Dietary characteristics of community-dwelling older adults with poor appetite: a cross-sectional analysis.

RATIONALE: Poor appetite is considered a key factor in the development of malnutrition, a link that can be explained by alterations in dietary intake. Given the limited data on dietary characteristics in community-dwelling older adults with poor appetite, the present study aimed to examine whether poor appetite is associated with lower nutrient intake and more unfavourable food choices. METHODS: In 569 participants of the Longitudinal Aging Study Amsterdam aged ≥70 years appetite was assessed using the Simplified Nutritional Appetite Questionnaire and dichotomised into normal (>14) and poor (≤14). Intake of energy, 19 nutrients, 15 food groups, the Dutch Healthy Diet Index 2015 (DHD15) and Mediterranean Diet Score (MDS) were calculated from a food frequency questionnaire. Dietary differences between appetite groups were examined using Mann-Whitney U test and binary logistic regression adjusted for potential confounders. RESULTS: Mean age was 78 ± 6 years and 52% were female. Appetite was poor in 12.5% of participants. Energy intake was 1951 (median; quartiles 1-3: 1,653-2,384) kcal/day with no difference between appetite groups. Poor appetite was associated with lower intake of protein (OR 0.948, 95%CI 0.922-0.973), folate (0.981, 0.973-0.989), zinc (0.619, 0.454-0.846), vegetables (0.988, 0.982-0.994) and lower scores of DHD15 (0.964, 0.945-0.983) and MDS (0.904, 0.850-0.961), as well as higher intake of carbohydrates (1.015, 1.006-1.023), and vitamins B2 (4.577, 1.650-12.694) and C (1.013, 1.005-1.021). CONCLUSIONS: Community-dwelling older adults with poor appetite showed poorer diet quality with a lower intake of protein, folate, zinc and vegetables, compared with those reporting normal appetite and should be advised accordingly.

Substitution of animal-based with plant-based foods on cardiometabolic health and all-cause mortality: a systematic review and meta-analysis of prospective studies.

BACKGROUND: There is growing evidence that substituting animal-based with plant-based foods is associated with a lower risk of cardiovascular diseases (CVD), type 2 diabetes (T2D), and all-cause mortality. Our aim was to summarize and evaluate the evidence for the substitution of any animal-based foods with plant-based foods on cardiometabolic health and all-cause mortality in a systematic review and meta-analysis. METHODS: We systematically searched MEDLINE, Embase, and Web of Science to March 2023 for prospective studies investigating the substitution of animal-based with plant-based foods on CVD, T2D, and all-cause mortality. We calculated summary hazard ratios (SHRs) and 95% confidence intervals (95% CI) using random-effects meta-analyses. We assessed the certainty of evidence (CoE) using the GRADE approach. RESULTS: In total, 37 publications based on 24 cohorts were included. There was moderate CoE for a lower risk of CVD when substituting processed meat with nuts [SHR (95% CI): 0.73 (0.59, 0.91), n = 8 cohorts], legumes [0.77 (0.68, 0.87), n = 8], and whole grains [0.64 (0.54, 0.75), n = 7], as well as eggs with nuts [0.83 (0.78, 0.89), n = 8] and butter with olive oil [0.96 (0.95, 0.98), n = 3]. Furthermore, we found moderate CoE for an inverse association with T2D incidence when substituting red meat with whole grains/cereals [0.90 (0.84, 0.96), n = 6] and red meat or processed meat with nuts [0.92 (0.90, 0.94), n = 6 or 0.78 (0.69, 0.88), n = 6], as well as for replacing poultry with whole grains [0.87 (0.83, 0.90), n = 2] and eggs with nuts or whole grains [0.82 (0.79, 0.86), n = 2 or 0.79 (0.76, 0.83), n = 2]. Moreover, replacing red meat for nuts [0.93 (0.91, 0.95), n = 9] and whole grains [0.96 (0.95, 0.98), n = 3], processed meat with nuts [0.79 (0.71, 0.88), n = 9] and legumes [0.91 (0.85, 0.98), n = 9], dairy with nuts [0.94 (0.91, 0.97), n = 3], and eggs with nuts [0.85 (0.82, 0.89), n = 8] and legumes [0.90 (0.89, 0.91), n = 7] was associated with a reduced risk of all-cause mortality. CONCLUSIONS: Our findings indicate that a shift from animal-based (e.g., red and processed meat, eggs, dairy, poultry, butter) to plant-based (e.g., nuts, legumes, whole grains, olive oil) foods is beneficially associated with cardiometabolic health and all-cause mortality.

