ESPEN guideline on nutrition and hydration in dementia - Update 2024.

BACKGROUND & AIMS: Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes. METHODS: The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process. RESULTS: 40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points. CONCLUSION: Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Swedish translation and cultural adaptation of the scored Patient-Generated Subjective Global Assessment (PG-SGA©)-A validated tool for screening and assessing malnutrition in clinical practice and research.

INTRODUCTION: The scored Patient-Generated Subjective Global Assessment (PG-SGA©) is a validated tool for the screening, assessment and monitoring of malnutrition, and triaging of interventions. It contains a patient-generated component and a healthcare professional (HCP)-generated component. AIM: To translate the PG-SGA into Swedish, assess the linguistic and content validity of the Swedish version, and ensure conceptional, semantic and operational equivalence to the original English PG-SGA. METHODS: In line with the methodology used in previously translated and culturally adapted versions, the standardised 10-step process suggested by the International Society for Health Economics and Outcomes Research (ISPOR) was followed. In step 7, a cross-sectional study targeting patients n = 51 and HCPs n = 52 was performed at a university hospital in Sweden. Using separate questionnaires, patients assessed the patient component and HCPs, the professional component regarding perceived comprehensibility and difficulty (linguistic validity). The HCPs also assessed perceived relevance (content validity) of all items on the PG-SGA. Item indices for comprehensibility (I-CI), difficulty (I-DI) and content validity (I-CVI) were calculated and averaged into scale indices (S-CI, S-DI and S-CVI). Cut-off standards for item and scale indices were used as reference. RESULTS: The Swedish version of the PG-SGA rated excellent for comprehensibility (S-CI 0.96) and difficulty (S-DI 0.93) for the patient component. The professional component rated acceptable for comprehensibility (S-CI 0.89) and below acceptable for difficulty (S-DI 0.70), with the physical examination rated most difficult (I-DI 0.39 to 0.69). Content validity for the full Swedish PG-SGA was rated excellent (S-CVI 0.94). CONCLUSION: The patient component was considered clear and easy to complete. The full Swedish PG-SGA was considered relevant by HCPs for screening and assessment of malnutrition. Due to perceived difficulty with the physical examination, training of Swedish HCPs in using the PG-SGA is essential before implementing the professional component into clinical practice or research.

Global Leadership Initiative on Malnutrition (GLIM) for the diagnosis of malnutrition - a framework for consistent dietetic practice.

Malnutrition is an alarming and ongoing healthcare problem globally. Malnutrition has a negative impact on the individual patient, leading to poorer clinical outcomes and increased mortality, but also poses an economic burden on society. Proper identification and diagnostics are prerequisites for initiation of treatment. In 2019, the Global Leadership Initiative on Malnutrition, a consensus-based global framework to uniformly diagnose malnutrition across populations, healthcare settings, and countries was published. Identifying and treating malnutrition is an interdisciplinary team effort. Nonetheless, the nutrition and dietetics profession is specifically trained for diagnosing and treating nutrition(-related) conditions, and therefore has a key role in the interdisciplinary team in implementing the GLIM framework in clinical practice. For the nutrition and dietetics profession, GLIM offers a great opportunity for moving both the scientific and clinical knowledge of malnutrition management forward. While the GLIM framework has been extensively studied since its launch, various knowledge gaps still remain. For the nutrition and dietetics profession, these knowledge gaps mainly relate to the GLIM implementation process, to the role of GLIM in relation to the nutrition care process, and to treatment strategies for various nutrition-related conditions. In this opinion paper, we aimed to describe the rationale for implementing the GLIM framework in clinical dietetic practice, and propose a research agenda based on knowledge gaps regarding GLIM in relation to nutrition care from a dietetic point of view.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND & AIMS: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation in support of the etiologic criterion for inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified-Delphi review. A multi-round review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable with 99 % overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (mg/dL or mg/L) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgement based upon underlying diagnosis or condition, clinical signs, or CRP.

