Elsevier

Appetite

Volume 95, 1 December 2015, Pages 571-576
Appetite

Variety within a cooked meal increases meal energy intake in older women with a poor appetite

https://doi.org/10.1016/j.appet.2015.08.029Get rights and content

Highlights

  • We performed a cross-over study among 19 older women with a poor appetite.

  • We tested if increased variety within a cooked meal increased meal energy intake.

  • Mean intake was 427 kcal (SD 119) (variety meal) and 341 kcal (SD 115) (control).

  • Mean adjusted difference was 79 kcal (95% CI = 25–134).

  • Meal variety may increase energy intake in older adults with poor appetite.

Abstract

Background

Effective strategies to increase dietary intake in older persons with a poor appetite are needed. Previous studies have shown that increasing diet variety may increase dietary intake. This has not been tested in older adults with a poor appetite.

Objective

We investigated if an increased variety of foods within a cooked meal results in a higher meal energy intake in older women with a poor appetite.

Methods

This study was a randomized, controlled, cross-over trial among 19 older (>65 years) women with a poor appetite. Two cooked meals of similar weight and energy density (except starch) were served under standardized conditions on two weekdays: a test meal consisting of three different varieties of vegetables, meat or fish, and starch components, and a control meal without variety. Participants ate ad libitum and the actual consumed amounts and their nutritional content were calculated. Data were analyzed by mixed linear models.

Results

Average intake in energy was 427 kcal (SD 119) for the test meal with variety and 341 kcal (SD 115) for the control meal without variety. This resulted in a statistically significant (for period effects adjusted) mean difference of 79 kcal (95% CI = 25–134). Total meal intake in grams was also higher for the test meal with variety (48 g, 95% CI = 1–97) but protein intake (g) was not (3.7 g, 95% CI = −1.4 to 8.8). This was consistent for all meal components except starch and within each component three varieties were consumed equally.

Conclusions

The results of the present study suggest that increasing meal variety may be an effective strategy to increase energy intake in older adults with a poor appetite.

Introduction

With the aging of society, healthy aging has become an important public health goal. A healthy diet is generally recognized as an important factor in reaching this goal. Consuming a healthy diet can however be a challenge in old age. Older persons often have a poor appetite due to various reasons including depression, poorer health, smoking, chewing problems and visual impairment (Lee et al., 2006), thereby increasing the risk of malnutrition. The prevalence of a poor appetite among older adults is estimated at 10–15% in the general community (Lee et al., 2006, Mowe and Bohmer, 2002, Schilp et al., 2011 Sep), around 50% in hospitals (Mowe and Bohmer, 2002, Mudge et al., 2011 Jun) and 65% in nursing or residential homes (Sullivan, Johnson, Bopp, & Roberson, 2004). A poor appetite is shown to be an important independent determinant of a poor dietary intake among older adults (Mudge et al., 2011 Jun, Shahar et al., 2003 Jan) and incidence of undernutrition as determined by body mass index <20 kg/m2 or unintentional weight loss (Schilp et al., 2011). It is also associated with a lower healthy eating score index (Shahar et al., 2009), less diet variety (Dean, Raats, Grunert, & Lumbers, 2009) and an increased mortality risk independent of total daily energy expenditure, age, smoking status, cognitive status and self-rated health (Shahar et al., 2009).

Increasing dietary intake in older persons with a poor appetite is a major challenge for both older adults themselves as well as for caregivers and meal providers of hospitals, nursing or residential homes and meals-on-wheels services. Most previous intervention studies have focused on increasing caloric intake in older undernourished adults by providing oral nutritional supplements. This has shown to result in a small but statistically significant weight gain after 3–6 months (Milne, Potter, Vivanti, & Avenell, 2009). Yet, long-term effects are unknown and most importantly these products are disliked by many older adults resulting in low compliance (Fiatarone Singh et al., 2000, Gosney, 2003 Aug, Remsburg et al., 2001 Nov–Dec). This will reduce the effectiveness of oral nutritional supplements in real life situations. Other approaches, like the treatment of a poor appetite with orexigenic drugs, may have serious side effects like for example venous thromboembolism with megestrol acetate (Koller, Gibert, Green, Mann, & Bernstein, 1999) and are therefore not advisable on a regular base (Thomas, 2006).

