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.

Appetite, food intake, and gut hormone responses to glycomacropeptide protein ingestion in older adults: A feasibility, acceptability, and pilot study.

Glycomacropeptide (GMP) has a unique amino acid profile which may make less satiating than other dietary proteins. This study assessed the feasibility and likely acceptability of a leucine-enriched GMP drink and determined appetite response in older adults (OA). Thirteen OA (11f; 70 ± 4 years) were recruited for sensory assessments of a leucine-enriched GMP drink when mixed with water and with fruit smoothie, compared with whey protein isolate (WHEY). Participants also partook in a single focus group exploring acceptability to protein and supplementation. Separately, a counterbalanced, double-blind study with twelve OA (8f; 69 ± 3 years) was conducted to determine appetite and gut hormone responses. Fasting subjective appetite was recorded using visual analogue scales and a fasted venous blood sample was collected (to measures acyl-ghrelin, PYY, GLP-1, and CCK) before participants consumed either: GMP protein (27g + 3g leucine, 350 mL water), WHEY (30g, 350 mL water), or water. Participants rested for 240 min, with appetite measures and blood sampling throughout. An ad libitum pasta-based meal was then consumed. Sensory testing revealed low pleasantness rating for GMP in water vs. WHEY (16 ± 14 vs 31 ± 24, p = 0.016). GMP addition to smoothie reduced pleasantness (26 ± 21 vs. 61 ± 29, p = 0.009) and worsened the aroma (46 ± 15 vs. 69 ± 28, p = 0.014). The focus group revealed uncertainty of protein needs and a scepticism of supplements, with preference for food. Gut hormone response did not differ between GMP and WHEY (nAUC for all gut hormones p > 0.05). There was no difference between conditions for lunch ad libitum intake (549 ± 171 kcal, 512 ± 238 kcal, 460 ± 199 kcal for GMP, WHEY, and water, p = 0.175), or for subjective appetite response. Leucine-enriched GMP was not less satiating than WHEY, and low palatability and scepticism of supplements question the likely acceptability of GMP supplementation. Providing trusted nutritional advice and food enrichment/fortification may be preferred strategies for increasing protein intake in OA.

Augmented gut hormone response to feeding in older adults exhibiting low appetite.

Age-related changes in gut hormones may play a role in anorexia of ageing. The aim of this study was to determine concentrations of ghrelin, PYY, and GLP-1 in older adults exhibiting an anorexia of ageing phenotype. Thirteen older adults with healthy appetite (OA-HA; 8f, 75 ± 7 years, 26.0 ± 3.2 kg m-2), fifteen older adults with low appetite (OA-LA; 10f, 72 ± 7 years, 23.6 ± 3.1 kg m-2), and twelve young adults (YA; 6f, 22 ± 2 years, 24.4 ± 2.0 kg m-2) completed the study. Healthy appetite and low appetite were determined based on BMI, habitual energy intake, self-reported appetite, and laboratory-assessed ad libitum lunch intake. Participants provided a fasted measure of subjective appetite and blood sample (0 min) before consuming a standardised breakfast (450 kcal). Appetite was measured and blood samples were drawn throughout a 240-min rest period. At 240 min, an ad libitum lunch meal was consumed. Relative intake at lunch (expressed as percentage of estimated total energy requirement) was lower for OA-LA (19.8 ± 7.7%) than YA (41.5 ± 9.2%, p < 0.001) and OA-HA (37.3 ± 10.0%, p < 0.001). Ghrelin suppression was greater for OA-LA (net AUC, -78719 ± 74788 pg mL-1·240min-1) than both YA (-23899 ± 27733 pg mL-1·240min-1, p = 0.016) and OA-HA (-21144 ± 31161 pg mL-1·240min-1, p = 0.009). There were trends for higher GLP-1 concentrations in OA-LA compared with YA at 90 min (8.85 ± 10.4 pM vs. 1.88 ± 4.63 pM, p = 0.073) and 180 min (5.00 ± 4.71 pM vs. 1.07 ± 2.83 pM, p = 0.065). There was a trend for a greater PYY response for OA-LA compared with OA-HA (net AUC p = 0.062). "Anorexigenic response score" - a composite score of gut hormone responses to feeding - showed greater anorexigenic response in OA-LA, compared with YA and OA-HA. No differences were seen in subjective appetite. These observations suggest augmented anorexigenic responses of gut hormones to feeding may be causal mechanisms of anorexia of ageing.

Poor Appetite in Frail Older Persons-A Systematic Review.

