Nutritional Care of Older AdultsLaurie B. Steenwyk M.Ed, RD, LDN

Class Overview

Assessing Nutritional StatusNutritional Needs of the ElderlyNutrition InterventionsEating Lifestyles

Meal planning for optimal health

Assessing Nutritional Status

Factors Impacting Nutritional Status in the Elderly

Assessing Weight Status

BMI <23 considered underweight >65 yrs

Percent Weight Loss (unintended) >5% in 1 month (quadruples risk of death) > 7.5% in 3 months >10% in 6 months

Cachexia Severe wasting accompanying diseases such as cancer

Mini Nutrition Assessment

6 question screening tool

Complete in <5 minutes Validated for age >65 More sensitive than BMI Available at:

http://www.mna-elderly.com/

Sarcopenia

Sarcopenia Loss of skeletal muscle associated with aging Affects 8-40% of adults >60 yrs 50% of adults >75 yrs

Sarcopenic ObesityCoexisting loss of skeletal muscle mass

and strength with excess body fat

Nutritional Needs of the Elderly

Energy

Energy (calorie) needs decrease with age, mostly due to decreased physical activity

LBM declines with age and influences energy needs

Protein and vitamin/mineral needs remain the same or increase

Challenge: adequate micronutrients within caloric requirement

Nutrients of Concern

Risk for deficiency with age WaterFiberProteinCalcium and Vitamin DVitamin B12Vitamin C and E – antioxidants

Water

Dehydration is a form of malnutritionKidneys’ decreased ability to

concentrate urineAdverse effects of medicationMobility disordersFear of incontinence25-30 mL/kg actual body wt

Fiber

Fiber Goals for adults over 50: Men: 30 g per day Women: 21 g per day

Insoluble: Tough, fibrous plant material that does NOT absorb water Most grains and vegetables

Soluble: Plant fibers capable of absorbing water and become gummy or gel-like Oats, fruit, legumes, pectin, inulin, psyllium

Sources of Fiber

OatsBarleyWheatQuinoa

FlaxBrown Rice

BranLegumes

SeedsFruits

Vegetables

Protein

Muscle mass (LBM) decreases 15% per decade after age 70

Needs increase with illness, injurySurgery, wounds, CHF, COPD, Cancer

Optimal intake: 25-30 gm/mealEven distribution most effective in preventing

muscle loss during illness

1-1.6 gm/kg IBW may prevent sarcopenia

PROTEINSources:

Animal Proteins Egg, Turkey, Fish, Beef…

Dairy Milk, Cheese, Yogurt, Cottage Cheese…

Legumes and Nuts Black Beans, Red Beans, Lentils, Walnuts…

Some from grains/breads/plants Quinoa, Greens, Broccoli, Oats, Pasta…

Vitamin D

800 IU >70 years Safe upper limit

4000 IU Supplements are

recommended for older adults

Sources Fortified milk Fatty fish, fish oil Liver Egg yolk Some enriched

beverages Exposure to sunshine

during Spring, Summer, early Fall

Calcium

1000 mg Men <70 years1200 mg Men >701200 mg Women >50Safe upper limit 2000 mg/dayA large recent study suggests that

calcium supplements don’t prevent hip fractures

Calcium

Dairy Sources 1 cup milk – 300 mg 4 oz yogurt – 200 mg 1 oz cheese – 200 mg ½ cup cottage cheese –

65 mg ¼ cup ricotta cheese -

200 mg

Non-Dairy Calcium Sources

1 cup Calcium fortified orange or apple juice (240 mg)

Enriched, GF almond, soy or rice milk – 300 mg

3 oz Sardines – 370 mg 3 oz Canned Salmon w/

bones – 180 mg Almonds ½ cup Broccoli (90 mg) 2 oz Tofu (made w/

calcium sulfate Firm Tofu (385 mg) Regular Tofu (200 mg)

1 T Blackstrap Molasses – 135 mg

1 T Tahini – 65 mg

Other Nutrients in Bone Health

Vitamin KLeafy greens, broccoli, soybean oil

ManganeseSpinach, peanuts, almonds, brown rice,

green teaExcesses of sodium, protein and

phosphorus decrease calcium availability.

Vitamin B-12

6-15% of older adults are deficientAnother 20% have marginal statusCompromised absorption

Pernicious anemiaLack of intrinsic factorAtrophic gastritisLong-term use of PPIs

Vitamin B-12 Deficiency

Symptoms Folate Deficiency Numbness, tingling of arms, legs Difficulty walking Memory loss Disorientation Dementia Sore tongue Poor appetite Constipation Possibly depression

Sources Meat Poultry Fish Dairy Products

Supplement Recs: Adults 2.4 mcg/day >50 yrs should take supplement >65 yrs 100-400 mcg/day

Anti-Oxidants (C and E)

