Soodeh Razeghi Jahromi

Soodeh Razeghi, PhD of nutrition, Assistant Professor, Geriatric group, Tehran University of Medical Sciences

A deficiency or excess ( or

imbalance) of energy,

protein and other nutrients function

Measurable adverse effect on tissue/body form (shape, size and composition)

Clinical outcome

As much as 15 kg over ideal body weight is healthier than IBW

Its protective from mortality

Minimal mortality rate: 26-28.9

Percent of obesity

Men Women

60-69 y 38.1 42.5

70-79 28.9 31

Winter, Jane E., et al. "BMI and all-cause mortality in older adults: a meta-

analysis." The American journal of clinical nutrition (2014): ajcn-068122.

range of body fat:10-25% in men (+56)

25-38% in women (+56)

there is a loss of LBM but increase in intraabdominal & intramuscular fat with age

U-shape relationship between weight and health

fat is protective from falls and injuries

Help to maintain core body temperature

Obesity decease the risk of pressure ulcer.

May protective against dementia in women

Excess accumulation cause medical complication

High waist/hip ratio:High risk of Dm, hypertension, CAD

Overeating

Decrease in physical activityMen: 20%

Women:13%

Decrease in metabolic rateIn men greater than women (due to household work)

Bernstein M., et al., Nutrition for the Older Adults, John’s and Barlett learning,

2011

Reduce hormone levelsDecrease in growth hormone and testostrone: decrease LBM/increase fat

Reduce energy need, results in weight gain

Poor nutritionChoose less expensive foods

Usu. Rich in added sugar & poor in protein, “empty calorie syndrome”

People may eat poorly if they are depressed, bored, lonely or under stress

Obesity is more likely to be related to morbidity and disability than to mortality

Dm: 2.9 fold higher in obese

Metabolic syndrome

OA: 45% of 85+, increased to 60% in overweight

Older adults who gain >5% of BMI=28.9Poorer upper & lower body function

Negative impact on ADLs

Increase in pain of the head, neck, shoulder, back legs, feet, abdomen, pelvis with obesity

TO LOSE OR NOT TO LOSE WEIGHT

In some studies:It is feasible for mild to moderate overweight and obese older adults to have moderate weight loss:

Improve in

Health related quality of life (regardless of weight maintenance)

Laboratory values

Physical performance

Weight fluctuation:Increase all cause and CVD mortality

SuggestionIncrease leisure time activity

Eliminate snacks and foods with empty calories

Mediterranean diet: lost weight and keep the weight off

This diet emphasizes on:fruits

root vegetables (carrots, turnips, potatoes, onions, radishes) and leafy green vegetables

breads and Cereals

Fish

foods high in a-linolenic acids (flax, canola oil)

nuts and seeds

Olive oil (is the primary source of fat)

eggs are consumed zero to four times per week.

Diet diaries double the weight loss

In a 20 weeks study:With track: 4.7-6.4 kg weight loss

Without track: 1.7-2.1 kg weight loss

High frequency face to face and telephone consultation

SibutramineHypertension

Seizure

Palpitation

Heart attack

stroke

Insufficient energy/protein to meet metabolic demands

Poor intake

Increased

losses

Increase

metabolic

demand (e.g.

illness, trauma

Assessing of malnutrition is an essential component of CGA

Malnutrition (unintentional weight loss) related to:Depression

Muscle wasting

Reduced functional status

Decreased immunocompetence

Higher risk of infection

Impaired wound healing

Increased rate of complications

Increased health care use

Nutritionally at risk patients: 19% higher hospital cost

decrease in

energy intake

(cachexia)

Acute phase

response

(increase in

inflammatory

mediators)

Increase

protein

degradation

May not

reserved

Western society Iran

Malnutrition At risk of malnutrition

Malnutrition At risk of malnutrition

Community 6% 40-50% PEM 12% (Khorasen

razevi)

45.3% (Khorasen

razevi)

Residential care 14% PEM 51% 3.2% (Kahrizak) 43.4% (Kahrizak)

Hospital 39% PEM 46% … …

Kaiser MJ, Bauer JM, Ramsch C, et al. Frequency of malnutrition in older adults: A multinational perspective using

the mini nutritional assessment. J Am Geriatr Soc. September 2010;58(9):1734-1738.

Aliabadi M, Kimiagar M, Ghayoor Mobarhan M, IlityFaizabadi AK, Prevalence of malnutrition and factors related to it

in the elderly subjects in Khorasan Razavi province, Iran, 2006, Nutrition Sciences & Food Technology 2007;2(3): 45-

56

Amirkalali B, Sharifi F, Fakhrzadeh H, Mirarefin M, Ghaderpanahi M, Larijani B. Evaluation of the mini nutritional

assessment in the elderly, Tehran, Iran. Public health nutrition. 2010;13(9):1373-9

Close monitoring of weightReflect imbalance in energy intake and requirement

Simple, reliable (esp. in outpatient setting)

Weight should be recorded at each visit

Weight change should be expressed as a percentage of change from past to current weight

Weight loss >5% of usual body weight need investigation

>10% illness related weight loss comparing to pre-illness weight is associated with functional decline and poor clinical outcomes

15-20% or more implies severe malnutrition

Calculate the total score:

Add the two scores ( total score)

If age 70 years: add 1 to the total score to correct for frailty of elderly

If age-corrected total 3: Start Nutritional Support

26

0=Low risk: Routine careIf obese / special diet – local policyHospital :repeat screen every week

Care homes :repeat screen every monthCommunity :repeat screen annually for special groups e.g. >75yr

1=Medium risk: ObserveHelp with food choices/ dietary adviceHospital: Document dietary/fluid intake x 3d, repeat screen weeklyLTC: Document dietary/fluid intake x 3d, repeat screen monthlyCommunity: Repeat screen (2-3 monthly)

2=High risk: TreatRefer to Dietician Improve nutritional intake Monitor and review care plan

NSI (points apply to “YES” answers)1. I have an illness or condition that made me change the kind

and/or amount of food I eat (2)2. I eat fewer than two meals per day (3)3. I eat few fruits or vegetables, or mild products (2)4. I have 3 or more drinks of beer, liquor, or wine almost every

day (2)5. I have tooth or mouth problems that make it hard for me to

eat-26. I don’t always have enough money to buy the food I need (4)7. I eat alone most of the time (1)8. I take 3 or more different prescribed or OTC drugs per day (1)9. Without wanting to, I have lost or gained 10 or more pounds

in the last six months (2)10. I am not always physically able to shop, cook and/or feed

myself (2)29

focuses on increasing awareness of nutritional risk in the community

Self-administered checklist determines need for referral to a health care professional

Not clinically validated

interpretation

0-2 Good

3-5 You are at moderate risk

>6 You are at high nutritional risk

Anthropometric measures of fat stores (skin folds) and muscle mass (mid arm muscle area) may help in the assessment of PEM

Inter rater variability can be high

Assessment of nutritional status requires information provided from:

Dietary history

Physical examination

Biochemical data

Nutrition screening

form-MNA

1. Body mass index (BMI) (kg/m2)

2. Weight loss in past 3 months?

3. Acute illness or major stress in past 3

months?

4. Mobility

5. Dementia or depression

6. Has appetite & food intake

declined in past 3 months?

MNA-SF

>12 Normal

nutrition

<11 possible

undernutrition

>24 normal

nutrition

Full MNA

<23 Further

assessment

4 sections:

Anthropometrics

Diet questionnaire

Global assessment lifestylemedicationsmobility

Subjective assessmentself perception of health

& nutrition

However, PEM is severe when:weight loss > 20% of premorbid weight

serum albumin <21 g/L

transferrin <1 g/L

total lymphocyte count <800/μL

BMI<19

BEE= X kcal*Kg body weight

X=

Healthy elderly 19.4

Sick elderly 20.4-30

BMI<21 32-38

38

Energy requirements in frail elderly people: A review of the literature.

Clinical Nutrition. 2007

Reported

weight loss

Dental/oral/GI

evaluation

Documented weight

loss

Adequate

calorie intake?

Anorexia

Adequate

access to food?

Oral or swallowing

problem

Social factors

assistance

no

noyes

no

yes

Depression

Drug

Disease

Dysguisea

Adequate

calorie intake?

yes

malabsorption

no

Altered

metabolism/catabolism

Endocrinopathy

Infection

Hypoxemic lung disease

Enhance oral intakeFrequent meals, snacks

Provide favorite foods

Meal fortification

Protein-calorie supplement

Multivitamins

Appetite stimulant

Anabolic agents

Enteral nutrition

Parenteral nutrition

Increase in energy intake (29-53%) by high GI carbohydrates

Satiety by fat: SFA and PUFA> MUFA

Perception of satietyAssociated with postprandial gastric volume not energy intake

energy dense foods in small portion size tend to be more palatable and increased intake

Quick emptying from the stomach

the absence

of chewing

A decrease in pancreatic

exocrine and endocrine

response

Lower satiety

Higher-calorie ONS (1.5–2.0 kcal/mL) are preferred over standard (1 kcal/mL) formulas

patients need not drink less volume

Supplements should be provided between, rather than with meals:

Less compensatory decreases in food intake at mealtime

Small volumes increase compliance

Nieuwenhuizen, W.F., et al., Older adults and patients in need of nutritional support: review of

current treatment options and factors influencing nutritional intake. Clin Nutr, 2010. 29(2): p .

160-9

A meta analysis of 24 trials (2387 patients) on protein and energy supp.

Reduced mortality esp.>400 kcal/d

>75 y

>35 days

In hospital

Reduced length of hospitalization (~ 6 d)

Increase in body weight (~ 2.4%)

مورد نیازپروتئین استرسمیزان

0.8-1 g/kg استرس معمول

1.25 g/kg استرس خفیف

1.5 g/kg استرس متوسط

1.75-2 g/kg استرس شدید و سوختگی

Entera Meal 1 sachet+100 ml water=120 ml 1 scope (30 g)+120 ml water=150

1 kcal/ml (15% from protein)

Entra meal(diabetic)

1 sachet (24 g)+100 ml water=120 ml1 scope (20 g)+80 ml= 100 ml

1 kcal/ml (15% from protein)

Entra meal (high protein)

1 sachet (26 g)+80 ml water= 100 ml1 scope (34 g)+ 100 ml= 130 ml

1.2 kcal/ml (17% from protein)

Pure protein 1 sachet (26 g)+ 100 ml water=120 ml 25 g protein

Ensure 6 scope (50 g)+190 ml water= 230 ml 1 kcal/ml (15% from protein)

Fresubin drink Original, energy, diben , ….

1 kcal/ml,1.5 kcal/ml, 90 kcal/ml, …

carbomass 1 scope (25 g)+330 ml= 350 ml 100 kcal/350 ml

Milatech drink StandardHigh proteinMilk freeenergy

1 kcal/ml20% of energySoy based1.5 kcal/ml

V.M.Protein 1 sachet+ 100 ml water= 120 ml 10.5 g protein

Multivitamin supplement for all older adults with poor intake

Increased physical activity is an important adjunct:

improve appetite and sense of well-being

improve caloric and micronutrient intake

Improve functional status

If depression causes poor intake:Selective serotonin reuptake inhibitors (SSRIs)

Tricyclic antidepressant

Thanks