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Nutrients of concern in an ageing population
It is well recognised that we are living longer. Average life expectancy in the UK is 82.8 years for women and 79 years for men. But while life expectancy has increased, this has not been matched by improvements in levels of ill-health from causes such as heart disease and cerebrovascular diseases such as stroke. For many, around 20% of their later life will be spent in poor health.
The role nutrition may play in the prevention of heart disease and cancers has been recognised but the role of nutrition in other age related conditions that are prevalent in care homes is perhaps less well known These conditions include:
- Muscle mass loss increasing risk of falls;
- Low bone density leading to fractures;
- Cognitive decline.
Last week, I was invited to attend an expert roundtable entitled: Nutrient intakes in older people- is it a problem? Where we discussed the importance of nutrition as we age. This provided a valuable opportunity to reflect on the diets of older people and consider, in particular, which nutrients may be of concern in the care home population.
Whilst we have good data on intakes of nutrients in free living older people, we have little current data on the nutrient intakes of older people in care homes. The last national survey that specifically looked at the nutrient intake and status of people aged 65 years and over in residential care (excluding hospitals and those in intensive care) was conducted in 1994/1995, so is now over 20 years old. This was the first national survey that looked at the oldest age categories, and remains the only one that included older people living in care homes. The survey suggested that older people living in residential care are at particular risk of micronutrient deficiencies, and reported poor status in vitamin C, vitamin D, folate and iron. A more recent publication, the 2014 Manual of Dietetic Practice, also suggested that intakes of protein and fibre may be a concern in older people.
Let’s take a look at these nutrients in a bit more detail
Age-related muscle loss can increase risk of falls, and is more marked in older people who have low physical activity and have poor diets. Muscle mass can be increased/preserved by ensuring protein and exercise needs are met. Increasingly research suggests the source, amount and timing of protein intake may have an impact on muscle. Yet in care homes older people can experience difficulties in consuming enough protein at each meal occasion to have an optimum effect on muscle.
Although fibre was highlighted as an important nutrient in the recent Scientific Advisory Committee on Nutrition (SACN) report Carbohydrates and Health, with an increase in the dietary reference value recommended, public recognition has largely been focussed on the report recommendations on reducing sugars intake. The conclusions of the report were that that a diet rich in dietary fibre reduces the risk of type 2 diabetes mellitus, cardiovascular disease and colorectal cancer. Yet older people in care homes may not be eating the foods that are good sources of fibre such as fruit and veg, wholegrains, potatoes with skins, beans, legumes and peas, and nuts and seeds.
Vitamins and minerals
Poor vitamin C intakes have been reported in individuals with poor appetites, are frail or dependent on institutionalised catering. Vitamin C supports the immune system. It also helps maintain connective tissue and supports wound healing. Fruit, fruit juice and vegetables are the main contributors to the UK diet yet consumption of these in care homes may be insufficient. Low folate intake has also been reported. Deficiencies of folate, along with vitamin B6 and vitamin B12, lead to elevations in plasma homocysteine, which has been associated with cardiovascular disease.
The prevalence of low vitamin D status in the UK has been recognised as a public health issue. In general, older adults are at an increased risk of vitamin D deficiency, not only due to reduced skin production of vitamin D with age but also because of age-related factors that can result in limited sun exposure, such as being more housebound, People aged 65 years or over are recommended to take a daily supplement containing 10 micrograms of vitamin D .The prevalence of deficiency is of particular concern in older people in care homes. A recent Swedish study in 11 nursing homes reported that 15% were deficient, and vitamin D deficiency was associated with increased mortality. Vitamin D status in older post-menopausal women is also of particular interest because of the association of low vitamin D status with increased risk of osteoporosis and fracture.
Iron intake can also be a particular concern in those who do not have a varied diet or who need texture modification. Iron contributes to normal cognitive function, reduction of tiredness and fatigue and is important for immunity.
Supporting healthy ageing must address nutritional concerns
Supporting the ageing process must address nutritional concerns including inadequate nutrition or nutritional deficit. Health areas in care homes where nutrition may be of particular interest and importance are cognitive health (e.g. B vitamins and long chain fatty acids) and bone health (e.g. vitamin D and calcium).
Underpinning the importance of a healthy varied diet is that it can provide adequate macro and micronutrients throughout the lifespan. It promotes the achievement of healthy pregnancy outcomes; supports normal growth, development and ageing; helps maintain healthful body weight; reduces chronic disease risks; and promotes overall health and well-being.
Where nutrient intake is not being met, consideration needs to be given as to how this can be achieved, and what this means in practice for each individual’s needs. Those with poor appetite, low intake or a lack of varied diet may be at particular risk.
Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor