Nutrition Across the Lifespan Quiz
e201611
NutritionandOlderAdults.pptxNutrition and Older Adults
Class Objectives
By the end of this class, the student will be able to:
Understand the theories of aging.
Recognize physiological changes that occur with aging and nutritional implications.
Describe the effectiveness of nutrition screening tools.
Understand the interactions of medications on nutrients.
Recognize nutrition recommendations and nutrients of concern during aging.
Know how to calculate energy and nutrient requirements.
Know about nutrition programs serving older adults.
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What Counts as Old?
There is no one age that defines “old”
70 – DRI category
60—the Elderly Nutrition Program
65—Eligibility for Medicare
60 - World Health Organization
U.S. Census Bureau uses:
“young old”
“aged”
“oldest old”
“Geriatric”
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A Picture of the Aging Population: Vital Statistics
More Americans are living longer
Currently, ~17.4% are >65 yrs
By 2050, ~19% will be >65 yrs
Persons ≥85 are the fastest growing population group
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Institutionalized Elderly
2008: 1.6 M (4%) aged > 65 years live in institutional setting
1.3% 65 – 74 years
3.8% 75 – 84 years
15.4% > 85 years
Have medical problems that impact diet and dependent on others for eating
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Global Population Trends: Life Expectancy and Life Span
Life expectancy
Average number of yrs of life remaining for persons in a population cohort or group; most commonly reported as life expectancy from birth
Life expectancy at birth in the United States is 78.5 years
Life span
Maximum number of yrs someone might live; human life span is projected to range from 110 to 120 yrs
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Aging Theories – Two Groups
1) Programmed aging
Programmed cell replication – natural limit to cell division
Hayflick’s theory of limited cell replication
Modular clock theory
2) Wear and tear theories of aging
Free-Radical or Oxidative stress theory
Rate of living theory
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Theories – ‘Wear and Tear’
Cellular mutations – Drugs, UV light, mutagens and radiation cause a decrease in DNA repair activity
Free radicals – Environmental exposures via radiation, natural body processes causes macromolecular damage
Cross-linking – Glycation causes cross-linking between protein molecules
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Calorie Restriction to Increase Longevity
Animal studies show that an energy-restricted diet that meets micronutrient needs can prolong healthy life
Calorie Restriction research ensures nutrient in diets of study subjects
Nutrient density used to decrease chronic disease risk
Spindler. Ann N Y Acad Sci 2001;928:296–304.
Mattison et al. Exp Gerontol 2003;38:35–46.
Bordone & Guarente. Nat Rev Mol Cell Biol 2005;6:298–305.
Lee et al. Science 1999;285:1390–3.
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CALEREI Study – Completed April 2012
Comprehensive Assessment of the Long-term Effects of Reducing Energy Intake
25% caloric restriction intervention on non-obese x 24 months – 2 Phases
n=220 across 3 sites (Tufts, Pennington, Washington University)
Men 21-50 y, Women 21-47 y initial BMI≥22 kg/m2
Randomized
25% Calorie Restriction (Intensive behavioral coupled with dietary modifications and daily self-monitoring of calories)
Control group (ad libitm diet)
Rickman et al. Contemporary Clinical Trials 32 (2011) 874–881
Theories of Aging
Decreased Hormonal Secretions
Growth Hormone
Testosterone in Males
Estrogen in Females
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Chronic Diseases in the Elderly
80-85% of seniors have one or more chronic diseases that require dietary intervention
Cardiovascular disease due to heart conditions and hypertension is the leading cause of death among the elderly
Cancer follows a close second as the most common cause of death of elderly
25% of females and 20% of males dying from cancer
40% of elderly after age of 80 are afflicted by diabetes
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Chronic Diseases in the Elderly
Hypertension (39%), High blood cholesterol (70% of Seniors), obesity (30%)
Visual impairments are common such as cataracts
Dementia (2/3 Is Alzheimer's Disease) afflicts 8-15% of Elderly
40% of females over the age of 65 will experience a fracture as a result of osteoporosis
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Body Composition Changes
Lean body mass (LBM)
Sum of fat-free tissues, mineral as bone, & water
Sarcopenia
Term used for loss of LBM associated with aging
“Cachexia”: loss of weight and muscle mass associated with underlying illness
LBM decreases 2-3% from age 20 to 70
Older people have lower mineral, muscle, & water reserves
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Muscles: Use It or Lose It
In older adults, weight-bearing & resistance exercise increase lean muscle mass & bone density
Regular physical activity helps maintain functional status
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Mean (±SE) Changes in Muscle Strength after Exercise, Nutritional Supplementation, Neither, or Both.
