Nutrition and Aging

Introducing the Socio-Ecological Model

In order to understand the personal and social frameworks of nutrition & healthy aging, the Social-Ecological Model is a useful tool to organize our exploration. If you research the social-ecological model, you will find there are different ways to represent these intersections of the influences on our food decisions, but the general layers are essentially the same. As you read this section, think back to the bio-psycho-social approach introduced early in this course (1.1 Read: Theoretical Perspectives: A biopsychosocial approach to positive aging). Compare the application of that model with this one. For our purposes, we'll use the version from the Dietary Guidelines for Americans 2015-2020

Notice that the model identifies four layers of influence nested one within the next:

• Individual factors
• Settings
• Sectors
• Social & cultural norms & values

At the level of clinical care, practitioners often focus on personal factors and prescribe a course of action for the individual. The Social-Ecological Model reminds us that individual choices are often influenced by a whole host of factors and that effective guidance respects and considers these layers of influence. Note that some models would include the fourth layer of "social & cultural norms & values" within the individual factors category. In my mind, it is less critical exactly where it appears in the model. The important point is that cultural norms & values are critical influences, whether at the personal or social level. For the rest of this module, we'll focus on the individual or personal layer. In Unit 6, we consider the social frameworks.

Health outcomes are influenced by individual factors that determine dietary intake, physical activity and lifestyle issues, within the context of the layers of settings, sectors and social & cultural norms & values.

Individual Factors- Demographics

Let's briefly examine the list from Figure 1 above.

• age
• gender
• socio-economic status
• race/ethnicity
• health, special needs
• psychosocial
• knowledge and skills
• gene-environment
• food preferences

Age & Gender

Age by itself is not necessarily informative to predict food and nutritional status but we do have established nutrient recommendations by age ranges and gender (DRIs or Dietary Reference Intakes). The recommendations assume: a) adults from age 51-70 and over 70 will have differences in specific nutrient requirements relative to younger age groups; and b) males tend to have more muscle mass than females, leading to increased energy needs for males relative to females.

Socioeconomic Status & Food Insecurity

Other individual factors such as socio-economic status, disability and race/ethnicity certainly inform health and wellness. For older adults, food insecurity is a big factor.

What, exactly, is meant by food insecurity? Isn't it just another word for hunger? A few basics here... hunger and food insecurity are caused by poverty. Food insecurity as a label recognizes the uncertainty that accompanies the risk of going hungry. Food insecurity is "limited or uncertain access to adequate food" (Source: Public Health Report)

The uncertainty is chronic- it is not because I forgot to bring lunch money today, but rather I have a persistent uncertainty essentially due to a lack of resources, rooted in poverty.

People experiencing food insecurity often consume a nutrient-poor diet, which may contribute to the development of obesity, heart disease, hypertension, diabetes, and other chronic diseases. People who live in food-insecure households also have difficulties in managing diet-related chronic conditions. For example, people with type 2 diabetes may find themselves limited to purchasing inexpensive, high-calorie, nutritionally poor foods (eg, foods high in refined carbohydrates) instead of foods that are more healthful, such as vegetables, lean proteins, and whole grains. (Source: Public Health Report)

Food security, on the other hand is a bit more nuanced. It is NOT the opposite of food insecurity. Giving someone a donated meal does NOT make them food secure. I like this World Food Summit definition of food security from the Food and Agriculture Organization (FAO):

Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life. (World Food Summit, 1996)

Source: FAO Policy Brief on Food Security (2006)

If you'd like to read more about this from an international perspective, this is a great overview document: FAO Food Security Concept Paper

In the United States, older adults are vulnerable to food insecurity. There are many individual factors that influence the risk for food insecurity. In addition, the impact of food insecurity has considerable negative effects on nutrition and health. The ability to remain in one's home and prepare meals may be affected by available social networks, level of income or disability. (We will explore community nutrition programs in Unit Six.)