Guidance for assessment of the inflammation etiologic criterion for the GLIM diagnosis of malnutrition: A modified Delphi approach.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) approach to malnutrition diagnosis is based on assessment of three phenotypic (weight loss, low body mass index, and reduced skeletal muscle mass) and two etiologic (reduced food intake/assimilation and disease burden/inflammation) criteria, with diagnosis confirmed by fulfillment of any combination of at least one phenotypic and at least one etiologic criterion. The original GLIM description provided limited guidance regarding assessment of inflammation, and this has been a factor impeding further implementation of the GLIM criteria. We now seek to provide practical guidance for assessment of inflammation. METHODS: A GLIM-constituted working group with 36 participants developed consensus-based guidance through a modified Delphi review. A multiround review and revision process served to develop seven guidance statements. RESULTS: The final round of review was highly favorable, with 99% overall "agree" or "strongly agree" responses. The presence of acute or chronic disease, infection, or injury that is usually associated with inflammatory activity may be used to fulfill the GLIM disease burden/inflammation criterion, without the need for laboratory confirmation. However, we recommend that recognition of underlying medical conditions commonly associated with inflammation be supported by C-reactive protein (CRP) measurements when the contribution of inflammatory components is uncertain. Interpretation of CRP requires that consideration be given to the method, reference values, and units (milligrams per deciliter or milligram per liter) for the clinical laboratory that is being used. CONCLUSION: Confirmation of inflammation should be guided by clinical judgment based on underlying diagnosis or condition, clinical signs, or CRP.

Does mandibular bone structure predict subsequent height loss? A longitudinal cohort study of women in Gothenburg, Sweden.

BACKGROUND: Several risk factors for loss of height with increasing age have been identified. OBJECTIVE: To investigate if mandibular bone structure predicts future height loss in middle-aged and elderly Swedish women. DESIGN: Prospective cohort study with longitudinally measured heights, radiographical assessments of the cortical bone using Klemetti's Index (normal, moderate or severely eroded cortex) and classification of the trabecular bone using an index proposed by Lindh et al (sparse, mixed or dense trabeculation). No intervention was performed. SETTING: Gothenburg, Sweden. PARTICIPANTS: A population-based sample of 937 Swedish women born in 1914, 1922 and 1930 was recruited. At the baseline examination, the ages were 38, 46 and 54 years. All had undergone a dental examination with panoramic radiographs of the mandible, and a general examination including height measurements on at least two occasions. MAIN OUTCOME MEASURE: Height loss was calculated over three periods 12-13 years (1968-1980, 1980-1992, 1992-2005). MAIN RESULTS: Mean annual height loss measures were 0.075 cm/year, 0.08 cm/year and 0.18 cm/year over the three observation intervals, corresponding to absolute decreases of 0.9 cm, 1.0 cm and 2.4 cm. Cortical erosion in 1968, 1980 and 1992 significantly predicted height loss 12 years later. Sparse trabeculation in 1968, 1980 and 1992 also predicted significant shrinkage over 12 or 13 years. Multivariable regression analyses adjusting for baseline covariates such as height, birth year, physical activity, smoking, body mass index and education yielded consistent findings except for cortical erosion 1968-1980. CONCLUSION: Mandibular bone structure characteristics such as severe cortical erosion and sparse trabeculation may serve as early risk factors for height loss. Since most individuals visit their dentist at least every 2 years and radiographs are taken, a collaboration between dentists and physicians may open opportunities for predicting future risk of height loss.

Disease-related malnutrition with inflammation and cachexia.

