Michelle Bremang, Registered Dietitian
Despite its reported health benefits¹,², fibre is often overlooked as a key nutrient in the nutritional support of older adults. This article will discuss the importance of dietary fibre in older adults (≥65 years) and offer ideas for incorporating high-fibre options into food-first strategies for those with or at risk of malnutrition.
Importance of fibre in older adults
Fibre is an important dietary component for all ages. It has a particularly important role in optimising health and quality of life in older adults.³,⁴
The ageing process leads to a decline in gut motility, function, and absorptive capacity.⁵ As a result, constipation is common in older adults; with up to 80% of care home residents experiencing constipation.⁶,⁷
Additionally, certain medications (e.g. antibiotics and opioids) used to manage common age-related conditions can affect gut health and transit time; contributing to constipation and other gastrointestinal conditions.⁸,⁹,¹⁰ Furthermore, research has shown a link between the onset of sarcopenia and associated frailty in older adults with lower dietary fibre intakes. This is likely due to a reduction in the diversity of the gut microbiota.⁴,¹¹
Improvements in dietary fibre intake can improve control of metabolic diseases associated with ageing²,¹²,¹³, help to stimulate intestinal motility and improve stool frequency in older adults; helping to address constipation and laxative use.¹⁴,¹⁵
Are older adults meeting dietary fibre targets?
In the UK, the government recommends that adults consume at least 30g fibre per day.1⁶ Recent National Diet and Nutrition Survey (NDNS) data, however, has revealed that the majority of older adults are not reaching this target.¹⁷ The average fibre intake in older adults is reported to be 18.7g/day; less than two-thirds of the recommended daily amount.¹⁷
Food-first strategies and increasing fibre intake
A “food-first” approach to oral nutrition support is a simple way of providing enhanced nutrition to those who are or at risk of becoming malnourished. It can be useful for patients who still have a good appetite.
Food-first strategies include offering small and frequent meals, providing additional snacks and nourishing drinks, alongside food fortification. Fortifying food increases the nutritional density of the diet without increasing the volume of food consumed. Fortifying foods with energy, protein and fibre can be a useful way of improving oral intake whilst optimising gut health in older adults.
It is important to remember that any increase in fibre intake, particularly in those with small appetites, should always be done cautiously and in conjunction with increased fluid intake to avoid gastrointestinal symptoms such as bloating or constipation.¹⁸
Below are some suggestions for increasing fibre intakes when applying food-first strategies for older adults with reduced oral intake.
- Add oils, fats, and condiments (e.g., butter, margarine, or mayonnaise) to sandwiches using wholemeal, granary or high-fibre white bread/rolls
- Use brown rice and wholemeal pasta in fortified rice/pasta dishes - or use half white and half brown!
- Offer fruit or oat-based puddings (e.g., apple crumble) with custard/cream/ice cream
Add pureed fruit or nut butter to fortified porridge
- Add pureed fruit or nut butter to fortified porridge
- Add banana and nut butter to wholemeal toast
- Offer fried mushrooms or tomatoes and/or baked beans alongside cooked breakfast items such as scrambled eggs (fortified with cream, butter, and cheese)
- Add crushed nuts, fruit (fresh, dried or pureed) to yoghurt or ice cream
- Offer high-fibre biscuits or cereal bars (e.g., fig rolls, flapjacks or oat-based biscuits)
- Serve high-fibre wholegrain crispbreads/crackers or oatcakes with high-energy toppings such as butter, cheese, avocado, or houmous
- Offer fruit/vegetable-based cakes such as carrot cake or banana bread
- Use wholemeal flour when baking sweet treats such as scones
- Offer fresh/stewed/tinned fruit with cream or custard
- Blend nut butters, oats or fruit/vegetables into fortified milk drinks (e.g., milkshakes, smoothies)
- Offer fruit juice drinks with added pulp
Oral Nutrition Supplements
For patients at high risk of malnutrition or for whom food-first approaches alone are not sufficient to meet their nutritional requirements, oral nutritional supplements (ONS) are recommended.¹⁹
When choosing ONS, unless contraindicated, fibre should be prioritised alongside protein, energy and fluid requirements.²⁰ ONS products with added fibre offer a useful strategy for optimising nutritional intake.
