prof. sandra capra - university of qld - the power of nutrition in dementia

Sandra Capra AM, PhD, FDAAProfessor of Nutrition, Academic Director, School of Human Movement and Nutrition SciencesCentre for Dietetics ResearchThe University of Queensland

The power of nutrition in dementia

The issues

• Can nutrition prevent or ameliorate cognitive decline? What is the evidence?

• Preventing and treating malnutrition- what is the evidence?

• The challenge of turning the evidence into foods and drinks which are appealing, interesting, nutritious and consumed

CRICOS Provider No 00025B

Complexities• Those with cognitive decline are often thought of as a

homogeneous group• There is confusion between the public health nutrition

messages aimed at chronic disease reduction and prevention in the free living population and focussing on this among some of other groups

• The focus on obesity has meant it is hard to get the malnutrition message across or recognised at times.

• We need to think differently about food and nutrition for those with cognitive decline.

The public health message (the dietary guidelines)

• For the fit and well– No polypharmacy– No chronic disease

• Focus on chronic disease prevention• Assumes no ‘special’ foods selectedBUT• Variations of this (high antioxidant/high anti-

inflammatory etc) might be beneficial in managing/preventing metabolic syndrome

Food Selection Guide

http://www.eatforhealth.gov.au/guidelines/australian-guide-healthy-eating

The evidence – weight and body mass

• We know that increased energy density of meals improves nutrient intakes in older people.

• Allen et al (2013) reviewed studies containing 1076 people in the supplement groups (intervention) and 748 people in the control groups. Meta-analysis shows there was a significant improvement in weight, Body Mass Index (BMI) and cognition at follow-up when oral nutrition supplements were given compared to the control group.

• There is a positive relationship between BMI and survival among people with dementia. There is considerable and consistent evidence that overweight and grade 1 obesity are not detrimental in later life.


Can nutrition prevent dementia?

• We do not have the evidence that any specific nutrient itself is useful BUT good nutrition in early and mid adulthood is related to the prevention of many chronic diseases.

• Newest research is suggestive that metabolic syndrome is linked to Alzheimer’s Disease, via insulin resistance – so treating and managing metabolic syndrome might be a useful strategy.

• There is promising research linking lower risk with polyunsaturates and fish.

• The B vitamins are associated with brain function (Kennedy 2016)


• There are some suggestions that a “mediterranean diet” can be protective against cognitive decline (Knight et al, 2016).

• Green leafy vegetables may be protective• Berries may be protective (not fruit generally)• Ie it looks like antioxidants may be useful• The “traditional” type of meals in Australia may be

unhelpful.


The issues are different for the different stages of dementia

– Early – Good nutrition, weight loss prevention, “Mediterranean diet”, fish, berries, green leaves

• Shopping,• Appetite and taste changes• Food hygiene

– Middle – Detect and prevent malnutrition• Food hoarding• Pica• Leaving meals

– Late – Treat malnutrition • Eating difficulties (up to 85%)• Tremors, agitation• “Type 3 diabetes”


Malnutrition

• Loss of muscle mass- age related inflammation (sarcopenia)

• Disease related inflammation (cachexia)• Protein energy malnutrition

• 1% muscle loss per yr >50yrs

Source Hall. Aging;3;702-715, 2011

Anorexia of Aging

• Comorbidities, depression, malnutrition, dementia and delirium can all contribute to the anorexia of aging.

• This is – Decreased appetite– Poor nutrient intake

• And can lead to– Dehydration– Pressure injuries– Poor wound healing– Increased susceptibility to diseases– Poorer response to treatments


Physical Examination: Fat StoresTriceps: fat layer between pinch

Well-nourished elderly:Large space between fingers

Well-nourished: Large space between fingers

Moderately malnourished:Lesser space between fingers

Severely malnourished:Very little space between fingers or fingers touch

Physical Examination: Muscle Stores Temple

You can feel the muscle if you put your finger on the muscle and clench and release your teeth

Well-nourished:muscle is flat

Elderly Well-nourished:Muscle is well-defined

Moderately malnourished: Slight depression

Severely malnourished: Hollowing

Physical Examination: Muscle Stores Clavicle

Usually slightly apparent in females; Usually not visible in malesMore the prominence = Greater the wasting

Well-nourished:Not prominent

Moderately Malnourished:Some protrusion(in some patients, may not be prominent entirely)

Severely MalnourishedProtruding/ Prominent bone

Well-nourishedSlightly prominent

Physical Examination: Muscle Stores Shoulder

Well-nourished:Rounded appearance

Moderately Malnourished:No square look, acromion process may protrude slightly

Severely Malnourished:Square Look, Bones prominent

Preventing and treating malnutrition

• The evidence supports food interventions and assisting with eating as better than supplements and tube feeding

• Need personalised care as there is no “one size fits all”.


What do we know?

• We know that for the elderly population, losing weight after the age of 70 is not good, and that the BMI with the lowest mortality is 31.

• In people with dementia this is a complex relationship– There is some evidence that obesity grade II or higher in mid life in

women is related to the development of dementia– Being OVERWEIGHT to obesity grade I though is not detrimental

and is protective in older people.– We know this is also true of people with dementia – there is good

evidence that obesity is protective (the obesity paradox).• We know that you have to eat “better” as you get older


Energy intake

Source: http://www.abs.gov.au/ausstats/[email protected]/Lookup/by%20Subject/4364.0.55.007~2011-12~Main%20Features~Energy~702

Energy from discretionary foods


Inadequate intakes worsen with age

B6

B1

Calcium Zinc

Food strategies

• Increase energy per mouthful– Use full fat dairy products and use those which have been

supplemented with additional milk.– Add cream, cheese etc to mashed potatoes, soups and similar

foods– Use fried foods

• Increase nutrients per mouthful– Choose coloured vegetables and fruits– Make products from “scratch” eg soups– Make nourishing soups, desserts and drinks by adding extra

ingredients– Consider multivitamins


What about specific foods?

• There is some evidence that dairy foods are beneficial (Hess et al, 2016)


• Increase interest in and recognition of foods– Coloured plates– Grazing rather than meals, – Prompting to eat and drink– Music and calming environment

• Provide assistance with meals– Ensure safety– Size and shape of food


Let them eat cake

This amount of cake with cream500kJ2.5g protein6g fat15g CHO0.4 g fibre

Same as eating1 slice white bread +1.5 tsp of margarine/butter

Is it easier to eat? More enjoyable for some?

Nutrient values from “Foodworks” 2007

So..

• A very difficult area• Nutrition is a critical quality of life issue for people with

dementia• Reducing and treating malnutrition is an imperative• Use foods as the first line of defence


prof. sandra capra - university of qld - the power of nutrition in dementia

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