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Helping the elderly keep fit and active

It is estimated that 10% of the world's population is elderly and this figure is expected to double by the year 2050. Indeed it is anticipated that by 2020 almost half of the UK population will be over 50 years old, and if trends continue, by 2029 the number of 65-74-year-olds will increase by 10.8%, with those over-75 rising to 11.5%.(1,2) Alison Shepherd shares some practical advice on how to keep this growing older population healthy

Alison A Shepherd
MSc(Nutritional Medicine) BSc(Hons) RGN
Community Care Practitioner
Leicester City Community
Healthcare Trust
Lecturer in Adult Nursing and Nutrition De Montfort University Leicester

NB. The term elderly refers to anyone who is over retirement age: 65 years for men and 60 years for women.

Data from the latest Health Survey for England and Wales have revealed that not all elderly individuals enjoy good health.(3) Cardiovascular disease (CVD) is the most commonly reported chronic disease affecting 37% of men and 31% of women aged 65 years, and this increases with age to 45% of woman and 43% of men aged 85 years.
Thirteen percent of women and 10% of men over the age of 65 are also reported to have type 2 diabetes which, interestingly, is inversely related to income.
Rates of osteoporosis are also rising rapidly. One in two women over the age of 50 will suffer a fracture after a fall due to osteoporosis. If this current trend persists, it is predicted that hip fracture rates in the older person could increase from approximately 46,000 in 1985 to 117,000 in 2016.(4)

What is going wrong?
There is a wealth of literature available that promotes both healthy eating and physical exercise as being of paramount importance if these and other nutritionally-related chronic diseases are to be prevented.
A recent survey published by the Food Standards Agency found that although awareness of healthy eating advice is high among the older adult population, certain misconceptions may be preventing people from putting this knowledge into practice.(4)
Out of 472 individuals questioned, 67% were confident that they knew why healthy eating was of significant importance as they grew older. This may be positive, but the survey also revealed that 23% of respondents felt that "life was too short to worry about eating", and a further 39% of respondents said that "I have always eaten this way and up until now I have not been harmed."

Finding a balance
Concern over poor nutrition has become more evident in the last decade, with both obesity and malnutrition reaching unprecedented levels in society. Both of these conditions pose a tremendous economic burden on our health system. It is estimated that malnutrition alone costs the NHS £7.3bn per year and the National Statistics Office estimate that treating obesity currently costs £3bn pounds per year, with a predicted rise in 2010 to £3.6bn.(5,6)

Obesity
A diagnosis of obesity is most commonly made using body mass index (BMI) levels. As a general rule, an ideal BMI is 20-25. Between 25 and 30 is considered overweight and over 30 is considered obese. A BMI in excess of 40 is called "morbidly obese", meaning that weight is a real and imminent threat to health. However, it has been argued that BMI is not the best measure of obesity, as it does not distinguish between mass due to body fat, its distribution through the body or muscular physique.(6)
Research has indicated that an alternative measure of obesity, namely the waist-hip ratio, which measures the level of abdominal fat, is a much more valid indicator of obesity in the elderly.(7)
In both men and women obesity is said to increase with age and the latest figures show that among adults aged between 25 and 74 years, 71.68% of men and 61.1% of women are either overweight or obese.(8) Obesity is a major risk factor in the development of chronic diseases including type 2 diabetes and cardiovascular disease, and is strongly associated with insulin resistance, dyslipidaemia and hypertension. It is suggested that obese people are more likely to die prematurely from cancer and cardiovascular disease and, on average, life expectancy is reduced by nine years. Obesity also leads to mechanical disorders including breathlessness and back and joint pain, causing many obese people to experience a significantly impaired quality of life.

