It is well recognized that nutrition plays an important role in health status, with increasing evidence of associations between intake of specific dietary components and risk of many non-communicable diseases (NCDs), such as cardiovascular diseases (CVDs), type 2 diabetes, and some types of cancer. For instance, the Global Burden of Diseases has recently indicated that high intake of sodium, low intake of whole grains, and low intake of fruits are the leading dietary risk factors for deaths and disability-adjusted life-years (DALYs) worldwide [1
]. These findings have been widely used to prepare national and international dietary guidelines aimed both at recommending the adequate intake of energy and nutrients for different targets of population and possibly at reducing the risk for the most common NCDs [2
The ageing process affects the nutrient needs of older subjects, whose requirements for some nutrients may be reduced or increased with respect to younger adults. In this life-stage, a variety of factors such as sensory losses, chewing and swallowing problems, and medications may compromise dietary intake and lead to nutritional deficiencies and malnutrition, which has been contributing to the progression of many diseases and common syndromes in older people [3
For this reason, specific recommendations have been proposed to meet the nutritional requirements of this target group; for instance, energy, protein and fibre intake should be individually adjusted by considering their nutritional status and physical condition and accounting for the presence of specific disease [4
]. In addition to macronutrients, micronutrients also play a fundamental role in promoting health and preventing NCDs and their deficiencies are often common in aged people for a number of reasons including reduced food intake or lack of a varied diet, but they are also associated with the vicious cycle promoted by diseases and pharmacological treatments.
It is noteworthy that these factors may also affect the intake, absorption and/or metabolism of bioactive compounds such as polyphenols. In this regard, data on polyphenol intake in different older target groups are not univocal, possibly due to differences in geographical area considered, and in the individual characteristics in terms of health/disease status, and living conditions, as previously evidenced [5
]. The interest in the assessment of polyphenol intake and the study of their potential impact on older subjects has been growing by considering several findings suggesting the protective role they can play against age-related diseases and in the promotion of healthy aging [6
]. Regarding the changes on polyphenol intake with age, conflicting results have been reported so far, with some studies showing an increased intake [7
] while others reporting no differences depending on age [9
For the above-mentioned reasons, the nutritional assessment of older people represents a critical issue, which may be particularly true for those living in residential care settings where the prevalence of malnutrition has been reported to be extremely variable, ranging from 1.5 to 66.5% [11
]. This represents a current clinical and public health concern at both the individual and population level [12
]. Several methods have been developed for the assessment of energy and nutrient intake, including food-frequency questionnaires, food diaries and 24-h dietary recalls, all having pros and cons to be considered when choosing the best method to use in each specific context [14
]. The estimation of micronutrients and bioactives like polyphenols is particularly challenging, mainly due to methodological issues, including the tool and the database used for the evaluation, as well as the type of polyphenol under consideration (e.g., total polyphenols versus single classes and subclasses of polyphenols) [5
]. Being able to make accurate estimates of actual polyphenol intake is a fundamental requirement of developing a better understand of the role of these compounds and their relationship with health or disease conditions. In addition, this information is crucial to define potential polyphenol exploitation for the development of dietary strategies to prevent against age-associated diseases.
Based on these premises, the aim of this research was to evaluate the nutritional composition of nursing home dietary menus and to estimate the actual intake of nutrients and polyphenols in a group of older subjects living in a residential care setting. The assessments were performed as part of the MaPLE (Microbiome mAnipulation through Polyphenols for managing Leakiness in the Elderly) project, funded within the European Joint Programming Initiative “A Healthy Diet for a Healthy Life” (JPI HDHL), with the aim to investigate benefits of a polyphenol-enriched diet on intestinal permeability in older subjects. An increased gut permeability, often associated with dysbiosis and inflammation, could play a role in the development of some age-related conditions. In this regard, it has been suggested that the intake of polyphenols may represent a promising strategy to improve intestinal permeability (IP) as demonstrated mainly in experimental studies suggesting the involvement of these bioactives in both direct and indirect modulatory mechanisms [15
]. In this context, a more accurate estimation of the intake of polyphenols in a vulnerable target such as older subjects, in terms of amount, sources and distribution across the day and even in different seasons, can be of relevance. This could enable a better understanding of their potential benefits and the development of specific recommendations based on findings from dietary intervention studies.
The evaluation of the adequacy of diets in older subjects is of utmost importance not only to identify possible deviations from desirable nutritional targets but also to contribute to the development of new recommendations that address gaps in the current guidance. In this context, the MaPLE project has given us the unique opportunity to assess dietary intake in a well-controlled setting where it is also possible to analyse the daily menus provided to the residents, while considering all the recipes and ingredients used for the preparation of the meals. At the same time, long-term residences often have facilities enabling the measurement of food intake (e.g., by collecting multiple weighed food records) and this represents the best procedure to estimate actual consumption. Menu planning in residential care involves modifications of recipes during the year to take account of seasonal changes in ingredient availability and this may partially affect not only nutritional characteristics in terms of macro- and micro- nutrients but also food sources of bioactive compounds with potential impact on host metabolism and other functions.
In the present study, the evaluation of three different menus showed that overall they were comparable in terms of nutritional composition, and also that they were in line with the dietary recommendations for older subjects in Italy (i.e., Italian Reference Intake) [2
], with some dissimilarities that are worth highlighting. In regards to total energy, menus provided suitable amounts for the target population, at least in consideration of the main Italian guidelines developed for dietary management in residential care [25
]. Some studies carried out in nursing homes showed lower energy provided by menus [26
], while others reported data higher or similar to our observation [28
]. The distribution in macronutrients was consistent with the recommendations: carbohydrates accounted for ~47% of total energy intake on average (reference intake range: 45–60% energy (E)), although we found there was a higher intake of simple carbohydrate in comparison with the recommendations (20% E vs. < 15% E) due to the wide use of fruit juices and hot beverages with added sugars as has been commonly reported in this target population. Protein intake derived mainly from animal sources (about two-thirds) and was higher in comparison with the suggested dietary target (1.1 g/kg/day), while total lipid intake was within the reference intake range (20–35% E). Specifically, SFAs were in accordance with the national/international recommendation (<10% E), while total PUFAs were slightly lower than 5% E due to the low intake of ω-6 in favour of higher MUFAs, as can often be found in the Mediterranean areas. The amount of fibre provided by the menus was slightly lower than the suggested dietary target of 25 g per day defined by Italian and international guidelines [2
]. Regarding micronutrients, iron contribution was adequate while, as also reported in the literature, calcium content in the three menus was lower than the population reference intake (PRI, 1200 mg for both women and men ≥ 60 years) [2
]. However, it is worth noting that these data included only calcium derived from recipes and did not consider contributions from other sources such as water and supplements. Vitamin B1, B6 and B12 provided by menus were higher than reference values, while folates were slightly lower than the established population reference intake of 400 μg per day. With regard to antioxidants, vitamins E and C were both adequate, in particular vitamin C largely exceeded the PRI levels (i.e., 85 mg and 105 mg per day for women and men respectively). Overall, the results on the nutritional composition of the menus suggest that, although they are generally developed following specific guidelines, it is still possible to improve the content of critical nutrients such as fibre, specific micronutrients and bioactives, above all in institutionalised subjects as also reported in the literature [29
Notably, actual food intake in older subjects can be significantly lower with respect to that provided by the menus. For these reasons, we also estimated the actual food consumption through the analysis of detailed and repeated weighed food records. Measured energy and nutrient intake were indeed lower than that provided through the menus (by about 20%), with no differences between women and men. In this regard, it is underlined that the subjects enrolled in the present study generally had a good nutritional status, evidenced also by their anthropometric characteristics (BMI = 26.8 ± 5.5 kg/m2).
The energy intakes we have reported here (mean approximately 1580 kcal) were slightly lower than those found in the InCHIANTI study, performed on about 1200 free-living older subjects (>65 years) in Tuscany, in which mean energy intakes ranged from 1764 to 2260 kcal/d and from 1521 to 1793 kcal/d in men and women, respectively [32
]. However, despite the higher energy intake, in the InCHIANTI study, a large group of subjects reported inadequate intakes of protein, calcium and other nutrients, which have been independently associated with frailty [33
]. In our assessments, the lower food intake was associated with reduced protein intake (about 0.9 g/kg day on average), increasing the rate of inadequate intake above all in male subjects (about 22% with intake ≤ 0.71 g/kg per day and only 18% with intake ≥ 1.1 g/kg per day as defined by the suggested dietary target). The consumption of simple carbohydrates in older subjects was confirmed to be higher than the suggested values, while the fat intake appeared to be within the suggested intake range, although the amount of ω-6 fatty acids remained lower than recommended values, as did the intake of calcium, vitamins B1, B6 and folates. These results confirmed previous observations of a potential risk of long-term inadequate intake of nutrients that are fundamental for maintenance of functional and metabolic integrity in older subjects, and that these inadequate intakes are likely due to the actual food intake being significantly less than the amount of food provided to the care home residents in each meal (i.e., incomplete meal consumption is likely a major cause). Moreover, there is not only a problem related to overall food intake but also to specific classes of products that appear to be consumed in lower amounts with respect to others, for example justifying a low intake of fibre that has been found for most, if not all, the subjects under study. This is an underestimated consideration that should be a target for future multidisciplinary research that is able to finally implement guidelines for the achievement of nutritional targets through traditional or possibly alternative strategies.
A major focus in this study was polyphenols because these compounds have the potential to provide further specific benefits to the target population under study. It has been reported that there is a large variation in the polyphenol content of foods available in different periods of the year [34
], and for this reason we specifically analysed recipes and ingredients used to develop seasonal menus and the results obtained showed a relatively comparable amount of these bioactive compounds (about 770 mg per day on average as TPC) among the different seasons. We could not find other data on the impact of seasonality on polyphenol content of dietary plans provided in long-term residences for older people, while more literature is available in free-living older subjects. In this regard, in the Blue Mountains Eye Study, a longitudinal study performed in Australia [35
], the authors found that season did not affect the overall total flavonoid intake in a group of adult and older subjects; however, it was relatively higher in spring and lower in autumn in line with our results. Conversely, Tatsumi et al. [37
] showed that total antioxidant intake in a Japanese population (39–77 years) was highest in winter and lowest in summer. The authors attributed this difference to the participants’ selection of food (in particular fruits and vegetables) but also beverages across seasons.
In our study, the assessment of actual food consumption at baseline indicated a mean TPC intake of ~660 mg/d (i.e., evaluated by Folin–Ciocalteau through the PE database and specific literature), about 15% less than the amount estimated in the menus served to the study participants. Although a thorough comparison with other published data must be done cautiously because of the differences in the populations under study and the methods and databases used for estimating the intakes of total polyphenols and polyphenol classes, the overall actual intake estimated in the present study seems to be comparable with mean intake observed in the InChianti study [20
], but lower with respect to others previously reported.
In fact, assessments in older subjects estimated polyphenol intakes from 333 mg/day up to 1492 mg/day, as reported previously [5
]. For example, in the PREDIMED study evaluating a big cohort of Spanish older subjects aged 55–80 years, a mean polyphenol intake of 820 ± 323 mg/day expressed as glycosides was estimated through the PE database, by analysis of food consumption data obtained from FFQs [38
]. With regard to the contribution of the classes, total flavonoid intake is generally the larger part of the intake, while data available in some studies suggest that up to 30–40% of the total polyphenol intake can be represented by phenolic acids [5
]. Results from the EPIC cohort showed that older subjects tended to have increased intake of flavonoids, stilbenes, lignans, and other polyphenols with respect to younger individuals, while no differences were found for total polyphenol intake [7
], and similar findings were reported by Karam and colleagues [8
], also showing an impact of gender. In our study in a controlled setting, the data confirmed that the flavonoid subclass was the greatest contributor to total polyphenol intake followed by phenolic acids, while no differences were detected between men and women. Some studies have suggested a higher total and subclass polyphenol intake in females compared to males [8
], above all when standardized by energy intake, and this may also be the reason for the lack of differences in our study. In addition, it is relevant that the overall lower availability of food alternatives for selection in controlled, with respect to a free-living condition, may have affected eating behaviour, increasing the comparability of the dietary intake.
