Dietary fat intake and quality of long-term care residents in two cohorts assessed 10 years apart | BMC Nutrition
We observed that the quality of dietary fat in long-term care facilities was poor in 2007, but even worse in 2017/18, despite official dietary guidelines. This worsening was due to a significant increase in SFA intake and, therefore, dietary fat quality indicators worsened in elderly long-term care residents. The 2017 cohort’s higher SFA intake was predicted by sugar intake, male gender, independent eating, eating larger amounts of food, and not having a dry mouth .
Very few studies have described the fat composition profile of long-term care residents. In a study by Rodríguez-Rejón et al.  the fat composition of Spanish long-term care facilities was reported, but quality indicators were not calculated. In their study, SFA intake was about half that of the 2017/18 cohort in our study. In a Canadian study, SFA intake assessed from long-term care facility menus was about the same as in the 2007 cohort, but MUFA and PUFA intakes were significantly higher than in the 2007 cohort. either of the cohorts in our study. .
Recommendations on fat quality are consistent across different national authorities and expert groups [14,15,16,17,18]. Generally, all authorities encourage reduction of SFA intake to less than 10% E or even reduction even further and replacement with PUFAs and PUFAs. . In our study, fat quality among long-term care residents was already poor in 2007, but even worse in 2017: residents’ SFA consumption averaged 17E% compared to 13E% in 2007. furthermore, in both cohorts, PUFA intake was below the recommended 5-10 E%. Malnutrition and its risk among residents was high (>80%) at both time points, which is common in long-term care facilities [5,6,7]. In order to avoid resident weight loss, it is common practice to increase the energy content of meals served by adding fat to meals during preparation. . Traditionally, this meant adding butter or cream to various foods and using whole dairy products instead of low-fat or fat-free products. In the recommendation recently published in Finland and targeting in particular the elderly, the quality of fats is considered an important issue and the use of vegetable oils and soft margarines is encouraged instead of butter and cream. . This obviously did not happen in long-term care facilities. Although data from both cohorts was collected before the new guideline was published, the general diet quality guideline was published in 2014 .
Good quality fat can slow some aspects of age-related health decline. High SFA intakes increase hepatic fat and serum cholesterol, while increased MUFAs and PUFAs appear to be beneficial in modulating hepatic fat and lipid metabolism. [27,28,29,30]. Additionally, diets high in MUFA and PUFA may improve insulin sensitivity,  reduce the risk of type 2 diabetes  and improve cardiovascular outcomes . A healthy brain also depends a lot on good cardiovascular health. . Fatty acids participate in multiple functions in the body and interact with other food components as well as the microbiome and therefore the composition of dietary fats can be pro- or anti-inflammatory [33, 34]. Cardiovascular disease, Alzheimer’s disease and frailty have all been linked to increased chronic inflammation [35,36,37]. It has been suggested that the n-6:n-3 ratio is also important for cardiovascular health although the optimal n-6:n-3 ratio for human health remains under debate . In our study, the n-6:n-3 ratio was reasonably good, but the problem with fat quality was more related to low PUFA intakes in general. Thus, a good quality of fats and an adequate intake of n-3 fatty acids are also important for older people.
Although residents of the two cohorts were the same age and did not differ in MNA score or BMI, residents of the 2017/18 cohort had poorer physical and mental health than residents of the 2007 cohort. reflects stricter national guidelines for admission to long-term care facilities . In Finland, due to public policy, institutionalized care for the elderly has been kept to a minimum and people are expected to live at home as long as possible. . Thus, only people with very severe dementia, reduced mobility or other serious health complications due to multiple chronic conditions are offered a place in a long-term care-type nursing home or assisted living facility. . This can also be seen in participants from the 2017/2018 cohort, who had very poor cognition measured with the CDR (Table 1) compared to participants from the 2007 cohort.
However, nutritional care factors such as intensive nutritional care, use of oral nutritional supplements, dysphagia, chewing problems, or other nutrition-related problems that might be associated with poor nutrition, do not were not associated with higher SFA intake in this study. Among specific nutritional problems, only dry mouth was inversely associated with SFA intake. This reflects higher food consumption, as those with dry mouth consumed significantly less energy than those without. Similarly, residents who ate independently and residents who reported consuming larger amounts of food had higher SFA intake than those who needed help eating or those who reported eating very little. Thus, all associations related to nutritional care were associated with the amount of food consumed.
Interestingly enough, despite official recommendations, the quality of fat has deteriorated. This could be because over the past 10 years, specific training on how to identify and treat malnutrition in long-term care facilities has been provided to nurses working in these facilities. This appears to have led to an increase in SFAs in the foods served to prevent residents from losing weight. As sugar intake was one of the strongest predictors of higher SFA intake, it is likely that sugar is also added to the diet to make the foods on offer more palatable to residents at risk of weightloss.
The strengths of our study include its large sample of long-term care residents in 2007 and 2017/18. To our knowledge, this is the first study that specifically explores the detailed composition and quality of fats and how they have changed in recent years in the diets of these people. Trained nurses or nutritionists performed all measurements in the 2007 and 2017/18 cohorts and all questionnaires and measurements were validated. In addition, demographic information and nutritional supplements were extracted from medical records, which increases the reliability of our results. However, our study also has many limitations. Food diaries can be subject to error. However, since trained nurses complete resident diaries, subjective under-reporting or over-reporting is unlikely. More problematically, when only 1-2 day food diaries are assessed, they may differ from the person’s average food intake over a longer period of time. However, although individual food intake may vary on a day-to-day basis, our results are relevant at the group level. . In addition, practices favoring the use of sources of SFAs such as whole milk products, high-SFA spreads, butter and cream are not likely to vary significantly from day to day in CHSLD. One limitation concerns the food diary data analysis tool used in 2007 (Nutrica). The data obtained in the last 2017/18 cohort was more detailed than in 2007 and also included the amounts of trans fatty acids, n-3 and n-6 fatty acids. Therefore, a very detailed comparison of fat composition between the two cohorts was not possible. The change in food diary analysis tools between the two cohorts should not affect the reliability of food intakes, since both programs are based on the same Finnish food database (Fineli) and are validated tools. Residents of the 2017/18 cohort had poorer health, cognition and mobility, making them more vulnerable to malnutrition compared to 2007 residents. However, the residents also had many similarities and did not differ significantly regarding nutrition between cohorts. Another limitation of our study is that the average length of stay in long-term care is only 2 years; it was therefore not possible to follow the same residents over time. However, although changes in dietary fat intake may be due to many confounding factors, e.g. dentition, BMI, health status or other dietary factors, in our study dietary intakes higher in SFA were related only to the amount of food consumed.
The 2017/18 sample was randomly selected from volunteer establishments. This latest sample included six long-term care facilities originally included in the 2007 sample. Although not all long-term care facilities were compared, all long-term care facilities are city-run Helsinki and all establishments must follow the same nutritional guidelines. In addition, they have the same resources, the same care and residents spend the last years of their lives there. Institutional participation in this study was voluntary and the investigators could not influence participation. Although fewer facilities participated in the cohort in 2017/2018, in fact, more residents participated in the study compared to the 2007 study. Results were obtained from facilities long-term care facilities in the Helsinki metropolitan area with predominantly Caucasian residents. The data may therefore not apply to other ethnic groups. Finally, due to the observational nature of our study, no causal relationship can be drawn from these results.