Manual Nutritional Care of Older People (Skills for Caring)

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Five-month follow-up data were collected in four homes. This enabled us to explore perceived and actual barriers to implementation. Formal evaluation of the impact of the implementation strategies was outside the scope of the study; our intention was to iteratively develop an implementation process addressing key barriers.

Overview of the context, process of implementation, and outcomes in participating homes. All participants gave written informed consent. Five public sector residential care homes participated in the study. The standard of care provided was rated by the UK Commission for Social Care Inspection as either good four homes or excellent one home. The homes were self-selected following discussions with senior managers. Participating homes catered for between 25 and 40 clients, the majority of whom were permanent residents. Additional services provided were respite care five homes , day centers four homes , and community meals for day centers, lunch clubs, or meals on wheels four homes.

The internal organization of the homes varied: One unitized home home 1 had dedicated staff in each unit. We aimed to recruit a maximum variation sample of staff, that is, staff with different responsibilities and diverse views on existing menus and nutrition guidelines [ 52 ]. We included home managers, who had overall responsibility for the food provided; senior staff and head cooks, who were responsible for menu development and food ordering; catering staff, who prepared and served meals; and care and domestic staff, who served food, collected client feedback, and cleared mealtime waste.

Background

The use of observation and informal conversations enabled us to engage with a wider range of staff than would have been possible had we relied solely on formal interviews and also facilitated the identification of potential interviewees. The wider study included interviews with service users and other stakeholders; these are reported elsewhere [ 35 ]. Interviews were electronically recorded with consent and transcribed verbatim. Where participants did not wish to be recorded, the researcher made contemporaneous notes and subsequently wrote a detailed account of the discussion.

Some participants were interviewed in pairs or small groups. Topic guides were informed by NPT [ 53 ] and were revised to include issues that emerged as important in early interviews. For example, resistance to external guidelines was a strong theme in home 2; we therefore explored staff confidence in government guidelines in subsequent homes. Copies of baseline and modified menus, the nutrition guidelines, and their underlying principles were also used to prompt discussion.

In each home, we observed food preparation and meal times to identify taken-for-granted work practices and routines. Additional observation and informal discussions with staff provided insight into the culture and values of the home.

Data on the process of menu development were collected through observation of meetings, training sessions, and informal discussions between the study dietitian and care home staff. Field notes were written as soon as possible following each period of observation and included thoughts and comments about what had occurred and suggestions for further data collection. Data analysis took place in two phases to avoid forcing the data into categories predetermined by the theoretical framework [ 47 , 48 ]. An initial thematic analysis conducted by CB and BH was discussed in data analysis workshops with the other authors and underwent a number of iterations, as new issues emerged at different time points and in different care homes.

In the second phase of analysis, we mapped emergent data themes to the NPT framework checking for fit. In view of the volume of data collected, the whole of the dataset was not systematically coded; all field notes were coded together with a purposively selected sample of interviews. We coded interviews with key staff cooks and managers and staff with strong views on the nutrition guidelines either positive or negative at each time point.

We then carefully scrutinized the remaining data to identify deviant cases, amend code boundaries if needed and identify any additional themes not captured by the existing coding frame [ 54 ]. The trustworthiness, or credibility, of the study was enhanced by the use of different methods and time points and the emphasis on purposive sampling.

The two researchers responsible for data collection worked closely together, reflecting on their experiences of data collection, the process of data analysis, and their role in constructing meaning from the data. A detailed codebook was produced to ensure consistency of coding. The involvement of the other coauthors in data workshops provided additional insights from experts in qualitative research and implementation science CM and nutrition PM. Observational data and notes of informal discussions resulted in pages of field notes.

The findings are presented within the NPT framework, together with illustrative quotations. The source of each quotation is indicated by phase baseline, menu development, implementation, one- or five-month follow-up , type of respondent, and home. Quotations are from interviews, unless otherwise stated. The nutrition guidelines and modified menus lacked coherence for many staff who:. While some staff viewed external guidelines as a resource for improving care, others argued that menus should be locally derived, primarily between cooks and clients. This resistance to external guidelines was particularly marked in home 2, which was situated in a remote close-knit community:.

Baseline, cook, Home 2 ". In addition, some staff perceived tensions between the UK policy emphasis on personalization and choice [ 55 ] and the nutrition guidelines. Staff wanted to provide a homely environment in which clients were free to choose favorite foods and dishes and perceived the nutrition guidelines as prioritizing the ingestion of nutrients over the emotional, social, and cultural qualities of food and mealtimes. Food and mealtimes were identified as a central focus of daily routines and a key source of well-being for clients:.

Five-month follow-up, care staff, Home 1 ". I know that sounds ageist but to me there is a difference. Baseline, senior staff, home 2 ". These concerns over the legitimacy and potential impacts of the nutrition guidelines meant that they did not make sense to significant numbers of staff. This lack of coherence was a significant barrier to implementation, to the extent that the cooks in Home 2 refused to implement the modified menus.

The uncertainties over the legitimacy and value of the nutrition guidelines clearly impacted the willingness of staff to sign up, or engage with, implementation. Additional barriers to individual and collective investment in the nutrition guidelines were. Reservations about the existing menus were expressed in all homes, and the nutrition guidelines were viewed as a catalyst for change. Typical concerns were that clients were given too many treats and too much to eat, which impacted their mobility, energy levels, and weight:. Baseline, care staff, Home 2 ". Other staff took pride in the existing menus and were reluctant to make changes, particularly where the home enjoyed a good local reputation for the food provided.

A further barrier to investment in nutrition guidelines was the perception that staff skills and expertise were not valued. Some cooks found suggestions to amend tried and tested recipes disempowering and insulting:. Are we not doing our job properly here? Some care staff perceived changes as disrupting and devaluing their personal relationships with, and detailed knowledge of, clients. Observation of mealtimes in this home indicated that staff rarely explicitly asked clients about their preferences, instead automatically adjusting the content and portion size to suit individual clients.

Suggestions to explicitly offer clients brown bread before white, water before juice, and polyunsaturated margarine before butter were rejected on the grounds that they would create a less homely, more institutional ambience. It might have proved possible to create collective investment in the nutrition guidelines despite the diversity of staff views had there been strong management support.

In most homes, however, there was little internal focus or impetus relating to the study. The organizational culture of the care homes did not foster widespread debate and discussion; instead, interactions centered on preexisting social networks, which tended to reinforce existing perceptions of the study. The exception was in Home 5, where there was an emphasis on ensuring all staff were on board:. By the time it gets down to the domestic, everybody has been put on a diet. One-month follow-up, senior staff, Home 5 ".

The lack of coherence of the nutrition guidelines resulted in staff reluctance to invest in implementation, and this was compounded by the factors described above. Cognitive participation—real and ideal conditions for investing in nutrition guidelines. The cooks were inevitably largely responsible for the practical work of developing and implementing the modified menus, although care staff also had a role in enacting changes, particularly in unitized homes where they were responsible for serving food.

Barriers to practical implementation of the nutrition guidelines included:. A consistent barrier in all homes was that staff responsible for developing menus usually the head cook and a senior manager lacked detailed knowledge of the nutritional content of foods and the nutritional needs of older people. Although some cooks had an interest in healthy eating on a personal level, nutritional knowledge was variable and was not always considered in the context of work. The training provided by the study dietitian went some way to improve knowledge and was often valued by the cooks:.

Five-month follow-up, cook, Home 3 ". The process of menu development, preparing new dishes and changing the orders created significant extra work. The situation was exacerbated by staff shortages in four homes. As a result, the cooks in all but one of the homes where staff were more unionized attended meetings on their days off and did additional work at home e.

Five-month follow-up, cook, Home 4 ". The procurement systems used by the County Council meant that cooks were reliant on specific suppliers for fruit and vegetables, meat, baked goods, and general supplies. Since the ordering and delivery dates varied between suppliers, changing the menus was not straightforward. The restrictions on ordering meant staff were reliant on food that was seen as incompatible with the nutrition guidelines:.

Baseline, cook, Home 3 ". There were no formal systems for monitoring implementation; following development of the modified menus, staff were individually responsible for putting them into practice. A few members of staff actively resisted implementation, either by refusing to make changes, making changes in ways that were likely to be unacceptable to clients, or sabotaging implementation e. Within all homes, the extent to which different cooks complied with the modified menus varied:.

Similar variation in support for the modified menus was evident amongst care staff, particularly in relation to serving fruit instead of biscuits with coffee and tea. While some care staff simply left the fruit platter on the trolley, others took an active role:. One-month follow-up, care staff, Home 5 ". Despite their reservations about the value of the nutrition guidelines, the majority of the cooks showed considerable commitment to developing modified menus and made some changes.

Collective action—real and ideal conditions for implementing nutrition guidelines. To successfully embed nutrition guidelines, staff need to review their experiences of implementation and, if necessary, adapt the modified menus to suit local circumstances. Barriers to reflexive monitoring were. While the nutrient profile of the modified menus was analyzed for the study, the results were not systematically fed back to participating homes. Staff were therefore largely reliant on their subjective impressions of the impact on clients:. Five-month follow-up, senior staff, Home 1 ".

Only two changes were attributed by staff to the modified menus. In home 1, the rapid introduction and high fiber content of the modified menus led to some clients experiencing loose bowels, causing embarrassment, discomfort, and additional work for staff. While loose bowels are associated with health benefits, the introduction of additional fiber needs to be carefully managed to avoid loss of dignity.

A reduction in the number of client falls was tentatively linked to the modified menus in one home:. Five-month follow-up, senior staff, Home 3 ". Staff often interpreted outcomes in line with their preconceptions about the nutrition guidelines. Cooks in unitized homes who relied on care staff for feedback expressed concern over the reliability of staff reports:.

This process highlighted the limitations of the training. While some cooks simply reinstated popular dishes from the baseline menus, others tried to follow the principles underlying the modified menus. However, they found it difficult to manage the tension between meeting the nutrition guidelines and client preferences:.

One-month follow-up, cook, Home 4 ". Most of the cooks reported paying more attention to the nutritional content of meals and some had adapted their usual practice as a result:. One-month follow-up, cook, Home 5 ". For some staff, the experience gained from implementing the nutrition guidelines led to new insights and understandings; for others, their views on the value and impact of the modified menus remained unchanged, reflecting the paucity of evidence that clients had benefitted from the modified menus. Reflexive monitoring—real and ideal conditions for appraising nutrition guidelines.

Our experience of working sequentially in five care homes provided evidence that some aspects of the nutrition guidelines became fully integrated into work practices. Across all homes, the most successful and enduring changes were those that went unnoticed by clients. For example, substituting polyunsaturated for saturated margarine in baking was reported to improve the texture of cakes and have no discernible impact on taste.

A gradual reduction in the sugar content of cakes proved acceptable to clients:. Five-month follow-up, cook, Home 1 ". The training and briefing sessions for all staff were generally well received and staff seemed better informed about the purpose of the nutrition guidelines in later homes. The shift in emphasis from changing the menus to changing recipes successfully addressed staff concerns over the emotional and cultural aspects of food and was particularly successful in home 5, where clients were largely unaware that the menus had been modified.

In general, staff in homes 3 to 5 had more positive attitudes to the nutrition guidelines, with some staff recognizing their wider relevance, suggesting that the strategies to improve coherence and cognitive participation had been successful:. Six-month follow-up, senior staff, Home 3 ". In some homes, the majority of the work was carried out by catering staff; in others, staff were content to limit their input to commenting on the draft menus produced by the study dietitian.

Initially we focused on engaging the cooks, only including care staff in the process of menu development in the final home. Informal discussion of this strategy with staff in other homes suggests that the careful selection of care staff is key to successful joint working with catering staff. As an external study team, we were concerned about the lack of resources and management support for implementation but felt relatively powerless to address these issues.

While we negotiated reimbursement for staff time with the senior manager at the County Council, the managers of participating care homes proved reluctant to use their budget to pay cooks for their work on menu development. Improving nutrition only appeared to be a priority if it could be achieved within existing resources. It proved difficult to enhance feedback systems, and there was little evidence of benefits to clients resulting from implementation of the nutrition guidelines. In the absence of other information, cooks valued information we provided on the nutrition content of the baseline and modified menus:.

The implementation of menus based on nutrition guidelines in UK care homes proved challenging, although some changes were successfully embedded in routine practice e. It proved difficult to build collective understanding of and commitment to the study, resulting in inconsistent implementation; similar issues with lack of compliance with nutritional interventions in care homes have previously been reported [ 46 ].

The four key constructs of NPT [ 44 ] proved useful in understanding the barriers to implementation. Most previous studies using NPT have focused primarily on collective action [ 45 , 49 ]; our work highlights the importance of the remaining constructs, in particular, the critical role of coherence.

In home 2, where the cooks refused to implement the modified menus, our experience can be conceptualized as a recursive loop, whereby the failure of the intervention to make sense coherence and to engage staff cognitive participation resulted in some staff acting out their resistance collective actions and bringing about outcomes that fulfilled their expectations, in a self-fulfilling prophecy reflexive monitoring. While we used the constructs of NPT to understand the findings, the barriers identified are largely consistent with previous work on guideline implementation.

The priority given to personal knowledge over scientific evidence by care staff [ 58 , 59 ] led to some staff contesting the value of the nutrition guidelines. Issues relating to role conflict and perceived incompatibility with other goals [ 60 - 63 ] have undermined the implementation of guidelines on lifestyle management [ 64 , 65 ] and nutrition in other contexts [ 33 , 66 ].

Given this uncertainty over the legitimacy of the nutrition guidelines, the concept of relative advantage was key [ 61 - 63 ]. In this context, the lack of observable benefits was a significant barrier. These factors individually and collectively undermined the coherence or sense of the intervention for many staff, leading to a lack of investment in the nutrition guidelines. The situation was exacerbated in most homes by the absence of strong leadership, which is well-established as a facilitator of guideline implementation e. Previous initiatives to improve nutrition have often provided additional staff to deliver aspects of the intervention e.

Although the study dietitian provided training and facilitated the process of menu development, the day-to-day implementation of the modified menus had to be achieved within existing resources. Despite the importance of supporting guideline implementation with additional financial and human resources [ 15 , 32 , 58 , 61 , 70 ], we were unable to secure these. The lack of nutritional knowledge and reliance on personal knowledge documented in previous studies [ 58 , 71 ] were also identified in the present study; furthermore, the limited training provided, while valued, was insufficient to enable cooks to modify menus and recipes without the continued support of the study dietitian.

The process of using NPT to identify real and ideal conditions for implementation [ 47 ] was useful in identifying potential strategies to address the barriers identified. One possible area for further development of NPT would be to link the theoretical constructs of NPT to specific behavior-change techniques; this would increase the practical utility of the theory.

NPT highlighted barriers related to the work of implementing the nutrition guidelines; using an alternative theoretical framework, such as the Promoting Action on Research Implementation in Health Services PARiHS framework [ 72 ], might have directed our attention more to the process of facilitation, in particular, the skills and attributes required for facilitation including understanding, nurturing staff, and support for learning [ 72 ] , but would not necessarily have enabled us to identify so clearly issues relating to the lack of coherence of the nutrition guidelines.

Strategies that may facilitate implementation of nutrition guidelines include:.

Introduction

An implementation team with a broad range of skills is needed to effectively implement these strategies, in addition to adequate resources. While not explored in the present study, policies on procurement of ingredients merit further exploration, since the most successful and enduring changes resulted from simple substitution of ingredients [ 35 ].

We studied five care homes in the North East of England. Many of the factors influencing implementation of the nutrition guidelines were identified in all of the homes.

The emergence of some new factors in Homes 4 and 5, however, suggests that data saturation may not have been achieved. While the sample of homes was diverse in terms of organization and socioeconomic status, they were public sector homes in one geographical region. Additional factors influencing implementation may emerge in privately run homes and those catering to more diverse client groups.

Facilitation was primarily provided by the study dietitian, who typically worked with individuals or groups at the contemplation or action stage in the cycle-of-change model [ 73 ]. In the present study, many staff were not at this stage; a greater emphasis on facilitation activities targeted at planning for change [ 74 ] might usefully have addressed staff reservations about the nutrition guidelines. The legitimacy and value of nutrition guidelines for older people living in care homes was disputed by significant numbers of staff, resulting in a lack of engagement with and commitment to the study.

Practical implementation of the nutrition guidelines was challenging due to the lack of nutritional knowledge of cooks and limited institutional support. Specialist support is also needed to equip staff with the technical knowledge and skills required for menu analysis and development and to devise systems to monitor and use information on the impacts of modified menus. CB and BH were jointly responsible for data collection and analysis. CB drafted the manuscript. CM participated in the design of the study and contributed to data analysis. PM conceived of the study, participated in its design and coordination and contributed to data analysis.

All authors commented on draft manuscripts and approved the final manuscript. This research was commissioned by the Food Standards Agency, project N The views expressed are those of the authors. We are grateful to colleagues in the Institute of Health and Society, in particular Nikki Rousseau, Tracy Finch, Martin Eccles and Justin Presseau, for helpful comments on previous drafts of this paper. National Center for Biotechnology Information , U. Journal List Implement Sci v. Published online Oct Received Mar 26; Accepted Oct This article has been cited by other articles in PMC.

Abstract Background Optimizing the dietary intake of older people can prevent nutritional deficiencies and diet-related diseases, thereby improving quality of life. Methods We conducted a process evaluation in five care homes in the north of England using qualitative methods observation and interviews to explore the views of managers, care staff, catering staff, and domestic staff. Results Many staff perceived the guidelines as unnecessarily restrictive and irrelevant to older people.

Conclusions The successful implementation of the nutrition guidelines requires that the fundamental issues relating to their perceived value and fit with other priorities and goals be addressed.

Normalization process theory, Nutrition policy, Guideline, Long-term care, Older people, Qualitative research. Background Despite receiving hour care, older people living in care homes long-term care facilities, including nursing and residential homes remain vulnerable to malnutrition. Methods Study design We used qualitative methods semistructured interviews, informal discussions, and nonparticipant observation to explore facilitators and barriers to the use of nutrition guidelines in residential care homes.

Table 1 Overview of the context, process of implementation, and outcomes in participating homes. Open in a separate window. Setting Five public sector residential care homes participated in the study. Participants We aimed to recruit a maximum variation sample of staff, that is, staff with different responsibilities and diverse views on existing menus and nutrition guidelines [ 52 ]. Data analyses Data analysis took place in two phases to avoid forcing the data into categories predetermined by the theoretical framework [ 47 , 48 ].

Table 2 Number of interviews by role, home, and time. Factors influencing implementation of modified menus The findings are presented within the NPT framework, together with illustrative quotations. Coherence — making sense of nutrition guidelines The nutrition guidelines and modified menus lacked coherence for many staff who: This resistance to external guidelines was particularly marked in home 2, which was situated in a remote close-knit community: Baseline, cook, Home 2 " In addition, some staff perceived tensions between the UK policy emphasis on personalization and choice [ 55 ] and the nutrition guidelines.

Food and mealtimes were identified as a central focus of daily routines and a key source of well-being for clients: Baseline, senior staff, home 2 " These concerns over the legitimacy and potential impacts of the nutrition guidelines meant that they did not make sense to significant numbers of staff. Table 3 Coherence—real and ideal conditions for making sense of nutrition guidelines.

Cognitive participation—investing in nutrition guidelines The uncertainties over the legitimacy and value of the nutrition guidelines clearly impacted the willingness of staff to sign up, or engage with, implementation. Additional barriers to individual and collective investment in the nutrition guidelines were satisfaction with existing menus, perceived threats to autonomy and expertise, and a lack of focus or impetus for implementation. Typical concerns were that clients were given too many treats and too much to eat, which impacted their mobility, energy levels, and weight: Baseline, care staff, Home 2 " Other staff took pride in the existing menus and were reluctant to make changes, particularly where the home enjoyed a good local reputation for the food provided.

Some cooks found suggestions to amend tried and tested recipes disempowering and insulting: Baseline, cook, Home 2 " Some care staff perceived changes as disrupting and devaluing their personal relationships with, and detailed knowledge of, clients. The exception was in Home 5, where there was an emphasis on ensuring all staff were on board: One-month follow-up, senior staff, Home 5 " The lack of coherence of the nutrition guidelines resulted in staff reluctance to invest in implementation, and this was compounded by the factors described above.

Table 4 Cognitive participation—real and ideal conditions for investing in nutrition guidelines. Collective action—implementing the nutrition guidelines The cooks were inevitably largely responsible for the practical work of developing and implementing the modified menus, although care staff also had a role in enacting changes, particularly in unitized homes where they were responsible for serving food.

Barriers to practical implementation of the nutrition guidelines included: The training provided by the study dietitian went some way to improve knowledge and was often valued by the cooks: Five-month follow-up, cook, Home 3 " The process of menu development, preparing new dishes and changing the orders created significant extra work. Five-month follow-up, cook, Home 4 " The procurement systems used by the County Council meant that cooks were reliant on specific suppliers for fruit and vegetables, meat, baked goods, and general supplies.

The restrictions on ordering meant staff were reliant on food that was seen as incompatible with the nutrition guidelines: Baseline, cook, Home 3 " There were no formal systems for monitoring implementation; following development of the modified menus, staff were individually responsible for putting them into practice. Within all homes, the extent to which different cooks complied with the modified menus varied: While some care staff simply left the fruit platter on the trolley, others took an active role: One-month follow-up, care staff, Home 5 " Despite their reservations about the value of the nutrition guidelines, the majority of the cooks showed considerable commitment to developing modified menus and made some changes.

Table 5 Collective action—real and ideal conditions for implementing nutrition guidelines. Reflexive monitoring—regaining ownership and embedding changes To successfully embed nutrition guidelines, staff need to review their experiences of implementation and, if necessary, adapt the modified menus to suit local circumstances. Barriers to reflexive monitoring were lack of systematic feedback on the impacts on client well-being, concerns over the reliability of feedback mediated by care staff, and lack of confidence in modifying menus and recipes.

Assessment and management of nutrition in older people and its importance to health

Staff were therefore largely reliant on their subjective impressions of the impact on clients: Five-month follow-up, senior staff, Home 1 " Only two changes were attributed by staff to the modified menus. A reduction in the number of client falls was tentatively linked to the modified menus in one home: Five-month follow-up, senior staff, Home 3 " Staff often interpreted outcomes in line with their preconceptions about the nutrition guidelines.

Cooks in unitized homes who relied on care staff for feedback expressed concern over the reliability of staff reports: However, they found it difficult to manage the tension between meeting the nutrition guidelines and client preferences: One-month follow-up, cook, Home 4 " Most of the cooks reported paying more attention to the nutritional content of meals and some had adapted their usual practice as a result: One-month follow-up, cook, Home 5 " For some staff, the experience gained from implementing the nutrition guidelines led to new insights and understandings; for others, their views on the value and impact of the modified menus remained unchanged, reflecting the paucity of evidence that clients had benefitted from the modified menus.

Table 6 Reflexive monitoring—real and ideal conditions for appraising nutrition guidelines. Real conditions Ideal conditions Strategies to promote reflexive monitoring Emphasis on adverse events and lack of systematic feedback on impacts of nutrition guidelines Access to information on a wide range of outcomes e.

Implementation processes and strategies Our experience of working sequentially in five care homes provided evidence that some aspects of the nutrition guidelines became fully integrated into work practices. A gradual reduction in the sugar content of cakes proved acceptable to clients: Five-month follow-up, cook, Home 1 " The training and briefing sessions for all staff were generally well received and staff seemed better informed about the purpose of the nutrition guidelines in later homes. In general, staff in homes 3 to 5 had more positive attitudes to the nutrition guidelines, with some staff recognizing their wider relevance, suggesting that the strategies to improve coherence and cognitive participation had been successful: In the absence of other information, cooks valued information we provided on the nutrition content of the baseline and modified menus: Discussion The implementation of menus based on nutrition guidelines in UK care homes proved challenging, although some changes were successfully embedded in routine practice e.

The value of Normalization Process Theory The process of using NPT to identify real and ideal conditions for implementation [ 47 ] was useful in identifying potential strategies to address the barriers identified. The role of cytokines has been discussed earlier. Older people commonly complain of increased fullness and early satiation during a meal which may be caused by changes in gastrointestinal sensory function, as with age there is reduced sensitivity to gastrointestinal distension.

Aging is associated with impairment of receptive relaxation of the gastric fundus, causing rapid antral filling and distension and earlier satiety. The young men ate more than at baseline and quickly returned to their normal weight, whereas the older men did not compensate and returned to their baseline intake and did not regain weight. The combination of age-related physiological anorexia and impaired homeostasis means older people do not respond to acute undernutrition compared with young men.

The hypothalamus controls hunger and satiety. The nucleus arcuatus has neurones that release neuropeptide Y NPY , an agouti-related peptide, which mediates hunger and inhibit satiety. Cholecystokinin CCK is released in the proximal bowel and is the protype satiety hormone.

It is released in the response to nutrients from the antrum, particularly lipids and proteins. Leptin is a hormone produced by adipose cells whose main role is maintaining energy balance. Low leptin signals loss of body fat and a need for energy intake, while high leptin level implies adequate body fat and no need for further food intake. Insulin regulates glucose metabolism. It is a satiety hormone that works by enhancing the leptin signal to the hypothalamus and inhibiting gherlin, the only peripheral hormone known to stimulate appetite. Aging is associated with reduced glucose tolerance and elevated insulin levels, which may amplify the leptin signal 48 and inhibit ghrelin.

Quantifying nutritional intake is best preformed by a dietitian. Different methods can be used. Twenty-four hour recall is commonly used and is based on an interview during which the patient recalls all food consumed in the previous 24 hours. Data can also be affected if the patient has cognitive impairment.

Food records for 7 days for all food and drink consumed can be used and help eliminate day-to-day variations. A food frequency multiquestion questionnaire is used to explore dietary intake over a period of time. Unintentional weight loss is one of the best predictors of worst clinical outcome and in older people is associated with significant morbidity and mortality. A large number of clinical signs indicate nutritional deficiencies. The general impression is a wasted, thin individual with dry scaly skin and poor wound healing. The hair is thin and nails are spooned and depigmented.

Patients complain of bone and joint pain and edema. Specific nutritional deficiencies are associated with specific clinical signs see Table 1. The tool is being used both in hospitals and in the community. The tool is easy to use and can be used by all care workers to derive a malnutrition risk score of either low, medium or high. It consists of three components: BMI, history of unexplained weight loss, and acute illness effect.

Studies have shown that it has a high predictive validity in the hospital environment length of stay, mortality in older people, and discharge destination in orthopedic patients. The MNA test consists of 18 items and takes less than 15 minutes to perform. It has been shown to predict morbidity and mortality in a study of an elderly Danish population. The subjective global assessment relies on physical signs of undernutrition and patient history and does not use laboratory findings. It is simple to use, quick takes a few minutes and has been shown to be reliable in elderly outpatients.

The Quetelet index relates weight kg to the square of the height m 2 , which enables calculation of body mass index BMI. In these cases height should be obtained from certain body segments, such as leg, arm and arm span. In addition it does not identify unintentional weight loss as a single assessment. Skinfold measurement using tricipital skinfold is particularly important together with arm circumference, and can be used to calculate muscular circumference of the arm, which indicates lean mass. This measurement has been shown to be an independent predictor of mortality in older people in long-term institution.

Biometric impedance analysis is a simple, non-invasive and inexpensive method to estimate total body water, extracellular water, fat-free mass and body cell mass. It is a measurement of the resistance that the body provides against the passing of an electric current. Several studies have demonstrated that low body cell mass has a prognostic value in malnourished patients. However the upper age group in the study was 64, and therefore at present there are a lack of data in older age groups.

Serum proteins synthesized by the liver have been used as markers of nutrition albumin, transferrin, retinol-binding proteins and thyroxine-binding prealbumin. However albumin can be affected by not only nutritional state but by other factors, including inflammation and infection. This limits their usefulness especially in acutely unwell patients. Albumin has a long half-life and therefore is not useful for looking at short-term changes in protein and energy intake.

To date there is no single biochemical marker of malnutrition as a screening test. The main value of biochemical markers is in a detailed assessment and monitoring. Pathological factors become more common with age and most causes are treatable. This treatment can be medical, social or psychological.


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All the diseases mentioned above are associated with higher rates of malnutrition in older people. Chewing problems are associated with a greater likelihood of poor health and decreased quality of life. The recommended dietary allowance RDA for protein is 0. Evidence has revealed that protein intake greater than the RDA helps to improve muscle mass, strength and function in older people.

Furthermore this intake can improve immune status, wound healing and blood pressure. It has been recommended that the RDA intake of 1. Reduced intake and unbalanced diet predispose older people to vitamin and mineral deficiencies. Drugs can affect the absorption of vitamins, and can also interfere with hepatic metabolism, causing delayed elimination of vitamins. Smoking interferes with absorption of vitamins, particularly vitamin C and folic acid.

Older people do not clear vitamin A well and are subsequently prone to hypervitaminosis. Reduced vitamin D can result from reduced dietary consumption, and gastrointestinal and renal disease. Vitamin D deficiency leads to osteomalacia, rickets and myopathy. It is associated with reduced bone density, impaired mobility, increased risk of falls and probably an increased risk for developing type 1 diabetes, cardiovascular disease and rheumatoid arthritis. Folate is present in orange juice, dark green leafy vegetables, peanuts, strawberries, dried beans and peas, and asparagus, among others.

Other causes are drugs eg, methotrexate and excess alcohol consumption. Mineral requirements in old age do not change. Zinc, selenium, chromium, copper and manganese levels are unchanged with healthy aging. Older people are more susceptible to develop problems with fluid and electrolyte balance due to physiological renal impairment and changes in thirst perception. Fluid deprivation and repletion studies comparing younger adults with the older population have demonstrated that despite physiological needs, older people do not consume adequate amounts of fluids to maintain ideal plasma electrolyte concentrations.

Adverse effects of drugs such as diuretics, either by altering thirst or prompting dieresis, cause dehydration. Reduced intake due to medical, social and physiological factors should be addressed. For example patients with difficulty chewing should have dental and oral care checked and possibly be given mushy food.

Patients with difficulty swallowing, eg, stroke patients, need speech and language therapy and possibly percutanous endoscopic gastrostomy PEG feeding. Patients with physical difficulties should have nursing assistance and those with low mood should have their medication reviewed and, if needed, started on appropriate treatment.

Older people in general have reduced oral intake. The main goal should be to help improve oral food intake. For example providing cafeteria style meals over a course of 3 weeks compared to traditional meal delivery on trays at one long-term home significantly increased energy intake. In patients with proven deficiencies of micronutrients, supplementation should be given.

Calcium and vitamin D supplementation have been shown to reduce the incidence of hip fractures. Oral liquid energy-dense and high-quality protein supplements have been shown to increase energy and protein intake in critically ill patients. Enteral feeding is indicated if a patient is severely malnourished or if food cannot be taken orally due to medical illness, eg, stroke.

In the short term, a nasogastric tube can be used and in the longer term PEG is indicated. The prevalence of overweight using standard BMI criteria older people in Westernized countries is increasing. Also older people with high BMI suffer from symptomatic osteoarthritis, increased rates of cataracts, mechanical urinary and bladder problems, and sleep apnea and other respiratory problems. Although intentional weight loss by overweight older people is probably safe and beneficial, caution should be exercised in recommending weight loss to overweight older people on the basis of body weight alone.

Methods of achieving weight loss in older adults are the same as in younger adults. Weight loss drugs have not been extensively studied in older people, and there is the potential for drug side effects and interactions. Older people are at an increased risk of inadequate diet and malnutrition, and the rise in the older population will put more patients at risk. Inadequate diet and malnutrition are associated with a decline in functional status, impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, poor wound healing, delay in recovering from surgery, and higher hospital and readmission rates and mortality.

Aging is associated with a decline in number of physiological functions that can affect nutritional status, including reduced lean body mass, changes in cytokine and hormonal levels, delayed gastric emptying, changes in fluid electrolyte regulation, and diminished sense of smell and taste. Pathological causes such as chronic illness, depression, medications and social isolation can all play a role in nutritional inadequacy.

Screening is vital in identifying and monitoring patients. The MUST tool has been well validated and is easy to use. Management involves treating pathological causes such as poor dentition and optimizing the management of chronic diseases. Oral liquid high-energy supplements or enteral feeding should be considered in high risk patients or in patients unable to meet daily requirements. National Center for Biotechnology Information , U. Journal List Clin Interv Aging v.

Tanvir Ahmed and Nadim Haboubi. Nadim Haboubi, Consultant Physician. Received Jul This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

Assessment and management of nutrition in older people and its importance to health

This article has been cited by other articles in PMC. Abstract Nutrition is an important element of health in the older population and affects the aging process. Introduction Malnutrition is defined as a state in which a deficiency, excess or imbalance of energy, protein and other nutrients causes adverse effects on body form, function and clinical outcome.

Biological changes of the digestive system There are age-related changes in the gastrointestinal tract. Physiological changes of digestive system and aging The anorexia of aging With increasing age appetite declines and food consumption declines. Open in a separate window. Changes in body weight and body composition Cross-sectional studies have shown that body weight and body mass index BMI increase with age until approximately 50 to 60 years, after which they both decline.

Etiology of weight loss Three distinct mechanisms of weight loss in older people have been identified 32 Wasting. Physiological anorexia Causes of physiological anorexia are not fully understood, but the following are thought to contribute: Diminished sense of smell and taste. Nutritional assessment Dietary assessment Quantifying nutritional intake is best preformed by a dietitian. Clinical assessment A large number of clinical signs indicate nutritional deficiencies. Table 1 Clinical signs and nutritional deficiencies.

Anthropometric assessment The Quetelet index relates weight kg to the square of the height m 2 , which enables calculation of body mass index BMI. Biochemical markers Serum proteins synthesized by the liver have been used as markers of nutrition albumin, transferrin, retinol-binding proteins and thyroxine-binding prealbumin.

Pathological and non-pathological causes of weight loss Pathological factors become more common with age and most causes are treatable. Medical Cardiac eg, chronic heart failure. Gastrointestinal, eg, malabsorption syndromes, dysphagia, Helicobacter pylori , atrophic gastritis. Drugs see Table 2. Table 2 Drugs that may cause anorexia in older people. Fluid and electrolyte regulation Older people are more susceptible to develop problems with fluid and electrolyte balance due to physiological renal impairment and changes in thirst perception.

Nutritional therapy in older people Reduced intake due to medical, social and physiological factors should be addressed. Overnutrition in older people The prevalence of overweight using standard BMI criteria older people in Westernized countries is increasing. Conclusion Older people are at an increased risk of inadequate diet and malnutrition, and the rise in the older population will put more patients at risk. Footnotes Disclosure The authors declare no conflicts of interest. Office of National Statistics. PT , table 14 population age and sex London: Am J Clin Nutr.

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