The best part of living a good life is acquiring quality health especially through the golden and productive age and, ensuring wellbeing and comfort through the less active years. WHO has done enormous research and work in advocating healthy lifestyles and diets and defines Healthy Ageing, “as the process of developing and maintaining the functional ability that enables wellbeing in older age.” According to WHO, in order to lead a healthy and fulfilling life, a complete functional ability is needed so that individuals can meet their basic needs, are mobile, learn, maintain healthy relationships and contribute to society. This ideal ability is attained through mental and physical capacities of an individual and Nutrition for Healthy Ageing is yet to receive the necessary focus, resources, and attention. Many healthcare professionals have expressed their need for more education on the nutritional status of the elderly. Moreover, nutrition has come to be recognised by experts as one of the most critical contributors to healthy ageing. Optimum nutrition is imperative for health in persons over the age of 65 and malnutrition in the elderly is highly prevalent and often underdiagnosed.
An in-depth study revealed that, 35% of community-dwelling elderly are nutritionally deficient in protein, calories, minerals and vitamins. Lack of proper amounts of protein and sedentary lifestyles can lead to loss of muscle and gain of fat. There are also hidden aspects of malnutrition with 20% - 65% of hospitalised elderly suffering from nutritional deficiencies. The prevalence of malnutrition in long-term care facilities is estimated to be between 30%–60%. The elderly population in Asia is becoming more conscious of their nutrition needs and are turning to functional foods that aim to promote better health, longevity by keeping chronic diseases at bay.
The challenge of healthy ageing and nutrition
Globally, the population of “older person”, aged 60 years or above showed an upsurge from 9.2% to 11.7% during 1990 – 2013. By 2050, this number is estimated to be at 21.1% and according to a United Nations Report on world population, ageing elderly population will be nearly 2.1 billion. If we observe this trend in Asia, by 2050, older persons are expected to account for 24% of the population. In addition, developing nations in Asia are experiencing a much more rapid rate of population ageing compared with developed nations. We need environments and surroundings that are safer; to care and tend to the needs of these seniors who have helped us build the world that we live in today.
An online survey was conducted by Herbalife Nutrition in May 2020 among 5,500 respondents in 11 countries i.e. Indonesia, Korea, Taiwan, Vietnam, Malaysia, Thailand, Philippines, Hong Kong, Singapore, Japan, Australia. This survey intended to better understand attitudes and understanding in Asia Pacific towards ageing. The insights from this survey revealed that people are concerned about ageing healthily, yet they are not confident they will be able to do so. The majority of respondents had a negative future outlook about their health and believed that they would likely suffer from chronic or acute illnesses or ailments. It’s also notable that the current set-ups are lacking and more concentrated to pharmaceuticals and housing and assisted devices.
The various surveys and research projects in this space indicate that concerns around ageing stem from the gaps in healthcare systems and lack of standard practices and guidelines in these program areas to take care of the elderly. Across Asia, efforts for integration between primary care and hospital care are underway to help relieve the health care burden, especially in the setting of increasing non-communicable diseases burden. It is a big challenge, but a stepwise, practical solution towards better integrated care can start on a smaller scale: the patients, the healthcare providers, and the community. In particular, community-based and commercial programmes can address the underlying issues of sedentary lifestyle and poor nutrition.
Hospitals and elderly care centres are the places where senior patients can be screened for their body’s nutritional quotient using validated tools however, malnutrition management has not been considered as an integral part of patient care. According to a study by Regional Nutrition Working Group to understand the gaps and standard practices in patient population and healthcare settings within the region, it was observed that the international guidelines for the management of malnutrition are available, but they may not be easily applicable to programs in Southeast Asia. It was also concluded that collaboration between clinical community, professional societies and policy makers is needed to facilitate a positive change in the overall nutrition practice.
How ageing happens
There are multiple theories around ageing however, there isn’t one reason for why our cells change and grow old and the researchers are juggling between multiple possible explanations. There is an internal process in cells that is genetically based with some individuals ageing faster than others called “Intrinsic Ageing”. At the same time, there are factors that affect ageing in a process called “Extrinsic Ageing”. Ultraviolet light, environmental pollutants, and cigarette smoke interact with the genetic factors controlling the ageing process. Ageing is a complex process and it varies in the ways it affects individuals and body functions from person to person. Heredity, external environment, lifestyle, diet, exercise and leisure, past illnesses, existing conditions, both genetic and acquired and many other factors determine individual rates of ageing.
Significant changes happen in the ageing body and a few of them may be a direct result of poor absorption and utilisation of nutrients leading to a lack of physiological balance of essential macro and micro-nutrients. As we age, the body may need more protein, vitamins, and minerals as the body absorbs a few nutrients with greater difficulty. Take vitamin B-12, for example. The body's ability to absorb the vitamin, after the age of 50 often fades because the gut produces lesser stomach acid required to break B-12 down from food sources. Skin ageing also leads to a lowered ability to convert sunlight to vitamin D and impacts absorption of calcium.
According to WHO, degenerative diseases such as cardiovascular and cerebrovascular disease, diabetes, osteoporosis and cancer, which are among the most common diseases affecting older persons, are all diet-affected. Dietary fat has been found to have some correlation with cancer of the colon, pancreas and prostate. Increased blood pressure, blood lipids and glucose intolerance are all significantly affected by dietary factors too. Bones also tend to shrink in size and density due to sedentary lifestyles and reduced protein, vitamin, and mineral intakes, especially calcium. A few elderly also look shorter and their muscles lose strength, endurance and flexibility. Structural changes in the large intestine result in more constipation in older adults and a lack of physical movement, fluids and fibre in diet enhances and worsens the condition.
