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WITH a prevalence of around 50%, malnutrition in aged care may be one of the most serious nutrition problems of our time, and the causative role that aged care facility meals have on the development of this condition has gained significant recent media attention and public debate.
Poor meal quality, decreasing food budgets, and “institutionalised” eating environments have been blamed for increasing the risk of malnutrition in our elderly. But is it justified to lump 100% of the blame on the food in aged care alone? And if not, what role does it really have in influencing malnutrition?
Protein-energy malnutrition is the unintentional loss of muscle and organ tissue caused by inadequate energy, protein and nutrient intake over time, and is highly predictive of falls, hospitalisation, poor quality of life and death. The causative link between unappealing food and malnutrition may appear obvious at first, but malnutrition is not as simple as that.
After 40 years of research, here is what we know about the causes of malnutrition
The causes of malnutrition may be broadly categorised as physiological, psychosocial, social and economic, and any unique combination of these may be responsible for the condition in any one individual.
The physiological causes include impaired dietary intake, which may be caused by a multitude of factors, such as general poor appetite, lost dentures, or the inability to open food packaging, just to name a few.
Other physiological causes are equally important and common in older adults who usually suffer from multimorbidity. They include elevated energy and protein requirements (eg, during fever, cancer, pneumonia, inflammation etc), impaired digestion or nutrient absorption (eg, gastritis and parasites), and excessive nutrient losses (eg, vomiting, diarrhoea, surgical drains and haemorrhages).
Psychological and social factors known to increase the risk of malnutrition include social isolation, self-perceived health and living alone. Mental health and economic disadvantage also play a large role, where depression and financial strain have both independently been found to increase the risk of malnutrition four-fold.
Every patient with malnutrition is unique
As stated above, malnutrition may be caused by any unique combination of these causative factors. An example would be an aged care resident with Parkinson’s disease (which increases energy and protein requirements), who has difficulty opening food packaging and eating with utensils (impaired dietary intake) and feeling social isolation due to mobility limitations (further decreasing appetite).
Another example would be a resident with a diabetic ulcer (increasing energy and protein requirements), receiving antibiotics (impairing digestion and absorption) as well as polypharmacy (impaired metabolic requirement and decreasing appetite) to manage their chronic disease risk factors. Perhaps diabetes-related dietary restrictions have also been imposed, further decreasing the intake of protein and energy through decreased food variety.
So why all the attention on aged care meal quality?
A poor meal and dining environment in aged care only contributes to one of the many causes of malnutrition – impaired dietary intake. But, it affects every resident in the facility, for the entire duration of their stay there.
In addition, while the causes of malnutrition are deeply complex and individualised, treating malnutrition is relatively simplistic: just consume the energy and protein required and the condition will be reversed. And how is this done in aged care? Eating food. Specifically, the food provided by the kitchen in the aged care facility.
If meal and dining quality is poor, a healthy resident will not be consuming enough energy and protein to meet their requirements, let alone an unwell resident. This nasty cycle is the reason for the increased use of oral nutritional supplements, which is essentially a band-aid approach, to try and treat malnutrition in this setting.
As discussed previously, this approach has limited effectiveness and is not suitable for the long term. The best evidence for both preventing and treating malnutrition in aged care lies with improving meal quality and the dining environment.
Is food solely to blame for malnutrition in aged care?
While there may be a vast array of physiological, psychosocial and economic reasons why any one resident in aged care may become and remain malnourished, poor meal and dining quality is a very important risk factor for the development for malnutrition. But, it is the most important factor in treating malnutrition and decreasing risk across resident population.
While facilities that have already made great progress to improve the dining experience for their residents are to be applauded, many have not yet taken these steps forward.
Australian physicians, nurses, allied health and the aged care staff and residents themselves must advocate for improved meal and dining quality in aged care if we want to ever see the prevalence of malnutrition go down.
So, if you think meal quality is not up to scratch, is today the day you will write that letter or set a meeting with your local aged care manager?
Dr Skye Marshall is an accredited practising dietitian, post-doctoral research fellow at Bond University on the Gold Coast. Her early career as a clinical dietitian in the Northern Rivers, NSW, inspired her research to build evidence for the role of dietitians to support happy and healthy ageing.
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In discussions of nutrition for the elderly, the adequacy of the host’s cardiac response, which is necessary for digestive activity to occur, should be not be ignored.
The digestive processes of
• gastric extension,
• production and release of digestive juices,
• peristalsis,
• absorption and removal of nutrients
are all dependent on an increased blood circulation to the gut, referred to as postprandial hyperaemia. Postprandial hyperaemia withdraws blood form the systemic circulation. To meet this demand and avoid a drop in blood pressure cardiac activity increases, both increased heart rate and cardiac contraction force. When the heart cannot cope, blood pressure drops, a condition referred to as postprandial hypotension. As well as digestive problems, stroke, angina and heart attack may result from postprandial hypotension.
Reduced postprandial hyperaemia results in inadequate gastric extension and disordered gastric emptying. Suffers report a feeling of fullness and exhibit altered eating behaviour, including reduced appetite, aversion to eating and unrealistic complaints about the quality and taste of the food. The occurrence of reduced postprandial hyperaemia is likely best detected by measuring postprandial blood pressure. Postprandial hypotension is a cardiovascular risk factor and in some elderly groups a more important risk factor than hypertension.
Several dietary strategies may be of benefit to reduce/prevent dyspepsia and improve digestion. Some bitter tastants (Artemisia absinthium and Gentian lutea), drunk in southern European countries as aperitifs, have been shown to increase peripheral resistance and reduce cardiac workload. As yet, the impact of these bitters on the digestion of meals has not been investigated. Alcoholic beverages, consumed both during and after meals, reduce the gastric emptying of meals whereas coffee increases gastric emptying. Reduced gastric emptying may improve digestion by slowing the rate at which a meal enters the small intestine and thus the rate at which carbohydrates and fats enter the circulation. In cases of gastroparesis, bitter drinks have been reported to reduce symptoms, likely due to increased hyperaemia. In contrast, alcoholic drinks should be avoided with gastroparesis.