Aspects of Community Nutrition for Elderly Patients

Diploma Thesis 2008 47 Pages

Nutritional Science



Listof Figures

Listof Tables

Listof Abbreviations

1. Introdu ction
1.1 Reason of Choice of Theme
1.2 Structure of this text

2. Nutrition and Elderly People
2.1 Energy
2.2 Carbohydrates
2.3 Protein
2.4 Fat and Fatty Acids
2.4.1 Cholesterol
2.5 Fibre
2.6 Minerals and Trace Elements
2.6.1 Cal cium
2.6.2 Magnesium
2.6.3 Iron
2.6.4 Zin c
2.7 Vitamins
2.7.1 Fat Soluble Vitamins Vitamin A and Beta Carotene Vitamin D Vitamin E Vitamin K
2.7.2 Water Soluble Vitamins Thiamine Riboflavin Nia cin Vitamin B Folate Vitamin B Ascorbic Acid
2.8 Water

3. Age- Associated Diseases
3.1 Sarcopenia
3.2 Diverti cular Disease
3.3 Diseases of Heart and Circulation
3.4 Can cer
3.5 Malnutrition and Immunity
3.6 Diabetes Mellitus Type
3.7 Osteoporosis
3.8 Dementia
3.9 Age Related Macular Degeneration

4. Community Nutrition
4.1 Importance of Community Nutrition
4.2 Community Nutrition in Hospitals and Nursing Homes
4.3 Distribution of Food in Hospitals
4.4 Frequency of Food
4.5 Food Based Dietary Guidelines
4.5.1 Food Plate Model
4.5.2 Food Pyramid
4.5.3 Food Circle
4.5.4 Mis cellaneous

5. Con clusion

6. Summary

7. References
7.1 Internet
7.2 Textbooks and journals

List of Figures

Fig. 1: Recommendations of carbohydrate intake [DACH, 2001; p.59]

Fig. 2: Characterisation of Sarcopenia [Lord C et al., 2007]

Fig. 3: Food plate model (three sectors plus addition) [VALSTA, LM; 1999] [NUTREC98]

Fig. 4: Food pyramid (four levels) [VALSTA, LM; 1999] [NUTREC98]

Fig. 5: Food circle [VALSTA, LM; 1999] [NUTREC98]

List of Tables

Tab. 1: Physiological reasons of ageing- different levels [AUSMAN et al., 1994; p.770- 780]

Tab. 2: DACH reference values related to PAL[DACH, 2001; p.25;32]

Tab. 3: Risk factors for Coronary Heart Diseases [MANN J, 2000; p.693]

Tab. 4: Dietary intake and risk of cancer (first results from the EPIC study) [GONZALEZ CA et al., 2006]

Tab. 5: The duties of a food catering company [DAHLSTEDT ML et al.,1986 (translated)]

Tab. 6: Results of a descriptive, cross-sectional study about patients in long-term care hospitals [SUOMINEN MH et al., 2007]

Tab. 7: Five different methods of catering [LIGHT, 1990; p.5 (modified)]

Tab. 8: General information by the National Nutrition Council [NUTREC98]

List of Abbreviations

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1. Introduction

On the 26th of May 2008 there was a small notice in an Austrian newspaper: a Spanish man aged 114(!) years died. Gene research did not reveal any special genetic differences that could explain his long life. But until late life he was physically active and his nutrition was based on vegetables, salad, fish and little vegetable oil. Additionally, he lived quite without stress.

My intention of this thesis is to give an overview of the nutritional situation of elderly people in an hospital. Nutrition in hospital is still being treated like anorphan child. Medications and medical care has more priority.

In the chapter "Nutrition and Elderly People" an overview of physiological changes and a description of nutrients and its relevance to elderly people is presented.

The next chapter deals with diseases that are associated with higher age. Those should be kept in mind for planning community nutrition.

The chapter "Community Nutrition" is also based on the information from the previous chapters to found a nutrition that suits best the needs of elderly patients living in a community.

1.1 Reason of Choice of Theme

Among the elderly, malnutrition is a common problem. People are getting always older than their previous generation. Are the existing programmes suitable to improve the situation? How can you update it? In many cases elderly people find their optimum care at institutions e.g. long term ward departments regarding their medical and nutritional needs. The nutrition should be suited to their special needs to reach optimal power to get a faster improvement of health. Community nutrition should always focus on special groups to be successful.

A better organisation and special training of health workers could improve screening and treatment of patients [BAILLY L et al., 2006].

Independent risk factors for developing malnutrition are higher age, polypharma cy (use of multiple medications by one patient) and malignant disease. The right nutritional support is important to optimise the clinical outcome of patients [PIRLICH M et al., 2006].

Especially nursing care is not valued highly enough. A shortage of time is described by doctors and nurses [FORDE R et al., 2006].

1.2 Structure of this text

This text is based on literature research and describes the basics of nutrition for elderly people, age related diseases and guidelines for community nutrition.