Characterisation of community-dwelling older adults with poor appetite.

PURPOSE: A poor appetite affects up to 27% of community-dwelling older adults in Europe and is an early predictor of malnutrition. Little is known about the factors associated with poor appetite. The present study, therefore, aims to characterise older adults with poor appetite. METHODS: As part of the European JPI project APPETITE, data from 850 participants, aged ≥ 70 years of the Longitudinal Ageing Study Amsterdam (LASA) from 2015/16 were analysed. Appetite during the last week was assessed with a five-point scale and dichotomised into "normal" and "poor". Binary logistic regression was used to examine associations between 25 characteristics from 5 domains-physiological, emotional, cognitive, social, and lifestyle-and appetite. First, domain-specific models were calculated using stepwise backward selection. Second, all variables contributing to poor appetite were combined in a multi-domain model. RESULTS: The prevalence of self-reported poor appetite was 15.6%. Fourteen parameters from all five single-domain models contributed to poor appetite and were entered into the multi-domain model. Here, female sex (total prevalence: 56.1%, odds ratio: 1.95 [95% confidence interval 1.10-3.44]), self-reported chewing problems (2.4%, 5.69 [1.88-17.20]), any unintended weight loss in the last 6 months (6.7%, 3.07 [1.36-6.94]), polypharmacy defined as ≥ 5 medications in the past 2 weeks (38.4%, 1.87 [1.04-3.39]), and depressive symptoms (Centre for Epidemiologic Studies Depression Scale without appetite item) (1.12 [1.04-1.21]) were associated with an increased likelihood of having poor appetite. CONCLUSION: According to this analysis, older people with the characteristics described above are more likely to have a poor appetite.

A Core Outcome Set for nutritional intervention studies in older adults with malnutrition and those at risk: a study protocol.

BACKGROUND: Malnutrition (i.e., protein-energy malnutrition) in older adults has severe negative clinical consequences, emphasizing the need for effective treatments. Many, often small, randomized controlled trials (RCTs) testing the effectiveness of nutritional interventions for the treatment of malnutrition showed mixed results and a need for meta-analyses and data pooling has been expressed. However, evidence synthesis is hampered by the wide variety of outcomes and their method of assessment in previous RCTs. This paper describes the protocol for developing a Core Outcome Set (COS) for nutritional intervention studies in older adults with malnutrition and those at risk. METHODS: The project consists of five phases. The first phase consists of a scoping review to identify frequently used outcomes in published RCTs and select additional patient-reported outcomes. The second phase includes a modified Delphi Survey involving experienced researchers and health care professionals working in the field of malnutrition in older adults, followed by the third phase consisting of a consensus meeting to discuss and agree what critical outcomes need to be included in the COS. The fourth phase will determine how each COS outcome should be measured based on a systematic literature review and a second consensus meeting. This will be followed by a dissemination and implementation phase. Patient and Public Involvement (PPI) representatives will contribute to study design, oversight, consensus, and dissemination. CONCLUSIONS: The result of this project is a COS that should be included in any RCT evaluating the effect of nutritional interventions in older adults with malnutrition and those at risk. This COS will facilitate comparison of RCT results, will increase efficient use of research resources and will reduce bias due to measurement of the outcome and publication bias. Ultimately, the COS will support clinical decision making by identifying the most effective approaches for treating and preventing malnutrition in older adults.

[Screening and Assessment for an Early Identification of Malnutrition in Older People]. / Screening und Assessment zur frühzeitigen Identifikation und Abklärung von Mangelernährung im Alter.