In 2010, the definition of cachexia was jointly developed by the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Groups (SIG) "Cachexia-anorexia in chronic wasting diseases" and "Nutrition in geriatrics". Cachexia was considered as a synonym of disease-related malnutrition (DRM) with inflammation by the ESPEN guidelines on definitions and terminology of clinical nutrition. Starting from these concepts and taking into account the available evidence the SIG "Cachexia-anorexia in chronic wasting diseases" conducted several meetings throughout 2020-2022 to discuss the similarities and differences between cachexia and DRM, the role of inflammation in DRM, and how it can be assessed. Moreover, in line with the Global Leadership Initiative on Malnutrition (GLIM) framework, in the future the SIG proposes to develop a prediction score to quantify the individual and combined effect(s) of multiple muscle and fat catabolic mechanisms, reduced food intake or assimilation and inflammation, which variably contribute to the cachectic/malnourished phenotype. This DRM/cachexia risk prediction score could consider the factors related to the direct mechanisms of muscle catabolism separately from those related to the reduction of nutrient intake and assimilation. Novel perspectives in the field of DRM with inflammation and cachexia were identified and described in the report.

Associations between dietary patterns and dementia-related neuroimaging markers.

BACKGROUND: The exploration of associations between dietary patterns and dementia-related neuroimaging markers can provide insights on food combinations that may impact brain integrity. METHODS: Data were derived from the Swedish Gothenburg H70 Birth Cohort Study (n = 610). Three dietary patterns were obtained using principal component analysis. Magnetic resonance imaging markers included cortical thickness, an Alzheimer's disease (AD) signature score, small vessel disease, and white matter microstructural integrity. Adjusted linear/ordinal regression analyses were performed. RESULTS: A high-protein and alcohol dietary pattern was negatively associated with cortical thickness in the whole brain (Beta: -0.011; 95% confidence interval [CI]: -0.018 to -0.003), and with an Alzheimer's disease cortical thickness signature score (Beta: -0.013; 95% CI: -0.024 to -0.001). A positive association was found between a Mediterranean-like dietary pattern and white matter microstructural integrity (Beta: 0.078; 95% CI: 0.002-0.154). No associations were found with a Western-like dietary pattern. DISCUSSION: Dietary patterns may impact brain integrity through neurodegenerative and vascular pathways. HIGHLIGHTS: Certain dietary patterns were associated with dementia-related neuroimaging markers. A Mediterranean dietary pattern was positively associated with white matter microstructure. A high-protein and alcohol pattern was negatively associated with cortical thickness.

Chewing and its influence on swallowing, gastrointestinal and nutrition-related factors: a systematic review.

The study aimed to evaluate the hypothesis that chewing is a mechanical and physiological contributor to swallowing, physiologic/pathologic processes of the gastrointestinal tract (GIT), and nutrition-related factors. A search strategy was applied to three different databases to investigate if chewing function in adults affects the swallowing, physiologic/pathologic processes of the GIT, and nutrition-related factors compared to controls with no exposure. The included studies were evaluated for methodological quality and risk of bias and certainty of evidence. The results showed 71 eligible studies. Overall, the results showed that 46 studies supported the hypothesis while 25 refuted it. However, the GRADE analysis showed low to very low certainty of the evidence to support the hypothesis that chewing is an important contributor in the swallowing process, and physiologic/pathologic processes in the GIT. The GRADE analysis also showed a moderate to very low certainty of the evidence to suggest that chewing function contributes to nutrition-related parameters. The overall results of the current study showed that a majority (64.7%) of the studies (46 out of 71) supported the hypothesis. However, robust studies with proper design, adequate sample size, and well-defined outcome parameters are needed to establish conclusive evidence.

Perceptions and Attitudes about Eating with the Fingers-An Explorative Study among Older Adults with Motoric Eating Difficulties, Relatives and Professional Caregivers.

Difficulties of managing cutlery, manipulating food on the plate and transporting food to the mouth may negatively influence the ability for self-provision and nutritional status among older adults with motoric eating difficulties. The purpose was to explore perceptions and attitudes about eating with the fingers among older adults with motoric eating difficulties, and relatives and professional caregivers of older adults with motoric eating difficulties. Qualitative data was collected through individual interviews with older adults >65 years (N = 14) with motoric eating difficulties and focus groups with relatives (N = 15) and professional caregivers (N = 15). Data was analyzed using deductive and inductive content analysis. Although the older adults had normative ideas about proper eating and culinary rules, they regularly consumed several foods with their fingers without previously reflecting upon this. Using bread to grip or wrap foods and inserting skewers into foods may increase the acceptability of eating with the fingers. However, the importance of the disease causing the eating difficulties, how it was perceived, and its severity were crucial in understanding how eating with the fingers was perceived. Finger foods may be suitable for older adults with major eating difficulties because they have developed a self-acceptance in relation to their condition over time.

