Inadequacy of Protein Intake in Older UK Adults

Older adults' acceptability of and preferences for food-based protein fortification in the UK, France and Norway

Research suggests that as we age, protein intake, recognised as vital for combating negative health outcomes, consistently falls below recommendations in older adults. Decreased food intake, combined with age-related eating complications is a major determinant of this protein undernutrition. If nutritional interventions are to be effective and sustainable, they must enable eating pleasure, cater for personal preferences and be adaptable to different eating patterns. As such, we aimed to identify successful strategies for at-home protein-fortification to empower older adults to take a personalised approach to their nutrition, without requiring a large behavioural change. To explore healthy older adults' (age 70+) acceptability and preferences for at-home protein fortification, European project Fortiphy led discussions with older adults (n = 37) and caregivers of older adults (n = 15) to develop high-protein recipes, which were then utilised in a home-use trial with healthy older adults (n = 158). Each fortified recipe was paired with a questionnaire to rate the ease of preparation and liking, and an end-of-study questionnaire was provided to capture overall opinions and preferences. The uniqueness of this study is that the protein fortified recipes were prepared and tested by older adults themselves, in their own homes. Findings showed that older adults were unaware of the importance of protein in ageing and did not have a desire to fortify their foods at present. Yet, they were positive regarding the concept and highlighted the importance of taste, familiar ingredients, and preferred preparation methods. Cultural preferences across countries were identified as having the most influence on the liking of fortified meals. This study also indicated a need for increased awareness of protein requirements to influence the motivation to use fortification.

Digital Intervention (Keep-On-Keep-Up Nutrition) to Improve Nutrition in Older Adults: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Digital health tools can support behavior change and allow interventions to be scalable at a minimal cost. Keep-on-Keep-up Nutrition (KOKU-Nut) is a free, tablet-based app that focuses on increasing physical activity and improving the dietary intake of older adults based on UK guidelines. The intervention targets an important research area identified as a research priority reported by the James Lind Alliance priority setting partnership for malnutrition.

OBJECTIVE

This study aims to assess the feasibility of using the digital health tool KOKU-Nut among community-dwelling older adults to inform a future randomized controlled trial. The secondary aims are to determine the acceptability, usability, preliminary effect sizes, and safety of the study and the intervention (KOKU-Nut).

METHODS

This is a feasibility randomized controlled trial. We plan to recruit a total of 36 community-dwelling older adults using purposive sampling. Participants will be randomized 1:1 to either the intervention or the control group. The intervention group will be asked to engage with KOKU-Nut 3 times a week for 12 weeks. Participants in the control group will receive a leaflet promoting a healthy lifestyle. All study participants will complete questionnaires at baseline and the end of the 12 weeks. A sample of participants will be asked to participate in an optional interview. The study will collect a range of data including anthropometry (height and weight), dietary intake (3-day food diary), physical function (grip strength and 5-times sit-to-stand), perceived quality of life (EQ-5D), usability (System Usability Scale), and safety (adverse events).

RESULTS

Data collection commenced in March 2024, and the results will be ready for publication by January 2025. Feasibility will be determined on the basis of participants' self-reported engagement with the intervention, and recruitment and retention rates and will be summarized descriptively. We will also consider the amount of missing data and assess how outcomes are related to group assignment. Acceptability will be measured using the modified treatment evaluation inventory and one-to-one semistructured interviews. Transcripts from the interviews will be analyzed using NVivo (version 12; QSR International) software using framework analysis to understand any barriers to the recruitment process, the suitability of the assessment measures, and the acceptability of the intervention and study design.

CONCLUSIONS

The study aligns with guidelines developed by the Medical Research Council for developing a complex intervention by using qualitative and quantitative research to examine the barriers of the intervention and identify potential challenges around recruitment and retention. We anticipate that these results will inform the development of a future powered randomized controlled design trial to test the true effectiveness of KOKU-Nut.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05943366; https://classic.clinicaltrials.gov/ct2/show/NCT05943366.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50922.

