Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: April 30^th 2015

Accepted: September 10^th 2015

Diet and polymer standard vs. standard in the nutritional status of elderly patients with fragility

Gissel Karelly Luna-Ramos,^a Miguel Ángel Pedraza-Zárate,^a Nubia Franco-Álvarez,^b Felipe González-Velázquez^a

^aDepartamento de Educación

^bDepartamento de GERIATRIMSS

Hospital de Especialidades 14, Instituto Mexicano del Seguro Social, Veracruz, Veracruz, México

Communication with: Miguel Ángel Pedraza-Zárate

Telephone: (229) 934 3500, extensión 61642

Email: mapz70@hotmail.com; miguel.pedrazaz@imss.gob.mx

Background: The elderly patients with fragility show different physiological changes, so they are given polymeric diets to maintain and/or alter their nutritional status. The aim of this paper is to demonstrate the effect of changing a standard polymeric diet and a standard diet on nutritional status in elderly patients with fragility.

Methods: Clinical randomized controlled trial in 23 elderly patients, 70 years of age or older, with fragility, hospitalized in a Internal Medicine Unity in a period from July to December 2014. Nutritional status was determined through Minimum Nutritional Consulting (MNA) and body mass index (BMI). Descriptive statistics, Chi square, Student t test and McNemar.

Results: In the G1: 12 patients were in the G2 and 11, a positive change was observed in the nutritional status G1 initially being 14.00 (malnutrition) and end 22.75 (risk of malnutrition). According to BMI (kg/m2) was evident at the beginning 25 % of patients (3) with mild malnutrition, but the final results show figures with a zero percentage of malnourished patients.

Conclusions: The use of standard polymeric diet increases body weight, BMI and nutritional status in elderly patients with fragility.

Keywords: Aged; Nutritional status; Diet; Mexico

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A geriatric patient is defined as a patient older than 60 years with one or more of chronic and evolved diseases; it is the older adult for whom the balance between their needs and the environment’s ability to meet them has broken, creating high risk of dependence and physical and cognitive disabilities. Moreover, frailty in the geriatric patient in the past decade has been considered a syndrome representing a decrease of physiological reserves and increased vulnerability to adverse health outcomes, with excessive weight loss and therefore difficulty regaining lost muscle mass.¹ In 2012, according to the UN population Fund (UNFPA), 11.5% of the world population was aged 60 years or more, while in more developed regions it came to be 22.6%. In Latin America there are currently 63.1 million older adults, i.e., 10% of the total population; it is estimated that the figure will triple to reach 187 million in the next 38 years and will represent 25% of the total population.² In Mexico, according to data provided by the Instituto Nacional de Geriatría (ING), there are 10.9 million older adults, 9.3% of the total population.³ The 2012 Encuesta Nacional de Salud y Nutrición (ENSANUT) reports an elderly population aged 60 or more corresponding to 9.2% of the total population, with a female majority (53.5%). The future outlook is even more complex, according to projections, and according to the demographic transition, the geriatric population is likely to double in 50 years.3 The Consejo Nacional de Población (CONAPO) reported a 3.75% growth rate for the older adult population, of which 886,828 (11.94%) live in the state of Veracruz.⁴ Regarding frailty syndrome, the Estudio Nacional de Salud y Envejecimiento en México (MHAS), in conjunction with the Instituto Nacional de Estadística Geografía e Información (INEGI), did a longitudinal survey initiated in 2001, with interviews of 15,186 people 50 years or older who received followed-up in 2003 and another in 2012, with the aim of providing information on the aging process, the impact of diseases on geriatric patients, and disability in the population 50 years and older in Mexico. The prevalence of perceived poor health was evident, that is, fair to poor, with 57.1% men and 67.5% in women. This means that, with advancing age, the impact and prevalence of disease increases in both genders and increases vulnerability, starting at 60 years of age.^5,6 For Fried et al., frailty is a biological syndrome resulting from the decrease in homeostasis and resistance to stress with increased vulnerability, disability, and favoring premature death. For this specific group, frailty exists if three or more of the following criteria prevail:

• Unintentional weight loss of at least five kilograms during the previous year
• Self-reported exhaustion
• Decreased muscle strength (assessed by dynamometer)
• Reduced physical activity
• Slow walking speed (meters per second)⁷

The prevalence and incidence of frailty vary depending on the population studied, for example, in Europe, the prevalence of frailty in women over 50 years is 7.8%, and in men it is 3.1%. In the Mexican population residing in Mexico, the prevalence of pre-frailty is 17 to 21%, with a 24% prevalence of frailty in patients aged 65-69 years and 47.6% in patients 85 years and older.⁸ Diaz de Leon did a study of frailty and its association with mortality, hospitalizations, and functional dependence in Mexicans aged 60 or older, conducted in Nuevo Leon, assessing variables of frailty such as problems like difficulty getting up from a chair after sitting for long, weight loss of five kilograms or more in the last two years, and lack of energy. They concluded that the state of frailty is associated with mortality, hospitalizations, and dysfunctionality in basic activities of daily life in the studied population.⁹ Based on this situation, the Instituto Mexicano de Seguridad Social (IMSS) decided to develop a strategy called Plan Geriátrico Institucional (GERIATRIMSS), in order to help improve health services and respond to the comprehensive medical care needs of older adults.¹⁰ In the Unidad Médica de Alta Especialidad (UMAE) "Adolfo Ruiz Cortines" at IMSS in Veracruz, Veracruz, this program has existed since 2013, where comprehensive geriatric assessment is carried out and the assessment of frailty syndrome is done, according to the proposal from Ensrud et al.;⁷ this assessment consists of the following diagnosis criteria:

• Weight loss of 5% or more in the last three years
• Inability to rise from a chair five times without using arms
• Low energy identified with a negative answer to the question: Do you feel full of energy?
• No criteria: robust, 1 criterion: pre-frail, 2 or more criteria: frail.

It is important to clarify that not all older adults with disabilities are frail and that not all frail patients have disabilities. While some individuals reach advanced ages of life with full power, others, however, suffer from a clear decrease in their quality of life as a result of geriatric syndromes such as falls, which with osteoporosis result in fractures; sensory impairment, understood as visual and/or hearing impairment; malnutrition, and others.^3,11 Among the reasons why geriatric patients are at increased risk of malnutrition is a diet limited to easily chewable or digestible foods, depending on their particular state of oral health, and the diminished ability to contract the mastication muscles, with an impact on tooth loss. This limited ability to chew makes it difficult to get enough caloric intake to ensure the required energy input because they usually consume less food, usually one-third less than the calories needed, which results in decreased body weight; this coupled with malnutrition, increases hospitalization time and cost of medical care.^12,13 In an outlying area of Mexico City, the estimated risk of malnutrition prevalence was 59.7% and malnutrition was at 11.3%, a situation associated with the conditions of frailty of this population; nutritional risk increases in elderly patients with chronic diseases, in poverty, and those with limited access to health care. The prevalence of malnutrition increases with age; in the geriatric patient over age 70 it goes from 30 to 70% during hospitalization.¹⁴ There are several tools used to determine nutritional status: anthropometric measurements (weight, height, average arm and calf circumference), biochemical parameters, and tools for nutritional screening, specifically nutrition screening in elderly patients using the Mini nutritional assessment (MNA), which classifies: healthy patients, those at risk of malnutrition, and those who are malnourished; this has shown that elderly patients can be correctly classified with a sensitivity of 96% and a specificity of 98%.¹⁵ Taking nutritional supplements improves nutritional status, or prevents malnutrition in patients who do not meet their nutritional needs with the standard diet, understood as the diet necessary to achieve and maintain health, and the most adequate in calories according the physical characteristics of the patient without causing displacement of diet.¹⁶ The concept of enteral nutrition includes oral administration of polymeric formulas or nutritional supplements, consisting of a defined mixture of macro- and micronutrients, either as the total diet or as a supplement to an insufficient oral diet; however, although the role of nutritional deficiency in the development of frailty has been suggested for some time, many authors have shown that supplementing the diet with oral nutritional supplements improves the nutritional status of institutionalized geriatric patients in a state of malnutrition or at risk of it.^16,17 The described beneficial effects of nutritional supplementation with polymeric diets include increased body weight and BMI, increased albumin concentration and other protein markers, as well as raising the values ​​of the MNA. The guides from ESPEN (European Society for Clinical Nutrition and Metabolism) recommend oral supplements in older adult patients with malnutrition or at risk of malnutrition to increase the supply of calories, protein, and micronutrients, to maintain or improve nutritional status, and to improve survival.^1,16,18-20 Most of the geriatric population with one or more disorder would benefit from nutritional interventions such as supplementation with polymeric diets because they can be an effective strategy to improve nutritional status and quality of life, which would decrease hospital stay and costs of care. There is a need for further studies on the effectiveness and adverse effects of oral supplementation, with longer follow-up of the study population, assessment of the effect on quality of life, as well as its cost-effectiveness.^16,21 

