Journal of Human Nutrition and Dietetics
ELDERLY CARE Dietary intake in the dependent elderly: evaluation of the risk of nutritional deficit ndez-Barre s,1,2 N. Martın,3 T. Canela,3 M. Garcıa-Barco,3 J. Basora,1,4 & V. Arija,1,2,4 Project S. Ferna ATDOM-NUT group† en Atencio Prim Unitat de Suport a la Recerca Tarragona-Reus, Institut Universitari d’Investigacio aria Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain Nutrition and Public Health Unit, Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, Reus, Spain 3 Primaria, Direccio d’Atencio Primaria Tarragona, Institut Catal Centre d’Atencio a de la Salut, Tarragona, Spain 4 Sanitaria Pere Virgili, Reus, Spain Institut de Investigacio 1 2
Keywords dependency, elderly patients, home care, nutrition, primary care. Correspondence V. Arija, Primary Health Center Sant Pere, Camı de Riudoms, 53-55, 43202 Reus, Tarragona, Spain. Tel.: +34 9777 59334 Fax: +34 9777 59322 E-mail: [email protected] How to cite this article Ferna´ndez-Barr es S., Martın N., Canela T., Garcı´a-Barco M., Basora J., Arija V., Project ATDOM-NUT group. (2016) Dietary intake in the dependent elderly: evaluation of risk of nutritional deficit. J Hum Nutr Diet. 29, 174–184 doi:10.1111/jhn.12310 †
Carme Anguera, Waleska Badia, Ana Isabel Alvarez Castelao, Antoni Garcıa-Campo, Ana Gonz alez-Bravo, Carme Lucena, Teresa MartınezBlesa, Roser Pedret, Sı´lvia Rovira.
Abstract Background: Malnutrition is a frequent problem in elderly dependent patients and their prognosis is adversely affected. Assessment of food consumption and adequacy of energy and nutrient intake of dependent elderly is needed to plan any selected actions for this population. Methods: The study comprised a multicentre cross-sectional study of 190 users (≥65 years) of a home care programme provided by primary care centers in Tarragona (Spain), at nutritional risk (Mini Nutritional Assessment: 17–23.5 points). Food consumption was assessed using a semiquantitative validated food frequency questionnaire. Energy intake was compared with the Spanish dietary reference intake (DRI) and nutritional intakes with the DRI of the American Institute of Medicine. Results: Mean (SD) age was 85.0 (7.2) years (67.5% female). The food items consumed were varied but lower than the recommended portions for cereals, fruits, vegetables and legumes. Energy intake was 7454.2 (1553.9 kJ day–1) [1781.6 (371.4) kcal day–1] (97.7% of recommended dietary allowance; RDA) and protein intake was 1.0 (0.4) g kg–1 of weight (121.4% of RDA). Proteins provided 13.3%, carbohydrates provided 39.9% and fats provided 45.8% of energy intake. The intakes of calcium, vitamin D, vitamin E and folates were less than two-thirds of the RDA and their probability of inadequate intake was >85%. Conclusions: Dietary intakes of elderly dependent patients at nutritional risk were well balanced. In general, energy and protein intakes meet the recommendations. The diet was high in energy density, low in complex carbohydrates, high in simple carbohydrates and excessive in fats. The dependent elderly had inadequate intake of micronutrients often related to fragility, such as calcium, vitamin D, vitamin E and folates.