Screening and Assessment for an Early Identification of Malnutrition in Older People Abstract: Malnutrition is common among older people and leads to numerous negative clinical consequences due to changes in body composition and body function. A prerequisite for successful prevention and treatment is the early identification of older persons with (risk of) malnutrition. Therefore, in geriatric settings, routine malnutrition screening with a validated tool (e.g., Mini Nutritional Assessment or Nutritional Risk Screening) is recommended at regular intervals. In case of a positive screening result, a subsequent nutritional assessment is performed to confirm the diagnosis, to clarify the causes and to determine the energy and protein deficit, in order to initiate a targeted nutritional therapy and to improve the nutritional status of the older persons and thereby the overall prognosis.

Association of eating motives with anthropometry, body composition, and dietary intake in healthy German adults.

Effective policies to address poor food choices and dietary patterns need to consider the complex set of motives affecting eating behavior. This study examined how different eating motives are associated with anthropometry, body composition, and dietary intake. Our analysis is based on a cross-sectional sample with 429 healthy adults in three different age groups collected in Germany from 2016 to 2018. Dietary intake, Body Mass Index (BMI), waist circumference (WC), and fat-free mass (FFM) were measured by standardized methods. Eating motives were measured using The Eating Motivation Scale (TEMS). Regressing dietary intakes and anthropometric indicators on TEMS motives, we identify the main sources of variation in diet and nutritional status separately for men and women. Results indicated the Health motive to be positively associated with FFM (B±SE=1.72±0.44) and negatively with WC (B±SE=-3.23±0.81) for men. For women, the Need & Hunger motive was positively associated with FFM (B±SE=1.63±0.44) and negatively with WC (B±SE=-2.46±0.81). While Liking and Habits were the most frequently stated eating motives, we did not find them to be significantly related to the nutritional status. Other motives were associated with dietary intake but not anthropometry or body composition. The Price motive was positively and the Convenience motive was negatively associated with energy (B±SE=63.77±19.98;B±SE=-46.96±17.12) and carbohydrate intake (B±SE=7.15±2.65;B±SE=-5.98±2.27) for men. The results highlight the need for more differentiated analyses of eating motives, beyond comparing the relative importance of motives based on mean values, towards the association of motives with dietary intake and nutritional status.

Dietary weight-loss interventions for the management of obesity in older adults.

The obesity epidemic has reached old age in most industrialized countries, but trials elucidating the benefits and risks of weight reduction in older adults above 70 years of age with obesity remain scarce. While some findings demonstrate a reduced risk of mortality and other negative health outcomes in older individuals with overweight and mild obesity (i.e. body mass index (BMI) < 35 kg/m2), other recent research indicates that voluntary weight loss can positively affect diverse health outcomes in older individuals with overweight and obesity (BMI > 27 kg/m2), especially when combined with exercise. However, in this age group weight reduction is usually associated with a reduction of muscle mass and bone mineral density. Since uncertainty persists as to which level overweight or obesity might be tolerable (or even beneficial) for older persons, current recommendations are to consider weight reducing diets only for older persons that are obese (BMI ≥ 30 kg/m2) and have weight-related health problems. Precise treatment modalities (e.g. appropriate level of caloric restriction and indicated dietary composition, such as specific dietary patterns or optimal protein content) as well as the most effective and safest way of adding exercise are still under research. Moreover, the long-term effects of weight-reducing interventions in older individuals remain to be clarified, and dietary concepts that work for older adults who are unable or unwilling to exercise are required. In conclusion, further research is needed to elucidate which interventions are effective in reducing obesity-related health risks in older adults without causing relevant harm in this vulnerable population.

Malnutrition and related risk factors in older adults from different health-care settings: an enable study.

