A cross-sectional study: Is there sex differences in food acceptance, serum albumin, and nutritional status among residents of social shelters in Surabaya, Indonesia?

Introduction

The conceptual framework for Gender Equality and Social Inclusion (Gesi) is a concept that gives special attention to women, including marginalized groups such as the poor, street children, elderly, and so on.¹ Elderlies can be defined as someone who has aged 65 years and above.² In 2022, there were 771 million people aged 65+ years globally, accounting for almost 10% of the world’s population.³ In Indonesia itself, the number of elderly people in 2023 will be 11.75% of the total population and this figure has increased by 1.27% compared to the previous year which was only 10.48% of the total population in Indonesia.⁴ Apart from that, the number of elderly people in East Java Province in 2022 also shows quite a large number, namely 14 million or 33.99% of the total population in East Java Province.⁵ As a person, including the elderly, ages, various health problems will arise. According to the World Health Organization (WHO), health problems that usually occur in the elderly are hearing loss, cataracts and refractive errors, back and neck pain and osteoarthritis, chronic obstructive pulmonary disease, diabetes, depression and dementia, and other diseases such as delirium, falls, urinary incontinence, and pressure ulcers.⁶

Shelters are generally a container that usually provides shelter and residence for the elderly.⁷ However, unfortunately not all shelters provide adequate services and welfare for their residents. In the world, it is estimated that there are 1.6 billion people living in inadequate shelters.⁸ In addition to elderlies, neglected people are also included in marginal groups who must receive special attention.⁹ In Surabaya, there are many social shelters, for example Keputih Social Pondok Environment (Liponsos). In Liponsos, it reported that until 2021, there are as many as 900 people.¹⁰ Based on the data obtained, the capacity of Liponsos residents in Surabaya was only 600 people.¹¹ This data shows that shelters in Indonesia are also not good enough for their residents.

Food security is a condition of fulfilling food for the state to individuals, which is available from the availability of sufficient food, both in quantity and quality, safe, diverse, nutritious, equitable and affordable and does not conflict with religion, belief, and culture of the community, in order to be healthy, active, and productive in a sustainable manner.¹² A study showed that as many as 82.2% of elderlies eat a variety of foods and only 17.8% of elderlies eat a variety of foods.¹³ This can affect the nutritional condition of elderlies. Based on the research that has been done, it was found that as many as 47.1% of elderlies have very poor nutritional status.¹⁴ Besides that, one study that was conducted in Malaysia showed that as many as 38.5% of elderlies in social shelters had body mass index (BMIs) less than 18.5 kg/m².¹⁵ Another study also showed that elderlies in social shelters were likely to be underweight or at risk of being underweight due to an illness that changed the type of food consumed, eating less than two times per day, and mostly eating alone.¹⁶

In addition, sex is an internal factor that can affect nutritional status.¹⁷ A study shows that women have a higher risk of experiencing nutritional status disorders such as malnutrition compared to men.¹⁸ This is probably because there is still a traditional tradition that requires women to eat after their children and husband have finished eating.¹⁹ Sex differences also affect albumin levels where serum albumin levels in women will decrease dramatically at the age of 60 compared to men with the same age.²⁰ In addition, sex differences can also affect the choice of food to be consumed where women tend to choose healthier foods such as fruit, vegetables, nuts, and whole foods. Meanwhile, men tend to choose foods that contain high energy and fat, such as soda, beer and wine.²¹ The choice of food will affect how acceptance of food from both male and female elderly towards the food that will be served. Therefore, researchers are interested to know and research the sex differences in food acceptance, serum albumin, nutritional status, and hypertension level of residents in social shelters in Surabaya, Indonesia.