Malnutrition
More recently in the general population, it is estimated that one in seven people aged over 65 years or over have a high or medium risk of malnutrition. The prevalence is higher in people in institutions than those who live in their own homes. Malnutrition is a serious issue and predisposes individuals to infections and other diseases, delays recovery from illness and adversely affects body function, wellbeing and clinical outcome.9

How can the trends be changed?
Both obesity and malnutrition are preventable. One way to tackle this is to find a balance, changing lifestyle to incorporate healthy eating and physical activity. Another method that is beyond the scope of this article is to promote behaviour change.
The FSA suggests in their recent study that some people worry that "it is hard to change habits of a lifetime, or that healthy eating means that food is not enjoyable."(4) However, the agency propose that healthy eating does not demand huge changes in lifestyle, just some adjustments that can be tailored to individual circumstances. This may be achieved with practical support in the community setting.(10,11)

Starchy foods
It is estimated that constipation affects the quality of life in around 20% of older people in the community.(12) Diet and lifestyle have a potentially important roles in the management of chronic constipation. Choosing plenty of wholegrain or brown types of starchy foods including wholegrain breakfast cereals, brown rice, bread and pasta and drinking at least one to two litres of water per day will seek to prevent constipation. However, it is suggested that raw bran should not be sprinkled directly onto food as this can prevent iron absorption.(13)

Protein-rich foods
Protein is an essential nutrient for growth and repair. Therefore it is important to incorporate some lean red meat in the diet at least once a week, which will also enhance iron status. When choosing meat it is best to choose lean cuts of meat instead of fatty cuts, sausages or pies. Chicken is a good low-fat alternative. It is recommended to try and consume at least two portions of fish per week, one of which should be oily, eg, salmon, sardines, mackerel or tuna.
When cooking meat, it is best to grill and not fry, and to bake and slow cook products rather than add additional fat. Vegetarians can have alternatives such as tofu, soya protein and textured vegetable protein. Nuts and pulses are also good sources of protein.

Milk and dairy products and vitamin D
Osteoporosis is a significant public health concern in the elderly and has been described as a "silent epidemic".(12) It has also been shown that there is a high prevalence of low vitamin D status throughout the entire UK population.(14) Milk and dairy products contain both calcium and vitamin D, both vital for good bone health. These foods should be consumed at least two to three times a day but the lower-fat spreads, semiskimmed milk and low-fat yoghurts are the best choices to keep cholesterol levels low. One of the best forms of obtaining vitamin D is by exposure to the sun - older people who rarely go outdoors may benefit from a daily 10 mg supplement.(13)

Salt intake
In the UK most people eat more salt than is good for their health. The average intake in adults is estimated at 9 g a day, but the government recommends that the intake of salt should be no more than 6 g per day.(13) This is a cause for concern as the accumulation of sodium, the major source of salt in the diet, causes a potential increase in hypertension, which will substantially increase the risk of developing heart disease and stroke.(15) To avoid consuming excess salt patients should be advised not to add salt to food when cooking and to check the salt content of ready meals.

Foods containing fat and sugar
Eating food high in saturated fat, eg, cakes and biscuits, should be limited as these are high in hydrogenated fats that can raise cholesterol levels in the blood. It has been recommended that foods high in unsaturated fats, eg, avocado, oily fish and food fortified with omega-3, are the best choices. Takeaway foods and fast foods can be included in the diet, but should be regarded as treats and eaten occasionally. A total ban of foods such as crisps, chocolates and sweets is not necessary as it can lead to bingeing in the long term, which could lead to weight gain.

Probiotic benefit for the elderly?
There is recent evidence to suggest that there are age-related changes to gut bacteria, which can alter the gut environment and make it more favourable for the growth of pathogenic bacteria. This has been shown to increase the risk of disease in the elderly.1 In an attempt to redress the balance between healthy and pathogenic bacteria probiotics, defined as "live microbial supplements that beneficially affect an individual by improving intestinal microbial balance", have been used, usually in the form of yoghurt drinks and dairy products.16  Hamilton Miller reviewed just how helpful these may be in the elderly population and suggested that they were beneficial for many reasons including:(17)

  • Boosting the immune system.
  • Helping improve nutritional status in cases of malnutrition, lactose intolerance and calcium availability.
  • Helping alleviate constipation and antibiotic-associated diarrhoea.