Introduction Malnutrition is a frequent problem in elderly dependent patients and their prognosis is adversely affected (1). Dependency and ageing together increase nutritional risk. A study in an elderly Spanish population showed that dependency is very common; 34% experienced some type of disability, and 62% of this group had mild dependence, 26% had moderate dependence and 12% had severe dependence (2). 174
Malnutrition is a highly prevalent geriatric syndrome that increases directly with the degree of dependency. A recent review in our area indicated that 6.9% of the elderly (aged ≥65 years) had malnutrition, 20.8% of whom were in nursing homes and 24.6% were hospitalised (3). Ricart et al. (4) observed that 51.9% of older users of a home care programme (HCP) were at risk of malnutrition and 20.2% had current malnutrition. One of the main causes of malnutrition in the elderly is an ª 2015 The British Dietetic Association Ltd.
ndez-Barre s et al. S. Ferna
inadequate food intake (5). This consumption may worsen when patients and their families are not aware of the importance of providing optimal nutrition (6). Malnutrition provokes deterioration in the quality of life, sarcopaenia, physical and cognitive decline, morbidity and mortality, and an increase in costs to the National Health Service (7). Spanish and European studies concluded that nutrition in the elderly was inadequate and unbalanced (8). However, the studies had included individuals >65 years of age, without segregation with respect to functional status (9) . We are aware of very few studies focusing on food consumption in the housebound elderly (10–12). Knowledge of dietary and food consumption habits of dependent elders form the basis for dietary advice focusing on potential dietary imbalances together with inadequate energy and nutritional intakes. The present study aimed to assess food consumption within a HCP. The energy and nutritional adequacy of dependent elderly patients at nutritional risk were assessed relative to the current dietary recommendations. Materials and methods This cross-sectional study was carried-out in 10 Primary Care Centers (PCC) of an area of Reus-Tarragona (Catalunya, Spain) with a remit for healthcare provision for 595 836 inhabitants. The research protocol was approved by the Ethics Committee of Institute of Primary Care Research (IDIAP Jordi Gol). Sample Participants comprised 190 subjects of both genders who were recipients of a HCP (Atencio Domiciliaria; ATDOM). Inclusion criteria were: (i) registered participant in the HCP; (ii) aged ≥65 years; (iii) Mini Nutritional Assessment (MNA) score between 17 and 23.5 points (at risk of malnutrition) (13); (iv) the need for a caregiver; and (v) written informed consent to participate in the study. Exclusion criteria were: (i) enteral feeding required; (ii) severe dysphagia; (iii) any serious illness that predisposes to malnutrition such as cancer; and (iv) regular consumption of vitamin and/or dietary supplements. The ATDOM programme is a home care service provided by a multidisciplinary team from the PCC. Patients with mobility impairments are registered in this ATDOM programme. These patients have a caregiver who can be a relative or a professional caregiver who takes responsibility for buying the food items, their preparation, and supervision of their consumption. A sample size of 190 individuals is sufficient to estimate the mean (SD) energy intake obtained in our sample ª 2015 The British Dietetic Association Ltd.
Dietary intake in the dependent elderly
7454.2 (1553.9 kJ day–1) [1781.6 (371.4) kcal day 1], with a confidence of 95% and a precision of 221.7 kJ ( 53 kcal), and also to estimate the mean percentage of adequacy [97.7% (21.1%)], with a confidence of 95% and a precision of 3%. Recruitment PCCs of the Institut Catala de la Salut (ICS) [Catalan Institute of Health] in the Reus-Tarragona area were stratified to represent different geographical areas: (i) five PCCs in two cities with >100 000 inhabitants; (ii) two PCCs in the suburbs of these cities; (iii) one PCC in a medium-sized urban area of approximately 30 000 inhabitants; and (iv) two PCCs in rural areas. The number of PCCs selected corresponded to the number of inhabitants receiving attention. All patients of the HCP registered with the PCC and who met the