OBJECTIVE: The origin of malnutrition in older age is multifactorial and risk factors may vary according to health and living situation. The present study aimed to identify setting-specific risk profiles of malnutrition in older adults and to investigate the association of the number of individual risk factors with malnutrition. DESIGN: Data of four cross-sectional studies were harmonized and uniformly analysed. Malnutrition was defined as BMI < 20 kg/m2 and/or weight loss of >3 kg in the previous 3-6 months. Associations between factors of six domains (demographics, health, mental function, physical function, dietary intake-related problems, dietary behaviour), the number of individual risk factors and malnutrition were analysed using logistic regression. SETTING: Community (CD), geriatric day hospital (GDH), home care (HC), nursing home (NH). PARTICIPANTS: CD older adults (n 1073), GDH patients (n 180), HC receivers (n 335) and NH residents (n 197), all ≥65 years. RESULTS: Malnutrition prevalence was lower in CD (11 %) than in the other settings (16-19 %). In the CD sample, poor appetite, difficulties with eating, respiratory and gastrointestinal diseases were associated with malnutrition; in GDH patients, poor appetite and respiratory diseases; in HC receivers, younger age, poor appetite and nausea; and in NH residents, older age and mobility limitations. In all settings the likelihood of malnutrition increased with the number of potential individual risk factors. CONCLUSIONS: The study indicates a varying relevance of certain risk factors of malnutrition in different settings. However, the relationship of the number of individual risk factors with malnutrition in all settings implies comprehensive approaches to identify persons at risk of malnutrition early.

Protein intake in older people : Why, how much and how?

The protein intake of older people has gained increasing scientific interest as a potential factor to delay the age-associated decline in muscle mass and consequently to counteract the development of sarcopenia. The skeletal muscle of older people seems less responsive to the anabolic stimulus of protein intake. Therefore, higher protein needs are discussed to overcome this anabolic resistance and to maintain muscle mass as far as possible. Besides the total amount of protein consumed, the distribution, quality and timing in relation to physical exercise are considered relevant; however, deriving clear recommendations for clinical practice is still difficult as positive results of protein intake on muscle metabolism found in experimental trials cannot simply be transferred to everyday conditions and randomized controlled trials often failed to show improvements in muscular outcomes related to protein supplementation. The effectiveness of protein supplementation may depend on functional resources of the older persons and the habitual protein intake. There is still a need for studies with well-defined protocols and populations to further elucidate the role of protein in the prevention and treatment of sarcopenia.

Prevalence and overlap of sarcopenia, frailty, cachexia and malnutrition in older medical inpatients.

BACKGROUND: Sarcopenia, frailty, cachexia and malnutrition are widespread syndromes in older people, characterized by loss of body tissue and related to poor outcome. The aim of the present cross-sectional study was to assess the prevalence of these syndromes and their overlap in older medical inpatients. METHODS: Patients aged 70 years or older who had been admitted to the internal medical department of a German university hospital were recruited. Sarcopenia, frailty, cachexia and malnutrition were assessed in a standardized manner according to current consensus definitions. Prevalence rates of these syndromes and their constituents and the concurrent occurrence of the syndromes (overlap) were calculated. RESULTS: One hundred patients (48 female) aged 76.5 ± 4.7 years with a BMI of 27.6 ± 5.5 kg/m2 were included. The main diagnoses were gastroenterological (33%) and oncological diseases (31%). Sarcopenia was present in 42%, frailty in 33%, cachexia in 32% and malnutrition in 15% of the patients. 63% had at least one syndrome: 32% one, 11% two, 12% three and 8% all four. All four syndromes are characterized by significant weight loss during the last 12 months, which was most pronounced in malnourished patients and least pronounced in frail patients, and by significantly reduced physical performance. All syndromes were significantly pairwise related, except malnutrition and frailty. In 19% of patients sarcopenia and frailty occurred concurrently, in 20% frailty and cachexia and in 22% sarcopenia and cachexia with or without additional other syndromes. All malnourished patients except one were also cachectic (93%) and 80% of malnourished patients were also sarcopenic. 53% of malnourished patients were in addition frail, and these patients were affected by all four syndromes. CONCLUSIONS: Nearly two thirds of older medical inpatients had at least one of the tissue loss syndromes sarcopenia, frailty, cachexia and malnutrition. The syndromes overlapped partly and were interrelated. Future studies with larger patient groups and longitudinal design are required to clarify the significance of single and concurrent occurrence of these syndromes for clinical outcome and successful therapy.

