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Clegg, M.E. and Williams, E.A. (2018) Optimizing nutrition in older people. Maturitas, 112.
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Optimizing nutrition in older people

Miriam E Clegg1*, Elizabeth A Williams2

1
Oxford Brookes Centre for Nutrition and Health, Department of Sport, Health Sciences and

Social Work, Faculty of Health and Life Sciences, Oxford Brookes University, Gipsy Lane,

Oxford OX3 0BP, UK; 2Department of Oncology & Metabolism, Human Nutrition Unit, The

University of Sheffield, Beech Hill Road, Sheffield, S10 2RX

*Corresponding author: Miriam Clegg, Oxford Brookes Centre for Nutrition and Health,

Department of Sport, Health Sciences and Social Work, Faculty of Health and Life Sciences,

Oxford Brookes University, Gipsy Lane, Oxford OX3 0BP, UK

Email: mclegg@brookes.ac.uk; Ph: +44 1865 484365

Declarations of interest: none

Older adults are at increased risk of malnutrition due to a variety of physiological and

psychological reasons. This has implications for health, quality of life, independence and

economic circumstances. Improvements in nutrition are known to bring tangible benefits to

older people and many age-related diseases and conditions can be prevented, modulated or

ameliorated by nutrition. However practical and realistic approaches are required to optimise

diet and food intake in older adults. One area where improvements can be made is in the area

of appetite. Encouraging older adults to prepare meals can increase appetite and food intake,

and providing opportunities for older adults to eat in company with a wide variety of foods

available are simple strategies to increase food intake.

Protein requirements in older adults is subject to controversy and although considered the

most satiating macronutrient, it appears that it does not elicit as great a satiating effect in

older adults as it does in younger individuals. This indicates that there is potential to increase

protein intake without impacting on overall energy intake. Other areas where simple practical

improvements can be made is in both packaging of foods that are easy to prepare and in the

education of older adults on the safe storage and preparation of food. Research into

improving the diets and nutritional status of older adults has indicated that many of the

known strategies can be easily and cost effectively undertaken in practice.

Keywords

Older adults; elderly; nutrition; diet; appetite; ageing

Increased life expectancy coupled with a decline in fertility rates has led to a global

demographic shift towards an ageing population. The number of older persons (those aged

60 years or over) is expected to more than double by 2050 and to more than triple by 2100,

[1]. From an individual’s perspective this is a positive phenomenon, however at a societal

level it presents numerous challenges in terms of managing people’s health, quality of life,

and economic circumstances.

Even though life expectancy has increased, for many the quality of these latter years has not

improved, which has a significant impact on healthcare costs. With ageing comes an

increased likelihood of developing chronic diseases such as diabetes, cancer and heart

disease, and an increased risk of frailty, cognitive decline and disability. Improvements in

nutrition are known to bring tangible benefits to older people and many age-related diseases

and conditions can be prevented, modulated or ameliorated by nutrition [2]. The current

review will focus on dietary issues and nutrition requirements of older adults. Furthermore, it

will examine how foods and diets can be adjusted to enhance appetite and optimize dietary

intake.

2. Methodology

This review presents a comprehensive detail of the nutritional problems and potential

solutions in available in older adults in order to enhance appetite and optimize dietary intake.

The review was written using peer-reviewed articles known to the authors and complemented

through a search of PubMed and CINAHL. Keywords used included “ageing”, “elderly” and
“older” alongside “nutrition”, “appetite” and “food intake”. Articles published in peer-

reviewed; English language journals up to January 2018 were reviewed and considered for

inclusion. Reference lists from articles retrieved were also checked.”

3. Dietary issues in older adults

A range of psychosocial and physiological factors influence nutritional intake and status in

older adults. For example a change in body composition with ageing has a profound effect on

nutritional status and requirements. From 70 years onwards both lean body mass and total

body weight decrease [3]. This reduction in body weight and loss of lean body mass, results

in an increased risk of sarcopenia, osteoporosis, frailty, a resulting increased propensity for

falls and fractures, infection and an overall increased risk of mortality and morbidity. Other

physiological factors include reduced physical function, visual impairment, poor dentition,

and gastrointestinal changes. From a psychological and social perspective bereavement,

depression, isolation, dementia and socioeconomic constraints are all factors that impact on

the nutritional status of older adults. Collectively these factors can result in a reduction in

appetite, and a reduced ability and motivation to purchase and prepare food [2]. Depression

and isolation are major contributors to weight loss in older people. Depression can lead to

increases in serotonin and corticotropin releasing hormone which are potent anorectic

neurotransmitters [4] and it is well established that people living alone consume less food [5]

and have a poorer diet quality [6]. The need to prepare foods or catering limitations for just

one person is also an issue [7].

