Unintended Weight Loss in Older Adults

UWL: Food, Appetite and Environment (2009)

Unintended Weight Loss in Older Adults -

Nutrition Intervention

• Intervention
  What is the relationship between modified texture diets and weight gain in adults over age 65?

  • Conclusion

    Seven studies were evaluated regarding the use of modified texture diets in older adults with dysphagia.  People consuming modified texture diets report an increased need for assistance with eating, dissatisfaction with foods, and decreased enjoyment of eating, resulting in decreased food intake and weight loss. Recognition of the social and psychological burden of dysphagia, an individualized treatment approach and the provision of eating assistance may contribute to increased food intake and weight maintenance or weight gain.

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What is the relationship between modified texture diets and weight gain in adults over age 65?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Colodny N.  Dysphagic independent feeders' justifications for noncompliance with recommendations by a speech-language pathologist.  Am J Speech Lang Pathol 2005;14(1):61-70. 
      • Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P.  Social and psychological burden of dysphagia:  its impact on diagnosis and treatment.  Dysphagia 2002;17:139-146. 
      • Foley N, Finestone H, Woodbury MG, Teasell R, Greene-Finestone L.  Energy and protein intakes of acute stroke patients.  J Nutr Health Aging 2006;10(3):171-5. 
      • Lorefalt B, Granerus AK, Unosson M.  Avoidance of solid food in weight losing older patients with Parkinson's disease.  J Clin Nurs 2006;15(11):1404-12. 
      • Nowson CA, Sherwin AJ, McPhee JG, Wark JD, Flicker L.  Energy, protein, calcium, vitamin D, and fibre intakes from meals in residential care establishments in Australia.  Asia Pacific J Clin Nutr 2003;12(2):172-77. 
      • Rypkema G, Adang E, Dicke H, Naber T, De Swart B, Disselhorst L, Goluke-Willemse G, Olde Rikkert M.  Cost-effectiveness of an interdisciplinary intervention in geriatric inpatients to prevent malnutrition.  J Nutr Health Aging 2004;8(2):122-7. 
      • Wright L, Cotter D, Hickson M, Frost G.  Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet.  J Hum Nutr Diet 2005;18(3):213-9. 
  • Search Plan and Results: Modified Texture Diets 2007
     
  What is the relationship between nutrient-dense oral supplements/fortified foods and weight gain in adults over age 65?

  • Conclusion

    Two positive-quality systematic reviews (including 70 studies) were evaluated regarding nutritional supplementation in older adults. Both concluded that oral protein and energy supplementation produces a small but consistent weight gain in older adults.

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: Relationship Between Nutrient-Dense Oral Supplements or Fortified Foods and Weight Gain in Adults Over Age 65
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Avenell A, Handoll HHG. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev 2006; (4): CD001880.
      • Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk for malnutrition. Cochrane Database Syst Rev 2005; (2): CD003288.
  • Search Plan and Results: Oral Supplements and Fortified Foods 2007
     
  What is the relationship between diet liberalization (selective diets, non-restrictive diets) and weight gain in adults over age 65?

  • Conclusion

    Seven studies were evaluated regarding liberalized diets, meal patterns and composition in older adults. Three studies report little scientific evidence to support the use of restrictive diets in the elderly. Resident involvement in menu planning, as well as flexibility of the meal pattern and composition, may result in improved intake of food and fluid. 

  • Grade: I
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: Relationship Between Diet Liberalization (Selective Diets, Non-Restrictive Diets) and Weight Gain in Older Adults
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Kofod J and Birkemose A. Meals in nursing homes. Scand J Caring Sci. 2004; 18(2): 128-134.
      • Schatz IJ, Masaki K, Yano K, Chen R, Rodriguez BL, Curb JD. Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: A cohort study. Lancet. 2001; 358: 351-355.
      • Simons LA, Simons J, Friedlander Y, McCallum J. Cholesterol and other lipids predict coronary heart disease and ischaemic stroke in the elderly, but only in those below 70 years. Atherosclerosis. 2001; 159: 201-208.
      • Tariq SH, Karcic E, Thomas DR, Thomson K, Philpot C, Chapel DL, Morley JE. The use of a no-concentrated-sweets diet in the management of type 2 diabetes in nursing homes. J Am Diet Assoc. 2001; 101(12): 1,463-1,466.
      • Taylor KA, Barr SI. Provision of small, frequent meals does not improve energy intake of elderly residents with dysphagia who live in an extended-care facility. J Am Diet Assoc. 2006; 106: 1,115-1,118.
      • Young KWH, Greenwood CE. Shift in diurnal feeding patterns in nursing home residents with Alzheimer's disease. J Gerontol A Biol Sci Med Sci. 2001; 56 (11): M700-M706. 
      • Young KWH, Greenwood CE, van Reekum R, Binns MA. A randomized, crossover trial of high-carbohydrate foods in nursing home residents with Alzheimer's disease:  associations among intervention response, body mass index, and behavioral and cognitive function. J Gerontol A Biol Sci Med Sci. 2005; 60 (8): 1,039-1,045.
  • Search Plan and Results: Diet Liberalization 2007
     
