Management of Micro Nutrition and Health Impacts on the Elderly: Literature Review

Background: The population of elderly worldwide is increasing unnoticed, including in Indonesia. The world's population is aging, and many elderly people experience age-related malnutrition, including deficiencies in some micronutrients. Malnutrition in the elderly is a serious condition when the nutritional needs of the elderly do not match their food intake. Objectives: This systematic review broadly reviews various micronutrient problems and health impacts on the elderly in several countries. Methods: Systematic review following PRISMA guidelines. Several databases have been accessed; the PubMed, Google Scholar


INTRODUCTION
The population of elderly worldwide is increasing unnoticed as time goes by 1 .It is estimated to reach 500 million with an average age of 60 years and is expected to reach 1.2 billion in 2025, and will continue to increase with an estimate of reaching more than 2 billion in 2050 2 .From 1990 to 2025, Indonesia's older people population is expected to multiply.One of the nations whose populations are beginning to age structurally is Indonesia, which is projected to have the world's fastest-growing elderly population 1 .Based on data from the Central Statistics Agency (BPS) shows that the elderly population numbered 14.4 million in 2000, totaling 23.9 million in 2013 3 .Projections from the UN also stated that the percentage of elderly in Indonesia will reach 25% in 2050, or around 74 million elderly 4 .
Aging is often seen as a weakness and a disability.Nonetheless, age-related functional changes in the elderly vary significantly, and they may have different dietary and nutritional needs 5 .Changes commonly experienced by the elderly are physiological changes, changes in psychosocial behavior, and cognitive changes 3 .The world's population is aging, and many elderly people experience age-related malnutrition, including deficiencies in some micronutrients.To help the elderly maintain their independence and prevent declining health status, adequate nutritional intake is crucial 2 .
One of the nutritional problems experienced by some Indonesian people today is hidden hunger or "hidden hunger."Humans who lack vital vitamins and minerals, called micronutrients, are said to be suffering from "hidden hunger" 6 .Global Hunger Index data for 2020 shows that Indonesia is in the 70th position out of 107 countries and this condition is experienced by around 20-40 percent of the population.Its broadest definition refers to a persistent lack of micronutrients, specifically vitamins and minerals, which can have serious, longlasting repercussions.The cause of hidden hunger is a lack of micronutrients caused by a lack of fruit and vegetable consumption.Anaemia can also be the cause of hidden hunger 7 .
Malnutrition in the elderly is a serious condition when the nutritional needs of the elderly do not match their food intake.This condition can also be referred to as malnutrition or unbalanced nutrition in the elderly, leading to the following two conditions: malnutrition (not getting enough nutrients) and excess nutrition (getting more nutrients than needed) 8 .Suppose an aged person has a reduced income, less access to appropriate, safe, and nutritious food, has functional restrictions, eats unsafe food, uses coping methods to "stretch" their diet, or has several chronic illnesses.In that case, they are more likely to suffer from malnutrition.The elderly with various chronic diseases and those recently hospitalized are at risk of experiencing malnutrition 7 .This review aims to broadly review various micronutrient problems and health impacts on the elderly in several countries.

Study Design and Search Strategy
A systematic review was conducted to review broadly various micronutrient problems and health impacts on the elderly in several countries.The report followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.A search was conducted in the PubMed, Google Scholar, and ScienceDirect databases using a combination of the following Medical Subject Heading (MeSH) terms and relevant keywords in a different order: 'aged,' 'malnutrition,' and 'micronutrient.'Boolean operators, such as AND, OR, and NOT, are used in searches.

Study Selection and Outcome Measure
The inclusion criteria applied in selecting scientific articles were quantitative study, written in English, evaluating the relevant topic, providing full text, and the study was published starting in 2017-2022.Case reports, animal studies, letters to the editor, study reviews, and abstracts without the complete text were excluded from this study.

