• Promote health and reduce chronic disease through the consumption of healthful diets and achievement and maintenance of body weight.
• Increase the proportion of primary care physicians who reg- ularly measure the body mass index in their adult patients.
• Increase the proportion of physician office visits made by adult patients who are obese that include counseling or education related to weight reduction, nutrition, or physical activity.
• Increase the proportion of physician visits made by all child and adult patients that include counseling about nutrition or diet.
• Increase the proportion of adults who are at a healthy weight.
• Reduce household food insecurity and in so doing reduce hunger.
Age-Related Requirements MyPlate for Older Adults
As part of the 2010 Guidelines, the new visual depiction of daily food intake, Choose MyPlate (ChooseMyPlate.gov), replaces the information formerly found on MyPyramid.gov.
The USDA Human Nutrition Research Center on Aging at Tufts University has introduced the MyPlate for Older Adults that calls attention to the unique nutritional and physical activity needs associated with advancing years. The drawing features different forms of vegetables and fruits that are convenient, affordable, and readily available. Other unique components of the MyPlate for Older Adults in- clude icons for regular physical activity and emphasis on adequate fluid intake, areas of particular concern for older adults (Figure 9-1).
Generally, older adults need fewer calories because they may not be as active and metabolic rates slow down.
However, they still require the same or higher levels of nutrients for optimal health outcomes. The recommenda- tions may need modification for the older adult with ill- ness. The Dietary Approaches to Stop Hypertension (DASH) eating plan is another highly recommended eating plan to assist older adults with maintenance of op- timal weight and management of hypertension. This plan consists of fruits, vegetables, whole grains, low-fat dairy products, poultry, and fish, and restriction of salt intake.
Information on DASH can be found at http://www.nhlbi.
nih.gov/health/health-topics/topics/dash/.
Other Dietary Recommendations
FatsSimilar to other age groups, older adults should limit intake of saturated fat and trans fatty acids. High fat diets cause obesity and increase the risk of heart disease and cancer. Recommendations are that 20% to 35% of total calories should be from fat, 45% to 65% from carbohy- drates, and 10% to 35% from proteins. Monounsaturated fats, such as olive oil, are the best type of fat since they lower low-density lipoprotein (LDL) but leave the high- density lipoprotein (HDL) intact or even slightly raise it.
Protein
Presently, the Institute of Medicine’s Recommended Dietary Allowance (RDA) for protein of 0.8 g/kg per day, based primarily on studies in younger men, may be inade- quate for older adults. Results of a recent study (Beasley et al., 2010) suggest that higher protein consumption, as a fraction of total caloric intake, is associated with a decline From U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion: Healthy people 2020 (2012). Available at http://www.healthypeople.gov/2020.
in risk of frailty in older adults. Protein intake of 1.5 g/kg per day, or 20% to 25% of total calorie intake, may be more appropriate for older adults at risk of becoming frail. Older people who are ill are the most likely segment of society to experience protein deficiency. Those with limitations affecting their ability to shop, cook, and consume food are at risk for protein deficiency and malnutrition.
Fiber
Fiber is an important dietary component that some older people do not consume in sufficient quantities. After age 50, women should receive around 21 g of dietary fiber daily, and men should receive around 30 g daily. However, even small amounts of fiber are beneficial (Academy of Nutrition and Dietetics, 2012). The benefits of fiber in- clude the following: facilitates the absorption of water;
helps control weight by delaying gastric emptying and providing a feeling of fullness; improves glucose tolerance by delaying movement of carbohydrate into the small intestine; prevents or reduces constipation by increasing the weight of the stool and shortening the transit time;
helps prevent hemorrhoids and diverticulosis by decreasing pressure in the colon, shortening transit time, and increas- ing stool weight; reduces the risk of heart disease by bind-
ing with bile (which contains cholesterol) and causes its excretion; and protects against cancer.
It is better to get fiber from food rather than from fiber supplements such as Metamucil because supple- ments do not contain the essential nutrients found in high-fiber foods and their anticancer benefits are questionable. Ways to increase fiber intake include eating cooked dry beans, peas, and lentils; leaving skins on fruits and vegetables; eating whole fruit rather than drinking fruit juice; and eating whole-grain breads and cereals (National Institute on Aging, 2011). Those who have difficulty chewing could sprinkle oat bran on cere- als or in soups, meat loaf, or casseroles. The quantity of bran depends on the individual, but generally, 1 to 2 tablespoons daily is sufficient. Individuals who have not used bran should begin with 1 teaspoon and progres- sively increase the quantity until the fiber intake is enough to accomplish its purpose. Fluid intake of 64 ounces daily is essential as well.
Vitamins and Minerals
Older people who consume five servings of fruits and veg- etables daily will obtain adequate intake of vitamins A, C, and E, and potassium. But, Americans of all ages eat less FIGURE 9-1 MyPlate for older adults. Available at http://now.tufts.edu/news-releases/tufts-university-nutrition-scientists-unveil.
than half of the recommended amounts of fruits and vege- tables (Haber, 2010). After 50 years of age, the stomach produces less gastric acid, which makes vitamin B12 absorp- tion less efficient. Vitamin B12 deficiency is a common and underrecognized condition that is estimated to occur in 12%
to 14% of community-dwelling older adults and up to 25%
of those residing in institutional settings (Ahmed &
Haboubi, 2010).
Atrophic gastritis and pernicious anemia are the most common causes of vitamin B12 deficiency. Although intake of this vitamin is generally adequate, older adults should increase their intake of the crystalline form of vitamin B12 from fortified foods such as whole-grain breakfast cereals. Use of proton pump inhibitors for more than 1 year, as well as histamine H2 receptor block- ers, can lead to lower serum vitamin B12 levels by impair- ing absorption of the vitamin from food. Metformin, colchicine, and antibiotic and anticonvulsant agents may also increase the risk of vitamin B12 deficiency (Cadogan, 2010).
Calcium and vitamin D are essential for bone health and may prevent osteoporosis and decrease the risk of fracture.
Chapter 18 discusses recommendations for calcium and vita- min D supplementation. Calcium is a difficult mineral to absorb, and some foods inhibit calcium absorption (e.g., spin- ach, green beans, peanuts, and summer squash) (Table 9-1).
High levels of protein, sodium, or caffeine also cause more calcium to be excreted in the urine and should be avoided. For older adults with inadequate calcium intake from diet, supple- mental calcium can be used.
Obesity (Overnutrition)
Although most of the research on nutrition and older adults has centered on underweight and frailty, the increase in the prevalence of obesity in the general population, and in older adults, is getting increased attention. More than two thirds of all adults in the United States are overweight (BMI 5 25 to 29.9) or obese (BMI 30), and the propor- tion of older adults who are obese has doubled in the past 30 years (Flicker et al., 2010). The obesity epidemic is occurring in parallel with the aging of the baby boomer generation. Adults over the age of 60 years are more likely to be obese than younger adults. Non-Hispanic black indi- viduals have the highest rate (44.1%) followed by Mexican Americans (39.3%) and non-Hispanic whites (32.6%) (Ogden et al., 2012). Socioeconomic deprivation and lower levels of education have been linked to obesity.
Although there is strong evidence that obesity in younger people lessens life expectancy and has a negative effect on functionality and morbidity, it remains unclear whether overweight and obesity are predictors of mortality in older adults. In what has been termed the obesity para- dox, for people who have survived to 70 years of age, mortality risk is lowest in those with a BMI classified as overweight (Felix, 2008, p. 36). Flicker and colleagues (2010) conclude that “BMI thresholds for overweight and obese are overly restrictive for older people. Overweight older people are not at greater mortality risk, and there is little evidence that dieting in this age group confers any benefit; these findings are consistent with the hypothesis that weight loss is harmful” (p. 239). For nursing home residents with severely decreased functional status, obesity may be regarded as a protective factor with regard to func- tionality and mortality (Kaiser et al., 2010).
At this time, maintaining weight in older persons seems to be a clinical recommendation, and any weight loss interventions in older persons must be “carefully considered on an individualized basis with special atten- tion to the weight history and the medical conditions of each individual” (Bales & Buhr, 2008, p. 311). Maintaining a healthy weight throughout life can prevent many ill- nesses and functional limitations as a person grows older.
Malnutrition
Malnutrition is defined as “a state in which a deficiency, excess or imbalance of energy, protein and other nutrients causes adverse effects on body form, function, and clinical outcome” (Ahmed & Haboubi, 2010, p. 207). The rising incidence of malnutrition among older adults has been documented in acute care, long-term care, and the community. Between 16% and 30% of older adults are TABLE
9-1
Calcium Content of SeveralCommon Foods
Food Item Serving Size Calcium (mg)
Plain yogurt, fat-free 8 oz 452
American cheese 2 oz 312
Yogurt with fruit (low
fat or fat-free) 8 oz 345
Milk 8 oz 300
Orange juice,
calcium-fortified 8 oz 350
Dried figs 10 figs 269
Cheese pizza 1 slice 240
Ricotta cheese, part
skim 1/2 cup 334
Ice cream, soft serve 4 oz 103
Spinach 4 oz 139
Cooked soybeans 1 cup 298
From National Institutes of Health: Sources of calcium, Washington, DC.
Available at www.nichd.nih.gov/milk.
malnourished or at high risk, and about half of this popu- lation has protein levels consistent with malnutrition when they are admitted to hospitals (Duffy, 2010). Older adults in skilled nursing facilities and long-term nursing home residents also have a higher incidence of malnutri- tion. These figures are expected to rise dramatically in the next 30 years (Ahmed & Haboubi, 2010). Malnutrition among older people is clearly a serious challenge for health professionals in all settings.
Malnutrition has serious consequences, including infections, pressure ulcers, anemia, hypotension, impaired cognition, hip fractures, and increased mortality and morbidity. “Malnourished older adults take 40% longer to recover from illness, have two to three times as many
complications, and have hospital stays that are 90% longer”
(Haber, 2010, p. 211). Many factors contribute to the occurrence of malnutrition in older adults (Figure 9-2).
Protein-energy malnutrition (PEM) is the most com- mon form of malnutrition in older adults. PEM is charac- terized by the presence of clinical signs (muscle wasting, low BMI) and biochemical indicators (albumin, cholesterol, or other protein changes) indicative of insufficient intake.
Signs and symptoms of PEM are nonspecific, and it is important that other conditions such as malignancy, hyper- thyroidism, peptic ulcer, and liver disease are ruled out.
Comprehensive nutritional screening and assessment are essential in identifying older adults at risk for nutrition problems or who are malnourished.
Chronic medical conditions
Functional and social problems Detailed history
Medical records Targeted evaluation Cardiac diseases Pulmonary diseases Cancer
Infections/AIDS Rheumatoid arthritis Helicobacter pylori Gallbladder disease Malabsorption Hyperthyroidism/
hypothyroidism Alcoholism Parkinson’s disease Pressure ulcers
Psychiatric and cognitive problems
Good psychiatric history Mini mental status testing Geriatric depression scale
Activities of daily living Instrumental activities of daily living
Physical therapy Occupational therapy Social status evaluation Depression
Dementia Late-life paranoia Anorexia nervosa Globus hystericus
Review diet Evaluate necessity Refer to a dietitian
Heart-healthy Low cholesterol No/low salt Renal
Medications Restrictive diets
Dental history
The dental screening tool Dry mouth
Dysgeusia Poor dentition Oral candidiasis Mouth sores
Oral health Angiotensin-converting enzyme inhibitors Analgesics Antacids Antiarrhythmics Antibiotics Anticonvulsants Antidepressants Beta blockers Calcium blockers Digoxin
Diuretics H2 blockers Laxatives Nonsteroidal anti- inflammatory drugs Oral hypoglycemics Potassium suppositories
Steroids Immobility
Poor dexterity Tremors Poverty Loneliness Poor support
FIGURE 9-2 Risk factors for undernutrition illustrated by clinical approach. (From Omran M, Salem P: Diagnosing undernutrition, Clin Geriatr Med 18:
719-36, 2002)
Factors Affecting Fulfillment of Nutritional Needs
Fulfillment of the older person’s nutritional needs is affected by numerous factors including changes associated with aging, lifelong eating habits, chronic disease, medication regimens, ethnicity and culture, socialization, socioeconomic deprivation, transportation, housing, and food knowledge.
Age-Associated Changes
Some age-related changes in the senses of taste and smell (chemosenses) and the digestive tract do occur as the indi- vidual ages and may affect nutrition. For most older people, these changes do not seriously interfere with eating, diges- tion, and the enjoyment of food. However, combined with other factors, they may contribute to inadequate nutrition and decreased eating pleasure (see Chapter 5).
Taste
The sense of taste has many components and primarily de- pends on receptor cells in the taste buds. Taste buds are scat- tered on the surface of the tongue, the cheek, the soft palate, the upper tip of the esophagus, and other parts of the mouth.
Components in food stimulate taste buds during chewing and swallowing, and tongue movements enhance flavor sen- sation. Individuals have varied levels of taste sensitivity that seem predetermined by genetics and constitution, as well as age variations. Early studies suggested that a decline in the number of taste cells occurs with aging, but more recent studies suggest that “taste cells can regenerate but that the lag time of this turnover may account for the diminished taste response in older adults” (Miller, 2008, p. 363).
Age-related changes do not affect all taste sensations equally. With age, the inability to detect sweet taste seems to remain intact, whereas the ability to detect sour, salty, and bitter taste declines. Many denture wearers say they lose some of their satisfaction with food taste, possibly because dentures cover the palate and because texture is a very important ele- ment in food enjoyment. Difficulty in flavor appreciation comes from individual variables such as smoking, olfactory sensitivity, attitude toward food and eating, and the presence of moistening secretions. There are also aberrations in flavor sensation caused by certain medications and medical condi- tions. The addition of flavor enhancers (bouillon cubes) and concentrated flavors (jellies or sauces) can amplify both taste and smell. Fresh herbs and spices also give an extra boost to flavor and may increase enjoyment and interest in eating.
Smell
Age-related changes in the sense of smell and the conse- quent effect on nutrition is in need of further research. In
the past, studies have shown a decline in the sense of smell as the individual ages. Research by Markovic and colleagues (2007) disputes this belief. Results of this study suggested that for perceived odors, olfactory pleasure increases at later stages in the life span, and the perceived intensity of odors remains stable. Decrease in the sense of smell may be related to many factors, including the following: nasal sinus disease, repeated injury to olfactory receptors through viral infections, age-related changes in central nervous system functioning, smoking, medications, and periodontal disease and other dentition problems. Changes in the sense of smell are also associated with Parkinson’s disease and Alzheimer’s disease (Cacchione, 2008).
Digestive System
Age-related changes in the oral cavity, the esophagus, the stomach, the liver, the pancreas, the gallbladder, and the small and large intestines may influence nutritional status in concert with other factors. However, these changes do not significantly affect function, and, in the absence of disease, the digestive system remains adequate throughout life. Presbyesophagus, a decrease in the intensity of propulsive waves, may be an age-related change in the esophagus. Some of these changes may be more attributable to pathological conditions rather than to age alone. The functional impact of presbyesophagus seems to be minimal, but combined with other conditions, may contribute to dysphagia.
Buccal Cavity
Age-related changes in the buccal cavity predispose older people to orodental problems that can significantly affect nutrition. Aging teeth become worn and darker in color and tend to develop longitudinal cracks. The dentin, or the layer beneath the enamel, becomes brittle and thickens so that pulp space decreases. People who are edentulous and are using complete dentures, continue to have oral health care needs. Ill-fitting dentures affect chewing and hence nutritional intake. People without teeth remain susceptible to oral cancer and other oral diseases. Oral care is discussed later in the chapter.
Another common oral problem among older adults is dry mouth (xerostomia). Approximately 25% to 40% of older adults experience xerostomia. More than 500 medi- cations have the side effect of reducing salivary flow.
A reduction in saliva and a dry mouth make eating, swal- lowing, and speaking difficult. It can also lead to significant problems of the teeth and their supporting structure (Jablonski, 2010). Artificial saliva preparations are avail- able (avoid those containing sorbitol), and adequate fluid intake is also important when xerostomia occurs. Chewing on xylitol-flavored fluoride tablets, sugar-free candies, or sugar-free gum with xylitol 15 minutes after meals may
stimulate saliva flow and promote oral hygiene (Miller, 2008). Medication review is also indicated to eliminate, if possible, medications contributing to xerostomia.
Regulation of Appetite
Appetite in persons of all ages is influenced by factors such as physical activity, functional limitations, smell, taste, mood, socialization, and comfort. With age, appetite and food con- sumption decline. Healthy older people are less hungry and are fuller before meals, consume smaller meals, eat more slowly, have fewer snacks between meals, and become satiated after meals more rapidly than younger people (Ahmed &
Haboubi, 2010). There is some evidence that the endogenous opioid feeding and drinking drive may decline in aging and contribute to decreased appetite and risk for dehydration.
Lifelong Eating Habits
The nutritional state of a person reflects the individual’s dietary history and present food practices. Lifelong eating habits are also developed out of tradition, ethnicity, and religion, all of which collectively can be called culture.
Food habits established since childhood may influence the intake of older adults.
Eating habits do not always coincide with fulfillment of nutritional needs. Rigidity of food habits may increase with age as familiar food patterns are sought. Ethnicity determines if traditional foods are preserved, whereas religion affects the choice of foods possible. Members of a particular ethnic or religious group will have unique eating patterns, so individual assessment is important. Cultural preferences affect nutrition and culturally and religiously appropriate diets should be available in any institution or congregate dining program (see Chapter 4).
Lifelong habits of dieting or eating fad foods also echo through the later years. Older people may fall prey to advertisements that claim specific foods maintain youth and vitality or rid one of chronic conditions. Everyone can benefit from improved eating habits, and it’s never too late to change dietary habits to improve health. Following the MyPlate for Older Adults (see Figure 9-1) is best for an ideal diet, with changes based on particular problems, such as hypercholesteremia. Older adults should be counseled to base their dietary decisions on valid research and con- sultation with their primary care provider. For the healthy older adult, essential nutrients should be obtained from food sources rather than relying on dietary supplements.
Socialization
The fundamentally social aspect of eating has to do with sharing and the feeling of belonging that it provides. All of
us use food as a means of giving and receiving love, friend- ship, or belonging. Often, older adults may be isolated from the mainstream of life because of chronic illness, depres- sion, and other functional limitations. When one eats alone, the outcome is often either overindulgence or disinterest in food. The presence of others during meals is a significant predictor of caloric intake (Locher et al., 2008).
Disinterest in food may also result from the effects of medication or disease processes. Misuse and abuse of al- cohol are prevalent among older adults and are growing public health concerns. Excessive drinking interferes with nutrition. Drinking alcohol depletes the body of neces- sary nutrients and often replaces meals, thus making an individual susceptible to malnutrition (see Chapter 22).
The elderly nutrition program, authorized under Title III of the Older Americans Act (OAA), is the largest national food and nutrition program specifically for older adults. Programs and services include congregate nutrition programs, home-delivered nutrition services (Meals- on-Wheels), and nutrition screening and education. The program is not means-tested, and participants may make voluntary confidential contributions for meals. However, the OAA Nutrition Program reaches less than one third of older adults in need of its program and services, and those served receive only three meals a week. With the emphasis on community-based care rather than institutional care, expansion of nutrition services should be a priority. These programs enable older adults to avoid or delay costly insti- tutionalization and allow them to stay in their homes and communities (ADA, 2010).
Chronic Diseases and Conditions
Many chronic diseases and their sequelae pose nutritional challenges for older adults. Functional impairments associ- ated with chronic disease interfere with the person’s abilities to shop, cook, and eat independently. For example, heart failure and chronic obstructive pulmonary disease (COPD) are associated with fatigue, increased energy expenditure, and decreased appetite. Dietary interventions for diabetes are essential but may also affect customary eating patterns and require lifestyle changes.
The side effects of medications prescribed for these conditions may further impair nutritional status. A number of prevalent disorders of the gastrointestinal (GI) tract are associated with nutritional concerns including gastroesoph- ageal reflux disease (GERD), ulcers, constipation, divertic- ulosis, and colon cancer. Dysphagia, often a result of stroke or dementia, significantly affects nutrition. Diseases affect- ing function, such as arthritis and Parkinson’s disease, may impair eating ability. Cancers and subsequent treatment impair appetite and ability to consume adequate nutrition.