New Definition of Malnutrition & the

Role of Nutrition on Improving Siti Setiati

Health Condition in the Elderly
1. Cruz-Jentoft AJ, et al. Sarcopenia: European Consensus on definition and diaagnosis (EWGS). Age Ageing. 2010;39(4):412-23
2. Chen LK, et al. Sarcopenia in Asia: Consensus Report of the Asian Working Group for Sarcopenia. Journal of the American Medical Directors Association. 2014;15(2)
 Sarcopenia
• Sarcopenia is generally defined as a decrease in skeletal muscle mass
and muscle strength or physical function, such as gait speed,
observed in elderly individuals.

Geriatr Gerontol Int 2018; 18 (Suppl. 1): 7–12

GrimbyG et al ClinPhysiol. 1983;3:209–218; Flakoll P, et al. Nutrition. 2004;20:445–451
BaierS, et al. JPEN J ParenterEnteral Nutr. 2009;33:71–82
Janssen I, et al. J Appl Physiol. 2000;89:81–88.
 The Impacts of Low Lean Mass

Wolfe R. AJCN 84:475-482, 2006

 Malnutrition Leading to Muscle Loss in Elderly
Factors
Decrease anabolic Inflammation or
hormones
Neurodegeneration
Cachexia Malnutrition Disuse Insulin Resistance

Muscle/Strength Loss

Frailty
 BMI only is NOT reflecting nutritional status

Same BMI, different Lean Mass

Age 75 31
Weight 56 56
Height 132 157
BMI 32.1 22.7

Vandewoude, M.F. Personal communication, 2014.

 BMI = BW (Kg)
BH (m)2

Be aware of POSTURAL INSTABILITY in

the elderly
Note: postural changes in the elderly

Measuring
knee height
 BH (♂) = 69,38+ (1,924 x KH)
(KH)  BH (♀) = 50,25 + (2,225 x KH)
Asia Pacific J Clin Nutr.2003;12(1):80-4.
Old Concept of
Malnutrition
• Malnutrition is defined as:
• BMI <18.5 kg/m2 OR
• Unintentional weight loss of >10% within
the previous 3-6 months OR
• BMI <20 kg/m2, and unintentional
weight loss >5% within the previous 3-6
months

BAPEN Malnutrition Advisory Group Guidelines

 New Concept of
Malnutrition

• Currently, the definition of

malnutrition is not just
only looking at the BMI
of a person, but also other
criteria
• Someone can have
normal BMI BUT
malnourished!

T. Cederholm et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition
community. Clinical Nutrition 38 (2019) 1-9.
Phenotypic and Etiologic Criteria (GLIM 2019)

T. Cederholm et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clinical Nutrition 38 (2019) 1-9.
T. Cederholm et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clinical Nutrition 38 (2019) 1-9.
Diagnosing Malnutrition (ESPEN)
 Definisi Malnutrisi
WHO: Suatu keadaan kekurangan kelebihan atau ketidakseimbangan protein, energi
dan zat gizi lain yang dapat menyebabkan perubahan komposisi tubuh, penurunan
fungsi fisik dan mental Kriteria Fenotip
↓ BB Tak Diinginkan IMT Rendah MASSA OTOT RENDAH
 ESPEN
 >5% dalam 6 bulan  usia <70 tahun  <18,5 AWGS:
 ↓ BB signifikan yang tidak ATAU kg/m2 DXA
diinginkan (>5% dalam 6 bulan atau  >10% dalam >6 bul ATAU ♂ <7 kg/m2;; ♀ <5,4 kg/m
2
>10% lebih dari 6 bulan) an  usia >70 tahun  <20 kg/m2
BIA
ATAU Catatan: untuk kriteria ♂ <7 kg/m2; ♀ <5,7 kg/m2
Catatan: malnutrisi b
 ↓ signifikan massa tubuh (IMT <20 erat jika >10% dala malnutrisi berat di Asia, perlu Laksmi, dkk
kg/m2) atau FFMI m 6 bulan ATAU >2 penelitian/ konsensus lebih BIA Tanita MC-780MA
0% dalam >6 bulan lanjut ♂ <6,9 kg/m2; ♀ <5 kg/m2
Kriteria Etiologik
 Konsensus Global (GLIM): Asupan atau Asimilasi Makanan Renda
Inflamasi
kombinasi setidaknya 1 kriteria fenotip DAN 1 h
kriteria etiologi  ↓ berapapun dari kebutuhan energi
selama >2 minggu
ATAU
PERGEMI. Pedoman Nasional Asuhan Nutrisi pada Lansia dan Pasien Geriatri. 2017.  Penyakit/ trauma akut
ESPEN guideline on clinical nutrition and hydration in geriatrics. 2018  ≤50% kebutuhan energi selama >1 min
GLIM criteria. Clin Nutr.2019;38:1–9. ATAU
Laksmi PW, et al. The need new cut-off value to increase diagnostic performance of BIA
ggu
 Terkait penyakit kronik
compared to DXA to measure muscle mass in Indonesian elderly. In press. ATAU
 Nutritional
Guideline in
Elderly