Therefore it could be seen as beneficial to consume at least one yoghurt, or yoghurt drink with probiotic bacteria added each day.

Physical activity
Physical inactivity is becoming a serious health issue and has been shown to have a negative impact on both individual and public health.(18) There is strong evidence to suggest that many leading causes of disease and disability in our society are associated with physical activity including coronary heart disease, stroke, obesity, type 2 diabetes, hypertension, colorectal cancer, stress, anxiety, osteoarthritis, osteoporosis and low back pain.(8)
Indeed in 2005, statistics showed that 120,709 men and 80,995 women died before the age of 75, which is classed as premature mortality.(8)
The Chief Medical Officer recommends that adults participate in at least 30 minutes of moderate-intensity physical activity on at least five days a week. This could include any activity that increases the heart rate and causes mild breathlessness, eg, brisk walking, swimming, or even housework and gardening. Achieving the recommended levels of moderate intensity physical activity has been shown to reduce premature mortality by between 20 and 30%.(18) Recently, it has also been shown that physical activity improved functional autonomy among frail older people and regular exercise is associated with a delay in onset of both dementia and Alzheimer's disease.(19,20)
However, despite the abundance of research that promotes the benefits of physical exercise it is worrying to note that only 37% of men and 24% of women meet these current recommended guidelines.(18)
Activity does decline naturally with age, but statistics suggest again that there are "barriers" which seek to prevent individuals from exercising regularly. According to the Department of Health the older person may be deterred from exercising because of fear of crime, shortage of transport and lack of suitable exercise settings.(18) A recent study has highlighted that some of these barriers may be overcome through group-based physical activity, and there is considerable evidence to suggest that exercising in groups may help to prevent and reduce age-related illness.(21)

Conclusion
The population is growing older and it is likely that those growing old will experience some form of ill health. As healthcare professionals we have a duty of care to our elders. Our ultimate goal is: "to achieve more years of life with minimal years of compromised health. We do this by starting on the right path, staying on the right path and dying as old as possible."(22)

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References

  1. Thomas L, Leeds A. Nutritional benefits for the elderly, the potential of probiotics. Complete Nutr 2007;7:49-51.
  2. Mizen N. Malnutrition on older adult wards: decade of progress? Network Health Dieticians 2007;28:39.
  3. Department of Health. Health survey for England 2005. London: TSO; 2005.
  4. Food Standards Agency. Never too late to change the habits of a lifetime. London: FSA; 2007. Available from: http://www.food.gov.uk/news/pressreleases/2007/oct/over50s
  5. The European Nutrition for Health Alliance. Preventing malnutrition of older people in the community: what must work? 2007. Available from: http://www.riph.org.uk/pdf/preventing_malnutrition.pdf
  6. National Statistics Office. Statistics on obesity, physical activity and diet: England, January 2008. Available from: http://www.ic.nhs.uk/pubs/opadjan08
  7. Price GM, Uauy R, Breeze E, et al. Weight, shape, and mortality risk in older persons: elevated waist-hip ratio, not high body mass index, is associated with a greater risk of death. Am J Clin Nutr 2006:84:449-60.
  8. British Heart Foundation. BHF National Centre Physical Activity and Health. London: BHF; 2007. Available from: http://www.bhfactive.org.uk
  9. British Society for Parenteral and Enteral Nutrition. The MUST report. London: BAPEN; 2007. Available from: http://www.bapen.org.uk/must_exec.html
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  13. Food Standards Agency. Eat well. Older people. London: FSA; 2007. Available from: http://www.eatwell.gov.uk/agesandstages/olderpeople/
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  18. Department of Health. At least five a week: evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. London. London: DH; 2004.
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