Letter on older people, nutrition and emergencies, by Yvonne Grellety and Michael Golden (with response by Vanessa Tilstone)

Dear Editor,

We refer to the Article by Vanessa Tilstone "Older people, Nutrition and emergencies in Ethiopia" (issue number 14, November 2001). We agree that the welfare of the elderly in emergencies has received much less attention than is necessary. The result is a dearth of field expertise upon which to draw and almost no data upon which to base judgements. There clearly needs to be a lot of research in this area. HelpAge is to be congratulated for initiating both research and debate on how to recognise and appropriately help the vulnerable elderly in emergency situations.

The cut-off points for definition of severe and moderate malnutrition in childhood are based upon over 50 years of data analysis (from the initial paper by Gomez published in the 1950's). The mass of data from around the world, for this age group, clearly shows relationships between the definitions of the grades of malnutrition and the risk of death. Severe malnutrition means that the child has a high risk of death from malnutrition. No relationships have been established for the elderly in terms of risk of death or even other adverse outcomes. This is an area where data is desperately needed to inform the debate so that meaningful opinions can be reached.

The use of the term "severe malnutrition" itself carries the connotation of the person being at high risk of death and should only be used when this is the case. This should not be an arbitrary decision, or even one based upon fulfilling some sort of quota of patients needed to justify a programme at field level, but upon the real risk and needs of this section of the population.

In the absence of a body of outcome data, there is no basis for the choice of any particular cut-off point, which will either divert the limited resources available in an emergency away from, or to, the elderly. Steve Collins comes closest to this with his analysis of outcome in relatively small numbers of adults (not the elderly) of particular ethnic groups. Collin's cut-off points are rejected by HelpAge; the basis for this rejection is unclear. Nevertheless, it is probable that very small numbers of elderly would be selected by Collins' criterion.

HelpAge therefore chose a criterion said to be based upon a personal communication from myself (Yvonne Grellety). In this I have been totally misrepresented. I have no data upon which to base such a judgement. I have therefore never advocated any cut-off point for either BMI or MUAC for definition of malnutrition in the elderly. We did not use the quoted cut-off point for selection of either adults or the elderly in Rwanda. Incidentally, I was with UNICEF in Ethiopia and not ACF. My main concern is to avoid confusion at field level and consequently ask the readership of Field Exchange to ignore all quotations ascribed to myself in this article.

Nevertheless, we agree that in the absence of meaningful data some reasonable cut-off point should be chosen pragmatically, on an experimental basis, for inclusion of the elderly in programs. The onus is then for the agency to determine the outcome of the elderly, both those included and particularly those excluded by that criterion, in order to build up a body of knowledge and experience with which to refine the criteria and definitions whilst not ignoring the humanitarian needs of this section of the community. Any particular cut-off point cannot be justified post hoc by quoting an incorrect personal communication that the readers cannot verify.

In case study 1, given the demography of Ethiopia, we are astonished that the ratio of age groups admitted was 1 pregnant/lactating mothers, 4.5 children and 14 elderly. Were resources in that programme really being distributed according to need? This case study seems to show how the selection of an inappropriate criterion for "malnutrition" in one age group can lead to real problems with resource allocation at field level.

Yvonne Grellety, Michael Golden

Dear Editor,

I received a copy of the letter from Yvonne Grellety and am grateful that she has reemphasised the need to do more research to define and measure malnutrition among older people.

I apologise sincerely for misquoting her in any way. What was written was based on my understanding of the recommendations she gave to HelpAge when she very kindly advised us on our programmes in Ethiopia while working for UNICEF there. As stated in the article, we were not happy with the MUAC cut off points suggested by Steve Collins nor HelpAge cutoffs, based on our nutrition survey results using the MUAC, and therefore we used those suggested by Yvonne on an experimental basis, based on what we understood was ACFs practical experience in Rwanda.

The fact that the number of older people registered in case study 1 was higher than the other groups may have a number of causes, including: the prioritisation of certain members of the family for food, the fact that supplementary feeding programmes for children had been carried out since 1999, and probably most significantly because older people may have been more actively recruited in the programme.

These issues need to be further explored and the understanding shared and I hope that this will be done, along with more comprehensive international and longitudinal studies of elderly malnutrition in order to help a group of people so often overlooked in emergency situations.

Vanessa Tilstone