Elderly eating healthy

You are What You Eat

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“You are what you eat” is an adage that is supported by research. Eating healthy foods can lead to a healthier body, while not having such foods can lead to problems such as nutrient and vitamin deficiencies, unintended weight loss, or obesity. In the elderly population, nutritional issues are of particular importance, as the aging body becomes more susceptible to chronic and acute disease states.

The Aging Body: As people age, the sphincter tension and contraction strength of the esophagus is diminished and the stomach mucosa can become more prone to damage (particularly as certain diseases that lower gastric acid secretion are more likely to occur). With the decrease in the elasticity of the stomach, there is a reduction in storage capacity and a delay in gastric emptying. This may result in a prolonged sensation of satiety. Changes in the small intestine can include a reduction of nutrient absorption, due to bacterial overgrowth, as well as intolerance of lactose, related to a decrease in lactase enzymes. Changes within the large intestine include a slight decrease in peristaltic movement and a slight enlargement of the rectal vault with a diminished ability for it to contract when filled with fecal matter.[1]  Additionally, the liver loses some metabolic capacity, while the ability to produce bile and its flow is reduced, as well. [2]  Although all of these changes can occur as the body ages, in an otherwise healthy body, the gastrointestinal system’s reserves will still function at near normal capacity. [1]

Pathophysiology: Pathophysiology has a profound impact on the nutritional status of a geriatric person. There are multiple disease states, common among the elderly, which can affect their ability to properly utilize the nutrients they consume. Some of these diseases are a result of genetics or changes in body physiology, whereas others are consequence of other disease. For example, changes in mucosal cells of the stomach and large intestine can lead to disease states such as colorectal and stomach cancer. [3] In diverticulosis, intestinal wall weakness creates pouches that can become sources of inflammation and infection. [4] Crohn’s disease and ulcerative colitis are both related to genetic predisposition and autoimmune compromise. In these disease states, inflammation occurs, creating pain, ulceration, and diarrhea, which often lead to complications of malabsorption and dehydration. [5,6] On the other hand, dyspnea, as experienced in chronic obstructive pulmonary disease, can lead to fatigue and loss of appetite, which in turn can lead to malnutrition. [7] Additionally, diseases such as severe arthritis, Parkinson’s, stroke, dementia, and depression can predispose older people to malnutrition as these problems can affect their ability to obtain and/or prepare food. [8]

Medication side effects: Diuretics, antacids, statins, antihypertensives, antibiotics, antidepressants, steroids, anti-glucose, and non-steroidal anti-inflammatory meds are just a sampling of drug categories that induce gastrointestinal upset, reduce saliva production, diminish the sensations of taste or smell [9] or decrease the body’s ability to adequately absorb nutrients. [10]

Limited resources: Seniors living with mobility, physical, or mental disabilities often are unable to shop for and prepare healthy foods independently. They may not have people available to assist in performing these tasks for them. Lack of access to the store and limited budgets to purchase healthier food also create other impediments to eating healthily. Those with dentition problems, who cannot afford dental services or appliances, may have trouble in chewing and swallowing their food adequately. Risk of choking can be a fear for them. Elderly who live by themselves may skip meals due to feelings of loneliness or not wanting the bother of cooking just for themselves. Additionally, those who are institutionalized oftentimes do not have control over the meal choices or the environment in which they must eat. For instance, lack of time to eat or lack of feeding assistance, unpalatable food presentation, and foods that do not address their cultural or dietary needs present such obstacles to nutritious eating. [11]

Lack of knowledge: Food falls within three nutritional categories: carbohydrates (complex, simple, and starches), proteins, and fats (monounsaturated, polyunsaturated, saturated, and trans fats). Foods within these categories can be further subdivided into five foods groups. [12]

Complex carbohydrates, that include starches and fiber, take longer for the body to digest thereby prolonging satiation. These are found in breads, cereal, grains and pasta. Whole grain, B-12 (at least 2.4 mcg/d) fortified, and folic acid (400 mcg/d) enriched products are the best choices, as these help nerves cells to function well, help produce red blood cells, reduce inflammatory homocysteine levels, and provide fiber to combat constipation. Six or more servings of these are recommended for people aged seventy and older and at least 20 grams of fiber, everyday. Fruit and vegetables are also complex carbohydrates and starches. The best choices within this group include those with the most vivid colorings of green, yellow, red, and orange, as they contain higher amounts of vitamins such as  C and A, as well as antioxidants. Fruit juices should be consumed in limited quantities due to their high sugar content. Canned vegetables are fine to eat, but those with lower sodium are most preferable. Three or more servings of vegetables and two or more servings of fruit each day are recommended for people over age seventy. Simple or refined carbohydrates, on the other hand, should be avoided or eaten minimally, as they have low nutritional value. Foods within this group include sweets, white rice and white flour. [13]

Proteins consist of a variety of food groups. Wise dairy product choices include low fat milk, cheeses, and yogurt which are rich sources of calcium (1200-1400 mg/d recommended) and Vitamin D (600 mg/d recommended). Elderly people should have three servings of these foods daily. Also, poultry, lean meats such as pork or T-bone steak, fish such as salmon or mackerel, and eggs are excellent protein sources. Legumes such as kidney beans, soy, and lima beans, and nuts such as almonds and walnuts are as well. [14] Those 70 or older are encouraged to have at least two or more servings of these foods every day. [13]