Fiatarone MA et al. N Engl J Med 1994;330:1769-1775.
n=100 nursing home residents 70 years + x 10 weeks
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Weight Gain
Weight gain accompanies aging, but is not inevitable
Mean body weight gradually increases with aging, peaking between 50 & 59 y
Physical activity moderates weight gain & increases in body fat
Lack of estrogen promotes fat accumulation
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BMI - Adults > 65 years
| BMI | Interpretation |
| < 24 | May be associated with health problems in some elderly |
| 24.0 – 29.0 | Healthy weight |
| > 29.0 | May be associated with health problems in some elderly |
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Unintentional Weight Loss
Epidemiology
The incidence of involuntary weight loss in community-dwelling elderly is between 5-15% of that population and more than 25% in frail elderly receiving home care services.
One year documented weight loss of greater than 4-5% was the single best predictor of death within two years.
Newman et al. J Am Geriatr Soc. Oct 2001;49(10):1309-1318.
Wallace et al. J Am Geriatr Soc. Apr 1995;43(4):329-337
Risk Factors for Malnutrition in Older Adults
Decrease in body functions
Disease
Multiple medications – “Polypharmacy”
Greater than 65% of elderly use more than one drug daily to treat a medical condition
3-8% of hospital admissions are due to adverse drug reactions and one third of these cases are elderly persons
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EXAMPLES OF DRUG SIDE EFFECTS ON NUTRITIONAL STATUS
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Adverse Effects of Drugs on Nutrient Metabolism
Antivitamin drugs block action of vitamins
inhibiting their absorption
binding to them in the body to make them unavailable to the tissues
enhancing their catabolism
enhancing their excretion
causing an inhibition of their activation in the body to an active form.
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Adverse Effects of Drugs on Nutrient Metabolism
Cholesterol lowering drugs that are bile acid sequestrants (cholestyramine)
prevent reabsorption of bile salts and thus decrease fat soluble vitamin absorption
Damage to the GI tract will also cause decreased nutrient absorption from use of antibiotic drugs (neomycin)
destroy intestinal mucosa, villi and microvilli and inhibit brush border enzymes
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Adverse Effects of Drugs on Nutrient Metabolism
Anti-inflammatory drugs
inhibit the lactase enzyme
directly damage the gut and decrease fat and micronutrient absorption
Laxatives can contain emollients such as mineral oil
Dissolve fat and fat-soluble vitamins that are then excreted in the feces rather than be absorbed
Decreased transit time from the use of laxatives and mineral oil can cause decreased nutrient absorption in terms of Ca and K losses.
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Adverse Effects of Drugs on Nutrient Metabolism
Loop diuretics (furosemide) used for blood pressure control
increase renal excretion of thiamin which can cause cardiac abnormalities as a result of excessive use
Other diuretics (thiazide) and corticosteroids
can cause potassium depletion, which increases the risk of cardiac arrhythmias
Aspirin increases folate excretion
by binding to folate binding sites on plasma protein normally involved with blood transport of the vitamin (albumin) causing increased urinary excretion folate
Adverse Effects of Drugs on Nutrient Metabolism
Anti-ulcer drugs (cimetidine) cause decreased HCl production
which decreases the amount of B12 released from foods and less B12 is available for binding with intrinsic factor for absorption
Drugs Associated with Diarrhea
Antibiotics
Temporary alteration of colonic bacteria
Damage to small intestinal mucosa
Osmotic Agents (Laxatives, Antacids)
Antimetabolites (Methotrexate)
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Risk Factors for Malnutrition in Older Adults
Needs assistance with self-care
Physical disabilities such as decreased eyesight and bone fractures decrease abilities to procure and prepare food
Surgery, injury, infection increase nutritional needs and decrease food intake
Tooth loss or oral pain
Loss of teeth and dentures make chewing less effective and increases the risk of choking
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Taste and Smell
“Anorexia of Aging”
Food Intake Declines
Taste & smell senses decline with age
Decline in ability to identify smells varies by gender
Women retain their sense of smell better than men do
Disease & medications affect taste & smell more than aging
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Appetite and Thirst
Appetite
Hunger & satiety cues weaken with age
Older adults may need to be more conscious of food intake levels since appetite-regulating mechanisms may be blunted
Thirst
Thirst-regulating mechanisms decrease with age
Studies support that dehydration occurs more quickly after fluid deprivation & rehydration is less effective in older men
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Chewing and Swallowing
Oral health depends on:
GI secretions (saliva)
Skeletal systems (teeth & jaw)
Mucus membrane
Muscles (tongue & jaw)
Taste buds