Ordóñez et al. determined the beneficial effect and tolerance of a high-protein nutritional supplements (Ensure Plus High Protein®, Abbott Laboratories, SA) in subjects older than 65 diagnosed with malnutrition, reporting an average weight increase at the end of the study of 2.78 ± 0.13 kg (p < 0.001).²² A meta-analysis by Stratton et al. examined the effects of oral nutritional supplements and found that consuming these products improved the supply of energy and protein to restore hunger and improve the feeling of wellbeing.²³

Therefore, knowing about the transition of the population pyramid of the country, comorbidities associated with geriatric age and nutritional status, the purpose of this study is to demonstrate the effect of a standard polymeric diet against a standard diet on the nutritional state of geriatric patients with frailty syndrome.

Methods 

A randomized controlled clinical trial was done in 23 geriatric patients 70 years of age or older who met the criteria of the GERIATRIMSS Program in tertiary care with frailty syndrome according to Ensrud’s criteria,7 hospitalized in the Internal Medicine area of the Hospital de Especialidades UMAE 14 "Adolfo Ruiz Cortines" at IMSS, Veracruz, Veracruz, Mexico, during the period from July to December, 2014. The number of patients analyzed were those who were attended by the dietician assigned to the program in the rotation period; it excluded patients with chronic renal failure on replacement therapy, chronic liver failure, patients healing with fractures or disabilities that prevent them performing anthropometric or total physical dependency determinations, and those who refused to participate in the project. Prior informed consent was obtained from each patient, and the study was approved by the local ethics and research committee, with acceptance number R-2014-3001-45. Two groups were formed: the first study group (G1) received a standard diet with macronutrient distribution of 55% carbohydrate, 15% protein, and 30% lipids plus a polymeric diet prescribed orally daily as nutritional supplement; and the other control group (G2) received only the standard diet with the same distribution of nutrients as the first study group. Each patient was given the MNA for baseline assessment and at six months follow-up and final assessment; this was done in 10 to 15 minutes by the assigned dietician. For the average arm circumference (AC in cm), a standard tape measure was used, and the measurement was recorded in centimeters at the midpoint of the acromion-olecranon length of the arm, preferably the non-dominant arm. For the average calf circumference a standard tape measure was used, taking the measure at the widest section of the distance between ankle and knee (calf muscle). The weight was obtained in kilograms (kg) in light clothing without shoes, with a SECA brand portable scale, accuracy 100 g, calibrated periodically. Height was measured with a SECA brand portable stadiometer, with 0.1 cm accuracy, and a tape measure was used for patients who could not be assessed while standing up, measuring the height of the leg, lying down, they were asked to cross their right leg over the opposite knee and the length was taken from a line connecting the proximal end of the (internal) medial border of the tibia to the lower part of the tibial malleolus, calculated using the formula described by Chumlea et al.²⁴ Body mass index (BMI) was calculated based on these weight and height values, and the values ​​considered for BMI classification were normal weight 22-27 kg/m², underweight 18.5-21.9 kg/m², mild malnutrition 17-18.4 kg/m², moderate malnutrition 16-16.9 kg/m², and severe malnutrition < 16 kg/m².¹² The assessment of nutritional status was determined based on the score and screening of the overall assessment specified in the MNA and classified as follows: 24 to 30 points, normal nutritional status; 17 to 23.5 points, risk of malnutrition; and less than 17 points, malnutrition.¹⁵

Statistical analysis

Descriptive statistics were made using frequencies, percentages, and the average measure of central tendency and standard deviation, as well as Pearson’s Chi-squared to determine the magnitude of association between two qualitative variables between groups; to compare the means of quantitative variables, Student’s t-test was used for independent groups and McNemar test was used to compare the change in the distribution of proportions between two measurements of a dichotomous variable. A p-value < 0.05 was considered significant. The data obtained were processed in the program Statistical Package for Social Sciences (SPSS, Chicago IL, USA.), Version 22. 

Results

Of the 23 patients studied, 12 patients belonged to study group G1 (standard diet plus an oral polymer diet), and the control group G2 had 11 patients (standard diet); there was no statistical difference in gender, age, and height (Table I).

There was a positive change in the study group according to the classification of nutritional status by MNA, initially at 14.00 (malnutrition) and 22.75 at the end (risk of malnutrition), p = 0.000 (Table II).

Regarding the MNA screening in Group 1, at the beginning there were 10 patients (83.3%) with malnutrition, and at the end only one (8.3%), p = 0.004 (Table III).

According to BMI (kg/m2), in Group 1 at the beginning there were 3 patients (25%) with mild malnutrition, and at the end there were no patients (Table IV).

