The poor and destitute are not the only ones facing the risk of malnutrition.
Many older adults and the elderly suffer from it, irrespective of their social standing, said Dr Krishnan Sriram, a tele-intensivist at Advocate Health Care in the United States. He is a critical care-trained physician who remotely monitors ICU patients in many hospitals round the clock.
And giving prompt attention can have unexpected benefits for the elderly, his research has found.
As part of a study, he implemented the use of validated malnutrition screening tools in four hospitals in the US.
"When a patient was identified as malnourished and if there was no order by the doctor to restrict feeding, the patient automatically received oral nutritional supplements," he said.
"A clinical dietitian would see the patient and modify the supplementation if necessary.
"This way, even if a patient was admitted into hospital at night and seen by a dietitian only in the morning, he did not have to starve for prolonged periods."
Dr Sriram said this programme cut the 30-day unplanned hospital re-admissions by 20 per cent, saving US$1.85 million (S$2.5 million) in the four hospitals in a year.
He presented these findings to over 250 healthcare professionals at the third Singapore Clinical Nutrition Meeting here in April.
Malnutrition leads to poor wound healing and a lowered immunity, and puts a person at higher risk of respiratory problems such as pneumonia because "muscle loss in the chest wall and diaphragm leads to an inability to cough and expel secretions".
Malnutrition indicators comprise insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localised or generalised fluid accumulation, and decreased functional status, he said.
If someone meets any two of these six criteria listed by the Academy of Nutrition and Dietetics, he is considered to be malnourished.
Nutrients can be grouped in two different ways - macronutrients and micronutrients.
Macronutrients include carbohydrates, proteins, fats and water, which make up the bulk of our diet.
Micronutrients include vitamins and minerals, which come from an intake of fruit and vegetables.
Dr Sriram warned that malnutrition leads to poor wound healing and a lowered immunity, and puts a person at higher risk of respiratory problems such as pneumonia because "muscle loss in the chest wall and diaphragm leads to an inability to cough and expel secretions".
Senior dietitian Elysia Low from Tan Tock Seng Hospital and Dr Sriram give some tips on eating challenges faced by the elderly:
Meal plans for the elderly
Senior dietitian Elysia Low from Tan Tock Seng Hospital draws up a day's meals for an elderly person with a daily nutritional requirement of 1,200kcal to 1,500kcal. This is for a person with no chronic illness.
Option 1: Wholemeal bread (2 to 3 slices) with a thin spread of margarine; milk (1 glass, 250ml)
Option 2: Plain cornflakes (1 ½ to 2 cups); calcium-fortified soya milk (1 glass, 250ml)
Option 1: Banana (1 medium-sized fruit)
Option 2: 10 grapes
Option 1: Rice porridge (2 bowls), cooked leafy vegetables (¾ cup or 100g), meat (90g fish or poultry)
Option 2: Noodle soup (1 to 11/2 bowls), raw leafy vegetables (150g), soft beancurd ( 170g)
Option 1: Papaya or watermelon (1 wedge)
Option 2: Apple or orange (1 small fruit)
Option 1: Brown rice (1 to 11/2 bowls), cooked leafy vegetables (¾ cup or 100g), meat (1 palm-sized or 90g fish or poultry)
Option 2: Chapati (2 to 3 pieces of up to 90g), raw leafy vegetables (150g), cooked pulses (¾ cup or 120g of beans, peas or lentils)
Option 1: Milk (1 glass, 250ml)
Option 2: Calcium-fortified soya milk (1 glass, 250ml)
LOSS OF APPETITE
This may be caused by acute illnesses, reduction of physical activity and side effects of medications.
- Opt for small meals throughout the day. Eating frequently can add up to a meaningful amount by the end of the day.
- Make every mouthful more valuable with fortified food items. For example, add an egg, two tablespoons of minced meat and a teaspoon of sesame oil to a bowl of plain porridge, which increases the protein content from 3g to 16g, as well as the energy value of the meal from 210 kcal to 372kcal. You can also add milk powder to malted beverages, coffee or tea to increase the protein content.
- Have ready-to-eat high-energy and high-protein snacks and drinks handy, such as cream biscuits and soya milk.
- Drink fluids between main meals, instead of during the meal, to avoid feeling too full.
CHEWING OR SWALLOWING ISSUES
- Visit a dentist for oral care and to get better-fitting dentures.
- Cut food into more manageable pieces.
- Prepare food that is softer and wetter, such as broth, gravy and sauces.
- Visit a speech therapist for swallowing assessment to get a recommendation for the safest and most appropriate food texture and fluid consistency.
REDUCED TASTE ACUITY OR SENSATION
Visit a doctor or pharmacist to find out about the side effects of medications.
- Some drugs impact nutrient absorption and alternative medications could be prescribed. Adjust the timing of medication and meals, under supervision from the medical professional, so as to maximise food absorption.
- Consider increasing the flavour of food by adding strong- smelling herbs, garnishes or spices. For Chinese cuisine, consider using parsley, coriander or roasted sesame. For Malay meals, use tamarind (assam), lemongrass or curry powder. For Indian food, opt for cumin, garam masala, cardamom powder or cinnamon.
- Ensure good oral hygiene by brushing and flossing daily as this can help to improve the ability to taste food.
PSYCHOSOCIAL FACTORS OR COGNITIVE CHANGES
Depression or loneliness may affect an elderly person's desire to eat.
Those with dementia may insist that they have already had their meal when, in fact, they have not, leading to inadequate food intake.
- Consider eating together with the family or caregivers at set meal times.
- Get them to eat familiar food in a familiar environment.
- Use memory aids, such as pictures of clocks corresponding with pictures of meals, to remind them of appropriate times for meals.
- Allow adequate time and an appropriate pace for meals.
GASTROPARESIS, OR DELAY IN GASTRIC EMPTYING
Food choices and food amounts can be modified to relieve any discomfort caused by gastroparesis, which is marked by symptoms such as bloating, loss of appetite and vomiting.
- As fat and fibre slow down gastric emptying, these patients are advised to consume a low-fat and low-fibre diet.
- Those who do not tolerate solid food do better with purees and liquid food. Liquids that contain fat, such as oral nutrition supplements, are generally well tolerated and provide extra calories and vital nutrients.
- Light physical activity after meals can help speed up gastric emptying rates. If lifestyle changes do not help, medications can also be used to treat gastroparesis.
LIMITED ACCESS TO NUTRITIOUS FOOD
For elderly people who have a hard time getting to a store because of poor mobility or are unable to find the right ingredients to eat properly, oral nutritional supplements may be prescribed.
- Oral nutritional supplements need not be consumed routinely, but can be used on certain days. They can be used as a meal supplement or replacement on days when it is known that a proper meal cannot be eaten.