Current Opinion in Clinical Nutrition & Metabolic Care:
AGEING: BIOLOGY AND NUTRITION: Edited by Ronni Chernoff and Tommy Cederholm
Fruit and vegetable intake in older hospitalized patients
Raynaud-Simon, Agathea,b; Aussel, Christianb,c
aService de Gériatrie, Hôpital Bichat-Claude-Bernard, Paris, AP-HP, and Faculté de Médecine Denis-Diderot
bEA 4466, Université Paris-Descartes, Paris
cUnité de Nutrition PUI, Groupe Hospitalier Henri-Mondor, Créteil, AP-HP, France
Correspondence to Christian Aussel, PhD, Unité de Nutrition, PUI, Hôpital Henri-Mondor, 51 avenue du Maréchal-de-Tassigny, 94000 Créteil, France. Tel: +33 1 45958335; fax: +33 1 45958395; e-mail:firstname.lastname@example.org
Purpose of review: Regular intake of fruit and vegetables (F&Vs) has been widely recommended to improve the health of the population. Observational studies show a preventive effect of long-term consumption of adequate nutrients on cancer, diabetes, dementia and other age-related diseases. However, the short-term impact of F&V intake in more specific populations has been under-researched. In the hospital setting, economic choices and logistic problems result in poor quality of food in general, and particularly in fresh F&Vs. As hospital geriatricians, we set out to address the issue of F&V intake in elderly hospitalized patients, for whom we felt F&Vs might be beneficial in association with a protein and energy-dense diet.
Recent findings: In the community and in nursing homes, F&V consumption is associated with better overall food intake and improved quality of life in older patients.
Summary: General inspection of the literature suggests that F&Vs may be beneficial to elderly hospitalized patients, but no clinical studies have been conducted. There is a need to address the question of the impact of improved quality and quantity of F&Vs on quality of life, total food intake and constipation, particularly in hospitalized elderly patients who often stay in hospital for long periods. Positive results might help to promote F&V consumption in diverse populations, with the objective of improving eating pleasure for better health.
Fruit and vegetables (F&Vs) are characterized by their high content of fibre, vitamins and trace elements. They also contain a wide variety of substances (polyphenols, carotenoides, phytosterols, etc.) that may have a positive impact on health. In the French population, F&Vs contribute strongly to recommended dietary allowances: 38% of vitamin A, 42% of folates, 73% of vitamin C, 29% of potassium and 22% of magnesium (National Study of Individual Food Consumption, Etude Individuelle Nationale sur la Consommation Alimentaire; INCA 1998–1999). Fresh F&V juices and soups may also help to cover water needs, and this can be useful in the elderly population.
Diet and lifestyle play an important role in the prevention of chronic diseases. Numerous epidemiological studies have highlighted the preventive role of F&Vs or some of their constituents (e.g. fibre, antioxidants, vitamins and micronutrients) on the prevention of cardiovascular disease, cancer, neurodegenerative diseases, age-related macular degeneration and osteoporosis [1–3]. The results of interventional clinical trials of prevention (prevention of subsequent coronary event or cancer) are relatively disappointing [4–6], but they must be interpreted with caution, particularly as dietary advice has changed food intake only modestly.
However, the short-term or medium-term impact of F&V intake in elderly hospitalized patients has not been studied. Protein and energy malnutrition is highly prevalent in this population, reaching 70% in some hospital wards . Although F&Vs will contribute only modestly to protein and energy intake, they may increase micronutrient, fibre and water intake, and increase global food intake through improved well-being and satisfaction with meals. Micronutrient deficiency is probably very high in hospitalized elderly patients, judging by the fact that one in 10 patients admitted to an acute care geriatric ward in France present with clinical symptoms of scurvy associated with very low serum ascorbic acid levels , but has rarely been thoroughly studied. Dehydration is one of the main causes for admission of elderly patients via emergency units. During hospitalization, constipation is routinely prevented or treated. Lastly, quality of life is poor in elderly hospitalized patients, and ripe and tasty F&Vs might be especially appreciated by the elderly and could improve their perception of meals during hospitalization. In what follows, we will discuss data that support the utility of providing quality F&Vs for elderly hospitalized patients.
FRUIT AND VEGETABLES, HOSPITAL MEALS AND MALNUTRITION
The prevalence of protein-energy malnutrition is even higher in elderly patients than in younger patients on admission to the hospital; malnutrition is associated with longer length of stay in the hospital and higher mortality . Malnutrition may have developed before hospitalization for medical, psychological or social reasons. Nutritional status then usually further deteriorates during hospitalization, in both surgical and medical patients.