years of age. The UK National Diet and Nutrition Survey (NDNS)1 showed that free-living

men and women aged 75 to 84 years were consuming just 88% and 77% of estimated

requirements for energy, respectively [9]. A secondary analysis of this data was performed

using the criteria of the Malnutrition Advisory Group (MAG) for detecting risk of

malnutrition. Approximately 14% of adults over 65 years of age were at medium or high risk

of undernutrition based on the composite measure of low body mass index (BMI) and recent

reported weight loss [8]. More recent data from the NDNS (combined 2012/13-2013/14)

shows that low energy intake persists in the UK, with the average for men and women 65

years and older falling below the estimated average requirements for individuals over 75

years of age [10].

Malnutrition is associated with an increase in morbidity and mortality rates in older adults

and a decrease in their quality of life. In residential and nursing homes, malnutrition often

associates with cognitive impairment, hypotension, infection and anaemia, and impaired

physical performance at everyday tasks such as dressing and washing. In hospitals,

malnutrition is related to longer length of hospital stay, increased morbidity and mortality rate

and increased complications such as fracture, infections and specific nutrient deficiencies

[11].

Decreases in physical function can cause a variety of issues in terms of eating and preparing

food. These include oral problems, impairment of masticatory function and swallowing

problems that can lead to food avoidance [11, 12]. Similarly decreases in enjoyment of food

1
The National Diet and Nutrition Survey assesses the diet, nutrient intake and nutritional
status of the general population of the UK. More information can be found here:
https://www.gov.uk/government/collections/national-diet-and-nutrition-survey
due to reduction in taste, smell and sight. Another major contributor to decreased food intake

is the use of medication and polypharmacy with many drugs and medications required by

older adults having a direct effect on appetite [13]. This decrease in appetite that occurs in

older adults is known as the anorexia of ageing.

4. Appetite in older adults

Anorexia of aging, has been defined by Morley and Silver [14] as ‘‘the physiological

decrease in food intake occurring to counterbalance reduced physically activity and lower

metabolic rate, not compensated in the long term’. Reduced appetite in older individuals has

been well documented [15] with changes in appetite correlated with the delayed gastric

emptying (GE) seen with advancing age. Most but not all studies suggest that the rate of GE

and gastrointestinal transit slows in older compared with younger adults [15, 16]. This means

that food remains in the stomach for longer resulting in prolonged postprandial satiety. This

delayed GE is caused by less compliant fundus of the stomach in older adults which further

contributes to anorexia due to more rapid antral filling and an earlier antral stretch [17].

Satiety hormones are also known to change with age. Several studies have demonstrated the

presence of higher circulating concentrations of the anorexigenic hormone cholecystokinin

(CCK) in older compared to young individuals, and a greater satiating effect of CCK in older

people [18]. Greater increases have also been found postprandially in glucagon-like peptide 1

(GLP-1), following a high fat meal in older compared to younger people [19]. Ghrelin is the

only peripheral hormone known to stimulate hunger. However, there is little consensus about

its effects on appetite in older adults [20]. It has been suggested that hyperinsulinemia in the

elderly could also be responsible for inhibiting ghrelin gastric expression and central
sensitivity [21]. Furthermore in older males, the decline in testosterone results in a further

increase in leptin [22] which may also decrease appetite. The combined actions of these

hormones convey important anorexigenic signals to the hypothalamus which may have

significant implications for food intake in the elderly.

5. Nutrient requirements of older adults

There is discussion in the extant literature as to the optimum nutrient requirements of older

adults. Energy requirements tend to be lower due to altered body composition and reduced

physical activity, however the requirements for many nutrients are thought to be unchanged

[2] resulting in a need for a lower energy, yet more nutrient dense diet.