Select dietary changes towards sustainability: Impacts on dietary profiles, environmental footprint, and cost

Healthy sustainable diets have the power to improve dietary intakes and environmental resource use. However, recommendations for improving food choices need to consider the effects of any changes across multiple dimensions of health, environmental sustainability, and dietary cost to promote long-lasting behaviour change. The aim of this study was to identify differences between original diets, and the diets that can be achieved through the implementation of select small dietary changes towards sustainability. Twelve hypothetical sustainable actions were investigated for the potential effects of these actions on dietary markers (protein, saturated fat, sugars, salt, iron, and calcium), environmental footprints (greenhouse gas emissions, freshwater withdrawals, and land use), and dietary cost. Dietary data from 1235 individuals, aged 19-94 years, participating in the UK National Diet and Nutrition Survey (2017/19) provided the original diet. Dietary changes were implemented as required by each sustainable action, and differences between the original diet and each new diet were investigated. Results revealed benefits to dietary markers and environmental characteristics from eleven sustainable actions (range: F(1,728) = 5.80, p < .001 to F(1,506) = 435.04, p < .001), but effects were stronger for some actions than for others. Greatest benefits for all three outcomes were found for actions which reduced meat consumption and/or replaced meat with pulses or eggs. The remaining sustainable actions tended to be beneficial for improving outcomes individually or to some degree. Our results demonstrate the possible impacts of a number of small sustainable dietary actions for dietary, environmental, and cost outcomes, and provide a hierarchy of actions based on benefit. Findings may facilitate dietary behaviours towards improved health, whilst also offering fruitful contributions towards environmental footprint targets in the UK.

A Narrative Review of Non-Pharmacological Strategies for Managing Sarcopenia in Older Adults with Cardiovascular and Metabolic Diseases

This narrative review examines the mechanisms underlying the development of cardiovascular disease (CVD) and metabolic diseases (MDs), along with their association with sarcopenia. Furthermore, non-pharmacological interventions to address sarcopenia in patients with these conditions are suggested. The significance of combined training in managing metabolic disease and secondary sarcopenia in type II diabetes mellitus is emphasized. Additionally, the potential benefits of resistance and aerobic training are explored. This review emphasises the role of nutrition in addressing sarcopenia in patients with CVD or MDs, focusing on strategies such as optimising protein intake, promoting plant-based protein sources, incorporating antioxidant-rich foods and omega-3 fatty acids and ensuring sufficient vitamin D levels. Moreover, the potential benefits of targeting gut microbiota through probiotics and prebiotic fibres in sarcopenic individuals are considered. Multidisciplinary approaches that integrate behavioural science are explored to enhance the uptake and sustainability of behaviour-based sarcopenia interventions. Future research should prioritise high-quality randomized controlled trials to refine exercise and nutritional interventions and investigate the incorporation of behavioural science into routine practices. Ultimately, a comprehensive and multifaceted approach is essential to improve health outcomes, well-being and quality of life in older adults with sarcopenia and coexisting cardiovascular and metabolic diseases.

The Food4Years Ageing Network: Improving foods and diets as a strategy for supporting quality of life, independence and healthspan in older adults

By 2050, it is predicted that one in four people in the United Kingdom will be aged 65 years and over. Increases in lifespan are not always translated into years spent in good health. Incidence rates for chronic diseases are increasing, with treatments allowing people to live longer with their disease. There is good evidence to support changes to lifestyle to maintain or improve body composition, cognitive health, musculoskeletal health, immune function and vascular health in older adults. Much research has been done in this area, which has produced significant support for foods and nutrients that contribute to improved healthspan. Yet two major barriers remain: firstly, older adult consumers are not meeting current UK recommendations for macro- and micronutrients that could benefit health and quality of life and secondly, the UK-specific recommendations may not be sufficient to support the ageing population, particularly for nutrients with key physiological roles. More work is needed to improve intakes of specific foods, diets and nutrients by older adults, through a variety of mechanisms including (i) development of specific food products; (ii) improved clarity of information and (iii) appropriate marketing, and policy changes to enable incentives. The Food4Years Ageing Network aims to build a wide-reaching and multidisciplinary community that is committed to the development, integration and communication of healthy, affordable foods and specific diets for all older adults across the UK food landscape. The Network will identify evidence-based strategies for improving food intake and nutrition in older adults, paving the way to "living well while living longer."