Vitamin C RDI 75 mg females

and 90 mg males 400 mg may be

beneficial to older adults

UL is 2,000 mg The role of anti-

oxidants in macular degeneration and dementia is unclear

Vitamin E RDI: 15 mg for adults UL is 1000 mg Supplements can

increase risk of bleeding in patients on anti-coagulant therapy

Sources: oils, nuts, peanuts, avocado

Nutritional Interventions

Increasing Calories

5-6 small meals/between meal snacks Calorically dense foods

Nut butters, dried fruits, fruit purees, starchy vegetables, legumes, cheese, yogurt

Drink calories Milk, juice, smoothies, soups

Increase fats butter, sour cream, cream cheese, oils,

mayonnaise, avocado

Oral Nutrition Supplements

Use 1.5 -2.0 cal/mL Ensure Plus, Ensure Clinical Strength, TwoCal,

Boost Plus, etc Serve 3-4 oz portions several times Use as a “med pass” Dilute with whole milk or serve frozen to

reduce sweetness Encourage 1 sip every 5 minutes to reduce

early satiety

Texture

Meats: chopped, ground, pureed Use puree molds or small colorful

dishes Piping soft foods, garnish with

sauce Cut hard fruits, vegetables into

bite sized pieces Finger foods work well with

dementia or severe arthritis

The Dining Experience

Buffet service, family style serviceEncourage selectionAvoid social isolationMusicAromaAppearance and presentation

Home Meals

Financial limits Eggs, peanut butter, canned beans, tuna,

turkey, frozen veggies, rice Limited cooking ability

Weight Watchers, Healthy Choice, Kashi Meals Precut fruits and veggies Prepared soups, crackers, whole grain bread,

bagels, quick oatmeal, cheese, yogurt, cottage cheese, frozen veggies, bananas, grapes, hummus

Appetite Stimulants

Limited evidence of effectiveness in the elderly

Megace Remeron Eldertonic Marinol Periactin Oxandrin

Eating Lifestyles

The Mediterranean DietThe DASH DietThe New American PlateMyPlate for Older Adults

2009 Version

Fruits, Vegetables, grains, olive oil, beans, nuts and seeds are grouped together at the base

Herbs and Spices are added at base

Fish is promoted over poultry and dairy

Benefits

9% decrease in overall mortality9% decrease in death from

cardiovascular disease6% decrease in death from cancer13% decrease in incidence of

Parkinson’s and Alzheimer’s Disease

Safi, F. et al, Adherence to Mediteranean Diet and Health Status: Meta-analysis. British Journal of Medicine, 2008: 337:a1344.

Key Mediterranean Principles

Generous amounts of fruits and vegetables

Healthy fats: olive oilSmall portions of nutsRed wine in moderation, for someVery little red meatFish on a regular basis

DASH Diet PyramidDietary Approaches to Stop Hypertension

DASH Benefits

Reduces blood pressure, especially in older adults.

Also protective againstOsteoporosisCancerHeart DiseaseHeart FailureStrokeDiabetes

Key DASH Principles

Limits sodium to <2300 or <1500 mg/day Generous amounts of fruits & vegetables Whole Grains Emphasizes low fat dairy Monounsaturated Fats

<27% of calories from fat Legumes, nuts or seeds daily Lean protein: fish, poultry, soy products High in calcium, potassium and magnesium

New American Plate Proportions:

2/3 plate should be plant based Whole grain Vegetables Fruit Legumes

1/3 from protein Fish Lean Beef Poultry Dairy

1/3

2007 Expert Report on Cancer Prevention

Joint effort of AICR and World Cancer Research Fund

7000 global scientific studies reviewed

10 lifestyle recommendations for cancer prevention

Diet Recommendations

Limit sugary drinks and energy dense foods Eat more of a variety of fruits, vegetables,

grains, legumes Limit red meat and processed meats Limit salt and foods processed with sodium

MyPlate for Older Adults

MyPlate for Older Adults

Bright-colored vegetables such as carrots and broccoli.  Deep-colored fruit such as berries and peaches. Whole, enriched and fortified grains and cereals such as brown rice

and 100% whole wheat bread. Low- and non-fat dairy products such as yogurt and low-lactose

milk. Dry beans and nuts, fish, poultry, lean meat and eggs. Liquid vegetable oils, soft spreads low in saturated and trans fat,

and spices to replace salt. Fluids such as water and fat-free milk. Physical activity such as walking, resistance training and light

cleaning.

http://now.tufts.edu/news-releases/tufts-university-nutrition-scientists-unveil-

Resources

Food & Nutrition Information Centerhttp://

fnic.nal.usda.gov/lifecycle-nutrition/agingTufts Human Nutrition Research

Center on Aginghttp://hnrca.tufts.edu/

Resources

DASH Eating Plan Booklet, free on the web: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

Mayo Clinic http://www.mayoclinic.com Use their search engine and type in “DASH Diet” or

“Mediterranean Diet” to view numerous consumer friendly articles.

Oldways: Mediterranean diet info http://www.oldwayspt.org/med_pyramid.html

Resources

AICR: The New American PlatePrintable brochures, Cookbook, recipes

http://www.aicr.org/site/PageServer?pagename=reduce_diet_new_american_plate

Linus Pauling Institute micronutrient information centerhttp://lpi.oregonstate.edu/infocenter/

Questions???