Data Extraction
The authors independently screened the included articles' titles and/or abstracts using standard Microsoft Excel forms.To address disagreements in consensus, a third external collaborator was consulted.Three independent research team members formally assessed article quality using Centre of Evidence-Based Medicine appraisal (CEBMa) tools for cross-sectional studies and Critical Appraisal Skills Programme (CASP) tools for cohort studies.Every systematic review includes a procedure for critiquing or evaluating the research evidence.This evaluation aims to evaluate a study's methodology and ascertain how well it has addressed the possibility of bias in its planning, execution, and analysis.

Data Abstraction and Synthesis
According to a thorough evaluation of the literature, the analysis is based on the findings and recommendations of each study.In order to identify subthemes and themes, relevant results are extracted, sequenced, and examined in the first step.All authors contributed to the synthesis's findings.The following data is presented in Table 3. Table 3 presents authors, year, country, aim, study type, data collection, participant and sample size, types of micronutrient deficiencies, and treatment.

Screening Results and Assessment of Article Quality
A total of 421 articles were found in 3 databases.After being examined abstract, the year, topics, and languages, as many as 103 entered the initial screening.There are eight studies accessed for eligibility.A total of 1 study was irrelevant age of the respondent; therefore, they are excluded.A total of 7 articles were analyzed.PRISMA flow chart is presented in Figure 1.The articles analyzed have the quality of the moderate category and are presented in Table 1 and Table 2.

Flowchart Study Selection
Notes: Y = yes, C= can't tell, N = No, M= moderate overall quality, L = low overall quality Notes: Y = yes, C= can't tell, N = No, M= moderate overall quality, L = low overall quality Further information for the question "What were the results of this study" has been presented in Table 3.

Aim of the Research
A total of seven articles were published to assess the nutritional status and micronutrient intake of older adults aged 60 and up.This research also describes the prevalence of diseases caused by micronutrient deficiencies and their treatments.This study investigates the effects of providing the elderly with different food and supplements.

Methods and Techniques of Analysis
Most of the research included in the review is quantitative research.Data were primarily collected using a structured questionnaire, in some articles also using anthropometric measurements, blood samples, and laboratory examination.Quantitative research is cross-sectional -survey type.Respondents of elderly involved ages ranging from 50 years and 82 years and over.

Finding
The results of this study indicated that the problem of nutritional inadequacy in the elderly is a nutritional problem encountered by diverse countries.Micronutrient deficiencies in the elderly can be caused by various factors, mainly due to inadequate food intake.Low food intake in the elderly can be influenced by socioeconomic status, culture, physical activity, and other social factors.Based on the seven countries that have been reviewed, it is stated that each country has almost the same type of micronutrient deficiency.Every elderly in various countries has a vitamin D deficiency.The rest is iron, vitamin B12, calcium, and folate.Lack of micronutrients in the elderly will lead to poor quality of life in old age.The Elderly who has malnutrition will be more susceptible to diseases.Diseases that accompany older adults with malnutrition are heart disease, high blood pressure, diabetes, electrolyte imbalance (hypokalemia, hypocalcemia), and decreased brain function, which will lead to dementia and anemia.The description of the included studies is presented in Table 3.

Micronutrient Deficiency in Elderly
Many disorders associated with aging are related to micronutrient deficiencies.The elderly are one of the groups at risk of experiencing micronutrient deficiencies.Many older people, including the infirm and those living in institutions, rely on ready-to-eat meals with variable, frequently subpar nutritional quality for most of their daily nutritional needs 6 .Micronutrient deficiency is a form of specific malnutrition 9 .Various factors cause micronutrient deficiencies in the elderly, but inadequate food intake is the main factor influencing this deficiency, especially the lack of vitamin D 2 .Poor eating patterns in the elderly10 cause less food intake.Diet in the elderly is influenced by ethnicity, economy, culture, and social factors.Age has an impact in addition to diet because aging brings about significant physiological changes such as sensory alterations (decreased olfactory function), decreased oral health (tooth loss), decreased saliva production, and swallowing issues.The elderly will no longer enjoy eating foods high in micronutrients and will consume far fewer of them due to all these dysfunctions 11 .Nutritional deficiencies experienced by the elderly are closely related to decreased immune function 12 .Vitamins C and D, B6 and B12, folic acid, trace minerals, zinc (Zn), and iron are among the nutrients directly connected to the body's immune system 13 .

