Role of nutrition in well-being of older people

Merja Suominen, PhD, Ad ProfessorSociety for Gerontological Nutrition in Finland

University of Helsinki

Ageing in Finland

• Finland is aging at a higher rate than other European countries

• The amount of 65 year olds and older is increasing

• 800 000 in 2000 1,4 millions by 2030

• Those who are 80 y and more will double

Malnutrition

• Energy-protein malnutrition, low body mass index (BMI), and unintentional weight loss are common problems among frail, old people

• Malnutrition predicts disability and increased mortality as well as poor psychosocial well-being among the aged population

• Protein malnutrition is associated with sarcopenia, falls, fractures and impaired immune response and infections

Nutritional status of service housing residents

0

10

20

30

40

50

60

70

80

90

Long-term care (n= 1087)

Nursing home (n= 1987)

Service-house (n= 1475)

Community (n =400)

Well-nourished

At risk for malnutrition

Malnourished

Soini et al. 2011

More than half of those living long term

care have poornutritional status

Sarcopenia and dynopeniaSarcopenia is loss of muscle mass

Dynopenia is loss of strength in muscles

Even with normal diet and moderate exercise

Caused by • Inadequate protein intake

• Reduced sensitivity to protein synthesis

Women have 30 % less muscle mass and they loose muscles earlier than men

Janssen et al. J Am Geriatr Soc 2002; 50: 889 - 89

Heterogenity in diet and nutrient intake

• Quality of the diet is often poor

• Energy intake may be small

• In SENECA study, 47% of older women and 24% of men received inadequate amount of micronutrients

• People with high-energy intakes have sufficient nutrient intake

• Special attention should be paid to the protein intake and protein content of food

• Psycho-social factors and inactive lifestyle relating to aging contribute to poor eating and impaired nutrition

Protein• For healthy adults RDA for protein is 0,8

g/kg/day• Food and Nutrition Board. Washington, DC: National

Academy Press, 2002.

• For aged people recommendation is too low to protect against sarcopenia

• It is needed 1,2- 1,4 (even 1,5) g/kg/day• NNR 2014 and Finnish recommendations

• Enough intake of protein helps maintainmuscular and skeletal health and also illnessesrecovery

18

.3.2

01

6

7

Less than one third received enough protein

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Energy Protein Vitamin A Vitamin D Vitamin E Vitamin C

Malnutrition Risk of malnutrition Normal nutritional status

p<0.001 p=0.60p=0.16 p=0.32p<0.001 p=0.15

Jyväkorpi SK et al. High proportion of older people with normal nutritional status have poor nutrient intakes and low diet-quality (in press)

MNA, N = 900

6.3

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14

Memory disorders and nutrition

• Nonpharmacological therapies have had promising effects on health-related quality-of-life (HRQoL) among people with Alzheimer's disease (Olazaran et al 2010)

• Possibilities of nutrition interventions in this patient group has received less attention

Food intake and dementia• Difficulties in cooking and dining are connected to memory

disorders: spoon doesn’t find plate or mouth, cutlery are difficultto use

• Served food in dementia wards has been sufficient or substantial, but the residents ate 72% of the food that service staff had planned

• Lack of help in eating has been the risk factor for the low intake of energy, protein and micronutrients; residents ate foods of a low nutrient density

Schmid et al, 2003 Priefer ja Robbins 1997, Rivière ym. 2002, Keller ym. 2007, Roqué ym. 2013 Ikeda

ym. 2002 Suominen et al 2004

Tailored nutrition guidance of persons with AD living at home with their spouses: RCT-trial (NuAD)

• Aim was to examine the effect of tailored nutrition guidance on nutrition and health-related quality-of-life (HRQoL) of older persons with Alzheimer disease (AD) living at home

• A total of 99 persons with confirmed AD (aged ≥65 years) living at home with their spousal caregivers were randomised to a controlled clinical trial

Study design: Jyvakorpi S, Puranen T, Pitkala KH, Suominen MH. Nutritional treatment of aged individuals with Alzheimer disease living at home with their spouses: study protocol for a randomized controlled trial. Trials. 2012;13:66.

Nutrients less than recommended among home dwelling AD patients and spouses

Figure 1. Proportions (%) of participants who received amounts of nutrients less than recommended (N=196)

Energy <1500 kcal

Protein <60 g

Calcium <800 mg

Vitamin C <75 mg

Vitamin E <8/10 mg

Folic acid <300 µg

0

10

20

30

40

50

60

70

80

90

100

Male

Female

Baseline results: Puranen TM, Jyvakorpi SK, Pitkala KH, Eloniemi-Sulkava U, Poysti M, Suominen MH. Nutritional intervention of home-dwelling patients with Alzheimer´s disease living at home with their spouse: A randomized, controlled trial. Baseline findings and feasibility. J Aging: Research and Practise. 2013;2:236-241.

Results• Mean age of AD patients was 77.4

years, mean MMSE 19.3

• Mean intake of protein increased in intervention group and decreased in control group, p=0.03.

