Australian and New Zealand Society for Geriatric Medicine: Position Statement - Obesity and the older person

Body Weight and Composition Changes in Geriatric Rehabilitation Are Dependent on Sarcopenia and Malnutrition: RESORT

OBJECTIVES

Body weight and muscle mass loss following an acute hospitalization in older patients may be influenced by malnutrition and sarcopenia among other factors. This study aimed to assess the changes in body weight and composition from admission to discharge and the geriatric variables associated with the changes in geriatric rehabilitation inpatients.

DESIGN

RESORT is an observational, longitudinal cohort.

SETTING AND PARTICIPANTS

Geriatric rehabilitation inpatients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital, Melbourne, Australia (N = 1006).

METHODS

Changes in body weight and body composition [fat mass (FM), appendicular lean mass (ALM)] from admission to discharge were analyzed using linear mixed models. Body mass index (BMI) categories, (risk of) malnutrition (Global Leadership Initiative on Malnutrition), sarcopenia (European Working Group on Sarcopenia in Older People), dependence in activities of daily living (ADL), multimorbidity, and cognitive impairment were tested as geriatric variables by which the changes in body weight and composition may differ.

RESULTS

A total of 1006 patients [median age: 83.2 (77.7-88.8) years, 58.5% female] were included. Body weight, FM (kg), and FM% decreased (0.30 kg, 0.43 kg, and 0.46%, respectively) and ALM (kg) and ALM% increased (0.17 kg and 0.33%, respectively) during geriatric rehabilitation. Body weight increased in patients with underweight; decreased in patients with normal/overweight, obesity, ADL dependence and in those without malnutrition and sarcopenia. ALM% and FM% decreased in patients with normal/overweight. ALM increased in patients without multimorbidity and in those with malnutrition and sarcopenia; ALM% increased in patients without multimorbidity and with sarcopenia.

CONCLUSIONS AND IMPLICATIONS

In geriatric rehabilitation, body weight increased in patients with underweight but decreased in patients with normal/overweight and obesity. ALM increased in patients with malnutrition and sarcopenia but not in patients without. This suggests the need for improved standard of care independent of patients' nutritional risk.

Nutritional status and post-operative complications in patients undergoing surgery for advanced pharyngeal or laryngeal cancer

PURPOSE

Malnutrition is an important prognostic indicator of post-operative outcomes in patients undergoing surgery for head and neck cancer, however, limited studies utilize validated nutrition assessment tools to accurately assess risk. The aim of this study was to determine the relationship between nutritional status on post-operative complications and length of stay for patients undergoing either a laryngectomy, pharyngectomy or pharyngolaryngectomy for head and neck cancer.

METHODS

Patients with head and neck cancer undergoing a laryngectomy, pharyngectomy or pharyngolaryngectomy at a tertiary hospital in Australia were eligible for this retrospective cohort study (n = 40). Nutritional status was assessed by the dietitian on admission using the validated Subjective Global Assessment tool. Clinical outcomes were collected via retrospective chart review and included length of stay and post-operative complications.

RESULTS

Pre-operative malnutrition incidence was 40%. Malnourished patients had higher incidences of any type of complication (57% vs 44%, p = 0.013) and pressure injury (86% vs 14%, p = 0.011) compared to well-nourished patients. Well-nourished patients had a clinically important shorter median length of stay compared to malnourished patients (17.5 vs 20 days).

CONCLUSION

Early identification and management of malnutrition is essential to minimize risk of post-operative complications and reduce length of stay and should be considered a key component of prehabilitation programs.

Changes in micronutrient intake and factors associated with this change among older Australian men: the Concord Health and Ageing in Men Project

OBJECTIVES

To examine changes in micronutrient intake over 3 years and identify any associations between socio-economic, health, lifestyle and meal-related factors and these changes in micronutrient intakes among older men.

DESIGN

Prospective study.

SETTING

Dietary adequacy of individual micronutrient was compared to the estimated average requirement of the nutrient reference values (NRV). Attainment of the NRV for twelve micronutrients was incorporated into a dichotomised variable 'not meeting' (meeting ≤ 6) or 'meeting' (meeting ≥ 7) and categorised into four categories to assess change in micronutrient intake over 3 years. The multinomial logistic regression analyses were conducted to model predictors of changes in micronutrient intake.

