1.12/ Malnutrition and the Older Adult - Part 2

INTRO: Hello, and welcome to Clinical Nutrition Notes, a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition. Brought to you by Nestlé Health Science Canada. This podcast is intended for healthcare professionals for education purposes. I’m your host Bethany Hopkins, medical affairs manager with Nestlé Health Science.

Hopkins: Today we’ll be talking with Dr. José Morais, about malnutrition in the older adult. Dr. Morais is an associate professor of medicine at McGill University, and director of the division of geriatric medicine at McGill University, McGill University Health Centre, and the Jewish General Hospital. Dr. Morais is also associate director of the Quebec network for research on aging. His research interests include protein metabolism and requirements in the older adult, nutrition and functional status. Dr. Morais has more than 100 original publications, most of them in high impact journals in the fields of aging, nutrition and metabolism. Thank you for joining us Dr. Morais. In your practice as a geriatrician, you work with older adults who may have nutrition related concerns. In our last conversation, we talked about malnutrition in the older adult and the association of malnutrition with frailty. Today we’ll be continuing to explore malnutrition, focusing on management strategies for clinicians to consider in practice. Dr. Morais in our last conversation you described malnutrition, the risk factors, the consequences for the older adult. Practically speaking, how should a physician consider approaching the identification of malnutrition?

Dr. Morais: Yes, I can talk about that. I mean, the first thing is being sensitized, or being aware of the problem exists and whenever we see an older person whose weight or height is low, something should light up in our brains. Typically, knowing the risk factors also helps a lot to identify that older person, but one should ask about is there is any weight loss. What was your weight 6 months/3 months ago and there is criteria if you lose more than 5% over 3 months, it’s an indication of something severe, of malnutrition of severe degree. We should start right away on trying to define why is that, investigate etc. Also typically in North America one eats 3 meals a day and a lot of older people that have less than that. Asking questions about the GI system, because if there is some pathology, we should address that right away. Based on the risk factors, is it the environment that is the cause, the socio-economic situation, the difficulty with mobility? And we have to address all of this in a quick questionnaire. There is some mnemonics to remind us of all of these causes we should look for. Meals on Wheels, Stop Weight-loss, to remind us of the different causes. But above all, be aware of the importance of the problem and ask very simple questions such as: weight loss and how many meals a day, and if there are difficulties at the GI tract including at the oropharyngeal sphere, involving dentition, mastication, swallowing, and then to make the diagnosis, we can perceive that the weight loss that comes with manifestations such as no fat under the skin, the squaring of the shoulders, the muscle atrophy, and if one does lab tests, we realize there’s always some kind of anemia, without having blood loss. There is low serum proteins, such as albumin and pre-albumin, and this completes the diagnosis, but the questionnaire and the physical exam are so important, and we tend to overlook these things.

Hopkins: It really is, as you’ve just mentioned, that level of awareness and working some of those basic and relatively simple questions into an assessment when working with the older adult. One of the things you mentioned, and I think a lot people when they think of a malnourished individual they picture that person who’s thin and emaciated and who looks or presents in that classical physical picture of a malnourished individual and one of the questions that does come up from time to time is regarding the individual who’s overweight, they may have a higher body mass index, and they’re sometime there can be a misconception that these individuals that because they’re carrying more weight aren’t malnourished or that they have ample reserves if they’re not eating well, and I’m wondering if you could just address this concept and this potential misconception for that larger individual?

Dr. Morais: Yes, certainly other more acute weight loss, this is often the case, in which there has not been enough time for all the surplus of all the calories in the form of fat to shrink so you somehow an obese person in front of you, and you consider this person as being well nourished. Already that person could be malnourished because of decreased intake that has not yet become manifested in the body composition. Not to mention that you can be malnourished because you succeed in taking calories in general, and that you’re lacking all of the other micronutrients and this is the case of some people who tend to drink a bit more, so they have calories from alcohol, but they lack a lot of essential nutrients. Now, as one ages, because of a universal accumulation of fat you can have individuals that present with a reasonable amount of fat but their lean tissue is very reduced. A condition that we call the sarcopenic obesity state. About 15% of older people have sarcopenic obesity. So we can get fooled by the appearance of excess fat but they lack lean tissue and protein reserves that is an important component for fighting infections because it’s a source of a pool of proteins to be used by immune systems to fight the infections as well as tissue repair and obviously it’s not the fat that gives us the strength in the muscle, and the sarcopenic people have weaknesses, and in fact they are 3 times more fall risk, than a person with the same muscle mass but without the excess weight. So it’s kind of the worst of the 2 worlds: excess fat and lack of muscle. These people also have more metabolic problems because of the metabolic syndrome with more high blood pressure, disturbance at the level of glucose regulation and cholesterol as well, with an increased risk of cardiovascular mortality. We can get fooled by the fat that there is some excess fat but they are malnourished.

Hopkins: Yes, I’m glad you clarified that because I do think that we still do hear that time to time that somebody judged by their weight alone or their appearance may not pick up on someone’s radar as being malnourished, just by virtue of their appearance or their size without having the consideration of lean body tissue versus fat tissue and so on. So thank you for that. When an older adult has been identified as malnourished or if someone is concerned that they may be at risk of being malnourished because they’re not eating well, they may have lost weight, they may have these body composition changes you’ve been talking about. What are some of the steps a clinician can take?

Dr. Morais: I think it’s very important to try to sort it out, the underlying causes, to address them, and also facilitate any barriers. An example is the typical older person that because of denture mal-fitting, who is now avoiding certain types of food and is now eating less, and eventually is becoming anorexic, and there is a vicious circle in there. So we have to treat the underlying causes. Sometimes it’s not so clear and takes time, especially in those cases where there is no obvious acute conditions, but one important aspect is not to prolong the state of investigating without doing anything to overcome the malnutrition. And at this point, many physicians they don’t have all the knowledge required to undertake this rehabilitation of the nutrition status and the nutritionist is of great importance at this stage to work along with the physician or the healthcare provider to see with more detail the reasons why the person isn’t eating and immediately offer food that is nutrient dense or high nutrition quality to overcome the problem.

Hopkins: Really utilizing the resources among the multi-disciplinary team and consulting a dietitian if more detailed assessment and intervention you believe is required would be an important consideration.

Dr. Morais: Definitely, especially because there are certain skills we don’t possess as physicians. In terms of interviewing, going over details of meals, and also they can, early on, provide intervention alternatives and advise on the details that we don’t know, because they are professionals themselves.

Hopkins: Yes, that’s their area of focus. As you mentioned Dr. Morais, a food first approach, and I think that’s something that resonates with everyone looking for nutrient dense foods, taking the food first approach, finding foods that work for that individual and that’s something the dietitian would be able to help with. Now I know some individuals use oral nutrition supplements. Can you comment for a moment on that?

Dr. Morais: Usually these are very well balanced nutrition. We have to be careful because there’s positive and negative aspects, because it’s easy to procure them, and you have it available, you can quickly replace the meal, and then by the end of the day you end up eating no more than your basic sustenance. So in order to really take benefit from these oral supplements, and I have patients who really are required to be on it, because otherwise they would never achieve their recommended energy, protein and nutrient intake, is to take them as far from the next meal, so it does not become a meal replacement, or not prevent you from feeling hungry for the next meal. One safe introduction of oral supplements is after the last meal in the evening, after 7 or 8pm, because you know that it’s going to be staying on you and will not affect your next meal. You can also offer it as a supplement again in early afternoon far from the time of the supper. This way it succeeds in ingesting more calories because otherwise it is dangerous and to the negative aspect of having a replacement instead of a supplement. If one can combine that, with an encouragement to do more steps, being more mobile, doing exercise which stimulates appetite, then it’s a winning situation.

Hopkins: Yes, there is really a positive synergy between physical activity and food intake. They work together very well. That actually leads me into one of the last questions I want to ask you about is about protein. Thinking about the physical activity you mentioned and intake, and you mentioned earlier about sarcopenia and loss of lean muscle mass in some older adults. We know as well with older adults when it comes to protein, they may experience anabolic resistance to protein, so attention to taking adequate amounts of protein in and throughout the day using what we have considered to be quality protein sources are particularly important in older adults. For someone that you’re seeing in your practice, what are the implications for protein dose and source for the older malnourished adult?

