Nourished to Thrive: How Nutrition and Functional Status Shape Quality of Life in Elderly With Diabetes

INTRODUCTION

As global demographics shift towards an ageing population, the intersection of nutrition, health, and quality of life becomes increasingly critical. Older adults face unique challenges, including a heightened risk of malnutrition and functional decline, exacerbated by prevalent non-communicable diseases such as diabetes mellitus (DM). The aging process itself, compounded by socio-economic disparities and health inequalities, amplifies these challenges, impacting both physical health and psychological well-being.^[1,2]

In 2019, the global population aged 60 and above reached 1 billion, with projections indicating a surge to 2.1 billion by 2050. This demographic shift necessitates a deeper understanding of the nutritional needs of older adults to mitigate the onset of chronic diseases and preserve functional independence. Malnutrition, defined by the World Health Organization as an imbalance between nutrient supply and demand, emerges as a critical issue affecting morbidity and mortality in this demographic. Furthermore, the prevalence of diabetes among older adults underscores the complexity of managing nutritional health in aging populations. With nearly 20% of individuals over 60 affected by diabetes in the United States alone, the coexistence of obesity and undernutrition presents a paradoxical challenge for healthcare providers and policymakers alike.^[3-5]

Beyond physiological changes, functional decline significantly impacts the quality of life among older adults. Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) serve as crucial indicators of functional status, influencing everything from personal autonomy to social integration. The deterioration of functional abilities not only increases the risk of adverse health outcomes during hospitalization but also perpetuates a cycle of dependency and decreased quality of life.^[6-8]

Addressing these multifaceted challenges requires a holistic approach that integrates nutritional education, personalized healthcare interventions, and policy reforms aimed at enhancing the nutritional status and functional capabilities of older adults. By prioritizing these aspects, healthcare systems can better support healthy aging and improve overall well-being among elderly populations worldwide.

This article explores the interconnectedness of nutrition, functional status, and quality of life in aging populations, highlighting the urgency for targeted interventions and policy frameworks to address the unique needs of older adults in the 21^st century. This study introduces a novel approach by examining how nutritional status and functional abilities together shape the quality of life in elderly individuals living with DM. Unlike previous studies that focused on these aspects separately, this research aims to provide a comprehensive understanding of their combined effect. The main objective of this study is to assess how variations in nutritional health and functional status influence overall quality of life among older adults with diabetes, thereby providing evidence to guide clinical practice and inform public health policy for healthy aging.

MATERIAL AND METHODS

Ethical clearance was obtained before the data collection process from the Institutional Ethics Committee (Protocol No. YEC1/2023/158). Permission to use the setting was obtained from the relevant authority. Informed consent was obtained from the patients. All study participants were informed in their own language about the study’s details.

A descriptive correlational research study involving 150 geriatric patients with type 2 DM was conducted in a selected hospital in Mangaluru. A non-probability purposive sampling technique was employed to choose the samples. Data were collected using a self-administered demographic proforma, the Mini Nutritional Assessment (MNA) scale, the Katz index of independence in Activities of Daily Living (ADL), and the 36-item short form survey (SF-36). The study included elderly patients aged 60 years and older, diagnosed with type 2 DM. Patients with mental illnesses (dementia, delirium, Alzheimer’s disease) were excluded from the study.

While calculating the sample size, the total sample size was calculated to be 150 by using Cochran’s sample size formula n = Z² p (1- p)/E², where n = sample size, Z = statistic for a level of confidence (1.96 for 95% confidence level), p = 0.497, anticipated population proportion, and E²= 0.08, margin of error.

The following tools were used in this study to collect data over 1 month from July to August 2023: a demographic proforma to collect demographic variables; a Mini Nutritional Assessment (MNA) scale to assess nutritional status; the Katz Index of ADL to assess functional status; and a 36-item short form survey for quality of life. Permission to use the standardized tools (MNA, Katz Index of ADL, and SF-36) was obtained from the respective authors/developers prior to data collection. The tool was given to seven experts for validation. Eighty percent of agreement among experts was considered for retaining the items in the demographic proforma. Three items were modified based on the suggestions of experts.

The MNA scale, an instrument tailored for elderly individuals, consists of 18 items, encompassing anthropometric measurements, a dietary questionnaire, a comprehensive health and social evaluation, and a subjective assessment of both health and nutrition.^[9]

Katz ADL is an ideal tool for evaluating functional status by measuring the physical capability to independently perform daily activities. It evaluates six functions: bathing, dressing, toileting, transferring from bed to chair, continence, and feeding.^[8]

The SF-36 consists of 36 items divided into eight categories: physical function, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Each category contains 2 to 10 questions, with lower scores reflecting a reduced quality of life.^[10]

The investigator handed out the questionnaire to elderly patients, and it took about 30 minutes for each participant to finish it. To evaluate reliability, the Kannada version of the tool was given to 10 participants. The internal consistency of the MNA scale, Katz index of ADL, and SF-36 was determined using Cronbach’s α, with values of 0.761, 0.867, and 0.71, respectively.

RESULTS

Among the participants, 25.3% had normal nutritional status, 48.7% were at risk of malnutrition, and 26% were malnourished, reflecting a critical nutritional challenge affecting 74.7% of the population.

A significant portion of participants (65.3%) demonstrated full independence, while 14% exhibited moderate dependence, and 20.7% were fully dependent, highlighting a diverse range of functional abilities within the group.

The elderly patients reported an overall quality of life score of 89.09 ± 9.20. Specific domain scores included physical functioning (46 ± 19.69), emotional well-being (48.29 ± 21.34), social functioning (55.58 ± 10.72), and pain (53.68 ± 8.55), reflecting a range of physical, emotional, and social health challenges [Table 1].

