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and function, despite the well-established relation w ith morbidity and mortality. Cross- sectional studies from the US and C anada have shown that even in old age, income is associated w ith function throughout th e full gradient o f income and remained significant after controlling for other socio-econom ic and socio-demographic variables (Forbes et al, 1991, Berkm an & Gurland, 1998). Jensen et al (1997) identified amongst others low income and depression as significant predictors o f functional limitation. In a Swedish dietary study the proportion with 'inadequate dietary habits' -as defined by the study- increased in groups o f progressively low er social status, social participation and physical activity (Steen et aL 1991).

The independent role o f socio-econom ic factors in function was also illustrated by longitudinal studies. A sue year prospective American study identified predictors o f successful ageing which was defined a s needing no assistance in ADL, IADL, mobility and physical performance measures. A fter adjustment for age, sex, baseline successful ageing, education, income and a num ber o f chronic conditions, the following predictors were identified: walking for exercise, no depression, close personal contacts and absence o f certain health conditions (Straw bridge et al, 1996). Among elderly living in Tokyo and

in the US, social activities emerged as a strong predictor o f function corrected for health related variables (Haga et al, 1991; Strawbridge et al, 1993). Maintaining or promoting the level o f social activities may be helpful in maintaining com petence in ADLs and IADLs and improving the quality o f life.

Research even indicated that individuals, whose social network and support are weak, are at greater risk o f death even w h en other important risk factors such as age, sex and health status are controlled for. Social networks function to meet basic emotional needs for social integration, reassurance o f worth and intimacy, as well as practical needs for assistance, guidance and information. There is evidence that perceptions o f whether support is available or adequate m ay be as important for well-being as actual levels o f support (Grundy, 1996).

However m en seem to benefit from a lower level o f social support than women. This may be due to gender differences in patterns o f social support and its psychological meaning and value. It has been suggested that given w om en’s larger networks and greater em otional and practical involvement in them, the care giving aspect o f their social role may result in costs to wom en’s social network participation, in addition to possible benefits. Therefore women may only enjoy the protective effects o f social support at relatively high support levels (Shye e t al, 1995).

Penninx et al (1997) considered n o t only structural, functional and perceived aspects o f social support, but also personal coping resources such as m astery and self-esteem among D utch elderly. They found th at rather than the number o f social relations, fewer feelings o f loneliness and greater feelings o f mastery w ere associated with a reduced mortality risk (controlled for multiple confounders). On the oth er hand, receiving a low level o f emotional support and a high level o f instrumental support w ere associated with a higher risk o f death.

Similarly Seeman et al (1996) found that a greater frequency o f instrumental support was associated with a tendency o f increased risk o f ADL-disability independent o f measured physical performance, and this w a s significant among men. G reater reliance on others may be indicative o f the health-related need for such support. O n the other hand it may

also, over tim e, result in loss o f confidence and loss o f actual ability, suggesting that instrumental support may have detrimental consequences for perceived independence, autonomy a n d general well-being o f older people. It should be questioned whether this line o f argum ent holds up in the context o f other cultures. The g rea ter cultural emphasis in developing countries on receipt o f instrumental assistance at o ld e r ages may positively contribute to general well-being and give a feeling o f independence from people outside the social netw ork.

Strawbridge et al (1998) developed a new measure o f frailty building on the concept o f frailty as a n individual's increased vulnerability to environmental challenge arising from problems a n d loss o f capability. Frailty was defined as having tw o o r more difficulties in the dom ains o f physical, nutritive (loss o f appetite, unexplained weight loss), cognitive and sensory (vision and hearing) functioning. Analyses w ere based on data from a large study am ong community-living older Americans that were collected each decade during a 30 year perio d . Frailty w as assessed in survivors and was found t o be strongly associated with fair o r poor perceived health, physical inactivity and depression assessed during the previous th re e decades. Frail subjects w ere less likely to go o u t for entertainment or visits, had low er life satisfaction and poorer mental health.

Vailas et al (1998) provided evidence for the role o f nutrition in elders’ judgem ent o f the quality o f life, encompassing distinct domains o f health such as functional ability, social, psychological and spiritual well-being and economic status. D ecreased food enjoyment, chewing problem s, unintentional weight loss and economic food insecurity w ere found to be significantly negatively associated with quality o f life. The sam e was tru e for health related fac to rs such as impaired functional status, poor health a n d depression. In contrast to the u su al emphasis on nutrient composition o f foods, th e authors highlighted the important contribution o f socio-psychological aspects o f food to quality o f life. Schlettwein-Gsell (1992) emphasised psychological aspects o f food for the quality o f life stating th a t with advancing age, increasing value is ascribed to the pleasure and enjoyment offered by food, the structuring effects o f meals o n social contacts and daily routine, and the impact o f eating for self-esteem and situation awareness.

Self-rated health and social factors related to function have rarely been studied in developing countries. M ore culture-specific studies w ould contribute to a better understanding o f this complex issue.

Chapter 4 Nutritional vulnerability

4.

Nutritional vulnerability

Taking into account the interactions between nutritional status and social, environmental and medical conditions, attention is paid in this chapter to an earlier preventive approach through the recognition o f the risk factors th a t may lead to undemutrition. Identification o f risk factors specific to elderly people in unstable situations would make it possible to target those who may be especially prone to undemutrition and those who are already undernourished.

In this section, operational terms will first be clarified and illustrated with examples. Then evidence o f vulnerability o f older people will be given and various components o f nutritional vulnerability will be discussed.