nutrition for bone health and falls prevention · o its needed to build bone & teeth, and...

Nutrition for Bone Health and Falls Prevention

Jacqueline Boyle Dietitian Manager

(CORU DI020327) 1

Aim and Learning Objectives Aims:

A. To increase awareness of the importance of nutrition in preventing falls and reducing the risk of injury from falls

B. Promoting bone health and empowering older people, communities and care providers to reduce the risk and rate of falling and the severity of injuries and to promote the best outcomes for people who have suffered falls, through nutrition.

By the end of this session you will be aware of:

1. Risk factors for falls and the MMEDS Bundle

2. The link between Malnutrition, Frailty and Falls

3. The importance of nutrition screening in falls prevention

4. Nutritional considerations in falls prevention and the key nutrients required to maintain good bone health

2

1 Risk factors for falls & falls injuries and the

MMEDS Bundle

3

Risk factors for falls1

• History of falls

• Age

• Gender

• Living alone

• Ethnicity

• Medicines

• Medical conditions

• Impaired mobility and gait

• Muscle Weakness

• Nutritional deficiencies

Jacqueline Boyle, Dietitian Manager, Peamount Healthcare, CORU DI020327

4 (1: Todd & Skelton, 2004)

• Sedentary behaviour

• Psychological status – fear of falling

• Impaired cognition

• Visual impairments

• Foot problems

Extrinsic Factors:

• Environmental hazards

• Footwear and clothing

• Inappropriate walking aids or assistive devices

What increases Osteoporosis risk?2 Non-modifiable • Advanced Age

• Female Gender

• White / Asian Race

• Family history osteoporosis & Hip fracture

• Metabolic bone diseases

• Certain malignancies (myeloma, lymphoma)

5

Modifiable • Nutrition:

• Low calcium intake • Low Vitamin D intake • Low body weight

• Sedentary Lifestyle • Smoking • Stress / depression • Glucocorticoid therapy • Surgical or drug induced

hypogonadism

(2: HSE, National council on ageing & older people, DoH, 2008)


Re-cap: What is the MMEDS Bundle?

6

O M edication

O M obility

O E xercise

O D iet

O S afety (Personal & Environmental)


2 The link between

Malnutrition, Frailty & Falls

7

What is malnutrition?

8

O ‘a state resulting from a lack of intake or uptake of nutrition that leads to altered body composition....leading to diminished physical and mental function and impaired clinical outcome from disease’.3,4

O The term malnutrition addresses 3 broad groups of conditions5:

O Under-nutrition, which includes wasting, stunting and underweight

O Micronutrient deficiencies or excess

O overweight, obesity and diet-related diseases (such as heart disease, stroke, diabetes and some cancers)

O No globally agreed diagnosis criteria as yet, however a standardised approach is strongly recommended to agree clear diagnostic characteristics to identify and document adult malnutrition in routine clinical practice internationally. 6,7

(3: AND/ASPEN, 2012; 4: Cederholm et al, 2019; 5: WHO, 2018; 6: Sobotka, 2012; 7:Cederholm et al, 2017)


Prevalence of Malnutrition in Ireland8,9,10,11,12,13,14

9 (8: BAPEN, 2012; 9: IrSPEN 2013; 10: Elia & Russell, 2009; 11: Milne et al, 2009; 12: HSE, 2018; 13: BAPEN, 2016; 14: Rice & Normand, 2012)


What can lead to malnutrition?

O Constipation or diarrhoea O Nausea / Reflux / Anorexia O Taste changes O Poor oral health / infections O Sore / Dry mouth O Dislike of hospital diets O Modified diets / Dysphagia O Pain / Discomfort swallowing O Embarrassment O Confusion / Forgetfulness

O Breathlessness

O Drowsiness

O Depression

O Reduced ability to self-feed

O Co-ordination

O Tremor

O Posture

O Poor supported feeding techniques

10


Consequences of malnutrition?15,16,17

11

(15: Russell & Elia, 2012; 16:Stratton et al, 2003; 17: Saunders & Smith, 2010 )


What is frailty?18

12

O A distinctive health state related to the ageing

process in which multiple body systems gradually lose their in-built reserves.

