Changes in type of foodservice and dining room environment preferentially benefit institutionalized seniors with low body mass indexes.

OBJECTIVE: To compare energy intakes in seniors with cognitive impairment residing in long-term care and receiving meals by bulk (cafeteria style with waitress service) vs traditional tray delivery systems and determine subject characteristics that identify responsiveness to type of foodservice provided. DESIGN AND SUBJECTS/SETTING: Usual energy intakes were compared in subjects residing in cognitive impairment units in either the old (tray delivery, n=23) or new (bulk delivery, n=26) nursing home at Baycrest, a teaching facility associated with University of Toronto Medical School. INTERVENTION: Changes to foodservice and physical environment (from institutional to more home-like environment). MAIN OUTCOME MEASURES: Twenty-one consecutive day investigator-weighed energy and macronutrient intakes and behavioral function (London Psychogeriatric Rating Scale). STATISTICAL ANALYSES PERFORMED: Analysis of variance determined mean differences in intake and regression analyses identified predictors of sensitivity to type of food delivery systems. RESULTS: Higher 24-hour total (P<0.001) and dinner (P<0.001) energy intakes in subjects receiving bulk compared to tray delivery were predominantly associated with greater carbohydrate intakes (P<0.001). Higher energy, carbohydrate, and protein, but not fat intakes, with bulk delivery were more apparent in individuals with lower body mass indexes (BMIs) (food delivery by BMI interaction, all P values <0.05). CONCLUSIONS: High-risk, cognitively impaired individuals with low BMI benefited the most from the changed foodservice and physical environment, whereas individuals with higher BMIs did not show substantive changes in intake. Bulk foodservice and a home-like dining environment optimize energy intake in individuals at high risk for malnutrition, particularly those with low BMIs and cognitive impairment.

The safety of whey protein concentrate derived from the milk of cows immunized against Clostridium difficile.

A whey protein concentrate prepared from the milk of cows that have been immunized against Clostridium difficile (C. difficile) and its toxins, toxin A and toxin B, is produced for use as a medical food for the dietary management of patients with C. difficile-associated diarrhea (CDAD) to prevent a relapse of the infection. The safety of anti-C. difficile whey protein concentrate (anti-CD WPC) is supported by analytical data comparing the composition of raw milk from immunized cows versus that from non-immunized cows, and the composition of anti-CD WPC versus that of regular whey protein concentrate. Additionally, a prospective clinical study was conducted in 77 patients with CDAD to demonstrate the safety of consuming anti-CD WPC to prevent relapse of the infection. This study, which included adverse event monitoring, physical examinations, and extensive hematological and biochemical assessments, showed that anti-CD WPC is safe to consume by patients with CDAD. The available analytical and clinical evidence demonstrate that anti-CD WPC is safe for use by individuals with CDAD, under the described conditions of use.

Energy-containing nutritional supplements can affect usual energy intake postsupplementation in institutionalized seniors with probable Alzheimer's disease.

OBJECTIVES: To determine whether increases in caloric intake associated with consumption of a mid-morning nutritional supplement for 3 weeks were maintained in the week after stopping the supplement and to investigate the effects of body mass index (BMI) and cognitive and behavioral measures on this response. DESIGN: Secondary analysis of a previously published randomized, crossover, nonblinded clinical trial. SETTING: A fully accredited geriatric care facility affiliated with the University of Toronto. PARTICIPANTS: Thirty institutionalized seniors with probable Alzheimer's disease (AD) who ate independently. MEASUREMENTS: Investigator-weighed food intake, body weight, cognitive (Severe Impairment Battery; Global Deterioration Scale) and behavioral (Neuropsychiatric Inventory--Nursing Home version; London Psychogeriatric Rating Scale) assessments. RESULTS: Individuals who responded successfully to supplementation as indicated by increases in daily energy intake were likely to maintain 58.8% of that increase postsupplementation, although stopping the supplement was associated with decreased habitual energy intake in low-BMI individuals who reduced their daily intakes during supplementation in response to the extra calories. Cognitive/behavioral tests were not reliable predictors of postsupplement intake. CONCLUSION: Institutionalized seniors with probable AD are likely to alter their usual energy intakes to maintain changes resulting from 3 weeks of supplementation. This effect may allow for rotating supplementation schedules in nursing homes that could reduce staff burden, but only for those individuals who are most likely to respond favorably. These data indicate that nutritional supplements and diet plans should be carefully prescribed in low-BMI individuals to limit variability in total energy provided and thus prevent lower-than-normal intake.