Certain older adults are at higher risk for food insecurity than others. Research shows that food insecurity rates tend to be higher among older adults who are:

• Low income
• Less educated (i.e., less than a high school education)
• Black
• Hispanic
• Separated or divorced, or never married
• Residing in the South
• Unemployed
• Living with a disability
• Living alone
• “Younger” older adults (food insecurity among older adults decreases somewhat with age due to the availability of age-specific safety net programs, such as Medicare and Social Security)

Source: Strickhouser, S., Wright, J. D., & Donley, A. M. (2014). Food Insecurity Among Older Adults. Washington, DC: AARP Foundation. (Technical note: Based on low and very low food security data presented in Table 2b for 50-59 year olds and Table 2c for those aged 60 and older.) from http://frac.org/hunger-poverty-america/senior-hunger

Consider other changes that may impact an older adult's food and nutrition status. Knowledge and skills play a big part for someone recently widowed or divorced. How might that change food access? Food preferences may be challenged if a person moves into a setting where meals are provided for them and choices are limited. What other personal scenarios can you imagine?

For a more in-depth examination of this issue, you might be interested in these resources:

• Securing the Essentials
• Highlighting Hunger and Health
• Hunger in Older Adults

Race/Ethnicity

Dietary differences that exist between ethnic groups have more to do with culture and traditions than physiological differences. There is also a growing body of research that documents the health impacts of racism as toxic stress that has significant implications for people of color. This is expressed as both individual effects and societal, structural, sectoral.

Imagine how cultural traditions related to food are affected when an older adult becomes reliant on someone new to provide meals, for example. What resources might help support cultural foodways? Here are a few places to get started:

• CDC Stacks- Native American Traditions
• Good Food is Power
• Oldways Traditional Diets
• Southern Foodways Alliance

Do you have other favorite sources? Share them with us by posting in Inquiring Minds Want to Know...

Health Factors

Canada's Ministry of Health includes the following overview in their guide "Healthy Eating for Seniors".

Some people experience life changes and health changes that can make it more challenging to eat well.

Within our personal frameworks, such changes may include physical changes that:

• impact appetite
• alter sense of taste or smell
• impact digestion, ability to chew or swallow
• make it more difficult to get to the grocery store
• make it more difficult to spend a lot of time preparing food
• impact your ability to shop for or cook food or do tasks like open jars

The impacts of these physiological changes vary. When the issues impact food intake and nutritional quality, consulting a nutritionist is warranted.

Source: https://food-guide.canada.ca/en/tips-for-healthy-eating/seniors/

Psychosocial & Knowledge/Skills & Preferences

Moods, feelings, and perceptions can alter dietary patterns. Cooking skills, knowledge about healthy food choices are also likely to impact eating. Of course, these influences are important across all ages. Changes in life circumstances may occur, such as divorce or death of a spouse that call upon an older adult to learn new skills, such as cooking for one, that can have big impacts on dietary intake.

Before we move on to consider specific health issues and nutrients of concern for aging adults, you might enjoy this article from BBC Future that gives you some interesting ways to think about a personal aspect- "appetite"- across the span of aging. How Age Affects Appetite

What is "Good Nutrition"?

Is there a short-cut to reach dietary nirvana? Well, there are a couple of sayings that I think are illuminating!

"You are what you eat " - multiple sources

If we are what we eat, perhaps this is an accurate infographic:

Or, how about this one?

"Eat food. Not too much. Mostly plants. " -Michael Pollan, In Defense of Food. New York: Penguin Books. 2008 p. 1.

Pretty simple and straightforward. But, what counts as food? How much is too much?

What is Food?