The Spearman correlation coefficient was employed to assess the relationship between nutritional status, functional status, and quality of life. A statistically significant, high positive correlation exists between nutritional status and functional status (r = 0.759, p ≤ 0.001). There was a moderate positive correlation between nutritional status and quality of life (r = 0.492, p ≤ 0.001) and between functional status and quality of life (r = 0.394, p ≤ 0.001). This indicates that better nutritional status is associated with improved functional status, and both nutritional and functional status positively influence the quality of life [Table 2].

The chi-square test was employed to examine the relationship between nutritional status, functional status, quality of life, and specific demographic variables. There was a significant association between nutritional status and demographic characteristics such as age (p ≤ 0.001), marital status (p ≤ 0.001), education (p ≤ 0.001), monthly income (p ≤ 0.001), caretaker (p ≤ 0.001), place of residence (p ≤ 0.001), smoking (p = 0.005), alcoholism (p = 0.05), tobacco chewing (p = 0.001),comorbidities (p ≤ 0.001) and financial help (p ≤ 0.001).

Functional status showed significant associations with age (p ≤ 0.001), sex (p ≤ 0.001), marital status (p ≤ 0.001), education (p ≤ 0.001), number of children (p ≤ 0.001), monthly income (p ≤ 0.001), caretaker (p = 0.020), smoking (p ≤ 0.001), tobacco chewing (p ≤ 0.046), comorbidities (p ≤ 0.001), and financial help (p ≤ 0.001).

Quality of life was significantly linked to age (p ≤ 0.001), marital status (p ≤ 0.001), number of children (p ≤ 0.001), education (p ≤ 0.001), monthly income (p ≤ 0.001), caretaker (p ≤ 0.001), place of residence (p ≤ 0.001), smoking (p ≤ 0.001), alcoholism (p = 0.038), and tobacco chewing (p = 0.024). The findings indicate that the nutritional status, functional status, and quality of life are affected by various demographic and health-related factors.

DISCUSSION

This study provides significant insights into the interconnected aspects of nutritional status, functional status, and quality of life in the elderly population. By exploring the relationships between these health indicators and demographic and socio-economic factors, the findings underscore the importance of addressing multiple determinants to enhance the overall well-being of elderly individuals. This knowledge is critical for guiding healthcare policies and interventions aimed at promoting healthy aging and reducing health disparities in this vulnerable population.

The participants were primarily in their early old age, with an equal distribution of males and females. Most were widowed and had only a basic education. These patterns are consistent with findings by Lokare et al., who reported a high prevalence of widowhood and lower literacy levels among elderly populations in both institutionalized and community settings.^[11]

In terms of nutritional status, only about one-third of participants were well-nourished, while the majority were at risk of malnutrition, and a smaller proportion were already malnourished. These findings highlight the ongoing struggle many older adults face in achieving adequate nutrition, particularly among those with low education, limited income, or living in underserved rural areas, which is consistent with previous research by Manna et al.^[12]

Regarding functional status, a majority of participants were fully independent in daily activities, while a smaller proportion were moderately or completely dependent. These findings are consistent with previous research by Thomas et al., which reported high levels of independence among rural elderly, with dependence primarily observed in those with advanced age or chronic health conditions.^[13]

Participants’ quality of life across physical, emotional, and social domains was moderate. While social functioning showed relatively better outcomes, areas such as physical limitations and emotional well-being were less favourable. These findings are consistent with previous research by Pius et al., who reported a similar pattern among rural older adults, highlighting that social aspects of life are often better preserved compared to physical and emotional health in elderly populations.^[14]

One of the key takeaways from this study was the strong association between good nutrition and functional independence. Older adults who were better nourished were more capable and active in performing daily activities. These findings are consistent with Kanwal et al., who demonstrated that improved nutritional status is closely linked to higher functional capacity among elderly outpatients.^[15]

Additionally, a moderately positive association was observed between functional status and quality of life. Elderly individuals who maintained higher levels of independence reported better life satisfaction and overall well-being. These findings are consistent with Baptista et al., who demonstrated that higher functional capacity among older adults is significantly associated with improved quality of life, particularly in physical and social domains.^[16]

Nutritional status was significantly associated with age, education, income, support systems, and living environment, underscoring the impact of social and demographic factors on elderly nutrition. These findings are in line with those of Khandhedia et al., who reported similar associations among older adults.^[17]

Functional ability was influenced by age, sex, marital status, number of children, smoking habits, and chronic health conditions, emphasizing how both demographic and lifestyle factors determine independence among elderly individuals. These findings align with those reported by Islam et al.^[18] Quality of life was closely linked to marital status, socio-economic conditions, the presence of caregiving support, and lifestyle behaviours such as smoking, emphasizing the combined effect of social and behavioural determinants on the well-being of older adults, in line with the observations of Samadarshi et al.^[19]

These findings highlight the multifaceted nature of health in the elderly population. Nutritional status, functional status, and quality of life are interconnected and influenced by demographic, socio-economic, and lifestyle factors. Effective interventions must address these determinants to holistically enhance the well-being of elderly individuals. Community health programs should focus on improving nutrition, promoting functional independence, and addressing socio-economic disparities to improve overall quality of life.

CONCLUSION

To mitigate the negative impact of malnutrition on functional status and quality of life, routine nutritional assessments should become standard practice for all elderly outpatients. Healthcare professionals must recognise the magnitude of this issue. Our findings underscore the critical need for consistent screening, monitoring, and support for the elderly to ensure their well-being and enhance their quality of life.