As more people approach their 65th birthdays, healthy aging has emerged as a public health priority. Thanks to Baby Boomers and longer lifespans, by 2030 there will be an estimated 71 million older adults in the U.S., accounting for roughly 20% of the country’s population (He et al. 2005). Improved longevity is associated with an increase in chronic conditions and related disabilities, which may have a significant impact on our healthcare system. According to “The State of Aging and Health in America 2007,” a report released by the Centers for Disease Control and Prevention (CDC) and The Merck Company Foundation, about 80% of older Americans are living with at least one chronic condition, and 50% have at least two (CDC & Merck 2007). The cost of providing health care for one person aged 65 or older is three to five times more than it is for a younger person. As a result, by 2030 the nation’s healthcare spending is projected to increase by 25% (CDC & Merck 2007).
But as the CDC emphasizes, poor health is not an inevitable consequence of aging. To maintain health over these additional “golden” years, it’s important to pay attention to nutrition and physical activity patterns early and at all stages of aging. (See the sidebar “DETERMINE Nutritional Health” for a checklist that clients can use to gauge their nutritional status.) Since a healthy lifestyle is key to preventing and managing disease—as well as maintaining quality of life—the growth of the older-adult demographic offers great opportunities for health promotion and preventive services. This article focuses on the special nutrition needs of the aging body and addresses specific concerns that can impact the nutritional well-being of seniors.
Aging is a normal, gradual process of physical change over time. However, the inevitable consequences of aging are far more pronounced in some individuals than others. Although some health problems are an unavoidable aspect of aging, many more are preventable and can be influenced by three major behaviors: eating a healthy diet, staying physically active and avoiding tobacco. In fact, there is evidence that these three behaviors alone are more influential than genetic factors in fighting age-associated decline (CDC & Merck 2007). Nutrition in particular is a major determinant of healthy, successful aging, which is defined as the ability to maintain a low risk of disease and related disability; good cognitive function; and an active social life (Rowe & Kahn 1998).
So what exactly happens in the aging body? Aging is generally associated with a slower metabolism, which leads to accumulation of extra body fat, particularly around the middle. Digestion slows, and the body becomes less efficient at managing the rise in blood sugar after eating. One of the first signs of aging is loss of muscular strength, giving way to stiff joints (Ritz 2001). Muscle strength remains similar up to age 45 and decreases by 50% between the ages of 50 and 80.
Preserving bone health also becomes a concern as the body naturally loses bone density. The kidneys work harder to remove waste and keep the body hydrated, while the circulatory system becomes less efficient. Blood vessels may become clogged and constricted. In addition, maintaining cognitive health becomes increasingly important. Even in the absence of disease, normal functional declines can impact the health and well-being of older adults (Brownie 2006).
While prevention is often the focus of younger and middle-aged adults, maintaining current levels of health and managing disease or conditions becomes the focus of older adults, explains Valentina M. Remig, PhD, RD, FADA, nutrition professor at Kansas State University in Manhattan, Kansas. Remig adds that nutrient needs among older adults differ only slightly from those of younger people.
Special Nutrition Needs of the Aging Body
It is the physiological changes that occur with aging that affect nutrient needs. Gradual loss of lean body mass and reduced energy expenditure lower caloric needs. However, nutrient needs do not drop, and in some cases they increase. As a result, packing more nutrition into fewer calories becomes a challenge for older adults (see the sidebar “Modified MyPyramid for Older Adults” for more details). For this reason, focusing on quality food choices becomes paramount. National surveys show a decline in energy intake with age, accompanied by a similar decline in protein and key vitamin and mineral intake after the age of 50. This decline reaches a low point in people 80 and older (Wakimoto & Block 2001).
While adults are not easily categorized, certain nutrients require greater attention as people age. Which vitamins and minerals are critical depends on the health status of the individual, Remig explains. “Most often, vitamin D and vitamin B are marginalized in older adults . . . followed by calcium and iron,” she adds. Studies confirm this. Inadequate dietary intakes of energy, folate, vitamin D, vitamin B6, calcium and zinc have been reported in community-dwelling adults over 60 years old (Marshall 2001).
