Running Header: Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
By: Kristen Bromaghim, Molly Cassella, Rachel Gallagher
James Madison University – The University of Malta
May 2011
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Abstract
This project explores the CINDI dietary guidelines that were set out by the World
Health Organization regional office in Europe and to what extent the Maltese elderly population
complies with all components. This paper also explores related morbidities that result from any
deviations from the recommended diet. To evaluate the degree to which this population follows
the guidelines, various means of information extraction took place reword. The majority of
information was retrieved from literature reviews authored by medical professionals, as well as
specific data sets relevant to the eating habits of the elderly Maltese population. Interviews with
various professionals in the health field, as well as information taken from lecture presentations
were also a means of data. In addition, a survey conducted by students at several locations in
Malta was used to focus on dietary trends of the elderly. It was found that the Maltese elderly
population deviates from the CINDI guidelines in many ways such as the inclusion of too many
carbohydrates, inadequate types and amounts of protein, unhealthy dairy consumption, lack of
fruits and vegetables, and a high intake of sugar. In conclusion, it is evident that if the dietary
guidelines set out by the CINDI program were followed correctly, then Malta would have a
lower prevalence of morbidities in the elderly population that result from improper nutrition and
diet.
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Introduction
According to the World Health Organization (WHO), individuals between the ages of 6074 years old are classified as ‘elderly’, 75-89 years are “old”, and 90 years and above are “very
old” (Shepherd, 2009). Projections for the European Union’s twenty-seven member states show
that by 2060, the mean age of the population will rise to 48 years and 151.5 million individuals,
30% of the total European Union population, are expected to be aged 65 years and over.
Additionally, 61.4 million people are predicted to be aged 80 years and over (Gauci, 2008). The
increasing size of the aging population can be attributed to numerous factors; however, the shift
from families with many children to families with fewer children due largely to financial
constraints is a major factor. Increased life expectancy is another key reason why the elderly
population is steadily growing.
The classification system of the elderly population established by the World Health
Organization is upheld in Malta as well. The Maltese elderly population is steadily increasing;
this population currently comprises 19.9% of the general population, and by the year 2060 that
number is predicted to increase to 24% aged 65 years and over (Gauci, 2008).
This aging population is a growing concern worldwide; they carry with them increasing
risks of diabetes, hypertension, cardiovascular disease, osteoporosis, obesity, and caloric
deficiencies (Baker, 2007). Amongst the elderly population in Malta, the leading cause of death
is heart disease (Gauci, 2008). The European Health Interview Survey of 2008 reported that
21% of deaths in females and 23% of deaths in males were due to this condition. Also published
by the European Health Interview Survey of 2008 were the top reported health conditions in
those aged 60 and over: the most common health condition in 2008 was high blood pressure,
afflicting 46% of the elderly population. Other common conditions were arthritis, back/neck
Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
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pain, diabetes, and mental health problems (Gauci, 2008). In fact, Malta has the highest diabetes
rate in Europe (Mizzi, 1995), and is second only to the United States in obesity rates. In the
National Obesity Campaign of 2010, Malta was estimated to have 50% of adults between 35 and
65 years of age were overweight or obese (National Obesity Campaign, 2010). These trends have
led health professionals to help create a healthful aging process in which the hallmark diseases
are diminished (Baker, 2007).
The current healthcare system in most of the world, and particularly in Malta, has been
described as reactive (M. Ellul, personal communication, June 6, 2011). A shift towards
proactive, preventative healthcare is therefore being encouraged. The CINDI (Countrywide
Integrated Noncomunicable Disease Intervention) food pyramid is a dietary guideline devised by
the World Health Organization Regional Office in Europe for health promotion and disease
prevention (CINDI dietary guide, 2000). This is a nutritional approach to prevent disease by way
of changing the food patterns in Europe toward a diet with low saturated fat and high fruits and
vegetables (CINDI dietary guide, 2000).
The purpose of this paper is to explore the CINDI food pyramid established by the World
Health Organization and determine the extent to which the Maltese elderly population deviates
from these dietary guidelines. Major deviances are possible causes for Malta’s already high and
increasing rates of diet-related morbidities. Promoting a healthier, more balanced diet in Malta
could alleviate much of the burden the growing elderly population is placing on the health care
system.
Background
Obesity and its consequences, which include diabetes, hypertension, high blood pressure
and cardiovascular disease can be prevented largely by diet modification. In nearly every part of
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the world there is an age-dependent increase in the prevalence of type 2 diabetes (Josse et al.,
2008 APA). On a global scale, the prevalence of diabetes in adults aged 65 years and older is
expected to increase exponentially to approximately 300 million by 2025, with a lifetime risk of
developing type 2 diabetes rising to approximately 20% (Josse et al., 2008). With these numbers,
the global burden diabetes and its related complications will have on social structures and health
care systems will be enormous (Josse et al., 2008).