O A state of increased vulnerability, associated with a

decline in physical and psychological reserves.

O An apparently small event may trigger a dramatic change in physical or mental wellbeing.

No Formal consensus on the Definition of Frailty, but there

is consensus that Nutrition is one of the main factors

(18: BGS 2014)


The Link between Nutrition, Frailty & Falls

O Malnutrition is associated with loss of muscle mass (sarcopenia).

O Excessive loss of muscle mass and strength results in:

O Physical impairment, frailty, disability and dependence on others

O Inadequate nutrition contributes to the progression of many diseases, and is considered one important contributing factor in the complex aetiology of sarcopenia and frailty

13


How does malnutrition and frailty increase risk of falls and injury from falls?

O Unintentional weight loss is often due to inadequate energy and protein intake.

O In relation to falls and injuries related to falls, unintentional weight loss leads to:

muscle wasting

lower muscle strength

poor physical performance.

feeling of exhaustion

reduced physical activity

cycle of not eating and weight loss

micronutrient deficiencies increasing the risk of anaemia and osteoporosis and fractures from falls. 14


3 The importance of

Nutrition screening in falls prevention

15

What is nutrition screening?

O It allows for prevention of nutrition-related problems when risks are identified and early intervention when problems are confirmed.

O It should be completed on admission to a health service (within 24 hours in acute

hospitals) 19,20,21,22,23 16

(19: Volkert et al, 2018; 20 &21: HIQA, 2016; 22: DoH, 2009; 23: DoH, 2019)


Nutrition screening is the first step in identifying patients who are at risk of nutrition problems or who

have undetected malnutrition.

Screening to Identify Malnutrition O Gold standard method is use of a

validated Malnutrition screening tool

O Examples of tools with the best validity in the older population are:

Hospital setting: 23,24,25

’MUST’ ‘MNA-SF-V1’

‘MST’ or ‘NRS-2002’

Rehabilitation Setting:24,25

‘NUFFE’

Residential / Institution Setting:24,25

‘SNAQ-RC’

Community Setting:24,25

‘DETERMINE’

It only takes 3-5

minutes to complete

a nutrition screening

tool

Examples of tools

are: MNA-SF

MST DETERMINE

SNAQ ‘MUST’

17 (23:DoH, 2019; 24&25: Power et al, MaNuEL Study, 2018)


Screening tool example: ’MUST’26 (Malnutrition Universal Screening Tool)

O Most commonly used screening tool

in Irish Hospitals (65%)20

O Completed by nursing staff on admission

O ‘MUST’ Education sessions available on HSELanD

O Three steps: O BMI (using weight and height – from

ulna length) O Unintentional weight loss / gain over

previous month O “Acute disease effect – there has been

or is likely to be little nutritional intake for > 5 days”

18 (20: HIQA, 2016; 26: BAPEN, 2003)


Management of Malnutrition after screening

Follow your local nutrition screening management guidelines e.g.

O Immediate referral to Dietitian for full dietary assessment

O Implementation of High Protein High Calorie diet

O Monitor dietary intake using detailed 3 day food & fluid intake charts

O Close weight monitoring and re-screen if further weight loss

O Provide nourishing snacks / fortified milk between meals

O Fortify foods with extra calories / protein

19

Food First Approach!


Early Referral to Dietitian is key!

Other appropriate referrals to help prevent falls include:

O Patients requiring enteral tube feeding (PEG/NG)

O Patients with Chronic Kidney Disease and elevated electrolyte levels

O Patients with wounds and poorly healing wounds

O Patients with newly diagnosed Coeliac Disease

O Newly diagnosed Diabetes Mellitus or unstable glycaemic control

O Patients with gastrointestinal conditions e.g. IBD, Diverticular Dx, constipation, diarrhoea etc

O Patients requiring texture modified diets and thickened fluids

O Patients who have been commenced on Oral Nutritional Supplements

O Patients with micronutrient deficiencies including anaemia’s

O Patients who have a BMI >30kg/m2

O Patients with hypertension

O And many more….