Texture modified diet in German nursing homes: availability, best practices and association with nursing home characteristics.

BACKGROUND: For nursing home (NH) residents with swallowing or chewing problems, appealing texture-modified-diets (TMD) need to be available in order to support adequate nutrition. The aim of this study was to describe the availability of TMD and best practices for TMD in German NHs and to identify related NH characteristics. METHODS: Information on NH characteristics, available texture-modified (TM)-levels (soft, "minced & moist", pureed) and implemented best practices for TMD (derived from menu plan, separately visible components, re-shaped components, considering individual capabilities of the resident) was collected in a survey in German NHs. The number of TM-levels as well as the number of best practices for TMD were tested for their association with 4 structural, 16 operational and 3 resident-related NH characteristics. RESULTS: The response rate was 7.2% (n = 590) and 563 NHs were included. The vast majority of NHs (95.2%) reported offering "minced & moist" texture and 84.2% preparing separately visible meal components. Several operational characteristics were more frequently (p < 0.05) reported from NHs offering three TM-levels (27.7%) or four best practices for TMD (13.0%) compared to NHs offering one TM-level (28.4%) or one best practice for TMD (20.1%): special diets and delivery forms (e.g. fingerfood 71.2% vs 38.8%; 80.8% vs. 44.3%), written recipes (69.9% vs. 53.1%; 68.5% vs. 53.9%), a dietetic counseling service (85.9% vs. 66.3%; 89.0% vs. 65.2%), a quality circle for nutritional care (66.7% vs. 43.8%; 71.2% vs. 50.4%), regular staff training (89.7% vs. 73.1%; 95.9% vs. 74.8%) and process instructions (73.7% vs. 53.1%; 75.3% vs. 47.8%). No associations were found regarding structural and resident-related NH characteristics, except a higher percentage of residents receiving TMD in NHs with three compared to one TM-level (median 16.3% vs. 13.2%, p = 0.037). CONCLUSION: All participating NHs offer some form of TMD, but only a small number offers a selection of TMD and pays adequate attention to its preparation. Operational NH characteristics - which might reflect a general nutritional awareness of the NH - seem to be pivotal for provision of TMD, whereas neither structural nor resident-related characteristics seem to play a role in this regard.

Measuring eating motives in older adults with and without functional impairments with The Eating Motivation Survey (TEMS).

Gaining a better understanding which motives play a role in daily eating is crucial in order to develop personalized interventions promoting adequate diet. The Eating Motivation Survey (TEMS) is a comprehensive tool to assess manifold reasons for eating but has not been specifically applied in an older sample including very old persons and persons differing in functional status. Therefore, the first step of the study was to investigate whether the basic motives of TEMS are consistent in an older sample and comparable across older adults with and without functional impairments. Second, the study aimed at describing which motives underlie eating behavior in older age most often as well as to analyze the relationship between eating motives and functional status. 376 community-dwelling older persons aged 70 years and older filled in the brief survey version (15 motives à 3 items) of TEMS. The sample comprises 149 unimpaired and 227 impaired participants in terms of physical function. Confirmatory factor analysis yielded good model fit with RMSEA 0.036 and SRMR 0.048. Furthermore, multi-group analysis revealed a generally invariant factor structure across participants with and without functional impairments. Liking was rated to underlie eating behavior most often, followed by Health and Natural Concerns. Considering gender, age and BMI, significant associations between functional status and the motive Sociability emerged. Since the results suggest that the fifteen basic eating motives are generalizable in older age and across different functional states, TEMS might be a valuable tool in nutrition-related health promotion to developing individualized approaches considering health aspects as well as hedonistic factors.

Daily and per-meal animal and plant protein intake in relation to muscle mass in healthy older adults without functional limitations: an enable study.