Adaptation and validation of a protein intake screening tool for a UK adult population

Adequate dietary protein intake is important in human subjects for maintaining muscle turnover, determining the protein content of tissues and thus the preservation of muscle mass and function as we age. A screening tool to assess if an older individual is likely to have a lower dietary protein intake (predicted probability of protein intake ≤1⋅0 g/kg per d), has been developed for a Netherlands dietary profile, but this has not been validated in a UK population. This study aimed to adapt and then validate the protein screening tool for use in a UK population. Amendment of the tool was undertaken using data from UK BioBank and the UK National Diet and Nutrition Survey to reflect protein sources in the UK diet. Validation of the amended version of the protein screener screening tool was conducted using protein intake derived from a food frequency questionnaire (FFQ) in a sample of UK adults (n = 184) (age range 18-91 years) as the reference standard. Using the FFQ, 40 % of respondents (n = 74) reported a protein intake of ≤1⋅0 g per kg body mass. The discriminative accuracy of the amended screener was tested using receiver operating characteristic (ROC) curves. The area under the curve for the ROC was 0⋅731 (95 % CI 0⋅657, 0⋅805), indicating that the amended screener may be a valid tool to screen for individuals consuming ≤1⋅0 g/kg adjusted BM/d in an adult UK population. This protein screener tool is a potential method to screen individuals with a likelihood of habitually consuming protein intakes of ≤1⋅0 g/kg per d. Further validation is needed using a more robust dietary intake methodology and for specific groups, such as older adults. The screener may be applicable across healthcare, clinical and research applications.

Review of protein intake and suitability of foods for protein-fortification in older adults in the UK

Protein is a vital dietary component for combating negative health outcomes associated with malnutrition in older adults, including sarcopenia, functional decline and reduced quality of life. Yet, recommended daily protein intake is consistently unmet, as evidenced in the literature and reaffirmed in this review. Poor appetite is recognized as a major determinant of protein-energy undernutrition and thus fortification of regular food or drinks provides a flexible and relevant approach for older adults with reduced appetite. To increase the likelihood of fortified products being successfully incorporated into the diets of older adults, they must be adaptable to older adults eating patterns, cater for their preferences and take the specific age-related problems that complicate food intake into account. This paper aims to highlight older adults' current sources of protein, shopping habits, typical eating patterns and commonly consumed foods, and hence consider appropriate carriers for protein enrichment. Data were reanalyzed from a combination of freely available UK datasets, including the National Dietary and Nutrition Survey and the Food and You Survey, alongside data purchased from market research consultancy, Kantar. These insights draw attention to the potential suitability of foods for fortification purposes, with the ultimate objective to promote eating pleasure and prevent malnutrition.

Relative protein intake and associations with markers of physical function in those with type 2 diabetes

AIMS

To examine the independent associations between relative protein intake (g kg^-1  day ¹ ) and markers of physical function in those with type 2 diabetes, while also comparing with current guidelines for protein intake.

METHODS

This analysis reports data from the ongoing Chronotype of Patients with Type 2 Diabetes and Effect on Glycaemic Control (CODEC) study. Functional assessments included: Short Physical Performance Battery (SPPB), 60 s sit-to-stand (STS-60), 4-m gait speed, time to rise from a chair (×5) and handgrip strength. Participants also completed a self-reported 4 day diet diary. Regression analyses assessed whether relative protein intake was associated with markers of physical function. Interaction terms assessed whether the associations were modified by sex, age, HbA1c or body mass index (BMI).

