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The Challenge of Malnutrition in Older Adults

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Published: May 19, 2023
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"For many older adults, lack of adequate protein and loss of lean body mass are particularly significant problems, including for those who may be overweight or obese. The importance of malnutrition prevention for older adults is magnified as it affects independent living, healthy ageing, and the severity of chronic conditions and disabilities." Malnutrition Quality Collaborative (2020).
Malnutrition is a condition characterised by a deficiency, excess, or imbalance of energy, protein and other essential nutrients required for optimal health, proper organ function, and cellular growth, causing detrimental effects on bodily processes, shape, and clinical outcomes.

The forms through which malnutrition manifests itself, encompassing undernutrition which includes wasting, stunting and being underweight, inadequate vitamins or minerals, overweight, obesity, and resulting diet-related noncommunicable, are diverse and multifaceted, presenting one of the most significant health challenges of our days.

Individuals of all ages, from infancy to late adulthood, may be indiscriminately affected by one or more forms of malnutrition. However, older adults, specifically those aged 65 years or above, are among the most vulnerable groups at risk of experiencing malnutrition due to various factors, including age-related physiological changes, limited access to nutritious food, and comorbidities.

Inadequate uptake or intake of nutrition in the elderly, commonly referred to as malnutrition in older people, is characterised by significant alterations in body composition and body cell mass, leading to diminished physical and mental function and impaired outcomes from disease.

The percentage of older adults who are malnourished in the world ranges from 23 to 46%, with undernutrition affecting up to 22% of them and therefore representing the most typical form they encounter.

Malnutrition varies dramatically according to the different parts of the ageing population. It is prevalent among older people who usually experience high levels of disability, declining health, multiple illnesses, poor physical function, and dependence on daily activities. In the community setting, malnutrition affects less than 10% of older people who live independently. This percentage is even lower when older adults reside in their homes and attend senior centres. However, it has been reported that malnutrition is 50% higher in nursing homes and acute care settings, with estimates ranging from 30 to 50%.

Nutrient deficiency-related symptoms associated with malnutrition generally lead to physical and cognitive impairments due to several organ systems’ immune dysfunctions. The ageing process renders individuals increasingly susceptible to weight loss and a decrease in muscle mass and strength, a disorder known as ‘sarcopenia’, namely one of the geriatric syndromes which also include dementia, depression, delirium, urinary incontinence, vertigo or falls, frequently occurring at higher ages. This condition may ultimately result in the onset of frailty syndrome, which can significantly impede recovery from illness and negatively impact overall clinical outcomes. As people advance in age, the likelihood of developing various diseases and conditions increases, resulting in a heightened risk of experiencing insufficient nutrient intake or malnourishment.

Individuals aged 65 or above, according to the United Nations, are the faster-growing proportion of the current global population. In its most recent publication, 2022 Revision of World Population Prospects, the UN Population Division of the Department of Economic and Social Affairs has estimated that by the year 2050, in the world, the percentage of people aged 65 and even older is expected to increase to approximately 16% by the year 2050, up from 9% in 2019. Additionally, the number of individuals aged 80 and above is projected to triple, reaching 426 million by 2050, up from 143 million in 2019.

For this reason, the World Health Organization (WHO) has declared ‘Healthy Ageing’ a priority in its work on reducing health populations’ inequities and improving the lives of older adults between 2021 and 2030 (UN Decade of Healthy Ageing). Healthier nutrition for older adults is part of the cross-sectoral WHO initiative launched to raise awareness about the importance of strengthening efforts towards a more focused intervention on age and ageism as well as enhancing the abilities of the most senior population while providing them with integrated care and primary health services and ensuring that those who require it have access to quality long-term therapy.

Spoke 06 of the OnFoods project for tackling malnutrition in vulnerable subjects.

Proper nutrition is increasingly vital during ageing as it contributes significantly to maintaining good health and reducing chronic disease risk.