Interactions between dietary patterns and genetic factors in relation to incident dementia among 70-year-olds.

PURPOSE: To investigate potential interactions between dietary patterns and genetic factors modulating risk for Alzheimer's disease (AD) in relation to incident dementia. METHODS: Data were derived from the population-based Gothenburg H70 Birth Cohort Studies in Sweden, including 602 dementia-free 70-year-olds (examined 1992-93, or 2000-02; 64% women) followed for incident dementia until 2016. Two factors from a reduced rank regression analysis were translated into dietary patterns, one healthy (e.g., vegetables, fruit, and fish) and one western (e.g., red meat, refined cereals, and full-fat dairy products). Genetic risk was determined by APOE ε4 status and non-APOE AD-polygenic risk scores (AD-PRSs). Gene-diet interactions in relation to incident dementia were analysed with Cox regression models. The interaction p value threshold was < 0.1. RESULTS: There were interactions between the dietary patterns and APOE ε4 status in relation to incident dementia (interaction p value threshold of < 0.1), while no evidence of interactions were found between the dietary patterns and the AD-PRSs. Those with higher adherence to a healthy dietary pattern had a reduced risk of dementia among ε4 non-carriers (HR: 0.77; 95% CI: 0.61; 0.98), but not among ε4 carriers (HR: 0.86; CI: 0.63; 1.18). Those with a higher adherence to the western dietary pattern had an increased risk of dementia among ε4 carriers (HR: 1.37; 95% CI: 1.05; 1.78), while no association was observed among ε4 non-carriers (HR: 0.99; CI: 0.81; 1.21). CONCLUSIONS: The results of this study suggest that there is an interplay between dietary patterns and APOE ε4 status in relation to incident dementia.

Relative Validity of a Short 15-Item Food Frequency Questionnaire Measuring Dietary Quality, by the Diet History Method.

Food frequency questionnaires (FFQ) are commonly used dietary assessment tools. The aim was to assess the relative validity of a 15-item FFQ, designed for the screening of poor dietary patterns with a validated diet history (DH). The study population was derived from the Gothenburg H70 Birth Cohort Studies. The DH registrations were harmonized in accordance with the FFQ frequencies. The agreement was assessed by Cohen's kappa with corresponding confidence intervals (CI) for the frequency and categorical variables. Bland-Altman plots were used for the numeric variables. The study comprised data from 848 individuals (55.2% women). Overall, there was high agreement between the methods, with the exact and adjacent level of agreement over 80% for eight variables. The proportion attributed to the opposite frequency was fairly low for most of the frequency variables. Most of the kappa values were in fair or moderate agreement. The highest kappa values were calculated for the type of cooking fat (k = 0.68, CI = 0.63-0.72) and sandwich spread (k = 0.55, CI = 0.49-0.53), and the lowest for type of bread (0.13, CI = 0.07-0.20) and sweets (0.22 CI = 0.18-0.27). In conclusion, the FFQ showed overall good agreement compared with the DH. We, therefore, think it, with some improvements, could serve as a simple screening tool for poor dietary patterns.

ESPEN guideline on hospital nutrition.

In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.

Comparison of the 2010 and 2019 diagnostic criteria for sarcopenia by the European Working Group on Sarcopenia in Older People (EWGSOP) in two cohorts of Swedish older adults.