inclusion criteria, were invited to participate in the present study (n = 206); those who signed the informed consent were recruited (94% n = 190). Subjects were recruited by initial identification in the electronic medical record, indicating that they met the criteria for participation, and verified by performing a baseline MNA. The recruitment was performed by ATDOM-nurses. Training A 2-h session was held to standardise the procedure and train the nurses of the different PCC participants. This session was conducted by expert nutrition researchers with experience in educating health professionals. Content included a presentation of the study, and data collection procedure: MNA, Food Frequency Questionnaire (FFQ), Barthel Index, Pfeiffer Mental Status Questionnaire and Yesavage Depression Scale. Outcomes The following variables were recorded by interviews conducted by ATDOM-trained nurses in dialogue with the patient and/or caregiver. Sociodemographic and health variables Sociodemographic and health variables included age, gender, chronic diseases and dental problems. Social and family support and socioeconomic risk levels were assessed in – five areas: financial status; family status; housing; social relations; and support of social networks. (14) . Basic activities of daily living measured by the Barthel Index (15), cognitive function by the Pfeiffer Mental Status Questionnaire (16) and depression risk by the Yesavage Depression Scale (17). 175
ndez-Barre s et al. S. Ferna
Dietary intake in the dependent elderly
Anthropometric measurements Anthropometric measurements included weight (kg), height (cm), middle-upper arm circumference (MUAC; cm) and calf circumference (CC; cm). Weight was recorded using a scale with a precision of 100 g, and height with a stadiometer with a precision of 1 cm. For those who were bedridden, height was estimated by the formula of Chumlea (18). Body mass index (BMI) (kg m–2) was classified in three categories: underweight 18.5–22 kg m–2 normal weight: 22–26.9 kg m–2; and overweight–obese: >27 kg m–2 (19). MUAC and CC were measured using a non-extensible tape with a precision of 1 mm. CC 0.05 was considered statistically significant. Results Sample characteristics General characteristics, anthropometric and morbidity data are summarised in Table 1. Participants (n = 190) were 85 (7.2) years of age and 67.4% were women. The MNA score was 20 (2.6) points. Social and economic support from the State and family were adequate–moderate in 54.8% of participants. Mean BMI was located in the normal weight range for the elderly, with 21% being underweight and 43% overweight–obese. Of the participants, 45% had a calf circumference of 27 kg m–2; MUAC, middle-upper arm circumference; CC, calf circumference; COPD, chronic obstructive pulmonary disease; dental problems, missing teeth and poorly fitting dentures; MNA, Mini Nutritional Assessment; basic activities of daily living measured by the Barthel Index (cut-off points:
ELDERLY CARE Dietary intake in the dependent elderly: evaluation of the risk of nutritional deficit ndez-Barre s,1,2 N. Martın,3 T. Canela,3 M. Garcıa-Barco,3 J. Basora,1,4 & V. Arija,1,2,4 Project S. Ferna ATDOM-NUT group† en Atencio Prim Unitat de Suport a la Recerca Tarragona-Reus, Institut Universitari d’Investigacio aria Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain Nutrition and Public Health Unit, Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, Reus, Spain 3 Primaria, Direccio d’Atencio Primaria Tarragona, Institut Catal Centre d’Atencio a de la Salut, Tarragona, Spain 4 Sanitaria Pere Virgili, Reus, Spain Institut de Investigacio 1 2
Keywords dependency, elderly patients, home care, nutrition, primary care. Correspondence V. Arija, Primary Health Center Sant Pere, Camı de Riudoms, 53-55, 43202 Reus, Tarragona, Spain. Tel.: +34 9777 59334 Fax: +34 9777 59322 E-mail: [email protected] How to cite this article Ferna´ndez-Barr es S., Martın N., Canela T., Garcı´a-Barco M., Basora J., Arija V., Project ATDOM-NUT group. (2016) Dietary intake in the dependent elderly: evaluation of risk of nutritional deficit. J Hum Nutr Diet. 29, 174–184 doi:10.1111/jhn.12310 †
Carme Anguera, Waleska Badia, Ana Isabel Alvarez Castelao, Antoni Garcıa-Campo, Ana Gonz alez-Bravo, Carme Lucena, Teresa MartınezBlesa, Roser Pedret, Sı´lvia Rovira.