An evaluation of the maximized survey-derived daily intake (MSDI) as a practical method to estimate intake of flavouring substances.

Realistic estimates of intake are essential for risk assessments of flavouring agents, since substantial over or underestimations introduce inaccuracies into such evaluations. The objectives of this study were to examine the relationship between intakes estimated using methods based on the reported volume of production [e.g., maximized survey-derived daily intake (MSDI)] versus use-level data [e.g., possible average daily intake (PADI) and modified theoretical added maximum daily intake (mTAMDI)]. The impact of volatility, self-limiting organoleptic properties and whether 10% of the population are eaters, an assumption in the MSDI calculation, on intake estimates were investigated. Analyses on 221 flavouring substances showed that intake estimates derived from MSDI correlated with values determined from detailed 14-day menu-census data, PADI, and mTAMDI. Comparisons of menu-census intake data adjusted to account for factors such as volatile losses showed that MSDI estimates are realistic and sufficiently conservative, whereas mTAMDI results in substantial overestimates of intake. Very few flavours have less than 10% eaters, and in the worst case, this assumption underestimates percent eaters by a factor of about 4. This investigation supports the use of MSDI as a conservative yet practical method to estimate intake of flavouring substances.

A randomized, crossover trial of high-carbohydrate foods in nursing home residents with Alzheimer's disease: associations among intervention response, body mass index, and behavioral and cognitive function.

BACKGROUND: Despite recognition that weight loss is a problem in elderly persons with probable Alzheimer's disease (AD), increasing their food intake remains a challenge. To effectively enhance intake, interventions must work with individuals' changing needs and intake patterns. Previously, the authors reported greater food consumption at breakfast, a high-carbohydrate meal, compared with dinner, and shifts toward carbohydrate preference at dinner in those with increased behavioral difficulties, low body mass index, or both. METHODS: Thirty-four nursing home residents with probable AD who ate independently participated in a randomized, crossover, nonblinded study of two nutrition interventions. The intervention described here included replacing 12 nonconsecutive "traditional" dinners with meals high in carbohydrate but comparable to traditional dinners in protein. Measures included weighed food intake, body weight, cognitive function (as assessed using the Severe Impairment Battery and Global Deterioration Scale), behavioral disturbances (as assessed using the Neuropsychiatric Inventory-Nursing Home Version), and behavioral function (as assessed using the London Psychogeriatric Rating Scale). RESULTS: Group mean dinner and 24-hour energy intake increased during the intervention phase compared with baseline, protein intake was unaffected, and carbohydrate intake increased. Increased dinner intake, attributable to intervention foods, was achieved in 20 of 32 of participants who completed the study and was associated with increased carbohydrate preference, poorer memory, and increased aberrant motor behavior. Those with low body mass indices were the most resistant to the intervention. CONCLUSIONS: Providing a high-carbohydrate meal for dinner increases food intake in seniors at later stages of the disease who are experiencing cognitive and behavioral difficulties, possibly as a result of a shift in preference for high-carbohydrate foods.

Behavioral disturbances, not cognitive deterioration, are associated with altered food selection in seniors with Alzheimer's disease.

OBJECTIVE: We previously reported alterations in circadian patterns of food intake that are associated with measures of functional and cognitive deterioration in seniors with probable Alzheimer's disease (AD). This study further explored disturbed eating patterns in AD, focusing on alterations in macronutrient (protein, carbohydrate, and fat) selection, and their association with measures of functional and behavioral losses. METHODS: Forty-nine days of food intake collections were conducted on 32 residents (26 females, 6 males; age = 88.4 +/- 4.1 years; body mass index = 24.1 +/- 4.0 kg/m(2)) with probable AD residing at a nursing home (a fully accredited geriatric teaching facility affiliated with the University of Toronto's Medical School). All residents ate their meals independently. The relationships between patterns of habitual food consumption and measures of cognitive function (Severe Impairment Battery), behavioral disturbances (Neuropsychiatric Inventory-Nursing Home Version) and behavioral function (London Psychogeriatric Rating Scale) were examined, cross-sectionally. RESULTS: Consistent with our previous studies, breakfast intakes were not predicted by any of the measures of behavioral, cognitive, or functional deterioration, although those residents with greater functional deterioration, especially disengagement, attained lower 24-hour energy intakes. The presence of "psychomotor disturbances," including irritability, agitation, and disinhibition, were strongly associated with shifts in eating patterns toward carbohydrate and away from protein, placing individuals with these conditions at increased risk for inadequate protein intakes. Between-individual differences in intake patterns could not be explained by the use of either anorexic or orexigenic medications. CONCLUSIONS: Behavioral, not cognitive, deterioration is associated with appetite modifications that increase risk of poor protein intake, perhaps indicating a common monoaminergic involvement.

