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JAMDA 14 (2013) 642e648
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Body Weight, Anorexia, and Undernutrition in Older People
Stijn Soenen PhD, Ian M. Chapman MD, PhD *
Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
a b s t r a c t
Keywords:
Anorexia of aging
body weight
appetite
health
Ideal body weight for maximum life expectancy increases with advancing age. Older people, however,
tend to weigh less than younger adults, and old age is also associated with a tendency to lose weight.
Weight loss in older people is associated with adverse outcomes, particularly if unintentional, and initial
body weight is low. When older people lose weight, more of the tissue lost is lean tissue (mainly skeletal
muscle) than in younger people. When excessive, the loss of lean muscle tissue results in sarcopenia,
which is associated with poor health outcomes. Unintentional weight loss in older people may be a result
of protein-energy malnutrition, cachexia, the physiological anorexia of aging, or a combination of these.
The physiological anorexia of aging is a decrease in appetite and energy intake that occurs even in
healthy people and is possibly caused by changes in the digestive tract, gastrointestinal hormone
concentrations and activity, neurotransmitters, and cytokines. A greater understanding of this decrease
in appetite and energy intake during aging, and the responsible mechanisms, may aid the search for ways
to treat undernutrition and weight loss in older people.
Copyright Ó 2013 - American Medical Directors Association, Inc.
In Western countries, there have been substantial increases over
recent decades in the number of older people who are overweight or
obese, according to standard body mass index (BMI) criteria.1 For
example, between 1995 and 2007 to 2008, the percentage of
Australians who were obese (BMI of 30 kg/m2) steadily increased
from 13% to 31% for 65- to 74-year-olds, and from 6% to 23% for those
older than 75 years.2 There is increasing evidence, however, that the
adverse effects associated with being overweight or obese by BMI
criteria are not as great in older as in younger adults. This is particularly so for life expectancy; in people older than 65 years, a higher
BMI is associated with neutral rather than detrimental effects on
length of life.1 Consistent with this, body weights associated with
maximum life expectancy are higher for older than younger adults.
For example, in a 12-year longitudinal study of 324,000 people in the
American Cancer Society Cohort, people younger than 75 had
a progressive reduction in subsequent life expectancy as baseline BMI
increased above 21.9 kg/m2. These adverse effects of increasing body
weight weakened, however, with increasing age above 45 years and
were absent altogether in those older than 75 years.3 Among 4736
people aged 60 or older followed for an average of 4.5 years in the
Systolic Hypertension in the Elderly Program (SHEP), those whose
baseline BMI was in the lowest quintile (<23.6 kg/m2) had the
highest subsequent mortality, and those within the highest BMI
quintile (31 kg/m2) had the lowest mortality.4 The optimum BMI for
* Address correspondence to Ian M. Chapman, MD, PhD, Discipline of Medicine,
Level 6 Eleanor Harrald Building, Frome Road, Adelaide, SA 5005, Australia.
E-mail address: [email protected] (I.M. Chapman).