The source of all food boils down to just a few simple components: sunlight + water + carbon dioxide yields sugars in plants. These simple constituents move up the food chain from plant to insect to poultry and on up to humans. Yet, no matter how high up the chain a food item rises, the human body must break it back down to sim

The Changing Food Supply

Pollan's rule to "Eat Food" may be honed a bit by saying "Eat REAL food. or Eat WHOLE food." It probably goes without saying that foods of today are not so simple. In the past fifty to seventy-five years, the U.S. (and much of the global) food supply has changed dramatically. On one end of a continuum, we consume foods that are "whole"- straight from the original source, such fruit off a tree or vine (think apple or grapes) that may only need a washing before eating. At the opposite end, highly processed foods and even ultra-processed foods, are scarcely recognizable in any food group category. Here's a great overview of the benefits and risks related to processed food consumption: UC Davis- What About Processed Foods?

Here's a pet peeve of mine-- be careful not to condemn processed foods. Remember that frozen fruits and veggies are processed. That is not a bad thing- it helps preserve foods affordably and they are still great foods to consume. The real culprits are the highly processed foods. And yes, you can have too much sugar or fat added to frozen fruits and veggies, for example, so we do need to know what is in our food. But, it is easy to cross the line and imply that someone without access to resources to afford and prepare whole foods from scratch won't be eating 'healthy'.

Food Groups

Imagine that you had the task of creating a dietary guidance system? How would you categorize or group foods to help make it easier for people without nutrition backgrounds to learn how to eat healthfully?

In the next module, we look at the way other countries/cultures categorize food. Currently, the USDA uses MyPlate as a visual cue. Tufts University has taken the USDA MyPlate model and applied it to meet needs of older adults. Here's an overview video. (Note, in MyPlate, the graphic presents food groups as Fruits, Vegetables, Grains, Dairy and Protein. Oils and Sweets are not considered actual food groups.) It is worth noting here, that while "Dairy" is considered a food group in the MyPlate model, it is well-understood that not everyone eats animal dairy products. The important concept is to consider where nutrients such as calcium are coming from in the diet. Don't get too hung up if you don't consume dairy.

So, to consider Pollan's statement, we need to agree on which foods are best to eat. Secondly, we need to know what is too much?

What is Too Much? (Also known as Dietary Guidance)

Perhaps one of the most frustrating issues in nutrition for many people is figuring out the 'best' or 'right' or 'optimal' amount of food to eat. In some respects, that's why following a published "diet" no matter what the diet, will produce weight loss because you take all the guess work out of it.

But if you think about it, it is IMPOSSIBLE to have a STANDARD SERVING SIZE that works for everybody, because our energy and nutrient needs change depending on age, gender, activity, and many other factors. So, we use a dietary guidance plan that tells us how much is recommended for our particular set of circumstances on a dailybasis. What matters is meeting those daily food group targets rather than eating one "standard serving" at each meal. The following chart gives suggested daily amounts.

Dietary Reference Intakes

The DRIs (Dietary Reference Intakes) are the specific targets for specific macro- and micro-nutrient intake as developed by an expert panel representing Canada and the United States. You can locate the full DRI tables at this link: but reproduced below are the tables for adults from 51 to 70 years of age and over 70 years.

Note: You can download these DRI tables in an Excel file: DRI Table [.xlsx].

Health Changes in Older Age

Hopefully by this point in the course, you are well aware of the dangers of generalizing about aging. That said, there are some changes that tend to occur to some degree in all humans as they age. This section provides a brief overview as a starting point.

Mobility

Muscle mass declines over time. Bone density also decreases and is markedly progressive for women who are post-menopausal. Joints and surrounding cartilage may weaken. The risks of declining muscle mass, bone and joint function means that strength, balance and stability may be affected. Layered upon a loss of bone density leads to increase risk for bone fractures and multiple complications.

Sensory functions

Vision

Age-related changes often result in near vision blurring, cataracts, and macular degeneration, especially in adults over 70 years.

Food & nutrition impacts:

• limits driving to grocery store
• difficult to read labels, recipes

Hearing

Age-related hearing loss (presbycusis) occurs most often in both ears, and has a multitude of causes including cellular aging, environmental exposure to noise, genetics and other factors.

