Executive Summary of Recommendations

Below are the major recommendations and ratings for the American Dietetic Association Unintended Weight Loss (UWL) in Older Adults Evidence-Based Nutrition Practice Guideline. Click here to view the Guideline Overview. More detail (including the evidence analysis supporting these recommendations) is available on this website to ADA members and EAL subscribers under Major Recommendations.

To see a description of the ADA Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence), click here.

The UWL Recommendations are listed below. [Note: If you mouse-over underlined acronyms and terms, a definition will pop up.]

UWL: Medical Nutrition Therapy

Medical nutrition therapy (MNT) is strongly recommended for older adults with unintended weight loss. Individualized nutrition care, directed by a registered dietitian (RD), as part of the healthcare team, results in improved outcomes related to increased energy, protein and nutrient intakes, improved nutritional status, improved quality of life or weight gain.

Strong
Imperative

UWL: Nutrition Screening

The registered dietitian (RD) should collaborate with other health care professionals, administrators and public policy decision makers to ensure that all older adults are screened for unintended weight loss, regardless of setting. Weight change is included in virtually all validated and unvalidated instruments for nutrition risk screening in older adults. Studies support an association between unintended weight loss and increased morbidity and mortality.

Strong
Imperative

UWL: Instruments for Nutrition Screening

The registered dietitian (RD) should collaborate with other health care team members and policy makers to ensure that nutrition screening tools have been validated in the older population. The Mini Nutritional Assessment Short Form and the Nutrition Screening Initiative DETERMINE Your Nutritional Health (DETERMINE) instruments are the most widely studied and validated in this population; several other nutrition screening instruments have been developed but not validated in older adults.

Strong
Imperative

UWL: Assessment of Food, Fluid and Nutrient Intake

The Registered Dietitian (RD) and/or Dietetic Technician Registered (DTR) should assess and evaluate food, fluid and nutrient intake in older adults with unintended weight loss. Research reports decreased intake of energy and nutrients in older adults who are acutely/chronically ill and/or underweight and those with cognitive impairment and dysphagia.

Strong
Imperative

UWL: Methodologies for Assessment of Food, Fluid and Nutrient Intake

To assess food, fluid and nutrient intake in older adults with unintended weight loss, the Registered Dietitian (RD) and/or Dietetic Technician Registered (DTR) should use quantitative methods (such as calorie counts, percentage of food eaten, individual plate waste studies, etc) rather than qualitative methods (such as interviews) over a period of several days. Research supports multiple days of assessment of food and nutrient intake, and studies report that quantitative methods are necessary to provide estimations of energy intake.

Fair
Imperative

UWL: Assessment of Nutritional Status

The Registered Dietitian (RD) should ensure that the nutrition assessment of older adults with unintended weight loss includes (but is not limited to) the following:

• Anthropometric measurements (e.g. height, weight, weight change)
• Biochemical data, medical tests and procedures
• Client history (e.g. cognitive decline, depression, neurological disease, hydration status, presence of infection and pressure ulcers, recent hospitalization, admission to healthcare communities and female gender)
• Food/nutrition-related history (e.g. loss of appetite, swallowing problems, eating dependency, low physical activity level, decreased activities of daily living)

Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions; all of these are associated with adverse health effects in older adults.

Strong
Imperative

UWL: Instruments for Assessment of Nutritional Status

The Registered Dietitian (RD) should collaborate with other health care team members and policy makers to ensure that nutrition assessment tools have been validated in the older population. The Mini-Nutritional Assessment is the most widely studied and validated in this population; several other nutrition assessment instruments have also been developed but not validated.

Strong
Imperative

UWL: Assess Anthropometric Measurements

The Registered Dietitian (RD) should ensure that older adults are weighed upon initial visit, admission or readmission to obtain a baseline weight, and then weekly thereafter, using standard procedures. Studies support an association between unintended weight loss and increased mortality.

Strong
Imperative

UWL: Nutrition Diagnosis of Involuntary Weight Loss

The Registered Dietitian (RD) will use clinical judgment in interpreting nutrition assessment data to diagnose unintended weight loss and/or underweight in the older adult. Studies support an association between increased mortality and underweight (BMI < 20 kg/m² or current weight compared with usual or desired body weight) and/or unintended weight loss (5% in 30 days, or any further weight loss after meeting this criteria).

Strong
Imperative

UWL: Estimating Energy Needs of Healthy Older Adults

When estimating energy needs for weight maintenance of healthy older adults, the Registered Dietitian (RD) should prescribe an energy intake of 25 - 35 kcal/kg/day in females and 30 - 40 kcal/kg/day in males. Research reports that applying physical activity levels ranging from 1.25 to 1.75 with measured RMR (via indirect calorimetry) in healthy older adults results in these mean total daily energy estimates.

Fair
Conditional

UWL: Estimating Energy Needs of Underweight Older Adults

When estimating energy needs for weight maintenance of underweight older adults, the Registered Dietitian (RD) should prescribe an energy intake of 25 - 30 kcal/kg/day, or higher energy levels for weight gain. Research reports that applying physical activity levels ranging from 1.25 to 1.5 with measured RMR (via indirect calorimetry) in older adults who are chronically or acutely ill and/or underweight results in these mean total daily energy estimates.

Weak
Conditional

UWL: Collaboration for Modified Texture Diets

The Registered Dietitian (RD) should collaborate with the speech-language pathologist and other healthcare professionals to ensure that older adults with dysphagia receive appropriate and individualized modified texture diets. Older adults consuming modified texture diets report an increased need for assistance with eating, dissatisfaction with foods, and decreased enjoyment of eating, resulting in reduced food intake and weight loss.

