By Dale Mayerson and Karen Thompson

At times, individuals living in long-term care face health issues that result in nutritional deficiencies, which can negatively affect their health and quality of life.

Nutrition supplements can help overcome nutritional deficiencies. We all need nutrients in their proper amounts for optimum health. When diet does not provide all of the nutrients necessary, providing a resident with nutrition supplements is a strategy that is often used to improve their status.

The home’s Registered Dietitian completes a full nutrition assessment in the first 21 days after a resident is admitted.  Early identification of risk can facilitate timely dietary intervention, assisting to prevent further decline.  Individuals identified at nutritional risk will have strategies put into place to manage the risk

Nutrition re-assessments are completed quarterly after admission and whenever there is a change of health status.  Body weight is measured monthly and is an indicator of nutritional status. Significant unplanned weight changes are assessed and strategies are developed according to individual needs in consultation with the resident and /or the Power of Attorney.

Aging and nutrition risk

Good health depends on eating a well-balanced diet, rich in nutrient dense foods. By the time residents move into long term care, changes of aging and chronic illness may have affected residents’ health. Nutrition supplements may help in bridging this nutritional gap because they can compensate or offset poor dietary habits, poor nutrient absorption, and help prevent/delay health problems associated with aging.   Social interaction and physical activity can also improve appetite.

As we age, both our physical and mental health are affected. During normal aging, our metabolic rate decreases, which slows down the rate at which we burn calories. The body loses muscle and gains more fat.  Organ systems may decline, causing changes to digestion and kidney function, leading to constipation, diarrhea or food intolerances. Prescribed medications may alter taste, appetite and nutrient absorption. Senses of smell and taste may decline, affecting appetite.

As aging continues, poor dentition, denture fit and difficulty chewing and swallowing may lead to a reduction in food intake. Arthritis and neurological conditions may make it challenging to eat food independently. Loss of mobility can result in less activity, muscle loss and constipation. In advancing years, loneliness, depression and loss of independence may affect appetite and result in weight loss.  In later years, there is also an increased risk of cognitive impairment, which also may adversely affect food intake.

Skin and wound problems (e.g. skin ulcers) may also develop as a resident becomes increasingly frail and elderly. Skin breakdown increases a person’s need for protein, calories and vitamins/ minerals.  Depending on the severity of the skin condition or ulcer, the calorie, protein and fluid needs may increase by 150 per cent. Residents who are already struggling to meet their nutrient needs are likely unable to consume the quantity required for optimal wound healing – that is where nutritional supplements can help!

To combat the negative effects of aging while also managing the natural aging process, resident usually benefit from increasing their intake of:

Protein: to sustain muscle mass. Meats, fish, legumes and dairy products offer healthy sources of proteins.

Calcium: to ensure strong bones and prevent osteoporosis. Dairy products, such as milk and cheeses, are good sources of calcium.  Vit D is often supplemented to improve calcium absorption.

Fibre: to promote regularity and lower cholesterol. Whole grain foods, legumes (beans), vegetables and fruits are good sources of fibre.

Iron: to maintain blood health and energy levels. Red meats, eggs, and spinach are good sources of iron.

Vitamin A: to foster eye health. Sweet potatoes, carrots, and squash are good sources of vitamin A.

Vitamin C: to boost the immune system and to promote healing. Citrus fruits, strawberries, and peppers provide substantial amounts of vitamin C.

Food first philosophy

There is a philosophy that using foods is better than immediately turning to supplements when residents are not eating their usual meals. This philosophy promotes the belief that nutrients are most potent when they come from food, because foods include many non-essential but beneficial nutrients, such as carotenoids, flavonoids, minerals, and antioxidants that are not in most supplements. Providing foods that give residents extra calories and protein without increasing the overall volume can be a huge benefit for residents’ overall health.

It may also be more cost effective to fortify food rather than purchase oral supplements, however extra staff time may be needed to prepare fortified foods and to assist residents to eat them. An example of a fortified food is milk mixed with skim milk powder. In some instances, nutrient dense foods such as ice cream, milkshakes and puddings, or frequent small meals of favourite foods work just as effectively as nutritional supplements.

In order to successfully improve intake with fortified foods, it is best to know a resident’s favourite foods and to know the best time of day to provide these fortified items.

Type of supplements

Supplements have been used for many years as a simple treatment to address poor appetite and/or unwanted weight loss. Most supplements are sweet which is well liked by many but can be a drawback for some people.

Supplements come in a variety of flavours and provide a nutritionally complete product with protein, fat, carbohydrates, vitamins and minerals. Many types and brands exist on the market. Commercial nutrition supplements routinely used include:

• “standard” product usually provides 1 Calorie per millilitre
• “1.5” provides 1.5 Calories per millilitre of product
• “2.0” provides 2 Calories per millilitre and is helpful for people who cannot manage excess volume. In long term care, this product is often served in 30 or 60 ml servings with medications
• pudding is a supplement in solid pudding form that is  suitable for residents requiring thickened fluids
• diabetic formula is formulated for residents with diabetes or for those requiring less calories from carbohydrate or that prefer a less sweet taste
• “high protein” supplements provide an increased proportion of calories from protein usually providing about 15g protein in an 250 ml serving
• protein powders or liquids can be used for residents with increased protein needs

Other specialized nutritional supplements are also available and may be prescribed for residents with more serious health conditions such a kidney failure, respiratory issues, various gastrointestinal disorders or anorexia.

Strategies to address appetite and weight changes

Typically a good starting point is to start with food first, giving a little extra at a meal, using fortified foods, or adding scheduled snacks. If this does not have the desired results, then a commercial supplement may be considered.   The Registered Dietitian or Nutrition Manager discusses this with the resident and/or family and an order is written by either the Physician or the Registered Dietitian. The resident’s plan of care will include information regarding the supplement and the intended goal.

Nutritional supplements are most often offered as between-meal snacks as eating regular meals is preferred and encouraged. Additionally, when supplements are given at mealtimes, a resident will feel full after taking the nutrient dense supplement and may not be able to eat the full meal.

Can family/friends help?

Encourage families and friends to visit at mealtimes and to assist loved ones in the dining room. Advising the Registered Dietitian and Care Team about the resident’s eating patterns, favourite foods or comfort foods can contribute to a more effective care plan to support optimal nutrition for the resident.

Dale Mayerson, BSc, RD, CDE, and Karen Thompson, BA Sc, RD are Registered Dietitians with extensive experience in Long-term care.  They are co-authors of “Menu Planning in Long Term Care and Retirement Homes:  A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.