Food & Nutrition Impacts:

• unable to hear cooking timers
• enjoy socializing at meals less

Smell and Taste

For some aging adults, declines in ability to detect strong aromas are associated with decreased interest and enjoyment in the taste of some foods.

Food & Nutrition Impacts:

• less enjoyment can lead to decreased food intake and weight loss/malnutrition
• diminished ability to discern smells to assess freshness or when a food is burning on the stove or oven

Cognitive function

Not all cognitive functions decline with age and things like language skills- reading, vocabulary, comprehension are generally stable throughout life. Many factors like socioeconomic status, lifestyle, chronic disease, medications can all impact cognitive function. Most commonly, some declines in speed of processing information and memory are frequent complaints.

Sexuality

People often remain sexually active throughout the life course. It is possible that the challenges posed by consequences of disease will impact sexual function, yet sexuality is important at all ages and frequently overlooked for older adults. How often are the sexual needs considered for older adults living in care facilities?

Immune Function

With age, certain immune function (notably T-cell activity) declines. This results in decreased capacity to respond to infections as well as vaccinations. While the immune process is incredibly complicated, these changes may be responsible for the increased susceptibility to infections among some older adults.

Skin

Age-related skin changes are caused by genetics, environmental changes and especially sun exposure. The protective role of skin as a first line of defense can be compromised.

Health Conditions in Aging

Many older adults maintain high levels of well-being even in the face of health disorders. The Global Burden of Disease project reports that the greatest impact of disability comes from:

• sensory impairments,
• back and neck pain,
• chronic obstructive pulmonary disease (COPD),
• depression and anxiety,
• falls,
• diabetes,
• dementia, and
• osteoarthritis.

Multiple Diseases

As people age, they are more likely to development multiple chronic conditions. At least half of all older adults are thought to have at least two chronic conditions, with sharp increases for people over 80 years of age. Perhaps not surprisingly, older adults with lower socioeconomic status are more likely to experience co-existence of multiple chronic conditions.

Polypharmacy

Polypharmacy refers to the use of multiple medications (prescription and non-prescription) by a single individual. While there is no internationally accepted definition of what constitutes polypharmacy, it is generally accepted that consumption of 5 or more medications is a reasonable definition.

As you might imagine, the use of multiple medications may present challenges to health at the same time treatments are trying to support health. Here's the abstract from a research review article that might interest you.

"Polypharmacy in older adults is a global problem that has recently worsened. Approximately 30% of adults aged 65 years and older in developed countries take 5 or more medications. Although prescribed and over-the-counter medications may improve a wide range of health problems, they also may cause or contribute to harm, especially in older adults. Polypharmacy in older adults is associated with worsening of geriatric syndromes and adverse drug events. Given the risks and burdens of polypharmacy and potentially inappropriate medications, nurses must use patient-centered approaches and nonpharmacologic strategies to treat common symptoms and to optimize patient function and quality of life." Source: Polypharmacy and Medication Management in Older Adults. Kim J, Parish AL. Nurs Clin North Am. 2017 Sep;52(3):457-468. doi: 10.1016/j.cnur.2017.04.007. Review.

Food & Nutrition Impacts

Food and drug interactions impact side effects, absorption and effectiveness of the drug or nutrient.

• Grapefruit Juice: some prescription medications that lower cholesterol (statins) and blood pressure may interact with grapefruit juice, either enhancing or limiting the effect of the drug.
• Milk: some antibiotics will not be well-absorbed when taken with milk, dairy or antacid type products.
• Dark green leafy vegetables: spinach and kale, for example, can impact vitamin-K blood clotting factors. Anyone taking anticoagulants (blood thinners) such as warfarin should discuss with your provider. Usually, balanced amounts of steady leafy green intake is recommended.
• Black licorice (the natural variety containing glycyrrhizin) can lead to irregular heartbeat in persons taking digoxin. Some other interactions with digoxin include: high fiber decreases absorption, so do not eat fiber within two hours of taking digoxin; senna and St. Johns wort can decrease the action of digoxin.
• Alcohol: alcohol can intensify symptoms such as drowsiness; always consult your provider/pharmacist to determine impact.