OBJECTIVE: Animal protein sources are considered to be of higher quality than plant protein sources in terms of stimulating muscle metabolism. Our objective was to investigate whether protein intake from animal and plant sources on a daily and per-meal basis differs between healthy older adults with normal and with low muscle mass. METHODS: In this cross-sectional study including 100 healthy, community-dwelling adults (51 women) aged 75-85 years without functional limitations dietary intake was assessed using 7-day food records. Protein intake was classified by six animal and six plant protein sources. Skeletal muscle index (SMI) was determined based on bioelectrical impedance analysis and categorized into 'normal' or 'low' (men ≤ 8.50, women ≤ 5.75 kg/m2). The absolute animal and plant protein intake and their proportion of total protein intake were compared between these groups using Mann-Whitney U test. RESULTS: Daily protein intake was 0.96 ± 0.27 g/kg body weight (BW), 61 ± 10% hereof were from animal origin with no difference between men and women. SMI was low in 39% of men and 35% of women. No differences in absolute daily animal and plant protein intake between participants with normal vs. low SMI were observed. The proportion of animal protein was not different on neither a daily nor a per-meal basis between those with normal and those with low SMI. Women with low SMI consumed less animal protein (in g) for breakfast (4.8 ± 4.1 g vs. 8.5 ± 6.9 g, p = 0.031) and fewer meals per day with at least 50% animal protein (2.2 ± 0.9 vs. 2.7 ± 1.0, p = 0.046) compared to those with normal SMI. CONCLUSION: On a daily basis, the absolute and relative animal protein intake does not differ between healthy older adults without functional limitations with normal vs. low SMI. However, our results indicate that in women animal protein intake on a per-meal basis might be of relevance for the maintenance of muscle mass.

[Musculoskeletal factors, sarcopenia and falls in old age]. / Skelettmuskuläre Faktoren, Sarkopenie und Stürze im Alter.

Falls in older adults are a major public health problem with a high incidence and severe consequences for the older individual. The age-related loss of muscle strength as well as muscle mass and muscle function (sarcopenia) are i) risk factors for falling, ii) associated with physical function and iii) markers of the frailty syndrome. Muscle function appears to play a bigger role than muscle mass. The operationalization of sarcopenia using the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm is consistently associated with falling events. Structured physical exercise plays the key role in the prevention of falls and the management of functional decline caused by sarcopenia and frailty. The combined supplementation with proteins and vitamin D supports muscle protein synthesis in undersupplied persons and improves aspects of physical function.

Functional determinants of dietary intake in community-dwelling older adults: a DEDIPAC (DEterminants of DIet and Physical ACtivity) systematic literature review.

OBJECTIVE: The identification of determinants of dietary intake is an important prerequisite for the development of interventions to improve diet. The present systematic literature review aimed to compile the current knowledge on individual functional determinants of dietary intake in community-dwelling older adults. DESIGN: A systematic search was performed in PubMed, Scopus, Web of Science and the Cochrane Library. Titles, abstracts and full texts were screened according to predefined inclusion and exclusion criteria. Studies were included when focusing on dietary intake as an outcome and on chemosensory, oral, cognitive or physical function as a determinant. SETTING: Community. SUBJECTS: Older adults at least 65 years old without acute or specific chronic diseases. RESULTS: From initially 14 585 potentially relevant papers, thirty-six were included. For chemosensory, cognitive and physical function only a few papers were found, which reported inconsistent results regarding the relationship to dietary intake. In contrast, oral function was extensively studied (n 31). Different surrogates of oral function like dental status, number of teeth, bite force or chewing problems were associated with food as well as nutrient intakes including fibre. As all except six studies had a cross-sectional design, no causal relationships could be derived. CONCLUSIONS: Among functional determinants of dietary intake oral factors are well documented in older adults, whereas the role of other functional determinants remains unclear and needs further systematic research.

Nutrition, frailty, and sarcopenia.

Frailty and sarcopenia are important concepts in the quest to prevent physical dependence, as geriatrics are shifting towards identifications of early stages of disability. Definitions of both sarcopenia and frailty are still developing, and both concepts clearly overlap in their physical aspects. Malnutrition (both undernutrition and obesity) plays a key role in the pathogenesis of frailty and sarcopenia. The quality of the diet along the lifespan has a close relation with the incidence of both entities, and nutritional interventions may be able to reduce the incidence or revert either of them. This brief review explores the role of energy and protein intake and other key nutrients on muscle function. Nutrition may be a key element of multimodal interventions for frailty and sarcopenia. The results of the "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) trial will offer key insights on the effect of such interventions in frail, sarcopenic older individuals.