Specific dietary recommendations are set for two age groups: adults 51-70 years old and those 70 and older (see the sidebar “Dietary Reference Intakes for Key Nutrients”). Adult Dietary Reference Intakes (DRIs) increase with age for vitamins C, D, K and B6, as well as calcium. Additionally, Dietary Guidelines for Americans 2005, published jointly by the U.S. Department of Health & Human Services (USDHHS) and the U.S. Department of Agriculture (USDA), highlights special key issues for older adults. “Nutrients are interactive; many nutrients are needed within each system of the body for that system to run efficiently,” says Adele Huls, PhD, RD, LMNT, chair elect of the American Dietetic Association’s (ADA) Healthy Aging Dietetic Practice Group. “Those needs continue as we age. So, in essence, all nutrients have benefits in aging.” Let’s review some of the most important.
Calcium. As it ages, the body does not absorb calcium as easily as it used to. Increased calcium excretion accompanies decreased absorption. Age-associated loss of bone density increases risk for fractures and osteoporosis. Losses of skeletal calcium in post menopausal women can reach more than 40% (Tucker 2003). Because bone fractures are a significant contributor to morbidity and mortality in older people, achieving daily calcium needs is critical; yet only 5% of older women and 10% of older men consume the DRI recommendation (Tucker 2003).
Vitamin D. Evidence suggests that vitamin D, best known for its role in bone health, may have a function in preventing a number of diseases. A recent meta-analysis concluded that adequate vitamin D intake is associated with lower death rates from all causes (Autier & Gandini 2007). According to the Dietary Guidelines, the need for the “sunshine vitamin” increases from 10 to 15 micrograms (mcg) after age 50 as blood levels of vitamin D decline. For the elderly, higher amounts (25 mcg, or 1,000 IU) from both fortified foods and supplements have been recommended. (Note: These amounts are greater than those recommended by the Institute of Medicine and shown in the sidebar "Dietary Reference Intakes for Key Nutrients".)
Even with supplementation, however, older adults are not consuming these higher amounts (Johnson & Kimlin 2006). Deficiency is common in the elderly and associated with many age-related conditions, including high blood pressure, cancer, fractures and falls (Holick 2004). The major causes of vitamin D deficiency are decreased exposure to sunlight, a decline in synthesis of vitamin D in the skin, poor nutrition and decreased renal function (Gennari 2001). Because of this vitamin’s role in calcium absorption and mineralization, chronic deficiency leads to osteomalacia, or softening-bone disease. In addition to calcium and vitamin D, magnesium and vitamin K have been shown to affect bone health, particularly with regard to risk of hip fractures (Gennari 2001).
Vitamin B12 and Folate. Most individuals over age 50 have a reduced ability to absorb naturally occurring vitamin B12 and must therefore consume it in its crystalline form (fortified foods or supplements). The major causes of vitamin B12 deficiency are atrophic gastritis and pernicious anemia. Atrophic gastritis affects nutrient bioavailability and is a problem that increases with age; research indicates that 40%-50% of individuals over age 80 have the condition (Chernoff 2005). Consequently, a significant portion of older people are at risk of impaired absorption of vitamin B12, folic acid and other vitamins and minerals. Pernicious anemia results from an age-related loss of gastric intrinsic factor. Vitamin B12 deficiency can cause cognitive dysfunction and neurological problems in older people (Carmel 1997).
There is concern that high intakes of folate might mask the macrocytic anemia of vitamin B12 deficiency, exacerbating cognitive dysfunction (Morris et al. 2007). In seniors with normal vitamin B12 status, on the other hand, higher folate is associated with protection from anemia and cognitive impairment. Nevertheless, 90% of women and 95% of men do not meet the DRI for this vitamin (Wakimoto & Block 2001).
Sodium. Since many people will develop hypertension at some point during their lifetime—and typically the higher their salt intake, the higher their blood pressure will be—older adults should aim to consume no more than 1,500 milligrams (mg) of sodium per day (about 3/4 teaspoon of salt). Older adults as a group tend to be more salt sensitive. To manage sodium intake, individuals should read labels, aim for foods with 5% or less of the Daily Value (DV) for sodium and avoid foods with more than 20% of the DV.
