The World Health Organisation’s (WHO) new Guidelines on Integrated Care for Older People recommend ways community-based services can help prevent slow or reverse declines in physical and mental capacities among older people.
And what has this to do with nutrition?
Two aspects concerned with the reversal or delay of declines in physical and mental capacities in older age are highlighted in the recommendations in the guidelines; physical activity and nutrition support.
Physical activity: Multimodal exercise is recommended, including progressive strength resistance training and other exercise components such as balance and flexibility
Nutrition support: Oral supplemental nutrition and dietary advice is recommended for older people affected by undernutrition
How can Physical Activity and Nutrition Impact on Capacity in Older People?
Physical activity and nutrition are important interrelated factors in supporting healthy ageing. Loss of muscle mass and strength, reduced flexibility and problems with balance are changes that can accompany ageing, and can all impair mobility. Poor nutrition can exacerbate such physiological changes, resulting in reduced quality of life. Interventions that improve nutrition and encourage physical exercise, when integrated into care plans and delivered together have been shown to slow or stop declines in capacity.
Malnutrition and Ageing
The decrease in lean mass or muscle in ageing is one of the reasons why adequate protein intake in older people is so important. Older people who do not consume enough protein are at increased risk of developing sarcopenia, osteoporosis and an impaired immune response.
Other changes in ageing that can increase the risk of malnutrition in older age include:
- Sensory impairments (a decreased sense of taste and smell, for example)
- Poor oral health
- Isolation, loneliness and depression individually or in combination
Evidence Behind the WHO Recommendations
In order to formulate these recommendations, WHO undertook three systematic reviews of the scientific literature, and looked at studies with the following characteristics:
- Participants were older people who were malnourished or at risk of malnutrition (usually defined by low body mass index below 18.5 kg/m2)
- Studies were conducted in hospital settings or long-term care facilities (nursing, retirement or residential homes)
- Studies used a nutrition intervention that aimed at improving energy and protein intake through oral means (i.e. not given through a tube or intravenously)
The types of nutrition intervention considered included commercial sip feeds; milk-based supplements; fortification of normal food sources; addition of fluid milk to the usual daily consumption of dairy products; commercial nourishing drink made up with either milk or water.
Weight Gain and Nutrition
One of the things the reviewers were interested in was what the studies showed on the effect of the nutrition intervention on weight. The data collected from 70 trials showed that the intervention improved weight gain for older adults affected by undernutrition. And this was noted in studies conducted both in the community setting and in the hospital or long-term care setting. Moderate-quality evidence also showed that administration of oral supplemental nutrition (plus dietary advice) could reduce mortality in older people affected by undernutrition.
Some of the recommendation put forward by WHO based on their review of the scientific literature are as follows:
- Nutritional assessments should be specific to the older person and include nutritional history and records of food intake
- Dietary counselling to ensure a diet provides adequate amounts of energy, protein and micronutrients should be encouraged for all older people, including those who are at risk of or affected by undernutrition
- To help meet the nutritional requirements of older people at risk of malnutrition, it is important to consider supplementary foods which are modified in their energy density, protein or micronutrient composition (like oral nutrition supplements/some fortified foods)
- Mealtime interventions (including family-style meals and social dining) are important approaches for managing undernutrition in older people
- Older people with evidence of potentially serious underlying physical illness such as rapid weight loss, obstruction or difficulty swallowing, vomiting, chronic diarrhoea, abdominal pain or swelling should be referred for medical review by a doctor or specialist health professional
Assessment by a Healthcare Professional Such as a Dietitian
Assessment by a healthcare professional such as a dietitian was also highlighted as a key issue. An individual’s nutrition needs assessed by a trained healthcare professional can allow for a tailored approach to improve nutritional status. Such an assessment allows for the best source and vehicle for any additional high-quality protein, calories and adequate amounts of vitamins and minerals to be defined, and whether the use of supplements, nutrient-rich foods, or specialised commercial or non-commercial nutritional formulations may be the most appropriate.
Use of Oral Nutrition Supplements or Dietary Advice?
Based on the evidence, the WHO guidance expert group made a strong recommendation in favour of oral supplemental nutrition for older people affected by undernutrition. The group also considered the evidence for increasing dietary intake and mealtime interventions. Although there was enough evidence about their benefits to support a recommendation, the group decided that, due to the generic nature of these two interventions, it was more appropriate not to issue a recommendation.
However WHO considered that if oral nutrition supplements or specialised food products were necessary to increase an individual’s dietary intake of protein, energy, vitamins and minerals, this should always be combined with dietary advice. The provision of dietary advice in these circumstances can aid an older person’s understanding of the need for oral supplemental nutrition and will ensure that their dignity and human rights are respected.