There is considerable debate regarding protein requirements in older age. Adequate dietary

protein is particularly important in older adults to maintain muscle mass, support wound

healing, skin integrity, immunity, and recovery from illness [23]. UK dietary reference

nutrient intake values indicate that protein requirements for adults are 0.75g/kg body weight

per day [24]. However it has been proposed that this should be increased to 1.0 to 1.2 g

protein/kg body weight/day for a healthy older adult, and to 1.2 to 1.5 g protein/kg body

weight/day for older people who are malnourished or at risk of malnutrition [25]. One

argument for increasing protein intake is that older adults may develop resistance to the

positive effects of dietary protein on synthesis of protein, a phenomenon termed anabolic

resistance that limits muscle maintenance and accretion. Older adults may also have higher

protein needs to offset the elevated metabolism of inflammatory conditions. In healthy older

adults and in a variety of diseases, protein anabolism is related to net protein intake. However

others argue that increased dietary protein is not required in the elderly due to reduced needs
associated with declines in lean body mass and the association between high protein intake

and impaired renal function [23]. Up to 10% of community-dwelling older adults and 35% of

those in institutional care in Europe do not have a sufficient food intake to meet a protein

intake of 0.7 g/kg body weight/day [26].

UK dietary references values for vitamins and minerals are the same for older adults (65+) as

they are for the adult population (50+) [24], yet some micronutrients are of particular concern

for certain sub-groups of the older adult population. Micronutrients that are highlighted as

important for older adults include calcium and vitamin D primarily for the preservation of

bone mineral density and fracture prevention. Current recommendations established in 2016

indicate all population groups aged 4 years and older should have a Reference Nutrient Intake

(RNI) of 10 µg/d (400 IU/d) vitamin D [27]. However a systematic literature review carried

out by Lamberg-Allardt et al [28] suggested that intakes greater than 10 µg/d vitamin D may

be required in older adults where the synthesis of vitamin D in the skin may be reduced and

the intestinal absorption of vitamin D may be lower than in younger persons.

There is evidence of low intake, impaired absorption and low status of certain B vitamins in

older adults. Vitamins B12, B6 and folic acid are all involved in homocysteine metabolism,

and elevated homocysteine has been linked with cardiovascular disease, impaired cognitive

function and dementia [29, 30]. Despite strong observational evidence to suggest that B

vitamins could benefit older adults through homocysteine lowering mechanisms, intervention

studies with B vitamins designed to lower homocysteine have failed to demonstrate any

convincing benefit to cardiovascular or cognitive health [31, 32].

of free radical damage implicated in a range of age-related chronic diseases including

Alzheimer’s disease and cancer. However, whilst deficiency of these nutrients is likely to be

detrimental in terms of risk of infection and wound healing, results from randomised

controlled trials aimed at chronic disease prevention have been inconsistent [33, 34]. A meta-

analysis of nutrition supplementation trials concluded that there was no benefit of antioxidant

supplements in the absence of deficiency for primary and secondary mortality prevention,

and some evidence that vitamin E , ß carotene high dose vitamin A, could even increase

mortality [35].

6. Optimising the dietary intake of older adults.

While understanding which nutrients are most needed by older adults is of importance,

insufficient food intake is a primary cause of malnutrition in older adults. Reduced food

intake is partly caused by a reduction in appetite. This can often occur alongside or because

of a decline in sensory perception including small and taste, poor dentition, and medication

[36]. Because of this innovative approaches are needed to increase energy intake but also to

ensure that the diets of older adults is optimal.

6.1 Food products

The palatability of food is related to the properties of the food such as taste, smell, texture

and temperature, as well as the visual appearance that invokes an enjoyable response.

Several of these parameters have been shown to influence food intake in older adults.

Previous research has indicated that providing older adults with food variety [37] and
enhanced flavoured foods can, via the use of enhancers such as mono-sodium glutamate,

increase their food intake [38].One study examining the effect of natural food flavours on

food and nutrient intake in hospitalised older patients in Hong Kong found that total energy

and protein intakes were increased by 13-26% and 15-28%, respectively, with flavour

enhancement [39]. However not all studies have been as successful in increasing food intake

by altering palatability [40] which may be due to the heterogeneity in chemosensory losses

among elderly people. Presenting older people with a varied meal may also be a valid

strategy to improve food intake in this group [37]. However there are obvious cost and waste

implications associated with this strategy. Several other tactics have been developed such as

sauces with additional nutritional value [41]. The addition of sauce to a test meal was shown

to increase protein intakes that was not fully (or even partially in some cases) compensated

for later on in the day. This potentially indicates that increases in protein intake can occur

with only minimal effects on satiety [42].

