Nutrition for Older Adults

Nutrition for Older Adults

The population of adults age 65 years and older is increasing at a faster rate than the under 65 years population of adults (U.S. Department of Health and Human Services [USDHHS], Administration on Aging [AOA], 2014). Not only is the older population increasing, it is also getting increasingly older. In 2013, an estimated 44.7 million people, or 14.1% of the population, were age 65 years and over; more than 67,000 of this group were over the age of 100 years (USDHHS, AOA, 2014). Despite the misconceptions and stereotypes people have of older adults, they are a heterogeneous group that varies in age, marital status, social background, financial status, health status, and living arrangements.

With the exception of Chapter 11 (pregnancy and lactation) and Chapter 12, (infants, children, and adolescents), this book implicitly addresses nutrition as it pertains to adults. Yet, adulthood represents a wide age range, from young adults at 18 years to the “oldest old.” Adults over 50 years, and especially those over 70 years, have different nutritional needs and concerns than do younger adults. This chapter focuses on how aging affects nutrition for older adults.


Aging is a gradual, inevitable, complex process of progressive physiologic, cellular, cultural, and psychosocial changes that begin at conception and end at death. As cells age, they undergo degenerative changes in structure and function that eventually lead to impairment of organs, tissues, and body functioning. Changes that may occur with aging are listed in Box 13.1; selected changes are presented in the following sections.

Changes in Body Composition

In general, aging causes a loss of bone and muscle and an increase in body fat due in part to hormonal changes that regulate metabolism. For instance, a decrease in growth hormone and
androgens contributes to the loss of lean body mass and insulin resistance reduces the ability to use protein. Prolactin, a hormone that helps maintain body fat, increases with age. These changes in body composition are one of the reasons why calorie needs decrease with aging.

Progressive loss of muscle mass is a common feature of aging (Paddon-Jones et al., 2015). Physiologic and behavioral changes account for the 1% to 2% annual loss of muscle mass that begins around the age of 50 years. Because the reserve of muscle mass is large, function is not impaired. In the early 60s, a person’s loss of muscle becomes evident as muscle strength declines an average of 3% per year. An estimated 20% to 40% of muscle strength may be lost by the time a person reaches the 70s. Acute or chronic illness and inactivity—alone or in combination with malnutrition or inadequate protein intake—hastens the loss of lean body mass and functionality (English & Paddon-Jones, 2010).

Sarcopenia occurs when age-related loss of skeletal muscle mass is accompanied by loss of muscle strength and function; it is a main determinant of disability and mortality (Manini & Clark, 2012). Advanced sarcopenia is characterized by physical frailty, increased likelihood of falls, impaired ability to perform activities of daily living, and diminished quality of life (Paddon-Jones, Short, Campbell, Volpi, & Wolfe, 2008). Sarcopenia is estimated to affect 8% to 40% of adults over the age of 60 years and approximately 50% of those over the age of 75 years (Berger & Doherty, 2010). Sarcopenia should be considered in all older adults with observed declines in physical function, strength, or overall health and especially in older adults who are bedridden, who cannot rise independently from a chair, or who have a slow gait (Evans, 2010).

Sarcopenia the loss of skeletal muscle mass, strength, and function that occurs with aging.

Decreased Appetite

Older adults exhibit less hunger and earlier satiety than younger adults (Bernstein & Munoz, 2012). Among the possible causes of diminished appetite are a decrease in physical activity, decrease in metabolic rate, a decrease in gastrointestinal (GI) hormone secretions, delayed gastric emptying, social isolation, cognitive impairments, medication side effects, and impaired chewing or swallowing. Diminished appetite contributes to undernutrition in both community and institutional settings and can lead to unintentional weight loss, which is often associated with poor health outcomes and is a marker for deteriorating well-being in older adults (Bernstein & Munoz, 2012).

Functional Limitations

A decrease in muscle mass and strength can lead to a progressive decline in physical function. Among community-resident Medicare beneficiaries 65 years and older in 2013, 33% had difficulty performing one or more activities of daily living (ADLs) and an additional 12% reported difficulty with one or more instrumental activities of daily living (IADLs) (USDHHS, AOA, 2014). Functional limitations may impair the ability to eat or prepare or shop for food. Chronic diseases that increase the risk of functional limitations include cerebrovascular accident, diabetes, ischemic heart disease, and arthritis (Bernstein & Munoz, 2012).

Activities of Daily Living (ADLs) bathing, dressing, eating, and getting around the house, and using the toilet.

Instrumental Activities of Daily Living (IADLs) using the telephone, doing housework, preparing meals, shopping, managing money, and taking medication.