2. Nutrition and Elderly People

Due to physiological changes in the elderly like

- decreased energy expenditure (lowered metabolism, physical activity, active muscle mass, and increased body weight),
- lowered ability of adaptation (lowered smelling and sense of touch, thirst sensitivity, difficulties of chewing and increased sickness like diabetes, gout and hypertension) and
- decelerated digestion (less forming of spit, stomach secretion, lowered fatand calcium absorption and carbohydrate tolerance), there is a need to adapt their nutrition.

Many elderly are vulnerable for developing nutrient deficiencies. As a consequence, physical and mental diseases, decreased immune function, higher morbidity and mortality, decreased convalescence and a higher vulnerability for necrosis and de cubitus are occurring, especially to those who are bed-ridden [ELMADFA et al., 2004; p.496].

An higher risk for nutritional deficiency in the elderly has often been noticed, especially during times of stress and healthcare problems. Also some other circumstances can interfere with appetite that are related with physical, social and emotional problems. These ones are affecting the ability to purchase, to prepare and to consume a proper diet [AUSMAN et al., 1994; p.770- 780].

Tab. 1: Physiological reasons of ageing- different levels [AUSMAN et al., 1994; p.770- 780]

Abbildung in dieser Leseprobe nicht enthalten

The Mini Nutritional Assessment (MNA) (See www.mna-elderly.com) is after 15 years of its introduction, an easy to use tool to diagnose malnutrition in elderly in long-term care facilities [SIEBER CC, 2006].

It should be used in the geriatric assessment for getting minimum data for nutritional interventions [GUIGOZ Y, 2006].

2.1 Energy

About two thirds of the energy requirement reduction in the elderly are due to a decrease in physical activity, and the rest to a decrease in basal metabolism [AUSMAN et al., 1994; p.770- 780].

Differences in dietary variety, taste and palatability are affecting the energy regulation in late-life. For practical interventions they have to be considered to prevent fluctuations of weight and fat in old age. Changing the energy expenditure is impaired in the elderly. Also reduced hunger and increased satiation is noticed in the elderly [ROBERTS SB et al., 2006].

Elderly men who consume diets over several weeks with either too few or too many calories are not able to compensate for the resulting energy difference when given a diet ad libitum. They appeared also to be less hungry at meal initiation and were becoming more rapidly satiated during a standard meal. A low reported hunger predicted an unintentional weight loss in a group of healthy older women. This may be a useful tool for identifying older people at risk [HAYS NP et al., 2006].

Nutrient based guidelines recommend an energy intake related to the PAL level for the elderly (65 years and older) between 1600 to 2100 kcal/d for women and 2000 and 2500 kcal/d for men. [DACH, 2001; p.32].

Tab. 2: DACH reference values related to PAL[DACH, 2001; p.25;32]:

Abbildung in dieser Leseprobe nicht enthalten

In a study in France with hospitalised elderly patients (n=90; age=79,7 ±7,5), who were recovering from an acute illness the energy intake and resting energy expenditure (REE) was measured over a 3-day period. Their energy intake was higher than REE (mean REE=18.8 kcal/kg/d) by 1.29, but lower than the requirement. Those who were lowest had poor results on the Mini-Mental State Examination. Hence, the energy intake was just enough to cover the minimal requirements, but elderly patients may still get some benefit with an higher calorie intake [ALIX E et al., 2007].

Besides the physiological changes mentioned above, there are also nonphysiologi cal ones like social (poverty, isolation), psychological (depression, dementia), physical (edentulism, dysphagia) circumstances and pharmacological factors that influence food intake regulation and mechanism and may lead to a reduced energy intake [HAYS NP et al., 2006].

2.2 Carbohydrates

In an average diversified diet more than 50% of the energy intake comes from carbohydrates. Epidemiologi c researches showed a decrease of cardiovascular risk factors and other diseases with an higher percentage of carbohydrates and smaller percentage of saturated fatty acids [DACH, 2001; p.59].

Fig. 1: Recommendations of carbohydrate intake [DACH, 2001; p.59]:

illustration not visible in this excerpt

To fulfil the required energy intake in the human diet the components fat and carbohydrate are the most important. It is recommended to consume rather food that is rich in starch, fibre, essential nutrients and secondary phytosterols. An increased consumption of complex carbohydrates results in decreased caloric density and increased mi cronutrient density [DACH, 2001; p.59].

A slightly impaired carbohydrate absorption in the elderly people has been described, particular for mannitol, xylose and 3-0-methylglucose. But changes in the renal function may interfere with the results of absorption tests based on urinary excretion. Generally, it is difficult to define the prevalence of lactose intolerance, because many elderly tend to avoid milk products [AUSMAN et al., 1994; p.770- 780].

2.3 Protein

Dietary protein is an important source for amino acids and other nitrogen substances that are enabling to build up body protein and other metabolic active substances. Some experimental studies suggest to increase the required protein intake for elderly people, but until now there is too little data available to form new recommendations for this special group. No direct experimental evidence shows neither a damaging effect nor positive physiologic effects of increased dietary protein. An increased renal calcium excretion may occur due to increased protein intake, which could have negative effects on the calcium balance and bone health. Furthermore, calcium oxalate stones, mild metabolic acidosis and increased insulin resistance can be found as an effect of increased protein intake. Nutrient based guidelines recommend a daily intake of 0.8g/kg/d for female and male elderly (65 years and older) [DACH, 2001; p.35- 40].

Diets with large amounts of protein may not be well absorbed in the elderly. There is a minor increase in faecal nitrogen content. Quantitative information is limited to show absorptive changes [AUSMAN et al., 1994; p.770- 780].

Different sources of dietary protein have diverse effects on bone metabolism due to acid precursors provided by animal foods and due to base precursors provided by vegetable foods. An imbalance leads to a chronic net dietary acid load that may have adverse consequences on bone metabolism. In that study with 1035 community-dwelling white women aged over 65 years with a mean 7.0 years (±1.5) follow-up Sellmeyer DE et al. were testing the hypothesis that high dietary animal protein increased bone loss and the risk of fracture. They concluded that elderly women with a high dietary ratio of animal to vegetable protein intake had more rapid femoral neck bone loss and a greater risk of hip fracture than to those with a low ratio. An increase in vegetable protein intake and a decrease in animal protein intake may decrease bone loss and the risk of hip fracture. They did not find associations with age, weight, oestrogen use, tobacco use, exercise, total calcium intake and total protein intake. They suggested to confirm these results in other prospective studies and in a randomised trial [SELLMEYER DE et al., 2001].

A study group in Sweden found out that smaller, but energy and proteinenri ched meals are improving energy and nutrient intakes in elderly geriatric patients. With the standard hospital menu 6 out of 10 patients (age: 77-87 years) had lower energy intake (-67 to -674 kcal/day) than the calculated energy requirements according to the Nordic Nutrition Recommendation. With the energy and protein-enriched menu, the daily energy intake increased by 37%. Also the daily intake of protein, fat, carbohydrate, some vitamins and minerals was significantly higher with the second menu [LOREFALT B et al., 2005].

Healthy elderly people require an higher protein intake of 1.0-1.3g/kg/d to maintain nitrogen balance according to published nitrogen balance studies. Possible explanations are a lower energy intake and an impaired insulin action during feeding compared to young people. The efficiency of protein utilisation is also decreased. With higher protein intakes the risk of sarcopenia may be minimised [MORAIS JA et al., 2006].

2.4 Fat and Fatty Acids

Fat intake is an important energy source. There is a general advise to decrease fat consumption due to findings about the relationship of high fat intake and diseases: saturated fat and dyslipoproteinemia, atherosclerosis, colon cancer and overweight. A diet with 30% or less of fat energy intake (and a balanced composition of fatty acids) is desirable for preventing chronic diseases of cancer and heart. Epidemiologi c researches showed that a diversified diet and physical activity may decrease the risk of cardiac infarction. The nutrient based guidelines of German speaking countries recommend a daily fat intake about 30% of energy and a daily fatty acids intake about 2.5% (linolei c) and 0,5%1 (alpha-linoleni c) of energy for female and male elderly (65 years and older). An intake of more than 40% fat of total energy may facilitate the development of atherosclerosis, colon cancer and adiposity [DACH, 2001; p.43,44;46-49].

Fat digestion and absorption differs between elderly and young adults. Elderly people show a slightly less absorption (institutionalised ones even less) compared to young adults. Also a slower appearance of chylomi crons is shown in the elderly. Fat malabsorption and digestion problems have different causes and frequencies in the elderly. They are due to de conjugation of bile salts (not too common) and bacterial overgrowth may occur in the small intestine. Rarely gastric atrophy per se causes fat malabsorption. A slower lipid hydrolysis and uptake may lead to difference in gastric emptying times [AUSMAN et al., 1994; p.770- 780].

2.4.1 Cholesterol

Among saturated fatty acids, cholesterol is also found in food of animal origin. Cholesterol intake should not exceed over 300 mg/d. Concentrations of LDL and HDL, that are out of the normal range are among the risk factors for cardiovascular diseases. Developing atherosclerosis has multiple and individual genetics reasons like high plasma cholesterol (dyslipoproteinemia), hypertonia, diabetes mellitus, smoking and little physical activity. More often, a combination of all these factors is a reason for developing an early atherosclerosis. A nutrition that lowers the whole plasma cholesterol helps to avoid cardiac attacks. A few intervention studies showed a protective effect of EPA (20:5 n-3) against deadly cardiac attacks. There is some evidence that oleic acid in the Mediterranean nutrition has a protective effect against cardiac attack and cancer [DACH, 2001; p.46-49].


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elderly patients hospital community nutrition ageing




Title: Aspects of Community Nutrition for Elderly Patients