BACKGROUND: The operational definition of sarcopenia has been updated (EWGSOP2) and apply different cut-off points compared to previous criteria (EWGSOP1). Therefore, we aim to compare the sarcopenia prevalence and the association with mortality and dependence in activities of daily living using the 2010 (EWGSOP1 and 2019 (EWGSOP2 operational definition, applying cut-offs at two levels using T-scores. METHODS: Two birth cohorts, 70 and 85-years-old (n = 884 and n = 157, respectively), were assessed cross-sectionally (57% women). Low grip strength, low muscle mass and slow gait speed were defined below - 2.0 and - 2.5 SD from a young reference population (T-score). Muscle mass was defined as appendicular lean soft tissue index by DXA. The EWGSOP1 and EWGSOP2 were applied and compared with McNemar tests and Cohen's kappa. All-cause mortality was analyzed with the Cox-proportional hazard model. RESULTS: Sarcopenia prevalence was 1.4-7.8% in 70-year-olds and 42-62% in 85 years-old's, depending on diagnostic criteria. Overall, the prevalence of sarcopenia was 0.9-1.0 percentage points lower using the EWGSOP2 compared to EWGSOP1 when applying uniform T-score cut-offs (P <  0.005). The prevalence was doubled (15.0 vs. 7.5%) using the - 2.0 vs. -2.5 T-scores with EWGSOP2 in the whole sample. The increase in prevalence when changing the cut-offs was 5.7% (P <  0.001) in the 70-year-olds and 17.8% (P <  0.001) in the 85-year-olds (EWGSP2). Sarcopenia with cut-offs at - 2.5 T-score was associated with increased mortality (hazard ratio 2.4-2.8, P <  0.05) but not at T-score - 2.0. CONCLUSIONS: The prevalence of sarcopenia was higher in 85-year-olds compared to 70-year-olds. Overall, the differences between the EWGSOP1 and EWGSOP2 classifications are small. Meaningful differences between EWGSOP1 and 2 in the 85-year-olds could not be ruled out. Prevalence was more dependent on cut-offs than on the operational definition.

A Western-style dietary pattern is associated with cerebrospinal fluid biomarker levels for preclinical Alzheimer's disease-A population-based cross-sectional study among 70-year-olds.

BACKGROUND: Diet may be a modifiable factor for reducing the risk of Alzheimer's disease (AD). Western-style dietary patterns are considered to increase the risk, whereas Mediterranean-style dietary patterns are considered to reduce the risk. An association between diet and AD-related biomarkers have been suggested, but studies are limited. AIM: To investigate potential relations between dietary patterns and cerebrospinal fluid (CSF) biomarkers for AD among dementia-free older adults. METHODS: Data were derived from the population-based Gothenburg H70 Birth Cohort Studies, Sweden. A total of 269 dementia-free 70-year-olds with dietary and cerebrospinal fluid (CSF) amyloid beta (Aß42 and Aß40), total tau (t-tau), and phosphorylated tau (p-tau) data were investigated. Dietary intake was determined by the diet history method, and four dietary patterns were derived by principal component analysis. A Western dietary pattern, a Mediterranean/prudent dietary pattern, a high-protein and alcohol pattern, and a high-total and saturated fat pattern. Logistic regression models, with CSF biomarker pathology (yes/no) as dependent variables, and linear regression models with continuous CSF biomarker levels as dependent variables were performed. The analyses were adjusted for sex, energy intake, body mass index (BMI), educational level, and physical activity level. RESULTS: The odds ratio for having total tau pathology (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.02 to 2.01) and preclinical AD (Aß42 and tau pathology; OR 1.79; 95% CI 1.03 to 3.10) was higher among those with a higher adherence to a Western dietary pattern. There were no other associations between the dietary patterns and CSF biomarkers that remained significant in both unadjusted and adjusted models. DISCUSSION: Our findings suggest that higher adherence to a Western dietary pattern may be associated with pathological levels of AD biomarkers in the preclinical phase of AD. These findings can be added to the increasing amount of evidence linking diet with AD and may be useful for future intervention studies investigating dietary intake in relation to AD.

Coronavirus Disease 19 from the Perspective of Ageing with Focus on Nutritional Status and Nutrition Management-A Narrative Review.