Furthermore, because potassium can counterbalance the harmful effects of sodium on blood pressure, older people should strive to meet the potassium recommendation (4.7 grams per day) with food. Consuming more potassium-rich foods may also help prevent the bone loss that occurs with aging. Potassium needs can be achieved by consuming the recommended daily servings of vegetables, fruits and low-fat or fat-free milk products.
Fiber. Since constipation may affect up to 20% of people over age 65, foods rich in dietary fiber become increasingly important for older adults (USDHHS 2005). Additional causes of constipation among this age group may include side effects of medications and lack of appropriate hydration. Low fiber intake may also contribute to other gastrointestinal diseases common among older adults, including diverticulosis. Although older people, especially women, are more likely to eat fruits and vegetables than younger people (Wakimoto & Block 2001), a large majority still fall short in meeting their daily needs (CDC & Merck 2007).
Adequate fluid intake not only eases constipation; it also helps avert dehydration, a serious threat to the elderly. Causes of impaired fluid and electrolyte balance include physiologic impairments in renal function and thirst perception, reduced body fluid and blunted medication effects (Ritz 2001). Severe dehydration in the elderly can lead to cognitive impairment and functional decline.
Other Nutrients. The role of antioxidants in the aging process is worth mentioning. Zinc, along with vitamins C and E, and the phytochemicals lutein, zeaxanthin and beta carotene from food sources, may help prevent or slow the onset of age-related macular degeneration, the leading cause of blindness in people over age 55. Evidence suggests that low dietary intake of these nutrients may also increase cataract risk (ADA 2005).
Concerns That Impact Seniors’ Nutritional Status
Sensory Underload. Age-related changes in sensory input can impact nutritional status and quality of life. Fewer taste buds and a loss of smell can make food seem bland, impacting appetite, nutrient intake and overall enjoyment of food (Amarantos, Martinez & Dwyer 2001). More than 50% of adults between the ages of 65 and 80 have problems with their senses of smell and taste, increasing to 75% in those over 80 (Brownie 2006). Age-related sensory declines can be exacerbated by disease and medication. These alterations in taste and smell often cause older adults to reach automatically for the saltshaker to enhance the flavor of food, a practice that can negatively influence blood pressure.
Dental Issues. Poor oral health can also affect food intake and nutritional status. Whether the issue is ill-fitting dentures or tooth loss due to gum or periodontal disease associated with diabetes or a heart condition, chewing and swallowing can be problematic for older adults (Brownie 2006). Intake of proteins and other nutrients may be compromised as meats, fresh fruits and vegetables become difficult to chew. Careful meal planning and preparation become important to ensure the right consistency and variety of softer foods. It is recommended that older adults with dental problems chop, steam, stew, grind or grate hard or tough foods to minimize the need to chew. Soft, fresh fruits and vegetables (like bananas and avocados) or juices are good choices. If raw fruits and vegetables are too hard, low-sodium canned varieties can be substituted.
Food Safety. Older adults are a high-risk population and need to take extra precautions to protect themselves from food-borne illness. It is recommended that seniors avoid eating or drinking raw (unpasteurized) milk or any products made from unpasteurized milk; raw or partially cooked eggs; raw or undercooked meat, poultry, fish and shellfish; unpasteurized juices; and raw sprouts. In addition, to reduce the risk of developing listeriosis, a potentially life-threatening illness caused by a bacterium, older adults should only eat certain deli meats and frankfurters that have been reheated to steaming hot (USDHHS & USDA 2005). As a protective measure, it is imperative that seniors practice good home food-safety practices, including proper hand washing.