Abstract Background: Malnutrition is a frequent problem in elderly dependent patients and their prognosis is adversely affected. Assessment of food consumption and adequacy of energy and nutrient intake of dependent elderly is needed to plan any selected actions for this population. Methods: The study comprised a multicentre cross-sectional study of 190 users (≥65 years) of a home care programme provided by primary care centers in Tarragona (Spain), at nutritional risk (Mini Nutritional Assessment: 17–23.5 points). Food consumption was assessed using a semiquantitative validated food frequency questionnaire. Energy intake was compared with the Spanish dietary reference intake (DRI) and nutritional intakes with the DRI of the American Institute of Medicine. Results: Mean (SD) age was 85.0 (7.2) years (67.5% female). The food items consumed were varied but lower than the recommended portions for cereals, fruits, vegetables and legumes. Energy intake was 7454.2 (1553.9 kJ day–1) [1781.6 (371.4) kcal day–1] (97.7% of recommended dietary allowance; RDA) and protein intake was 1.0 (0.4) g kg–1 of weight (121.4% of RDA). Proteins provided 13.3%, carbohydrates provided 39.9% and fats provided 45.8% of energy intake. The intakes of calcium, vitamin D, vitamin E and folates were less than two-thirds of the RDA and their probability of inadequate intake was >85%. Conclusions: Dietary intakes of elderly dependent patients at nutritional risk were well balanced. In general, energy and protein intakes meet the recommendations. The diet was high in energy density, low in complex carbohydrates, high in simple carbohydrates and excessive in fats. The dependent elderly had inadequate intake of micronutrients often related to fragility, such as calcium, vitamin D, vitamin E and folates.
Introduction Malnutrition is a frequent problem in elderly dependent patients and their prognosis is adversely affected (1). Dependency and ageing together increase nutritional risk. A study in an elderly Spanish population showed that dependency is very common; 34% experienced some type of disability, and 62% of this group had mild dependence, 26% had moderate dependence and 12% had severe dependence (2). 174
Malnutrition is a highly prevalent geriatric syndrome that increases directly with the degree of dependency. A recent review in our area indicated that 6.9% of the elderly (aged ≥65 years) had malnutrition, 20.8% of whom were in nursing homes and 24.6% were hospitalised (3). Ricart et al. (4) observed that 51.9% of older users of a home care programme (HCP) were at risk of malnutrition and 20.2% had current malnutrition. One of the main causes of malnutrition in the elderly is an ª 2015 The British Dietetic Association Ltd.
ndez-Barre s et al. S. Ferna
inadequate food intake (5). This consumption may worsen when patients and their families are not aware of the importance of providing optimal nutrition (6). Malnutrition provokes deterioration in the quality of life, sarcopaenia, physical and cognitive decline, morbidity and mortality, and an increase in costs to the National Health Service (7). Spanish and European studies concluded that nutrition in the elderly was inadequate and unbalanced (8). However, the studies had included individuals >65 years of age, without segregation with respect to functional status (9) . We are aware of very few studies focusing on food consumption in the housebound elderly (10–12). Knowledge of dietary and food consumption habits of dependent elders form the basis for dietary advice focusing on potential dietary imbalances together with inadequate energy and nutritional intakes. The present study aimed to assess food consumption within a HCP. The energy and nutritional adequacy of dependent elderly patients at nutritional risk were assessed relative to the current dietary recommendations. Materials and methods This cross-sectional study was carried-out in 10 Primary Care Centers (PCC) of an area of Reus-Tarragona (Catalunya, Spain) with a remit for healthcare provision for 595 836 inhabitants. The research protocol was approved by the Ethics Committee of Institute of Primary Care Research (IDIAP Jordi Gol). Sample Participants comprised 190 subjects of both genders who were recipients of a HCP (Atencio Domiciliaria; ATDOM). Inclusion criteria were: (i) registered participant in the HCP; (ii) aged ≥65 years; (iii) Mini Nutritional Assessment (MNA) score between 17 and 23.5 points (at risk of malnutrition) (13); (iv) the need for a caregiver; and (v) written informed consent to participate in the study. Exclusion criteria were: (i) enteral feeding required; (ii) severe dysphagia; (iii) any serious illness that predisposes to malnutrition such as cancer; and (iv) regular consumption of vitamin and/or dietary supplements. The ATDOM programme is a home care service provided by a multidisciplinary team from the PCC. Patients with mobility impairments are registered in this ATDOM programme. These patients have a caregiver who can be a relative or a professional caregiver who takes responsibility for buying the food items, their preparation, and supervision of their consumption. A sample size of 190 individuals is sufficient to estimate the mean (SD) energy intake obtained in our sample ª 2015 The British Dietetic Association Ltd.