Dietary fibre is an important, yet often overlooked nutrient in older adults. Unless contraindicated, fibre intake should be increased gradually alongside increased fluid intake; to reduce risk of gastrointestinal side effects. For older adults requiring nutrition support, dietary fibre intake can be optimised through a food-first approach and/or ONS with added fibre.
- Gill SK, et al. 2021. Dietary fibre in gastrointestinal health and disease. Nature Reviews Gastroenterology & Hepatology;Feb 18;18(2).
- Barber TM, et al. 2020. The Health Benefits of Dietary Fibre. Nutrients;Oct 21;12(10).
- Nagpal R, et al. 2018. Gut microbiome and aging: Physiological and mechanistic insights. Nutrition and Healthy Aging;Jun 15;4(4).
- Casati M, et al. 2019. Gut microbiota and physical frailty through the mediation of sarcopenia. Experimental Gerontology;Sep;124.
- An R, et al. 2018. Age-dependent changes in GI physiology and microbiota: time to reconsider? Gut; Dec;67(12).
- Gustafsson M, et al. 2019. Constipation and laxative use among people living in nursing homes in 2007 and 2013. BMC Geriatrics;Dec 8;19(1).
- Potter J, Wagg A. 2005. Management of bowel problems in older people: an update. Clinical Medicine;May;5(3).
- Dumic I, et al. 2019. Gastrointestinal Tract Disorders in Older Age. Canadian Journal of Gastroenterology and Hepatology;Jan 17;2019.
- Volkert D, et al. 2019. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clinical Nutrition;Feb;38(1).
- Donini LM, Savina C, Cannella C. 2009. Nutrition in the Elderly: Role of Fibre. Archives of Gerontology and Geriatrics;Jan;49.
- Montiel-Rojas D, et al. 2020. Dietary Fibre May Mitigate Sarcopenia Risk: Findings from the NU-AGE Cohort of Older European Adults. Nutrients;Apr 13;12(4).
- Reynolds AN, Akerman AP, Mann J. 2020. Dietary fibre and whole grains in diabetes management: Systematic review and meta-analyses. PLOS Medicine;Mar 6;17(3).
- Kim Y, Je Y. 2016. Dietary fibre intake and mortality from cardiovascular disease and all cancers: A meta-analysis of prospective cohort studies. Archives of Cardiovascular Diseases; Jan;109(1).
- Scientific Advisory Committee on Nutrition (SACN). 2021. Position Statement on Nutrition and Older Adults Living in the Community. Accessed online:https://www.gov.uk/government/collections/sacnreports-and-position-statements#position-statements (May 2021).
- Scientific Advisory Committee on Nutrition (SACN). 2008. SACN statement on dietary fibre. Accessed online: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/339367/SACN_Draft_position_statement_on_dietary_fibre_and_health_and_dietary_fibre_definition_2008.pdf (May 2021).
- Scientific Advisory Committee on Nutrition (SACN). 2015. Carbohydrates and Health. Accessed online: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf (May 2021).
- British Nutrition Foundation. Summary of Key Findings from the NDNS Report of Years 7 and 8 (combined). Accessed online: https://www.nutrition.org.uk/nutritioninthenews/new-reports/ndnsyears7and8.html . 2018 (May 2021).
- British Dietetic Association. Date Unavailable. Food Fact Sheet Fibre. Accessed Online: https://www.bda.uk.com/resource/fibre.html (May 2021).
- Holdoway A, et al. (2017). Managing Adult Malnutrition in the Community: Including a pathway for the appropriate use of Oral Nutritional Supplements (ONS). 2nd Edition. Accessed online: https://www.malnutritionpathway.co.uk/ (May 2021).
- National Institute of Health and Care Excellence (NICE). 2017.Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. [online] Clinical Guideline 32. Accessed online: https://www.nice.org.uk/guidance/cg32 (May 2021).