For more information, you might be interested in this brochure: Food and Drug Interactions (FDA)

Preventing and Managing Disease with Aging

In the clinician's office, it is easy to focus on individual actions, lifestyle and personal choices when trying to diagnose and prescribe treatments. Public health has long recognized that personal health is not only about personal choice- the context of our choices exists in the world around us. We will explore these social frameworks by looking at how the personal and the public intersect in Unit 7. Before we do, let's spend some time understanding a bit more about chronic diseases that affect many aging Americans and have clear lifestyle and diet connections.

Chronic Disease AKA Noncommunicable Diseases

There is a shift in the public health field from talking about chronic disease to using the term 'noncommunicable disease' or NCD. Along with the shift in label, emerging research suggests that dietary guidance based patterns of eating (more fruits and vegetables, for example) carries a greater impact for health than a focus on specific nutrients (limit saturated fat or consume adequate vitamin A, for example). The DRIs (Dietary Reference Intakes) for older adults prescribe the ranges of specific nutrient intake that prevents deficiency or toxicity, so it is important to acknowledge nutrition at the macro- and micro- level of nutrients. Yet, there is now an international research commission studying the idea of creating DRIs based on food patterns rather than nutrients. It will be interesting to see the results of their work. If you are interested in reading more about this issue, see: Tapsell et al. Foods, Nutrients, and Dietary Patterns

Nutrients of Concern

In this section, we will examine some of the more common nutrition-related concerns of older adults, recognizing that few of these concerns are inevitable or caused by aging.

(If you are interested in a more detailed take on nutrition and aging, you might be interested in this text: Nutrition for the Older Adult by Melissa Bernstein and Nancy Munoz from Jones & Bartlett.)

Energy

In general, at a certain point in the life course, levels of physical activity decrease from younger years. While that point is different for each individual, let's examine some of the implications of decreasing energy needs.

At any age, the more sedentary the person, the lower the need for consuming calories. There is a sweet spot however, pardon the pun. Consider that metabolic processes (all the reactions that take place to keep the heart beating, the lungs breathing, the brain working, the liver processing, the digestion and absorption in the gut and so on) require about 1200 calories each and every day. SO, even if you were a total couch potato, you need to consume at least that many calories just for survival. But, what happens if you don't consume that minimum required amount?

• Over time, our body adapts to what is essentially starvation, tries to use even fewer calories and becomes even more efficient at storing energy.
• A reasonable amount of food intake (including calories) is required daily in order to get all the nutrients (macros and micros) needed. (Think- eating less than 1200 calories a day makes it hard to get the nutrients needed.)

So, for sedentary older adults, the nutrition quality of foods eaten is possibly more important than ever before.

Water

As an essential nutrient, water is important for all ages. Water maintains body temperature, is required for metabolic reactions, transports nutrients and waste, essential for digestive activity and more. Some aging adults experience changes in thirst perception- both from physiological changes and/or due to certain medications- that can lead to dehydration. Consequences of dehydration can lead to low blood pressure, dizziness, confusion and falls.

When looking at water intake, we consider drinking water, beverages, and foods that contain water (such as fruits, for example) for adequate sources. However, alcohol is dehydrating and therefore does not count toward fluid intake.

NOTE: there are health conditions that require individuals to limit fluid intake, so, it is always important to know individual needs.

Recommended fluid intake for healthy men over the age of 49: 3.7 liters per day (about 15.5 cups) and fluid intake for healthy women between 50 and above: 2.7 liters per day ( about 11.5 cups). NOTE: this is total fluid so it includes water, beverages and foods.

