M. Gyenes1, I.-Y. Wang2, S.K. Sinha2,3,4
1. School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; 2. Division of General Internal Medicine and Geriatrics, Sinai Health System and the University Health Network, Toronto, Canada; 3. Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada; 4. Division of Geriatrics and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
Corresponding Author: Michelle Gyenes, School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland, firstname.lastname@example.org, @michellegyenes; Samir Sinha, Division of General Internal Medicine and Geriatrics, Sinai Health System and the University Health Network, Toronto, Canada, email@example.com @DrSamirSinha
J Frailty Aging 2021;in press
Published online April 30, 2021, http://dx.doi.org/10.14283/jfa.2021.11
OBJECTIVES: Unintentional weight loss (UIWL) is common among older adults but lacks standardized methods for its diagnosis and management. With a limited understanding on how geriatricians actually address UIWL, we conducted a survey to examine how they diagnose and manage it, and their opinions regarding the use of ice cream to address it.
DESIGN, SETTING, AND PARTICIPANTS: An international descriptive, cross-sectional, online survey conducted over a 16-week period in 2019 involving 1131 geriatricians in clinical practice across 51 countries.
MEASUREMENTS: We collected information around respondent demographics, use of screening tools and diagnostic investigations, and pharmacological and non-pharmacological approaches to address UIWL.
RESULTS: 89.1% of respondents reported frequently seeing UIWL. The most common methods reportedly used to evaluate UIWL were performing a comprehensive history and physical examination (97.4%) and assessing for cognitive impairment (86.5%). 74.2% noted that they routinely prescribed oral nutritional supplements and 71.6% involved non-medical professional(s) to help manage UIWL. While 50.4% reported recommending ice cream to their patients with UIWL, only 30.6% reported being aware of other colleagues recommending it. Geriatricians in practice for 30+ years were significantly more likely to recommend ice cream (P < 0.05). A thematic analysis of qualitative responses identified that prescribing ice cream tended to align both with patient preferences and socio-economic realities. CONCLUSION: While a majority of geriatricians surveyed routinely prescribe ONS and involve others to manage UIWL, at least half are also recommending ice cream. A key practice amongst experienced geriatricians, the use of ice cream could be better acknowledged as a practical and cost-effective way to address UIWL.
Key words: Geriatrics practice, malnutrition, weight loss, ice cream.
Unintentional weight loss (UIWL), defined as an involuntary decline in body weight (1), is experienced by between 15-25% of older adults (1–5) and has been associated with adverse health outcomes, including an increased risk of functional decline, hospitalization, and mortality (2, 6-8). Existing research has helped identify risk factors and etiologies for UIWL in older adults, which are typically multi-factorial. These include physiological determinants, such as disease- or medication-related effects, psychological factors such as depression or bereavement, and social determinants, such as low socio-economic status and decreased social activity; UIWL often involves a combination of these (6-12). UIWL occurs in community-dwelling older adults, in those receiving home care, in acute hospital settings, and in individuals living in long-term care homes (13). Despite being relatively common, the definition of UIWL remains ambiguous and accepted standardized methods for its diagnosis and management do not exist. UIWL is typically described as weight loss over a specified time period, such as a 5% loss of body weight over 6-12 months (2, 9, 10, 12), a decrease >3kg in the past 3 months (13), a 5% decline in 30 days or a 10% decline in a greater than 6 month period (6, 7).
The diagnosis of UIWL is essentially supported by the administration of malnutrition screening tools, along with a detailed history-taking and clinical examination, followed by additional investigations if required (6, 9, 13, 14). There is diagnostic association between unintentional weight loss and malnutrition, as described by the Global Leadership Initiative on Malnutrition in 2018, who proposed UIWL as one of the five majority criteria for diagnosing malnutrition (15). Despite this link, a recent review conducted by Power et al. (2018) found that of the 34 malnutrition screening tools used in older adults, 25 did not use appropriate reference standards (16). Validation studies for several of the tools yielded different results, questioning the overall validity of some tools (16) which further complicates the appropriate assessment of malnutrition and UIWL in older adults. To our knowledge no standardized guidelines to assess for and treat UIWL exist or have been widely adopted; as such, physician practices likely differ internationally (4, 13, 14).
The first-line treatment of UIWL typically involves a non-pharmacological approach, where patients are encouraged to eat their favorite foods and snack frequently to supplement their daily dietary intake (3, 17). If food supplementation is ineffective, oral nutritional supplements (ONS) or pharmacologic agents are often prescribed; however, evidence supporting the use of ONS has traditionally been of low quality, and compliance associated with their use is reportedly low (16). The use of pharmacologic agents to promote weight gain in older adults experiencing UIWL also remains controversial and is primarily employed on a case-by-case basis, mostly due to adverse effects associated with their use (7).