survival in people older than 70 years is probably in the range of 25 to
30 kg/m2, and close to the upper end of that range. There is also
evidence that above (so-called) “normal” BMIs (18.5e24.9 kg/m2)
may be more beneficial in women than men.5
Of note, in older people, the body weight associated with
maximum life expectancy is probably higher than that associated
with optimum function and lack of disability. Among 12,725 people
aged 65 or older in the Established Populations for Epidemiologic
Studies of the Elderly, life expectancy was greatest with a BMI
between 25 and 27 kg/m2, but disability-free life expectancy was
greatest at a BMI of 24 kg/m2.6
Whereas high BMI values are associated with fewer adverse
effects on life expectancy and possibly function in older than young
adults, the opposite is probably true for low body weights. There is
good evidence that BMI values below approximately 21 to 22 kg/m2
are associated with significant adverse events and increased
mortality in older people;4,6,7 BMIs below 18.5 kg/m2 are a particular
concern.6 Thus, with increasing age, the U-shaped curve describing
the association between BMI and mortality moves to the right, and
the curve becomes flatter at higher BMIs.8
Weight Loss in Older People
Although optimum body weight for survival is probably higher for
older than younger adults, they tend to weigh less. This is documented in population-based, cross-sectional, and longitudinal
studies9,10 and is due to a combination of lower peak body weight and
weight loss in old age. For example, in the 1997 to 1998 US National
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S. Soenen, I.M. Chapman / JAMDA 14 (2013) 642e648
Health Interview Survey, more people aged 75 years or older were
“underweight” (BMI <18.5 kg/m2; 5.0% vs 1.2%) than those aged 45 to
64 years, and substantially fewer were “overweight” (BMI >25 kg/m2;
47.2% vs 63.5%).9 The lower average body weight of older than
younger adults is not just because overweight people die earlier,
leaving the healthier, more lean ones behind. On average, older
people are more likely to lose than gain weight.11,12 For example, 247
community-dwelling American men older than 65 lost on average
0.5% of their body weight per year over 2 years, and 13.1% had
involuntary weight loss of 4.0% per annum or more.11 The reasons for
such weight loss are multiple and vary between individuals. Unintentional weight loss and associated adverse outcomes in older
people may be attributable to protein-energy malnutrition, cachexia,
the physiological anorexia of aging, or some combination of these
factors.
Weight Loss Is Associated With Poor Health Outcomes
in Older People
Numerous studies have shown that weight loss in older people
not resulting from malignancy is associated with poor outcomes,
certainly if unintentional, but possibly even when intentional. The
prospective Cardiovascular Health Study,12 for example, studied 4714
home-dwelling subjects older than 65 years without known cancer.
In the 3 years after study entry, 17% of the subjects lost 5% or more of
their initial body weight, compared with 13% who gained 5% or more.
The weight-loss group had significant increases in total (2.09-fold
increase; 95% confidence interval [CI] 1.67e2.62) and risk-adjusted
mortality (1.67-fold increase; 95% CI 1.29e2.15) over the following 4
years compared with the stable weight group, with no increased
mortality in the weight-gain group. Increased mortality among those
who lost weight occurred irrespective of starting weight and whether
or not the weight loss was intentional. In the SHEP study,4 which
studied 4736 people aged 60 or older, those subjects who had
a weight loss of 1.6 kg per year or more experienced a 4.9 times
greater death rate (95% CI 3.5e6.8) than those without significant
weight change. Weight gain was also associated with increased
mortality, but less so than weight loss (2.4- vs 4.9-fold increase). Of
particular note, the adverse association between mortality and
weight loss was present even in the subjects who were heaviest at
baseline (BMI 31 kg/m2). Subjects with a low baseline weight (BMI
<23.6 kg/m2) who lost more than 1.6 kg per year had a mortality rate
of 22.6%, almost 20 times greater than the mortality rate of those with
a baseline BMI of 23.6 to 28 kg/m2 whose weight remained stable.
Thus, the combination of initially low body weight and weight loss
is especially bad news for older people. This interaction is a particular
concern as the tendency for older people to lose weight is variable,
with lean individuals probably most at risk.13
Lean Tissue Loss and Sarcopenia in Older People
There are many reasons why weight loss in older people is associated with adverse effects. In some cases, weight loss is attributable
to an illness, such as a malignancy, which is mainly responsible for
the poor outcome. The loss of body weight after the age of 50 to 60 is
disproportionately due to losses of lean body tissue, with average
decreases of up to 3 kg of lean body mass, mainly skeletal muscle, per
decade after the age of 50.14 When skeletal muscle mass falls too far,
sarcopenia results. This has been defined in various ways, often by
comparison of skeletal muscle mass with values in young adults (eg,
more than 2 standard deviations below the young adult mean as
measured by dual-energy X-ray absorptiometry),15 and sometimes
also by the coexistence of functional impairments, such as reduced
grip strength16 and decreased gait speed.17 The prevalence of
643
sarcopenia increases dramatically as the “young-old” age and is up to
4 times higher in those older than 85 years than in those 70 to 75
years.18 Sarcopenia is an independent predictor of poor gait, falls,
fractures, and other disability. In the National Health and Nutrition
Examination Survey III (NHANES III), older people with marked sarcopenia were 3.3 times (women) to 4.7 times (men) more likely to
have physical disability than those with low-risk skeletal muscle
mass.19
For these reasons, a high level of awareness needs to be maintained to detect unintentional weight loss, low body weight, and
undernutrition in older people.