Protein is well known to be the most satiating macronutrient, and because of this has the

potential to decrease food intake. However studies that manipulated the portion size and

protein content of meals found that the protein enriched meals increased the protein intake

[43]. Recent research also showed that although whey-protein loaded drinks slowed GE and

increased secretion of satiety hormones, they had no suppressive effect on subsequent ad

libitum energy intake in older adults [44]. This body of research indicates that protein rich

ingredients are unlikely to hinder food intake potentially due to the reduced satiating effect of

satiety hormones, and offers a potential means to increase protein intake in older adults.

Poor dentation is a common reason given for lack of food intake in older adults however

research has shown that increased chewing does not influence meal size in older adults but
did influence palatability, which may cause reductions in intake due to sensory specific

satiety [45]. Liquids were also found to be less filling in older adults which suggests liquids

are the best route for increasing food intake especially protein intake [46]. A 24 week protein

shake intervention has been shown to have positive impacts on body composition with

increases in lean tissue mass of 0.45 kg [47]. Another recent novel study incorporating the

addition of walnuts (15% energy) to an ad libitum diet resulted in significantly higher intake

of total protein, vegetable protein, total polyunsaturated fatty acids (PUFA) and omega-3and

omega-6 PUFA; and significantly lower intake of total carbohydrate, animal protein,

saturated fatty acids, and sodium [48].These measures indicate that simple manipulations to

meals and diets can result in increases in energy and nutrient intake.

6.2 Food packaging, preparation and the eating environment

Older adults living alone may not consume meals due to lack of desire in preparing single

portions [49]. Loneliness is one of the key factors causing decreased food intake in older

adults and living alone is a major contributor to malnutrition as those that dine alone eat less.

Eating with others, particularly with friends, is associated with increased energy intake due

to a social facilitation effect [7]. Companionship can mitigate the impact of age-related

appetite loss on energy intake too, this is particularly true for older adults who live alone [50].

Declining functional abilities can increase the risk of malnutrition, a decline in general health,

increased risk of injuries or food poisoning [51]. Loss of strength and dexterity can make

packaging difficult to open resulting in an avoidance of certain foods [52]. This is not helped

by packaging and labelling of food products in font sizes that are difficult to read for older

adults due to declines in eyesight. Older adults are at a much greater risk of becoming ill from
food borne disease due to a weakened immunity. Listeriosis in particular can be fatal in high

risk groups such as the elderly [53]. The World Health Organization reported that adults aged

>60 years are 2.6 times more likely to develop serious illness as a result of consuming high

concentrations of L. monocytogenes (the form of listeria that is pathogenic to humans) than

the healthy general population [54]. The incidence of listeriosis over the last decade has

increased among those aged 60 years and older and in particular among adults older than 70

years [55]

In a survey conducted in the domestic kitchens of adults over 60 years in South Wales, forty-

one percent of foods in home refrigerators were beyond the use-by date, of which 11% were

unopened ready to eat (RTE) food products commonly associated with listeriosis. Sixty-six

percent of opened RTE foods had been or were intended to be stored beyond the

recommended 2 days after opening. Fifty per cent of central storage and 85% of door storage

areas were operating at temperatures >5°C. The study demonstrated that many older adults

fail to adhere to food storage recommendations and subject RTE foods associated with L.

monocytogenes to prolonged storage at unsafe temperatures, which may render food unsafe

for consumption [56].

One way to avoid these pitfalls is through home delivered meals. Home-delivered meals have

the advantage of providing quality food to individuals at risk; and helps these individuals to

remain living independently. Research indicates that that home delivered meals can improve

both dietary intake and quality. The greatest health benefits are achieved when home

delivered meals reach the neediest individuals, resulting in a decrease in institutionalization

of older adults and associated healthcare costs [57]. However, in contrast to this regular meal

preparation can stimulate appetite and interest in food resulting in improved nutrition and
lower risk of mortality [49]. Mealtime interventions that constitute a shared mealtime have

also been used effectively in institutionalised older adults in long-term residential care to

improve energy intake [58].

7. Conclusions

Nutrition is a major determinant of health and wellbeing in old age, however there is

considerable debate with regards to the nutrient requirements of older adults and risk of

malnutrition is known to increase with advancing age. Evidence-based strategies are needed

to combat declines in food intake and enhance nutrient intake, particularly in the very old and

in socially isolated older adults. Recent studies suggest that the satiating properties of protein

are lower in older adults and protein enriched beverages can promote positive changes in

food intake and lean body mass. Encouraging older adults to prepare meals can improve

appetite and food intake, however strategies are also needed to develop food packaging that is

suitable for older adults and to ensure food safety education is provided to improve food

handling and storage practices. Shared meals remain an important mediator of food intake as

depression and loneliness are a key cause of age related anorexia.

In view of the increasing age of the population and the associated health and social care costs,

further research is needed to help combat nutrition-related problems and to define specific

nutrient requirements in old age for the benefit of individuals and society as a whole.

Contributors

Miriam Clegg developed the original outline of the review. Both authors contributed equally

to the research and the writing of the manuscript. Both authors approved the final submission
Competing interest

Neither author (EW, MC) has any competing interests.

Funding

None was secured or received for writing the review.

References

[1] United Nations., United Nations Department of Economic and Social Affairs/Population

Division. World Population Prospects: The 2017 Revision, Key Findings and Advance

Tables, 2017.

[2] J. Shlisky, D.E. Bloom, A.R. Beaudreault, K.L. Tucker, H.H. Keller, Y. Freund-Levi,

R.A. Fielding, F.W. Cheng, G.L. Jensen, D. Wu, S.N. Meydani, Nutritional Considerations

for Healthy Aging and Reduction in Age-Related Chronic Disease, Adv Nutr 8(1) (2017) 17-

26.

[3] L. Genton, V.L. Karsegard, T. Chevalley, M.P. Kossovsky, P. Darmon, C. Pichard, Body

composition changes over 9 years in healthy elderly subjects and impact of physical activity,

Clin Nutr 30(4) (2011) 436-42.

[4] J.E. Morley, Depression in nursing home residents, Journal of the American Medical

Directors Association 11(5) (2010) 301-3.

[5] Y.M. Hsieh, T.S. Sung, K.S. Wan, A survey of nutrition and health status of solitary and

non-solitary elders in taiwan, J Nutr Health Aging 14(1) (2010) 11-4.

[6] X. Irz, L. Fratiglioni, N. Kuosmanen, M. Mazzocchi, L. Modugno, G. Nocella, B.

Shakersain, W.B. Traill, W. Xu, G. Zanello, Sociodemographic determinants of diet quality

1177-89.

[7] J.M. de Castro, N. Stroebele, Food intake in the real world: implications for nutrition and

aging, Clin Geriatr Med 18(4) (2002) 685-97.

[8] B.M. Margetts, R.L. Thompson, M. Elia, A.A. Jackson, Prevalence of risk of

undernutrition is associated with poor health status in older people in the UK, European

journal of clinical nutrition 57(1) (2003) 69-74.

[9] G. Smithers, S. Finch, W. Doyle, C. Lowe, C.J. Bates, A. Prentice, P.C. Clarke, The

National Diet and Nutrition Survey: people aged 65 years and over., Nutrition and Food

Science. 98(3) (1998) 133-134.

[10] Public Health England., National Diet and Nutrition Survey: Results from Years 5 and 6

(Combined) of the Rolling Programme (2012/2013–2013/2014), London, UK, 2016.

[11] I. Feldblum, L. German, H. Castel, I. Harman-Boehm, N. Bilenko, M. Eisinger, D.

Fraser, D.R. Shahar, Characteristics of undernourished older medical patients and the

identification of predictors for undernutrition status, Nutr J 6 (2007) 37.

[12] M.D. Patel, F.C. Martin, Why don't elderly hospital inpatients eat adequately?, J Nutr

Health Aging 12(4) (2008) 227-31.

[13] S.P. Fitzgerald, N.G. Bean, An analysis of the interactions between individual

comorbidities and their treatments--implications for guidelines and polypharmacy, Journal of

the American Medical Directors Association 11(7) (2010) 475-84.

[14] J.E. Morley, A.J. Silver, Anorexia in the elderly, Neurobiol Aging 9(1) (1988) 9-16.

[15] W.K. Clarkston, M.M. Pantano, J.E. Morley, M. Horowitz, J.M. Littlefield, F.R. Burton,

Evidence for the anorexia of aging: gastrointestinal transit and hunger in healthy elderly vs.

young adults, Am J Physiol 272(1 Pt 2) (1997) R243-8.

Changes in gastric emptying rates with age, Clin Sci (Lond) 67(2) (1984) 213-8.

[17] K. Sturm, B. Parker, J. Wishart, C. Feinle-Bisset, K.L. Jones, I. Chapman, M. Horowitz,

Energy intake and appetite are related to antral area in healthy young and older subjects, The

American journal of clinical nutrition 80(3) (2004) 656-67.

[18] C.G. MacIntosh, J.E. Morley, J. Wishart, H. Morris, J.B. Jansen, M. Horowitz, I.M.

Chapman, Effect of exogenous cholecystokinin (CCK)-8 on food intake and plasma CCK,

leptin, and insulin concentrations in older and young adults: evidence for increased CCK

activity as a cause of the anorexia of aging, J Clin Endocrinol Metab 86(12) (2001) 5830-7.

[19] V. Di Francesco, R. Barazzoni, L. Bissoli, F. Fantin, P. Rizzotti, L. Residori, A.

Antonioli, M.S. Graziani, M. Zanetti, O. Bosello, G. Guarnieri, M. Zamboni, The quantity of

meal fat influences the profile of postprandial hormones as well as hunger sensation in

healthy elderly people, Journal of the American Medical Directors Association 11(3) (2010)

188-93.

[20] M. Amitani, H. Amitani, K.C. Cheng, T.S. Kairupan, N. Sameshima, I. Shimoshikiryo,

K. Mizuma, N.T. Rokot, Y. Nerome, T. Owaki, A. Asakawa, A. Inui, The Role of Ghrelin

and Ghrelin Signaling in Aging, Int J Mol Sci 18(7) (2017).

[21] G. Murdolo, P. Lucidi, C. Di Loreto, N. Parlanti, A. De Cicco, C. Fatone, C.G. Fanelli,

G.B. Bolli, F. Santeusanio, P. De Feo, Insulin is required for prandial ghrelin suppression in

humans, Diabetes 52(12) (2003) 2923-7.

[22] H.M. Perry, 3rd, D.K. Miller, P. Patrick, J.E. Morley, Testosterone and leptin in older

African-American men: relationship to age, strength, function, and season, Metabolism:

clinical and experimental 49(8) (2000) 1085-91.

[23] J.I. Baum, I.Y. Kim, R.R. Wolfe, Protein Consumption and the Elderly: What Is the

Optimal Level of Intake?, Nutrients 8(6) (2016).

of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food

Policy. , Stationary Office, London.1991.

[25] N.E. Deutz, J.M. Bauer, R. Barazzoni, G. Biolo, Y. Boirie, A. Bosy-Westphal, T.

Cederholm, A. Cruz-Jentoft, Z. Krznaric, K.S. Nair, P. Singer, D. Teta, K. Tipton, P.C.

Calder, Protein intake and exercise for optimal muscle function with aging: recommendations

from the ESPEN Expert Group, Clin Nutr 33(6) (2014) 929-36.

[26] M. Tieland, K.J. Borgonjen-Van den Berg, L.J. van Loon, L.C. de Groot, Dietary protein

intake in community-dwelling, frail, and institutionalized elderly people: scope for

improvement, European journal of nutrition 51(2) (2012) 173-9.

[27] Scientific Advisory Committee on Nutrition (SACN). SACN vitamin D and health

report, in: P.H. England (Ed.) 2016.

[28] C. Lamberg-Allardt, M. Brustad, H.E. Meyer, L. Steingrimsdottir, Vitamin D - a

systematic literature review for the 5th edition of the Nordic Nutrition Recommendations,

Food Nutr Res 57 (2013).

[29] C. Homocysteine Studies, Homocysteine and risk of ischemic heart disease and stroke: a

meta-analysis, JAMA 288(16) (2002) 2015-22.

[30] R. Clarke, A.D. Smith, K.A. Jobst, H. Refsum, L. Sutton, P.M. Ueland, Folate, vitamin

B12, and serum total homocysteine levels in confirmed Alzheimer disease, Arch Neurol

55(11) (1998) 1449-55.

[31] R. Clarke, D. Bennett, S. Parish, S. Lewington, M. Skeaff, S.J. Eussen, C. Lewerin, D.J.

Stott, J. Armitage, G.J. Hankey, E. Lonn, J.D. Spence, P. Galan, L.C. de Groot, J. Halsey,

A.D. Dangour, R. Collins, F. Grodstein, B.V.T.T. Collaboration, Effects of homocysteine

lowering with B vitamins on cognitive aging: meta-analysis of 11 trials with cognitive data

on 22,000 individuals, The American journal of clinical nutrition 100(2) (2014) 657-66.
[32] R. Clarke, J. Halsey, S. Lewington, E. Lonn, J. Armitage, J.E. Manson, K.H. Bonaa, J.D.

Spence, O. Nygard, R. Jamison, J.M. Gaziano, P. Guarino, D. Bennett, F. Mir, R. Peto, R.

Collins, B.V.T.T. Collaboration, Effects of lowering homocysteine levels with B vitamins on

cardiovascular disease, cancer, and cause-specific mortality: Meta-analysis of 8 randomized

trials involving 37 485 individuals, Archives of internal medicine 170(18) (2010) 1622-31.

[33] S.P. Fortmann, B.U. Burda, C.A. Senger, J.S. Lin, T.L. Beil, E. O'Connor, E.P.

Whitlock, Vitamin, Mineral, and Multivitamin Supplements for the Primary Prevention of

Cardiovascular Disease and Cancer: A Systematic Evidence Review for the U.S. Preventive

Services Task Force, Agency for Healthcare Research and Quality (US); , Rockville (MD),

2013.

[34] J.B. Blumberg, R.L. Bailey, H.D. Sesso, C.M. Ulrich, The Evolving Role of

Multivitamin/Multimineral Supplement Use among Adults in the Age of Personalized

Nutrition, Nutrients 10(2) (2018).

[35] G. Bjelakovic, D. Nikolova, L.L. Gluud, R.G. Simonetti, C. Gluud, Antioxidant

supplements for prevention of mortality in healthy participants and patients with various

diseases, Sao Paulo Med J 133(2) (2015) 164-5.

[36] J.E. Morley, Decreased food intake with aging, The journals of gerontology 56 Spec No

2 (2001) 81-8.

[37] H.A. Wijnhoven, B.S. van der Meij, M. Visser, Variety within a cooked meal increases

meal energy intake in older women with a poor appetite, Appetite 95 (2015) 571-6.

[38] M. Dermiki, J. Prescott, L.J. Sargent, J. Willway, M.A. Gosney, L. Methven, Novel

flavours paired with glutamate condition increased intake in older adults in the absence of

changes in liking, Appetite 90 (2015) 108-13.

[39] V. Di Francesco, M. Zamboni, A. Dioli, E. Zoico, G. Mazzali, F. Omizzolo, L. Bissoli,

S.B. Solerte, L. Benini, O. Bosello, Delayed postprandial gastric emptying and impaired
gallbladder contraction together with elevated cholecystokinin and peptide YY serum levels

sustain satiety and inhibit hunger in healthy elderly persons, The journals of gerontology

60(12) (2005) 1581-5.

[40] N.H. Essed, S. Kleikers, W.A. van Staveren, F.J. Kok, C. de Graaf, No effect on intake

and liking of soup enhanced with mono-sodium glutamate and celery powder among elderly

people with olfactory and/or gustatory loss, International journal of food sciences and

nutrition 60 Suppl 5 (2009) 143-54.

[41] R. Tsikritzi, J. Wang, V.J. Collins, V.J. Allen, Y. Mavrommatis, P.J. Moynihan, M.A.

Gosney, O.B. Kennedy, L. Methven, The effect of nutrient fortification of sauces on product

stability, sensory properties, and subsequent liking by older adults, J Food Sci 80(5) (2015)

S1100-10.

[42] K.M. Appleton, Limited compensation at the following meal for protein and energy

intake at a lunch meal in healthy free-living older adults, Clin Nutr (2017).

[43] J. Beelen, N.M. de Roos, L.C. de Groot, Protein Enrichment of Familiar Foods as an

Innovative Strategy to Increase Protein Intake in Institutionalized Elderly, J Nutr Health

Aging 21(2) (2017) 173-179.

[44] C. Giezenaar, L.G. Trahair, N.D. Luscombe-Marsh, T. Hausken, S. Standfield, K.L.

Jones, K. Lange, M. Horowitz, I. Chapman, S. Soenen, Effects of randomized whey-protein

loads on energy intake, appetite, gastric emptying, and plasma gut-hormone concentrations in

older men and women, The American journal of clinical nutrition 106(3) (2017) 865-877.

[45] Y. Zhu, J.H. Hollis, Chewing thoroughly reduces eating rate and postprandial food

palatability but does not influence meal size in older adults, Physiol Behav 123 (2014) 62-6.

[46] A.J. Stull, J.W. Apolzan, A.E. Thalacker-Mercer, H.B. Iglay, W.W. Campbell, Liquid

and solid meal replacement products differentially affect postprandial appetite and food

intake in older adults, Journal of the American Dietetic Association 108(7) (2008) 1226-30.
[47] C. Norton, C. Toomey, W.G. McCormack, P. Francis, J. Saunders, E. Kerin, P. Jakeman,

Protein Supplementation at Breakfast and Lunch for 24 Weeks beyond Habitual Intakes

Increases Whole-Body Lean Tissue Mass in Healthy Older Adults, J Nutr 146(1) (2016) 65-

9.

[48] E. Bitok, K. Jaceldo-Siegl, S. Rajaram, M. Serra-Mir, I. Roth, T. Feitas-Simoes, E. Ros,

J. Sabate, Favourable nutrient intake and displacement with long-term walnut

supplementation among elderly: results of a randomised trial, The British journal of nutrition

118(3) (2017) 201-209.

[49] R.C. Chen, M.S. Lee, Y.H. Chang, M.L. Wahlqvist, Cooking frequency may enhance

survival in Taiwanese elderly, Public Health Nutr 15(7) (2012) 1142-9.

[50] J.L. Locher, C.O. Robinson, D.L. Roth, C.S. Ritchie, K.L. Burgio, The effect of the

presence of others on caloric intake in homebound older adults, The journals of gerontology

60(11) (2005) 1475-8.

[51] S. Baugreet, R.M. Hamill, J.P. Kerry, S.N. McCarthy, Mitigating Nutrition and Health

Deficiencies in Older Adults: A Role for Food Innovation?, J Food Sci 82(4) (2017) 848-855.

[52] A. Yoxall, J. Langley, C. Musslewhite, E.M. Rodriguez-Falcon, J. Rowson, Husband,

Daughter, Son and Postman, Hot-water, Knife and Towel: Assistive Strategies for Jar

Opening, in: P.M. Langdon, P.J. Clarkson, P. Robinson (Eds.), Designing Inclusive

Interactions:, Springer London2010, pp. 187-96.

[53] J. Denny, J. McLauchlin, Human Listeria monocytogenes infections in Europe--an

opportunity for improved European surveillance, Euro Surveill 13(13) (2008).

[54] FAO. Food and Agricultural Organization of the United Nations, Risk assessment of

Listeria monocytogenes in ready-to-eat foods—technical report., in: R. Food and Agricultural

Organization of the United Nations (Ed.) Microbiological risk assessment series 5. , 2004.
[55] V. Goulet, C. Hedberg, A. Le Monnier, H. de Valk, Increasing incidence of listeriosis in

France and other European countries, Emerg Infect Dis 14(5) (2008) 734-40.

[56] E.W. Evans, E.C. Redmond, Analysis of older adults' domestic kitchen storage practices

in the United Kingdom: identification of risk factors associated with listeriosis, J Food Prot

78(4) (2015) 738-45.

[57] N.R. Sahyoun, A. Vaudin, Home-Delivered Meals and Nutrition Status Among Older

Adults, Nutr Clin Pract 29(4) (2014) 459-465.

[58] R.A. Abbott, R. Whear, J. Thompson-Coon, O.C. Ukoumunne, M. Rogers, A. Bethel, A.

Hemsley, K. Stein, Effectiveness of mealtime interventions on nutritional outcomes for the

elderly living in residential care: a systematic review and meta-analysis, Ageing Res Rev

12(4) (2013) 967-81.