Anorexia of aging is a common problem in older adults. Depending on the setting, its prevalence varies from about 10% (among community-dwelling older adults) to over 30% in acute wards and nursing homes. The objective of this systematic review was to establish the prevalence of poor appetite in frail persons ≥60 years of age. We performed a literature search for studies where the prevalence of anorexia of aging among frail and pre-frail old adults was reported. 957 articles on this topic were identified. After eligibility assessment, three articles were included in the review. The studies included 4657 community-dwelling older adults. The weighted total prevalence of anorexia of aging in all the included studies was 11.3%. Among frail and pre-frail participants, loss of appetite was reported in 20.5% (weighted estimate). Overall, robust status was associated with a 63% lower probability of concomitant anorexia of ageing (OR 0.37, 95%CI 0.21-0.65, p = 0.0005). Frailty or risk of frailty are associated with more prevalent anorexia of ageing. This has potential practical implications; however, more research, especially to elucidate the direction of the relation, is needed.

Clinical approach to the older person with anorexia.

OBJECTIVE: Anorexia is a challenging problem among older people. Apart from being the consequence of normal ageing, it can also be a symptom of underlying disease. Despite the high prevalence of anorexia, only few recommendations exist on the evaluation in older people. The objective of this study is to summarize evidence and provide guidance through creating a flowchart. METHODS: A systematic literature search was performed through combining following keywords: older people (aged, geriatrics, older adult), anorexia (also loss of appetite, unintentional weight loss) and diagnosis. After removal of duplicates and case-reports, articles were selected based on title and abstract by two reviewers. Guidelines, reviews, studies and relevant publications discussing anorexia or unintentional weight loss were included. Relevant data were extracted and processed into a flowchart. RESULTS: Out of 619 hits, 25 articles were included discussing either the evaluation of anorexia or unintentional weight loss. Consensus in the work-up of unintentional weight loss is to start with a detailed history and physical examination followed by full bloodwork, urinalysis, chest x-ray and a faecal occult blood test. In certain cases, ultrasound and upper endoscopy are further recommended. In the work-up of anorexia, medication, social, psychological, logopaedic and neurocognitive aspects need to be taken into consideration. CONCLUSIONS: One of the main challenges of the evaluation of anorexia in older people is the lack of guidance in existing literature. Therefore, we investigated what is currently known about the management of anorexia and unintentional weight loss as well and combined best practices to form a flowchart.

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.

Implicit satiety goals and food-related expectations predict portion size in older adults: Findings from the BAMMBE cohort.

Portion size selection is an indicator of appetite and within younger adults, is predicted by factors such as expected satiety, liking and motivations to achieve an ideal sensation of fullness (i.e., implicit satiety goals). Currently, there is limited research available on the determinants of portion size selection within older adults. Therefore, the current study aimed to examine the relationship between individual differences in implicit satiety goals, food-related expectations, and portion size selection in older adults. Free-living older adult Singaporeans (N = 115; Nmales = 62; age: M = 66.21 years, SD = 4.78, range = 60-83 years) participated as part of the Brain, Ageing, Microbiome, Muscle, Bone, and Exercise Study (BAMMBE). Participants completed questionnaires on their subjective requirements for experiencing different states of satiety and food-related expectations (i.e., liking, how filling) as well as a computerised portion size selection task. Using a multiple regression, we found that goals to feel comfortably full (B = 3.08, SE = 1.04, t = 2.96, p = .004) and to stop hunger (B = -2.25, SE = 0.82, t = -2.75, p = .007) significantly predicted larger portion size selection (R2 = 0.24, F(4,87) = 6.74, p < .001). Larger portion sizes (R2 = 0.53, F(5,90) = 20.58, p < .001) were also predicted by greater expected satiety (B = 0.47, SE = 0.09, t = 5.15, p < .001) and lower perceptions of how filling foods are (B = -2.92, SE = 0.77, t = -3.79, p < .001) but not liking (B = -0.09, SE = 0.91, t = -0.10, p = .925) or frequency (B = -18.42, SE = 16.91, t = -1.09, p = .279) of consumption of target foods. Comparing our findings to results of studies conducted with younger adults suggests the influence of factors such as satiety related goals on portion size selection may change with ageing while the influence of other factors (e.g., expected satiety/fullness delivered by foods) may remain consistent. These findings may inform future strategies to increase/decrease portion size accordingly to ensure older adults maintain an appropriate healthy weight.

Association between anorexia of ageing and sarcopenia among Japanese older adults.