20


4 Prevention of falls and falls injuries and maintaining good bone health: Some key nutritional considerations

21

Nutritional Assessment

NCPM Assessment:

1. Medical Tests, Procedures, and Social history

2. Biochemistry

3. Medications

4. Nutrition focussed physical findings

5. Anthropometry & nutritional requirements

6. Food and nutrition related history

7. Nutrition Diagnosis

8. Nutrition care Plan devised 22 (27: Diagram Source BDA 2017)

Must be completed by a Registered Dietitian. The Dietitian then makes a nutrition diagnosis, selects an appropriate intervention and monitors progress with the care plan.


Diet related issues that can lead to falls:

23

Diet related issues that can

lead to falls

Anaemia

Diabetes and poor glycaemic

control

Constipation

Hyper or Hypotension

Dehydration

Sarcopenia

Weight loss and Frailty


Is Hydration important in falls Prevention?

O Even mild dehydration affects mental performance and tiredness

O Common complications:

O Low blood pressure

O Constipation

O Urinary tract infections

O Weakness

O Dizziness

O Overall increased risk of falls

24


Tips to help promote optimal hydration

Regular / Hourly prompting

Accessibility of fluids

Regular prompting / assistance to use the toilet

Preferred fluids: minerals, fruit juices, favourite drinks, fresh water

and at preferred temperature

Squash or juice added to water rather than plain water if thickened

Assess if assisted beaker / adapted cups or assistance to take the fluids

is required

Encourage foods with good fluid content such as pureed fruit, yoghurt,

jelly, custard, soup

Determine an individualised daily goal and to use self monitoring tools

25


http://www.google.ie/imgres?imgurl=http://www.tno.nl/images/shared/markten/KvL-FOOD-Nutilis1.jpg&imgrefurl=http://www.tno.nl/content.cfm?context=thema&content=inno_case&laag1=891&laag2=903&item_id=541&Taal=2&usg=__QGq2b7v_Rkzf3a11jEmzDCmBEU0=&h=240&w=207&sz=27&hl=en&start=6&zoom=1&itbs=1&tbnid=ddv3ZFkecHuq2M:&tbnh=110&tbnw=95&prev=/search?q=nutilis&hl=en&gbv=2&biw=1004&bih=612&tbm=isch&ei=62LJTf7RDpCdOqSqpMEG

Nutrition, Falls and the food pyramid28:

26

(28: DoH, 2016)

Main Key Nutrients for Falls Prevention & Bone Health?

1. Calcium & Vitamin D

2. Protein

3. Phosphorus

4. Magnesium

5. Iron & Vitamin C

27


1. Calcium and Vitamin D

Adequate amounts can help prevent fractures

O Calcium is the most abundant mineral in the body:

O 99% in bones & teeth and 1% tissue and fluid

O Its needed to build bone & teeth, and supports muscle function

O Vitamin D helps helps the body to absorb calcium and phosphorus, helps improve muscle function, and the maintenance of normal bones

O It also helps reduce the risk of falls associated with poor balance and muscle weakness.29,30

28 (29: Avenell et al, 2009; 30: Karlsson et al, 2013)


How much Calcium is needed?

Aim for 3 portions of dairy foods/day for older adults: = 200ml glass of milk / milk on cereal = 125 g carton of yoghurt / 200ml yogurt drink = 25g hard cheese (matchbox size piece) = 50g soft cheese = 1 portion of milk pudding

Other non dairy sources include: O Dark green vegetables O Tinned fish e.g. sardines / salmon with bones O Pulses, nuts & dried fruit e.g. figs / apricots O fortified cereals O Tofu

How Much? RDA (mg)12

Adults 950 – 1000mg / day

29 (12: HSE Food, Nutrition and Hydration Policy, 2018)


Food Weight Calcium Content (mg)31

Whole milk 190ml 224

Skimmed Milk 190ml 235

Soy Milk (non fortified) 190ml 25

Goats Milk 190ml 190

Yoghurt 150g 225

Cheddar Cheese 28g 202

Boiled spinach 112g 179

Boiled broccoli 112g 45

Baked Beans 112g 59

Large orange 1 58

Dried apricots 100g 92

Brazil nuts 100g 170

Salmon (tinned) 56g 52

Tofu 100g 480 30

(31: Irish Osteoporosis Society, 2018)


What reduces the absorption of Calcium?

