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Recommendations Summary

MiOA: Food Fortification (2023)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    MiOA: Food Fortification in Long-Term Care

    Healthcare practitioners may consider food fortification as part of a comprehensive nutrition intervention for older adults with malnutrition or at risk of malnutrition living in long-term care. Food fortification is commonly used and is a feasible nutrition intervention to improve calorie and protein intake.

    Rating: Level 2(C)
    Conditional

    MiOA: Food Fortification in the Community

    Healthcare practitioners may consider food fortification as part of a comprehensive nutrition intervention for older adults with malnutrition or at risk of malnutrition living in the community. Food fortification is commonly used and is a feasible nutrition intervention to improve calorie and protein intake.

    Rating: Consensus
    Conditional

    • Risks/Harms of Implementing This Recommendation

      Limited available evidence indicates that food fortification alone may not sufficiently meet older adults’ nutrition needs. Instead, food fortification interventions may be considered as a part of a comprehensive nutrition intervention.

      Side effects from food fortification may include feelings of fullness, flavor fatigue or gastrointestinal upset. These conditions are likely to be transitory and can be addressed by stopping the fortification or serving a different form eg, replacing lactose-containing items with reduced/lactose-free. For other individuals, allergies to a component of a specific food fortification (eg, casein or whey) may exist and therefore the selection of an appropriate food fortification may benefit from the advice of a dietitian. 

      In the community, techniques to fortify food may increase the risk of food-borne illness when food safety techniques are not used.  This may include cross-contamination, time under temperature abuse, and the use of outdated products. 

    • Conditions of Application

      Food fortification as part of a comprehensive nutrition care plan, may be a feasible strategy to help older adults meet calorie and increased protein requirements. Food fortification does not have to increase the volume of food that an individual eats, thus making it a positive intervention for those who cannot eat large amounts of food. Food fortification fits within a food first approach, which is a well-accepted strategy to promote calorie and protein intake (Roberts et al. 2019). Food fortification may be best used by adding calorie and protein boosters to typical meal items the individual already enjoys (Bauer et al. 2013). Healthcare practitioners should assess patients and clients' desired portion sizes for meals, snacks and drinks; evaluate current eating habits; and provide individualized nutrition recommendations pertaining to food fortification. Practitioners may consider developing individualizing meal plans and consider the incorporation of fortified foods based on the following protein requirements:

      • 1.0–1.20 grams protein/kg body weight 
      • ≥ grams protein/kg body weight for older adults who exercise or are active 
      • 1.2–1.5 grams protein/kg body weight for older adults with acute or chronic conditions (individuals with kidney disease not on dialysis may need to limit protein)  

      Acceptability

      It is likely that older adults, their families, and caregivers would value the simplicity, affordability, acceptability, and accessibility of food fortification to deliver positive effects related to increasing protein and calorie intake.  Norton et al. 2022, evaluated preferences for protein fortification. The older adults consumed protein-fortified food significantly less often than younger adults. Older and younger adults preferred consuming fortified foods at breakfast or between meals as snacks, and preferred consuming fortified cereal, pasta, porridge, cakes, and biscuits. Taste and flavor were reported as the most important characteristics of fortified foods, followed by texture, cost, smell, and appearance. Another study, Roberts et al. 2023,  evaluated dietitians' perceptions of nutrition strategies, and authors reported that dietitians perceived food fortification strategies as accessible and affordable.     

      Table. Barriers and Facilitators for Implementation of Fortified Foods for Older Adults Living in Long-Term Care and the Community.

      Barriers Facilitators
      Lack of patient or client knowledge on how to fortify foods.
      • Dietitians should work with the individual and/or family members to provide education on how to easily fortify foods through the use of calorie and protein boosters.
      Lack of patient or client access to fortifiers and/or fortified foods. 
      • Patients and clients should be encouraged to increase the calorie and protein content of foods they prefer with food that may be already available in their home such as oil, butter, cream, or sauces.  
      • Academy Resources: 
      • Patients and clients may also be referred to meal assistance programs such as those provided under the Older American’s Act.  

    • Potential Costs Associated with Application

      Although food fortification costs financially vary in the form of products, food enhancements, and number of products used, the benefits of food fortification may outweigh risks. Food fortification may be a cost-effective nutrition intervention in collaboration with other interventions to prevent or treat malnutrition in older adults.

    • Recommendation Narrative

      Older adults frequently have reduced appetite, altered sensory sensitivity, and oral impairments that may impact calorie and protein intake (Norton et al. 2022). Furthermore, older adults may have greater protein requirements to maintain or regain lean body mass and function than younger adults (Bauer et al. 2013). Older adults with acute or chronic disease may require even more protein than healthier older adults. The most frequently used nutrition interventions to improve calorie and protein intake are oral nutrition supplements and food fortification.  

      A systematic review was conducted to evaluate the effectiveness of food fortification for the treatment or prevention of malnutrition of older adults living in long-term care or in the community. For the purpose of this systematic review, fortified food was defined as the adaptation of everyday food through the addition of calories and protein.

      Six studies reported the effectiveness of food fortification on identified outcomes in older adults living in long-term care (Bjorkman et al. 2012, Van Wymelbeke et al. 2016, Leslie et al. 2013, Smoliner et al. 2008, Bjorkman et al. 2020). Food fortification may help increase or maintain weight in older adults with malnutrition or at risk for malnutrition living in long-term care (low certainty) (Bjorkman 2012, Van Wymelbeke 2016, Leslie 2013, Smoliner 2008).  

      Evidence on the effect on calorie and protein intake is limited and conflicting (very low certainty) (Van Wymelbeke 2016, Leslie 2013, Smoliner 2008). There may be no effect on nutrition status (low certainty) (Van Wymelbeke 2016, Bjorkman 2020),  or physical function (low certainty) (Bjorkman 2012, Van Wymelbeke 2016, Odlund 2003, Smoliner 2008). The effect of food fortification on identified outcomes in older adults living in the community was uncertain; only one small study with 29 participants was included in the systematic review (Arjuna et al. 2018). 

      The current evidence is limited to assess the effectiveness of food fortification for older adults considered malnourished or at risk of malnutrition living in long-term care or the community. There is a research gap in high quality studies designed to assess the effectiveness of food fortification.

    • Recommendation Strength Rationale

      The evidence supporting the recommendations is based on Grades D (Very Low) and C (Low).

    • Minority Opinions

      None.