RESULTS

413 participants were included (mean ± SD:age = 65.0 ± 7.7 years, 33% female, BMI = 30.6 ± 5.1 kg/m² ). The average total protein intake was 0.88 ± 0.31 g kg^-1  day^-1 . 33% of individuals failed to meet the reference nutrient intake for the United Kingdom (≥0.75 g kg^-1  day^-1 ), and 87% for European recommendations (≥1.2 g kg^-1  day^-1 ). After adjustment, each 0.5 g/kg of protein intake was associated with an 18.9% (95% CI: 2.3, 35.5) higher SPPB score, 22.7% (1.1, 44.3) more repetitions in STS-60, 21.1% (4.5, 37.7) faster gait speed and 33.2% (16.9, 49.5) lower chair rise time. There were no associations with handgrip strength or any interactions.

CONCLUSIONS

Relative protein intake was positively associated with physical function outcomes, even after consideration of total energy intake. As a number of individuals were below the current guidelines, protein intake may be a modifiable factor of importance for people with type 2 diabetes.

Effect of low carbohydrate diets on insulin resistance and the metabolic syndrome

PURPOSE OF REVIEW

This review outlines recent research in the application of low carbohydrate diets (LCD) for insulin resistance (IR) and metabolic syndrome (MetS).

RECENT FINDINGS

Studies included in this review explore how a LCD can be used in the management of patients with IR and MetS. LCDs have been shown to result in Type 2 Diabetes Mellitus (T2DM) remission, improve lipid profiles and dramatically reduce intrahepatic fat.

SUMMARY

The field of nutritional science is notoriously complex. The LCD has a simple narrative, which can easily and safely be applied in clinical practice. Current guidelines recognise and encourage the use of LCD as a valid option for patients with T2DM and obesity. Structured, evidence-based education should be available for all clinicians to increase confidence and ensure consistency and quality control. Further real-world evidence into the application and scalability of a LCD are required. The use of digital health solutions and improved health technology should see significant advances in this field, with dietary habit being driven by patient-derived health data in response to food, and not population-based food guidelines. The narrative around MetS and IR needs to change from progression to remission, with a LCD being a valid option for this.

Optimising protein intake in older people to maintain their musculo- skeletal health

The concept of healthy ageing has become a significant aspect of the public health approach to older people's well-being. Physiological changes that occur with ageing, such as a lack of mobility and sarcopenia (an age-related decline in muscle mass and strength), have the potential to negatively affect older people's quality of life and musculoskeletal health, often contributing to falls and fractures. Protein intake is a crucial element in maintaining optimal health in older people, and is important in delaying sarcopenia. This article discusses the role of protein in healthy ageing and outlines various recommendations for optimising protein intake in older people.

Weight Loss Strategies and the Risk of Skeletal Muscle Mass Loss

With energy intake restriction and exercise remaining the key diet and lifestyle approaches to weight loss, this is not without potential negative implications for body composition, metabolic health, and quality and quantity of life. Ideally, weight loss should be derived almost exclusively from the fat mass compartment as this is the main driver of metabolic disease, however, several studies have shown that there is an accompanying loss of tissue from the fat-free compartment, especially skeletal muscle. Population groups including post-menopausal women, the elderly, those with metabolic disease and athletes may be particularly at risk of skeletal muscle loss when following a weight management programme. Research studies that have addressed this issue across a range of population groups are reviewed with a focus upon the contribution of resistance and endurance forms of exercise and a higher intake dietary protein above the current guideline of 0.8 g/kg body weight/day. While findings can be contradictory, overall, the consensus appears that fat-free and skeletal muscle masses can be preserved, albeit to varying degrees by including both forms of exercise (but especially resistance forms) in the weight management intervention. Equally, higher intakes of protein can protect loss of these body compartments, acting either separately or synergistically with exercise. Elderly individuals in particular may benefit most from this approach. Thus, the evidence supports the recommendations for intakes of protein above the current guidelines of 0.8 g/kg body weight/d for the healthy elderly population to also be incorporated into the dietary prescription for weight management in this age group.