Caffeine33,34

O A lot of Caffeine (i.e. 1g/day or more) will lead to more loss of Calcium (in urine). Its found in:

O Brewed coffee: 100mg/cup,

O Instant coffee: 65mg/cup,

O Decaf coffee: 5mg/cup,

O Tea : 47mg/cup,

O Cola: 35mg/can,

O Red bull: 80mg/can,

O Dark chocolate: 20mg/oz,

O Milk chocolate: 6mg/oz 31 (32: Maurel et al, 2012; 33: Hallstrom et al, 2006; 34: Liu et al, 2012)

Alcohol 32 • Excess- often leads to poor / unbalanced diet • Poor intake of most nutrients • Reduces bone formation & calcium absorption • Increased likelihood of falls


Source and how much Vitamin D?

O Sunshine (UVB)35,36 O Sunshine vitamin, produced by action of UVB light on skin O Due to Irelands latitude, between late September and March the body

cannot synthesise vitamin D O 10 – 15 minutes of sunshine exposure during the summer is enough to

make sufficient vit D for each day. O Ability to synthesise vitamin D decreases with age and the frail and bed

bound are most at risk O 2013 study, 40.1% of the population had vitamin D levels considered

inadequate for bone health

O Dietary sources: • Fortified milks, spreads, cereals • Egg yolks • Fish oils and oily fish ( salmon, mackerel) • Liver 32

How Much? Vitamin D µg/day12

Adults 15µg/day

(12: HSE Food, Nutrition and Hydration Policy, 2018; 35: Cashman et al, 2013; 36: Laird, 2018)


2. Protein

O Building block for tissue and contributes to the maintenance of healthy bones and growth of muscle

O Calcium, Vitamin D and Protein all have positive effect on bone health and maintenance when used together

O But if you have low calcium intake and increased protein intake then you can lose bone mass

O Protein improves recovery from hip fracture

O It is recommended to spread protein intake across each meal

O Food examples of foods rich in protein:

O Milk, yogurt, cheese, eggs, fish, poultry, lean meats, pulses – beans and lentils, nuts and seeds

33


3. Phosphorus37,38 O Phosphorus is an essential bone forming element as it is

required for the appropriate mineralisation of the skeleton O It supports bone development and healthy teeth O Intake of phosphorus is generally adequate to meet likely

skeletal needs in most patients with osteoporosis, however some people with poor intake of dairy or meat may struggle to meet requirements

O Sources of phosphorus: O Dairy O Eggs O Fish O Meat O Pulses O Nuts O Wholegrains O Soybeans

34 (37: Heaney, 2004; 38: Palacios, 2006)


4. Magnesium38,39 O Magnesium is essential:

O It is essential for the absorption and metabolism of calcium

O It is necessary to convert Vitamin D into its active form

O It assures the strength, firmness and health of bones and teeth

O It is also essential to the proper functioning of the nerves and muscles and all living cells

O 60% body reserves of magnesium are held in the bone

O low levels can inhibit vitamin D and calcium homeostasis in the body and be a risk factor for osteoporosis

O New research suggests that magnesium may prevent bone fractures in middle aged and older adults:

O Men with higher levels of magnesium were 44% less likely to have bone fractures, and those with a very high level of magnesium had no fractures over 20 year follow up period

O Magnesium is found in green vegetables, nuts, seeds, squash, whole grains, legumes and avocado

35 (38: Palacios, 2006; 39: Sandoiu, 2017)


5. Iron & Vitamin C

O Intake of Iron rich foods can decrease at times as a person ages or iron stores can reduce due to health complications leading to anaemia

O Symptoms of Anaemia leads to dizziness, weakness & increased risk of falls

O Good sources of iron include meat, poultry, fish, eggs, pulses, dried fruit, dark green vegetables, fortified foods, nuts

O Vitamin C helps support the absorption of Iron

O The Dietitian can help advise around iron rich foods to help avoid anaemia, and strategies to maximise absorption of iron in the diet

O Vitamin C also contributes to normal collagen formation and normal function of the bones and cartilage

O Good sources include fresh fruit and vegetables, and potatoes 36


RECAP: So why is diet (nutrition) important to include in the MMEDS Bundle?