BACKGROUND: Malnutrition plays an essential role in the mechanism of pathogenesis for sarcopenia. In late life, both food consumption and energy intakes decline. One of key factors for reduced energy intakes is anorexia of ageing. The aim of this study is to examine the association between anorexia of ageing and sarcopenia among community-dwelling elderly Japanese individuals. METHODS: This uses population-based, cross-sectional cohort study of elderly Japanese individuals. Anorexia of ageing was assessed via a simplified nutritional appetite questionnaire. Handgrip strength and walking speed were tested, and skeletal muscle mass was assessed using a bio-impedance analysis device. Subjects with sarcopenia were defined as those who met the criteria of the Asian Working Group for Sarcopenia. The association between anorexia of ageing and sarcopenia was then analysed via multiple regression analysis. RESULTS: In total, 9,496 elderly Japanese individuals were evaluated (mean age 74.1 ± 5.4 years; male, 47.0%). The prevalence of anorexia of ageing was 9.8% (n = 927) in the present study. The prevalence of sarcopenia in men was 1.1%, 1.8%, 6.1%, 10.1%, and 21.2% and was 1.6%, 3.3%, 3.6%, 4.8%, and 7.4% in women aged 65-69, 70-74, 75-79, 80-84, and 85 years and older, respectively. The prevalence of anorexia also showed an age-dependent increase in both sexes (P < 0.001, respectively). The prevalence of anorexia in men was 8.3%, 6.3%, 9.8%, 13.6%, and 12.9% and was 7.9%, 9.4%, 10.5%, 17.6%, and 17.1% in women aged 65-69, 70-74, 75-79, 80-84, and 85 years and older, respectively. In multivariable logistic regression model adjusted for the covariates except for albumin, anorexia of ageing was independently associated with sarcopenia (OR: 1.45, 95% CI: 1.07 to 1.95; P = 0.015). This significant association remained even after adjusting for all covariates including nutritional status (OR: 1.42, 95% CI: 1.06 to 1.92, P = 0.020). CONCLUSIONS: Anorexia of ageing is associated with sarcopenia among Japanese elderly individuals. Further studies are needed to determine whether a causal association exists between anorexia and sarcopenia.

Differences in circulating appetite-related hormone concentrations between younger and older adults: a systematic review and meta-analysis.

Ageing is associated with reduced appetite and energy intakes. However, the mechanisms underlying this phenomenon are not fully understood. This systematic review and meta-analysis quantified differences in circulating concentrations of appetite-related hormones between healthy older and younger adults. Six databases were searched through 12th June 2018 for studies that compared appetite-related hormone concentrations between older and younger adults. Data were pooled using random-effects meta-analysis and are presented as standardised mean difference (Hedges' g) with 95% confidence intervals (95% CI). Thirty-five studies were included involving 710 older adults (mean ± SD; age: 73 ± 5 years) and 713 younger adults (age: 28 ± 7 years). Compared with younger adults, older adults exhibited higher fasted and postprandial concentrations of the anorectic hormones cholecystokinin (Fasted: SMD 0.41 (95% CI 0.24, 0.57); p < 0.001. Postprandial: SMD 0.41 (0.20, 0.62); p < 0.001), leptin [Fasted: SMD 1.23 (0.15, 2.30); p = 0.025. Postprandial: SMD 0.62 (0.23, 1.01); p = 0.002] and insulin [Fasted: SMD 0.24 (- 0.02, 0.50); p = 0.073. Postprandial: SMD 0.16 (0.01, 0.32); p = 0.043]. Higher postprandial concentrations of peptide-YY were also observed in older adults compared with younger adults [SMD 0.31 (- 0.03, 0.65); p = 0.075]. Compared with younger adults, older adults had lower energy intakes [SMD - 0.98 (- 1.74, - 0.22); p = 0.011], and lower hunger perceptions in the fasted [SMD - 1.00 (- 1.54, - 0.46); p < 0.001] and postprandial states [SMD - 0.31, (- 0.64, 0.02); p = 0.064]. Higher circulating concentrations of insulin, leptin, cholecystokinin and peptide-YY accord with reduced appetite and energy intakes in healthy older adults. Interventions to reduce circulating levels of these hormones may be beneficial for combatting the anorexia of ageing.

Gastrointestinal Sensing of Meal-Related Signals in Humans, and Dysregulations in Eating-Related Disorders.