Dietary intake in the dependent elderly
7454.2 (1553.9 kJ day–1) [1781.6 (371.4) kcal day 1], with a confidence of 95% and a precision of 221.7 kJ ( 53 kcal), and also to estimate the mean percentage of adequacy [97.7% (21.1%)], with a confidence of 95% and a precision of 3%. Recruitment PCCs of the Institut Catala de la Salut (ICS) [Catalan Institute of Health] in the Reus-Tarragona area were stratified to represent different geographical areas: (i) five PCCs in two cities with >100 000 inhabitants; (ii) two PCCs in the suburbs of these cities; (iii) one PCC in a medium-sized urban area of approximately 30 000 inhabitants; and (iv) two PCCs in rural areas. The number of PCCs selected corresponded to the number of inhabitants receiving attention. All patients of the HCP registered with the PCC and who met the inclusion criteria, were invited to participate in the present study (n = 206); those who signed the informed consent were recruited (94% n = 190). Subjects were recruited by initial identification in the electronic medical record, indicating that they met the criteria for participation, and verified by performing a baseline MNA. The recruitment was performed by ATDOM-nurses. Training A 2-h session was held to standardise the procedure and train the nurses of the different PCC participants. This session was conducted by expert nutrition researchers with experience in educating health professionals. Content included a presentation of the study, and data collection procedure: MNA, Food Frequency Questionnaire (FFQ), Barthel Index, Pfeiffer Mental Status Questionnaire and Yesavage Depression Scale. Outcomes The following variables were recorded by interviews conducted by ATDOM-trained nurses in dialogue with the patient and/or caregiver. Sociodemographic and health variables Sociodemographic and health variables included age, gender, chronic diseases and dental problems. Social and family support and socioeconomic risk levels were assessed in – five areas: financial status; family status; housing; social relations; and support of social networks. (14) . Basic activities of daily living measured by the Barthel Index (15), cognitive function by the Pfeiffer Mental Status Questionnaire (16) and depression risk by the Yesavage Depression Scale (17). 175
ndez-Barre s et al. S. Ferna
Dietary intake in the dependent elderly
Anthropometric measurements Anthropometric measurements included weight (kg), height (cm), middle-upper arm circumference (MUAC; cm) and calf circumference (CC; cm). Weight was recorded using a scale with a precision of 100 g, and height with a stadiometer with a precision of 1 cm. For those who were bedridden, height was estimated by the formula of Chumlea (18). Body mass index (BMI) (kg m–2) was classified in three categories: underweight 18.5–22 kg m–2 normal weight: 22–26.9 kg m–2; and overweight–obese: >27 kg m–2 (19). MUAC and CC were measured using a non-extensible tape with a precision of 1 mm. CC 0.05 was considered statistically significant. Results Sample characteristics General characteristics, anthropometric and morbidity data are summarised in Table 1. Participants (n = 190) were 85 (7.2) years of age and 67.4% were women. The MNA score was 20 (2.6) points. Social and economic support from the State and family were adequate–moderate in 54.8% of participants. Mean BMI was located in the normal weight range for the elderly, with 21% being underweight and 43% overweight–obese. Of the participants, 45% had a calf circumference of 27 kg m–2; MUAC, middle-upper arm circumference; CC, calf circumference; COPD, chronic obstructive pulmonary disease; dental problems, missing teeth and poorly fitting dentures; MNA, Mini Nutritional Assessment; basic activities of daily living measured by the Barthel Index (cut-off points:
