For dietitians working in long-term care, many daily activities revolve around minimizing a resident’s risk of losing or gaining a clinically significant amount of weight. Unintentional weight gain and loss is a common problem within long-term care residents and is associated with a multitude of costly clinical outcomes.
Changes in weight may be an early indicator of changes to someone’s health or nutritional status. Monthly weights are used to determine the prevalence of weight gain/loss, which is reported quarterly to the MDS (Minimum Data Set) as a quality indicator. However, some myths still persist regarding weight gain and loss involving the elderly population in the long-term care setting. Here are a few of the most common, and the facts to dispel them.
Myth #1: If a person has been thin, or “skinny” their entire life, dietitians have an obligation to bring them up to their Ideal Body Weight
This is a myth because significant weight gain or loss is related to a person’s usual body weight (UBW), which refers to the resident’s usual weight through adult life or a stable weight during a specific amount of time.
For example, take an 80-year-old woman, who is 5’3” and weighs 100 pounds, which happens to be a weight that she has consistently maintained for the past five years up until recently. However her “ideal” weight for her height is 115 pounds, a difference of 15 pounds/15 percent.
The fact that she weighs less than her ideal body weight is not a risk factor in itself. What matters is if we see a clinically significant weight gain or loss, not that this resident happens to be below her ideal body weight.
And as clinicians, dietitians take a look at her entire nutritional history – was her appetite fluctuating prior to admission, what types of foods was she eating (nutrient-dense vs. non-nutrient dense), does she have any physical signs of malnutrition according to the ‘Nutrition Focused Physical Exam,’ etc.?
And just a quick reminder of what clinically significant weight change looks like according to the MDS:
- > 5% Weight Gain/Loss in 30 Days
- > 7.5% Weight Gain/Loss in 90 days
- > 10% Weight Gain/Loss in 180 Days
Myth #2: Obese Residents Can Never be Malnourished
This is one of the most common myths among staff members who participate in the daily care of residents. Dietitians are often questioned for recommending the addition of a nutritional supplement to an obese resident’s daily regimen.
Although at first, these residents may not have any obvious signs of malnutrition, obese people can still be in poor nutritional status as a result of not eating the correct combination of foods, or their nutritional needs are increased related to their current medical condition/state.
Skeletal muscle atrophy, or “sarcopenia,” increases with age, and is very prevalent within the elderly population. The elderly population is at the greatest risk for being simultaneously sarcopenic and obese.
So knowing that dietitians need to make sure that this population is consuming a nutrient-rich diet and provide them with the proper nutrition and caloric intake suited to their individual needs.
One helpful tactic is identifying those “empty calorie” foods and replacing those with more “nutrient-dense” foods that can better help to maintain a healthy weight while also supplying more nutrients for overall health.
If the desired goal is for weight loss because the resident’s weight is becoming a quality-of-life issue, careful monitoring and documentation are necessary. It is also important to keep in mind that weight loss for older adults/the elderly population may result in a loss of lean muscle mass and accelerating sarcopenia along with its associated negative consequences.
So if you find that weight loss is clinically necessary, it should be gradual, planned, documented, and closely supervised with an individualized nutrition plan and consideration of incorporating some type of exercise (if possible) in efforts to minimize muscle loss.
Myth #3: All Weight Loss is Related to Poor Nutrition
This is a myth because not all weight loss is related to poor nutritional status. Irreversible weight loss is caused by diseases and is an end-of-life issue within the elderly population.
Reversible weight loss is because of inadequate nutritional intake and this is where RDs/RDNs can have a direct effect. Sometimes it can be very difficult for residents and their families to understand that at times, significant weight loss can be related to a loved one’s decline. But it is important to recognize and distinguish the difference between irreversible/reversible weight loss.
If you discover a resident has reversible weight loss, there are numerous nutritional interventions to help the resident gain weight and prevent further loss. Some interventions may include: providing feeding assistance, assessing the effects of current medications, liberalizing their diet, and further managing any underlying medical conditions.
Dietitians can also consider adding smaller, more frequent meals, changing a resident’s diet to include finger foods, adding nutrient-dense snacks, and liquid nutritional supplements.
Deirdre Carlson, RD, is a Minnesota native who now lives in Northern California thanks to a travel position with Dietitians On Demand. Deirdre started out in a temporary position but was converted to a permanent employee at a long term care facility. She spent nearly two years working in long term care before transitioning to acute care.
Bopp, M. E., Johnson, L.E., Roberson, P.K., Sullivan, D.H. (2004) Prognostic Significance of Monthly Weight Fluctuations Among Older Nursing Home Residents, The Journals of Gerontology: Series A, Volume 59, Issue 6, Pages M633–M639, https://doi.org/10.1093/gerona/59.6.M633. Accessed November 28, 2018.
Simmons, S. F., Peterson, E. N., & You, C. (2009). The accuracy of monthly weight assessments in nursing homes: implications for the identification of weight loss. The journal of nutrition, health & aging, 13(3), 284-8. Accessed November 20, 2018.
Texas Department of Aging and Disability Services. Healthy Weight Management: Addressing Weight Loss & Weight Gain in Long Term Care. www.texasqualitymatters.org. Accessed November 24, 2018.