A key feature of the changing demographics in Asia is the growing number of elderly people in the population.1 Estimates suggest that the number of people aged over 65 years in Asia will treble by the year 2050, including a marked increase in the number of people aged 75 years and above.1 As a result, geriatric syndromes including frailty, loss of muscle mass and declining cognitive function are expected to become major health concerns across the region.2

Special Considerations 5

As described in previous reports, frailty makes older people more vulnerable to stresses, that a small health event can have a disproportionately large impact on their physical and mental state.2 Often, frail older people are undernourished,3–6 and weight loss is a key criterion in the definition of frailty, as well as a determinant of patient outcomes.7 This article describes the causes and consequences of undernutrition in elderly people, and what approaches are being undertaken in Asia to overcome issues of undernutrition in this age group.

How common is undernutrition in elderly people?

Cross-sectional studies in Asia show that low body weight and undernutrition are common in elderly people, particularly in those who are hospitalized or institutionalized (Table 1).7-12 In Singapore, estimates suggest a high prevalence of underweight and malnutrition among nursing home residents,7whereas in Malaysia and Indonesia, studies noted that more than 10% of elderly people admitted to hospitals were malnourished.10,12 Among community–dwelling elderly people in Taiwan, the prevalence of low bodyweight was 13.3% among those living alone and 2.5% in those not living alone.11

Table 1. Incidence of poor nutrition or low body weight in elderly Asian people

Source Study group Mean age (range) N BMI <18.5 kg/m2 MNA <17
Singapore
Chan et al. 20108 Nursing home residents 77 154 52% 39%
Malaysia
Chen et al. 20129 Shelter home residents 72 (60-97) 236 17.4%
Harith et al. 201010 Hospital inpatients 73 (65-90) 181 18.1%
Taiwan
Hsieh et al. 201011 Community residents living alone 74 120 13.3% 5.0%
Community residents not living alone 240 2.5% 0
Indonesia
Setiati et al. 201012 Hospital inpatients NR (>60) 702 10.40% 2.14%*

*Using a definition of malnutrition of MNA <18.5.

BMI, body mass index; MNA, Mini Nutritional Assessment; NR, not reported.

A survey of nutrition status among hospital inpatients in Singapore found that older people were at a significantly increased risk of being malnourished, and that malnourishment significantly increased the length of their hospital stay, as well as their risk of in-hospital mortality or readmission, even after adjusting for age and medical unit.13 Therefore, improving the nutrition status of elderly people is likely to have a range of health benefits for these individuals, as well as economic benefits for health budgets.13

Causes

There may be multiples reasons for undernutrition in elderly people (Table 2), including physiological, socioeconomic and psychological factors. Elderly people often experience decreased appetite, and may also have poor dentition, changes in gastrointestinal function, cognitive impairment or swallowing difficulties that compound their ability or willingness to eat.14 Mobility difficulties may make it hard for some elderly people to shop, cook or feed themselves.14 Those who live alone are also more likely to be malnourished, as are those with low incomes.9,11,14 Depression, stress, anxiety and social isolation can exacerbate other physical or economic factors that contribute to poor nutrition.14

Table 2. Causes of undernutrition in elderly people

Physiological Socioeconomic Psychological
Changes in gastrointestinal function
Poor dentition
Swallowing impairment
Diminished senses (smell, taste)
Cognitive impairment
Fatigue/mobility difficulties
Multimorbidity
Social isolation/family support
Housing/residence
Low income
Food insecurity
Poor cooking skills
Low food variety
Poor education/literacy
Depression/stress
Sense of control and health-related behaviour
Food preferences

Impact of undernutrition

The importance of nutrition in ageing people 2

Weight loss in elderly people is not only caused by a loss of fat, but also muscle mass (sarcopenia) and bone (osteopenia). Chronic undernutrition is a key component of the development of sarcopenia and frailty.15 As muscle mass is lost, an elderly person loses strength and aerobic capacity, and generally become less active and slower in their movements. This in turn leads to lower energy expenditure, which can further exacerbate loss of appetite.15 Eventually, these changes can affect the person’s ability to carry out their daily activities and impact their quality of life.16