ESPEN guideline on clinical nutrition and hydration in geriatrics, 2019

 Mini Nutritional Assessment
MNA®
Last name: First name:

Sex: Age: Weight, kg: Height, cm: Date:

Complete the screen by filling in the boxes with the appropriate numbers.
Add the numbers for the screen. If score is 11 or less, continue with the assessment to gain a Malnutrition Indicator Score.

Screening J How many full meals does the patient eat daily?
0 = 1 meal
A Has food intake declined over the past 3 months due to loss 1 = 2 meals
of appetite, digestive problems, chewing or swallowing 2 = 3 meals
difficulties?
K Selected consumption markers for protein intake
0 = severe decrease in food intake
• At least one serving of dairy products
1 = moderate decrease in food intake yes no
(milk, cheese, yoghurt) per day
2 = no decrease in food intake
• Two or more servings of legumes yes no
or eggs per week
B Weight loss during the last 3 months
• Meat, fish or poultry every day yes no .
0 = weight loss greater than 3kg (6.6lbs)
0.0 = if 0 or 1 yes
1 = does not know
0.5 = if 2 yes
2 = weight loss between 1 and 3kg (2.2 and 6.6 lbs)
1.0 = if 3 yes .
3 = no weight loss
L Consumes two or more servings of fruit or vegetables
C Mobility per day?
0 = bed or chair bound 0 = no 1 = yes
1 = able to get out of bed / chair but does not go out
2 = goes out M How much fluid (water, juice, coffee, tea, milk...) is
consumed per day?
D Has suffered psychological stress or acute disease in the 0.0 = less than 3 cups
past 3 months? 0.5 = 3 to 5 cups
0 = yes 2 = no 1.0 = more than 5 cups .
E Neuropsychological problems N Mode of feeding
0 = severe dementia or depression 0 = unable to eat without assistance
1 = mild dementia 1 = self-fed with some difficulty
2 = no psychological problems 2 = self-fed without any problem

F Body Mass Index (BMI) = weight in kg / (height in m)2 O Self view of nutritional status
0 = BMI less than 19 0 = views self as being malnourished
1 = BMI 19 to less than 21 1 = is uncertain of nutritional state
2 = BMI 21 to less than 23 2 = views self as having no nutritional problem
3 = BMI 23 or greater
P In comparison with other people of the same age, how does
Screening score (subtotal max. 14 points) the patient consider his / her health status?
12-14 points: Normal nutritional status 0.0 = not as good
8-11 points: At risk of malnutrition 0.5 = does not know
1.0 = as good
0-7 points: Malnourished 2.0 = better .
For a more in-depth assessment, continue with questions G-R
Q Mid-arm circumference (MAC) in cm
Assessment 0.0 = MAC less than 21
0.5 = MAC 21 to 22
1.0 = MAC greater than 22 .
G Lives independently (not in nursing home or hospital)
1 = yes 0 = no R Calf circumference (CC) in cm
0 = CC less than 31
H Takes more than 3 prescription drugs per day 1 = CC 31 or greater
0 = yes 1 = no
Assessment (max. 16 points) .
I Pressure sores or skin ulcers
0 = yes 1 = no Screening score .
Total Assessment (max. 30 points) .

References Malnutrition Indicator Score

1. Vellas B, Villars H, Abellan G, et al. Overview of the MNA® - Its History and
Challenges. J Nutr Health Aging. 2006; 10:456-465. 24 to 30 points Normal nutritional status
2. Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for 17 to 23.5 points At risk of malnutrition
Undernutrition in Geriatric Practice: Developing the Short-Form Mini
Nutritional Assessment (MNA-SF). J. Geront. 2001; 56A: M366-377 Less than 17 points Malnourished
3. Guigoz Y. The Mini-Nutritional Assessment (MNA®) Review of the Literature - What
does it tell us? J Nutr Health Aging. 2006; 10:466-487.
® Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners
© Nestlé, 1994, Revision 2009. N67200 12/99 10M
For more information: www.mna-elderly.com

Paillaud E, Bories PN, Le Parco JC, Campillo B. Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up. Br J Nutr 2000;83:97-103.
Miu KYD, et al. Effects of Nutritional Status on 6-Month Outcome of Hip Fractures in Elderly Patients. Ann Rehabil Med. 2017;41(6):1005-12.
 Macronutrients
• Calorie Requirement
• Without metabolic stress: 25-30
kcal/kgBW
• With metabolic stress: 30-35
kcal/kgBW
• Protein Requirement
• Without metabolic stress: 1-1.2
gr/kgBW
• With metabolic stress: 1-2
gr/kgBW
• Carbohydrate Requirement
• 45-65% of the total calorie
• Types: complex carbohydrate, 4
spoons/day for simple carbohydrate
• Fat Requirement
• 20-35% of the total calorie
• Saturated fat <10% of the calorie
and cholesterol <300 mg/day
• Fluid Requirement
• 25-30 mL/kgBW
 Nutrient Reference Intakes and Recommended Dietary
(Protein) Intakes for Elderly
Males Males Females Females
Age range (years) 51-70 70+ 51-70 70+
US EAR 0.66 0.66 0.66 0.66
Australian EAR 0.68 0.86 0.60 0.75
US RDA 0.8 0.8 0.8 0.8
Australian RDI 0.84 1.07 0.75 0.94
UK NRI 0.8 0.8 0.8 0.8
General recommendation (>65 year) 1.1-1.2 1.1-1.2
Recommendation with endurance and resistance exercise (>65 1.2 1.2
year)
Recommendation for acute and chronic disease (>65 year) 1.2-1.5 1.2-1.5
Recommended 25-30 g per meal (>65 year)
*All values are in g/kg/day. EAR: estimated average requirement. RDA: recommended daily allowance. RDI: recommended
dietary intake. NRI: nutrient reference intake.
Nowson C, O’Connell S. Protein requirements and recommendations for older people: a review. Nutrients. 2015;7:6874-6899.
Natural Sources of Vitamin D and Calcium
Vitamin D:
• Sunlight
• Fish, such as sardines, salmon
• Mushroom
• Egg Yolk

Calcium:
• Dairy products, such as milk, yoghurt, tofu,
tempeh
• Vegetables, such as spinach, broccoli
• Orange
Chen LR, et al. Calcium and Vitamin D Supplementation on Bone Health: Current Evidence and Recommendations. International Journal of Gerontology. 2014;8:183-8.
• Published in 2017
• Frail elderly aged 65 years old, living in community or institutionalized
• 19 eligible studies
• Tools: Frail criteria based on Fried (FRAIL), et al; MNA for nutrition; Diet Quality Index (DQI-R)
• Results:
• Frailty syndrome is associated with low intakes of specific micronutrients.
• A higher protein intake was associated with a lower risk of frailty !!!...
• Quality of the diet is inversely associated with the risk of being frail
• Relationship between scores on both the Mini Nutritional Assessment (MNA) and frailty, and revealed an
Association between MALNUTRITION and/or the RISK OF MALNUTRITION with FRAILTY
 Protein Only

• 12-week double-blind RCT

• Population: 120 elderly subjects (70-85 y.o) with ≥1 of the
Cardiovascular Health Study frailty criteria (pre-frail or frail) and a
Mini Nutritional Assessment score ≤23.5
• Intervention (3 groups): Protein powder 0.8 or 1.2 or 15
gr/kgBW/daily (along with usual diet and physical activity)
• Outcomes: appendicular skeletal muscle mass (ASM) and skeletal
muscle mass index (SMI) measured by dual-energy X-ray
absorptiometry; others: CHS frailty index, gait speed, TUG, HGS, etc
Park, et al. Am J Clin Nutr 2018;108:1026–1033.
• After the 12-wk intervention, ASM and SMI indicators, such as ASM/weight, ASM/BMI, and
ASM:fat ratio, were significantly HIGHER in the 1.5-G PROTEIN group than in the 0.8-g protein
group
• For gait speed, there was a significant group time interaction between the 3 groups; thus, GAIT
SPEED was significantly HIGHER IN THE 1.5-G PROTEIN group than in the 0.8-g protein group at
week 12
Park, et al. Am J Clin Nutr 2018;108:1026–1033.
 Vitamin D
and Calcium

