. Department of Palliative Medicine, Poznan University of Medical Sciences, Poland; 2. International Institute of Molecular and Cell Biology in Warsaw, Poland; 3. Department of
Internal Medicine and Gerontology, Jagiellonian University Medical College, Krakow, Poland; 4. Home Hospice, Poznan, Poland; 5. Laboratory for Occupational Therapy, Department
of Geriatric Medicine and Gerontology, Poznan University of Medical Sciences, Poland; 6. Department of Pathophysiology, Medical University of Silesia in Katowice, Katowice, Poland.
Corresponding author: Roma Krzymińska-Siemaszko, Department of Palliative Medicine, Poznan University of Medical Sciences, os. Rusa 25a, Poznan, Poland,
Phone/fax: +48 618738303, e-mail: romakrzyminska@interia.pl

Abstract: Objectives: The aim of this study was to evaluate the prevalence of malnutrition in Polish elderly
population and analyse its social and economic correlates based on the data from the PolSenior project, the
first large-scale study of a representative group of Polish seniors. Design: A cross-sectional population-based
study. Setting: All territorial provinces in Poland. Participants: 4482 community-dwelling respondents aged 65
years or above (women: n=2142, age=79.0±8.4 years; men: n=2340, age= 78.3±8.6 years). Measurements: The
nutritional status of participants was assessed through the Mini Nutritional Assessment Short Form (the revised
MNA-SF). Out of social and economic correlates we evaluated age, sex, level of education, marital status, place
of residence, living conditions and economic status. Economic status of the respondents was determined on the
basis of questions on how well they could manage their own budgets. Those who could afford only the cheapest
food or clothes were considered the group of self-reported poverty. Results: Frequency of malnutrition in the
PolSenior population accounted for 7.5% (in 5.0% men and 9.0% women; p<0.001). The risk of malnutrition
was present in 38.9% (33.3% men and 42.4% women; p<0.001). In our study female sex, older age, unmarried
status, living in a rural area and self-reported poverty were independent correlates of malnutrition. Conclusions:
Our data showed high prevalence of malnutrition and the risk of its development among the community-dwelling
elderly people in Poland. Screening with MNA-SF should focus in particular on unmarried, poorly educated
individuals, in late old age, living in rural areas and self-reporting a poor financial state, especially women.

Key words: Malnutrition, MNA-SF, socio-economic status, elderly.

