21 minute read
The Role of Nutrition in Healthy Ageing
The article talks about how in the current scenario, it has become critical to lay enhanced emphasis on nutrition and health of the seniors. This applies to all possible set-ups where the elderly is living/being treated like, hospitals, old age homes as well as at home with families. Multiple researches have shown how with old age it becomes difficult to deliver optimal nutrition to body and suffer from malnutrition. There are steps that can be taken in right the direction to tend to the delicate nutrition balance required by our seniors.
David Heber, Chairman, Herbalife Nutrition Institute
Readiness to change our approach to healthcare for the elderly
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 per cent 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 per cent of hospitalised elderly suffering from nutritional deficiencies. The prevalence of malnutrition in long-term care facilities is estimated to be between 30 - 60 per cent. 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 and 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 - 11.7 per cent during 1990 – 2013. By 2050, this number is estimated to be at 21.1 per cent 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 per cent 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 dietaffected. 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 per cent of hip fractures; their lifetime risk for osteoporotic fractures is at least 30 per cent, and probably closer to 40 per cent. In contrast, the risk is only 13 per cent 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.
AUTHOR BIO
David Heber is the Chairman of the Herbalife Nutrition Institute (HNI), which promotes excellence in nutrition education for the public and scientific community and sponsors scientific symposia. He is also the Founding Director of the Center for Human Nutrition at the University of California, Los Angeles, where he has been on the faculty of the UCLA School of Medicine since 1978. He is currently Professor Emeritus of Medicine and Public Health and Founding Chief of the Division of Clinical Nutrition in the Department of Medicine of the David Geffen School of Medicine at UCLA. His main research interests are obesity treatment and nutrition for cancer prevention and treatment.
A New World for Hospital Infection Control
ResMed talks respiratory care
Mervyn Lim, Vice President, ResMed Asia
COVID-19 has put a significant strain on healthcare systems in Asia and around the world. With the outbreak of the pandemic and the surge in the number of patients requiring beds for COVID-19 response, many hospitals in the region have had to shift resources away from any non-intensive ICU treatments.1 This has led to the temporary closure of many so-called ‘elective’ treatments, including testing for chronic obstructive pulmonary disease (COPD) as well as services for patients with sleep disorders.
As the word ‘elective’ implies optional, this has created a complex situation for respiratory specialists responsible for the management of the
PROF. SUSANNA NG
COPD patient population during this pandemic. According to a recent article in the European Respiratory Journal, we have not yet quantified how many COPD patients may have chosen, or were unable to, visit hospitals during this pandemic.2 Although researchers hypothesise—drawing on learnings
from the previous SARS epidemic, where chronic disease patients not affected by SARS ‘presented with worsened disease/symptom control’ largely attributed to ‘a widespread avoidance of the health care system’—that a similar situation is likely occurring in the COVID-19 pandemic.3
According to the Global Burden of Diseases (GBD) Study 2017, there were 3.2 million deaths due to Chronic Obstructive Pulmonary Disease (COPD) and 495 thousand deaths due to asthma.4 In Asia, the estimated prevalence of COPD in the region is rising according to Asia Pacific Family Medicine. However, the disease has historically been under-diagnosed and under-reported even before the outbreak of COVID-19.5 This situation will likely be exacerbated as health systems move towards recovery due to overburdened hospitals with backlogged cases and where spirometry cannot be performed.
The first reality that hospital leaders now face is the huge backlog of respiratory service cases caused by the closure of all non-critical services during the peak of the pandemic. However, even now despite this backlog and services reopening, volumes remain low. For example, South Korea and Thailand hospitals were conducting as low as 40 percent volume of elective/semi-elective procedures as of last month.6
A primary reason for this low volume could be patients’ concern over safe care environment and risk of infection when seeking so-called ‘elective’ services. Given the devastating impact that COVID-19 can have on the lung, it is natural for patients with underlying COPD to avoid hospitals during this time.7
“Even though some services have restarted, patients are quite concerned about hygiene in a hospital setting,” said Prof. Susanna Ng of the Department of Medicine & Therapeutics Faculty of Medicine, The Chinese University of Hong Kong in a recent interview with ResMed.
Such fears can lead to further delays in administering proper care, which can culminate in lasting impact on health.
Hospital administrators are striving to ensure patients of hygiene so that they are more likely to access necessary treatments, while also taking measures to protect the long-term wellness and safety of their staff. Minimising potential exposure to infection and creating a safe environment during the pandemic is top of mind. This has caused many administrators to re-examine some standard practices as they begin their post-pandemic planning.
Operational planning for post-pandemic resilience requires a balance of the following pillars:
Quality of Patient Care Environment Safety Staff Safety
Many hospitals are facing a huge backlog of uncompleted procedures due to the various policies during the height of the pandemic. A wealth of literature points to negative patient outcomes and higher costs when certain treatments are delayed.8
It is important that hospitals are leveraging all technologies at their disposal to start bridging these gaps early. The pandemic has exacerbated longstanding public health and environmental challenges, requiring administrators to balance the need for staff safety against impacts to the environment.9 The crisis will require a careful balance of both reusables and disposables to ensure that they are minimising exposure to infection. At least 72,346 US healthcare workers have been infected during this pandemic as of June 4, 2020.10 Countless more healthcare workers are exposed to infection around the world, spurring the Harvard Business Review to implore administrators to re-examine their practices to ‘make staff safety a fundamental value that you won’t compromise for other organisational priorities.’11
For example, many hospitals in Asia that perform in-patient testing for respiratory patients, still rely on reusable masks for cost efficiencies.