The conceptual framework for Gender Equality and Social Inclusion (Gesi) is a concept that gives special attention to women, including marginal groups such as the poor, street children, elderly, and so on.¹ Elderlies can be defined as someone who have aged 65 years and above.^2,22 In 2022, there were 771 million people aged 65+ years globally, accounting for almost 10% of the world’s population.²³ In Indonesia itself, the number of elderly individuals in 2023 amounted to 11.75% of the total population, marking an increase of 1.27% compared to the previous year, which was only 10.48% of the total population in Indonesia.²⁴ The number of elderly individuals in East Java Province in 2022 also showed a considerable figure, totaling 14 million (33.99%).²⁵ As someone’s age increases, various health issues may arise. According to the World Health Organization (WHO), health problems commonly experienced by the elderly include hearing loss, cataracts and refractive errors, back and neck pain and osteoarthritis, chronic obstructive pulmonary disease, diabetes, depression and dementia, and others disease such as delirium, falls, urinary incontinence, and pressure ulcers.²⁶

Shelters generally serve as a refuge and residence for the elderly. However, unfortunately, not all shelters provide adequate services and welfare for their residents. Worldwide, it is estimated that 1.6 billion people live in inadequate shelters (Habitat for Humanity 2022). In addition to elderlies, neglected people are also included in marginal groups who must receive special attention. In Surabaya, there are many social shelters, for example Keputih Social Pondok Environemnt (Liponsos). In that Liponsos, it reported that until 2021, there are as many as 900 people.⁵ Based on the data obtained, the capacity of Liponsos residents in Surabaya was only 600 people.⁶ This data showed that shelters in Indonesia are not considered adequate for their residents

Food security is a condition of fulfilling food for the state to individuals, which is available from the availability of sufficient food, both in quantity and quality, safe, diverse, nutritious, equitable and affordable and does not conflict with religion, belief, and culture of the community, in order to be healthy, active, and productive in a sustainable manner.¹¹ A study showed that as many as 82.2% of elderlies eat a variety of foods and only 17.8% of elderlies eat a variety of foods.¹² This can affect the nutritional condition of elderlies. Based on the research that has been done, it was found that as many as 47.1% of elderlies have very poor nutritional status.¹³ Besides that, one study that was conducted in Malaysia showed that as many as 38.5% of elderlies in social shelters had body mass index (BMIs) less than 18.5 kg/m².¹⁴ Another study also showed that elderlies in social shelters were likely to be underweight or at risk of being underweight due to an illness that changed the type of food consumed, eating less than two times per day, and mostly eating alone.¹⁵

In addition, sex is an internal factor that can affect nutritional status.¹⁶ A study shows that women have a higher risk of experiencing nutritional status disorders such as malnutrition compared to men.¹⁷ This is probably because there is still a traditional tradition that requires women to eat after their children and husband have finished eating.¹⁸ Sex differences also affect albumin levels where serum albumin levels in women will decrease dramatically at the age of 60 compared to men with the same age.¹⁹ In addition, sex differences can also affect the choice of food to be consumed where women tend to choose healthier foods such as fruit, vegetables, nuts, and whole foods. Meanwhile, men tend to choose foods that contain high energy and fat, such as soda, beer and wine.²⁰ The choice of food will affect how acceptance of food from both male and female elderly towards the food that will be served. Therefore, researchers are interested to know and research the sex differences in food acceptance, serum albumin, nutritional status, and hypertension level of residents in social shelters in Surabaya, Indonesia.

Methods

This was a quantitative study with a cross-sectional design that was located in Griya Werdha, Surabaya, East Java, Indonesia. The sample size of this study was 44 samples of elderlies. Elderly people in Griya Werdha are divided into 3 groups. The first group is the independent group, consisting of elderly individuals who are capable of carrying out daily activities without assistance from a caregiver. The second group is the partial group, comprising elderly individuals who require caregiver assistance in some daily activities. The last group is the total care group, consisting of elderly individuals who are bedridden and need assistance from a caregiver to carry out daily activities. In this study, we involve elderly individuals from the independent group aged 51-90 years who reside in Griya Werdha, Surabaya, East Java, Indonesia, and are willing to be research respondents. The exclusion criteria are respondents who are not willing to participate in the data collection process and do not fill out the questionnaire completely.