• Same trend was seen in other nutrients. P

rot/

Kg a

t baselin

e

0,6

0,7

0,8

0,9

1,0

1,1

1,2

1,3

1,4Controls

Intervention

Pro

t/K

g a

t end o

f fo

llow

-up

0,6

0,7

0,8

0,9

1,0

1,1

1,2

1,3

1,4

Suominen MH, Puranen TM, Eloniemi-Sulkava U , Jyvakorpi SK, Kautiainen H, Siljamaki-Ojansuu U, Pitkala KH. Nutritional guidance improves nutrient intake and quality of life, and may prevent falls in aged persons with Alzheimer disease living with a spouse (NuAD trial). J Nutr Health Aging 2015.

Results and conclusions• Participants’ HRQoL according to 15D

improved in the intervention group, declined in the control group, p=0.007.

• Differences were seen in mental functioning reflecting cognition, breathing, usual activities reflecting daily physical functioning and depression.

• Conclusions: Tailored nutritional intervention has beneficial effects on nutrient intake and HRQoL of home-dwelling AD patients.

Change from baseline

-0,3 -0,2 -0,1 0,0 0,1 0,2 0,3

15D-score

Sexual activity

Vitality

Distress

Depression

Discomfort and symptoms

Mental function

Usual activities

Excretion

Speech

Eating

Sleeping

Breathing

Hearing

Vision

Mobility

p=0.007

p=0.63

p=0.24

p=0.26

p=0.048

p=0.42

p=0.72

p=0.35

p=0.49

p=0.41

p=0.27

p=0.046

p=0.006

p=0.18

p=0.045

p=0.47

Intervention

Control

Puranen T, Pietilä S, Jyvakorpi S, Eloniemi-Sulkava U, Pitkala KH, Suominen MH. Nutrient intake of home dwelling Alzheimer patients and their spouses – gender perspective.Puranen T, Eloniemi-Sulkava U, Pitkala KH, Suominen MH. How to improve nutrient intake of Alzheimer´s patients living at home with their spouses - qualitative description of tailored nutritional advice

Caregivers and spouses

• Living with a spouse is associated with regulareating and better nutrition for both

• Changes in eating habits and increaseddependence of AD patient are the biggestchallences for spouses

• Nearly all spouses experienced frustration and stress in daily dining and they didn’t know how to improve situation

Keller 2007, Gustafsson and Sidenvall 2002, Kullberg et al 2008 Silvan et al

2013

Caregiver burden

Caregiver

Male Female

Pro

tein

inta

ke,

g/K

g

0,5

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0,7

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0,9

1,0

1,1

1,2

1,3

1,4Caregiver

AD

Caregiver

Male Female

Vitam

in C

inta

ke,

mg

20

30

40

50

60

70

80

90

100

110

120Caregiver

ADThere is a gender difference in ability to cope with caregiver responsibilities related to nutrition (Puranen et al, JNHA 2014)

Figure 1. Protein and vitamin C intakes in the families with a male and a female caregiver. NuAD-trial

Male caregivershave difficulties

Multidisciplinary educational program

We developed an educational program for professionals (nurses and food service personal) in dementia wards to improve their skills to assess the nutrition of aged residents and to respond to the problems in their nutrition

The aims of this study were

• to evaluate the effectiveness of the educational program on learning of the professionals

• to clarify its impact on the nutrition of aged residents

Team work

Small group discussion

Learning by doing

Personal feedback

Studying literature

Lectures

1. Learning to assess the nutritional status by the MNA and to measure food consumption

3. Recognizing low points in the MNA -> problems in nutrition

2. Analysing the results of the MNA

4. Measuring food consumption during three days

6. Comparing energy and nutrient intake with the recommendations

7. Discussing in the team why the nutrient intake differs from the recommendation

8. Making changes to residents’ diets individually

9. Following-up with the MNA and measuring the food consumption

5. Analysing energy and nutrient intake

Educational process Incorporating nutrition as a part of good care of residents

Methods

• The assessment of the nutritional status with the MNA-tests

• Food consumption during three days energy and nutrient intake

were counted before and after education of nurses and food service among the studied

residents (N=21)in dementia wards

Results Professionals’ evaluation of the learning methods

0 1 2 3 4 5

Lecture

Filling the food diaries

Discussing the results of diaries in

multiprofessional team

Assessing residents by the MNA

Studying alone

Results

• The nutrition education for professionals had a positive impact on the energy and protein intake, on the BMI, and on the results of the MNA-tests of many frail residents living in dementia wards

• After the education professionals were very surprised at their overestimation of residents’ food intake

• Professional felt easy to respond to residents’ nutritional needs after calculating the energy content of residents’ diets and discussing nutritional matters in multi-professional teams.

Suominen MH, Kivisto S, Pitkala KH. The effects of nutrition education on professionals’ practice and further to the nutrition of aged nursing home residents. European Journal of Clinical Nutrition, 2007;61:1226-1232.