One non-pharmacological approach that has yet to be understood and empirically measured is the prescribing of ice cream by geriatricians. Dairy food supplementation has specifically been found to reduce malnutrition risk in older populations (17-19). For over a decade, physicians have been alluding to the prescribing of ice cream to their patients to promote weight gain (20). Furthermore, ice cream has been introduced in case reports as a meal supplement for older adults experiencing UIWL as early as the late 20th century (22-25). While ice cream may not be an ideal meal supplement for all older adults, particularly those with diabetes or lactose intolerance, it does appear to promote compliance and accommodate patient dietary preferences. Older adults often experience dysphagia, xerostomia, and anorexia (26-29), all risk factors contributing to reduced oral intake, malnutrition and weight loss. Nostalgia, ease of swallowing, cold temperature, “mouthfeel”, and the unique ability to match patient preferences with adequate caloric intake have all been suggested (30, 31) as potential reasons why encouraging the consumption of ice cream can be effective in promoting weight gain in older patients experiencing UIWL.
Despite the relatively high prevalence of UIWL in older adults, and the robust body of existing literature around the causes of and management strategies for UIWL, we are not aware of any research that explores how geriatricians throughout the world are actually assessing and managing this challenge in their patients. Furthermore, while prescribing ice cream has been briefly mentioned as a potential strategy to promote weight gain in nutritional guidelines and research papers, the practice has yet to be examined empirically to determine its scope and utility. To address this gap, we developed a survey to determine the self-reported practices of geriatricians around the world to assess and manage UIWL in their patients and their opinions regarding the use of ice cream to address it.
A literature search was conducted to determine existing studies surrounding UIWL in older adults, geriatrician methods for assessment and management of UIWL, and the use of ice cream to promote weight gain in patients experiencing UIWL. The search criteria included the following terms: “unintentional weight loss”; “unexplained weight loss”; “malnutrition”; “involuntary weight loss”; “geriatric”; “older adult”; “elderly”; “ice cream”; “oral nutritional supplements”; and “nutrition”, using MEDLINE, PubMed, PSYCInfo, AccessMedicine, and Cochrane Library. A grey literature search was further conducted using Google Scholar to obtain policy documents and additional reports. Literature related to the assessment and management of unintentional weight loss was included if it pertained to older adults or other vulnerable groups, as well as literature that referred to the prescribing of ice cream to treat UIWL in any population.
An English-language survey was developed for this study based on a literature review to explore existing studies surrounding UIWL in older adults, geriatrician methods for assessment and management of UIWL, and the use of ice cream to promote weight gain in patients experiencing UIWL. The survey was pilot tested by a team of academic geriatricians at Sinai Health System in Toronto, Canada for content and usability before being distributed internationally in accordance with SAGE research methods (32). The final 38-item survey (see Appendix A) also collected demographic information about training and practice settings of the survey respondents. Multiple choice and free text open response questions to obtain qualitative responses were utilized in the design of this survey. It was created and distributed using Survey Monkey, a well-established online survey tool that restricts surveys from being completed more than once from the same IP address, and was approved for use by the Mount Sinai Hospital Research Ethics Committee.
We used several methods to engage geriatricians in completing the survey. These included working with over a dozen national and international societies to recruit their members through various channels to encourage completion of this web-based survey. The Survey Monkey link was shared via e-mail, newsletter and social media platforms over a 16-week period between August and November 2019.
Survey Response Data Analysis
A descriptive analysis of participant characteristics was performed. An analysis of the multiple choice response data was based on creating dummy variables to corresponding potential answers. Statistical significance among categorical variables was determined using the Pearson’s chi-squared test and followed by a Bonferroni post hoc multiple comparison where appropriate. All tests were 2-tailed and a p value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS Statistics version 26.0 (IBM Corp., Armonk, NY). The data were reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Responses to open-ended survey questions were coded and categorized for a qualitative analysis. Braun and Clarke’s six phases of thematic analysis were used to generate codes and search for, review, and define themes (33).
Respondents Demographic Information
In total, 1,131 responses were received from geriatricians in active clinical practice across 51 countries (see Appendix B for by-country breakdown of respondents). The countries with the greatest representation were the United States (n=233; 20.6%), Australia (n=160; 14.2%), and Italy (n=121; 10.7%).
66.3% (n=748) of respondents practiced in inpatient settings, 59.2% (n=668) practiced in outpatient/ambulatory settings and 30.2% (n=341) practiced in residential and other community-based settings. 548 (48.7%) respondents reported practicing in academic settings and 577 (51.3%) reported practicing in non-academic settings. Close to half of respondents had been practicing geriatric medicine for fewer than 10 years (n=547, 48.4%), with 24.3% (n=275) practicing between 10-19 years, 16.5% (n=186) practicing between 20-29 years, and 10.5% (n=119) practicing for more than 30 years.
Assessment/Management of UIWL in Older Adults
Among respondents, 933 (89.1%) reported that UIWL is commonly seen in their practice. 55.4% (n=592) reported that they screen their patient’s nutritional status between 76-100% of the time, while 23.2% (n=257) screen 51-75% of the time, 12.4% (n=137) screen 26-50% of the time, and 9.2% (n=102) screen 1-25% of the time. 21 (1.9%) respondents reported that they never screen their patients’ nutritional status. The most common screening tools used in the routine assessment of nutritional status were the Mini-Nutritional Assessment (n=499, 56.9%), the Malnutrition Universal Screening Tool (n=137, 15.6%) and the Subjective Global Assessment (n=100, 11.4%).
Geriatricians who reported practicing in primarily academic (p = 0.002) and inpatient (p = 0.004) settings were significantly more likely to routinely screen for UIWL than those in non-academic and primarily outpatient/ambulatory or residential and other community-based settings (Table 1). The two most common clinical practices reported in evaluating UIWL were conducting a comprehensive history and physical examination (n = 1,017; 97.4%) and assessing for cognitive impairment (n = 903; 86.5%). The most common laboratory, imaging, and other investigations reportedly used in suspected UIWL were a complete blood count (n=974, 94.2%), followed by thyroid function tests (n=937, 90.6%) and renal function tests (n=899, 86.9%).
The reported routine management of UIWL among respondents involved the prescription of ONS, the referral to another non-medical professional, and the recommendation of specific dietary modifications. 772 (74.2%) respondents reported prescribing ONS in treating UIWL, while 15.6% (n=177) of respondents reported not prescribing ONS. Of those prescribing ONS, 24.1% (n=248) reported prescribing ONS to their patients 76-100% of the time, whereas 32.1% (n=317) reported 51-75% of the time, 25.2% (n=247) reported 26-50% of the time, and 17.0% (n=168) reported less than 25% of the time. In total 745 (71.6%) geriatricians reported making a referral to another non-medical professional as a means to manage UIWL. The most common non-medical professional that geriatricians reported referring patients with UIWL to were dieticians (n=889, 85.6%), followed by speech-language pathologists (n=527, 50.7%) and social workers (n=444, 42.7%).
69.2% (n=720) of respondents reported recommending specific dietary modifications to manage UIWL. The most common non-pharmacological interventions reportedly recommended by the respondents comprised of: optimizing energy intake (for example maximizing high-caloric foods at meals, eating smaller meals more often, eating favorite foods and snacks, providing finger foods) (n=932, 91.0%); minimizing dietary restrictions (n=816, 79.7%); and ensuring adequate oral health (n=673, 65.7%). The majority of survey respondents reported that they did not prescribe medications to treat UIWL (n=741, 72.7%). Of those that did (n=278, 27.3%), the most commonly reported prescribed medication was mirtazapine (n=233; 84.1%), followed by megestrol acetate (n=46; 16.6%).
Utilizing Ice Cream to Address UIWL in Older Adults
50.4% (n=540) of respondents reported having prescribed ice cream to their patients experiencing UIWL. Several demographic factors were identified as being associated with the likelihood of prescribing ice cream. Geriatricians in Italy (p < 0.0001), Singapore (p< 0.01), and the United States (p < 0.0001) were significantly more likely to have prescribed ice cream to their patients experiencing UIWL. Geriatricians in Australia (p < 0.0001), the Czech Republic (p < 0.05), Germany (p < 0.05), Japan (p < 0.0001), Turkey (p < 0.05) and the United Kingdom (p < 0.05) were significantly less likely to have prescribed ice cream (Figure 1). Respondents who reported practicing geriatric medicine for over 30 years were significantly more likely to have reported prescribing ice cream to their patients (p < 0.001) than those who practiced less than 30 years; practicing geriatric medicine for less than 10 years was associated with a significantly lower likelihood of having prescribed ice cream (p < 0.0001) (Table 1). Additionally, geriatricians who reported practicing in inpatient settings were more likely to have reported recommending ice cream for UIWL (p = 0.001) than geriatricians practicing in outpatient/ambulatory or residential and other community-based settings (Table 1).
Australia (p<0.0001), Czech Republic (p=0.014), Germany (p=0.025), Italy (p<0.0001), Japan (p<0.0001), Singapore (p=0.007), Turkey (p=0.039), UK (p=0.025), USA (p<0.0001_216) had significant differences. Sample size varied across different countries. The Czech Republic, Germany, Japan, Singapore, Turkey, UK had the number of respondents below 50 (Appendix C). Rx indicates prescription.
Of those who did not report prescribing ice cream (n=499), the majority explained that they did not because they had never heard of this strategy (n=303, 60.7%). 44% of respondents who reported that they did not prescribe ice cream reported that they would be more likely to prescribe ice cream if there was evidence to support this practice. Only 18 geriatricians responded that they will never prescribe ice cream (3.6%). Of the geriatricians reporting that they did prescribe ice cream, the vast majority reported not prescribing a specific quantity, but rather encouraging their patients to eat ice cream as a meal supplement (n=384, 75.7%). 205 (44.8%) respondents who reported prescribing ice cream further indicated that they would consider prescribing ice cream more often if some evidence existed to support this practice. Of all geriatrician respondents, 69.4% (n=699) reported not being aware of their colleagues prescribing ice cream as a meal supplement to promote weight gain.
Screening the nutritional status of patients 1-25% of the time (p=0.003), 26-50% of the time (p=0.043), and 76-100% of the time (p<0.0001) had significant differences. Rx indicates prescription.
Rx indicates prescription.
Significant correlations were found between the reported likelihood of prescribing ice cream and approaches to assessing and managing UIWL. Respondents who reportedly screened the nutritional status of their patients 76-100% of the time were found to be significantly more likely to prescribe ice cream (p < 0.0001), while geriatricians who reported screening for nutritional status between 26-50% (p<0.05) and 1-25% (p<0.01) of the time were significantly less likely to have reported prescribing ice cream (Figure 2). Similarly, those who reported routinely screening for UIWL in their practices were significantly more likely to have prescribed ice cream (p < 0.001) (Figure 3). Finally, a reported awareness of their colleagues prescribing ice cream to patients experiencing UIWL was significantly associated with a higher likelihood of the geriatrician respondents prescribing ice cream (p < 0.0001) (Figure 4).
Rx indicates prescription.
Geriatrician responses to the open-ended survey questions further contributed to this study’s qualitative thematic analysis. The following themes were identified pertaining to UIWL management and the use of ice cream: support of and alignment with patient preferences, acknowledging ethno-cultural and socio-economic factors, addressing specific etiologies of UIWL and the concept of “recommending” vs. “prescribing” a specific food.
Our international survey demonstrated that almost 90% of geriatricians reported commonly seeing UIWL in their practices; accordingly, over half reported screening the nutritional status of their patients more than 75% of the time. In understanding how geriatricians address this common problem, our survey showed that the majority follow a methodological evaluative approach that most commonly involves performing a comprehensive history and physical examination, assessing for cognitive impairment and depression, conducting laboratory investigations, and conducting a detailed medication review.
In order to treat UIWL, it further became clear that the majority of geriatricians do not prescribe medications to their patients but are more likely to prescribe ONS and seek the support of other healthcare professionals such as dieticians, social workers, speech-language pathologists, and dentists. According to our survey results, more geriatricians tended to report prescribing ONS (n=772, 74.2%) than recommending specific dietary changes (n=720, 69.2%). This finding, however, is inconsistent with existing ‘food first’ oriented guidelines (34-38), which recommend that ONS should typically not be used as a first-line treatment for malnutrition, and instead appropriate snacking routines and the fortification of foods should be used as initial treatments (34-39). While recent research has shown both improved quality of life and economic benefits to ONS use in long-term care or nursing home settings, there is less evidence supporting the use of ONS compared to the use of dietary advice and food supplementation strategies in community settings (17, 34, 35). In recommended care pathways, the possible prescription of ONS remains secondary to the assessment of malnutrition, setting treatment goals, and the provision of food fortification advice (18, 34-39).
Our study is the first to specifically examine ice cream prescribing to address UIWL and to report a 50.4% prescribing prevalence rate amongst geriatricians internationally to promote weight gain in their patients experiencing UIWL. Unsurprisingly, geriatricians who reported recommending ice cream were significantly more likely to be aware of their colleagues engaging in the practice. However, interestingly, while over half of the geriatricians surveyed have reportedly recommended the use of ice cream, only 30% reported being aware of their colleagues doing the same. Furthermore, it was clear that geriatricians, particularly with 30+ years of experience, felt more comfortable ascribing to the practice of prescribing ice cream compared to their less experienced colleagues.
While ice cream prescribing has been a seemingly surreptitious practice among many geriatricians to date, it became evident that this research survey began prompting a discussion surrounding the topic, including the practice’s potential benefits to patients. The prescribing of ice cream to manage UIWL seems to support the common theme of delivering more patient-centred care among many geriatricians, who felt that the ability to choose between brands and flavours helps to better align treatments with patient goals and preferences. Similar research has been conducted in other areas of medicine, including oncology, with reported decreased levels of anxiety and depression and improved quality of life having been achieved when ice cream was used (40). From an economic perspective, research supports the further exploration of the management of UIWL in older adults through the use of food supplementation. Recent reports have found that promoting choice in nursing home settings using a ‘food first’ approach had numerous economic benefits (41). One study found that increasing food budgets in nursing homes decreased the risk of malnutrition, thus proving to be ultimately cost-effective (42).
From the responses to our survey’s open-ended questions, it became evident that some geriatricians felt that there is an important distinction between “recommending” and “prescribing” a food, and that ethno-cultural and socio-economic factors are important considerations in determining which foods or supplements should be recommended to older adults. Furthermore, while many respondents acknowledged that prior to completing the survey, they had never heard of the practice of using of ice cream to address UIWL, several respondents indicated that they would now start recommending its use.
A key strength of this study is its large sample size, the largest known international survey of geriatricians on any topic known to date, that further allowed for distinct country and regional differences to be appreciated. A methodological weakness of this study was its sampling procedure which could have also introduced a potential for bias. While the survey tool specifically mentions geriatricians as its target group, there is a possibility that other professionals could have filled out the survey. Additionally, each geriatrics society had different policies, protocols and methods for promoting and circulating surveys amongst their members, which potentially allowed for differential country level response rates. A common weakness in study designs involving surveys is the potential for response bias (43). It is possible that geriatricians choosing to respond to our survey had a particular interest in or experience in managing UIWL or the prescribing of ice cream. These potential biases were mitigated as much as possible by obtaining a large sample size, to further ensure this study’s survey responses were representative and consistent. Finally, this is the first international survey on geriatrician practices regarding management of UIWL. As the survey was developed in English, we recognize that language barriers may have limited the volume of respondents surveyed from non-majority English speaking countries. This sample bias could further limit the capability of conclusions drawn about international geriatrician practice. Further study allowing better international engagement is required.
UIWL is commonly diagnosed and treated by geriatricians, with at least half of those surveyed describing they have recommended ice cream in the past to address it. The results of this survey can be used to further develop the evidence base and future potential guidelines for the assessment and management of UIWL in older adults that better emphasizes a ‘food first’ approach to treatment. Furthermore, geriatricians including both those that do and do not prescribe ice cream, reported that their likelihood of prescribing it would likely increase if there were greater evidence or even supportive guidance to further encourage and promote the practice. Finally, the practical value of prescribing ice cream or other calorie-rich desserts as a meal supplement for patients with UIWL that promotes a cost-effective and likely more preferred ‘food first’ approach should also be further explored.
Acknowledgments: We would like to thank Drs. Goldlist, Liberman, Romanovksy, and Stall at Sinai Health System for reviewing the draft survey. We would like to thank Nicoda Foster at Sinai Health System for guidance and assistance throughout the project. We would like to thank the Savlov and Schmidt families for supporting the Savlov/Schmidt Summer Scholars Program at Sinai Health System/University Health Network. We would like to thank the Royal College of Surgeons in Ireland (RCSI), University of Medicine & Health Sciences, for their support of MG in pursuing this research. We would like to thank the following geriatrics societies for distributing the survey to their members: Canadian Geriatrics Society (CGS), American Geriatrics Society (AGS), European Geriatric Medicine Society (EuGMS), Danish Geriatric Society (DGS), Icelandic Geriatrics Society (IGS), the Irish Society of Physicians in Geriatric Medicine (ISPGM), Israel Geriatric Society (IGS), South African Geriatrics Society (SAGS), Australian and New Zealand Society for Geriatric Medicine (ANZSGM), the Finnish Gerontological Society (FGS), the Czech Society of Gerontology and Geriatrics, the Austrian Society of Geriatrics and Gerontology, the Italian Society of Gerontology and Geriatrics (SIGG), the Singapore Geriatrics Society (SGS), the Hong Kong Geriatrics Society (HKGS), and the Malaysian Society for Geriatric Medicine (MSGM).
Conflicts of Interest: None to disclose.
Author Contributions: M.G. and S.S. contributed to the study design, survey development, data analysis and manuscript preparation. I.W. contributed to the data analysis and manuscript preparation.
Sponsor’s Role: None.
Ethical Standards: This research study was approved by the Mount Sinai Hospital Research Ethics Committee.
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