Compliance with an oral hyperproteic supplement with fibre in nursing home residents

A Comparison of Dietary Intake and Nutritional Status between Aged Care Residents Consuming Texture-Modified Diets with and without Oral Nutritional Supplements

Oral nutritional supplements (ONS) are high-energy and protein-rich nutrition drinks that are commonly prescribed to individuals with compromised nutritional status. Aged care residents requiring texture-modified diets are exposed to poor oral intake and malnutrition. This study aimed to investigate the dietary intake and nutritional status of residents consuming texture-modified diets with and without ONS. This multicentre cross-sectional study included 85 residents consuming texture-modified diets (86.0 ± 8.7 y; n = 46 requiring ONS and n = 39 without ONS). A one-day dietary record was completed using a validated visual plate waste estimation method. To determine the adequacy, nutrition intake was then calculated using FoodWorks (Xyris Ltd., Brisbane, Australia) and compared to the recommended dietary intake for Australia and New Zealand. The Mini-Nutritional Assessment Short Form was collected to assess nutritional status. Residents receiving ONS had significantly higher energy, protein, carbohydrates and fat intake than those who did not consume ONS (p < 0.05). No significant differences were found in saturated fat, fibre or sodium intake. With the administration of ONS, residents were able to meet their protein requirement but fell short of their energy and carbohydrates requirements. Both groups had inadequate fibre intake and a high saturated fat intake. A total of 48% of the residents were at risk of malnutrition and 38% were malnourished. Aged care residents requiring texture-modified diets are at high risk of malnutrition as a result of inadequate dietary intake. Administration of ONS may be an effective strategy to optimise nutrition intake.

Guidance for Healthy and More Climate-Friendly Diets in Nursing Homes-Scenario Analysis Based on a Municipality's Food Procurement

Reducing the climate impact of food provided for residents in nursing homes is challenging, as the diets for older, frail adults must be high in protein content and energy density while at the same time ensuring that the meals are palatable and recognizable. This study aimed at providing guidance on healthy and more climate-friendly diets for nursing homes in the City of Copenhagen. The goal was to decrease greenhouse gas emissions (GHGE) by at least 25% while at the same time providing nutritionally adequate and recognizable menus. First, food purchase data were compiled with datasets matching each food item to a proxy food item and then to databases containing GHGE and nutrient information. Secondly, two diet scenarios were modelled based on current procurement practices, i.e., an energy- and protein-dense diet and a standard protein-dense diet, and converted into guidelines for menu planning. The diets contained less total meat, especially beef, and significantly more pulses, nuts and seeds in order to increase protein content according to recommendations for older adults. Finally, a combined scenario was calculated to reflect the joint climate impact reduction. This kind of innovation in food procurement is required in order to achieve the necessary transition to a sustainable food system.

Nutrition Assessment and Interventions for the Prevention and Treatment of Malnutrition in Older Adults: An Evidence Analysis Center Scoping Review

Older adults living in the community or long-term residence such as a nursing home are at increased risk for malnutrition due to factors such as depression and isolation. The purpose of this scoping review is to identify the best available research that evaluates the validity and reliability of nutrition assessment tools, and the effectiveness of nutrition interventions to prevent or treat malnutrition among older adults. A literature search was conducted in Medline, Embase, CINAHL, and Cochrane Central databases to identify clinical trials, published in the English language, evaluating assessment and intervention methods aimed to treat or prevent malnutrition among older adults living in the community or their long-term residence such as nursing homes. Articles were screened by 2 reviewers, then data were extracted and narratively synthesized. The literature search retrieved 20,937 articles and 197 articles were included in narrative synthesis. A total of 73 assessment articles were identified, 36 of which were validity and reliability trials. A total of 122 intervention articles were identified, the majority of which were randomized controlled trials. A few of the most commonly evaluated interventions were oral nutrition supplements, medical nutrition therapy, fortification and enrichment, and nutrition education. Several systematic reviews were identified, however, that did not meet the criteria of this review. There is a need to conduct systematic reviews for nutrition assessment and intervention trials to guide development of evidence-based nutrition practice recommendations for older adults living in the community or their long-term residence.

Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.

Results of High-Protein, High-Calorie Oral Nutritional Supplementation in Malnourished Older People in Nursing Homes: An Observational, Multicenter, Prospective, Pragmatic Study (PROT-e-GER)

OBJECTIVES

To assess if the impact of oral nutritional supplements (ONS) on nutritional and functional status in malnourished older persons living in nursing homes shown by clinical trials are also found outside a trial setting.

DESIGN

Observational, multicenter, prospective, pragmatic study.

SETTING AND PARTICIPANTS

This study was carried out in 38 nursing homes throughout Spain. Nursing home physicians recruited consecutive residents, older than 65 years, with a diagnosis of malnutrition, when a clinical decision to start ONS had been taken after unsuccessful initial management with dietary interventions.

INTERVENTION

The participants received daily 2 bottles of an energy-rich, high-protein commercial ONS for 3 months.

MEASURES

Primary outcomes were changes in nutritional status [body weight, body mass index (BMI), and Mini Nutritional Assessment-Short Form (MNA-SF)]; secondary outcomes were functional changes [Functional Ambulation Classification, Barthel index, handgrip strength, and Short Physical Performance Battery (SPPB)], as well as safety and adherence after 12 weeks of follow-up.

RESULTS

A total of 282 residents (median age 86 years, 67% women) were included, and 244 (86.5%) completed the follow-up. At baseline, 77.3% of the participants were malnourished (BMI 19.7 kg/m², interquartile range 18.3-21.8). After 12 weeks of follow-up, participants experienced significant increases in body weight (2.6 ± 3.1 kg, 5.2 ± 5.9%), BMI (1.0 ± 1.2 kg/m²) and MNA-SF (4.0 ± 2.5 points). There were also significant improvements in functional status measured by the Barthel index, handgrip strength, SPPB, and gait speed. Good adherence was registered in 94.6% of the participants. No relevant side effects were found.

CONCLUSIONS AND IMPLICATIONS

Improvements in nutritional and functional status can be found when using a high-protein, high-calorie ONS in older undernourished people living in nursing homes.

Are the therapeutic strategies in anorexia of ageing effective on nutritional status? A systematic review with meta-analysis

BACKGROUND

Anorexia of ageing (AA) may be considered as a risk factor for frailty and has an important impact on quality of life, morbidity and mortality.

METHODS

A systematic review and a meta-analysis were performed to summarise the results from several trials on the effectiveness of treatments in AA, as associated with depression, sensory impairment of taste and smell, decreased appetite or early satiety, and disability. Eligible studies were required to report baseline and follow-up values, the mean change (∆-change) from baseline, and/or the mean difference among intervention groups versus control group, concerning food intake (kcal/daily) and/or nutritional outcomes, such as body weight, body mass index, albumin and Mini Nutritional Assessment.

RESULTS

The systematic review included 20 papers based on different therapeutic approaches concerning food intake and/or nutritional outcomes. The results of the meta-analysis indicate that the interventions for AA have an important impact on body weight [+1.59 kg; 95% confidence interval (CI) = 1.48-+1.71 kg; P < 0.001) and on energy intake (+56.09 kcal; 95% CI = -54.05 to +166.25 kcal; P = 0.32). Regarding secondary outcomes, it was not possible to meta-analyse the limited amount of data availab le.

CONCLUSIONS

The different variants of AA need to be defined because diverse therapeutic approaches are available. A more precise definition of the functional impairments associated with AA may allow a more correct decision about the most appropriate therapy to be prescribed. Moreover, this may allow for a more effective performance of the different therapeutic approaches once they are better targeted to the different scenarios of AA.

Is Fibre an Effective Strategy to Improve Laxation in Long-Term Care Residents?