A recent paper12 lead by Dr. Ken Junyang Goh, Department of Respiratory and Critical Care Medicine, Singapore General Hospital, and Dr. Jolin Wong, Division of Anaesthesiology, Singapore General Hospital, discusses practical considerations in hospital planning during and after COVID-19. The authors advise that whenever staff are utilising reusable items it is of utmost importance to ‘ensure adequate capacity for prompt disinfection and sterilisation’ and that in some cases of infection control where facilities and manpower are strained ‘single use items may be preferable.’
Proper disinfection and sterilisation processes of CPAP and NIV masks used in clinic settings require staff follow specific disinfection protocols or specially approved sterilisation machines. The need to minimise healthcare workers’ exposure to potential infections has driven several hospitals to consider stocking on disposable masks, in addition to reusable supply as a precautionary measure.
While both reusable and disposable variants have their roles respectively, the rising attention to minimise staff exposure to infection and patient preference are driving facilities to equip themselves with adequate supplies of both. In addition to ensuring availability of disposable masks in clinic, administrators are also considering supplying disposable accessories to accompany ventilation systems, such as disposable anti-bacterial filters, to mitigate exposure to both staff and patients.
AcuCare is one type of disposable mask, designed to achieve fast patient acceptance of noninvasive ventilation (NIV). By helping patients accept NIV quickly and successfully, healthcare providers can reduce the need for intubation, decrease the risk of infection, and reduce the cost and length of patients’ hospital stay.13
In addition to making preparations to minimise infection risk in a hospital setting, there are also new considerations for respiratory patients who are able to avoid hospital visits entirely, but still need support in managing their conditions during this pandemic. Administrators are paying attention to the shift in adopting technologies to empower patients to take charge of their own health. Such innovations may also help in reducing the burden on hospital facilities and healthcare workers as well as for carers at home.
“Through the pandemic, many rules around telehealth have been relaxed but this is not a problem. You can certainly avoid infection risk with virtual care, it’s much easier to reach out to a patient without travel issues,” said Dr. Patrick Strollo, Professor of Medicine and Clinical & Translational Science in the University of Pittsburgh’s division of Pulmonary, Allergy and Critical Care in an interview with ResMed.
There are several technologies that hospitals are considering for non-dependent patients with obstructive or restrictive respiratory conditions. For example, certain noninvasive ventilator systems such as Lumis 150 VPAP ST are designed to continuously monitor and support both the upper airway and alveolar ventilation from the comfort and safety of a patient’s home. Healthcare providers serving respiratory patients with reservations about visiting clinics may find such technology to be a viable alternative to ensure continued care while minimising infection risks.
Knowing the options available and empowering patients through technology can support continuity of care in out of hospital settings during this period.
The burden caused by COVID-19 to hospital systems in Asia is beginning to cause small but significant shifts in our care delivery. In light of this changing landscape, healthcare leaders need to understand the technology and tools available to help the ecosystem stay on top in infection control, and continue to deliver quality care for respiratory patients.
DR. PATRICK STROLLO
To hear from experts and download valuable resources, visit ResMed at bit.ly/ea-hcp
In line with the World COPD Day, ResMed Emerging Asia will be hosting a webinar on Telemonitoring of Home NIV patients – which will include an expert panel discussion
Saturday, 28th November 2020 3.00 pm - 4.30 pm (Singapore time) Scan to register today.
About the Author
Mervyn Lim is Vice President at ResMed Asia. He is driven by a passion to improve patients’ quality of life by integrating technology and innovation into care models. With a superior track record in industry digital transformation, he is leading the way in digital health solutions for sleep apnea, COPD and other chronic diseases. Mervyn is an alumni of NUS Business School and University of Hull. He has extensive experience across Asia Pacific and in leading teams to re-imagine the delivery of healthcare.
1. Oliver Wyman. COVID-19: Responses & Implications to Healthcare in Asia. https://www.oliverwyman. com/content/dam/oliver-wyman/v2/publications/2020/apr/covid-asia-implications/COVID-19-Responses-andImplications-To-Healthcare-In-Asia.pdf 2. To, Teresa. Viegi, Giovanna. Cruz, Alvaro, et al. A Global Respiratory Perspective on the COVID-19 Pandemic: Commentary and Action Proposals. European Respiratory Journal 2020. https://erj.ersjournals.com/content/ early/2020/06/08/13993003.01704-2020 3. Ibid 4. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392: 1789–1858. doi:10.1016/S0140-6736(18)32279-7 5. Lim, S., Lam, D.C., Muttalif, A.R. et al. Impact of chronic obstructive pulmonary disease (COPD) in the AsiaPacific region: the EPIC Asia population-based survey. Asia Pac Fam Med 14, 4 (2015). https://doi.org/10.1186/ s12930-015-0020-9 6. https://www.healthcareitnews.com/news/asia-pacific/impact-COVID-19-apac-hospitals 7. To, Teresa. Viegi, Giovanna. Cruz, Alvaro, et al. A Global Respiratory Perspective on the COVID-19 Pandemic: Commentary and Action Proposals. European Respiratory Journal 2020. 8. https://hbr.org/2020/08/covid-19-created-an-elective-surgery-backlog-how-can-hospitals-get-back-on-track 9. https://www.eco-business.com/opinion/innovating-for-impact-dealing-with-a-mountain-of-medical-waste/ 10. https://hbr.org/2020/06/health-care-workers-protect-us-its-time-to-protect-them 11. Ibid 12. https://link.springer.com/content/pdf/10.1186/s13054-020-02916-4.pdf 13. Lindenauer PK et al. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014 Dec 1;174(12):1982–93