37

Adequate nutrition and awareness of the role of diet in falls prevention can:

1. help prevent muscle wasting and weakness which is a major risk factor for falls

2. Prevent low body weight which can increase the risk of osteoporosis and fractures from falls

3. Prevent calcium and vitamin d deficits in the diet which can increase the risk of osteoporosis and fractures from falls

4. Help prevent nutritional anaemia's which can lead to dizziness, weakness and tiredness which can increase the risk in falls


Recommendations & Take Home Messages O Screen for malnutrition on admission / within 24 hours

O Follow all local malnutrition management guidelines

O Refer to Dietitian as early as possible

O Monitor for signs of dehydration & encourage fluids

O Some of the key nutrients are: calcium & vit D, Protein, Phosphorus, Magnesium,

iron & vit C

O Calcium is better absorbed from dairy products than from other food sources &

food sources of vitamin D are limited

O Be careful of caffeine & alcohol affecting the absorption of calcium

O If inadequate intake via diet, supplementation may be needed

O Being a healthy weight can help protect falls injuries

O A healthy balanced diet provides adequate nutrients for most people without

the need for supplementation 38


Acknowledgements & Thanks! O Big thanks goes to all Dietitians who have reviewed

and provided feedback which contributed to this presentation, in particular:

Theresa Rennick

(INDI Unscheduled Care HSCP Advisory Group)

Ciara Pender & Anne-Marie Bennett

(Affinity Programme Dietitian Representatives)

O Also thank you kindly to all OPDIG members of the INDI for contributing to the OPDIG Bank of Presentations

O Thank you kindly to Teresa O’Callaghan for requesting Dietetic input to the Collaborative, and highlighting the importance of Nutrition in Falls prevention

39

Thank you!

Any Questions? 40


References 1. Todd C & Skelton D, (2004). ‘What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls’. Copenhagen, WHO Regional Office for Europe (Health Evidence Network

Report; Retrieved from: http;//www.euro.who.int/document/E82552.pdf [Accessed 29/04/2019].

2. HSE, National Council on Aging & Older people, DoH, (2008). ‘Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population’.

3. Sobotka L, editor. Basics in clinical nutrition. 4th ed. Galen; 2012

4. Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC , Compher C, Correia I, Higashiguchi i T, Holst M , Jensen GL , Malone A, Muscaritoli M, Nyulasi I, Pirlich M, Rothenberg E, Schindler K, Schneider SM, de van der Schueren MAE, Sieber t C, Valentini L, Yu JC, Van Gossum A and Singer P (2017). ‘ESPEN guidelines on definitions and terminology of clinical nutrition’. Clinical Nutrition: (36), 49 – 64.

5. WHO (16th February 2018). Malnutrition Definition Retrieved from: https://www.who.int/news-room/fact-sheets/detail/malnutrition [Accessed on: 17/09/2018]

6. White JV, Guenter P, Jensen G, Malone A, Schofield M, the Academy Malnutrition Working Group, the A.S.P.E.N. Malnutrition Task Force and the A.S.P.E.N. Board of Directors (2012). ‘Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)’. Journal of Perenteral and Enteral Nutrition:(36), 275 – 283.

7. Cederholm T, Jensen GL, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, Baptisa G, Barazzoni R, Blaauw R, Coats A, Crivelli A, Evans DC, Gramlich L, Fuchs-Tarlovsky V, Keller H, Llido L, Malone A, Mogensen KM, Morley JE, Muscaritoli M, Nyulasi I, Pirlich M, Pisprasert V, de van der Schueren MAE, Siltharm S, Singer P, Tappenden K, Velasco N, Waitzberg D, Yamwong P, YuJ, Van Gossum A, Compher C, GLIM Core Leadership Committee, and GLIM Working Group (2019). ‘ GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community’. Clinical Nutrition: (38), 1-9.

8. British Association for Parenteral and Enteral Nutrition (BAPEN) (2012) ‘Nutrition Screening Survey in the UK and Republic of Ireland in 2011’. BAPEN, UK.

