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Nutrition and the elderly: encouraging healthy eating

Vanessa McConkey
BSc MSc ANutr
Information Manager
The Sugar Bureau
Duncan House
Dolphin Square
London SW1V 3PW
W:www.sugar-bureau.co.uk

Since the 1930s the proportion of the population living to and above the age of 65 has more than doubled.(1) This has been attributed to falling mortality rates in infancy and childhood, better living conditions and improvements in healthcare.(2) In 2001, one-fifth of the population was over 65 years of age,(1) and this is estimated to rise to 25% by the year 2030.(3)

Older people are not a uniform group and may be broadly divided into three categories:(1)

  • Entering old age - these people are active, ­independent and remain so into late old age.
  • Transitional phase - this group are in transition between a healthy status and frailty.
  • Frail older people - vulnerable as a result of health problems, social care needs, or a ­combination of both. They have a high prevalence of undernutrition, which increases with increasing dependence and disease.(4)

Inadequate or poor nutritional status is associated with reduced health and vitality and lowered cognitive function.(5) Nutrition, or more precisely the prevention of undernutrition, is therefore of high priority in maintaining the health and wellbeing of the growing elderly population. Health professionals play a key role in improving the nutritional status of undernourished patients, reducing the prevalence of infection and nutrition-related diseases, and improving quality of life.
 
Energy requirements
 
Energy expenditure
In the elderly, energy expenditure is reduced for two principal reasons: a decline in muscle mass and lower levels of physical activity.(6) A decline in lean body mass (muscle mass) occurs with increasing age. Loss of muscle mass reduces energy requirements by reducing basal metabolic rate (BMR), and can also reduce mobility.(3) Physical activity is the second largest component of energy expenditure. Levels of activity tend to decline with age, especially among those who become sick, infirm or disabled.(3,6) Maintaining a level of activity into older age, and increasing activity in the sedentary, can help to increase energy expenditure and can slow the decline in muscle strength and prolong the individual's physical abilities. In addition, it will have a beneficial effect on appetite and energy intake.

Energy intake
When energy expenditure is low, dietary intake is likely to be low, restricting the variety and amount of food consumed and reducing nutritional status. Although energy requirements decline with age, requirements for micronutrients generally do not.(3) Disruptions to appetite and normal eating behaviours can result from, among other reasons, illness, depression, bereavement and changes to living arrangements. Sense of taste and smell deteriorate with age,(3) removing a lot of the pleasures associated with food and mealtimes, and consequently the desire to eat. Dietary intake must be adequate to provide the energy and nutrients essential to maintain a healthy body and lifestyle and prevent degeneration. Moreover, in the event of illness or immobility it is often the case that nutritional (and energy) requirements are increased.(3)

A healthy diet
Good nutrition plays an important role in the health of older people, and may help offset some aspects of ageing by reducing susceptibility to illness and disease, by aiding recovery from illness, and by delaying the deterioration of some physiological functions associated with ageing.(3) Although energy requirements may be reduced, it is essential to maintain an optimal nutritional status. Certain health conditions and diseases can affect or be influenced by nutritional status,(3) such as anaemias, cardiovascular disease, some cancers, constipation, infection and osteoporosis. Consuming a healthy, nutrient-rich, balanced diet is the best way to ensure adequate nutrition.

Fruit and vegetables
Encouraging the elderly to eat a variety of brightly coloured fruit and vegetables (eg, cabbage, peas, tomatoes, ripe bananas and oranges) is a simple way to obtain the antioxidants, vitamins and minerals required for optimal immune function and general health.(7) Green leafy vegetables, such as spinach, require little preparation or cooking and can be eaten easily, even by those with a compromised dentition.

Cooking vegetables that are regarded as being "hard" or difficult to chew will help to soften their texture. Steaming, baking and poaching are all simple cooking methods that help retain the nutritive value of foods; mashing potatoes will equally reduce the need for chewing. Slices of apples, oranges or other fruits are useful, easy-to-prepare snacks. Puréed fruit can be used to make wholesome desserts, such as stewed apples served with custard.

Carbohydrates
Starchy foods, such as wholegrains, bread, other cereals and potatoes are a good source of energy and fibre in the diet. For those with compromised dentition, white or wholemeal bread will be broken down in the mouth and swallowed with greater ease than granary bread, which contains the harder wholegrains. Spreads, such as jam, yeast extract (Marmite), pâté and cheese spread, can be useful additional sources of energy and nutrients. Eating regular small meals throughout the day, as opposed to less frequent large meals, can help to increase energy and nutrient intake and improve suppressed appetite. Similarly, adding favourite foods to the menu helps to improve enthusiasm for food and mealtimes.

