Nutrition & Fall Prevention (Spring 2015)

 

By Anna Wren

Nutrition plays a key role in fall prevention.

  • Reducing risk of falls among seniors through evidence based prevention measures is an important objective outlined in BC's Guiding Framework for Public Health
  • Despite efforts across health sectors to reduce risk of falls, there is a lack of evidence-based provincial resources in the area of nutrition and fall prevention

 Consider nutritional status and weight:

  • One third of older Canadians are at increased nutritional risk and poor nutrition leads to weakness, frailty and falls.  Nutritional screening identifies seniors at risk to prevent or reverse malnutrition
  • Factors that increase risk include eating alone, lack of support with shopping/cooking, limited access to affordable transportation, and having an illness or condition that affects dietary intake
  • There is limited evidence that being overweight or underweight increases risk of falls, but weight loss can result in loss of muscle and bone, leading to poor balance increasing risk of falls and fractures
  • Fall prevention programs are unlikely to have a lasting impact if they fail to address malnutrition

Get enough protein:

  • Older adults need more protein than younger adults to support good health, recover from illness, and maintain functionality,  yet loss of appetite and reduced intake are common with aging
  • Protein intake must be coupled with adequate calorie intake to ensure protein is used efficiently
  • Low protein diets and loss of muscle mass (sarcopenia) are associated with higher fall risk
  • Older adults need 1.0-1.2 grams of protein per kilogram of body weight per day (or 25-30 grams at meals).  For protein-rich foods, check out: http://www.healthlinkbc.ca/healthyeating/protein.html

Take a Vitamin D supplement:

  • Despite lack of consensus, most research recommends vitamin D to prevent falls among older adults
  • Vitamin D deficiency is common - 25% of Canadian seniors were deficient in 2011.  Deficiency leads to muscle weakness, postural sway, and more frequent falls and fractures among older adults
  • To reduce the risk of falls and fractures, the bulk of evidence recommends older adults take a daily vitamin D supplement providing 1000IU.  Vitamin D3 is most commonly recommended by BC clinicians
  • General guidelines are: avoid cod liver oil (high vitamin A content), and to enhance absorption, avoid taking vitamin D supplements with high fiber cereals / fiber supplements, and take with meals containing fats
  • Toxicity is rare - the kidneys limit vitamin D activation. Vitamin D is safe with intakes < 10 000IU/day

Consider calcium intake:

  • Calcium and vitamin D's roles are closely intertwined.  Calcium reduces fractures in older adults and may influence the impact of protein on the skeleton
  • Low vitamin D impairs calcium absorption and increases risk of bone loss.  As little as 10% of calcium is absorbed with vitamin D deficiency, while sufficiency enhances absorption by 30-40%
  • The goal for calcium intake to prevent fractures is 1000-1200mg per day

Rule out anemia:

  • Anemia (low iron and possibly low vitamin B12) in older adults is associated with muscle weakness, dizziness and fatigue and is a treatable risk factor for prevention of falls and fractures

Consider hydration:

  • Age related changes (decreased kidney function, conscious decision to restrict fluids due to incontinence, and diminished sense of thirst) increase risk of dehydration among older adults
  • Orthostatic hypotension (drop in blood pressure with standing) can cause dizziness and increase fall risk.  Adequate fluids (9 cups for women and 12 cups for men) are recommended to prevent falls

 Implications for public health:

  • Nutrition is key to maintaining functionality and independence among older adults and registered dietitians are uniquely qualified to identify nutritional risk and improve population health outcomes
  • A public health approach to fall prevention draws on scientific evidence and expertise from many disciplines to resolve issues that impact large populations

The following outline of the model's 4 steps illustrates the role of dietitians and nutrition in fall prevention:

  1. Identifying the problem: Surveillance is key to monitoring population health status.  Data on nutritional status of BC seniors is needed to support the role of nutrition in fall prevention
  2. Assessing risk: Fall prevention programs should incorporate nutritional risk screening  by a dietitian to identify seniors at risk and provide evidence for policy and targeted programs
  3. Applying best practice: Dietitians must keep current on latest evidence, and existing nutrition resources (Healthy Eating for Seniors) should be updated with evidence on nutrition and fall prevention
  4. Evaluating the intervention: Use of a validated nutrition screening tool provides ability to monitor changes in nutritional status among older adults participating in fall prevention program

There is substantial evidence that healthy eating behaviours directly influence risk of falling later in life.  Strategic investments in programs and services that promote healthy eating for older adults in BC will help meet the Guiding Framework's objective to reduce falls among seniors, save health care dollars, and contribute to a strong, effective public health system

Key References:

American Geriatrics Society. (2014). Recommendations abstracted from the American Geriatrics Society consensus statement on Vitamin D for prevention of falls and their consequences. Journal of the American Geriatrics Society, 62(1), 147-152.

Bauer et al. (2013). Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE study group. Journal Of The American Medical Directors Association, 14(8), 542-559.

BC Ministry of Health. (2013). Promote, protect, prevent: our health begins here. BC's guiding framework for public health

Bischoff-Ferrari et al. (2009). Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ, 339(7725), 843-846.

Buhr & Bales (2009). Nutritional supplements for older adults: review and recommendations - part I. J Nutr Elder, 28(1), 5-29.

Cameron, I. (2013). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Systematic Reviews, (3)

Dawson-Hughes, B., Mithal, A., Bonjour, J.P., Boonen, S., Burckhardt, P., Fuleihan, G.E.H., ... 

Yoshimura, N. (2010). IOF position statement: vitamin D recommendations for older adults. Osteoporos Int, 21(7), 1151-1154.

Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C. Gates, S., Clemson, L.M., & Lamb, S.E. (2013). Interventions for preventing falls in older people living in the community. Cochrane Systematic Reviews, (9)

Moore & Boltong (2011). Don't fall for weight: A systematic review of weight status and falls. Nutrition & Dietetics, 68(4), 273-279.

Ramage-Morin & Garriguet (2013). Nutritional risk among older Canadians. Statistics Canada Health Reports, 24(3), 3-13.

Scott et al. (2010). Falls & Related Injuries Among Older Canadians: Fall-related hospitalizations & Intervention Initiatives. Prepared on behalf of the Public Health Agency of Canada, Division of Aging and Seniors.

Scott et al. (2010). A public health approach to fall prevention among older persons in Canada. Clinics in Ger Med, 26(4), 705-718.

Stolz, et al. (2002). Nutrition screening and assessment of patients attending a multidisciplinary falls clinic. Nutrition & Dietetics, 59(4), 234-239.

Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. (2011). Journal of the American Geriatrics Society, 59(1), 148-157.

Tsai & Lai (2013). Mini Nutritional Assessment and short-form Mini Nutritional Assessment can predict the future risk of falling in older adults-Results of a national cohort study. Clinical Nutrition, 1-6.