Nutritional Care of Older Adults

1. Nutritional Care of Older Adults Laurie B. Steenwyk M.Ed, RD, LDN

2. Class Overview • Assessing Nutritional Status • Nutritional Needs ofthe Elderly • Nutrition Interventions • Eating Lifestyles • Meal planning for optimal health

3. Assessing Nutritional Status

4. Factors Impacting Nutritional Status in the Elderly

5. 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

6. 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/

7. Sarcopenia • Sarcopenia • Loss of skeletal muscle associated with aging • Affects 8-40% of adults >60 yrs • 50% of adults >75 yrs • Sarcopenic Obesity • Coexisting loss of skeletal muscle mass and strength with excess body fat

8. Nutritional Needs ofthe Elderly

9. 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

10. Nutrients of Concern • Risk for deficiency with age • Water • Fiber • Protein • Calcium and Vitamin D • Vitamin B12 • Vitamin C and E – antioxidants

11. Water • Dehydration is a form of malnutrition • Kidneys’ decreased ability to concentrate urine • Adverse effects of medication • Mobility disorders • Fear of incontinence • 25-30 mL/kg actual body wt

12. 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

13. Oats Barley Wheat Quinoa Flax Brown Rice Bran Legumes Seeds Fruits Vegetables Sources of Fiber

14. Protein • Muscle mass (LBM) decreases 15% per decade after age 70 • Needs increase with illness, injury • Surgery, wounds, CHF, COPD, Cancer • Optimal intake: 25-30 gm/meal • Even distribution most effective in preventing muscle loss during illness • 1-1.6 gm/kg IBW may prevent sarcopenia

15. 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…

16. 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

17. Calcium • 1000 mg Men <70 years • 1200 mg Men >70 • 1200 mg Women >50 • Safe upper limit 2000 mg/day • A large recent study suggests that calcium supplements don’t prevent hip fractures

18. 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

19. 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

20. Other Nutrients in Bone Health • Vitamin K • Leafy greens, broccoli, soybean oil • Manganese • Spinach, peanuts, almonds, brown rice, green tea • Excesses of sodium, protein and phosphorus decrease calcium availability.

21. Vitamin B-12 • 6-15% of older adults are deficient • Another 20% have marginal status • Compromised absorption • Pernicious anemia • Lack of intrinsic factor • Atrophic gastritis • Long-term use of PPIs

22. 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 Vitamin B-12 Deficiency

23. Anti-Oxidants (C and E) Vitamin C 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 • 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

24. Nutritional Interventions

25. 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

26. 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

27. 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

28. The Dining Experience • Buffet service, family style service • Encourage selection • Avoid social isolation • Music • Aroma • Appearance and presentation

29. 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

30. Appetite Stimulants • Limited evidence of effectiveness in the elderly • Megace • Remeron • Eldertonic • Marinol • Periactin • Oxandrin

31. Eating Lifestyles The Mediterranean Diet The DASH Diet The New American Plate MyPlate for Older Adults

32. 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

33. Benefits • 9% decrease in overall mortality • 9% decrease in death from cardiovascular disease • 6% decrease in death from cancer • 13% 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.

34. Key Mediterranean Principles • Generous amounts of fruits and vegetables • Healthy fats: olive oil • Small portions of nuts • Red wine in moderation, for some • Very little red meat • Fish on a regular basis

35. DASH Diet PyramidDietary Approaches to Stop Hypertension

36. DASH Benefits • Reduces blood pressure, especially in older adults. • Also protective against • Osteoporosis • Cancer • Heart Disease • Heart Failure • Stroke • Diabetes

37. 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

38. 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

39. 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

40. 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

41. MyPlate for Older Adults

42. 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-

43. Resources • Food & Nutrition Information Center • http://fnic.nal.usda.gov/lifecycle-nutrition/aging • Tufts Human Nutrition Research Center on Aging • http://hnrca.tufts.edu/

44. 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

45. Resources • AICR: The New American Plate • Printable brochures, Cookbook, recipes http://www.aicr.org/site/PageServer?pagename=reduce_diet_new_american_plate • Linus Pauling Institute • micronutrient information center • http://lpi.oregonstate.edu/infocenter/

46. Questions???