Malnutrition in the elderly: a growing health crisis needing a multidisciplinary approach

✅ By 2050, people aged 65 and over will double children under 5 and surpass adolescents aged 15 to 24 globally. The WHO has therefore declared healthy aging as one of its priorities for 2016-2030 to improve the functional capacity of the elderly, enabling them to participate in society. Malnutrition is highly prevalent among the elderly and is a major cause of mortality and hospitalization. Why are the elderly particularly vulnerable to malnutrition, and what are the main causes of malnutrition in this age group?

The elderly are a particular population category, they are exposed to numerous risk factors. They usually have one or more pre-existing conditions that can also lead to eating difficulties. For example, tooth loss requires support such as dentures. Then, difficulties in swallowing often arise. Beyond these purely physiological aspects, there is also a social and psychological component: elderly people live alone or in insufficient economic conditions and need assistance because they are no longer autonomous. All these factors increase the risk of malnutrition: cooking alone negatively impacts the habit of cooking, which gradually declines, and the way of eating becomes less healthy. Other risk factors for malnutrition include the progressive loss of muscle mass and the gradual cognitive decline. Thus, there is a physiological decline but also a social one.
 

✅ People over 65 are more prone to having health problems adding up and reinforcing malnutrition phenomena. What are the consequences of malnutrition on the general health of the elderly and how does it affect their recovery from illnesses, injuries, and surgeries?

Malnutrition leads to a reduction in the functioning of the immune system, making the elderly more susceptible to infections. The elderly are more likely to develop the flu and respiratory diseases. This increases the risk of rehospitalization, prolongs the length of hospital stays, and worsens the clinical course due to malnutrition.


✅  We know that malnutrition isn’t only related to the absence of food or neglect in intake. Malnutrition also includes an excess of nutrients or an irregular intake of these: what could be, in your opinion, a definition of malnutrition about both deficiencies and excesses in nutrition? 

Malnutrition means eating poorly and does not refer exclusively to eating less or too much. We have undernutrition, which includes people with a reduced diet and underweight. On the other hand, we also have overnutrition, which is simply overeating and concerns all those who are overweight or obese. There is also malnutrition due to the deficiency of one or more micronutrients necessary for our body. This aspect of malnutrition is more subtle because it is less visible than other forms like undernutrition or overnutrition. Obese or overweight people can therefore be malnourished, rapidly losing weight with muscle mass impairment and the presence of acute or chronic diseases associated with an inflammatory state.


✅  Malnutrition in the elderly is a heavy burden on the healthcare system due to increased complications and associated costs. What is the economic impact of malnutrition on the elderly in Italy?

Based on data presented by the Italian Society for Parenteral and Enteral Nutrition (SINPE), which models the annual economic effects of malnutrition, the cost ranges from an optimistic estimate of 2.5 billion to around 10 billion euros. It is a significant burden for the National Health System. Considering the increasing number of elderly people, the economic burden will grow, if malnutrition is not countered.


✅  Simple caloric support, as a response to weight and muscle tone loss in the elderly, is initially effective but insufficient in the long term. Therefore, it is necessary to address this phenomenon from multiple fronts with innovative tools and methods. In this multidisciplinary context, how can precision nutrition help prevent and treat malnutrition, and what role can personalized nutrition play? 

It is necessary to intervene with a high-energy, high-protein dietary protocol that also considers the nutritional needs of the patient and their conditions. The dietary plan must also be accepted and meet the patient’s needs. They must be easy to prepare, simple, quick, and pleasant dishes to encourage long-term consumption. The equally important goal is that the recipes are sustainable and satisfying for the person, allowing them to realize the benefits of following this dietary plan.


✅  With advancing age, it becomes increasingly difficult to maintain a physical structure and muscle tone that can ensure optimal health. What strategies can be adopted to improve these conditions? Are there recommended dietary protocols that can be applied on a large scale? 

It is important to follow a varied and balanced diet, energetic and with significant protein intake. Fluid intake shouldn’t be underestimated. We often only consider the intake provided by food in the diet, but water also plays a fundamental role. The summer period is problematic for the elderly because they drink little, often forgetting. Every year there are hospitalizations and sometimes deaths due to dehydration. WHO recommends aerobic and anaerobic physical activity for proper muscle tone maintenance. Walking and swimming, where possible, as well as gentle gymnastics to keep muscles active. It will prevent falls improving balance maintenance.


✅ You mentioned an increase in protein intake. Why is there such a need for protein in the elderly compared to a young person?

Our body goes through different phases throughout life. A newborn, needs nutrients gradually introduced, allowing the body to adapt to assimilation. Similarly, in a young body, the organism maintains a balance in nutrient intake. However, as the body ages, it faces significant changes and finds it more difficult to assimilate specific macromolecules, including proteins. This difficulty in assimilating substances like proteins can also depend on alterations in the gut microbiota.
 

✅ Since you mentioned the gut microbiota, our intestines have a rich biodiversity that plays a fundamental role in digestion and food assimilation. How can research on the gut microbiota and new functional foods improve the nutritional health of the elderly?

For many years, the microbiota has been referred to as the intestinal flora, and it has been widely discussed recently, becoming very popular. In the elderly, the microbiota balance varies compared to a young person. In the intestines of a young person, there is a balance between anti-inflammatory and pro-inflammatory bacteria. With increasing age, however, anti-inflammatory bacteria decrease. For example, the well-known Lactobacillus, often mentioned in yogurt commercials, decreases in favor of pro-inflammatory ones like Clostridia. This alteration can have repercussions for the elderly at the tissue level. That’s because these bacteria produce metabolites capable of altering extraintestinal action, thus promoting the development of metabolic, neurodegenerative, and cardiovascular diseases. Therefore, it is important to research to enhance the effect of bioactive molecules like prebiotics and probiotics, improving the action of the microbiota and the balance between microorganisms in the intestines of malnourished elderly people.

✅ The situation in Italy is not rosy regarding the nutritional health of the elderly. We are among the countries with the highest average age and have a much higher prevalence of at-risk individuals in this age group. We are talking about approximately 11% of malnourished individuals compared to much less striking values in other European countries. How is the SENIOR project of Spoke 6 trying to address these challenges and what results do you expect to achieve?

SENIOR helps researchers and healthcare system operators understand the prevalence of malnutrition in the elderly. It also delves into the factors impacting the onset of malnutrition in this target population. The SENIOR project aims to develop a personalized and sustainable nutritional protocol that is safe, easy to implement, and can be incorporated into hospital clinical practice. The target is patients discharged from healthcare facilities due to certain conditions and patients accessing outpatient clinics. The results will provide updated data to policymakers and healthcare professionals to combat malnutrition in hospitalized and non-hospitalized elderly patients.


✅  What analyses and studies are the SENIOR project conducting to obtain more precise data and understand what concrete actions to pursue regarding the health of malnourished or at-risk elderly individuals? How is it collaborating with other institutions and partners to develop and implement sustainable dietary models? 

Recruitment of elderly subjects in the hospital, at the Maugeri Foundation in Pavia, and the San Matteo Polyclinic, has been underway for some time. Several systematic literature reviews on dietary interventions to treat malnutrition in these subjects and on products available on the market in Italy to combat malnutrition in the elderly are being conducted. I am conducting a literature review on the action of inflammatory cytokines in the elderly. The inflammatory state in these subjects is of fundamental importance. The SENIOR project also collaborates with researchers from the University of Milan Bicocca to create a specific product to combat malnutrition. Also, engineers from the University of Pavia are developing an app targeted at malnourished elderly individuals, and CREA is analyzing the environmental impact of dietary protocols. In addition, we are training activities for health professionals and dissemination activities aimed at the general population. We are also creating a Biobank to conduct further analyses on the blood samples of subjects recruited in the study.


✅ Speaking of cytokines, we know there is an information gap on the complete functioning of these protein-based molecules on inflammation and how it affects malnutrition. Are there any updates on this? 

Cytokines are small pro-inflammatory molecules. They are produced depending on the presence or absence of an inflammatory process. In this case, there is a balance between pro-inflammatory and anti-inflammatory cytokines. This balance in the elderly shifts towards a pro-inflammatory profile. This phenomenon, called inflammaging, is related to a widespread onset of diseases and illnesses typical of this age group. Although inflammaging and cytokines have been known for decades, the introduction of the omics sciences has provided more precise knowledge on gene regulation and expression. The transcriptome and proteome provide fundamental data on how cytokine expression is regulated. In this sense, using new molecular biology techniques to integrate omics data will allow for identifying more specific markers. Consequentially, it will be possible to set up interventions on these factors to reduce the risk of malnutrition in the elderly.


✅ You mentioned the creation of a Biobank of biological samples in collaboration with Spoke 5. What does it consist of and what would it be used for?

It is a serum bank containing blood samples obtained from recruited patients, stored at -80 degrees Celsius. The Biobank is a large freezer that allows for the long-term preservation of blood samples. The preservation of samples is important because, while certain lines of research are prioritized today, in the future the literature might indicate the need for studies that other molecules play in malnutrition. We will need additional parameters to analyze in the future. In this sense, the Biobank is extremely useful for saving time, as it would be enough to re-examine the preserved samples to conduct new analyses.


✅  Returning to the prototype of a functional food or dietary supplement. Do you already have any results? What are the goals and expectations of the randomized clinical trial (RCT) phase in the SENIOR project on the new functional food or dietary supplement prototype?

It will be a plant-based product containing bioactive molecules extracted from plant matrices. Researchers at the University of Milan Bicocca are evaluating various innovative raw materials, including algae and food production waste. The product, still in the preparation phase, is designed to support a dietary protocol created by a nutrition professional. That’s because malnutrition is a clinically complex condition, and a single product isn’t sufficient for its management. However, it can aid the clinician's intervention. There is a general need to develop a product to combat inflammation, which has also been confirmed by our research on other similar products currently on the market. The prototype is still in the preparation phase, but its goal, and therefore what we expect, is to combat inflammation.


✅ So, there is a strong need for dietary protocols to combat malnutrition, especially in the Italian context. How long do you think it will take to implement mandatory protocols for nutritional rehabilitation in Italy?

Unfortunately, a major obstacle is bureaucracy. It took us a year to obtain the approval for the study, from the ethics committee. This slowness suggests the implementation of dietary protocols will be late too. Still, there isn’t enough awareness about the importance of nutrition and its role in preventing possible diseases and supporting a person affected by any health problem.


✅ Directly involving subjects might be a way to increase awareness about the topic. We know you are about to develop an educational mobile app to engage people enrolled in the clinical trial. What will it be used for and how can it help the participants?

It is an ambitious project that will see the creation of an app developed by an elderly person. It will be structured as a multiple-choice quiz to guide the elderly towards healthier eating and lifestyle habits. The concern is its use by elderly people who often do not even own a smartphone. The idea is that there will be a figure supporting the elderly in its use. It is a very ambitious project with potential utility: it could serve to collect data that is undoubtedly fundamental for advancing research.