Weight Loss Programs in Older People
Weight loss is often recommended for overweight and obese older
adults in the same manner as for younger adults, and for similar
increases in body weight and BMI. At any given time, a substantial
proportion of older people wish to lose weight and are trying to
reduce their energy (food) intake to do so. There is evidence from
studies in species as varied as yeast, spiders, mice, and possibly
primates that long-term restriction of energy intake by 30% to 60%
compared with ad libitum intake prolongs life.20 It might seem,
therefore, that reducing food intake to lose weight would be good for
most older people. This is not necessarily the case, however. In fact,
the opposite may be true. The effects of long-term voluntary energy
restriction have not been tested in humans, and the benefits observed
in other species may not apply to ours.21 Moreover, marked energy
restriction in older adults is likely to lead to a substantial loss of
beneficial lean body tissue as well as fat mass and increases the risk of
vitamin, mineral, and other dietary deficiencies. Thus, caution should
be exercised in recommending weight loss to older people, unless
there are definite health problems resulting from the excess weight.
Cachexia in Older People
Cachexia can also contribute to weight loss and harmful undernutrition in older people. Cachexia is a complex metabolic syndrome
associated with underlying illness and characterized by loss of muscle
with or without loss of fat mass. A prominent feature of cachexia is
weight loss, but inflammation is also a key component, with an
increase in levels of inflammatory cytokines such as tumor necrosis
factor (TNF), interleukin (IL)-1, and IL-6. Anorexia, insulin resistance,
and increased muscle protein breakdown are also frequently associated with cachexia. Conditions that often afflict older people that are
associated frequently with cachexia include cancer, cardiac failure,
chronic obstructive pulmonary disease, and chronic renal failure.
Although there is often considerable overlap between them,
cachexia and malnutrition are not the same. Although all patients
with cachexia are malnourished, not all malnourished patients are
cachectic.22 Cachexia is distinct from age-related loss of muscle mass,
primary depression, hyperthyroidism, malabsorption, and starvation
and does not respond readily to increased feeding.23 Recently, the
European Society of Clinical Nutrition and Metabolism subclassified
cachexia on the basis of severity, into pre-cachexiaddefined as (1) an
underlying chronic disease, (2) a systemic inflammatory response, (3)
anorexia, and (4) unintentional weight loss over the previous 6
months of less than 5% of usual body weightdand cachexia, defined
as (1) to (4) but with weight loss of more than 5%.22
Protein-Energy Malnutrition in Older People
Weight loss in older people predisposes to the development of
protein-energy malnutrition. This is surprisingly common in developed countries, with up to 15% of community-dwelling and home-
644
S. Soenen, I.M. Chapman / JAMDA 14 (2013) 642e648
bound older people, 23% to 62% of hospitalized patients, and up to
85% of nursing home residents estimated to suffer from proteinenergy malnutrition.24 Protein-energy malnutrition is more likely to
develop in the presence of other “pathological” factors, which
become more common with increased age (Table 1). Most of these
factors are at least partly responsive to treatment, so recognition is
important.
Social factors that contribute to decreased food intake in the
elderly include poverty25; difficulties with shopping, meal preparation, and self-feeding; living alone; social isolation; and loneliness.26
Psychological factors include depression, present in 2% to 10% of
community-dwelling older people and a much greater proportion of
those in institutions,27 dementia and Alzheimer disease,28 and
bereavement. Undernutrition per se, particularly if it produces folate
deficiency, may further worsen depression.29
Physical factors include poor dentition and ill-fitting dentures
leading to problems with chewing, biting, and swallowing30; immobility (eg, stroke); Parkinson disease; and impaired vision.