Less attention has been paid to adapting the regular meals in order to increase energy intake. A study among long-term care residents with dysphagia found that serving small frequent meals did not improve energy intake (Taylor & Barr, 2006). Another study among older patients from a geriatric rehabilitation ward found that energy intake increased by offering smaller but energy enriched meals (Lorefalt, Wissing, & Unosson, 2005), thus suggesting that increasing the energy density of meals may be an effective approach to increase energy intake. The effects of adding flavor enhancers to the cooked meal are inconsistent (Essed et al., 2007 Jan, Mathey et al., 2001 Apr).

We recently examined food preferences in older adults with poor appetite by means of a computer based forced choice test displaying images of pairs of food images and asking which food they would prefer to eat at that instant (van der Meij, Wijnhoven, Finlayson, Oosten, Visser). A clear preference for variety in foods and color variety in foods (compared to no variation) was found in older adults with a poor appetite. More importantly, the higher preference for variety in foods was statistically different from those with a good appetite. Earlier experimental studies have shown that increased food variety may increase food intake in humans (Hollis and Henry, 2007 Aug, Meengs et al., 2012 Aug, Rolls et al., 1981 Feb, Stubbs et al., 2001 Jan), however, only one study was performed among healthy older adults (Hollis & Henry, 2007). More studies on this subject are clearly needed as increasing meal variety may seem a feasible approach to increase energy intake among older adults with a poor appetite.

The aim of the present randomized, controlled, cross-over study was therefore to test if an increased variety of foods within a cooked meal results in a higher meal energy intake in older women with a poor appetite.

Section snippets

Participants

We recruited older women with a poor appetite through advertisements in local papers, community centers for older persons, and care and nursing homes located in the area of Amsterdam, the Netherlands, from January 2013 to April 2013. Those willing to participate were further informed about the study and screened for in- and exclusion criteria by means of a general questionnaire by telephone or in person. Inclusion criteria were: women aged 65 and older, poor appetite in the last week and a poor

Results

In total, 70 older women applied for enrolment in the study. Of these, 46 were found ineligible mostly because they did not have a poor appetite. One participant did not show up at her first test day and four participants dropped out of the study after the first test day because they felt too weak and did not want to spend another test day. Baseline characteristics of the 19 participants that completed the study are shown in Table 2. Six participants chose to consume meals with meat and 13

Discussion

This randomized, controlled, cross-over trial showed that older women with a poor appetite consume more in terms of energy of a cooked meal that contains three varieties of meat (or fish), three varieties of vegetables different in color, and three varieties of a starch component than of a control meal that contains no variety within meal components. The higher energy intake was consistent for each of the three meal components and within each component the three varieties were consumed equally.

Funding

This study was supported by the Netherlands Organisation for Health Research and Development (200320014).

Acknowledgments

We would like to thank Elise de Jongh, Andrea Lagendijk, Kristina Maric, Judith van de Polder, Stephanie Stelten and Petra Wingender for their contribution to this project as part of their BSc and MSc graduation projects.

References (29)

  • H.A. Wijnhoven et al.

    Development and validation of criteria for determining undernutrition in community-dwelling older men and women: the short nutritional assessment questionnaire 65+

    Clinical Nutrition

    (2012 Jun)
  • M. Dean et al.

    Food in later life T. Factors influencing eating a varied diet in old age

    Public Health Nutrition

    (2009 Dec)
  • M.A. Fiatarone Singh et al.

    The effect of oral nutritional supplements on habitual dietary quality and quantity in frail elders

    The Journal of Nutrition, Health & Aging

    (2000)
  • M. Gosney

    Are we wasting our money on food supplements in elder care wards?

    Journal of Advanced Nursing

    (2003 Aug)
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