The way an ageing body burns calories also slows down with age and metabolism and energy requirements for the elderly lower by about 100 kcal/day per decade. Micronutrients play a significant role in promoting health and preventing non-communicable diseases and these deficiencies are often common in elderly people due to several factors such as their reduced food intake and a lack of variety in the foods they eat. On the contrary, an elderly person who is less active than usual and continues to consume the same number of calories will surely gain weight.
Women comprise the majority of the older population in virtually all countries, largely because globally women live longer than men. By 2025, both the proportion and number of older women are expected to soar from 107 to 373 million in Asia. This pattern involves its own special nutritional needs, emphases and patterns of malnutrition, including for example the incidence of osteoporosis in older women.
Osteoporosis and associated fractures are a major cause of illness, disability and death, and are a huge medical expense. It is estimated that the annual number of hip fractures worldwide will rise from 1.7 million in 1990 to around 6.3 million by 2050. Women suffer 80% of hip fractures; their lifetime risk for osteoporotic fractures is at least 30%, and probably closer to 40%. In contrast, the risk is only 13% for men. Women are at greater risk because their bone loss accelerates after menopause.
A lack of exercise, malnutrition during ageing years and ageing as a process has led to the emergence of a previously silent phenomenon known as sarcopenic obesity (SO). SO is described as a syndrome characterised by the rise of body fat mass in parallel with excessive low muscle mass, with underlying elements such as endocrine, inflammatory, and lifestyle disruptions. SO is highly correlated with metabolism-related disease, chronic disease and functional disabilities, and has been described as ‘‘thin outside, fat inside” or ‘‘TOFI”. In a meta-analysis involving 12 prospective cohort studies, over 35,000 participants and >14,000 deaths, it was also concluded that SO is associated with an increased risk of death.
Diet, in addition to physical activity, play key roles in the prevention and management of multiple ageing conditions and disorders, SO being just one of them. In many countries around the world, diets have become energy rich, yet nutrient poor, and populations are overfed, yet undernourished. In other words, diets are high in energy density and low in nutrient density, contributing to an increase in the intake of ‘‘empty” calories. To combat this trend, experts and nutrition policy makers have emphasised the importance of consuming high nutrient density diets. Nutrition for an ageing body can be a complex and, delicate processes are required to ensure the right amount of nutrition is available through this phase of life.
Steps in the right direction
Healthy ageing requires a sustained commitment and focussed action from country leaders to formulate systematic enhancements and interventions; healthcare workforce training and education that can strengthen and support an active ageing population. Governments also need to consider public-private partnerships to improve quality of care, promote healthy ageing, and impact outcomes for non-communicable diseases.
According to Ageing International, a 10-step framework to implement integrated care for older persons can be hugely beneficial for countries. Based on this framework, the first and the most critical step and role is of the governance in establishing requisite structures followed by an in-depth evaluation of the demographics, current as well as future. The healthcare systems including local care resources and care pathways specific to older age group (also including their nutritional evaluation and care) form the backbone of this integrated framework.
It is also critical to start the health and nutrition journey earlier. Beyond 50s, it is important to consciously make effort to keep both the body and mind active through community and social engagements. The contribution of healthcare professionals in this regard can be immense in helping individuals work towards their older age, early.
We have come across innumerable reasons that may lead to malnourishment in the elderly and a few practical tips and checklists for hospitals, care givers and therapy centres, on elderly care and nutrition can be very helpful in dealing with this issue.
Stay calorie-wise and nutrition-dense: Most seniors have a small appetite and therefore their meal plans should be full of nutrition-rich foods that do not add volume to the diet. A simple example of this would be to add wheat germ into their cereals and baked goods, such as breads and muffins.
Mix-it-up: The sense of taste and flavour diminishes in most old age individuals and therefore, feel free to spice up and herbify the meals. Turmeric, cumin, basil, coriander and lemongrass are not just adding to flavour but have health benefits associated too.
Many meals in a plan: Meal plans for the elderly should be small, frequent and lack non-nutritious fill-up food options completely. Water should be ample, fresh juices in moderation and coffee, tea, carbonated drinks should be avoided.
It’s not just a meal: In older age, eating is not just about consumption of a meal served. The inability to execute as many social interactions and physical activities in old age, can lead to monotony and boredom. Food can be a way to break this monotony. For hospital and elderly care set ups, special initiatives should be taken to break the routine like adding more colour to the food, organising brunch and lunches in open spaces and socialising opportunities for the elderly during their meals.
Supplement the missing nutrients: Vitamins, calcium, omega-3 fatty acids, iron supplements are imperative for the elderly as their bodies gradually loose the potential to absorb nutrients from food. In order to keep the essential macro and micro-nutrients levels in the body, supplementation should be included whenever needed.
Train for fitness: Physical activity is as essential as a nutritious meal for the elderly and hospitals and elderly care centres should invest in spaces and trainers for exercises and physical activities and recreation. Fitness plans and schedules should be created for the elderly and adhered too as well.
I engage with the elderly through communities that focus on healthy ageing and would like to share an experience of a fellow community member who once said that, his most grilling and torturous experience at the hospital was during the discharge process. Any complex procedure, lacking proper communication and elderly friendly practices can lead to a dissatisfaction and impact on patient’s state of health. Nutrition, surroundings, processes, communication practices and facilities at the elderly care centres, all need a fresh scrutiny and perspective and we clearly have a long way to go. A systematic approach towards the cause of elderly care with equal participation from public and private entities will help achieve a standard that these seniors, in their golden age, deserve.
This article was originally published in Asian Hospital and Healthcare Management