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
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|
|Chan et al. 20108||Nursing home residents||77||154||52%||39%|
|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%||–|
|Hsieh et al. 201011||Community residents living alone||74||120||13.3%||5.0%|
|Community residents not living alone||240||2.5%||0|
|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
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.14Mobility 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
|Changes in gastrointestinal function
Diminished senses (smell, taste)
|Social isolation/family support
Poor cooking skills
Low food variety
Sense of control and health-related behaviour
Impact of undernutrition
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
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.4 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.
- East West Center. Asia’s Aging Population.
- Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. 2013;381(9868):752-762.
- Bonnefoy M, Berrut G, Lesourd B, et al. Frailty and nutrition: searching for evidence. J Nutr Health Aging. 2015;19(3):250-257.
- Lorenzo-López L, Maseda A, de Labra C, et al. Nutritional determinants of frailty in older adults: a systematic review. BMC Geriatrics 2017;17:108.
- Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14(6):392-397.
- Cederholm T, Barazzoni R, Austin P, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr2017;36(1):49-64.
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156.
- Chan M, Lim YP, Ernest A, Tan TL. Nutritional assessment in an Asian nursing home and its association with mortality. J Nutr Health Aging. 2010;14(1):23-28.
- Chen ST, Ngoh HJ, Harith S. Prevalence of malnutrition among institutionalized elderly people in Northern Peninsular Malaysia: gender, ethnicity and age-specific. Sains Malaysiana. 2012;41(1):141-148.
- Harith S, Shahar S, Yusoff NAM, Kamaruzzaman SB, Hua PPJ. The magnitude of malnutrition among hospitalized elderly patients in University Malaya Medical Centre. Health and the Environment Journal. 2010;1(2):64-72.
- Hsieh YM, Sung TS, Wan KS. A survey of nutrition and health status of solitary and non-solitary elders in taiwan. J Nutr Health Aging. 2010;14(1):11-14.
- Setiati S, Istanti R, Andayani R, et al. Cut-off of anthropometry measurement and nutritional status among elderly outpatient in Indonesia: multi-centre study. Acta Med Indones. 2010;42(4):224-230.
- Raja R, Lim AV, Lim YP, Lim G, Chan SP, Vu CK. Malnutrition screening in hospitalised patients and its implication on reimbursement. Intern Med J. 2004;34(4):176-181.
- Yap KB, Niti M, Ng TP. Nutrition screening among community-dwelling older adults in Singapore. Singapore Med J. 2007;48(10):911-916.
- Fried LP, Walston J. Frailty and failure to thrive. In: Hazzard WR, Blass JP, Ettinger Jr WH, eds. Principles of Geriatric Medicine and Gerontology. 4th ed. New York, NY: McGraw Hill; 1998:1387-1402.
- Chen LK, Liu LK, Woo J, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95-101.
- Ng TP, Feng L, Nyunt MS, Larbi A, Yap KB. Frailty in older persons: multisystem risk factors and the Frailty Risk Index (FRI). J Am Med Dir Assoc. 2014;15(9):635-642.
- Haveman-Nies A, de Groot L, Burema J, et al. Dietary quality and lifestyle factors in relation to 10-year mortality in older Europeans: the SENECA study. Am J Epidemiol. 2002;156(10):962-968.
- Van Staveren W, de Groot LCPMG, Haveman-Nies A. The SENECA study: potentials and problems relating diet to survival over 10 years. Public Health Nutr 2002;5(6A):901-905.
- de Groot CP, van den Broek T, van Staveren W. Energy intake and micronutrient intake in elderly Europeans: seeking the minimum requirement in the SENECA study. Age Ageing. 1999;28(5):469-474.
- Setiati S. Vitamin D status among Indonesian elderly women living in institutionalized care units. Acta Med Indones. 2008;40(2):78-83.
- Van Staveren WA, Steijus JM, de Groot LCPGM. Dairy products as essential contributors of (micro-)nutrients in reference food patterns: an outline for elderly people. J Am Coll Nutr 2008;27(6):747S-754S.
- Lee MS, Huang YC, Su HH, Lee MZ, Wahlqvist ML. A simple food quality index predicts mortality in elderly Taiwanese. J Nutr Health Aging. 2011;15(10):815-821.
- Van Staveren WA, de Groot LCPGM. Evidence-based dietary guidance and the role of dairy products for appropriate nutrition in the elderly. J Am Coll Nutr 2011;30(5):429S-437S.
- Feart C, Samieri C, Rondeau V, et al. Adherence to a Mediterranean diet, cognitive decline, and risk of dementia. 2009;302(6):638-648.
- Scarmeas N, Luchsinger JA, Schupf N, et al. Physical activity, diet, and risk of Alzheimer disease. 2009;302(6):627-637.
- Chen RC, Chang YH, Lee MS, Wahlqvist ML. Dietary quality may enhance survival related to cognitive impairment in Taiwanese elderly. Food Nutr Res. 2011;55.
- Ng TP, Feng L, Nyunt MS, et al. Nutritional, Physical, Cognitive, and Combination Interventions and Frailty Reversal Among Older Adults: A Randomized Controlled Trial. Am J Med. 2015;128(11):1225-1236 e1221.
- Chia CL, Mantoo SK, Tan KY. ‘Start to finish trans-institutional transdisciplinary care’: a novel approach improves colorectal surgical results in frail elderly patients. Colorectal Dis. 2016;18(1):O43-50.