Critical outcomes to be included in the Core Outcome Set for nutritional intervention studies in older adults with malnutrition or at risk of malnutrition: a modified Delphi Study.

INTRODUCTION: As part of the development of an agreed minimum set of outcomes or Core Outcome Set (COS) for future nutritional intervention trials in older adults with malnutrition or at risk of malnutrition, this work reports on the Delphi surveys and final consensus. METHODS: Outcomes from a scoping review were incorporated into a two-round Delphi survey. Researchers and healthcare professionals experienced in malnutrition in older adults were invited to take part in an online survey to rate 38 selected outcomes on a nine-point Likert scale ranging from 'not important' to 'critical' for their setting (community, hospital, or long-term care). Consensus for inclusion was reached when ≥75% (or ≥60% if a patient-reported outcome) of the participants scored the outcome as 'critical' and <15% as 'not important'. Resulting outcomes were voted for inclusion or exclusion in the COS in a final online consensus meeting. RESULTS: Ninety-three and 72 participants from diverse professional backgrounds and countries participated in the 1st and 2nd Delphi round, respectively. After both rounds eleven outcomes met the inclusion criteria, largely irrespective of setting. Fifteen participants, representing academia, health care, health policy, industry, and PPI, voted in a final online consensus meeting resulting in ten outcomes: malnutrition status, dietary intake, appetite, body weight or BMI, muscle strength, muscle mass, functional performance, functional limitations, quality of life, and acceptability of the intervention. CONCLUSIONS: Ten outcomes will form the COS which is intended to be used by the scientific community in all future nutritional intervention studies for older adults with malnutrition or at risk of malnutrition. The subsequent phase will establish the appropriate methods to measure these outcomes.

Substitution of Dairy Products and Risk of Death and Cardiometabolic Diseases: A Systematic Review and Meta-Analysis of Prospective Studies.

Substitution models in epidemiologic studies specifying both substitute and substituted food in relation to disease risk may be useful to inform dietary guidelines. A systematic review of prospective observational studies was performed to quantify the risks of all-cause mortality, cardiovascular disease, and type 2 diabetes (T2D) associated with the substitution of dairy products with other foods and between different dairy products. We systematically searched MEDLINE, Embase, and Web of Science until 28th June, 2023. We calculated summary relative risks (SRRs) and 95% confidence intervals (95% CI) in random-effects meta-analyses. We assessed the risk of bias with the Risk Of Bias In Non-randomized Studies - of Exposure (ROBINS-E) tool and certainty of evidence (CoE) using the Grading of Recommendations Assessment, Development, and Evaluations (GRADE) approach. Fifteen studies (with 34 publications) were included. There was moderate CoE that the substitution of low-fat dairy with red meat was associated with a higher risk of mortality, coronary artery disease, and T2D [SRR (95% CI): 1.11 (1.06, 1.16), 1.13 (1.08, 1.18), and 1.20 (1.16, 1.25)]. A higher risk of mortality and T2D was also observed when substituting low-fat dairy with processed meat [SRR (95% CI): 1.19 (1.11, 1.28) and 1.41 (1.33, 1.49); moderate CoE]. A lower mortality risk was associated with the substitution of dairy and yogurt with whole grains [SRR (95% CI): 0.89 (0.84, 0.93) and 0.91 (0.85, 0.97)], and butter with olive oil [SRR (95% CI): 0.94 (0.92, 0.97); all moderate CoE]. Mainly no associations were observed when substituting dairy products against each other on disease and mortality risk. Our findings indicate associations between substituting dairy with red or processed meat and higher disease risk, whereas its substitution with whole grains was associated with a lower risk. However, there is little robust evidence that substituting whole-fat with low-fat dairy is associated with disease risk. (CRD42022303198).

Association between substituting macronutrients and all-cause mortality: a network meta-analysis of prospective observational studies.