Fat
Reduced-fat diets are recommended for general health. However, in cases of malnutrition it is important that energy requirements are met. Consuming foods with higher calorie content, for example full fat instead of low fat, will help frail patients to maintain or gain weight and provide energy.(8)
 
Protein and other nutrients
Animal-derived products, such as meat, fish and eggs, are a useful source of micronutrients and protein in the diet. Milk and other dairy foods provide calcium, necessary for the maintenance of healthy bones. Oily fish, such as trout, salmon, tuna and mackerel, are a good source of omega-3 polyunsaturated fats (PUFA) and fat-soluble vitamins. Furthermore, the flaky, soft texture of oily and white fish is ideal for older people, even those with poor dentition.

Meat can sometimes be difficult to break down and digest. Cooking meat at a lower temperature for longer - for example, in a stew or casserole - will increase its tenderness. Another option is using more tender cuts, such as chicken breast.

Iron is essential for the transport of oxygen around the body and therefore, despite a reduction in the requirements in postmenopausal women, red meat or offal (liver) should be included in the diet. Folate deficiency occurs more frequently in the elderly than in younger adults, illustrating the need to boost intakes of folate-containing foods such as liver, yeast extract(7) and green leafy vegetables.(6)
 
Fluids
Older people should drink approximately six to eight glasses of fluids per day ­to prevent dehydration.(3) There are a wide variety of drinks from which they can choose, such as water, tea, fruit juices and milk-based drinks.

Oral health
Nutritional wellbeing may be adversely compromised by poor oral health, and consequently a reduced ability to chew.(9) In Britain, people aged 65 years and over who have their own teeth generally have better vitamin and mineral intakes than those who have lost some or all of their teeth.(10) In these circumstances, foods viewed as difficult to chew, such as raw fruit and vegetables, are often avoided or overcooked,(3) a practice detrimental to their nutritive value. Adding sauces to meals will help to soften foods deemed as difficult to chew, while at the same time increasing flavour and the nutritive value of meals - parsley sauce can be made from milk used to poach fish, and cheese sauce is an ideal accompaniment with cauliflower.

Good oral hygiene should be maintained throughout older age to prevent further deterioration of dental health.(11) Regular visits to the dentist will help to address troublesome teeth, persistent problems and ensure dentures are well fitting and comfortable. The resultant improvement in dental health will help to alleviate the avoidance of certain foods observed when dental health is poor.

Physical activity
It is important to bear in mind that there is considerable variation in physical activity levels in the elderly population.(6) Regular participation in physical activity is associated with reduced risk of cardiovascular disease and stroke,(12) attenuated bone loss(3) and reduced overall mortality.(7)

The energy cost of physical activity is higher in the elderly,(6) and so regular short walks or light gardening (in sunshine whenever possible) may be all that is needed to increase energy expenditure sufficiently to obtain notable changes in appetite and the subsequent health benefits. More sedentary patients should be encouraged to eat their meals in the dining area, rather than in bed, providing a change of surroundings and increasing activity. The abilities of the individual will dictate the amount of activity participated in and will be dependent on their physical health and wellbeing.
 
Conclusion
Undernutrition and poor health do not need to be inevitable consequences of ageing. Dietary advice given to the patient will depend on their physical and mental health. Advice should take into account the differences in lifestyle and the impact of cultural/religious beliefs. Good nutrition, increased physical activity and improved nutritional care of the elderly will lessen the risk or progression of several degenerative diseases and reduce the impact of chronic disease on nutritional status and quality of life.(7)

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References

  1. Department of Health. National ­service framework for older people. London: Department of Health; 2001.
  2. Grimley-Evans J. Elderly people: demographic considerations. 2002. Available from URL:http://www.jr2.ox. ac.uk/geratol/docdemog.doc(Last accessed 27 Nov 2002.)
  3. British Nutrition Foundation. Nutrition in older people. London: BNF; 1996.
  4. Reilly JJ. Understanding chronic malnutrition in childhood and old age: role of energy balance research. Proc Nutr Society 2002;61:321-7.
  5. Gonzalez-Gross M, Marcos A, Pietrzik K. Nutrition and cognitive impairment in the elderly: a review. Br J Nutr 2001;86:313-21.
  6. Department of Health. Dietary ­reference values for food energy and nutrients for the United Kingdom. Report on Health and Social Subjects 41. London: HMSO; 1991.
  7. Rosenberg IH. Nutrition and ageing. In: Garrow J, James W, Ralph A, editors. Human nutrition and dietetics. 10th ed. London: Churchill Livingstone; 2000.
  8. Tolsen D, Schofield I, Booth J, Ramsay R. Nutrition for physically frail older people. Nursing Times 2002;98(28):38-40.
  9. Finch S, et al. National diet and ­nutrition survey: people aged 65 years and over. Volume 1: report of the diet and nutritional survey. London: The Stationery Office; 1998.
  10. Steele JG, et al. National diet and nutrition survey: people aged 65 years and older. Volume 2: report of the oral health survey. London: Stationery Office; 1998.
  11. British Nutrition Foundation.10 key facts: nutrition and older people. London: BNF; 2002.
  12. Department of Health. Saving lives: our healthier nation. London: The Stationary Office; 1999.

Resources
British Nutrition Foundation
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