Immune System Changes

With aging, levels of inflammatory mediators typically increase, even in the absence of acute infection or other physiologic stress (Szarc vel Szic, Declerck, Vidaković, & Vanden Berghe, 2015). “Inflammaging” is the term used to describe the phenomenon of chronic, systemic low-grade inflammation that is characteristic of aging (Franceschi & Campisi, 2014). Many age-related chronic diseases are low-lying inflammatory states, such as cardiovascular disease, chronic obstructive pulmonary disease, congestive heart failure, diabetes, metabolic syndrome, and obesity (Malone & Hamilton, 2013). Inflammaging is a significant risk factor for morbidity and mortality in older people (Franceschi, 2007). Among the potential strategies that may prevent or cure inflammaging and its pathologies are a healthy lifestyle, namely, age-appropriate exercise and a healthy eating pattern that includes pro- and prebiotics (Franceschi & Campisi, 2014).

Psychosocial Changes

Loss of a spouse, difficulty ambulating, and sensory impairments such as loss of vision or hearing are factors that contribute to social isolation. Eating alone is a risk factor for poor nutritional status among older adults, especially among men. Food choices are not necessarily poor; rather, it is the quantity of food consumed that is often inadequate.

Depression is not a normal consequence of aging but occurs in many older adults. As many as 5% of community-dwelling older adults meet the diagnostic criteria for major depression and up to 15% have clinically significant symptoms of depression that interfere with functioning (Hybels & Blazer, 2003). The prevalence of depression is even higher among older adults with medical illnesses. Weight loss or gain is among the many symptoms of depression.


A study of community-dwelling older adults found that 51% reported using five or more medications daily (Heuberger & Caudell, 2011). Medications can cause side effects that interfere with intake, such as changes in taste and smell, dry mouth, early satiety, anorexia, and GI upset. Polypharmacy in older adults is associated with a decrease in walking speed, disability, mortality, cognitive decline, and delirium (Husson et al., 2014). Nutritionally, an inverse relationship has been observed between the number of medications used and the intakes of fiber, fat-soluble vitamins, B vitamins, and minerals; a positive relationship was noted for the intake of cholesterol, carbohydrate, and sodium (Heuberger & Caudell, 2011).


Genetic and environmental “life advantages”—such as genetic potential for longevity, intelligence, motivation, curiosity, good socialization, religious affiliation, marriage and family, avoidance of substance abuse, availability of health care, adequate sleep, and sufficient rest and relaxation—have positive effects on both length and quality of life. Although there is no universally agreed upon definition of healthy or successful aging, a major study used the following as its criteria: no major chronic diseases, no cognitive impairment, no physical disabilities, and no mental health limitations (Sun et al., 2009). Healthy lifestyle behaviors—being physically active, eating healthy, maintaining healthy weight, and not smoking—may help prevent or delay physical and mental deteriorations associated with aging (Bernstein & Munoz, 2012).

Physical Activity

Older adults are urged to follow the adult guidelines for physical activity or as their abilities allow (Box 13.2). Strong evidence shows that for adults and older adults, physical activity lowers the risk of heart disease, stroke, type 2 diabetes, hypertension, dyslipidemia, metabolic syndrome,
and weight gain in addition to improving cardiovascular and muscular fitness, preventing falls, reducing depression, and improving cognitive function (USDHHS, 2008).

Healthy Eating

Healthy eating can enhance wellness, improve nutritional status, reduce the risk of chronic disease, help manage chronic disease, and help maintain energy levels. Although a lifetime of healthy eating is optimal, adopting a healthy eating pattern even in later life has health benefits. A study among women who began a Mediterranean-style eating pattern in their 50s and 60s found they had a 40% greater chance of living beyond 70 years with greater health and well-being (Samieri et al., 2013).

Dietary Guidelines for Americans

The Dietary Guidelines for Americans are intended to help all people age 2 years and older, including older adults, choose healthier eating plans to support a healthy body weight and help prevent and reduce the risk of chronic disease throughout the life span (USDHHS & U.S. Department of Agriculture [USDA], 2015a) (see Chapter 8). The key recommendations are to

  • Consume a calorie-appropriate healthy eating pattern

  • Eat more vegetables, fruits, whole grains, lean protein foods, and low-fat or fat-free dairy

  • Choose foods low in added sugars and saturated fats

  • Limit sodium to 2300 mg

  • Drink alcohol only in moderation

Older adults, like the general population, consume too much added sugar, saturated fat, and sodium. Also consistent with the U.S. population as a whole, adults aged 50 years and older underconsume vegetables, fruits, whole grains, seafood, dairy, and oils (USDHHS & USDA, 2015b). Low intakes of these groups are to blame for the overall low intakes of potassium, fiber,
calcium, and vitamin D—the nutrients of public health concern. Women age 50 years and older and men age 71 years and older may also underconsume the protein group.