Vitamin D Deficiency
An essential component of both innate and adaptive immune system function is vitamin D.Moreover, cathelicidin antimicrobial peptide gene activation in activated monocytes and macrophages depends on vitamin D 14 .Many studies have been conducted in recent years on vitamin D insufficiency, which is still a persistent issue in public health.According to some studies, vitamin D deficiency affects people of all ages, genders, and ethnicities worldwide and is a significant public health issue 13 .
Vitamin D insufficiency raises the likelihood of sarcopenia in the elderly and is linked to fractures, falls, poor physical performance, and maybe age-related cognitive impairment 15 .In addition, vitamin D deficiency can accelerate the age-related decline in the expression of vitamin D receptors in skeletal muscle 16 .Serum vitamin D levels in aged people can be used to predict the degree of functional decline and skeletal muscle atrophy 17 .According to studies, vitamin D insufficiency is highly prevalent in the aged population, and muscle VDR levels decline with aging 2 .
Many illnesses, including autoimmune conditions like type 1 diabetes, rheumatoid arthritis, and multiple sclerosis, have been linked to vitamin D insufficiency.In addition to type 2 diabetes and several types of cancer, vitamin D insufficiency is linked to cardiovascular disease (including stroke), infectious diseases (bacterial, viral, and fungal), and infectious diseases (colorectal, breast, and prostate gland).Recent research has revealed that 25-hydroxyvitamin D impacts many diseases and mortality 18 .

Folate
Folate is essential for the brain and nervous system, especially mood and cognitive function as we age 8 .Low folate levels in serum, red blood cells, and cerebrospinal fluid, elevated plasma homocysteine levels, and an increased prevalence of depression and dementia in senior individuals are all indicators of folate insufficiency.There is proof that a folate shortage may contribute to cognitive loss in the aging brain, raising the likelihood of vascular dementia and Alzheimer's disease while occasionally causing reversible dementia.This result may be due to methylation-related processes or homocysteine-mediated vascular or neurotoxic mechanisms.It is well-known that, in some neuropsychiatric diseases, depression may act as a precursor to dementia 19 .
An extensive nationwide sample of aged people was used in the study to investigate the relationship between serum folate insufficiency and the risk of dementia development and all-cause death.A greater risk of dementia (HR = 1.68; 95% CI 1.32 to 2.13; p<0.001) and all-cause death (HR = 2.98; 95% CI 2.52 to 3.52; p<0.001) was found when serum folate insufficiency was present compared to absence.A biomarker that can be used to identify people at risk of dementia and death is serum folate levels 20 .

Calcium
It takes a lifetime to build and maintain healthy bones.One of them has to do with calcium.According to a study, some people can lower their risk of fractures, osteoporosis, and diabetes by consuming enough calcium 21 .According to a study, older people frequently have hypocalcemia, which is potentially fatal.It was shown that 97 (24.1%) older people had hypocalcemia.Hypocalcemia was observed in 75 (26.2%) of the 286 participants in the 60-74 age group out of the total 286 participants and 22 (19%) of the 116 participants in the >74 age group.44 (24.3%) of the 181 male individuals and 53 (24%) of the 221 female participants had hypocalcemia 22 .
Ordinary aged people have a calcium balance that is out of equilibrium, which causes them to lose bone mass.In the US, adults 65 and older typically take roughly 600 and 480 mg of calcium daily, respectively.The elderly consume less calcium than the young, and their lower absorption rates further lower their adequate intake.The requirement for calcium is also effectively increased by other nutrients like protein and fiber, which are ingested in excess.When estrogen is withheld during menopause, intestinal calcium absorption, and renal calcium retention become less effective, increasing the need for an effective calcium intake 23 .
Vitamin D has a connection to the issue of calcium insufficiency.The main element in keeping calcium homeostasis is vitamin D. Growing evidence points to the elderly's low vitamin D levels as the cause of the altered calcium balance with aging 24 .