In this study, the researchers examined several variables such as the characteristics of the respondents which included age, sex, and education level using questionnaires. However, the hypertension level was examined by blood examination. The determination of sex in this study was based on statements and direct confessions from respondents. Nutritional status was determined using the body mass index (BMI) obtained from the results of measurements of the respondent’s weight and height. The measurements for the respondent’s weight and height were done by nurses in that shelter. The nutritional status was classified into two categories, underweight and not underweight. The classification that was used was based on body mass index (BMI) classification guidelines from the Indonesian Health Ministry. The underweight group contains those who have BMI <18.5 kg/m² and the non underweight group contains those who have BMI >18.5 kg/m². In addition, other variables that were studied by the researchers were the mean of leftover food and the respondent’s albumin levels. Albumin levels were obtained from collecting urine samples from respondents. The collected urine samples were then sent to the Surabaya National Laboratory for a complete urine examination. Meanwhile, the average of leftover food was obtained by filling out a questionnaire related to food consumed in a day. In this study, the chi-square test was used to examine the relationship between leftover food, hypertension, albumin levels, and the nutritional status of the respondents. In this study, all variables that have been tested using the chi-square test will be tested for the relationship using a multinomial logistic regression test. If the p-value is <0.05, then there is a significant relationship between the various variables that were studied.

In this study, sex differences were taken into consideration due to differences in brain anatomy, physiology, and neurochemistry, especially given the differential prevalence of many psychiatric and developmental disorders in men and women, signs and symptoms of pathophysiology, and response to treatment cannot be ignored.^21,27

All the study participants provided written informed consent and are all being informed about the research. This study was granted ethical approval by the Health Research Ethics Commission, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia on April 8, 2022, with approval number 152/HRECC.FODM/IV/2022.

Results

From the data collection, most elderly were between the ages of 71-80 years old (38.63%) and mostly women (68.2%). Nineteen elderly people whose last education was elementary school (43.1%). It was found that the elderly with underweight nutritional status were 25 elderly (55.6%) and 19 elderly who were identified as not underweight. In addition, the elderly with normal blood pressure were two people (4.6%), categorized as pre-hypertension in as many as 16 people (36.3%), hypertension level onein as many as eight people (18.2%), hypertension level two in as many as six people (13.6%), and isolated systolic hypertension as many as 12 people (27.3%). In addition, most of the respondents had positive albumin status (59%) and only 41% of respondents had negative albumin status. The characteristics of respondents can be seen further in Table 1.

From the results of filling out questionnaires related to the food consumed by respondents, it was found that most of the food components which included staple food (rice), animal side dishes, vegetable side dishes, vegetables, and fruit were quite well received by the respondents. Most of the respondents in this study only consumed staple food (rice) 50% (60%) and only 2.2% of respondents did not consume and only consumed this food 25%. For animal side dishes, most respondents finished all of the food (82.2%) and there was only one respondent (2.2%) who did not consume or still left the food at 75%. Likewise, with vegetable protein dishes, as many as 68.9% of respondents finished all the vegetable side dishes given. Most respondents did not leave food or consume all the vegetables given (57.8%) for the average leftover vegetables. In addition, for the average fruit leftovers, most respondents also did not leave food or consumed all the fruit that was given by Indonesia’s government (80%). The frequency distribution of the average food waste can be seen further in Table 2.

Based on the relationship test, it showed that there was no significant relationship between characteristics of the respondents such as age (p = 0.196), nutritional status (0.495), and hypertension level (p = 0.669) with sex of respondents. However, albumin level has a significant relationship with the sex of respondents (p = 0.014). From that result, it showed that most of those who had positive albumin status were women (31.8%), but these results were not so different from men (27.3%). The relationship between the characteristics of respondents and the sex of respondents can be seen further in Table 3.

Besides that, the relationship test showed that the average of leftover food (rice) was not significantly related to the sex of the respondents (p = 0.822). This result was the same as the average of leftover food (animal protein) which also has no significant relationship with the sex of the respondents (p = 1.000). Moreover, there was no significant relationship between the average leftover food (vegetable protein) with the sex of the respondents (p = 0.809). In addition, the average of leftover food (vegetables) and the average of leftover food (fruits) were not significantly related to the sex of the respondents (p = 1.000; p = 0.549). The relationship between leftover food with the sex of the respondents can be seen further in Table 4.

