Malnutrition


Malnutrition, commonly understood as “undernutrition”, results from a negative balance between dietary intakes and body requirements. The deficiency is generally caused by insufficient nutrient intake (proteins, vitamins, energy…), but can also be a consequence of higher energy expenditure.

Protein-energy malnutrition affects every system in the body and inevitably results in greater vulnerability to illness, increased complications and increased morbidity/mortality, especially in the elderly. It affects body composition, worsening physiological involuntary weight loss due to aging.

Malnutrition affects 19-38% of people living in institutions1,2, and 30-90% of patients in hospital3,4.

References: 1 Margetts BM, Thompson RL, Elia M, Jackson AA. Prevalence of risk of undernutrition is associated with poor health status in older people in the UK. European Journal of Clinical Nutrition. 2003;57:69. 2 Crogan NL, Pasvogel A. The influence of protein-calorie malnutrition on quality of life in nursing homes. The Journals of Gerontology Series A. 2003;58:159. 3 Thomas DR, Zdrowski CD, Wilson MM, Conright KC, Lewis C, Tariq S, Morley JE. Malnutrition in subacute care. The American Journal of Clinical Nutrition. 2002;75:308. 4 Pablo AM, Izaga MA, Alday LA. Assessment of nutritional status on hospital admission: nutritional scores. European Journal of Clinical Nutrition. 2003;57:824.

What is sarcopenia?

Sarcopenia is the loss of muscle mass (lean body mass), strength and function related to aging. This loss is a complex and multifactorial process, generally occurring as a consequence of physiological and/or pathological changes. Generally associated with weight loss1, sarcopenia is a significant risk factor for disability in the aging population2.
The estimated prevalence of sarcopenia nowadays is 50 million people; regarding the general aging population around the world, it is estimated that sarcopenia will affect more than 200 million people over the next 40 years.

The 3 key risk factors of sarcopenia are:

  • Malnutrition, especially protein deficiency, which occurs in the elderly when the metabolic efficiency is decreasing, requiring a higher protein intake for protein synthesis than in younger people.
  • Aging: as a normal physiological process, lean muscle mass is lost at the rate of approximately 1% per year after 30 years of age3. Sarcopenia tends to start at the age of 40 and progresses more rapidly after the age of 754.
  • Sedentary lifestyle: muscle inactivity reduces muscle mass.

Recommendations for managing sarcopenia (According to the Society for Sarcopenia, Cachexia, and Wasting Disease5):

  • Protein supplementation

Older people have a high risk of inadequate protein intake6, as they need more protein per kilogram than young people to maintain proper levels that reinforce muscle mass7,8.
There is a positive association between protein ingestion and muscle mass in elderly people9,10. As a consequence, an adequate protein and energy intake is key in preventing and reversing sarcopenia as part of a multimodal therapeutic approach.
It is recommended that the total protein intake is 1 to 1.5 g/kg/day11,12. Essential aminoacids, specially Leucine, are powerful stimulants of protein synthesis in the muscle5. Thus, quantity and quality of proteins are both capital for the management of sarcopenia.

  • Physical exercise

A minimum of 20 to 30 minutes daily of resistance training and aerobic exercise 3 times a week is recommended to slow muscle loss and prevent sarcopenia, in combination with adequate protein-intake.

  • Other supplements

There is some evidence that creatine supplements13,14 and maintenance of appropriate blood levels of vitamin D may improve muscle development, as well as maintain muscle strength and physical performance15.

Laboratoires Grand Fontaine offers a complete range of nutritional options adapted to the patient’s condition:

References
1 Janssen I, Shepard DS, Katzmarzyk PT, Roubenoff R. The healthcare costs of sarcopenia in the United States. Journal of the American Geriatrics Society 2004;52:80–85.
2 Volpi, E, Nazemi R, Fujita S. Muscle tissue changes with aging. Current Opinion in Clinical Nutrition & Metabolic Care. 2004 July, 7(4):405-410.
3 Morley JE. Anorexia, sarcopenia, and aging. Nutrition 2001;17:660–663.
4 Waters D.L., R.N. Baumgartner & P.J. Garry. “Sarcopenia: Current Perspectives.” The Journal of Nutrition, Health & Aging. 2000; 4(3):133-139.
5 Morley JE. Nutritional Recommendations for the Management of Sarcopenia. Journal of the American Medical Directors Association 2010; 11: 391–396.
6 Fulgoni VL 3rd. Current protein intake in America: Analysis of the National Health and Nutrition Examination Survey, 2003–2004. Am J Clin Nutr 2008;87:1554S–1557S.
7 Campbell WW, Crim MC, Dallal GE, Young VR, Evans WJ. Increased protein requirements in elderly people: data and retrospective reassessments. The American Journal of Clinical Nutrition. 1994 Oct;60(4):501-9.
8 Campbell WW, Evans WJ. Protein requirements of elderly people. European Journal of Clinical Nutrition. 1996 Feb;50 Suppl 1S180-3.
9 Vellas BJ, Hung WC, Romero LJ, et al. Changes in nutritional status and patterns of morbidity among free-living elderly persons: A 10-year longitudinal study. Nutrition. 1997;13:515–519.
10 Lesourd B, Decarli B, Dirren H. Longitudinal changes in iron and protein status of elderly Europeans. SENECA Investigators. European Journal of Clinical Nutrition. 1996;50:S16–S24.
11 Campbell WW. Synergistic use of higher-protein diets or nutritional supplements with resistance training to counter sarcopenia. Nutrition Reviews. 2007;65:416–422.
12 Arnal MA, Mosoni L, Boirie Y, et al. Protein pulse feeding improves protein retention in elderly women. The American Journal of Clinical Nutrition. 1999;69:1202–1208.
13 Brose A, Parise G, Tarnopolsky MA. Creatine supplementation enhances isometric strength and body composition improvements following strength exercise training in older adults. The Journals of Gerontology. Series A. 2003 Jan;58(1):11-9.
14 Chrusch MJ, Chilibeck PD, Chad KE, Davison KS, Burke DG. Creatine supplementation combined with resistance training in older men. Medicine & Science in Sports & Exercise. 2001 Dec;33(12):2111-7.
15 Mithal A, Bonjour J-P, Boonen S, Burckhardt P, Degens H, El Hajj Fuleihan G,  Josse R,  Lips P, Morales Torres J, Rizzoli R, Yoshimura N, Wahl D.A., Cooper C, Dawson-Hughes B. Impact of nutrition on muscle strength and performance in older adults. Osteoporosis International (in press). 2005.

What is anorexia of aging?

The physiological processes of aging, and factors prevalent in the elderly such as comorbidities and polypharmacy, often cause loss of appetite and decline of energy intake. This is also called anorexia of aging. Satiation (the process that leads to the termination of eating) and satiety (the feeling of fullness that persists after eating) are important factors in the control of appetite and energy intake: some mechanisms of satiation and satiety are altered in older adults.

Although there is a high prevalence of excess weight among elderly people, the main concern in this population is the decline in food intake, leading to significant involuntary weight loss and protein-energy malnutrition. The Centers for Medicare & Medicaid Services (CMS) defines significant unplanned or undesired weight loss as a 5% decline in body weight over 1 month, 7.5% over 3 months, and 10% over 6 months.1

Various factors increase the risk of anorexia of aging:

  • Social factors: poverty, depression, loneliness, and social isolation.
  • Physiological factors: reduced hunger levels.
  • Physical factors:
    • Poor dentition and ill-fitting dentures.
    • Age-associated changes in taste and smell.
    • Medical conditions such as gastrointestinal disorders, malabsorption problems2, chronic obstructive pulmonary disease, Parkinson’s disease, and arthritis.3
    • Cognitive impairment can also lead to weight loss; individuals affected by Alzheimer’s disease or dementia may experience loss of appetite or forget to eat.4
  • Medication: the elderly are major users of prescription medications, a number of which can cause malabsorption of nutrients, gastrointestinal disorders, and loss of appetite.

How to prevent or manage anorexia of aging:

  • Dietary management
    • Increase/enrich food intake.
    • Add flavour enhancers and adapt food textures
    • Use of oral supplements with high caloric density, proteins, and essential nutrients (vitamins, minerals)
  • Medical management:
    • Determine and treat the underlying disease.
    • When dietary management isn’t sufficient, choice of feeding route (enteral tube feeding/peripheral parenteral nutrition), drug treatments.