  What is the relationship between eating assistance and weight gain in adults over age 65?

  • Conclusion

    Seventeen studies were evaluated regarding eating assistance in older adults. Four studies report that residents needing assistance to eat are more likely to receive assistance when staffing levels are adequate. Eight studies report a positive association between eating dependency and poor nutritional status. Five studies evaluating the impact of eating assistance on food intake and weight status report conflicting findings due to study length and degree of comorbidity; studies of longer duration in residents with different levels of illness acuity are needed.        

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: Relationship Between Eating Assistance and Weight Gain in Adults Over Age 65
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Crogan NL, Shultz JA, Adams CE, Massey LK. Barriers to nutrition care for nursing home residents. J Gerontol Nurs. 2001; 27: 25-31. 
      • Hickson M, Bulpitt C, Nunes M, Peters R, Cooke J, Nicholl C, Frost G. Does additional feeding support provided by health care assistants improve nutritional status and outcome in acutely ill older in-patients? A randomized controlled trial. Clinical Nutrition. 2004; 23: 69-77.
      • Holm B, Soderhamn O. Factors associated with nutritional status in a group of people in an early stage of dementia. Clin Nutr. 2003; 22: 385-389. 
      • Horn SD, Buerhaus P, Bergstrom N, Smout RJ. RN staffing time and outcomes of long-stay nursing home residents. American Journal of Nursing. 2005; 105: 58-70.  
      • Riviere S, Gillette-Guyonnet S, Voisin T, Reynish E, Andrieu S, Lauque S, Salva A, Frisoni G, Nourhashemi F, Micas M, Vellas B. A nutritional education program could prevent weight loss and slow cognitive decline in Alzheimer's disease. The Journal of Nutrition, Health and Aging. 2001; 5(4): 295-299.
      • Simmons SF, Levy-Storms L. The effect of dining location on nutritional care quality in nursing homes. Journal of Nutrition Health and Aging. 2005; 9: 434-439. 
      • Simmons SF, Patel AV. Nursing home staff delivery of oral liquid nutritional supplements to residents at risk for unintentional weight loss.  J Am Geriatr Soc 2006; 54: 1372-1376.   
      • Simmons SF, Garcia ET, Cadogan MP, Al-Samarrai NR, Levy-Storms LF, Osterweil D, Schnelle JF. The minimum data set weight-loss quality indicator: Does it reflect differences in care processes related to weight loss? Journal of the American Gerontological Society 2003; 51: 1,410-1,418.  
      • Simmons SF, Lam HY, Rao G, Schnelle JF. Family members' preferences for nutrition interventions to improve nursing home residents' oral food and fluid intake. J Am Geriatr Soc. 2003; 51: 69-74. 
      • Sullivan DH, Morley JE, Johnson LE, Barber A, Olson JS, Stevens MR, Yamashita BD, Reinhart SP, Trotter JP, Olave XE. The GAIN (Geriatric Anorexia Nutrition) Registry: The impact of appetite and weight on mortality in a long-term care population. J Nutrition Health and Aging. 2002; 6 (4): 275-281.
      • Suominen M, Laine A, Routasalo P, Pitkala KH, Rasanen L. Nutrient content of served food, nutrient intake and nutritional status of residents with dementia in a Finnish nursing home. J Nutr Health Aging. 2004; 8 (4): 234-238.
      • Westergren A, Karlsson S, Andersson P, Ohlsson O, Hallberg IR. Eating difficulties, need for assisted eating, nutritional status and pressure ulcers in patients admitted for stroke rehabilitation. J Clin Nursing. 2001; 10: 257-269.
      • Westergren A, Ohlsson O, Hallberg IR. Eating difficulties, complications and nursing interventions during a period of three months after a stroke. J Adv Nurs. 2001; 35 (3): 416-426.
      • Westergren A, Ohlsson O, Hallberg IR. Eating difficulties in relation to gender, length of stay, and discharge to institutional care, among patients in stroke rehabilitation. Disability and Rehabilitation, 2002; 24: 523-533. 
      • Westergren A, Unosson M, Ohlsson O, Lorefalt B, Hallberg IR. Eating difficulties, assisted eating and nutritional status in elderly (>65 years) patients in hospital rehabilitation. International Journal of Nursing Studies, 2002; 39: 341-351.
      • Woo J, Chi I, Hui E, Chan F, Sham A. Low staffing level is associated with malnutrition in long-term residential care homes. Eur J Clin Nutr. 2005; 59: 474-479.
      • Xia C, McCutcheon H. Mealtimes in hospital: Who does what? Journal of Clinical Nursing. 2006; 15: 1,221-1,227.
  • Search Plan and Results: Feeding Assistance 2007
     