The novel severe acute respiratory syndrome coronavirus (COVID-19) has hit older adults harder due to a combination of age-related immunological and metabolic alterations. The aim of this review was to analyze the COVID-19 literature with respect to nutritional status and nutrition management in older adults. No studies only on people aged 65+ years were found, and documentation on those 80+ was rare. Age was found to be strongly associated with worse outcomes, and with poor nutritional status. Prevalence of malnutrition was high among severely and critically ill patients. The studies found a need for nutrition screening and management, and for nutrition support as part of follow-up after a hospital stay. Most tested screening tools showed high sensitivity in identifying nutritional risk, but none were recognized as best for screening older adults with COVID-19. For diagnosing malnutrition, the Global Leadership Initiative on Malnutrition (GLIM) criteria are recommended but were not used in the studies found. Documentation of olfactory and gustatory dysfunction in relation to nutritional status is missing in older adults. Other COVID-19-associated factors with a possible impact on nutritional status are poor appetite and gastrointestinal symptoms. Vitamin D is the nutrient that has attracted the most interest. However, evidence for supplementation of COVID-19 patients is still limited and inconclusive.

Health and Sustainability in Public Meals-An Explorative Review.

The world is facing a number of challenges related to food consumption. These are, on the one hand, health effects and, on the other hand, the environmental impact of food production. Radical changes are needed to achieve a sustainable and healthy food production and consumption. Public and institutional meals play a vital role in promoting health and sustainability, since they are responsible for a significant part of food consumption, as well as their "normative influence" on peoples' food habits. The aim of this paper is to provide an explorative review of the scientific literature, focusing on European research including both concepts of health and sustainability in studies of public meals. Of >3000 papers, 20 were found to satisfy these criteria and were thus included in the review. The results showed that schools and hospitals are the most dominant arenas where both health and sustainability have been addressed. Three different approaches in combining health and sustainability have been found, these are: "Health as embracing sustainability", "Sustainability as embracing health" and "Health and sustainability as separate concepts". However, a clear motivation for addressing both health and sustainability is most often missing.

Time trends in nutrient intake and dietary patterns among five birth cohorts of 70-year-olds examined 1971-2016: results from the Gothenburg H70 birth cohort studies, Sweden.

BACKGROUND: Nutrition is a key factor in healthy ageing but there are still gaps in knowledge about risk- and protective factors linking diet and healthy ageing. The aim of this study was to investigate time trends in dietary patterns and nutrient intake in an older population, in order to increase the understanding of whether dietary recommendations are followed and if nutrient needs are met. METHODS: Cross-sectional data was derived from five samples of 70-year-olds examined 1971-72, 1981-83, 1992-93, 2000-02 and 2014-16 from the Gothenburg H70 birth cohort studies in Sweden. A total of 2246 individuals (56% women) participated. Dietary intake was determined by the diet history method, which is an interview including questions on usual frequencies and portion sizes of food intake during the preceding three months. Recommended values of nutrient intake and determinants of healthful dietary patterns were based on the Nordic Nutrition Recommendations 2012. Statistical analyses were performed using general linear models, student's t-test and chi-square test, stratified by sex. RESULTS: The intake of fruits and vegetables, fish and seafood, whole grain products and nuts and seeds increased during the study period (p < 0.0001), among both sexes. However, there was also an increase in alcohol intake (p < 0.0001), especially from wine and beer, and in 2014-16 more than 30% had an alcohol intake above recommendations. Protein intake increased (p < 0.0001 for women and p = 0.0004 for men), and 48% of the women and 37% of the men had a protein intake above recommended 1.2 g/kg body weight and day in 2014-16. The proportion of participants at risk of inadequate intake of vitamins C, D and folate decreased during the study period, among both sexes (p < 0.0001). However, vitamin D intake from diet was still below average requirement level of 7.5 µg/day for 49% of the women and 32% of the men in 2014-16. CONCLUSIONS: Dietary patterns have changed among 70-year-olds during the past five decades, with an increase in healthful foods and a higher nutrient density in later born birth cohorts. However, the intake of alcohol increased, especially among women. Results from this study can be useful as a basis for dietary guidelines and used for prevention strategies involving older adults in population-based and health care settings.