A key cause of weight loss is undernutrition, which is a predictor of frailty17 and poor health outcomes.3 Epidemiological data from the large–scale SENECA study suggest that there is a 25% difference in the 10-year risk of mortality between elderly people who eat a high–quality diet and those who eat a low–quality diet.18,19

 What constitutes a healthy nutritional intake for elderly people?

Common nutritional deficiencies in elderly people (including those in Asia) include low intake of energy, protein, fruit and vegetables, fibre, micronutrients, and long-chain polyunsaturated fatty acids.3,20,21 Adequate protein intake contributes to the growth and maintenance of muscle mass.3 Key micronutrients that may be lacking in the diets of elderly people are vitamins, zinc, calcium, iron and selenium.3,20,21,22 Vitamin D intake is especially important; deficiency impairs physical performance and predicts the development of disability.3 Besides effects on physical performance and bone strength, vitamin D also helps to normal immune function.3

Biodiverse diets represent a nutritional and health advantage, especially for older people.23 This means including a range of fruits, vegetables, nuts, seeds/grains, polyunsaturated vegetable oil (eg, olive oil), and protein in the form of eggs, soy, fish and meats.23 Dairy products may be an underutilised source of protein, calcium, vitamins (B12, B6) and minerals(zinc, phosphorus, iodine) for older people. Fortified dairy products can contribute to the vitamin D intake.22,24 For elderly people, adequate protein intake (>25 g/meal) is needed to increase lean muscle mass, and 20μg (800 IU) of vitamin D is needed per day to reduce frailty. A healthy diet has also been linked with maintaining cognitive function during ageing,25,26 and research from Taiwan shows that in patients with cognitive impairment, a diverse diet can reduce mortality.27

What can be done?

A balance of proper nutritional intake to achieve enough protein and energy intake, paired with lifestyle modifications, such as physical activity, are key to preventive strategies and improving health outcomes. Approaches to improving nutrition and lifestyle in elderly people can be at a population or community level or targeted to specific patient groups. A number of initiatives have been undertaken in Asia to help improve nutrition in among elderly people.

Several Asian countries have developed population–wide initiatives targeting nutrition and/or the elderly. For example, In Vietnam, the focus of the 2016 Joint Annual Health Review (JAHR) was ageing and healthcare for the elderly, which included a strategy for geriatric nutrition. In Indonesia, there is a National Action Plan on Healthy Ageing, and Malaysia has a Nutrition Month, although this is not specifically focused on elderly people. In China, there is the Healthy China 2030 initiative and National Nutrition Plan, one of which is focused on the elderly.

Other programmes in the region are being conducted at the community level. For example, in Hong Kong, the SK Yee Medical Foundation funded a programme called Senior Eat Smart, Cook Healthy for elderly citizens, which included regular newsletters, exercise workshops, cooking classes, health carnivals and healthy lunch gatherings.

Importantly, research in the region has been able to clarify the scale of the problem in Asia, and to test initiatives specifically in Asian populations. For example, researchers in Singapore have shown that frailty can be ameliorated or reversed with specific nutritional, physical or cognitive interventions,28 and that surgical outcomes can be improved in elderly patients who undergo “prehabilitation”, including education, nutritional intervention, and an exercise programme.29

Conclusions

There is increasing recognition in Asia about the scale and impact of frailty and muscle mass loss among elderly people. Preventing frailty requires attention to both the quantity and quality of nutritional intake among elderly people.The growing recognition of the impact of frailty in Asia has spawned a range of research initiatives and national and community-level programmes, to help elderly people within the region maintain their health as much as possible by receiving the right nutrition and physical activity.

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