Review.
Year: 2017

• Older adults with sarcopenia showed a significant increase in muscle

mass and better lower limb function following a course of vitamin D
and leucine-enriched whey protein supplementation (Bauer et al.
2015)
• In 300 older women with a baseline 25OHD level under 60 nmol/l,
significant improvements in TUG, were reported with 2000 IU
vitamin D daily (Zhu et al., 2010).
• Meta-analysis showed beneficial effect of daily vitamin D (with doses
ranging from 800 to 1000 IU) in older subjects with improvements in
balance and muscle function (Muir and Montero-Odasso, 2011).
Bone Reports 8 (2018) 163–167
 Review.
Year: 2017

• An RCT of 625 older residents of assisted-living facilities reported

significantly fewer falls in subjects on calcium (600 mg daily) and
vitamin D2 (initially 10,000 IU weekly, then 1000 IU daily) for 2 years
versus calcium alone (Flicker, 2005)
• An annual oral dose of 500,000 IU of vitamin D3 increased the
incidence of falls in over 2000 community-dwelling older women
(Sanders et al., 2010).
• US Preventive Services Task Force (Meta-Analysis) demonstrated 17%
reduction in falls in response to vitamin D and its analogues
(calcitriol and alfacalcidol) (Michael et al., 2010)
Bone Reports 8 (2018) 163–167
 Protein and
Vitamin D

Year: 2014

• Vitamin D increased muscle protein

synthesis; enhance the stimulating
effect of leucine and insulin on
protein synthesis rate in muscle
cells
• Vitamin D status and VDR expression
in skeletal muscle are reduced in
elderly people, and associated with
a significant loss of muscle function

R. Rizzoli et al. / Maturitas 79 (2014) 122–132

 Year: 2014

• Protein intake of 1.0–1.2 g/kg BW/d, with at least 20–25 g of high-

quality protein. An average daily protein (such as can be supplied by dairy
protein) with each main meal (breakfast, lunch, dinner) during the day.
• Regular physical exercise 3–5 times per week should be under-
taken, which may be combined with protein intake in proximity to
exercise, for optimal muscle reconditioning.
• Vitamin D intake at 800 IU/d to maintain serum 25-(OH)D
concentration >50 nmol/L (>20 ng/mL)

R. Rizzoli et al. / Maturitas 79 (2014) 122–132

 Vitamin D,
Calcium, and
Leucine
Year: 2019

• 13 weeks double-blind RCT study

• Populations: 380 (control: 196, active: 184) non-malnourished older
participants (>65 y.o) with mobility limitations and reduced muscle
mass
• Mild to moderate limitations in physical function (SPPB score 4-9)
• Low skeletal muscle mass index (≤37% in men and ≤ 28% in women)
• Interventions:
• Protein products: 20 g whey protein (3 gr total leucine), 800 IU vitamin D,
500 mg of calcium, and a mixture of vitamins, minerals, fibres  twice daily
• Control: iso-caloric product
Hill TR, et al. Calcified Tissue International (2019) 105:383–391
 • Prevalence of low Serum
25(OH)D decreased in the
active group
• Serum IGF-1 change during
intervention was
significantly different
between active and control
groups
• Serum calcium (corrected
for albumin) increased
slightly after 13 weeks in
the active treatment group
only
• Total body BMD increased
in the active group only,
and the improvement was
significantly different from
control

Hill TR, et al. Calcified Tissue International (2019) 105:383–391

Whey Protein Supplementation

• Whey protein is high digestibility, quick

absorption and rich content of essential amino
acids (EAAs)
• Leucine is a high proportion of the branched-
chain amino acid (AA) in Whey protein, (one of
the crucial factors for THE STIMULATION OF MPS)
 IMPROVE POSTPRANDIAL MUSCLE PROTEIN
SYNTHESIS
• One randomized controlled trial (RCT) showed
that whey protein stimulates gains in lean body
mass and strength in healthy elder men (Whey +
Exercise showed the best result)
The Differences between Whey and Casein

Whey Casein
• Still has it liquid form even when • Becoming a curd when mixed
mixed with gastric acid with gastric acid
• Faster gastric emptying • Delay gastric emptying
• Faster to be absorbed • Takes time to be absorbed

Has 7x higher cystein compared to casein

 important in GSH development 
antioxidant properties

1. Fried MD, et al. 1992; 2. Clemens,R.A, et al. 2002

 Protein
Comparison
 Conclusion
• There are several physiological changes
in elderly that may make elderly more
prone towards malnutrition
• There is a new definition of
malnutrition, which involving lean
mass measurement
• Screening of malnutrition need to be
done for each elderly to detect
malnutrition as early as possible
• Whey Protein, Calcium, and Vitamin D
are proven to be beneficial in
improving bone and muscle health