PARTICIPANTS

Seven hundred and ninety-four men participated in a detailed diet history interview at the third wave (baseline nutrition) and 718 men participated at the fourth wave (3-year follow-up).

RESULTS

The mean age was 81 years (range 75-99 years). Median intakes of the majority of micronutrients decreased significantly over a 3-year follow-up. Inadequacy of the NRV for thiamine, dietary folate, Zn, Mg, Ca and I were significantly increased at a 3-year follow-up than baseline nutrition. The incidence of inadequate micronutrient intake was 21 % and remained inadequate micronutrient intake was 16·4 % at 3-year follow-up. Changes in micronutrient intakes were significantly associated with participants born in the UK and Italy, low levels of physical activity, having ≥2 medical conditions and used meal services.

CONCLUSIONS

Micronutrient intake decreases with age in older men. Our results suggest that strategies to improve some of the suboptimal micronutrient intakes might need to be developed and implemented for older men.

Associations of Serum 25-Hydroxyvitamin D with Physical Performance and Bone Health in Overweight and Obese Older Adults

Low vitamin D status commonly accompanies obesity, and both vitamin D deficiency and obesity have been associated with falls and fracture risk in older adults. We aimed to determine the associations of serum 25-hydroxyvitamin D (25(OH)D) concentrations with physical performance and bone health in community-dwelling, overweight and obese older men and women. Serum 25(OH)D concentrations were measured in 84 participants with body mass index ≥25 kg/m² (mean ± SD age 62.4 ± 7.9 years; 55% women). Physical function was determined by short physical performance battery, hand grip and quadriceps strength, and stair climb power tests. Body composition and bone structure were assessed by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, respectively. Mean ± SD 25(OH)D was 49.6 ± 17.7 nmol/L, and 50% of participants had low 25(OH)D (<50 nmol/L) levels. 25(OH)D concentrations were positively associated with quadricep strength and stair climb power in women (B = 0.15; 95% CI 0.02–0.27 kg and B = 1.07; 95% CI 0.12–2.03 W, respectively) but not in men. There were no associations between 25(OH)D and bone parameters in either sex after multivariable adjustment (all p > 0.05). Lower 25(OH)D concentrations are associated with poorer quadricep strength and muscle power in overweight and obese older women but not men.

ESPEN guideline on clinical nutrition and hydration in geriatrics

BACKGROUND

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.

AIM

To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.

METHODS

This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process.

RESULTS

We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.

CONCLUSION

A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Obesity in Older Adults

The percentage of older obese adults is on the rise. Many clinicians underestimate the health consequences of obesity in the elderly, citing scarce evidence and concerns that weight loss might be detrimental to the health of older adults. Although overweight and obese elders are not at the same risk for morbidity and mortality as younger individuals, quality of life and function are adversely impacted. Weight loss plans in the elderly should include aerobic activities as well as balance and resistance activities to maintain optimal physical function.

[Obesity in old age and its importance for functionality and frailty]

In later life a high body mass index (BMI) is associated with the lowest age-related mortality rate. The BMI range used by the World Health Organization (WHO) to classify overweight, a BMI of 25-30 kg/m², can be regarded as normal weight in old age; nevertheless, obesity is associated with an increased risk of disability and of a deterioration in physical functionality, particularly among older age groups. This relationship to obesity has also been established for frailty. For this reason, a reduction in weight may be appropriate under functional aspects if BMI values exceed 30 kg/m²; however, such a decision cannot be made on the basis of an individual BMI alone. The functional status, body composition, comorbidities and, in particular the life perspectives of the patient should also be taken into consideration. If weight loss is intended, it must always be performed under strict medical supervision involving optimized protein intake, a carefully calculated moderate reduction in calories and adequate physical training. In the case of chronically ill elderly patients, weight reduction is not usually appropriate. Restrictive diets of any kind should principally be critically viewed in old age because even temporary inadequate energy intake may lead to accelerated deterioration of muscle and bone structure.