Fats can be further divided into saturated and unsaturated. The mono and poly unsaturated fats help the body by reducing blood cholesterol levels, cardiovascular disease risk, and increasing brain cell function.  These foods include avocados; olive, vegetable, and canola oils; and fish and fish oils (omega-3 fatty acids). These oils remain in liquid form whether in the refrigerator or at room temperature. Trans and saturated fats, on the other hand, are bad for body’s health since they lower good HDL cholesterol, increase bad LDL cholesterol, and increase cardiovascular disease risk. These foods include butter, animal fats, peanut oil, and coconut oil, which solidifies when, cool. [15]  The elderly, however, should eat all fats, sparingly. [13]

By following these serving size and food suggestions, the elderly who consume at least 1200 to 1600 kilocalories daily, will receive 100% of their daily recommended nutrient and protein allowances. Daily fluid intake of at least eight glasses of water (two quarts) is recommended to prevent dehydration and constipation. [13] Additionally, in healthier older people, consuming 30 kilocalories for each kilogram of body weight (consisting of 30% or less of fat calories and 0.8 to 1.0 gram of protein per kilogram each day), their daily recommended kilocalories can be achieved.  Of course, calorie and fluid requirements will differ in those who are ill, already fluid overloaded, or malnourished, and should be adjusted and monitored accordingly. [16]

In my practice, a female patient came to see me with her sister, who was concerned with the patient’s weight loss.  The patient had been widowed two years prior and had problems with depression and insomnia. The patient used to enjoy cooking for her family, but after her husband’s passing, she did not enjoy cooking and would even skip meals stating she “just wasn’t hungry.” The patient was also on a fixed income and did not drive, so she did not often venture out to the grocery store.  The patient had atrophic gastritis for which she was on an H2-blocker, as well as hypertension for which she was on a diuretic and an ACE inhibitor.  After a history and physical with bloodwork was completed, it was determined that the patient was also B-12 deficient for which Cobalamin supplementation was added. Also, mirtazapine (Remeron) was added to help to combat both the depression and insomnia, which would enhance her ability to take better care of herself. I spoke with the sister about healthy food choices and hydration for this patient. She agreed to purchase these foods for her sister each week when she did her own grocery shopping. She even agreed to the idea of cooking several dishes her sister would enjoy and place them into small one-serving containers that her sister could microwave and eat. She purchased healthy snacks such as cheese sticks, baby carrots, and fruit. Additionally, she kept a pitcher of lemonade and bottled water in the fridge to remind her sister to drink her fluids. With the help of a social worker, Meals on Wheels provided meals whenever her sister was unavailable.

Within one year, and with med dose adjustments, the patient’s mood improved and she felt that she had more energy. She had almost returned to her normal weight and began going to the grocery store with her sister. She also developed a friendship with a woman at church who transported her to a senior center for socialization, outings, and even daily lunch!  She participated regularly and slowly began to enjoy life again.

Nutrition in the elderly can be a challenge, as their needs can vary according to their state of health. With careful evaluation of their situations and assistance from resources such as area agencies on aging and social work, geriatric people have a better chance of receiving the help they may need to eat more nutritiously. Also, having a better understanding of the types of food available for consumption and how they can affect the body, older people can make wiser food selections and enjoy what they eat. Bon appétit!

 

 

Karen Digby, GNP-BC
Chair of Family Medicine, Northside Hospital
Atlanta, GA
Published on April 23, 2013

 

Biosketch
Karen Digby is a nurse practitioner specializing in geriatrics. She received her training from New York University and the University of Michigan in Ann Arbor. In over ten years of practice, Karen has obtained a wealth of experience in various aspects of health care including home care, outpatient/ambulatory care, dementia care, subacute care, hospice, assist living and long-term care. Due to her expertise in geriatrics, Karen was selected as an item writer, by the American Nurses Credentialing Center, for the Gerontological Nurse Practitioner Board Certification Examination. She also co-authored an article on “Falls in the Elderly” in the Plastic Surgical Nursing Journal. Additionally, Karen is certified as a Wound Care Specialist through the American Academy of Wound Management.

References

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2.    Cohen S. Effects of aging on the liver. The Merck Manual Home Health Handbook. July 2006.
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5.    Mayo Clinic. Crohn’s disease. http://www.mayoclinic.com/health/crohns-disease/DS00104
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12.    CDC. Nutrition for everyone: Food groups. http://www.cdc.gov/nutrition/everyone/basics/foodgroups.html
13.    Russell RM, Rasmussen H, Lichenstein AH. Modified food guide pyramid for people over seventy years of age. J Nutr. March 1, 1999; Vol. 129; 3: 751-753.
14.    CDC. Nutrition for everyone: Nutrition basics. http://www.cdc.gov/nutrition/everyone/basics/protein.html
15.    American Hearth Association. Fats and Oils: AHA Recommendation. http://www.heart.org/HEARTORG/GettingHealthy/Fats and Oils/Fats101
16.    DiMaria-Ghalili RA. Nutrition in the elderly. July 2012. http://consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more