Background: Suboptimal diet quality is a key risk factor for premature death. Assuming relatively stable energy intake among individuals, changes in nutrient intakes occur by exchanging different nutrients. Therefore we aimed to examine the association of isocaloric substitution of dietary (macro)nutrients with all-cause mortality using network meta-analysis (NMA). Methods: For this systematic review and NMA of prospective observational studies MEDLINE, Embase, and Scopus were searched from inception to February 13th, 2024. Eligible studies reported substitution analyses for quantity and/or quality of macronutrients, including carbohydrates, proteins, and fatty acids on all-cause mortality. Random-effects NMA were used in order to evaluate the pooled hazard ratios (HR) and 95% confidence intervals (CI) of substituting each included nutrient with another. We assessed risk of bias with the ROBINS-E tool, and the certainty of evidence (CoE) using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach. This study is registered with PROSPERO (CRD42023450706). Findings: Thirty-nine studies with 1,737,644 participants, 395,491 deaths, 297 direct comparisons, and seven nutrient-specific networks were included. Moderate CoE was found for an association with lower mortality risk when replacing 5% of energy intake from carbohydrates with polyunsaturated fatty acids (PUFA; HR: 0.90; 95%CI: 0.84, 0.95), n-6 PUFA (0.85; 0.77, 0.94), n-3 PUFA (0.72; 0.59, 0.86), and plant monounsaturated fatty acids (MUFA; 0.90; 0.85, 0.95), and when replacing 5% of energy from saturated fatty acids (SFA) and trans-fatty acids (TFA), with PUFA, MUFA, and plant-MUFA (HRrange: 0.75 to 0.91). A lower mortality risk was additionally found when 5% of animal-MUFA was replaced with plant-MUFA, and when replacing animal protein, and SFA with plant protein (HRrange: 0.81 to 0.87, moderate CoE). Interpretation: Our results provide practical knowledge for public health professionals and can inform upcoming dietary guidelines. The beneficial association of increasing PUFA (both n-3 and n-6) and (plant-) MUFA intake while reducing carbohydrates, SFA and TFA, along with replacing animal protein and animal-MUFA with plant-based sources of protein and fat (MUFA) on the all-cause mortality risk, underscores the importance of plant-based dietary recommendations. Funding: None.

Validation of the German version of the Protein Screener 55.

BACKGROUND/OBJECTIVES: The Protein Screener 55 + (Pro55 + ) is a brief food questionnaire to screen older community-dwelling adults for low protein intake. The result is the predicted probability of protein intake <1.0 g/kg adjusted body weight (aBW)/d ranging from 0-1. For purposes of cross-cultural validation, we translated the Pro55+ into German and tested its discriminative accuracy in detecting low protein intake of older community-dwelling people in Germany. SUBJECTS/METHODS: After translation and pilot-testing, the Pro55+ and the reference standard (3-day dietary record) were completed by 144 participants (81.6 ± 3.9 years, 61.8% female). Discriminative properties were tested by receiver operating characteristic curves and by calculating sensitivity and specificity for different cut-offs of predicted probability (>0.3/>0.5/>0.7) using <1.0 or <0.8 g/kg aBW/d to define low protein intake. RESULTS: Protein intake was <1.0 g/kg aBW/d in 39.6% of the sample and <0.8 g/kg aBW/d in 17.4%. Area under the curve was 62.0% (95%CI 52.6-71.5) and 68.8% (58.1-79.4), respectively. Specificity was 82-90% using probability cut-offs of 0.5 and 0.7 for both protein thresholds. Sensitivity was poor for protein threshold of 1.0 g/kg aBW/d regardless of the used probability cut-offs. For protein threshold of <0.8 g/kg aBW/d, sensitivity was 88.0% (71.8-96.9) using a probability cut-off of 0.09. CONCLUSION: The overall discriminative accuracy of the German Pro55+ to identify older community-dwelling people with low protein intake was poor. However, applying different probability cut-offs allows increasing specificity and sensitivity for 0.8 g/kg aBW/d to levels justifying the use for certain purposes e.g. excluding individuals with adequate protein intake. Further validation is needed.