Malnutrition. Older people are at increased risk for nutrient deficiency and malnutrition. The prevalence of malnutrition among older adults living independently is 5%-10%, and it increases to 60% for those institutionalized or hospitalized (Brownie 2006). Regardless of whether an individual is underweight or overweight, malnutrition exacerbates disease and decreases functionality, which affects quality of life. Protein-energy malnutrition and nutrient deficiencies can compromise the elderly immune system. Furthermore, malnourished individuals are at higher risk for disability, and disabled individuals are more likely to be malnourished (ADA 2005). “Good nutritional status affects the body’s ability to attain and maintain healthy organs,” says Huls. “When organs are healthy, systems work well. When systems work well, decline is slowed.”
Food Insecurity. Financial constraints and poverty can be a determinant of nutritional status. Food insecurity (lack of food resources) is a problem among the elderly, affecting 1.4 million households (ADA 2005). Not surprisingly, older people who don’t have enough food have consistently lower intakes of key nutrients, including protein, iron and vitamin B12, compared with those who have access to enough food. These older adults are more likely to be underweight, which compromises health and quality of life (ADA 2005).
Social Isolation. Social determinants can impact food quantity and quality for older adults. Living alone, being socially isolated and having decreased independence to shop and cook may lead to depression and can cause a person to eat less and make poor food choices. The impact of these social changes appears to affect the nutrient intake of men more than women (Brownie 2006).
Federal meal programs can increase access to nutrient-dense foods and meals and influence overall nutrient intake. These programs even have the potential to improve functional independence and quality of life (ADA 2005). Also, studies show that more food is consumed when meals are eaten with others (de Castro & Stroebele 2002). Social interaction lengthens meal duration and can make eating a more pleasurable experience.
Many programs exist that strive to serve the nutrition requirements of seniors in need. The Older Americans Nutrition Program offers nutritious meals that meet the DRIs and special nutrition needs of older people. Food is served at congregate sites, and delivery is available for the vulnerable homebound. In addition to serving meals, the Congregate Nutrition Program provides nutrition education and opportunities for physical activity. USDA offers the Food Stamp Program and the Senior Farmers’ Market Nutrition Program as additional services to older adults who meet eligibility requirements.
It Is Never Too Late
While early attention to healthy eating and physical activity patterns are most effective for prevention, the positive effects of a healthy lifestyle can be realized at any age. As Remig explains, “Older adults who achieve healthy aging are better prepared to live more years disease and/or illness free.” Regular physical activity can reduce functional declines associated with aging. In addition, wise nutrition choices are crucial for enabling older adults to live a long, healthy, active life. Aging is inevitable, but a healthy lifestyle can improve how we age.
SIDEBAR: Determine Nutritional Health
The warning signs of poor nutritional health in older adults are often overlooked. Use this checklist with clients to determine whether they are at risk. Refer those who are to a registered dietitian or a physician.
Read the statements below. Circle the numbers in the “yes” column for those that apply, and then total the yes scores.
Interpret your total:
0-2: Good! Recheck your nutrition score in 6 months.
3-5: You are at moderate risk for nutritional deficiencies. See what can be done to improve your eating habits and lifestyle. Recheck your nutrition score in 3 months.
6 or more: You are at high risk for nutritional deficiencies. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional.
Remember that warning signs suggest risk but do not represent a diagnosis of any condition. The above checklist is based on the warning signs described below. Use the word DETERMINE to remind you of the warning signs.
Tooth loss/mouth pain
Reduced social contact
Involuntary weight loss/gain
Needing assistance in self-care
Elder years, above 80
SIDEBAR: Dietary Reference Intakes for Key Nutrients
Source: The Nutrition Screening Initiative, a project of American Academy of Family Physicians, the ADA and the National Council on the Aging Inc.
SIDEBAR: Modified MyPyramid for Older Adults
Tufts University researchers have updated the Food Guide Pyramid for Older Adults to correspond with changes to the USDA food pyramid, now known as MyPyramid. The Tufts version, published in the January 2008 issue of the Journal of Nutrition, is specifically designed for older adults and continues to emphasize nutrient-dense food choices and the importance of fluid balance, but it offers additional guidance about the forms of foods that could best meet the unique needs of older adults. Physical activity is also highlighted.