Despite the overwhelming data proving the detrimental effects of malnutrition in the older population, nowadays, clinicians still face several challenges in understanding, identifying, and treating its related determinant variables. While several evidence-based strategies exist to prevent and treat malnutrition in older adults, these approaches are only sometimes well implemented in clinical practice, thus leading to a considerable gap between the care provided and the successful treatments.

In the elderly population, efficient and timely identification and management of malnutrition require multiple interventions targeting patients with different health conditions across various care settings. According to the World Health Organization (WHO), primarily older adults’ care interventions include performing specific nutritional assessments, physical examinations, and laboratory tests. The evaluation, aimed at identifying possible signs of inadequate nutrition or overconsumption, assessing muscle mass and muscle strength, and encouraging specific dietary counselling, is fundamental to initiating important nutritional programs and tackling older people’s malnutrition through health-tailored methods.

Within the slogan “To restore resilience and defeat malnutrition", Spoke 06 of the OnFoods project is centred on developing nutritional strategists for vulnerable individuals, including older adults, by providing a roadmap for malnutrition involving these specific subjects and profiling them through the examination of data and biological samples. The research team of Spoke 06 aims to reduce malnutrition through sustainable nutritional approaches based on the interactions among multidimensional factors such as the environment, food, lifestyle. 

The Spoke finally focuses on restoring resilience through sustainable dietary patterns as a nutritional treatment for the population’s target-specific groups suffering from malnutrition, including people aged 65 and over the years old.

W.P 6.1

Work Package 6.1 for a malnutrition roadmap in vulnerable subjects

The issue of malnutrition in the elderly population is a grave concern. It can result in a higher risk of dependence on daily activities, hospitalisation, prolonged recovery times with potential complications, and increased vulnerability to morbidity and mortality. This, in turn, can lead to several significant adverse impacts, not only on the health-related quality of life of older adults but also on society as a whole and health and social care services. As such, it is essential to face the malnutrition issue with the utmost care and attention to ensure the well-being and safety of the elderly population.

Within this goal, Work Package 6.1 will extensively evaluate the nutritional status of the ageing population, which is considered more susceptible to malnutrition and non-communicable diseases (NCDs). Additionally, it will explore critical factors impacting their health and establish a biobank for the storage of human-derived biological samples. 

WP 6.1 will also design an ICT database for integrating data from different sources, including social and environmental lifestyle and their related actual dietary patterns, nutritional status, and biochemical and omics data.

The overall goal is to provide a comprehensive and successful strategy to address malnutrition in this proportion of the population.

W.P 6.2

Work Package 6.2 for reducing malnutrition through sustainable strategies.

Work Package 6.2 focuses on reducing malnutrition in target-specific populations through a sustainable, tailored, multidimensional approach based on the interrelations between environment, food, genotype, and phenotype. 

This entails the analysis of positive and negative interactions between lifestyle, socioeconomic status, clinical condition, psychological distress, medical treatment, and diet for implementing sustainable dietary patterns, validating malnutrition biomarkers, and drafting new sustainable nutritional protocols. 

Developing an experimental model which examines the impacts of new sustainable bioactive molecules on malnutrition is part of the package activities, as well as creating a personalised web-responsive application for monitoring sustainable target-specific dietary patterns.

W.P 6.4

Work Package 6.4 for restoring resilience while tackling malnutrition.

Work Package 6.4 aims to restore resilience in target-specific groups suffering from malnutrition, including older adults, through sustainable dietary patterns. In collaboration with Spoke 4 ‘Food Quality and Nutrition’, the goal is to provide a nutritional treatment prototyping foods, supplements, ingredients, and nutraceuticals to prevent and treat malnutrition. 

The project also includes the development of a user-friendly, personalised, and web-responsive application to remotely promote and monitor the implementation of sustainable dietary patterns for target-specific individuals. 

Activities of dissemination and communication relevant to food policy will also be offered within Work Package 6.4 in order to ensure a broader impact of the research and its findings.

SENIOR

The Research Project SENIOR “Sustainable eating patterns to limit malnutrition in older adults”.