Food intake from hospital meals and/or snacks is low. The NutritionDay is a multinational 1-day cross-sectional survey of nutritional factors that included 16 290 adults in 2006 . In that study, more than half of the patients did not eat their full meal provided by the hospital. Eating about a quarter of their meal was associated with a two-fold (and eating nothing with a three-fold) risk of dying at 1 month. In Danish hospitalized patients of mean age 70 years, 20% of the patients ate less than 50% of their estimated energy requirements and 24% between 50 and 75% . Causes for low food intake in the hospital vary. The French energie 4+ study showed that more than two-thirds of hospital meal trays were only partially eaten; in geriatric departments, this was due to medical reasons (anorexia, pain, secondary effects of drugs, nil-by-mouth for exploratory tests, etc.) in 30% of the cases and due to logistic reasons (unavailable or inadequate flatware, no help from the nursing staff, etc.) in as many as 42%. Additionally, poor quality of the food was given as a cause for incomplete meal consumption by 8% of patients (J.F. Zazzo, unpublished data). Yet increasing energy and protein intake in malnourished elderly patients has been shown to reduce complications and mortality [12,13].
Elderly patients are high consumers of fresh F&Vs at home (INCA), especially in high-income and well educated elderly populations . Fresh F&Vs are much more a part of their eating habits than in younger generations and could improve satisfaction of elderly patients with hospital meals. In nursing homes, elderly patients who consume at least 400 g per day of F&Vs also take in the largest total weight of food and have the largest macronutrient, fibre, vitamin and mineral intakes. They also have higher serum and erythrocyte folate concentrations and lower plasma homocysteine concentrations than those who consume less than the recommended 400 g per day of F&Vs . Although it is probable that high F&V intake patients have higher appetite, better dietary habits and better health status, it is important to note that a higher intake of F&Vs is associated with a better total micronutrient and macronutrient nutritional status and favours the intake of vitamins and minerals with probable cardioprotective effects.
It is common knowledge that the quality of F&Vs served in hospitals is particularly low, due to economic choices and logistics (time and conditions of transport and maturation). Thus, F&Vs, if present on the tray, are often hard and/or tasteless, and sometimes even impossible to eat for patients with a disability (difficulty in peeling and cutting) or chewing or swallowing impediments. Also, age, smoking, disease or drug-related dysgeusia/anosmia need to be compensated for by flavour-rich food. Colour of the F&Vs on a plate may positively affect the perception of the meal and increase appetite. Thus, although no clinical studies have been conducted so far, we would expect good quality F&Vs served with the meals to improve not only micronutrient status but also satisfaction and appetite and thereby food intake.
FRUIT AND VEGETABLES AND CONSTIPATION
F&Vs, mainly because of their fibre and water content, contribute to bowel movement. Constipation affects 24–40% of elderly persons living at home . It is associated with physical pain and negative perception of health. Constipation is even more prevalent in hospitalized elderly patients, due to insufficient hydration and mobility, side-effects of drugs and various medical conditions. The gastrointestinal symptoms alter the sense of well-being in its severe forms. Particularly in the frail elderly, constipation may be complicated by fecal impaction, incontinence or acute urinary retention . Constipation is one of the factors leading to poor nutritional status and poor quality of life.
Laxatives are usually prescribed to treat constipation. However, these are not risk-free because the frequent use of laxatives may be accompanied by several side-effects, including psychological ones. Laxatives intervene in stool transit by preventing the colon from resorbing water, irrespective of the physiological interactions between the gut epithelium cells and the gut bacteria. By contrast, dietary fibres increase stool weight by means of fibres that are not fermented and through bacteria mass. Trials have been conducted in long-term care hospital wards and nursing homes to test the efficacy of different fibre-rich products. In long-term care patients aged 50–100 years, the addition of 7–8 g of oat bran to the diet for 12 weeks allowed laxatives to be discontinued by 59%, whereas in the control group, there was an 8% increase in the use of laxatives . In a nursing home, a ‘fiber 7’ supplement (natural powdered fibre, 7 g a meal twice a day) allowed discontinuation of laxatives in 63 of the 92 patients in a period of 2.5 years . Lastly, a natural F&V laxative mixture was tested: this Beverley-Travis mixture  contains raisins, pitted prunes, figs, dates, currants and prune concentrate. In a randomized controlled study, the natural mixture was compared with prescribed laxatives over an 8-week period (treatment group discontinued prescribed laxatives and received two tablespoons of the natural mixture twice a day for 4 weeks). The treatment group displayed a significant increase in the average number of bowel movements following initiation of the natural laxative, although no change was observed in the control group. The natural laxative mixture was rated as ‘easy’ or ‘very easy’ to administer by the nurses. The natural laxative was also cheaper, as it cost 30 cents a day, whereas the usually prescribed laxatives cost 52 cents a day .
Although we can expect prescription of laxatives to be needed in some cases, a regular supply of F&Vs could help to prevent and treat constipation.
FRUIT AND VEGETABLES AND QUALITY OF LIFE
There has been no study on the impact of the provision of F&Vs on quality of life among elderly hospitalized patients. Similarly, few controlled studies have related the effects of dietary counselling or overall nutritional intervention to quality of life. The few published studies are nevertheless encouraging.