To battle such burdens, the World Health Organization has created the CINDI dietary
guide along with the accompanying food pyramid. The CINDI dietary guide respectively known
as the Countrywide Integrated Noncommunicable Disease Intervention was created through the
collaboration of the WHO CINDI program and the WHO program for nutrition policy, infant
feeding, and food security (CINDI dietary guidelines, 2000). The WHO program was designed
to be a global initiative involved in the improvement of health and lifestyle through health
promotion, disease prevention, and reduction of the various mortalities and morbidities resulting
from the major identified non-communicable diseases. To reduce and hopefully eliminate the
risks of such non-communicable diseases, the WHO intends to identify and diminish the risk
factors relevant to them (CINDI dietary guidelines, 2000). Some of these risk factors that may
contribute to an individual’s overall health include alcohol and/or tobacco use or abuse, stress,
physical inactivity, and unhealthy nutrition and diet. Malta’s use of this guide is largely due to
its low-fat, low salt and low carbohydrate content as well as its heavy inclusion of fruits and
vegetables (Denny & Stanner, 2008).
The guide provides a reference for healthy eating which is based on foods, rather than
nutrients. This essentially is a more practical means of direction simply because we purchase
and consume foods and not nutrients (CINDI dietary guidelines, 2000). The dietary pyramid is
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divided into separate color schemes that help to navigate the structure while demonstrating the
variety and proportions of food necessary to comply with healthy standards. The color schemes
can be comparable to that of traffic lights and their meanings. The green section identifies foods
that are full of nutritional benefits similar to “proceeding” through a green light. The
orange/yellow section indentifies foods that an individual should be cautious of. The remaining
red section identifies foods that should be thought through and considered before consuming
similar to the “stopping” mechanism (CINDI dietary guidelines, 2000). These illustrations
provide a simple means of understanding what and how much to eat. Although, it is important to
keep in mind that the more physical activity an individual engages in, the more servings
necessary to meet their daily caloric intake needed.
The metric form, the joule (kJ) is the most universal unit of measurement of food (1 kcal
= 4.2 kJ). As a result, the WHO recommends that a normal adult requires approximately 6,50014,000 kJ each day (CINDI dietary guidelines, 2000). This recommendation also must take into
account the individuals gender, age, body size, and amount of physical activity as mentioned
previously. Half of the total energy each day should come from a combination from the two
green layers. These layers are found at the base of the pyramid and include fruits, vegetables,
and grains. Specifically regarding vegetables which can be found in the upper green layer, the
WHO recommends the inclusion of 400 g into daily food intake. In regards to fruits, 5-6
portions daily are recommended with one portion being recognized as equating to one fruit (i.e.
an apple) (CINDI dietary guidelines, 2000). The orange layer implies caution, meaning that only
small amounts of this section are needed to maintain a healthy diet. This section includes meats
and meat alternatives, and is recommended that only 0.8 g protein per kg is needed per day for an
individual (CINDI dietary guidelines, 2000). The other half of the orange portion includes dairy
Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
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products, which are necessary to maintain the recommended amount of calcium in the diet. The
CINDI pyramid does not identify an exact amount per day but rather implies that amounts differ
among individuals due to the varying factors that may have influence (age, body size, gender,
etc.). Finally, the top red layer includes foods that supply little nutrients to the diet. Though
these foods help supply additional energy, very small amounts are only needed. In addition to
the dietary pyramid, the WHO has also incorporated a specific list of 12 dietary guides which
explain steps to healthy eating: this could be best presented as a table prnted in color
1. Eat a nutritious diet based on a variety of foods originating mainly from plants, rather
than animals
2. Eat bread, grains, pasta, rice or potatoes several times per day
3. Eat a variety of vegetables and fruits, preferably fresh and local, several times per day
(at least 400 g per day)
4. Maintain body weight between the recommended limits (a BMI of 20-25) by taking
moderate levels of physical activity, preferably daily
5. Control fat intake (not more than 30% of daily energy) and replace most saturated fats
with unsaturated vegetable oils or soft margarines
6. Replace fatty meat and meat products with beans, legumes, lentils, fish, poultry or
lean meat
7. Use milk and dairy products (kefir, sour milk, yogurt and cheese) that are low in both
fat and salt
8. Select foods that are low in sugar, and eat refined sugar sparingly, limiting the
frequency of sugary drinks and sweets
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9. Choose a low-salt diet. Total salt intake should not be more than one teaspoon (6 g)
per day, including the salt in bread and processed cured and preserved foods. (Salt
iodization should be universal where iodine deficiency is endemic.)