The Modified MyPyramid for Older Adults represents foods in the following categories, as well as fluids and physical activity:
- whole, enriched and fortified grains and cereals, such as brown rice and 100% whole-wheat bread
- bright-colored vegetables, such as carrots and broccoli
- deep-colored fruits, such as berries and melon
- low-fat and nonfat dairy products, such as yogurt and low-lactose milk
- dried beans, nuts, fish, poultry, lean meat and eggs
- liquid vegetable oils and soft spreads low in saturated and trans fat
A new pyramid foundation depicts physical activities characteristic of older adults; for example, walking, yard work and swimming. Icons representing packaged fruits and vegetables in addition to fresh varieties may be more appropriate for older adults for a number of reasons. Fiber-rich foods are also emphasized, as is the importance of consuming fluids (there is a row of glasses at the pyramid’s foundation). Another integral part of the modified pyramid is a flag at the top suggesting that older adults may need certain supplemental nutrients, such as calcium, vitamin D and vitamin B12.
Administration on Aging, www.aoa.gov
Centers for Disease Control and Prevention, www.cdc.gov/aging
Eldercare Locator, www.eldercare.gov/Eldercare/Public/Home.asp
Meals on Wheels, www.mowaa.org/
National Institutes of Health, Senior Health, www.nihseniorhealth.gov
National Resource Center on Nutrition, Physical Activity & Aging, http://nutritionandaging.fiu.edu/DRI_and_DGs/dg_resources.asp
Older Americans Nutrition Program Toolkit, www.fiu.edu/~nutreldr/OANP_Toolkit/OANP_Toolkit_homepage.htm
Senior Farmers’ Market Nutrition Program, www.fns.usda.gov/wic/SeniorFMNP/SFMNPmenu.htm
Jennie McCary, MS, RD, LD, is the wellness
coordinator for the Albuquerque Public School District and a part-time
nutrition instructor at the University of New Mexico.
Amarantos, E., Martinez, A., & Dwyer, J. 2001. Nutrition and quality of life in older adults. Journals of Gerontology: Series A, 56A (Special Issue 11), 54-64.
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Chernoff, R. 2005. Micronutrient requirements in older women. American Journal of Clinical Nutrition, 81 (Suppl.), 1240S-45S.
De Castro, J.M., & Stroebele, N. 2002. Food intake in the real world: Implications for nutrition and aging. Clinics in Geriatric Medicine, 18, 685-97.
Gennari, C. 2001. Calcium and vitamin D nutrition and bone disease of the elderly. Public Health Nutrition, 4 (2B), 547-59.
He, W., et al. 2005. 65+ in the United States: 2005 (Current Population Reports). U.S. Census Bureau,Washington, DC: U.S. Government Printing Office. www.census.gov/prod/2006pubs/p23-209; retrieved Nov. 3, 2007.
Holick, M.F. 2004. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. American Journal of Clinical Nutrition, 80 (6, Suppl.), 1678S-88S.
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Morris, M.S., et al. 2007. Folate and vitamin B12 status in relation to anemia, macrocytosis, and cognitive impairment in older Americans in the age of folic acid fortification. American Journal of Clinical Nutrition, 85, 193-200.
Ritz, P. 2001. Factors affecting energy and macronutrient requirements in elderly people. Public Health Nutrition, 4 (2B), 561-68.
Rowe, J.W., & Kahn, R.L. 1998. Successful Aging. New York: Pantheon.
Tucker, K.L. 2003. Dietary intake and bone status with aging. Current Pharmaceutical Design, 9, 2687-2704.
U.S. Department of Health & Human Services (USDHHS)and U.S. Department of Agriculture (USDA). 2005. Dietary Guidelines for Americans 2005 (6th ed.), Washington, DC: U.S. Government Printing Office. www.health.gov/dietaryguidelines/dga2005/document/html/chapter7.htm; retrieved Nov. 3, 2007.
Wakimoto, P., & Block, G. 2001. Dietary intake, dietary patterns, and changes with age: An epidemiological perspective. Journals of Gerontology: Series A, 56A (Special Issue 11), 65-80.
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