Conclusions

• Adult education may also have real positive effects on the nutrition of older residents

• Practical learning by doing in nutritional issues is an effective way in training professionals who work among older residents

Food service The food is planned considering aged individuals’ needsThe nutritional content of the offered food is countedThe food contains enough energy and nutrientsThe nutritional content of the food is balancedFavourite dishes are prepared oftenThe feedback is acquired and it will be answeredThe food is prepared well: the right cooking timefor every dish, specially tomeat and vegetablesThe hygiene and self control is done well

Nurses Nutritional status is assessed regularlyThe MNA test is done when necessaryThe elderly are weighed regularly and theirBMIs countedThe cause of the poor nutritional status is defi nedEnergy dense diet is offered to the residentin the case of low BMI and weight lossNutritional supplements are used when needed

Multi-disciplinary co-operation leaded

by the managementFood service personal participate in the meetings in wards

in multi-disciplinary teams. Food service personal visit the wardsduring meal times in order to see in practise residents eating.

Dining and food intake The food and liquid consumptions are measuredand compared to recommendationsThe meal times are used as an activationThe atmosphere at the meal time is pleasantThe elderly eat together and the moment is unhurriedIf the appetite is poor the resident is encouraged to eatThe d rugs are not given at the meal time

Implications for the future1. Assessment of elderly nutrition

Simple methods for assessing nutritional status as well as food and nutrient intake of elderly people are needed

2. Education of professionalsEducation of nurses and general practitioners is urgently required in order to increase awareness about malnutrition and nutrition care possibilities

3. Nutrition recommendationsClear dietary guidelines directed at frail, elderly people are needed

4. Co-operation of the staffMore co-operation between different professionals is requiredto identify the risk of malnutrition and individual nutritionalneeds of elderly people

Suominen M. Nutrition and Nutritional Care of Elderly People in FinnishNursing Homes and Hospitals. University of Helsinki 2007

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Bie

den

fop

f

“Eating and having a good meal is part of

our everyday life and important to

everybody, not least to people living with

dementia. But it is still an almost totally

neglected area of focus in relation to these

diseases.”

Compass Group and Alzheimer’s Disease

International (ADI)

February 2014

Nutrition recommendations

Suominen M, Finne-Soveri H, Hakala P, Hakala-Lahtinen P, Männistö S, Pitkälä K, Soini H, Sarlio-Lähteenkorva S.

Nutr Health Aging

Volume 18, Number 10, 2014

Groups of aged individuals

Points of recommendations

1. Heterogeneity of nutritional needs in different age and disability groups should be taken into consideration

2. Aged individuals’ nutrition should be assessed regularly1. Weight control once a month

2. Assessment of food intake, in particularly protein intake

3. Adequate intake of energy, protein, nutrients, fiber and fluid

4. Vitamin D supplement (20 micrograms per day) after 60 years should be taken

5. Physical activities, maintenance of muscular strength should be emphasized and also made possible

PROMISS 2016-2020

• PROMISS (PRevention Of Malnutrition In Senior Subjects in the EU) is a multi-country project aiming to turn the challenge of tackling malnutrition in community-dwelling older persons into an opportunity for healthy ageing for the future.

• The PROMISS consortium contains worldwide expertise in epidemiology, clinical trials, geriatrics, nutrition, physical activity, microbiomics, as well as in behaviour, consumer, sensory and computer sciences. It builds on strong collaborations with food industry and SMEs to strengthen innovation of the European agri-food sector and their market position.

• The dietary and physical activity strategies and food products will be specifically developed with older user involvement to meet the needs and fit the preferences of older consumers

• Coordinated by STICHTING VU-VUMC in Netherlans, University of Helsinki is a partner in RCT

Publications

• Jyväkorpi SK, Pitkälä KH, Puranen TM, Björkman MP, Kautiainen H, Strandberg TE, Soini H, Suominen MH. Low protein and micronutrient intakes in heterogeneous older population samples. Arch Gerontol Geriatr 2015;15:30022-30024.

• Puranen TM, Pitkala KH, Suominen MH. Tailored nutritional guidance for home-dwelling ad families: the feasibility of and elements promoting positive changes in diet (NuAD-trial) ). J Nutr Health Aging 2015

• Suominen MH, Puranen TM, Eloniemi-Sulkava U , Jyvakorpi SK, Kautiainen H, Siljamaki-Ojansuu U, Pitkala KH. Nutritional guidance improves nutrient intake and quality of life, and may prevent falls in aged persons with Alzheimer disease living with a spouse (NuAD trial). J Nutr Health Aging 2015.

• Puranen TM, Pietila SE, Pitkala KH, Kautiainen H, Raivio MM, Eloniemi-Sulkava U, JyvakorpiSK, Suominen MH. Caregivers’ male gender is associated with poor nutrient intake in AD families J Nutr Health Aging. 2014;18:672-6.

• Puranen TM, Jyvakorpi SK, Pitkala KH, Eloniemi-Sulkava U, Poysti M, Suominen MH. Nutritional intervention of home-dwelling patients with Alzheimer´s disease living at home with their spouse: A randomized, controlled trial. Baseline findings and feasibility. J Aging: Research and Practise. 2013;2:236-241.

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