10. If alcohol is consumed, limit intake to no more than 2 drinks (each containing 10 g of
alcohol) per day
11. Prepare food in a safe and hygienic way. Steam, bake, boil or microwave to help
reduce the amount of added fat
12. Promote exclusive breastfeeding and the introduction of safe and adequate
complementary foods from the age of about 6 months, but not before 4 months, while
breastfeeding continues during the first years of life. (CINDI dietary guidelines,
2000)
These steps should be recognized as a whole rather than individually due to the overall context
they provide in terms of maintaining a healthy diet and lifestyle.
Methods
The data obtained for this paper came from a variety of sources. A wide range of
literature was reviewed and mostly authored individually ?? or as a collaboration of medical
professionals holding various doctorate degrees. In the articles, the nutritional topics most
commonly discussed were obesity, malnutrition, and diabetes. In order to further evaluate the
nutritional status of the elderly population in Malta, we drew statistical data from a document
concerning the changing eating habits of the Maltese written by Mary Bellizzi of the Nutrition
Unit of the Department of Health in Floriana, Malta. This information was specific to lifestyle,
nutrition choices, and general health status of the population that identified as being 60 years of
Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
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age and older. An additional data set entitled the CINDI dietary guide was obtained from the
World Health Organization Europe to illustrate the compilation of the dietary pyramid and lay
out the steps for healthy eating. A random, anonymous survey was also conducted by us and our
fellow students of 258 individuals that were approached in various locations around Malta. We
explained the purpose of our study and the confidentiality in order to guarantee anonymity. The
surveys included 49 questions that covered many aspects of lifestyles. We then extracted the
data retrieved from the surveys that was relevant to supplement the literature cited. This
information was specific to nutrition choices relating to the food pyramid. We also worked
closely with several individuals appropriate to our topic of research. Geriatric specialist Dr.
Stephen Abela, Dr. Neville Calleja of the Department of Health Information and Disease
Prevention, and Public Health Nutritionist, Maria Ellul all provided insight on new data as well
as past data already retrieved. Dr. Neville Calleja made available a compilation of the results of
the European Health Interview Survey conducted in 2008 that focused entirely on the health
status of the elderly. All sessions were documented and incorporated into our results.
Results
The Nutrition Unit of the Department of Health in Floriana, Malta conducted a study of
the eating habits of the Maltese from 1961 to 1988. The results summarized the supply of
different foods available and the rates of their consumption during that time period. These
results represent the diet decisions made by the current elderly population discussed in this
paper, assuming that the dietary habits of a middle-aged individual directly contribute to their
health later in life. Thus, the data from 1961 to 1988 about Maltese dietary patterns offer insight
into the dietary causes for the morbidities associated with the present aging population, such as,
cardiovascular disease, diabetes, and obesity.
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The results of the study indicate that the supply of cereals and other wheat products fell
steadily from 1961 to 1988, but seem to be stabilizing at the present time. Fruits and vegetables
increased in supply and there was a 20% increase in the supply of sugar during the considered
period of time do you mean sugar intake??. The supplies of meat, fish, eggs, and dairy products
have increased steadily since 1961. Trends in the supply of separated fats and oils in Malta
indicate the substitution of butter with margarines and vegetable oils (Bellizzi, 1993).
At the time of the study, the largest sources of energy in the Maltese diet were cereals.
Cereals include bread, pasta, and other wheat products. The most commonly consumed wheat
products were processed bread, followed by pastas. The second largest component of the
Maltese diet was meat, specifically, beef and pork. Steadily increasing, yet significantly lower
than the percent of red meat consumed, was the percent of fish consumed by the Maltese
population. The third greatest source of energy in the Maltese diet was milky and dairy products.
These products were often high in fat and salt and the previously noted 20% increase in sugar
consumption equates to 21 grams consumption per person daily. The consumption rate of fruits
and vegetables by the Maltese was lower than that of Greece, Italy and Spain, with fruits and
vegetables constituting only 6% of total energy intake per day (Bellizzi, 1993).
In addition, an interview with Dr. Anna McElhatton, a professor of Dietetics at the
University of Malta, shed light on the present dietary decisions of the elderly population in
Malta. She described decreased protein consumption characterized by an aversion to red meat
and increased consumption of refined carbohydrates. These refined carbohydrates are most
commonly purchased in the form of qaghaq, a soft bun.
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Also evident is a lack of nutritional education. Student survey results revealed that of the
29 respondents aged 66 years and older, 35% had never heard of the food pyramid. Of the 52%
who reported knowing a little about the food pyramid, 28% were not interested in learning more.
Findings and Discussion
The Maltese population’s deviance from the CINDI nutrition guidelines is apparent
through its dietary patterns. The CINDI model recommends a diet high in complex
carbohydrates and low in total fats. In contrast, the Maltese diet summarized in the document,
The Changing Eating Habits of the Maltese, is one that is low in complex carbohydrates and
high in total fats (Bellizzi, 1993).
The Maltese population derived 37% of its total energy intake from complex
carbohydrates from 1961-1988. Ninety-nine percent of the breads consumed were the local
white types of bread, which are high in salt content. Whole-meal and brown bread, the healthier
alternative, constituted just 0.1% of bread consumption at the time. Protein consumption
contributed to 12% daily energy intake; however, this number represented consumption of fatty
meats, such as beef and pork in the form of lunchmeat and bacon. Furthermore, fish
consumption constituted only a small portion of protein consumption on the island (Bellizzi,
1993). These numbers deviate from the CINDI dietary guideline suggesting protein be
consumed in the form of legumes, lentils, and fish.
The CINDI model recommends that fruits, vegetables and whole grains be consumed in
nearly equal amounts. However, these three food groups were consumed in dismally low
amounts during the period from 1961 to 1988. Already mentioned was the population’s
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preference for white rather than whole wheat bread. Also, the Maltese trailed behind their
Mediterranean neighbors in fruit and vegetable consumption by up to 3% (Belizzi, 1993).
Recommendations concerning milk and dairy products promote the consumption of low
fat and sodium dairy products. However, nearly two-fifths of Maltese dairy consumption was
consumed in the form of high-fat cheddar cheese. Though Maltese bread and pasta consumption
is consistent with a traditional Mediterranean diet, the Maltese diet is similar to a British diet.
This is evidenced by the high consumption of cheddar cheese, sugar, and beef and the low
consumption of fruit. Thus, it can be concluded that the British presence from the early 1900s
until 1964 greatly influenced Maltese dietary decisions in the following years (Mizzi, 1993).
Salt intake, as recommended by the CINDI model, should not exceed 6 grams per day.
During the period from 1961-1988, men were consuming 11 grams and women, 9 grams, per day
of salt. Also during this period, sugar made up 15% of the population’s total energy intake. This
value exceeds what is considered to be the sparingly consumption of sugar recommended by the
CINDI plan. The plan urges individuals to limit the frequency of sugar drinks and sweets.
However, it is estimated that Malta is second highest per capita consumer of soft drinks. This
estimate suggests that soda could have been the source of such a high intake of sugar in the
Maltese diet (Bellizzi, 1993). The only aspect in which the Maltese diet followed the CINDI
guidelines was in the substitution of saturated fats with unsaturated fats such as vegetable oil and
margarine.
An interview with Dr. Anna McElhatton, a professor of Dietetics at the University of
Malta, shed light on the present dietary decisions of the elderly population in Malta. She
described decreased protein consumption and increased consumption of refined carbohydrates.
She pointed out that food choices of the elderly are largely influenced by their physical abilities
Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
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or rather, inabilities. For example, elderly individuals may chose to shop at neighborhood corner
shops because of their location. These corner shops, though convenient, receive shipments only
twice a week. Thus, the fruit and vegetables purchased by an elderly individual are normally of
low quality and diminished nutritional value due to inadequate storage.
The Health Interview Survey of 2008 revealed that as age increases, reported difficulty
with instrumental activities of daily living increases. Instrumental activities of daily living
include cooking, shopping, cleaning and other tasks necessary for one to maintain his or her
home environment. The Health Interview Survey concluded that 28.7% of elderly males and
19.4% of elderly females have difficulty preparing meals (Gauci, 2008). With such difficulty,
meal choices become monotonous over time and a balanced is not achieved.
Those elderly individuals limited physically to an extent that requires institutionalization
in a nursing home suffer as well. Currently, there are only two dieticians on the island. This
scarcity results in the near absence of nutritional assessment in the nursing home environment.
The continuing assessment of an elderly patient’s nutritional status is fundamental to a positive
health outcome. Without a dietician, an accurate assessment of the patient’s eating patterns and
the result to which these patterns affect the patient’s health is nearly impossible to attain (Baker,
2007). Nutritional supplements, which are meant to substitute for protein or other nutrients, are
unheard of in nursing homes on the island. Such supplements are often served in the form of a
smoothie for patients with mastication problems. Without these supplements, patients with
missing teeth or ill-fitting dentures are likely to compromise their nutritional status by choosing
foods such as bread and pasta because they are easy to chew (Dr. A McElhatton, personal
communication, June 6, 2011).
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In conclusion, the discussed eating patterns represent a need for the reduction of red meat
consumption and an increase in the consumption of fish and poultry. Also a concern is the
failure to substitute high fat dairy products with low fat alternatives. The consumption of fruits,
vegetables, and whole grain products by the Maltese population are also lower than
recommended.
Recommendations
There are numerous ways in which the Maltese population, particularly the government
and ministry of health, could work to help combat the rising obesity and morbidity rates. An
increase in the extremely low number of dieticians and nutritionists would be beneficial for
education and follow up of patients. These health care professionals are able to make personal
recommendations and specific diets for patients suffering from all different conditions. For the
percentage of the population already in the obese category, dieticians and nutritionists would be
able to create a diet to help decrease their health risks and help them lose weight. These
professionals are also able to serve an educational purpose by instructing patients how to prevent
obesity and its resulting morbidities. Increased education could see a rise in the obesity rates.
In the absence of dieticians and nutritionists, Malta could choose to educate and utilize
their nursing staff to assess and teach patients about nutrition and obesity. While these groups
will not be able to specialize to the extent of a dietician, they can still serve some of the same
roles and provide brief education with current patients.
Education in general is an area that needs improvement in Malta. Numerous health care
professionals could work together to help make the public more aware of the CINDI food
pyramid and dietary guide. The results of the survey implied that education may be a key in the
fight against obesity; education will help increase the number of people who are fully understand
Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
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the recommended diet. Currently, people reply that they do not know much about the food
pyramid and this could be a major reason why they are not following the guidelines. Awareness
can be raised using different channels. A simple option is having physicians and other medical
professionals educate their patients during office visits and via brochures or posters at their
offices. However, due to the fact that the entire population will not be frequenting doctors’
offices, it would be effective to spread the word using mass communication. Television, radio,
and the internet are all valid options on which to place advertisements and programs designed to
get the public’s attention. Upon increased education, more people will be likely to at least
attempt to follow the CINDI food pyramid.
The United States has a program by the American Heart Association in which foods that
have been certified “heart healthy” are stamped with a common recognizable logo (Food
Certification, 2010). This allows the public to quickly and easily learn which foods will help
improve or maintain their heart health. Bring a similar program to Malta would be helpful for
those already combating obesity as well as those who are trying to maintain their current health
status. An idea for a program in Malta is to indicate not only which food are heart healthy, but
which foods are overall effective in avoiding diabetes. Word playing the CINDI dietary guide,
the symbol would be a young girl named Cindy. When the cartoon is red, representative of heart
health, the food is certified heart healthy; when the cartoon is blue, representative of diabetes
awareness, the food is low in sugars to prevent diabetes.
A last major recommendation for the Maltese is an assessment/screening program that
would test the general public on their nutritional status. This is a preventative measure that will
show patients where they fall on the overweight/obese scale. If a patient meets criteria for
overweight or obesity they will be given a dietary plan and then brought in for continued follow-
Dietary Trends of the Maltese Aging Population and the Resulting Morbidities
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up. This preventative program will aim to help not only the currently obese and overweight
population, but mainly the large sector of the population that is at risk of becoming obese. In the
Journal of Community Nursing, author Susan Holmes indicated an example of such a program
called a Nutritional care pathway. In this example, patients are nutritionally screened then
assessed to determine the cause of any medical conditions. If the assessment determines nutrition
as the issue the patient is referred to a dietitian and is given a diet plan. After some time,
reassessment is done and if the problem still exists the process begins again (Holmes, 2006).
Due to the severe rates of obesity and the resulting morbidities in the Maltese population,
numerous recommendations can be made to help improve these statistics. The problem needs to
be prevented not only reacted to, the population should be educated of dietary guidelines, and a
simple way of introducing healthy foods are will all be beneficial actions for this population.
Conclusion
Considering all the above findings, we have concluded that with proper adherence to a
set of standards set out by the World Health Organization through the CINDI program, Malta can
aim to reduce the health deficiencies particularly evident in the elderly population that result
from nutrition choices high in fat, salt, and carbohydrate content. Through this compliance,
Malta should hopefully observe a radical decline in the prevalence of various morbidities faced
by the elderly that will put them in better health standing.
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