Olfactory nerves (smell & taste)
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Risk Factors for Malnutrition in Older Adults
Eating poorly
Tend to eliminate whole food groups such as fruits and vegetables
Economic hardship
High rate of poverty among elderly
Reduced social contact
Loss of vision and hearing increases social isolation
Loneliness and depression due to loss of loved one
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Nutritional Risk Factors
Risk factors for older adults are:
Hunger, poverty, low food & nutrient intake
Functional disability
Social isolation or living alone
Urban & rural demographic areas
Depression, dementia, dependency
Poor dentition & oral health
Diet-related acute or chronic diseases
Polypharmacy
Minority, advanced age
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Assessing Risk of Malnutrition
Malnutrition observed in 2 – 38% of institutionalized older adults, 37 – 62% considered at risk
Consequences: Increased mortality, loss of strength, depression, lethargy, immune dysfunction, pressure ulcers, delayed recovery from illness, increased hospital admission, poor wound healing
Unintended weight loss indicator of undernutrition
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DETERMINE Checklist
Developed by the:
American Academy of Family Physicians
Academy of Nutrition and Dietetics
National Council on Aging
Integrates a list of warning signs of poor nutritional health in older adults
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Determine Your Nutritional Health Checklist
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MNA Nutritional Screening and Assessment
The MNA short form uses six screening items
More extensive includes:
Dietary intake
Anthropometrics
Blood chemistries
mna-elderly.com
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Nutrient Recommendations
Nutrient recommendations change as scientists learn more about effects of foods on human functions
Specific DRI for those >51 yrs were 1st established in 1997
Estimating Energy Needs
Decrease in physical activity & BMR from early to late adulthood results in 70-100 fewer calories needed
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Carbohydrate and Fiber
Carbohydrate
AMDR between 45 to 65% of calories
A listing of food that provides at least 50% of carbohydrates with fiber levels is in
Minimum of 22 to 28 grams of dietary fiber daily for older females and males
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Protein
Inactive, older adults living alone may have low protein intakes
Several researchers report protein needs for older adults are 1 to 1.3 g/kg body wt (higher than the DRI of 0.8 g)
Nitrogen balance is easier to achieve when:
Protein is a high quality
Adequate calories are consumed
Individuals participate in resistance training
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Fats and Cholesterol
Minimize saturated fat & keep total fat between 20 to 35% of calories
Even though eggs are high in cholesterol, they are a nutrient-dense, convenient, & safe food for older adults that do not have lipid disorders
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Recommendations for Fluid
The total amount of water decreases with age, resulting in a smaller margin of safety for staying hydrated
≥6 glasses of fluid/day will prevent dehydration in most older adults
To individualize fluid recommendations, 1 mL of fluid/kcal consumed, with a minimum of 1500 mL
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Age-associated Changes: Nutrients of Concern
Vitamin D, Calciferol
Factors that put older adults at risk for deficiency:
Limited exposure to sunlight
Institutionalization or homebound
Certain medications (barbiturates, cholestyramine, Dylantin, laxatives)
Gloth et al. JAMA. 1995; 274: 1683-6.
% of Individuals with
25(OH)D levels
< 25 nmol/L
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Age-associated Changes in Metabolism: Nutrients of Concern
Calcium
Need adequate intake for bone health and to reduce hypertension
UL has been lowered because of toxic effects
Magnesium
Need adequate intake for bone health, nerve activity, glucose utilization
Excessive intake from supplements can cause overdose
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Age-associated Changes in Metabolism: Nutrients of Concern
Vitamin B12
Despite adequate intake, ~30% of older adults have serum B12 levels
B12 linked to levels of HCL & pepsin (from atrophic gastritis) in aged persons resulting in inability to split B12 from protein carriers
Synthetic or purified B12 is not protein bound and is much better absorbed
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Atrophic Gastritis
Inflammation of stomach mucosa
Increased prevalence with aging
Results in decreased secretion of HCL, pepsin and intrinsic factor
Type A: Pernicious Anemia
Type B: Inflammatory Disorder associated with H. pylori infection
Age-associated Changes in Metabolism: Nutrients of Concern
Folate, Folic acid
Absorption may be impaired
Some medications used can affect folate metabolism
Folate deficiency can mask B12 deficiency, which is a more common problem in elderly
Folate supplementation may decrease dementia like symptoms and increase mental functioning among elderly.