Discussion

The aim of this study was to gain an understanding of sex differences in age, food acceptance, serum albumin, and nutritional status among residents of social shelters in Surabaya, Indonesia. This study showed that the elderly’s average leftover food per day in Social Shelters reached 21.8%. That average amount of leftover food was higher when compared to the results of a study by Wirasamadi which found that the average food waste in inpatients at Sanglah Hospital Denpasar Bali reached 14.7%.²⁷ That number was also high when compared to the study conducted by Handayani at GRHA Permata Ibu Hospital Depok which has an average of 17.1%.²⁹ The level of food waste in a person can be caused by two factors, namely internal factors which include psychological and physical conditions, eating habits, age, sex, and work, also external factors which include food quality, variety and type of food, timeliness of serving, food temperature served, and the friendliness of the food serving staff.³⁰

This study found that there was no significant relationship and difference between the age (p = 0.240), and nutritional status (p = 0.495) with the sex of the respondents. There were no differences between the nutritional status and sex of the respondents because there were various factors that more influenced a person’s nutritional status. A study showed that food intake was a dominant variable that would influence the nutritional status of people.³¹ In addition, both women and men have no differences in food preferences and eating habits, so sex does not significantly affect a person’s nutritional status.³² However, hypertension levels also did not have a significant relationship and difference based on the sex of the respondents (p = 0.671). Hypertension levels can be influenced by many factors such as older age, being overweight or obese, not being physically active, a high salt diet, drinking too much alcohol, and genetics.³³ Although, both men and women have a risk to develop hypertension, but men have a higher incidence of hypertension compared to women at the same age until the 6th decade of life.^34–36 This can happen because the male androgen hormone plays a role in the blood pressure mechanism that affects high blood pressure.³⁷ In this study, most of the respondents who experienced hypertension were elderly women, so there might not be a relationship because of this.

This study found no significant differences between the sex of the respondents with their nutritional status. Our findings were contrary to those reported in a study conducted by Zhang that said sex had a significant effect on the association between nutritional statuses.³⁸ Besides that, this results was in line with another study that showed that sex was not significantly related to nutritional status.³⁹ A study showed that for both women and men, no differences in food preferences and eating habits were found so sex does not significantly affect a person’s nutritional status.³²

On the other hand, this study found that there was a significant relationship between sex and the albumin level of the respondents. The other study reported that there were more elderly women whose urine contained albumin than men. It is in line with Akman’s study that shows at admission to the emergency department, the mean serum albumin levels were found to be higher in women than in men.⁴⁰ The difference in albumin levels between women and men might be explained by menopause and aging, which affect total serum albumin levels.⁴¹

In addition, our findings showed there is no relationship between the sex of the respondents with the leftover food. These results are in line with research conducted by Nisa (2018) which states that there is no relationship between sex and the respondents’ leftover food.⁴² This might be due to differences in eating habits at home and in nursing homes which affect the acceptability of the respondents. If the eating habits of male and female respondents do not match the food served, it will affect whether or not the food is finished.⁴³

To our knowledge, this is the first study to assess elderly leftover food in social shelters in Surabaya, Indonesia. There were some limitations, such as bias. Selection bias may arise from the recruitment of respondents by enumerators. Respondent bias can be caused by the demographic of respondents above the age of 40 and the recall process of the respondents. To minimize memory and measurement bias, we used trained enumerators to guide respondents through questionnaires and used detailed questions where appropriate. Moreover, this study was also limited to a different number of male and female elderly. This happens due to the majority of residents in the shelters are women.

According to these data, there were no sex differences in food acceptance, serum albumin, and nutritional status among residents of social shelters in Surabaya, Indonesia based on a relationship test. However, it was found that elderlies having a positive albumin level was the most significant variable that relates to their nutritional status. The leftover food in social shelters was still relatively high. While high food waste will affect the nutritional status, better food service delivery and quality diet modifications are demanded to maintain the health of the elderly. It is hoped that this research can create social shelters both in Surabaya and in Indonesia to pay more attention to the health of the elderly, including in terms of serving and type of food to reduce food waste and which will then have an impact on better nutritional status.