9. The Irish Society for Clinical Nutrition and Metabolism (IrSPEN), Irish Nutrition & Dietetic Institute (INDI), European Nutrition for Health Alliance (ENHA) (2013) ‘Every patient deserves good nutritional care: A call to action’. Retrieved from: http://irishpatients.ie/wp-content/uploads/2013/07/Call-toAction-every-patient-deserves-good-nutritional-care.pdf. [Accessed on 03/05/2019]

10. Elia M & Russell C (2009). ‘Combating Malnutrition: Recommendations for Action. Report from advisory group on malnutrition led by BAPEN. Retrieved from: https://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf. [Accessed on 03/05/2019]

11. Milne AC, Potter J, Vivanti A, Avenell A (2009). ‘Protein and energy supplementation in elderly people at risk from malnutrition’. Cochrane Database Systematic Reviews: 16(2): https://doi.org/10.1002/14651858. CD003288.pub3

12. HSE Food, Nutrition and Hydration Policy: For Adults Patients in Acute Hospitals (2018)

13. BAPEN (2016) Introduction to Malnutrition. Retrieved from http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition on 20th March 2019

14. Rice N & Normand C (2012). ‘The cost associated with disease-related malnutrition in Ireland’. Public Health Nutrition: (15), 1966–72.

15. (15) Russell CA & Elia M (2012). ‘Nutrition Screening Survey in the UK and Republic of Ireland in 2011 – A Report by the British Association for Parenteral and Enteral Nutrition (BAPEN)’: 1 – 76.

16. Stratton, RJ, Green, C.J., Elia, M. (2003). ‘Disease-related Malnutrition: An Evidence based approach to treatment’, Clinical Nutrition Journal: 22(6): 585.

17. Saunders J & Smith T (2010). ‘Malnutrition: Causes and Consequences’. Clinical Medicine: 10(6): 624-627.

18. British Geriatrics Society with RCGP & Age UK, (2014), ‘Fit for Frailty Part 1 – Consensus best practice guidance for the care of older people living in community and outpatient settings’ pg 1 – 22.

19. Volkert D, Beck AM, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L, Kiesswetter E, Maggio M, Raynaud-Simon A, Sieber CC, Sobotka L, van Asselt D, Wirth R and Bischoll SC (2018). ‘ESPEN Guideline on Clinical Nutrition and Hydration in geriatrics’. Clinical Nutrition: 1 – 38. https://doi.org/10.1016/j.clnu.2018.05/024

20. HIQA (2016). ‘Report of the review of nutrition and hydration care in public acute hospitals’ 1 – 122. Retrieved from: https://www.hiqa.ie/sites/default/files/2017-02/Review-nutrition-hydration-hospitals.pdf [Accessed on 01/04/2019]

21. HIQA (2016). National Standards for Residential Care Settings for Older People in Ireland. 1 – 102. Retrieved from: https://www.hiqa.ie/sites/default/files/2017-01/National-Standards-for-older-People.pdf. [Accessed on 13/03/19]

22. DOH (2009). Key recommendation of national guidelines for preventing under-nutrition in acute hospitals is use of ‘MUST’.

23. Department of Health (2019). ‘Nutrition screening and use of oral nutrition support for adults in the acute care setting’ (NCEC National Clinical Guideline No.). Available at: http://health.gov.ie/national-patient-safety-office/ncec/national-clinical-guidelines. [Accessed on 03/05/2019).

24. Power L, de van der Schueren MAE, Leij-Halfwerk S, Bauer J, Clarke M, Vissser M, Volkert D, Bardon L, Gibney E, Corish CA, and the MaNuEL Consortium (2018). ‘Development and application of a scoring system to rate malnutrition screening tools used in older adults in community and healthcare settings – A MaNuEL study’. Clinical Nutrition: DOI: 10.1016/j.clnu.2018.07.022

25. Power L, Mullally D, Gibney ER, Clarke M, Visser M, Volkert D, Bardon L, de van der Schueren M, Corish CA, on behalf of the MaNuEL Consortium (2018). ‘A Review of the validity of malnutrition screening tools used in older adults in various settings –A MaNuEL study’. Clinical Nutrition ESPEN: 24: 1 – 13.