Laboratoires Grand Fontaine offers a complete range of nutritional options adapted to the patient’s condition:

References
1 US Centers for Medicare & Medicaid Services. State Operations Manual. Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Section 483.25(i). Rev. 70. Revised January 7, 2011. Accessed September 15, 2011.
2 Donini L, Savina C, Cannella C. Eating habits and appetite control in the elderly: the anorexia of aging. International Psychogeriatric. 2003;15(1):73-87.
3 van Staveren WA, de Graaf C, de Groot LC. Regulation of appetite in frail persons. Clinics in Geriatric Medicine. 2002;18(4):675-684.
4 Johansson L, Sidenvall B, Malmberg B, Christensson L. Who will become malnourished? A prospective study of factors associated with malnutrition in older persons living at home. The Journal of Nutrition Health and Aging. 2009;13(10):855-860.

What is cancer?

The National Cancer Institute (NCI) of the United States defines cancer as a disease in which abnormal cells divide without control and are able to invade other tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems. There are more than 100 different types of cancer, including prostate, bladder, colon, uterus, pancreas, stomach, rectum and lung.

Cancer incidence increases exponentially with advancing age, people over 65 account for 60% of newly diagnosed malignancies and 70% of all cancer deaths 1,2.  Malnutrition and cachexia (extreme weakening of the body induced by malnutrition and weight loss) are major causes of morbidity and mortality in cancer: it is estimated that 20% of cancer patients die from those two conditions3,4,5.
Malnutrition and weight loss also reduce response to chemotherapy, due to chemotherapy-induced toxicity.

Cancer treatments often damage healthy cells and tissues, therefore side effects are common. Indeed, cancer and cancer treatment can affect food intakes and increase energy expenditure, thus leading to malnutrition and weight loss:

  • Anorexia (loss of appetite)
  • Altered taste and smell, food aversion
  • Mucositis
  • Mouth sores
  • Dry mouth (xerostomia)
  • Trouble swallowing
  • Nausea, Vomiting
  • Diarrhea, Constipation
  • Pain
  • Anxiety, Depression

How is cancer and its side effects treated and managed?

  • Medical treatment: the treatment plan depends on the type and stage of cancer, as well as on patient’s age and general health. The goal of treatment can be to cure the cancer, to control disease spreading or to reduce symptoms. Treatments can include :
    • Surgery (to remove or destroy cancer in one part of the body)
    • Radiation therapy (to shrink or destroy a tumour)
    • Chemotherapy (to kill or slow the growth of cancer cells that have spread beyond the original tumour)
    • These treatments can involve hormone therapy or biological therapy, stem cell transplantation.
  • Nutritional intervention is vital to counteract malnutrition-related issues due to cancer.  It can improve the response to chemotherapy, lower the risk of infections, and thus improve the patient’s quality of life. Some nutrients have a synergistic effect with chemotherapy treatments. Nutritional assessment is fundamental for the clinical management of patients with cancer.
    • A good protein-energy status is essential, since cancer increase the energy expenditure and reduces muscle mass.
    • Some specific nutrients, such as polyunsaturated fatty acids (PUFAs), oligosaccharides (FOS and GOS), antioxidants (vitamin A, C, E, carotenoids, selenium, zinc) and amino acids, help improve the immune system of patients with cancer.
    • Glutamine supplementation reduces mucositis6, a common side effect of chemotherapeutic agents. It also improves protein metabolism by decreasing the protein breakdown and increasing protein synthesis in gut mucosa and skeletal muscles6.

Laboratoires Grand Fontaine offers a complete range of nutritional options adapted to the patient’s condition:

References
1 Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg LX, Edwards SEER. Cancer Statistics Review, 1973–1998. National Institute of Health. 2000 NIH publication 00-2789.
2 Yancik R, Holmes ME. NIA/NCI Report of the Cancer Center Workshop (June 13–15, 2001). Exploring the Role of Cancer Centers for Integrating Aging and Cancer Research. 2002.
3Muscaritoli M, Molfino A, Gioia G, Laviano A, Rossi Fanelli F. The “parallel pathway”: a novel nutritional and metabolic approach to cancer patients. Internal and Emergency Medicine. 2011 Apr;6(2):105-112.
4Paccagnella A, Morassutti I, Rosti G. Nutritional intervention for improving treatment tolerance in cancer patients. Current Opinion in Oncology. 2011 Jul;23(4):322-330.
5Muscaritoli M, Bossola M, Aversa Z, Bellantone R, Rossi Fanelli F. Prevention and treatment of cancer cachexia: new insights into an old problem. European Journal of Cancer. 2006 Jan;42(1):31-41.
6 Noe JE. L-glutamine use in the treatment and prevention of mucositis and cachexia: a naturopathic perspective. Integrative Cancer Therapies. 2009 Dec;8(4):409-415.

Food for special medical purposes.
Use under medical supervision.