  What is the relationship between dining environment and weight gain in adults over age 65?

  • Conclusion

    Nine studies were evaluated regarding dining environment in older adults. Three studies report improved food intake and nutritional status in residents eating in a socially stimulating common dining area. Two studies focusing on improved dining ambience (such as physical environment and atmosphere of the dining room, food service and meals, and organization of the nursing staff assistance) resulted in resident weight gain. Two studies based on creative dining programs (such as buffet-style dining and meal portioning on resident floors) demonstrate improvements in quality of life and food intake. Studies of longer duration in residents with different levels of illness acuity are needed.

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: Relationship Between Dining Environment and Weight Gain in Adults Over Age 65
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Mamhidir AG, Karlsson I, Norberg A, Mona K. Weight increase in patients with dementia, and alteration in meal routines and meal environment after integrity promoting care. J Clin Nurs. 2007; 16(5): 987-996.
      • Mathey MF, Vanneste VG, de Graaf C, de Groot LC, van Staveren WA. Health effect of improved meal ambience in a Dutch nursing home: A one-year intervention study. Prev Med. 2001; 32(5): 416-423.
      • Remsburg RE, Luking A, Baran P, Radu C, Pineda D, Bennett RG, Tayback M. Impact of a buffet-style dining program on weight and biochemical indicators of nutritional status in nursing home residents: A pilot study. J Am Diet Assoc. 2001; 101(12): 1,460-1,463.
      • Shatenstein B, Ferland G. Absence of nutritional or clinical consequences of decentralized bulk food portioning in elderly nursing home residents with dementia in Montreal. J Am Diet Assoc. 2000; 100(11): 1,354-1,260. 
      • Simmons SF, Levy-Storms L. The effect of dining location on nutritional care quality in nursing homes. Journal of Nutrition Health and Aging. 2005; 9: 434-439. 
      • Simmons SF, Lam HY, Rao G, Schnelle JF. Family members' preferences for nutrition interventions to improve nursing home residents' oral food and fluid intake. J Am Geriatr Soc. 2003; 51: 69-74. 
      • Stroebele N, De Castro JM. Effect of ambience on food intake and food choice. Nutrition, 2004; 20: 821-838.
      • Wright L, Hickson M, Frost G. Eating together is important: Using a dining room in an acute elderly medical ward increases energy intake. J Hum Nutr Diet. 2006; 19(1): 23-26.
      • Xia C, McCutcheon H. Mealtimes in hospital: Who does what? Journal of Clinical Nursing. 2006; 15: 1,221-1,227.
  • Search Plan and Results: Dining Environment 2007
     
  What is the evidence regarding the use of appetite stimulants in older adults with unintended weight loss?

  • Conclusion

    There is no research on the effectiveness of appetite stimulants for older adults that meets the American Dietetic Association criteria for evidence analysis.

  • Grade: V
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Search Plan and Results: Appetite Stimulants 2007