Clearer focus — food not fat

It isn't fatness that poses the greatest health risks for an aging population and contributes to higher medical care expenses. It’s people not getting enough to eat.

Dr. Olle Ljungqvist of the Karolinska Institute in Stockholm, Sweden, took issue with the European Commission’s “fight against Europe’s obesity epidemic.” He called attention to the burden on healthcare systems throughout Europe brought on by malnutrition.

He wrote in the Financial Times:

Lack of adequate nutrition in the community, in residential care and in hospitals inhibits patient recovery, lengthens the stay in hospital by 50 percent – an average of six days – and substantially increases mortality.

I am involved in the annual NutritionDay study in Europe, which takes place in more than 30 countries and examines the food intake of some 30,000 patients in one day. The study has revealed that 47 percent of patients are hospitalised with signs of disease-related malnutrition. Only 38 percent of patients eat all that they have been served, and one in five eats less than a quarter or nothing. Mortality rates of patients maintaining a regular food intake are 1.3 per cent, whereas in patients eating less than one-quarter or nothing, mortality rates are as high as 5.5 per cent.

As Europe faces an aging population, with increasing numbers of people of 50 years and older, the challenge will grow. We need policymakers and people working in the field to recognise the issue and to set in place measures to monitor weight and promote good nutrition to reduce human suffering and optimise recovery.

If action is not taken, malnutrition will continue to be the silent killer of the 21st century.

Decades of studies, showing higher weights as we age offer a survival advantage, have led to calls for weight guideline changes. This was reviewed in part here. This is not an obesity “paradox,” but so well established, a comprehensive review of more than 400 studies found most showed fatness as we age to be especially favorable for longevity. Despite efforts to depict fat as a pathology, most of the claims have used flawed statistical models to estimate risks, or have used surrogate endpoints rather than actual death statistics. A wide variety of weights and sizes share equal good health. The CDC National Center for Health Statistics has concluded that existing studies have shown “little relationship between BMI and mortality.”

We’ve also come to believe that a “poor diet” means eating the “wrong” foods, but malnutrition results primarily from not eating enough and restricting food choices. In wealthier cultures, sadly undernutrition most afflicts older people. Behind this grievous fact are difficulties faced by elderly, such as transportation problems, living alone, isolation and depression, dental problems, diminished senses of smell and taste, and financial hardships. As emergency room physicians in Minneapolis found, 24% of the patients they saw screened positive for hunger, many forced to choose between medications or food.

Low-fat or any form of dietary restrictions is especially ill-advised among elderly. According to the National Health and Nutrition Examination Surveys, which gathers detailed dietary and health data on a representative segments of the U.S. population, 25 to 40 percent of senior citizens are getting inadequate calories, and as a result, are dramatically short on such nutrients as riboflavin; vitamins B6, A and C; and calcium. Other studies have found that as many as 15 percent of older citizens in the community and 35-65 percent of hospitalized ones suffer from poor nutritional status. The Malnutrition Advisory Group reported in 2001 that one in seven people in the UK were malnourished or at severe risk.

The medically-documented consequences of not eating enough (for any age) include functional decline, delayed wound healing, impaired immune system and increased risks of infection, damaged heart and intestinal functions, depression, apathy, loss of muscle strength, falls and increased fractures.

Undernourished older people have “longer hospital stays, higher rates or rehospitalization, significantly higher total healthcare costs, higher complication rates and higher mortality rates,” documented the 2002 report, “Improving the Care of Older Adults with Common Geriatric Conditions,” commissioned by the trade organization, American Association of Health Plans.

This report showed the plethora of studies showing people with low BMIs have higher mortality, healthcare costs and functional impairment compared to people with higher BMIs. In one study, older people just at-risk for undernutrition were found to have longer average hospital stays (six versus four days), have higher average hospital costs ($6,196 versus $4,563), use more home health care services, and require more post-hospital subacute care.

You may remember the ‘fat arm’ study from Sheffield Institute for Studies on Ageing at the University of Sheffield in Sheffield, UK. Assessing the nutritional status of a random 445 older patients admitted to the hospital, excluding any with severe medical or psychiatric illnesses which could be factors in underweight, they looked to see who was alive a year later. The survivors had significantly higher fasting blood sugars and albumin levels, indicative of better food intakes. It has also been well established in the medical literature, they said, that protein and higher calorie diets are strong predictors of lower mortality among people in and out of the hospital.

The evidence points to the need to turn our attention and help, not on those getting enough to eat, but on those who aren't.