The PROMOTe study: targeting the gut microbiome with prebiotics to overcome age-related anabolic resistance: protocol for a double-blinded, randomised, placebo-controlled trial

BACKGROUND

Loss of skeletal muscle mass and strength occurs with increasing age and is associated with loss of function, disability, and the development of sarcopenia and frailty. Dietary protein is essential for skeletal muscle function, but older adults do not anabolise muscle in response to protein supplementation as well as younger people, so called 'anabolic resistance'. The aetiology and molecular mechanisms for this are not understood, however the gut microbiome is known to play a key role in several of the proposed mechanisms. Thus, we hypothesise that the gut microbiome may mediate anabolic resistance and therefore represent an exciting new target for ameliorating muscle loss in older adults. This study aims to test whether modulation of the gut microbiome using a prebiotic, in addition to protein supplementation, can improve muscle strength (as measured by chair-rise time) versus protein supplementation alone.

METHODS

The study is a randomised, double-blinded, placebo-controlled trial, with two parallel arms; one will receive prebiotic and protein supplementation, and the other will receive placebo (maltodextrin) and protein supplementation. Participants will be randomised as twin pairs, with one twin from each pair in each arm. Participants will be asked to take supplementation once daily for 12 weeks in addition to resistance exercises. Every participant will receive a postal box, containing their supplements, and the necessary equipment to return faecal, urine, saliva and capillary blood samples, via post. A virtual visit will be performed using online platform at the beginning and end of the study, with measures taken over video. Questionnaires, food diary and cognitive testing will be sent out via email at the beginning and end of the study.

DISCUSSION

This study aims to provide evidence for the role of the gut microbiome in anabolic resistance to dietary protein. If those who take the prebiotic and protein supplementation have a greater improvement in muscle strength compared with those who take protein supplementation alone, this would suggest that strategies to modify the gut microbiome may reduce anabolic resistance, and therefore potentially mitigate sarcopenia and frailty in older adults.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04309292 . Registered on the 2nd May 2020.

Short-Term Protein Supplementation Does Not Alter Energy Intake, Macronutrient Intake and Appetite in 50-75 Year Old Adults

Ageing is associated with a reduction in muscle mass and strength, termed sarcopenia. Dietary protein is important for the maintenance of muscle mass through the promotion of muscle protein synthesis. However, protein is also reported to be a highly satiating nutrient. This raises concerns that protein intake for musculoskeletal health reasons in older adults may exacerbate age-related decreased appetite and may result in reduced energy and nutrient intake. This study aimed to investigate the effect of short-term protein supplementation and its timing (morning vs. evening), on energy and nutrient intake and appetite measures in middle-older age adults. Twenty-four 50-75 year olds were recruited to a randomised cross-over trial. In phase 1 (pre-supplementation) participants completed a food diary and reported hunger and appetite on three alternate days. During the second and third phases, participants consumed a 20 g whey protein gel (78 mL/368 kJ), for four days, either in the morning (after breakfast) or the evening (before bed), whilst completing the same assessments as phase 1. No differences in dietary intakes of energy, macronutrients and micronutrients were recorded when comparing the pre-supplementation phase to the protein supplementation phases, irrespective of timing (excluding the contribution of the protein supplement itself). Similarly, no differences were observed in self-reported feelings of hunger and appetite. In conclusion, a 20 g/day whey protein supplement given outside of meal-times did not alter habitual dietary intakes, hunger or appetite in this middle-older age adult population in the short-term. This approach may be a useful strategy to increasing habitual protein intake in the middle-older age population.

