Are you borderline malnourished?

Strange but true. As you age not only must you avoid being in the overweight camp, but you also need to escape undernourishment which has even worse consequences. The reason malnourishment happens is either physiological, social, or medical issues. Your food is absorbed a lot less well, we all get reduced appetite, may be solitary and less ’bothered’ about food so eating too little, or have increased needs because of long term illness. Nowadays, rising food costs add another cause. Medically, inflammation is the key driver ie the ‘inflammaging’ addressed in other InfoSheets,

Really? How often does it actually happen?

Borderline malnourishment occurs in 26% of our older adult population and actual clinical malnourishment in 3%*. Malnutrition is obviously dangerous but borderline loss is critical first because the slightest mishap that arises, will tip an individual into frank malnourishment and secondly it mandates corrective action. Once borderline, even a short illness, an operation, further loss of appetite following bereavement, financial stress or depression can be your undoing. 

Why undernourishment matters.

‘You don’t know what you’ve got ‘til it's gone’ Joni Mitchell sang in Big Yellow Taxi. Sadly once gone, it [meaning muscle, bone, collagen] may be difficult or impossible to regain. Recovery of normal function after significant weight loss is difficult because of loss of skeletal muscle mass and thus strength. Just refeeding will not replace lost muscle, only resistance training and substantial protein supplementation can achieve that. 

Specific adverse outcomes of malnutrition include frailty, decreased immunity, susceptibility to hypothermia, osteoporosis, mood change, cognitive [mental] impairment, lowered quality of life, and premature death. Delayed treatment of malnutrition means poor wound healing, pressure sores, and falls leading to hospitalisation, or nursing home admission.

Whose problem is it to identify it?

Well … you would think that this was the sort of thing all family practitioners should be hot on ... and clinical guidelines recommend routine screening for malnutrition in all older adults. The trouble is nobody does take responsibility for it and awareness of the issue is low [which is why I am writing about it!].

Now you know about it you can raise the issue [with yourself or with others].

Spotting it.

Malnourishment means loss of muscle. Although unintended weight loss, chronic illness, BMI< 18.5 [Weight/Height2 in metric units] are all markers, the the simplest and quickest test is to measure maximum calf circumference of the right leg - in a seated position. This correlates well with other complex measures of poor nutrition.

The cutoff values for males [defined in a large USA NHANES group] are 34 and 32 cm (moderate/severe muscle loss ) and for females, 33 and 31 cm. The two figures are 1 and 2 standard deviations below the mean respectively)**.

Fixing it

Οlder adults require higher protein intake than a young adult to maintain lean body mass and physiological function because of poor absorption and utilisation of protein. Additional protein intake is required for older adults in times of illness, infection, and for adequate recovery from surgery. Aim for 1·2 to 1·5 g/kg per day and up to 2·0 g/kg per day if severely ill. Energy intake needs to also increase in to prevent malnutrition in older adults. Aim for 25-30 kcal/kg body weight.

What about the overweight?

You would say ‘they can’t be malnourished’. But in illness or on a low calorie diet they will lose muscle mass readily. In illness they need the same nutrition guidelines. If there is dietary intervention eg to reduce weight for say diabetes control or heart disease issues then it must maintain the high protein intake above, include resistance exercise and be carefully monitored.

Summary

Recognize the problem; check calf measurement; maintain appropriate protein intake.