Providing nutrition supplements to institutionalized seniors with probable Alzheimer's disease is least beneficial to those with low body weight status.

OBJECTIVES: To examine whether providing a midmorning nutrition supplement increases habitual energy intake in seniors with probable Alzheimer's disease (AD) and to investigate the effects of body weight status and cognitive and behavioral function on the response to the intervention. DESIGN: Randomized, crossover, nonblinded clinical trial. SETTING: A fully accredited geriatric teaching facility affiliated with the University of Toronto's Medical School with a home for the aged. PARTICIPANTS: Thirty-four institutionalized seniors with probable AD who ate independently. INTERVENTION: Nutrition supplements were provided between breakfast and lunch for 21 consecutive days and compared with 21 consecutive days of habitual intake. MEASUREMENTS: Investigator-weighed food intake, body weight, cognitive function (Severe Impairment Battery and Global Deterioration Scale), behavioral disturbances (Neuropsychiatric Inventory-Nursing Home Version), and behavioral function (London Psychogeriatric Rating Scale). RESULTS: Relative to habitual intake, group mean analyses showed increased 24-hour energy, protein, and carbohydrate intake during the supplement phase, but five of 31 subjects who finished all study phases completely compensated for the energy provided by the supplement by reducing lunch intake, and 24-hour energy intake was enhanced in only 21 of 31 subjects. Compensation at lunch was more likely in subjects with lower body mass indices, increased aberrant motor behavior, poorer attention, and increased mental disorganization/confusion. CONCLUSION: Nutrition supplements were least likely to enhance habitual energy intake in subjects who would normally be targeted for nutrition intervention-those with low body weight status. Those likely to benefit include those with higher body mass indices, less aberrant motor problems, less mental disorganization, and increased attention.

Malnutrition in institutionalized seniors: the iatrogenic component.

OBJECTIVES: To provide practitioners with benchmarks for micronutrient supplementation policies for older residents of long-term care (LTC) facilities, based upon residents' usual energy intake. DESIGN: Retrospective secondary analysis of nutrient intake and delivery data, obtained from 21 consecutive collection days. SETTING: A fully accredited geriatric teaching facility, affiliated with the University of Toronto's Medical School, that includes a chronic care hospital and a home for the aged, housing more than 800 senior residents. PARTICIPANTS: Twenty-three cognitively impaired residents who retained the ability to feed themselves. MEASUREMENTS: Average daily micronutrient (vitamin and mineral) content of two common diet types--unrestricted diet as tolerated and lactose-free--were evaluated based upon all foods served during a 28-day cycle of menus, providing an estimate of total possible micronutrient intake. Energy intake needed to meet recommended intakes for each of the micronutrients was then determined and compared with actual dietary intakes. RESULTS: Even if entirely consumed, neither diet (providing approximately 2,000 kcal/d) supplied sufficient quantities of vitamins (vitamin E, pantothenic acid) and minerals (calcium, zinc, copper and manganese) to enable residents to meet recommended intakes, making these deficiencies iatrogenic in nature. As projected intake levels fell to reflect ranges more consistently observed in LTC residents (1,000-1,500 kcal/d), the number and severity of risk nutrients increased. Similar predictions, based upon actual intake measurements, were made and confirmed. CONCLUSIONS: The traditional approach of developing LTC menus using resources such as Canada's Food Guide or the Food Guide Pyramid of the United States results in iatrogenic malnutrition. New guidelines are needed that are targeted toward the special needs of older adults who have low food intakes. In the interim, all older LTC residents require full-spectrum vitamin and mineral supplements.