The Association between Poor Diet Quality, Physical Fatigability and Physical Function in the Oldest-Old from the Geisinger Rural Aging Study

More perceived physical fatigability and poor diet quality are associated with impairments in physical function in older adults. However, the degree to which more perceived fatigability explains the association between poor diet quality and low physical function is unknown. We examined this relationship in 122 (66F, 56M) of the oldest-old participants from the Geisinger Rural Aging Study (GRAS). We used 24-h dietary recalls to assess the Healthy Eating Index (HEI), the Pittsburgh Fatigability Scale (PFS, 0–50) to assess perceived physical fatigability, and the PROMIS Physical Function 20a* to assess physical function. We grouped participants into three age categories: 80–84 (n = 51), 85–89 (n = 51), and 90+ (n = 20) years. Multiple linear regression revealed that a lower HEI was associated with higher PFS Physical score after adjusting for age group, sex, body mass index, and the number of medical conditions (p = 0.001). Several macro- and micro-nutrient intakes were also lower in those reporting more (≥15) compared to less (<15) perceived physical fatigability. Mediation analysis revealed that PFS Physical scores explained ~65% (p = 0.001) of the association between HEI total score and PROMIS19 Physical Function score. Poor diet quality may contribute to more perceived physical fatigability, which could exacerbate impairments in the oldest-old’s physical function.

Sarcopenia during COVID-19 lockdown restrictions: long-term health effects of short-term muscle loss

The COVID-19 pandemic is an extraordinary global emergency that has led to the implementation of unprecedented measures in order to stem the spread of the infection. Internationally, governments are enforcing measures such as travel bans, quarantine, isolation, and social distancing leading to an extended period of time at home. This has resulted in reductions in physical activity and changes in dietary intakes that have the potential to accelerate sarcopenia, a deterioration of muscle mass and function (more likely in older populations), as well as increases in body fat. These changes in body composition are associated with a number of chronic, lifestyle diseases including cardiovascular disease (CVD), diabetes, osteoporosis, frailty, cognitive decline, and depression. Furthermore, CVD, diabetes, and elevated body fat are associated with greater risk of COVID-19 infection and more severe symptomology, underscoring the importance of avoiding the development of such morbidities. Here we review mechanisms of sarcopenia and their relation to the current data on the effects of COVID-19 confinement on physical activity, dietary habits, sleep, and stress as well as extended bed rest due to COVID-19 hospitalization. The potential of these factors to lead to an increased likelihood of muscle loss and chronic disease will be discussed. By offering a number of home-based strategies including resistance exercise, higher protein intakes and supplementation, we can potentially guide public health authorities to avoid a lifestyle disease and rehabilitation crisis post-COVID-19. Such strategies may also serve as useful preventative measures for reducing the likelihood of sarcopenia in general and in the event of future periods of isolation.

Comparing supermarket loyalty card data with traditional diet survey data for understanding how protein is purchased and consumed in older adults for the UK, 2014-16

Background

Our ability to understand population-level dietary intake patterns is dependent on having access to high quality data. Diet surveys are common diet assessment methods, but can be limited by bias associated with under-reporting. Food purchases tracked using supermarket loyalty card records may supplement traditional surveys, however they are rarely available to academics and policy makers. The aim of our study is to explore population level patterns of protein purchasing and consumption in ageing adults (40 years onwards).

Methods

We used diet survey data from the National Diet and Nutrition Survey (2014–16) on food consumption, and loyalty card records on food purchases from a major high street supermarket retailer (2016–17) covering the UK. We computed the percentage of total energy derived from protein, protein intake per kg of body mass, and percentage of protein acquired by food type.

Results

We found that protein consumption (as the percentage of total energy purchased) increased between ages 40–65 years, and declined thereafter. In comparison, protein purchased in supermarkets was roughly 2–2.5 percentage points lower at each year of age. The proportion of adults meeting recommended levels of protein was lowest in age groups 55–69 and 70+. The time of protein consumption was skewed towards evening meals, with low intakes during breakfast or between main meals. Meat, fish and poultry dominated as sources of protein purchased and consumed, although adults also acquired a large share of their protein from dairy and bread, with little from plant protein.

Conclusions

Our study provides novel insights into how protein is purchased and consumed by ageing adults in the UK. Supermarket loyalty card data can reveal patterns of protein purchasing that when combined with traditional sources of dietary intake may enhance our understanding of dietary behaviours.