Introduction age and thus single indicators (such as albumin concentration

Demographic data show a steady increase in the percentage
of elderly in the entire population. These tendencies are
also observed in Poland. According to the Eurostat data for
2011, seniors accounted for 13.6% of the Polish population, a
percentage which is forecast to almost double in 2030, reaching
23.8%. It is estimated that, out of all EU member states, this
process will be the fastest in Poland (1, 2).
In elderly individuals proper nutritional status is one of
the major correlates of health, independence and quality
of life (3-5). In contrast, malnutrition leads to progressive
disability, as well as to the increased risk of dependency
and institutionalisation (4, 6, 7). Additionally, malnourished
subjects are hospitalized for a longer time and the cost of their
treatment is higher (6, 8).
The risk of malnutrition increases with age. It is estimated
that the problem concerns 5-20% of elderly Europeans
and its occurrence is significantly more pronounced in
hospitalised subjects as well as those in long-term care (9, 10).
Nevertheless, malnutrition in old age is often not diagnosed
and thus not treated. It is therefore important to use screening
tools to assess the risk of malnutrition in order to increase the
possibility of early treatment (10, 11).
There are many factors contributing to malnutrition in old
Received April 11, 2014
Accepted for publication June 12, 2014
397
or BMI) are not reliable enough to diagnose it. It is thus
recommended, e.g. by The American Society for Parenteral
and Enteral Nutrition (A.S.P.E.N), The European Society
for Clinical Nutrition and Metabolism (ESPEN) and The
International Academy of Nutrition and Aging (IANA),
to use the Mini Nutritional Assessment (MNA) to identify
malnourished individuals. Also in Europe this questionnaire
is considered the best screening test for the assessment of
nutritional status in geriatric medicine, because of its high
sensitivity and specificity (12, 13). Over the last two decades
the questionnaire has been modified three times (14, 15) and is
currently available in 24 language versions (16).
In elderly individuals malnutrition may be caused by a wide
range of factors. These are most often complex with no single
key factor to identify (17). Polypathology and polypharmacy
are among them. However, the impact of low socio-economic
status is also highlighted in literature. Social isolation (resulting
from death of the spouse and ensuing depression) is conducive
to malnutrition (18, 19). A poor financial situation makes
food of good quality unaffordable and elderly individuals are
often forced to choose between buying food or medicine. Poor
education correlates with lack of knowledge about nutrition
and unsatisfactory dietary choices and behaviours. This, in
turn, may lead first to qualitative and then also to quantitative
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malnutrition (20, 21).
The epidemiology of malnutrition in the elderly has been
intensely studied in various environments. There are, however,
no published papers based on representative groups in any
European country that allow general conclusions applicable
to entire populations. The aim of this paper is to present the
epidemiology of malnutrition in Polish elderly population and
analyse its social and economic correlates based on the data
from the PolSenior project, the first nation-wide study of a
representative group of Polish seniors.
Methods
PolSenior was a nation-wide multidisciplinary research
project, conducted in 2007-2012, to assess medical,
psychological, social and economic aspects of ageing in
Poland. The aim of the project was to define the status of
elderly subjects as well as their social and medical needs. The
outcomes were expected to facilitate the establishment of care
needed for the increasing number of elderly individuals. The
study protocol was approved by the Bioethics Committee
of The Medical University of Silesia. Informed consent was
obtained from each respondent or their caregiver prior to the
study (22).
There were 4979 people involved in the project (2412
women and 2567 men) aged 65 years and older. Sample size
was calculated assuming assessment of traits that occur with
the prevalence of at least 5% within the elderly population,
with 0.6% error and 10% lower recruitment. The subjects
were selected through multi-stage draw, planned so as to
obtain a representative group for Poland. The selection was
performed independently in six 5-year age cohorts: 65-69
years (n=759), 70-74 years (n=882), 75-79 years (n=795),
80-84 years (n=726), 85-89 years (n=746), 90 years and above
(n=574). A detailed description of the study design has already
been presented (22). The analysis of malnutrition based on Mini
Nutritional Assessment Short-Form (the revised MNA-SF) (23)
included 4482 subjects (2142 women and 2340 men).
Excluded because of incomplete data were 497 subjects
(10.0% of PolSenior population). Most of them (342
respondents) were excluded due to the inability to maintain the
upright position which was necessary to measure their body
mass and height and thus calculate Body Mass Index (BMI).
The percentage of excluded individuals increased across the
5-year age cohorts: 2.9%, 4.4%, 5.8%, 8.2%, 14.4% and 25.0%,
respectively.
The Mini Nutritional Assessment - Short Form (MNA-SF)
is composed of 6 questions and evaluates decrease in food
intake, weight loss, mobility, psychological stress or acute
disease, neuropsychological problems (dementia or depression)
and BMI. The nutritional condition of the respondents was
classified into three categories based on Kaiser et al (15):
normal nutritional status (12-14 points), risk of malnutrition
(8-11 points) and malnutrition (≤7 points).
398
Cognitive status was assessed with the Mini-Mental State
Examination (MMSE) (24). The test was not performed with
entirely deaf or mute respondents (n=59) or those with an
inability to engage in logical verbal contact (n=219). A result
of 24-30 points meant that there was no dementia. Results of
20-23 points were classified as mild dementia, 10-19 points as
moderate dementia and 0-9 points as severe dementia.
The risk of depression was assessed by means of a short
version of the Geriatric Depression Scale (GDS), composed of
15 questions. GDS was performed only for those respondents
who obtained at least 70% of all possible points in MMSE
(n=3984), thus excluding persons with cognitive impairments
(who might not fully understand the questions). Subjects with at
least 6 points in the GDS scale were classified as belonging to
the group with symptoms of depression (25).
Statistical analysis
Statistical analysis was performed with STATISTICA 10.0
software (StatSoft, Poland). For analysed parameters mean
values and standard deviations were calculated. Normality in
the distribution of variables was assessed with the Shapiro-Wilk
test. Comparison between two unpaired groups was made with
the Mann-Whitney test, and the Kruskal-Wallis test for more
than two groups. In the case of significant differences between
studied variables detected by the Kruskal-Wallis test, a post hoc
Dunn test was performed. Statistical significance of differences
in the distribution of quality variables between two or more
groups was analysed with the χ2 test.
To assess simultaneous interdependence between many
variables, multiple regression (logistic regression) was used,
specifying the odds ratio and the confidence interval with the
confidence limit of 95%. P<0.05 was considered as statistically
significant.
The sample was intended to include the same number of
men and women in all age cohorts. It thus allowed for precise
assessment of studied factors in the oldest groups; on the other
hand, compared to the population structure, older groups and
men were overrepresented. Consequently, in order to make the
sample representative of the Polish population and assure that
the results reflected the distribution of studied characteristics
(including malnutrition and the risk of its occurrence) in the
entire population of elderly people in Poland, post-stratification
was necessary (22).
Results
Of the 4482 respondents with a mean age of 78.7±8.5
years (range: 65-104 years), 47.8% were women. Almost
half of respondents were unmarried (1456 women and 676
men), including widows/widowers (n= 1921), those who were
divorced or separated from their spouses (n=93), as well as
those never married (n=118). An education level lower than
primary was declared by 12.9% of the individuals. 60.8%
of the respondents lived in urban areas. Over one fifth of all
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Table 1
Social and economic characteristics of the Polish elderly population by gender (base rate: % of line)