Protein

Currently, researchers are debating the protein needs for older adults. Muscle mass tends to decrease with aging- whether from lack of use or other metabolic reasons. So, some evidence exists to suggest that a higher protein intake might improve protein status for older adults. We usually focus on the role of proteins as muscle, but recall that proteins are also critical for immune function, and may be implicated in declining ability to fight disease with aging. But don't reach for the protein powder just yet.

Sarcopenia

"Sarcopenia is the loss of muscle mass that happens to everyone with age. However, the rate of sarcopenia and the severity of its sequelae vary greatly according to health status, physical activity, and possibly diet. " Source: Abstract, (Ronenn Roubenoff; Sarcopenia: Effects on Body Composition and Function, The Journals of Gerontology: Series A, Volume 58, Issue 11, 1 November 2003, Pages M1012–M1017, https://doi.org/10.1093/gerona/58.11.M1012)

Sources vary as to when adults start losing muscle mass associated with aging- is it in our 40s? our 50s? And, as the definition above notes, there are a number of factors that affect the loss of muscle mass. From an aging perspective, we are most concerned about delaying or mitigating any impacts because the losses of muscle mass, strength and function lead to limitations such as mobility, balance and falls, fractures and admissions to skilled nursing facilities. A 2017 article by Robinson et al., concludes that "the considerable evidence that links nutrition to muscle mass, strength and function of older adults, suggests that nutrition has an important role to play in both the prevention and management of sarcopenia." pp.1128

The article goes on to highlight the importance of dietary patterns that provide adequate vitamin D, antioxidants and long-chain polyunsaturated fatty acids. The emphasis is on food intake, NOT supplements, as the evidence indicates the value of the whole diet effects along with physical activity. The conclusion:

...the high prevalence of poor nutrition currently observed among older populations, including in high-income countries, highlights the immediate need to ensure all older adults are supported effectively to have sufficient dietary intakes and adequate nutritional status...wider efforts to promote diet quality alongside a physically active lifestyle are also essential; they have significant potential to slow losses of muscle mass and strength and protect physical function, central to enabling mobility and independence in older age. (p1128)

If you are interested in this topic, the following review article (while a few years old) is a great resource: Ronenn Roubenoff; Sarcopenia: Effects on Body Composition and Function, The Journals of Gerontology: Series A, Volume 58, Issue 11, 1 November 2003, Pages M1012–M1017, https://doi.org/10.1093/gerona/58.11.M1012

Vitamin D

Aging is associated with decreased ability to synthesize vitamin D from sun exposure to the skin. And, for any age, sun exposure may not be adequate during winter months (such as at our latitude in the Pacific Northwest) and other factors such as darker skin pigments may also limit vitamin D synthesis from sun exposure.

Vitamin B12

Vitamin B12 is a rather interesting vitamin. Only bacteria can produce B12 and therefore all our natural sources of B12 are from animals and animal products. Vitamin B12 is important for many reasons- the primary ones include production of healthy blood cells and neurological function.

Despite marketing to the contrary, algae and spirulina are not adequate sources. We need very small amounts of B12 and unlike other water-soluble vitamins, the body maintains a store of B12. For that reason, diets deficient in B12 may not produce any deficiency symptoms for up to five years or more! Vegans must get vitamin B12 from supplements or enriched foods in order to be sure to maintain adequate intake. For many years, nutritional yeast was promoted as a source of B12- but buyer beware- not all nutritional yeast is a good source.

Another interesting thing about vitamin B12 is that it requires adequate stomach acidity and something called 'intrinsic factor' secreted in the stomach to facilitate absorption of vitamin B12 from foods or oral supplements. It is not unusual for adults over 60 years or so to have limited absorption of vitamin B12- either due to decreasing stomach acidity, decreasing amounts of intrinsic factor and/or interactions with other medication. For this reason, it is common to assess B12 status as people approach 60 years or older.