By Mary Ellen Posthauer, RDN, CD, LD, FAND

Building on the evidence that I have reviewed in the past several blogs concerning diagnosing adult malnutrition, this month we'll discuss some solutions for meeting energy and protein needs for elderly clients with pressure ulcers.

Calorie and Protein Recommendations for Wound Healing

The typical older adult (over 65) doesn't consume the recommended calories or protein as defined by the Institute of Medicine which suggests adult males consume 2,080 calories and females 1,762 calories. If elderly men decrease their daily intake by 1,000-1,200 calories/day and women by 600-800, then the challenge is to offer foods that pack calories and protein into smaller portions. In addition to calories, multiple studies support the need for increasing protein to 1.0-1.5 grams/kg of body weight per day for the elderly vs. the 0.8 grams/kg/day for healthy younger adults.

The current NPUAP/EPUAP guidelines for pressure ulcer treatment recommend offering 30-35 calories/kg of body weight/day and 1.2-1.5 grams of protein/kg of body weight/day for individuals with pressure ulcers. Based on the guidelines, an elderly individual with a stage IV pressure ulcer weighing 130 lbs. requires 1,772-2,068 calories and 74-88 grams of protein for healing. The daily menus in the majority of assisted living and/or nursing facilities provide approximately 1,800-2,200 calories and 75-85 grams of protein. The challenge is encouraging older adults to consume the meals. The frequent comment is "this is too much food" or "I am not hungry". Elderly individuals living at home are often challenged with food insecurity or difficulty preparing meals.

Tips and Tricks to Increase Calorie and Protein Intake

Consider these ideas for adding calories and protein without increasing the portion:

• Prepare hot cereals or cream soups with whole milk or half and half to increase calories and protein.
• Skim milk powder can be added to cooked cereals, scrambled eggs, cream soups, puddings, potatoes, casseroles, muffins or meat mixtures such as meat loaf or meat balls (begin with 1 Tbsp. per serving).
• Milk is a good source of protein and calcium and whole milk has 150 calories vs. 121 calories in 2%. Why not offer hot chocolate and cookies before bed or as an afternoon snack?
• Add whole milk and/or 1 Tbsp. of grated cheese to mashed potatoes.
• Mix instant breakfast with whole milk vs. skim and add ice cream to boost calories and protein. Offer 4 oz. between meals to increase intake.
• Make homemade milkshakes with whole milk and a variety of ice cream flavors to avoid taste fatigue. Remember to top with whip cream.
• Peanut butter is a high quality protein that can be used in multiple ways- in sandwiches, spread on crackers, toast, or bananas, or added to pudding, muffins or shakes. There are many other nut butters on the market including almond or pecan butter as alternative choices.
• Eggs are an excellent source of protein and are easy to digest. In addition to serving them at breakfast, make egg salad sandwiches, deviled eggs, sliced hard-boiled eggs or add them to casseroles. Many older adults like breakfast foods in the evening vs. a heavy meal so prepare omelets or a quiche.
• Cheese is a simple food to add to salads, scrambled eggs, vegetables, casseroles, soups or serve on crackers and sandwiches. Cream of tomato soup and a grilled cheese sandwich are considered comfort foods. Why not cheese grits?
• Lentils, split peas, kidney, navy and pinto beans are good sources of fiber and protein and are easy on the budget. They can be used in soups or casseroles. If you live in the mid-west or south, ham and beans, corn bread and buttermilk are considered staples.
• Yogurt is currently a popular product. Try Greek yogurt for increased protein. Substitute plain Greek yogurt for salad dressing when making sandwich spreads or add a dollop to a baked potato. Check on coupons available for most brands.

Fluids are important for all individuals especially when we are increasing the protein in the diet. Older adults' decreased sense of thirst presents an additional challenge. Offer four ounces of water or juice with each medication given and keep fresh water handy. Remember most elderly individuals cannot lift heavy mugs. An alternative to these large pitchers is an insulated 8-10 oz. covered cup. The nursing facility where I consult has a juice station on every unit that offers three types of juice. Both residents and staff have access to the juice station. In addition to the traditional beverages served, the facility also offers a variety of regular or low calorie soft drinks at mealtimes and during the hydration pass between meals. Enhancing water by adding a low calorie flavor packet can boost fluid intake. Gelatin, ice cream, fruit juice bars, sherbet and soup are favorite foods that increase the daily fluid content of the diet.

Rather than three large meals offer several small meals during the day and be certain that each one has a good source of high quality protein. An ounce of meat, fish, or poultry is equivalent to 1/4 cup of cooked dried beans, 1/2 oz. of nuts, 1(1/4) Tbsp. of peanut or almond butter, one egg (2 egg whites), 1 oz. of cheese or 1/4 cup of cottage cheese. Aim for at least two or more ounces of protein at each meal.

Bon Appétit!

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association's Unintentional Weight Loss work group.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.