Variable Total % (n) Males % (n) Females % (n) p

Age
65-69 years 16.93 (759) 47.43 (360) 52.57 (399) p<0.05
70-74 years 19.68 (882) 51.93 (458) 48.07 (424)
75-79 years 17.74 (795) 52.58 (418) 47.42 (377)
80-84 years 16.20 (726) 53.17 (386) 46.83 (340)
85-89 years 16.64 (746) 55.76 (416) 44.24 (330)
90 and over 12.81 (574) 52.61 (302) 47.39 (272)
Marital status
Unmarried 49.14 (2132) 31.71 (676) 68.29 (1456) p<0.001
Married 50.86 (2207) 72.36 (1597) 27.64 (610)
Level of education
Less than primary 12.92 (561) 42.07 (236) 57.93 (325) p<0.001
At least primary 87.08 (3782) 53.97 (2041) 46.03 (1741)
Place of residence
Rural areas 39.20 (1757) 50.77 (892) 49.23 (865) ns
City 60.80 (2725) 53.14 (1448) 46.86 (1277)
Living conditions
Living alone 21.98 (947) 34.74 (329) 65.26 (618) p<0.001
Living with others 78.02 (3362) 57.32 (1927) 42.68 (1435)
Self-reported poverty
Yes 11.55 (468) 41.67 (195) 58.33 (273) p<0.001
No 88.45 (3583) 54.17 (1941) 45.83 (1642)

p represents the difference between males and females

respondents lived alone. 11.6% of all studied subjects declared malnutrition (16.5% vs. 9.6%; p<0.001).
that they could afford buying only the cheapest food/clothing or
not even that, which was considered as self-reported poverty. Figure 1
Table 1 shows the social and economic characteristics of the The prevalence of malnutrition in the Polish elderly population,
studied group. including age and sex
According to the MNA-SF, 7.5 % respondents (5.0% men
and 9.0% women; p<0.001) were malnourished and 38.9%
were at risk of malnutrition (33.3% men and 42.4% women;
p<0.001). Data including age and sex are presented in figure 1.
Table 2 shows the impact of social and economic parameters
on the prevalence of malnutrition. Women were twice as
likely to be malnourished as men (14.7% vs. 8.6%; p<0.001).
Age had a strong impact on the frequency of malnutrition.
In subjects from the oldest cohort malnutrition was detected
4 times more frequently than in those in the youngest one
(age 90+: 24.7%; age 65-69: 5.8%; p<0.001). Married
individuals were less frequently malnourished compared to
single ones (6.6% vs. 16.1%; p<0.001). Subjects who had
lower than primary education level were malnourished 2 times
more frequently than those with at least primary education
level (20.7% vs. 9.8%; p<0.001). Malnutrition was more Multiple regression analysis
frequent among respondents living in rural areas (12.6% vs. All factors increasing the risk of malnutrition in univariable
10.8%; p<0.05). In addition, those who were living alone analysis were included in the multiple regression model (age,
had significantly higher rate of malnutrition in comparison sex, level of education, marital status, place of residence,
with those living with families (12.6% vs. 10.8%; p<0.05). living conditions and economic status). The model established
Self-reported poverty also correlated with higher risk of the following independent correlates of malnutrition: female

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Table 2
The prevalence of malnutrition and its risk in the Polish elderly population including social and economic parameters (base rate:
% of line)