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Other Nutrients May Inhibit Age-Related Diseases
Vitamins C and E decrease incidence of cataracts.
Antioxidants play a role in Age-Related Macular Degeneration
May improve mental ability in old age and prevent some forms of dementia
Intake of fish and fish oils has also been implicated in better cognitive performance among elderly.
Community Food and Nutrition Programs
Nutrition Programs Serving Older Adults—
USDA’s Supplemental Nutrition Assistance Program (SNAP)
Seniors’ Farmers Market Nutrition Programs
Commodity Supplemental Foods
Child and Adult Care Food Program
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Community Food and Nutrition Programs
Nutrition Programs Serving Older Adults—
The U.S. Department of Health and Human Services (HHS) administers the Older Americans Act programs
Meals on Wheels-Home delivered meal programs
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Geriatric Nutrition Case Study: Mrs. H
Chief Complaint:
Mrs. Heraldo is a 78 year old Latina woman brought in by her niece. The niece is concerned that Mrs. H looks much thinner. Mrs. H seems unconcerned about her weight loss and just repeats she is old now and “just not hungry.”
Mrs. H has no idea if she has lost weight. However, her chart documents that she is 5’4” tall and weighed 174 lbs 3 months ago. Today she weighs 154 lbs.
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Continuation of Chief Complaint:
The niece explains that her aunt lives alone in a subsidized, senior housing facility. She does not go out much. Mrs. Heraldo tells you that her two children, both grown, live in California and Arizona and she sees them about once a year. Her husband died 5 years ago. Her eyes tear a bit as she tells you this.
Discussion Question 1
What is the percentage of body weight that Mrs. H has lost in the last three months?
Given that Mrs. H’s BMI is still in the overweight range, is her weight loss currently a significant issue? Why or why not?
Discussion Questions 2
What should our weight goals for Mrs. H be at this point?
Is Mrs. H’s weight loss to be expected at her age? Why or why not?
Discussion Question 3
How do the physical effects of weight loss from decreased energy intake (reduced calories) differ from cachexia? What are the physiological effects of both?
Discussion Question 4
What are some of the causes of inadequate food intake in the elderly?
Brief 24 Hour Food Recall
Mrs. H lives alone and reports that she shops and cooks for herself. She says that she eats two meals a day and that she eats pretty much the same thing every day. Her 24 food recall for yesterday is:
Morning: 1 cup of instant coffee with non-dairy creamer, 1 tsp sugar and 1 slice toast with 1 tsp margarine and 1 tsp jam.
Noon: 1/2 can chicken noodle soup, 3-4 saltines and 1 slice American cheese.
Evening: 1 broiled chicken thigh, 1 spoonful of string beans and 1 spoonful rice.
She drinks at least 5 cups of water a day and sometimes has a cup of tea with 1 teaspoon sugar and 2-3 vanilla wafer cookies before bed.
She takes a daily multivitamin/mineral supplement.
Discussion Question 5
Approximately how many calories is Mrs. H eating each day?
Breakfast?
Lunch?
Dinner?
Evening Snack?
Total: On a good day, maybe 1000 calories!
Breakfast: ~200 calories
Lunch: ~200-300 calories
Dinner: ~200-300 calories
Evening Snack: ~ 200 calories
Discussion Question 6
What formula could we use to quickly estimate Mrs. H’s total daily caloric requirements?
Discussion Question 7
What formula should we use to calculate Mrs. H’s ideal protein intake?
Discussion Question 8
What dietary recommendations would be appropriate given Mrs. H’s current reported diet and health history?
Discussion Question 9
Use the MNA – short form to assess Mrs. H’s risk for malnutrition?
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| Homebound Elderly | 54 |
| Nursing Home Residents | 38 |
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