Medical factors include gastrointestinal disease, malabsorption
syndromes, acute and chronic infection, hypermetabolism (ie,
hyperthyroidism and chronic obstructive pulmonary disease), micronutrient deficiencies, increased energy requirements, and conditions that cause cachexia, such as cancer and rheumatoid arthritis, by
releasing cytokines.24 Older people are major users of medications,
a number of which can cause malabsorption of nutrients, gastrointestinal symptoms, and loss of appetite, particularly if taken in excess
doses or by interaction with other drugs. For example, digoxin and
chemotherapy can cause nausea, vomiting, and loss of appetite, and
high doses of antacids can deplete phosphate and potassium stores,
Table 1
Nonphysiologic Causes of Anorexia in Older Persons
Social factors
Poverty
Inability to shop
Inability to prepare and cook meals
Inability to feed oneself
Living alone/social isolation/lack of social support network
Failure to cater to ethnic food preferences in institutionalized individuals
Psychological factors
Depression
Dementia/Alzheimer disease
Alcoholism
Bereavement
Cholesterol phobia
Medical factors
Cardiac failure
Chronic obstructive pulmonary disease
Infection
Cancer
Alcoholism
Dysphagia
Rheumatoid arthritis
Malabsorption syndromes
Gastrointestinal symptoms
Dyspepsia
Helicobacter pylori infection/atrophic gastritis
Vomiting/diarrhea/constipation
Parkinson disease
Hypermetabolism (eg, hyperthyroidism)
Medications
Anti-infectives
Antineoplastics
Antirheumatics
Nutritional supplements
Pulmonary agents
Cardiovascular agents
Central nervous system agents
Gastrointestinal agents
leading to muscle weakness and anorexia. Older individuals often
take multiple medications that increase the risk of drug interactions
that can cause malnutrition.
Protein-Energy Malnutrition and Poor Health
Outcomes in Older People
In older persons, unintentional weight loss of 5% or more over 6 to
12 months is associated with an increased risk of adverse effects,
whereas a loss of 10% or more is associated with a particularly high
risk of protein-energy malnutrition and poor outcomes. Proteinenergy malnutrition is associated with decreased bone mass,
impaired muscle function, anemia, immune dysfunction, reduced
cognitive function, poor wound healing, delayed recovery from
surgery, and, ultimately, increased morbidity and mortality (Table 2).
Protein-energy malnutrition is a strong independent predictor of
mortality in elderly people, regardless of their living situation.31 The
increased mortality rate in elderly people with protein-energy
malnutrition is further increased in the presence of other medical
diseases, such as renal failure, cardiac failure, and cerebrovascular
disease. For example, the 9-month mortality rate among patients 70
years or older, without cancer, admitted to a Swedish medical ward
was 80% in those both malnourished and with cardiac failure, twice
that of the malnourished patients without cardiac failure, and more
than 4 times that of well-nourished patients without cardiac failure.31
Anorexia of Aging: Reduced Appetite and Energy
Intake in Older People
All of the previously noted changes can be superimposed on, and
tend to exacerbate, the effects of the steady decline in overall appetite
and food intake that occurs as healthy adults age. Numerous studies
have documented an age-related decline in energy (food) intake in
healthy, ambulant, noninstitutionalized people of approximately 30%
between 20 and 80 years.32e35 For example, the NHANES III crosssectional study reported a decline in energy intake between the
ages of 20 and 80 years of 1321 kcal per day in men and 629 kcal per
Table 2
Effects of Weight Loss and Protein-Energy Malnutrition on Function in Older People
Y Muscle function
Y Muscle relaxation
Y Muscle mass
Y Muscle strength
[ Risk of fracture
Y Bone mass
[ Incidence of falls
Y Functional status
Immune dysfunction
[ Risk of infection
Y Skin hypersensitivity
T-cell lymphocytopenia
Y Synthesis of interleukin-2
Y Cytolytic cell activity
Y Response to influenza vaccination
Anemia
Poor wound healing
Fatigue
Pneumonia
Delayed recovery from surgery
Y Cognitive function
Y Cardiac output
Y Intravascular fluid (dehydration)
[ Incidence of pressure sores
Y Maximal breathing capacity
[ Hospital admission and length of stay
[ Mortality
S. Soenen, I.M. Chapman / JAMDA 14 (2013) 642e648
day in women;36 a 7-year New Mexico longitudinal study of 156
persons aged 64 to 91 years reported a decrease of 19.3 kcal per day
per year in women and 25.1 kcal per day per year in men;37 and