26. Elia, Marinos: BAPEN (2003). ‘The ‘MUST’ Report: Nutritional screening of adults: a multidisciplinary responsibility’ 1 – 138. Retrieved from: https://www.bapen.org.uk/pdfs/must/must-report.pdf. [Accessed on 03/05/2019]

27. BDA (2017) ‘What is your dietitian thinking about’ (Infographic). Retrieved from: https://www.bda.uk.com/improvinghealth/awareness_raising/dw2017_thinkingposterpdf [date accessed 19/05/2019]

28. Department of Health and Healthy Ireland (2016), ‘Healthy Food for Life – the healthy eating guidelines and Food Pyramid’. Available at: https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/heal/healthy-eating-guidelines/ [accessed on 19/05/2019]

29. Avenell A, Gillespie WJ, Gillespie LD, and O’Connell D (2009). ‘Vitamin D and vitamin d analogues for preventing fractures associated with involutional and post-menopausal osteoporosis’. Cochrane database systematic review (2);CD000227

30. Karlsson MK, Magnusson H, Von Schewelov T and Rosengren BE (2013). ‘Prevention of falls in the elderly –a review’, Osteoporosis International, 24(3) 77 – 762.

31. Irish Osteoporosis Society (2018). ‘Diet & Osteoporosis’ . Retrieved from: https://www.irishosteoporosis.ie/treatments/diet-osteoporosis [date accessed: 03/05/2019]

32. Maurel DB, Boisseau N, Benhamou CL and Jaffre C (2012). ‘Alcohol and bone: review of dose effects and mechanisms’, Osteoporosis International 23(1), 1-16

33. Hallstrom H, Wolk A, Glynn A and Michaelsson K (2006). ‘Coffee, tea and caffeine consumption in relation to osteoporotic fracture risk in a cohort of Swedish women’. Osteoporosis International, 17(7): 1055-1064.

34. Liu H, Yao K, Zhang H, Zhou J, Wu T and He C (2012). ‘Coffee consumption and risk of fractures: a meta-analysis’. Archives of Medical Science: 8(5), 776-783.

35. Cashman KD, Muldowney S, McNulty B, Nugent A, Fitzgerald AP, Kiely M, Walton J, Gibney MJ and Flynn A (2013). ‘Vitamin D status of Irish Adults: findings from the National Adult Nutrition Survey’. The British Journal of Nutrition: 109(7): 1248 – 1256.

36. Mind Your Bones (2018) – ‘Meet the experts - Eamon Laird – Vitamin D’. Retrieved from: https://mindyourbones.ie/eamon-laird.html [Date accessed 03/05/19]

37. Heaney, (2004). ‘Phosphorus Nutrition and the Treatment of Osteoporosis’. Mayo Clinic Proceedings: (79), 91-97

38. Palacios, (2006). ‘The Role of Nutrients in Bone Health, from A to Z’. Critical Reviews in Food Science and Nutrition: (46), 621-628.

39. Medical News Today: Sandoiu A (13th April 2017). ‘Magnesium may prevent bone fractures’. Retrieved from: https://www.medicalnewstoday.com/articles/316922.php. [Date accessed 03/05/2019].

40. Food Safety Authority or Ireland (FSAI) (1999). ‘Recommended Dietary Allowances for Ireland’, Dublin: FSAI

41

https://www.who.int/news-room/fact-sheets/detail/malnutrition





http://irishpatients.ie/wp-content/uploads/2013/07/Call-toAction-every-patient-deserves-good-nutritional-care.pdf

















https://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf

http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition on 20th March 2019







https://www.hiqa.ie/sites/default/files/2017-02/Review-nutrition-hydration-hospitals.pdf









https://www.hiqa.ie/sites/default/files/2017-01/National-Standards-for-older-People.pdf











http://health.gov.ie/national-patient-safety-office/ncec/national-clinical-guidelines











https://www.bapen.org.uk/pdfs/must/must-report.pdf



https://www.bda.uk.com/improvinghealth/awareness_raising/dw2017_thinkingposterpdf

https://www.hse.ie/eng/about/who/healthwellbeing/our-priority-programmes/heal/healthy-eating-guidelines/









https://www.irishosteoporosis.ie/treatments/diet-osteoporosis



https://mindyourbones.ie/eamon-laird.html



https://www.medicalnewstoday.com/articles/316922.php

nutrition for bone health and falls prevention · o its needed to build bone & teeth, and...

Documents