With regard to polyphenol food sources, tea and coffee have been underlined as the main polyphenol contributors in northern European older subjects, while red wine, extra virgin olive oil and fruit are the main sources in Southern Europe [7
]. In our evaluation, fruit and fruit juices, vegetable and extra virgin olive oil represent the main food categories providing polyphenols. In addition, we could not demonstrate a different selection of polyphenol sources depending on gender, despite some studies having reported a higher contribution from fruit and vegetables in females compared to males [8
]. It is noteworthy that in the nursing home, the intake of coffee and wine was strongly limited, if not denied, to limit risks associated with caffeine and alcohol consumption and this may represent an important behavioural difference with respect to what may be observed in free-living older subjects.
The evaluation of habitual polyphenol intake in the older target group was a fundamental step in the process of developing a reliable and evidence based polyphenol rich dietary pattern to use for the intervention trial. In particular, the aim was to approximately double the habitual polyphenol intake of the nursing home residents when on the PR-rich diet in order to reach amounts in the highest quantile of intake identified in previous observational studies, where older subjects were included or specifically considered [7
Indeed, the main objective of the MaPLE study was to investigate whether the increased intake of polyphenols might cause a reduction in intestinal permeability (IP) and inflammation associated with an improved intestinal microbial ecosystem, also affecting metabolic and functional activities in the older subjects [16
]. In particular, the intervention was developed by replacing three portions per day of low polyphenol foods/beverages with specific products rich in polyphenols. The selection of the products was performed by considering different aspects: (i) the total amount of polyphenols provided, (ii) the contribution of the different polyphenol classes, (iii) the adequate portion of food able to provide a reliable high dose of polyphenols, and (iv) the possible food preparation in order to ensure polyphenol bioavailability. Additionally, foods selection was carried out by considering the characteristics of the target group and their specific needs in terms of acceptability and suitability in the context of residential care settings. Through the administration of the selected foods, we provided mainly flavonoids (approximately four times higher compared to the amount introduced through the C-diet) and phenolic acids. These bioactives have been suggested as potential modulators of critical factors and specific targets regulating IP, including the impact on microbiota composition and activities [15
]. Overall, our results demonstrate that it is possible to obtain a significant increase in polyphenol intake in older subjects, through the use of small amounts of well-accepted polyphenol-rich food products. Moreover, it has been demonstrated that the intake is well tolerated and without undesirable effects. Participants appreciated the products and were interested in continuing with the dietary protocol after the end of the trial, suggesting that older people can change their diet if it does not dramatically modify their eating habits.
An interesting observation highlighted was that older subjects preferred the consumption of PR-products during the intervention as mid-morning and afternoon snacks. In fact, the protocol adopted did not fix the timing for the PR-food intake, but the products should have been consumed within the day according to preferences and/or habits. For this reason, our results give an important contribution to the development of dietary guidelines for this target population. At the same time, the analysis of the pattern of consumption of polyphenol-rich foods may also contribute to a better understanding of chronobiological aspects related to the effect of bioactive compounds. In this regard, it has been suggested that the inclusion of polyphenols within the meals may have an impact on related metabolic responses, e.g., through reduction of glucose and lipid levels, inflammation, oxidative stress, and blood pressure, associated with food intake [42
]. Consuming most of the polyphenols outside of the main meals could also affect their bioavailability for direct absorption and their use as substrates for microbial transformation.
This work has several strengths mainly related to the well-controlled setting of the intervention, enabling both the evaluation of the nutrient and bioactive content of the menus and the actual intake during the whole intervention, ensuring high adherence to dietary instructions. Conversely, possible study limitations include the small sample size and the partial generalizability to free-living community dwelling older subjects. Finally, the limited food choices available in the main standard menus provided could have reduced the possibility of showing gender differences.