a Swedish longitudinal study of 98 people found an even greater
decline of energy intake of 610 kcal per day in men and 440 kcal per
day in women between the ages of 70 and 76 years.38
The decline of food intake, and associated decrease in appetite,
occurs even in healthy, illness-free adults and is therefore not solely
due to aging-associated illnesses. This apparently physiological, agerelated reduction in energy intake has been termed “anorexia of
aging.”24 An important component is reduced appetite (decreased
hunger). Older people consistently report that they are less hungry
than young adults and have increased fullness and early satiation
during a meal.33e35,39 On average, older individuals consume smaller
meals more slowly, and fewer snacks between meals,24 resulting in
overall lower energy intake, and, in some cases, adverse events. For
example, in one cross-sectional study of 1247 people aged 60 or older
living in Mexico City, anorexia of aging, defined as reporting that they
had been eating less in the past 12 months than previously because of
loss of appetite, was present in 30% and independently associated
with disability and reduced mobility.40
Aging is associated with a reduction in energy expenditure, owing
to reduced physical exercise, loss of energy-demanding lean tissue,
and reduction in energy intake itself (via the decreased metabolic
cost of metabolizing the smaller amount of consumed food). In
many individuals, the decrease in daily energy intake is greater
than the decrease in energy expenditure, resulting in the loss of
body weight during aging, as described previously. One of the
mechanisms underlying the decrease in energy intake is a diminished
homeostatic regulation of many physiological functions, including the
regulation of energy intake. For example, in a landmark study, Roberts et al41 underfed 17 young and old men by 3.17 MJ per day
(z750 kcal/day) for 21 days, during which time both the young and
old men lost similar amounts of weight. After the underfeeding
period, the men were allowed to again eat ad libitum. The young men
ate more than at baseline (pre-underfeeding) and quickly returned to
normal weight, whereas the old men did not compensate, returned
only to their baseline intake, but not above it, and did not regain the
weight that they had lost. This indicates that after an anorectic insult
(for example, major surgery), older people are likely to take longer
than young adults to regain the weight lost, remain undernourished
longer, and be more susceptible to subsequent superimposed
illnesses, such as infections.41
Mechanisms Responsible for Reduced Appetite and Energy
Intake in Older People
645
velocity within visceral neurons and with a reduced sensitivity to
gastrointestinal tract distension (for example, impaired receptive
relaxation of the gastric fundus,50 probably as a result of increased
peripheral and fundic nitric oxide concentrations). As a result, for any
given gastric volume, there is more rapid antral filling and distension,
slower gastric emptying, and earlier satiety (Table 3).35
Older people may also have lower plasma concentrations of the
orexigenic hormone ghrelin than younger adults,34,51 possibly related
to the slightly decreased gastric emptying39 and reduced circulating
testosterone concentrations,52 as normal aging is accompanied by
reductions in circulating androgen levels.53,54 Plasma concentrations
of the anorectic hormone leptin in humans often increase with aging,
in women to a large extent because of the increased fat mass that also
accompanies aging,55 and in men to a large extent because of agerelated decreases in circulating testosterone concentrations.56
In addition, older compared with younger subjects have shown
increased small intestinal responses, such as a greater stimulation of
phasic pyloric pressure waves by intraduodenal (ID) lipid infusion,57
a greater satiating effect of ID glucose,33 and altered gastrointestinal
hormone responses, such as high fasting and postprandial CCK and
GLP-1 concentrations, which may contribute to the slowing of gastric
emptying mediated by increased pyloric motility.34,35,58e61 Healthy
older people seem to retain their sensitivity to the satiating effects of
exogenous GLP-161,62 and may even have increased sensitivity to the
satiating effects of CCK.42,60 In addition, older people, particularly
those who are undernourished, have higher circulating concentrations of CCK than young adults,61 suggesting that these gut hormones,
particularly CCK, may contribute to the anorexia of aging.