MyPlate for Older Adults, produced by Tufts University, is designed to help healthy, older adults who are living independently choose an eating pattern that reflects the 2015-2020 Dietary Guidelines for Americans (Fig. 13.1). The graphic features a variety of colorful fruits and vegetables,
whole and fortified grains, low-fat and nonfat dairy milk and dairy products, lean proteins, and oils. Noteworthy features are as follows:

Figure 13.1MyPlate for Older Adults. (Source: Copyright © 2016 Tufts University. For details about the MyPlate for Older Adults, please see

  • Nutrient-dense food choices are used to illustrate each food group. As calorie needs decrease, there is less room for empty-calorie foods that are high in solid fats or added sugar.

  • The examples of foods featured on the plate are convenient, affordable, and readily available. For instance, frozen broccoli and canned legumes are shown because they are easy to prepare and have a long shelf life.

  • Low-sodium canned vegetables appear as an option to help lower sodium intake.

  • A variety of beverages are featured next to the plate to highlight the importance of adequate fluid intake.

  • The use of herbs and spices is recommended to enhance flavors and reduce the use of salt.

  • Older adults engaged in common activities appear in an icon on the bottom of the placemat as a reminder that there are a variety of options for engaging in physical activity.

Frequently, food choices of older adults are based on considerations other than food preferences, such as income; the individual’s physical ability to shop, prepare, chew, and swallow food; and the occurrence of food intolerances related to chronic disease or side effects of medication. Box 13.3 features tips for eating well for the older adult.


Although the healthy eating patterns recommended by the Dietary Guidelines and illustrated in MyPlate are appropriate for older Americans, actual nutrient needs among older adults may differ from those of younger people due to changes in metabolic processes, physical functioning, body composition, and nutrient absorption and other factors such as frailty, comorbidities, and polypharmacy (Bolzetta et al., 2015). Health status, physiologic functioning, physical activity, and nutritional status vary more among older adults (especially people older than 70 years) than among individuals in any other age group, so nutrient recommendations may not be appropriate for all older adults at all times.


Calorie recommendations decrease with aging related to the typical decrease in physical activity and the changes in body composition that lower metabolic rate (Fig. 13.2). As with other age groups, individual variations in activity exist. Compared to younger adults, older adults need fewer calories yet generally have the same or higher requirements for vitamins and minerals, making the concept of nutrient density even more important.


The Recommended Dietary Allowance (RDA) for protein remains constant at 0.8 g/kg for both sedentary and physically active men and women from the age of 19 years on (Institute of Medicine, 2005a). This level represents the minimum protein intake necessary to avoid progressive loss of lean body mass as determined by nitrogen balance studies (Wolfe, Miller, & Miller, 2008). However, the data were gathered almost entirely in college-aged men who can maintain nitrogen balance on less protein than can older adults (Wolfe et al., 2008). This one-size-fits-all protein recommendation does not consider age-related changes in metabolism, immunity, hormone levels, or progressing frailty (Bauer et al., 2013).

Lean Body Mass all body components except stored fat; the fat-free mass of the body.

A protein intake greater than the RDA has been shown to improve muscle mass, strength, and function in older adults and may also improve immune status, wound healing, blood pressure, and bone health (Wolfe et al., 2008). One reason why older adults need more protein than younger adults is that they have a declining anabolic response to protein intake; that is, their threshold for the amount of protein needed to stimulate protein synthesis is higher. Protein need may be higher in response to the inflammatory and catabolic impact of chronic and acute diseases that commonly occur with aging (Walrand, Guillet, Salles, Cano, & Boirie, 2011). Paradoxically, although older adults

need more protein, their intake is less than that of younger adults. Approximately one-third of adults over the age of 50 years do not even meet the RDA for protein (Houston et al., 2008). Factors that may contribute to a decrease in protein intake include the cost of high-protein foods, the decreased ability to chew meats, lower overall calorie intake, and changes in digestion and gastric emptying.

Figure 13.2Estimated calorie needs per day for males and females ages 51 to 76 years and older.

The PROT-AGE Study Group, composed of an international panel of experts, met for the first time in 2012 for the purpose of developing updated evidence-based recommendations for optimal protein intake for older adults (Bauer et al., 2013). A summary of PROT-AGE recommendations is listed in Box 13.4. In addition to consuming more total protein, it is recommended that protein be evenly distributed throughout the day (e.g., 25-30 g protein per meal, the equivalent of 3-4 oz protein foods) to maximally stimulate muscle protein synthesis and thus slow or prevent the progression of sarcopenia in older adults (Paddon-Jones et al., 2015). Animal protein, but not vegetable protein, may be associated with less lean mass loss. Higher amounts of leucine, an essential amino acid that stimulates the majority of protein synthesis, are recommended (Bauer et al., 2013). Researchers are also considering whether increasing protein intake earlier in life, such as during middle-age, will promote long-term muscle health. More research is needed to determine protein and leucine thresholds, what causes anabolic resistance to low protein intakes in older adults, and who best benefits from protein interventions to prevent or manage sarcopenia (Rodriguez, 2015).

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Nov 8, 2018 | Posted by in NURSING | Comments Off on Nutrition for Older Adults

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