Strong
Conditional

UWL: Eating Assistance

The Registered Dietitian (RD) should collaborate with other health care professionals and administrators to ensure that all older adults who need assistance to eat receive it. Research indicates a positive association between eating dependency and poor nutritional status, especially in older adults with dysphagia who receive modified texture diets. In addition, research reports an association between poor nutritional status, frailty, underweight and/or weight loss with cognitive impairment and a decrease in the activities of daily living, including decreased ability to eat independently.

Strong
Conditional

UWL: Dining with Others

The Registered Dietitian (RD) should collaborate with other health care professionals and administrators to encourage all older adults to dine with others rather than dining alone. Research reports improved food intake and nutritional status in older adults eating in a socially stimulating common dining area.

Strong
Imperative

UWL: Improvement of Dining Ambience

The Registered Dietitian (RD) should collaborate with other health care professionals and administrators to promote improvement of dining ambience. Research indicates that improvements in physical environment and atmosphere of the dining room, food service and meals, and organization of the nursing staff assistance may result in weight gain in older adults.

Strong
Imperative

UWL: Creative Dining Programs

The Registered Dietitian (RD) should encourage creative dining programs for older adults. Research indicates that dining programs, such as buffet-style dining and decentralization of food service, demonstrate improvements in food intake and/or quality of life.

Strong
Imperative

UWL: Indications for Enteral Nutrition

The Registered Dietitian (RD) should recommend consideration of enteral nutrition for older adults who are undernourished or at risk of undernutrition; it is clearly indicated in patients with severe dysphagia. Studies support enteral nutrition as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition.

Strong
Imperative

UWL: Contraindications for Enteral Nutrition

Enteral nutrition may not be appropriate for terminally ill older adults with advanced disease states, such as terminal dementia, and should be in accordance with advance directives. The development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team, including the Registered Dietitian (RD).

Consensus
Conditional

UWL: Initiation of Enteral Nutrition

To improve energy and nutrient intake in older adults at nutritional risk, enteral nutrition should be initiated as early as possible after confirming tube placement. Studies support that enteral nutrition can be initiated 3 hours after a percutaneous endoscopic gastrostomy (PEG) tube is placed, and placement is confirmed.

Strong
Imperative

UWL: Route of Enteral Nutrition

For older adults with neurological dysphagia and/or if enteral nutrition is anticipated for longer than 4 weeks, the use of a percutaneous endoscopic gastrostomy (PEG) tube is preferable to nasogastric tubes. Studies report that PEG tube use is associated with fewer treatment failures and improved nutritional status.

Strong
Conditional

UWL: Indications for Medical Food Supplements

The Registered Dietitian (RD) should recommend medical food supplements for older adults who are undernourished or at risk of undernutrition (i.e., those who are frail, those who have infection, impaired wound healing, pressure ulcers, depression, early to moderate dementia and/or after hip fracture and orthopedic surgery). Studies support medical food supplementation as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition.

Strong
Imperative

UWL: Diet Liberalization

For older adults the Registered Dietitian (RD) should recommend liberalization of diets with the exception of texture modification. Increased food and beverage intake is associated with liberalized diets. Research has not demonstrated benefits of restricting sodium, cholesterol, fat and carbohydrate in older adults.

Strong
Imperative

UWL: Resident Involvement in Meal Planning

The Registered Dietitian (RD) should collaborate with other health care professionals and administrators to encourage older adults' involvement in planning menus and meal patterns, since studies show that this may result in improved food and fluid intake.

Strong
Imperative

UWL: Evaluation and Treatment of Depression

The registered dietitian (RD) should collaborate with other healthcare professionals to consider evaluation and treatment of depression for patients who are undernourished or at risk of undernutrition when medical nutrition therapy (MNT) interventions have not resulted in improved nutrient intake or stabilization of weight. Research reports an association between depression and weight loss or poor nutritional status.

Strong
Conditional

UWL: Appetite Stimulants

When medical nutrition therapy (MNT) interventions for older adults have not resulted in improved nutrient intake and/or stabilization of weight, the Registered Dietitian (RD) should collaborate with other healthcare professionals to consider appetite stimulants. There is no research on the effectiveness of appetite stimulants for older adults that meets the American Dietetic Association criteria for evidence analysis.

Consensus
Conditional

UWL: Monitor and Evaluate Nutritional Status

The Registered Dietitian (RD) should monitor and evaluate the nutritional status of older adults with unintended weight loss, based on the methodology initially used during assessment, including (but not limited to) the following:

• Anthropometric measurements (e.g. weight, weight change)
• Biochemical data, medical tests and procedures
• Client history (e.g. cognitive decline, depression, neurological disease, hydration status, presence of infection and pressure ulcers, recent hospitalization)
• Food/nutrition-related history (e.g. loss of appetite, swallowing problems, eating dependency, low physical activity level, decreased activities of daily living)

Monitoring and evaluation of the above factors is needed to determine the effectiveness of medical nutrition therapy (MNT); all of these are associated with adverse health effects in older adults.

Strong
Imperative

UWL: Monitor and Evaluate Food, Fluid and Nutrient Intake

The Registered Dietitian (RD) and/or Dietetic Technician Registered (DTR) should monitor and evaluate food, fluid and nutrient intake in older adults with unintended weight loss, based on the methodology initially used during assessment. Research reports decreased intake of energy and nutrients in older adults who are acutely/chronically ill and/or underweight and those with cognitive impairment and dysphagia. In addition, research supports multiple days of assessment of food and nutrient intake, and studies report that quantitative methods are necessary to provide estimations of energy intake.

Strong
Imperative

UWL: Monitor and Evaluate Anthropometric Measurements

The Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). Studies support an association between unintended weight loss and increased mortality.

Strong
Imperative