Aging tends to be associated with increased postprandial circulating insulin concentrations,63 mainly attributable to insulin resistance and impaired glucose tolerance,64 which may be influenced by
increased adiposity and changes in the incretins GLP-1 and GIP
secretion.65 These changes may contribute to reduced appetite. There
is also evidence that aging is associated with a reduced opioid feeding
drive66 and preliminary evidence from animal studies that aging may
be associated with reduced neuropeptide Y (NPY) activity, resulting in
a reduced stimulation of energy intake.67 A reduced sensitivity to the
orexigen galanin might also contribute to the anorexia of aging; older
compared with younger women displayed a reduced growth
hormone secretory response to galanin.68
Increased cytokine levels, owing to the “stress” of aging per se, or
the amplified stressful effects of other pathologies, may provide an
Table 3
Some Endocrine Factors Influencing Feeding and Their Possible Contribution to the
Anorexia of Aging
Effect of Aging
Appetite and energy intake are dependent on central and
peripheral mechanisms, the latter including interrelated “intragastric” and “small intestinal” sensory and motor functions, triggered by the interaction with the nutrients ingested. There is
evidence that changes at multiple sites, both central and peripheral,
contribute to reduced appetite and food intake that accompany
normal aging. In young people, appetite and energy intake are suppressed by distension of the distal stomach (antrum) and increased
pyloric motility,42 which results in slowing of gastric emptying, and
by stimulation of gastrointestinal hormone secretion: cholecystokinin
(CCK),43 glucagon like peptide-1 (GLP-1),44 peptide tyrosine tyrosine
(PYY),45 and gastric inhibitory polypeptide (GIP).46e48 Feedback
signals from peripheral fat cells via leptin, as well as absorption of
nutrients from the gut, also contribute to satiation. In older individuals, a diminished suppression of energy intake has been observed.49
Many of the underlying appetite-related mechanisms are affected by
healthy aging. Aging is associated with a decline in conduction
Factors that stimulate feeding
Opioids Y activity not proven in humans
NPY no good evidence for role
Galanin circulating levels unchanged sensitivity unknown
Orexins no good evidence for role
Ghrelin circulating levels possibly Y sensitivity unknown
Testosterone stimulatory role unconfirmed (? indirect) Yactivity with age
possible effects via leptin, ghrelin, and others
Factors that inhibit feeding
CART possible [ central levels (rodents)
CCK [ circulating levels [ CSF levels [ sensitivity to satiating effects
GLP-1 few data, possibly [ activity
PYY few data, no evidence for role
Insulin effect on feeding unconfirmed, no evidence for role
Leptin situation complex: circulating levels increase in men (Y testosterone)
BUT? leptin resistance
Cytokines [ activity likely
CART, cocaine-amphetamine-regulated transcript; CCK, cholecystokinin; CSF,
cerebrospinal fluid; GLP-1, glucagon like peptide-1; NPY, neuropeptide Y; PYY,
peptide tyrosine tyrosine.
646
S. Soenen, I.M. Chapman / JAMDA 14 (2013) 642e648
explanation for some of the decline in appetite and body weight that
occurs in many older people. Increased cortisol and catecholamines
stimulate the release of IL-6 and TNF-a, and decreased sex hormones
inhibit IL-6 and growth hormone.69 Once undernutrition is established in older people, this may promote further worsening of
undernutrition. For example, undernourished older women report
being less hungry and more full than their well-nourished young and
older counterparts.34
The senses of smell and taste deteriorate with age,70 leading to
a reduced capacity to enjoy food and develop sensory-specific
satiety,71 the normal decline in pleasantness of the taste of a particular food after it has been consumed, leading to a decrease in its
consumption and a tendency to shift consumption to other food
choices during a meal. Age-related reduction in sensory-specific
satiety favors a less varied, more monotonous diet, and the development of micronutrient deficiencies.
Diagnosis and Treatment of Weight Loss and Undernutrition
in Older People
To reduce the risk of harmful weight loss, weight loss diets should
be recommended to “overweight” older people with caution, and
probably only if the excess weight is clearly causing functional
impairment, rather than because of body weight alone. Weight loss
from dieting leads to loss of lean (muscle) as well as fat tissue, and
this is particularly so and harmful in older people. Such diets should
therefore contain sufficient amount of protein to build up muscle
tissue in older people, as has been observed in young people,72,73 and
should be combined with a muscle-preserving exercise program if
possible, preferably with a component of resistance exercise.17,74
Numerous screening tools and methods to diagnose undernutrition in older people have been developed and proposed,75 and
a detailed discussion of them is beyond the scope of this article.
Nevertheless, weight loss and undernutrition in older people, and
their association with adverse outcomes, are still often not recognized. Important clues are loss of weight, particularly if more than 5%
and unintentional, and low body weight (BMI <22 kg/m2). Once
identified, causes or exacerbating factors, such as depression, lack of
availability of food, and excessive medications, should be addressed if
possible. A multidisciplinary approach, including the timely involvement of a nutritionist/dietician, is often useful.
A logical and common strategy for undernourished older people is
to try to increase their energy intake. Intake of “usual” food can be
increased by encouragement to eat more and eat with others (for
example, by residents of nursing homes eating in a communal dining
area and having a staff member sit with them and encourage them to
eat76 or by providing meals at home through programs such as
“Meals on Wheels”). Liberalizing diets as opposed to restrictive diets
have been shown to enhance quality of life and food intake, and the
addition of flavor enhancers, such as sauce, to food may be of
benefit.77
Energy-rich, often protein-rich, nutritional supplements are being
increasingly recommended to older, undernourished people.78e81
There is evidence that they help. A Cochrane review of 62 trials
(10,187 hospitalized and community-dwelling participants randomized to a protein-energy supplements or a control) concluded that
“energy and protein” supplementation resulted in a small, but
consistent, weight gain and reduced mortality, particularly when
participants were undernourished, 75 years or older, and when
supplementation was 400 kcal or more or sustained for more than 35
days.78 A systemic review and meta-analysis of effects of high protein
oral nutritional supplements (36 trials among 3790 older people aged
>65 years) concluded that protein supplements produce clinical
benefits (eg, reduced complications, reduced readmissions to
hospital, improved grip strength, and increased intake of protein and
energy) with little reduction in normal food intake and improvements in body weight.82 Another recent systemic review of 17 trials,
including measurements of body composition, between 1991 and
2012 (1287 patients aged between 65 and 85 years) concluded that
protein supplementation has a protective and beneficial effect on
muscle mass and strength, which is furthermore increased when
combined with physical exercise.17
The optimum composition for nutritional supplements is not
known. They appear to be least satiating, and therefore increase
overall energy intake (total of supplement and other food) the most, if
given in liquid form between meals.83 Daily protein intakes of 1.25 to
1.5 g/kg (higher than the Recommended Dietary Allowance for adults
of 0.8 g/kg) are often recommended. However, protein has higher
satiating effects than fat or carbohydrate in younger adults.84 If it has
similar effects in older people, this may limit the increase in overall
energy intake resulting from the use of high-protein supplements
and possibly also contribute to the relatively poor long-term adherence to such supplements.17 The effects of nutritional supplements of
different macronutrient compositions on appetite and energy intake
in both well-nourished and malnourished older people, as well as
further study of the mechanisms underlying the physiological
anorexia of aging, warrant more examination.
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