The high prevalence of constipation in long-term care (LTC) residents has been a long-standing issue for caregivers, attending health professionals, and the residents themselves. The traditional medical response has been to utilize pharmaceutical laxatives, enemas, and suppositories for treatment. The purpose of this review was to determine if fibre supplementation (including fibre added to foods) is effective in increasing stool frequency, improving stool consistency, and decreasing laxative use in LTC residents. A systematic search was conducted using PubMed and CINAHL databases, inclusive to March 2017. Search terms included: "long-term care" or "nursing home" AND "fiber (fibre)," "bran," "psyllium," "inulin," or "prebiotic." Intervention trials of fibre supplementation with ≥5 LTC residents were included. The search generated 456 articles following removal of duplicates; 8 studies met the inclusion criteria. Three additional trials were identified through a hand search of references of pertinent articles. Current evidence suggests that added fibre may be effective in increasing stool frequency and/or decreasing laxative use in LTC residents and, thus, may lessen the burden of constipation. However, randomized controlled trials are needed to clearly demonstrate the effects of adding fibre to foods, particularly insoluble and less fermentable sources, on constipation in LTC residents.

Supplementation with nutrients modulating insulin-like growth factor-1 negatively correlated with changes in the levels of pro-inflammatory cytokines in community-dwelling elderly people at risk of undernutrition

BACKGROUND

Suboptimal nutrition accompanied by chronic low-grade increases in circulating cytokine levels is more common in elderly people. We explored the improvement in nutritional status, especially in the level of insulin-like growth factor-1 (IGF-1) and its relationship with changes in circulating cytokine levels, after providing extra protein and energy content to community-dwelling older adults at risk of undernutrition.

METHODS

Sixty nondiabetic subjects, aged ≥65 years and living independently in a community for elderly people, with a serum pre-albumin level ≤30 mg dL^-1 and a body mass index <25 kg m^-2 , were recruited. The subjects were followed for a 2-week pre-intervention period, during which they maintained routine dietary habits. This was followed by an intervention period, during which they received oral nutritional supplementation for 2 weeks.

RESULTS

Following 2 weeks of intervention, there were significant increases in total lymphocyte count (TLC) and insulin-like growth factor (IGF)-1, pre-albumin and transferrin compared to baseline. Body weight and mid-arm circumference significantly increased without alteration of tricep skinfold thickness at the end of the intervention. There was a significant reduction in interleukin (IL)-6 levels and a trend toward a decrease in the tumor necrosis factor (TNF)-α levels. At baseline, age was negatively correlated with IGF-1 levels and positively correlated with IL-6 and TNF-α levels. The change (▵, from baseline) in IGF-1 level was positively correlated with age and negatively correlated with ▵IL-6 and ▵TNF-α.

CONCLUSIONS

A 2-week intervention with oral nutritional supplementation improved nutritional status and decreased circulating cytokine levels. Specifically, ▵IGF-1 was negatively correlated with changes in pro-inflammatory cytokine levels in community-dwelling elderly people at risk of undernutrition. (Clinicaltrials.gov: NCT02656186).

Effectiveness of Food-Based Fortification in Older People. A Systematic Review and Meta-Analysis

BACKGROUND

Early intervention with nutritional support has been found to stop weight loss in older people malnourished or at risk of malnutrition. Enriched food could be a more attractive alternative to improve meals, than conventional oral nutritional supplements.

AIMS

To determine the effectiveness of food-based fortification to prevent risk of malnutrition in elderly patients in community or institutionalized elderly patients.

METHODS

A systematic review was conducted of randomized controlled trials, quasi-experimental, and interrupted time series including a longitudinal analysis.

PARTICIPANTS

Elderly patients who are institutionalized, hospitalized or community-dwelling, with a minimum average age of 65 years. All type of patient groups, with the exception of people in critical care, or those who were recovering from cancer treatment, were included.

INTERVENTION

Studies had to compare food-based fortification against alternatives. Studies that used oral nutritional supplementation such as commercial sip feeds, vitamin or mineral supplements were excluded. The search was conducted in Cochrane, CINAHL, PubMed, EMBASE, LILACS, and Cuiden. An independent peer review was carried out.

RESULTS

From 1011 studies obtained, 7 were included for the systematic review, with 588 participants. It was possible to perform meta-analysis of four studies that provided results on caloric and protein intake. Food-based fortification yielded positive results in the total amount of ingested calories and protein. Nevertheless, due to the small number of participants and the poor quality of some studies, further high quality studies are required to provide reliable evidence.