The upper gastrointestinal (GI) tract plays a critical role in sensing the arrival of a meal, including its volume as well as nutrient and non-nutrient contents. The presence of the meal in the stomach generates a mechanical distension signal, and, as gastric emptying progresses, nutrients increasingly interact with receptors on enteroendocrine cells, triggering the release of gut hormones, with lipid and protein being particularly potent. Collectively, these signals are transmitted to the brain to regulate appetite and energy intake, or in a feedback loop relayed back to the upper GI tract to further adjust GI functions, including gastric emptying. The research in this area to date has provided important insights into how sensing of intraluminal meal-related stimuli acutely regulates appetite and energy intake in humans. However, disturbances in the detection of these stimuli have been described in a number of eating-related disorders. This paper will review the GI sensing of meal-related stimuli and the relationship with appetite and energy intake, and examine changes in GI responses to luminal stimuli in obesity, functional dyspepsia and anorexia of ageing, as examples of eating-related disorders. A much better understanding of the mechanisms underlying these dysregulations is still required to assist in the development of effective management and treatment strategies in the future.

Are the therapeutic strategies in anorexia of ageing effective on nutritional status? A systematic review with meta-analysis.

BACKGROUND: Anorexia of ageing (AA) may be considered as a risk factor for frailty and has an important impact on quality of life, morbidity and mortality. METHODS: A systematic review and a meta-analysis were performed to summarise the results from several trials on the effectiveness of treatments in AA, as associated with depression, sensory impairment of taste and smell, decreased appetite or early satiety, and disability. Eligible studies were required to report baseline and follow-up values, the mean change (∆-change) from baseline, and/or the mean difference among intervention groups versus control group, concerning food intake (kcal/daily) and/or nutritional outcomes, such as body weight, body mass index, albumin and Mini Nutritional Assessment. RESULTS: The systematic review included 20 papers based on different therapeutic approaches concerning food intake and/or nutritional outcomes. The results of the meta-analysis indicate that the interventions for AA have an important impact on body weight [+1.59 kg; 95% confidence interval (CI) = 1.48-+1.71 kg; P < 0.001) and on energy intake (+56.09 kcal; 95% CI = -54.05 to +166.25 kcal; P = 0.32). Regarding secondary outcomes, it was not possible to meta-analyse the limited amount of data availab le. CONCLUSIONS: The different variants of AA need to be defined because diverse therapeutic approaches are available. A more precise definition of the functional impairments associated with AA may allow a more correct decision about the most appropriate therapy to be prescribed. Moreover, this may allow for a more effective performance of the different therapeutic approaches once they are better targeted to the different scenarios of AA.

Aging-related anorexia and its association with disability and frailty.

BACKGROUND: Anorexia of ageing may be a precursor to various geriatric syndromes. We elucidated whether anorexia of ageing had a significant impact on incident disability and investigated whether anorexia of ageing had a direct association with future disability or an indirect association with disability via frailty. METHODS: This study employed an observational, longitudinal, cohort design in a community setting. Participants were 4393 older adults (75.9 ± 4.3 years). Anorexia of ageing was assessed by a simplified nutritional appetite questionnaire. Frailty was operationalized as slowness, weakness, exhaustion, low physical activity, and weight loss. Participants who had none of these characteristics were considered robust, those with one or two characteristics were considered pre-frail, and those with three or more characteristics were considered frail. We examined sociodemographic variables (age, sex, and education), medical history (medication and chronic disease history), lifestyle factors (smoking and drinking habits and living arrangement), body mass index, blood nutrition data, depressive symptoms, physical functioning, and cognitive functioning. RESULTS: The prevalence of anorexia of ageing was 10.7% (n = 468). The proportion of physical frailty, pre-frailty, and robustness were 8.4, 52.0, and 39.6%, respectively, in the without anorexia of ageing group, and 20.3, 57.7, and 22.0%, respectively, in the anorexia of ageing group (P < 0.001). During a 2-year follow-up, the prevalence proportion of disability was 5.6% in the without anorexia of ageing group and 10.7% in the anorexia of ageing group (P < 0.001). Adjusted for covariates (except for frailty status), the participants with anorexia of ageing had an independently associated higher risk of incident disability compared with those without anorexia of ageing (hazard ratio: 1.43, 95% confidence interval: 1.04-1.95, P = 0.03). However, adjusted for covariates (including frailty status), anorexia of ageing was not significantly associated with incident disability (P = 0.09). Structural equation models revealed that anorexia of ageing had no direct effect on disability; however, anorexia of ageing was associated with frailty. CONCLUSIONS: Older adults with anorexia of ageing had a higher proportion of frailty and a higher prevalence proportion of disability compared with those without anorexia of ageing. Although anorexia of ageing may not have a direct effect on incident disability, the structural equation model suggests an indirect relationship between anorexia of ageing and incident disability via frailty status.