Regarding safety measurement for the polymer diet, no gastrointestinal effects were reported from it.

Discussion

The nutritional status of geriatric patients is closely related to age; deficiency in food consumption is associated with comorbidities, also the association of malnutrition with the development of frailty has been suggested. Kaiser et al.17 in 2010 assessed the frequency of malnutrition in older adults by applying the MNA, which reported that the prevalence of malnutrition was 22.8%, with significant differences between assessment sites: 50.5% in patients in the community, i.e. approximately 2/3 of the participants in the study were at risk of malnutrition or were malnourished. The average age of patients was 82 years, and similar data are reported in the present study, in which the mean age of patients included in the study group was 79 ± 6, and 81 ± 5 years in the control group; malnutrition was present in over 80% of patients. Dorner et al.²⁵ evaluated the association between nutritional status and deterioration of frailty in elderly hospitalized patients, using two tools: SHARE-FI (the Survey of Health, Ageing and Retirement- Frailty Instrument), and the MNA, including 133 patients, 39% of whom were male and 61% female, with an average age of 74 (65-97) years, reporting malnutrition or risk of malnutrition in 76.7%. This follows the similarity in our work in that according to the score obtained in the MNA, malnutrition was present in 83.3%, and the risk of malnutrition was found in 16.7% of patients in the G1, while in G2 malnutrition was reported in 81.8%, and 18.2% of patients were at risk. The work done by Mota Sanhua et al.14 in geriatric patients of an outlying area of Mexico City found the estimated prevalence of risk of malnutrition was 59.7%, and malnutrition was 11.3%, asserting that this situation is closely associated with the condition of frailty in this population. The data are also compared with the present work, where more than 80% of geriatric patients with frailty syndrome had malnutrition. Supplementation of the diet with oral nutritional supplements improves the nutritional status of malnourished patients or those at risk of malnutrition, with the benefit of increased body weight, BMI, increased albumin concentration, and elevated ​​MNA values.^18,26 It is therefore recommended to initiate this early in patients with nutritional risk where normal food intake is insufficient; although this is a smaller sample, this is consistent with the results obtained from our study, concluding that weight and BMI increased in older adult patients who received treatment with the standard diet plus the polymer diet. Clinical experience shows that frail older adults with nutritional risk may benefit from nutritional supplementation, as long as their general condition is stable. Although data are scarce, it is recommended that nutritional support be initiated early, as soon as there are indications of nutritional risk.¹⁸ A study in Spain on the prevalence of malnutrition and the influence of oral nutritional supplementation on nutritional status in 50 institutionalized older adults found that the prevalence of malnutrition was 39%, and 50% in frail residents; however, oral supplementation to a normal diet for 12 months significantly increased serum albumin and the geriatric nutritional risk index produced no decrease in body weight or BMI, which resulted in low or no risk of malnutriton.¹⁹ Nutritional risk, we reiterate, is increased in patients with chronic diseases, in poverty, and those with limited access to health care; in addition, the prevalence of malnutrition increases with age, so it is noteworthy that in geriatric patients over 70 it goes from 30 to 70% during hospitalization.¹⁵ As for anthropometric measurements, is important to mention that the BMI parameters in older adults over age 60 differ from those of the adult population; this allows us to determine low weight or risk of malnutrition in geriatric population groups. During aging, anthropometric indicators can be useful because they can serve as a guide for medical and nutritional intervention.¹³ In this paper, anthropometric data, both body weight and BMI, in patients in the study group increased after the administration of the polymeric diet to complement the standard diet; in the case of the control group, the data remained unchanged. The lack of improvement in these parameters in the control group, despite having the same characteristics as the study group, could also be an object of study, since there was a beneficial effect of the polymeric diet in the geriatric patients who did consume it. Different clinical studies have demonstrated the usefulness of the MNA in nutritional assessment and prediction of the risk of morbidity and mortality in institutionalized frail older adult patients.^16,18 This study demonstrates its usefulness to assess the effectiveness of polymer diet supplementation in this specific group of people. One limitation of this study could be the short time of intervention and the small number of participants who met the inclusion criteria, however, despite these limitations, the results reported are consistent with the results observed by other authors already cited, where institutionalized older adult patients demonstrate the effectiveness of polymer diet consumption in improving nutritional status, being older adult patients with frailty syndrome.

Conclusions

In groups of patients under equal physical conditions such as age, gender, weight, and height, the consumption of a polymeric diet to complement the standard diet increases body weight, BMI, and nutritional status.

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