Most studies have been conducted in the community. In a low-income neighbourhood, nutritional education counselling to increase F&V consumption in patients in the age range 18−75 years led to an increase in physical and mental health status, and self-rated health measured by medical outcome Short Form-36 (SF-36), in addition to improved beta-carotene and vitamin E plasma concentrations . In prehypertension or stage one hypertension patients of mean age 50 years, ‘dietary advice only’ was compared with two lifestyle interventions: low total and saturated fat, increased fruit and vegetable intake, along with at least 4 kg weight loss resulted in health related quality of life (SF-36) improvements at 6 and 18 months . It is of course impossible to know how much of the improved quality of life could be attributed to F&V intake among all the dietary pattern changes. But previous work compared, in the same population, a control diet, an F&V diet and a combination diet for 8 weeks. The combination diet emphasized fruits, vegetables and low-fat dairy products. Health-related quality of life improved in both the F&V diet and the combination diet. When all the subscales were summed into a total score, the control diet was associated with a mean improvement of 4.0%, the F&V diet with 5.0% and the combination diet with 5.9% from baseline. These data suggest that the F&V diet can not only lower blood pressure but may also improve the perception of health-related quality of life .
High F&V intake is an important feature of the Mediterranean diet, and some studies on the beneficial effects of this diet have focused on quality of life. In a multipurpose cohort study in university graduates from Spain (Seguimiento Universidad de Navarra project), Mediterranean diet was advised to 11 015 participants, who were followed for 4 years. Multivariate-adjusted models revealed a significant direct association between adherence to Mediterranean diet and all the physical and most mental health domains (vitality, social functioning and emotional role). More importantly, those who improved their initial Mediterranean diet scores had better scores in physical functioning, general health and vitality [25▪]. In postmenopausal women with type 2 diabetes randomized to a Mediterranean lifestyle (MLP) programme, results showed significantly greater improvements in the MLP condition compared with the usual care group on HbA1c, BMI, plasma fatty acids, and quality of life at the 6-month follow-up . Here again, the role of improved F&V intake among the other changes remains to be more precisely defined.
We note that ‘pills’, for example a multivitamin and mineral supplement, had no effect on quality of life as assessed by the SF-12 in community-dwelling adults ; thus, improved quality of life may be related more to the pleasure of eating F&Vs than to improved micronutrient status alone.
We know of only two studies of nutritional intervention and quality of life in hospitalized undernourished patients. Thirty-six patients admitted to a department of medicine, aged 70 ± 13 years, were randomized to either individual nutritional counselling, in the form of an individual nutritional plan adapted to the patient's requirements and course of the disease by a dietician with a variety of interventions such as enrichment of foods with energy and protein, protein-rich snacks, beverages and energy-dense oral nutritional supplements (ONSs), or to nutritional supplements alone (information about the risks of undernutrition, 2 units of ONS, no further nutritional information). Quality of life was assessed with the functional assessment of anorexia cachexia therapy (FAACT) questionnaire and with a visual analog scale (VAS). Energy and protein intake and quality of life increased in both groups between baseline and discharge, but in the individual nutritional counselling group, quality of life as assessed by the FAACT questionnaire further increased at 2 months. Energy intake was significantly correlated with quality of life as assessed with the VAS score both at baseline and before discharge from the hospital . F&Vs were not emphasized in the nutritional counselling, but this study shows that a nutritional intervention is liable to improve quality of life in elderly hospitalized patients. In the second study , 80 malnourished patients admitted to a gastroenterology ward with digestive benign disease were randomized to either ONS and dietary counselling or to dietary counselling only for 3 months. The age of the patients is not mentioned. Quality of life was assessed with the SF-36 questionnaire. At 3 months, the changes in weight and body composition were not different between groups. However, both hand grip strength and peak flow were significantly improved, and quality of life in the physical functioning, physical role, general health and vitality subscales of the SF-36 were significantly better in ONS patients vs. dietary counselling-only patients. An extension of this study [30▪▪] confirmed data on quality of life in 114 patients and suggested nutritional intervention to be cost-effective when considering quality-adjusted life years. In this study also, dietary advice focused on improving protein and energy intake, and intake in F&Vs was probably low because of digestive symptoms. Nevertheless, it is worth noting that a higher total macronutrient intake in these ill patients can improve muscle function and quality of life.
Long-term adherence to nutritional recommendations comprising high F&V intake has now been shown to promote health and help prevent cancer, cardiovascular disease and degenerative diseases such as Alzheimer's disease or age-related macular degeneration. However, little effort has been made to study the more immediate benefit of an improvement in the variety and organoleptic qualities of the diet that can be achieved by increasing F&V content. Elderly hospitalized patients are not a target for long-term disease prevention, but must first benefit from screening, preventing and treating malnutrition. Protein and energy supplementation reduces morbidity and mortality and must be offered to all hospitalized malnourished elderly patients. However, we also consider that although data are scarce, elderly patients could also benefit from quality F&Vs being included in the meal tray. Quality of food and especially of F&Vs has clearly not been a priority for hospital management teams, but further studies are now warranted on the benefit of a quality F&V diet on overall energy intake, constipation and quality of life in elderly patients.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
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