IMPLICATIONS FOR PRACTICE

Despite the limited evidence, due to their simplicity, low cost, and positive results in protein and calories intake, simple dietary interventions based on the food-based fortification or densification with protein or energy of the standard diet could be considered in patients at risk of malnutrition.

Consuming two additional serves of dairy food a day significantly improves energy and nutrient intakes in ambulatory aged care residents: a feasibility study

OBJECTIVES

[corrected] Low-level aged-care residents are at risk of malnutrition. Oral supplements and fortified foods used to treat malnutrition in the elderly require special preparation and administration by staff. Therefore we aimed to determine if increasing dairy food intake in residents by two serves per day would improve energy and nutrient intakes and prevent malnutrition in residents.

DESIGN

Prospective intervention study.

SETTING

2 intervention and 2 control low-level aged-care facilities in Melbourne, Australia.

PARTICIPANTS

130 residents (n = 68 intervention, 78% female, mean age 86.5 years).

INTERVENTION

This feasibility study was a 4-week intervention where menus were modified to include at least two additional serves of dairy food/day. Control facilities consumed from their regular menus.

MEASUREMENTS

Mean macro- and micro-nutrient intakes before and after intervention and over the same time period in controls were recorded using observed intake (food served minus waste) and changes over time determined using paired t-tests. Comparison in proportion of residents meeting nutritional requirements was determined using Chi-square distribution test.

RESULTS

Following intervention, daily increases in mean energy intake (900kJ, P<0.001), protein intake (+25g, P<0.0001), proportion of energy from protein (+4%, P<0.0001) and proportion of estimated energy requirements (EER) (+18%, P<0.0001) were observed, while proportion of energy from fat decreased (-3%, P<0.0001). In controls mean energy intake remained below the EER, and protein intake remained unchanged. Increases in mean daily micronutrient intakes were observed for numerous nutrients including calcium (+679mg, P<0.0001), vitamin D (+1.4μg, P<0.0001), phosphorus (+550mg, P<0.0001), and zinc (+2.8mg, P<0.0001), which remained unchanged in control residents. Calcium and zinc intakes achieved recommended intake levels on the higher dairy diet, but were below recommended levels in controls. Mean sodium intakes remained unchanged. During intervention a greater proportion of residents achieved the EER for energy and the RDI for protein and calcium compared to controls.

CONCLUSION

Two additional serves of dairy food can significantly improve nutrient intake in aged-care residents and its ease of provision makes it a viable option to potentially prevent malnutrition.

Meeting the nutritional needs of elderly residents in aged-care: are we doing enough?

OBJECTIVES

[corrected] Institutionalized elderly are at high risk of malnutrition, including those residing in low-level aged-care and able to self-feed. We used comprehensive dietary intake assessments to determine the nutritional adequacy of food served to residents and if food waste contributed to insufficient nutrient intakes.

DESIGN

Cross sectional.

SETTING

18 low-level aged care facilities.

PARTICIPANTS

199 residents (mean age 86.7 yrs, 76% females).

MEASUREMENTS

Dietary data using 3-6 day weighed food records. Foods were categorized into main food groups (grains, fruit, vegetables, meats, dairy and 'extra') and quantified based on recommended serving sizes. Chi squared test was used to determine sex differences in proportion of residents below recommended intake levels.

RESULTS

Residents were provided with sufficient serves of fruit (>2) and meats (>1), but not dairy (<3), vegetables (<5) and grain foods (women only, <4), and excess serves of 'extra' foods (>2). Mean dietary intakes did not meet recommendations for calcium, zinc, magnesium, potassium, folate and dietary fibre with many residents not meeting energy and protein requirements. Sodium intake was up to 3 times higher than recommended, and sugars consumed in excess. Food waste was 0-15% and resulted in men not consuming recommended serves of grain foods. 'Extra' foods contributed substantially to energy intake but provided few of the required nutrients.

CONCLUSION

Substituting some 'extra' foods for serves of dairy, vegetables and wholegrain foods would improve the nutritional quality of foods, without altering food volume, so is feasible to improve nutritional status in elderly aged-care residents.