Variable Malnutrition % (n) Risk of malnutrition % (n) p

Sex
Females 14.71 (315) 46.87(1004) p<0.001
Males 8.63 (202) 38.72 (906)
Age
65-69 years 5.80 (44) 32.80 (249) p<0.05
70-74 years 4.65 (41) 34.47 (304)
75-79 years 9.43 (75) 40.63 (323)
80-84 years 10.06 (73) 47.93 (348)
85-89 years 19.03 (142) 48.66 (363)
90 and over 24.74 (142) 56.27 (323)
Marital status
Unmarried 16.14 (344) 47.56 (1014) p<0.001
Married 6.57 (145) 37.79 (834)
Level of education
Less than primary 20.68 (116) 55.26 (310) p<0.001
At least primary 9.84 (372) 40.69 (1539)
Place of residence
Rural areas 12.64 (222) 43.94 (772) ns
City 10.83 (295) 41.76 (1138)
Living conditions
Living alone 12.57 (119) 44.77 (424) p<0.001
Living with others 10.80 (363) 41.82 (1406)
Self-reported poverty
Yes 16.45 (77) 47.44 (222) p<0.001
No 9.57 (343) 41.53 (1488)

p represents the difference between males and females

sex (OR =1.51, 95% Cl 1.19-1.92, p<0.01), age (for every
10 years)(OR=2.18, 95% Cl 1.90-2.51, p<0.01), unmarried
status (OR=1.50, 95% Cl 1.16-1.95, p<0.01), living in rural
areas (OR=1.27, 95% Cl 1.02-1.56, p=0.02), and self-reported
poverty (OR= 1.72, 95% Cl 1.38-2.14, p<0.01).
Discussion
The paper presents the epidemiology of malnutrition in the
population of the elderly in Poland and its correlates. To the
authors’ best knowledge no similar nationwide data from other
countries has ever been presented.
The prevalence of low nutritional status (malnutrition:
7.5% and risk of malnutrition: 38.9%) was rather high in our
study. De La Montana et al., who assessed the nutritional
status of 728 community-dwelling elderly aged 80.7±7.4 years,
living in northwestern Spain, identified by means of MNA-SF
malnutrition and risk of malnutrition even more frequently
(12.4% and 46.8% respectively) (9). Similar results were
obtained by Hirose et al., who evaluated the nutritional status
using the same tool in 511 community-dwelling elderly in
Japan, aged 65 years and over (mean age 81.2±7.9 years). That
study showed malnutrition: 16.2% and, risk of malnutrition:
50.5% among its subjects (26). Also Kiesswetter et al., in a
study of 309 elderly (mean age 80.9±7.9 years) from three
large German cities (Bonn, Nuremberg and Paderborn), have
classified 14.9% of all participants as malnourished and 41.1%
as being at risk of malnutrition according to the MNA-SF (27).
In all three papers cited above the included subjects were older
than those studied in our project and, as we showed, old age is
an important risk factor for malnutrition. Moreover, subjects
analysed in cited papers were not chosen randomly, so that the
results should not be extrapolated into other groups of elderly
individuals.
On the other hand, in a southern Norwegian study with
MNA-SF (2106 individuals, mean age 74.5 ± 6.9 years)
Sőderhamn et al. detected malnutrition in only 1.7% of
respondents and its risk in 11.8%. The studied group was
randomly selected in a sample of 6033 home-dwelling older
people living in five counties in southern Norway (28). In
turn, Nykänen et al., in an analysis on a randomly selected
sample (n=696) of persons aged ≥75 years from Finland (mean
age 81±4.6 years), recognized malnutrition only in 7 patients
(1.0%) and the risk in 15.2% of studied participants (29). The
differences may be at least partially related to different life
style of community-dwelling Scandinavian elderly, e.g. more