"The world's population is rapidly aging with people aged over 60 expected to reach 2 billion by 2050. The latest ISTAT data show that in 2023 the Italian population aged 65 or over comprises a total of 14 million and 177 thousand individuals, equal to 24.1% of the total population. This epidemiological transition underlines the importance of promoting healthy aging and interventions to address the adverse effects of aging by focusing on key modifiable risk factors, such as malnutrition. In fact, the global prevalence of malnutrition in older adults ranges from 1 to 24%, with Italy that shows the highest prevalence in Europe (11%). Many factors are acknowledged as determinants of malnutrition; however, its multifactorial etiology is complex and at present not fully understood. In this framework, the research project SENIOR aims to map malnutrition status and investigate the association with lifestyle and socioeconomic factors, improving the condition of older adults and malnutrition management in and out of Italian hospital settings, with important public health impact." Prof. Hellas Cena.
As individuals advance in age, particularly those 65 or older, they may encounter a range of malnutrition issues.

In Europe, the prevalence of malnutrition ranges from 0.8% in the Netherlands and Sweden to 11.0% in Italy and France. In addition, 50% of the older people in rehabilitation, 20% in residential care, and 40% in hospitals are malnourished. As a result of population ageing, malnutrition prevalence is increasing, and it is expected to reach 29.1% by 2080.  

Older people are more likely to experience malnutrition due to hospitalisation, illness-related appetite loss, and drug-related adverse effects. 

In older people, nutrition plays a significant role in regulating health and well-being. Inadequate nutrition has been shown to significantly influence the complicated aetiology of sarcopenia and frailty, as well as the development of numerous illnesses. As a result, nutritional status evaluation and sufficient nutrition assistance are crucial for prevention and treatment with significant effects on public health.

In cooperation with researchers from Spoke 05 ‘Lifelong Nutrition’ and Spoke 07 ‘Policy, Behaviour and Education’, the SENIOR’s project team will be provided within 36 months with a systematic evaluation of existing data on nutritional status and critical issues for target-specific groups with malnutrition. 

An overview of the dietary conditions of older adults and the detection of potential new risk factors is expected to be provided via the identification through screening of older patients who are at risk or who have malnutrition. The research team is also planned to implement new care pathways and interventions tailored to more senior individuals' requirements.

On the operational level, it is foreseen that at least 200 older adults (≥65 years) will be enrolled for examination in the Internal Medicine and Rehabilitation units of ICS Fondazione Maugeri (Pavia, Italy) and Fondazione IRCCS Policlinico San Matteo, (Pavia, Italy). Exclusion criteria will be dysphagia, preexisting nutritional, medical treatment, terminal illness, history of gastric bypass, anorexia nervosa, liver and kidney failure, and severe dementia/confusion. Inclusion criteria will be age > 65 y and written informed consent. 

The following parameters will be evaluated in each participant:
  • anthropometric measurements (height, weight, waist circumference, handgrip, bioimpedance);
  • socio-demographic characteristics;
  • nutritional status by GLIM diagnostic scheme for screening, assessment, diagnosis, and classification of malnutrition;
  • lifestyle factors (mediterranean and mind diet adherence, physical activity, sleep habits, smoking, alcohol consumption, independency);
  • healthy status;
  • sarcopenia assessment, diagnosis, and severity grading by EWGSOP2 consensus.

Additionally, blood samples will be collected for biobanking and a complete nutritional assessment. Based on the results and the information from the literature, new sustainable healthy regimes will be created to prevent and treat malnutrition.

The final group of competitors to be chosen will be:
  • evaluation of the new sustainable nutrition protocols developed;

  • clinical evaluation (pilot randomised control trial) of 1 new prototype of functional food or a food supplement for preventing and treating malnutrition, which the other partners of Spoke 6 ‘Tackling Malnutrition’ will develop.

This blog post is related to

Spoke 06

Tackling malnutrition

To restore resilience and defeat malnutrition

Lead organisationUniPv

Spoke leaderHellas Cena
Research projectSENIOR

Sustainable eating patterns to limit malnutrition in older adults


Managed by


Principal investigators

Hellas Cena,Flavia Magri,Antonio Di Sabatino

Referred to

Spoke 06

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