Vitamin B 12
The clinical signs of vitamin B 12 deficiency in the elderly are prevalent (> 20%), but they are sometimes overlooked because they are modest.These clinical manifestations are also potentially dangerous, particularly from the standpoints of neuropsychiatry and hematology 25 .The cobalamin-food malabsorption syndrome, pernicious anemia, inadequate dietary intake, and malabsorption are the main contributors to deficiency, accounting for more than 60% of all cases 26 .
The elderly have a very high incidence of undiagnosed vitamin B12 deficiency, yet no identifiable risk category should be screened.Consequently, it is appropriate to screen the aging population by employing biochemistry.The early detection of vitamin B12 insufficiency is crucially determined by general practitioners 27 .
Due to many causes, such as inadequate consumption of foods derived from animals and agingrelated declines in intestinal B12 absorption ability, specific sub-group populations are at risk of subclinical vitamin B12 deficiency.While a plant-based diet raises the risk of B12 deficiency, consuming animal products has some detrimental health effects and negatively influences ustainability 28 .
Dementia patients have a 7.5% frequency of vitamin B12 deficiency.Shorter duration, more severe dementia, and macrocytosis were all related to it.Six weeks and 12 weeks after beginning vitamin B12 treatment, the median Mini-Mental Status Examination (MMSE) score significantly improved 29 .

Prevention and Intervention
According to studies conducted in Germany, elderly people unable to follow dietary recommendations can benefit from frequent micronutrient supplementation in the optimum dosage, which can help them avoid chronic diseases by raising low micronutrient levels 9 .Increases in BMD (Bone Mineral Density), muscle strength, decreased falls, and fractures in the elderly have all been linked to vitamin D and calcium supplementation.The impact of interactions with all vitamin Ds on metabolic pathways can be seen in the human vitamin D status.Hence, any condition that disrupts a person's metabolic processes can impact the levels of 25-hydroxyvitamin D in the blood 18 .
The Chilean government established PACAM (Programa de Alimentación Complementaria del Adulto Mayor), a particular program for the elderly, in 1998.This complementary feeding program for older people was created to preserve health and activity levels in the future, lower acute morbidity and functional decline, lower health disparities, and provide complementary food for the elderly.With about 70% of the elderly being delivered, the PACAM food distribution in the Chilean region was deemed successful.However, it was discovered that the PACAM diet did not help maintain acceptable serum levels of certain significant micronutrients, such as vitamin B12, presumably due to its poor absorption due to individuals' stomach atrophy 11 .The elderly Indonesian population may not be getting enough vitamin B12 due to diet-related reasons.Animalderived foods like meat, milk, eggs, fish, and shellfish are good sources of vitamin B12.In order to prevent vitamin B12 insufficiency in at-risk groups, it is crucial to select food sources with a high natural vitamin B12 content 15 .
The incidence of vitamin D insufficiency in the aged population can be reduced by consuming dairy products.Dewiasty's research from Indonesia demonstrates that consumers of dairy products are primarily women and people with higher monthly earnings.They are less likely to suffer from malnutrition and have fewer co-morbid conditions, particularly hypertension, diabetes, and dyslipidemia.In addition, people who consume dairy products have lower protein, calcium, vitamin D, and vitamin B-12 deficiency rates than those who do not.For micronutrients (calcium, vitamin D, and vitamin B12), differences in deficit were more pronounced and statistically significant for both sexes 30 .

CONCLUSIONS
Micronutrient deficiency in the elderly causes a variety of comorbidities that reduce the elderly's quality of life in old age, such as heart disease, high blood pressure, diabetes, electrolyte imbalance, dementia, and anemia.The development of food-based dietary guidelines in several countries should be recommended, and it is also necessary to update national dietary intake references.There is a need for health promotion related to increasing knowledge about nutritional intake and

Table 1 .
Article quality assessment for cross-sectional design study using Centre of Evidence-Based Medicine (CEBM) appraisal tools

Table 2 .
Article quality assessment for cohort study using Critical Appraisal Skills Programme (CASP) tools