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physical activity - and thus better nourished - or having higher
living standards. It should, however, be emphasised that
both Scandinavian studies included individuals living in cities
only. In the Polish population the frequency of malnutrition
was significantly higher in rural than in urban areas. If the
Norwegian and Finnish studies included also subjects living
in rural areas, one might speculate that the frequency of poor
nutritional status in the entire populations would have been also
at least a bit higher.
It is frequently stressed in the literature that social and
economic factors are important correlates of malnutrition. In
our study, multi-regression analysis showed that the risk of
malnutrition increases more than twice with every extra 10
years of age. The differences may be even more pronounced as
data for the oldest age groups was more likely incomplete, due
to the inability to assess the anthropometric parameters required
to calculate the BMI. The increased frequency of malnutrition
with age has also been mentioned by other authors (6, 18). It is
commonly believed that the worsening of the nutritional status
with age is at least partially related to increasing comorbidity
and polypharmacy in older individuals.
Female sex is another factor related to malnutrition (9, 18)
In our study, females were 1.5 times more prone to develop
malnutrition. Based on Gustafsson and Sidenvall, one may
speculate that it results from losing their partners sooner and
more often than males do. Afterwards females most often
manage a single-person household, the financial situation of
which is relatively worse (30). However, it must be underlined
that the female sex remained a significant factor in malnutrition
after controlling for all other correlates.
In our study multiple regression analysis also showed that
being unmarried is related to a 1.5 higher risk of malnutrition.
Other authors observed a similar correlation. Using the full
version of the MNA questionnaire, Pereira Machado et al.
studied 344 elderly people in institutional care in Rio de
Janiero, Brazil, age 75.4±9.4 years. This study showed that
people living in a relationship did not suffer from malnutrition
at all. On the other hand, 9.1% of single dwellers were
malnourished (31). Timpini et al. showed in an Italian study
that unmarried women and unmarried men were twice as prone
to be at risk of malnutrition than those who were married
(18). A very similar difference was shown by Kabugari et al.
when assessing the nutritional status of 130 elderly Japanese
(76.6±6.3 years) (32). It is believed that being married at a
later stage in life is related to better physical and mental health.
Schone et al. showed that marriage has a positive influence on
health-related behaviour in the elderly and thus widows and
widowers were more exposed to increased risk of morbidity
and mortality (33).
Living in a rural areas also proved to be an independent
factor contributing to malnutrition. Iranian data point
to differences in nutritional status between rural and urban
dwellers, underlining that these may be due to different
nutritional patterns and income levels (34, 35). The authors are
401
not familiar with any similar data (concerning both rural and
urban areas) from other countries.
Our study shows that the incidence of malnutrition was
higher in elderly people with self-reported poverty. Other
authors (18, 36) have also highlighted the problem of the
growing risk of malnutrition in individuals with low income.
It may result from buying the cheapest food of low quality in
insufficient quantity and so contribute to malnutrition. The
number of respondents who reported good financial status in
our study was higher than expected. Only 11.6% of respondents
described their financial position as poor. It is believed that this
may be the result of a common tendency in this age group to
consciously limit one’s needs in old age and concentrate only
on what is really necessary. The other needs which cannot be
met given current financial limitations, are not identified at all
and consequently no actions are taken to satisfy them (37).
Our study has some limitations. We used the shortened
version of the MNA scale (the revised MNA-SF of 2009)
instead of its full version in the PolSenior project. We decided
in its favour as it is a screening tool allowing for a quick
identification of elderly people who are malnourished or whose
risk of malnutrition is increased. The shortened questionnaire
requires less time than the full version of the scale to complete
the screening, which is advantageous, especially in studies
of elderly population. High sensitivity and specificity of the
MNA-SF scale, as well as its good correlation with the full
version, have been confirmed in many clinical studies [9,14].
It should be emphasized that the MNA-SF scale has also been
validated in community-dwelling elderly in Poland by Kostka
et al. (38).
The obtained frequencies of risk of malnutrition and
malnutrition itself in the PolSenior project increased with age.
Due to incomplete data 10.0% of the PolSenior population was
excluded: as little as 2.9% of the younger age cohort and up
to 25.0% of the oldest one (mainly because of the inability to
maintain the upright position, which was the main obstacle in
collecting height and body mass data). Consequently, one can
speculate that the analysed problems are in real life even more
pronounced in the oldest age cohorts.
Conclusions
Based on the MNA-SF scale, malnutrition was detected
in every fourteenth person in the group of people above
65 years of age which was representative of the Polish
population; however, risk of malnutrition was present in almost
every second individual. Considerably high prevalence of
malnutrition and the risk of its occurrence in the Polish elderly
population indicates that there is a need for screening tests that
diagnose this nutritional disorder in primary care. Particular
attention (e.g. performing regular screening) should be paid
to unmarried, poorly educated individuals, in late old age,
living in rural areas and self-reporting a poor financial state,
especially women.
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Acknowledgements: Implemented under publicly-funded project No. PBZ-
MEIN-9/2/2006, Ministry of Science and Higher Education.
Conflict of interest: not declared.
Etical standards: Study protocol approved by Bioethics Committee of the Medical
University of Silesia in Katowice.
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