Dr. Morais: This concept of anabolic resistance is coming from research studies clearly demonstrating that when we offer small amounts of protein it does not trigger the same quantity of protein synthesis as in the younger population. But we call that resistance, because it we supply more protein than what a young person would require to increase protein synthesis, we can overcome that resistance. The approach here is to offer more protein per meal, and the fact is that most bodies, agencies ... recommend for older persons to take 1.2g of protein/kg of body weight/day. Whereas the recommendation from the WHO is 0.8g of protein/kg of body weight/day. This can be very abstract... but it means to take enough protein to trigger synthesis in older people. We’re talking about 20-30g of protein a day (per meal). I think in a 3 ounce steak, there’s about 20g, which gives you an idea. If you take a piece of fish it has about 20g as well. Two eggs is 20g. This is more concrete. Same with a glass of milk, which also contains 15-20g. I’m giving you examples, but you have to make sure that in each meal there is enough protein to benefit and to trigger synthesis. Synthesis of your lean tissue, your muscles, the immune system functioning. So this is a concept of anabolic resistance that can be overcome by more protein in each meal, and because in North America we tend to have a skewed intake of protein. Very little at breakfast and much more at night. So if you can make an effort to diversify what we eat and distribute the amount in every single meal then you are assured that there’s always enough protein to trigger synthesis with each meal. Obviously to improve that resistance being more physically active also helps, because amongst other factors leading to the resistance, is insulin resistance. Our own insulin becomes less active and insulin is required with the meal to encourage protein synthesis. So physical activity overcomes that part of the insulin resistance of age. Also, it contributes to improve the circulation of the amino acids with are the constituents of protein from the blood stream into the cells for synthesis with exercise. I encourage people, even if we think we need to run, by walking we already achieve some exercise, and increase insulin resistance and so that’s one way of developing less anabolic resistance to protein.

Hopkins: So engaging just regular activities of daily living, walking, any type of activity could be beneficial, paired with adequate protein, and spacing that protein out as you mentioned, 20 or 30g at each meal, evenly throughout the day.

Dr. Morais: Yes, and if you can, do this after a good walk. There seems to be that there is an extra benefit so if we take a meal half hour to an hour after exercise, we might even give a little more push into increasing muscle protein synthesis.

Hopkins: Protein synthesis. Yes. A good point. Again, coming back to that timing, isn’t it. Dr. Morais, thank you for sharing for your experience related to malnutrition and the management of malnutrition in older adults and some of these practical tips and information that you’ve been providing over these last 2 episodes. One of the takeaways for me, and I think is important to remember is that malnutrition is something that is amenable to intervention, so it’s a matter of us being aware and recognizing this, but it’s nice to know that there’s something that can be done, that can potentially have an impact on an individual’s quality of life and their functional status and overall health. So before we sign off, I do actually have one last question for you so our listeners can get to know you a little bit better. Can you tell us how you first became interested in the field of nutrition?

Dr. Morais: Probably because I recognized during my training that a lot of older people were weak. When I started 25 years ago, even the definition of frailty did not exist, but already we knew that malnutrition would lead to an accelerated aging. Then I became aware of that, and decided to take a research career on what we call a clinician/scientist. Half/half. I’m exposed to patients, and some of my knowledge can benefit my clinical decisions and intervention and I learn from my older patients too about always keeping in mind to be proactive in overcoming the malnutrition of many of our older patients.

Hopkins: Nutrition has such an intimate connection to, as you mentioned, the health and well-being of older adults. It must be rewarding to be able to combine that research aspect with the clinical aspect, and you can really see some of the things that you’re studying have an effect on the lives of the people that you’re working with.

Dr. Morais: It is a concrete field of research, that of nutrition, with a clear impact on the lives of our patients.

Hopkins: And to be able to see that in action is very interesting and must be very rewarding. On that note we’ll conclude this podcast, and I want to thank you Dr. Morais for joining us and sharing this information and thank all of our listeners.