The importance of good nutrition for our overall health and in the prevention (and even the reversal) of disease tends to be somewhat overlooked in modern-day society. Its role only takes on further importance among older people living in the community, where frailty can often be seen as a ‘normal’ part of ageing, rather than a sign of a risk that should be addressed with appropriate intervention.
It has been estimated that 93% of the 3 million people in the UK who are at risk of being under- or malnourished reside in community settings and nearly half are aged over 65 years (British Association for Parenteral and Enteral Nutrition, 2009). As people age and eat less, they are consuming fewer nutrients and the quality of their nutrition becomes ever more important to prevent loss of muscle mass leading to frailty (Boulos et al, 2016), disease and even mortality (Soderstrom et al, 2017).
While energy needs and intake decline in older age, particularly in the over-75-year age group (van Dijk et al, 2020), nutrient absorption also becomes less efficient, meaning that a person's need for certain essential nutrients actually increases (Shlisky et al, 2017).
Nutrients that have been identified as being inadequately consumed among older people include protein in particular, as well as fibre, calcium, magnesium, vitamins B6 and B12, as well as vitamins D and E, and potassium, among others (Tucker et al, 2015; Millen et al, 2016). In the US, inadequate intakes have been observed among older people of fruit, vegetables, legumes, whole grains, nuts or seeds, fish and lean meat and poultry, while excess intakes are seen of refined grain products, processed and fatty meats, fried foods and added sugars (Ervin, 2008). Furthermore, medications commonly taken for chronic conditions that are prevalent in older age groups can further affect nutrient absorption and metabolism, changing nutrient requirements (Chan, 2013).
A nutrient-dense (but not energy-dense) diet is recommended for people of older age (Shlisky et al, 2017). However, various age-related factors such as loss of appetite, dental and chewing problems, changes in taste and smell, limitations in mobility, lack of access to high-quality foods, and often a lack of family support, can make it even more difficult for older people in community settings to access the nutrient-dense foods their bodies require (Shlisky et al, 2017).
Social and psychological factors also affect the quality of a person's nutritional intake. For example, people who live alone are more likely to be at risk of malnutrition, whereas higher social interaction is linked with improved nutritional habits (Robinson, 2018). Qualities such as high self-efficacy and resilience are also linked with more optimal dietary intake and habits (Robinson, 2018).
In cases where a person is malnourished or at risk of malnutrition (as defined by guidelines indicating nutrition support in the community) and are not obtaining adequate or safe nutrition orally (and who have a functional and accessible gastrointestinal (GI) tract), enteral tube feeding should be considered (National Institute for Health and Care Excellence (NICE), 2017). Parenteral nutrition can be considered in cases where enteral nutrition is not adequate or safe, or where the GI tract is non-functional, in accessible or leaking (NICE, 2017). However, such nutrition support methods should be stopped once the person has been established on an adequate intake of oral nutrition (NICE, 2017).
The population is ageing and adults aged 65 years and over are set to represent close to a quarter of the UK population by 2045 (Office for National Statistics, 2017). There is a need for more widespread recognition of malnutrition risk among older people and increased routine screening to achieve earlier diagnosis and community intervention (Robinson, 2018).
Malnutrition is putting many in the community at risk, and in addition to the personal costs endured by these individuals, the economic costs to health and social care is significant, with older people accounting to more than half of this expenditure (Robinson, 2018).
Poor nutrition has sadly become a norm in Western society and is much more easily accessible to the population than high-quality nutrition. This requires both governmental policy changes and increased awareness through health promotion patient education initiatives and appropriate training for community healthcare staff.