Elsevier

Clinical Nutrition

Volume 29, Issue 2, April 2010, Pages 160-169
Clinical Nutrition

Review
Older adults and patients in need of nutritional support: Review of current treatment options and factors influencing nutritional intake

https://doi.org/10.1016/j.clnu.2009.09.003Get rights and content

Summary

Background & aims

Many older adults and patients do not achieve sufficient nutritional intake to support their minimal needs and are at risk of, or are suffering from, (protein-energy) malnutrition. Better understanding of current treatment options and factors determining nutritional intake, may help design new strategies to solve this multifactorial problem.

Methods

Medline, Science Citation Index, ScienceDirect and Google databases (until December 2008) were searched with the keywords malnutrition, elderly, older adults, food intake, energy density, variety, taste, satiety, and appetite.

Results

37 Factors affecting nutritional intake were identified and divided in three categories; those related to the environment, the person, and the food. For older adults in nursing homes, encouragement by carers and an appropriate ambiance seem particularly important. Meal fortification, offering variety, providing frequent small meals, snacks and particularly Oral Nutritional Supplements (ONS) between meals are other possibilities for this group. Product factors that stimulate intake include palatability, high energy density, low volume, and liquid format.

Conclusion

The current review gives a comprehensive overview of factors affecting nutritional intake and may help carers to improve nutritional intake in their patients. The product factors identified here suggest that especially small volume, energy and nutrient dense ONS can be effective to improve nutritional intake.

Introduction

Much attention is given to the obesity problem i.e. people who consume more energy than they need, and less attention is given to the many, often older people who do not consume enough nutrients and/or energy to support their minimum requirements. Malnutrition is very common in this group, even in Western society.1 Up to 12.5% of patients residing in the community with chronic disease are underweight. The prevalence of undernutrition and risk of undernutrition in community dwelling older adults (>65 years) have been reported to be 4.3% and 25.4%, respectively.2 Two recent studies showed that 49.5% of residents (average age 84.2 years) in residential care facilities were moderately to severely malnourished,3 and that 6% of frail older adults (78–86 years) undergoing rehabilitation were malnourished and 13% mildly malnourished.4 The prevalence of malnutrition in long-term care home residents has been estimated to be as high as 85%.5 It has been estimated that the mean prevalence of being underweight in patients admitted to hospital is approximately 18% (range 5%-37.5%).6 On average nutritionally at risk patients incurred 19% higher hospital costs than the average of those not at risk with a similar diagnosis.7 Other studies have reported figures of up to 75% and even 300% greater treatment costs associated with the presence of malnutrition.8, 9, 10

Malnutrition has been defined as “…a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome”.11

Malnutrition is one of the greatest threats to the health, well-being and autonomy of older adults.12 The National Health and Nutrition Survey (NHANES) II in the USA, has shown that involuntary weight loss is disproportionately high in older adults and is associated with increased mortality.12 In older patients unintentional weight loss is associated with higher risk of infection, depression and death. Unintentional weight loss can lead to muscle wasting, decreased immunocompetence and increased rate of complications.7

A BMI below 20 kg/m2 and/or recent unintentional weight loss can be used to detect protein-energy malnutrition, which has been defined as undernutrition due to an inadequate intake of protein, fat, and carbohydrate.6 A loss of approximately 5–10% of body weight in the previous 12 months may indicate a problem in the older patient. The leading causes of involuntary weight loss are depression, cancer, cardiac disorders, lower socioeconomic status, functional disabilities and benign gastrointestinal diseases. Overall, psychiatric disorders, including depression, account for 58% of the cases of involuntary weight loss in nursing home patients.13

The aim of this review is to give an overview of malnutrition factors that influence nutritional intake in older adults and current ways to treat protein-energy malnutrition status.

Section snippets

Methods

Medline, Science Citation Index, ScienceDirect and Google databases were searched (until December 2008) with the keywords malnutrition, elderly, older adults, food intake, energy density, variety, taste, satiety, and appetite. The first author prepared the initial list of publications based on the search results. Based on this initial list, all authors (WFN, HW, PR and MMH) made the selection of the papers together and analyzed the scientific studies used in this review. Publications were

Results

Based on our search and subsequent selection of papers, 123 papers have been reviewed. These were reviewed for their topic content and then sub-divided into the topics of factors influencing nutritional intake i.e. personal, food and environmental factors. Current practices to improve nutritional intake in malnourished older adults i.e. dietary advice, meal fortification, variety, between-meal snacks and frequent small meals, and Oral Nutritional Supplements were also reviewed.

Conclusion

From the evidence reviewed here, it is clear that improving nutritional intake in older adults in need of nutritional support is a multifactorial problem. We have identified 37 factors affecting nutritional intake that can be divided in three categories:

  • (1)

    Personal factors

Older adults undergo a series of social, physiological and psychological changes that affect their eating process and ultimately their energy intake (Fig. 2). Older adults are more quickly satiated, often suffer from olfactory

Conflict of interest statement

Willem F. Nieuwenhuizen, Hugo Weenen, Paul Rigby are employees of Danone, a supplier of ONS. This work was funded by Danone Research, Center for Specialised Nutrition, Wageningen The Netherlands.

Statement of authorship and author agreement

WFN, HW, PR and MMH analyzed scientific studies used in this review and wrote the manuscript together. All authors read and approved the final manuscript.

Acknowledgements

We gratefully acknowledge Willemijn van Schuppen and Jennifer Hall for literature searches used in this review.

References (123)

  • C.M. Lermer et al.

    Perception of dietary fat: ingestive and metabolic implications

    Prog Lipid Res

    (1999)
  • A.C. Bach et al.

    The usefulness of dietary medium-chain triglycerides in body weight control: fact or fancy?

    J Lipid Res

    (1996)
  • M. Krondl et al.

    Food use and perceived food meanings of the elderly

    J Am Diet Assoc

    (1982)
  • V.B. Duffy et al.

    Olfactory dysfunction and related nutritional risk in free-living, elderly women

    J Am Diet Assoc

    (1995)
  • J.E. Morley et al.

    Anorexia and aging: pathophysiology

    Nutrition

    (1999)
  • S.S. Schiffman et al.

    Effect of flavor enhancement of foods for the elderly on nutritional status: food intake, biochemical indices, and anthropometric measures

    Physiol Behav

    (1993)
  • B.J. Rolls et al.

    Effects of age on sensory-specific satiety

    Am J Clin Nutr

    (1991)
  • M.L. Pelchat et al.

    Dietary monotony and food cravings in young and elderly adults

    Physiol Behav

    (2000)
  • B.J. Rolls

    Do chemosensory changes influence food intake in the elderly?

    Physiol Behav

    (1999)
  • M.T. Fanelli et al.

    Characterizing consumption patterns by food frequency methods: core foods and variety of foods in diets of older Americans

    J Am Diet Assoc

    (1985)
  • A. Drewnowski et al.

    The dietary variety score: assessing diet quality in healthy young and older adults

    J Am Diet Assoc

    (1997)
  • B.J. Rolls et al.

    Volume of food consumed affects satiety in men

    Am J Clin Nutr

    (1998)
  • J.M. de Castro

    Macronutrient and dietary energy density influences on the intake of free-living humans

    Appetite

    (2006)
  • E.A. Bell et al.

    Energy density of foods affects energy intake across multiple levels of fat content in lean and obese women

    Am J Clin Nutr

    (2001)
  • E.A. Bell et al.

    Energy density of foods affects energy intake in normal-weight women

    Am J Clin Nutr

    (1998)
  • B.J. Rolls et al.

    Energy density but not fat content of foods affected energy intake in lean and obese women

    Am J Clin Nutr

    (1999)
  • R.J. Stubbs et al.

    Energy density, diet composition and palatability: influences on overall food energy intake in humans

    Physiol Behav

    (2004)
  • T.V. Kral

    Effects on hunger and satiety, perceived portion size and pleasantness of taste of varying the portion size of foods: a brief review of selected studies

    Appetite

    (2006)
  • T.V. Kral et al.

    Energy density and portion size: their independent and combined effects on energy intake

    Physiol Behav

    (2004)
  • R. Mattes

    Fluid calories and energy balance: the good, the bad, and the uncertain

    Physiol Behav

    (2006)
  • R. Mattes

    Soup and satiety

    Physiol Behav

    (2005)
  • B.J. Rolls et al.

    Effects of temperature and mode of presentation of juice on hunger, thirst and food intake in humans

    Appetite

    (1990)
  • A.J. Stull et al.

    Liquid and solid meal replacement products differentially affect postprandial appetite and food intake in older adults

    J Am Diet Assoc

    (2008)
  • R.D. Mattes

    Fluid energy–where's the problem?

    J Am Diet Assoc

    (2006)
  • E. Almiron-Roig et al.

    No difference in satiety or in subsequent energy intakes between a beverage and a solid food

    Physiol Behav

    (2004)
  • J.M. Brunstrom

    Effects of mouth dryness on drinking behavior and beverage acceptability

    Physiol Behav

    (2002)
  • T. Hulshof et al.

    The effects of preloads varying in physical state and fat content on satiety and energy intake

    Appetite

    (1993)
  • R.D. Mattes et al.

    Beverage viscosity is inversely related to postprandial hunger in humans

    Physiol Behav

    (2001)
  • G. Hughes et al.

    Old and alone: barriers to healthy eating in older men living on their own

    Appetite

    (2004)
  • M.F. Mathey et al.

    Health effect of improved meal ambiance in a Dutch nursing home: a 1-year intervention study

    Prev Med

    (2001)
  • M.J. Gall et al.

    Effect of providing fortified meals and between-meal snacks on energy and protein intake of hospital patients

    Clin Nutr

    (1998)
  • A.D. Barton et al.

    A recipe for improving food intakes in elderly hospitalized patients

    Clin Nutr

    (2000)
  • A. Odlund Olin et al.

    Energy-dense meals improve energy intake in elderly residents in a nursing home

    Clin Nutr

    (2003)
  • B.M. Margetts et al.

    Prevalence of risk of undernutrition is associated with poor health status in older people in the UK

    Eur J Clin Nutr

    (2003)
  • M. Cuervo et al.

    Nutritional assessment interpretation on 22,007 Spanish community-dwelling elders through the Mini Nutritional Assessment test

    Public Health Nutr

    (2009)
  • D. Gaskill et al.

    Malnutrition prevalence and nutrition issues in residential aged care facilities

    Australas J Ageing

    (2008)
  • J.L. Adolphe et al.

    QA novel solution is needed to correct low nutrient intaks in elderly long-term care residents

    Nutr Rev

    (2007)
  • Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. An evidence-based approach to treatment, UK;...
  • M.I. Correia et al.

    The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis

    Clin Nutr

    (2003)
  • C. Gallagher-Allerd et al.

    Malnutrition and clinical outcomes: the case for medical nutrition therapy

    J Am Diet Assoc

    (1996)
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