EEALTB PROMOTION AND AGING
      NUTRITION

Nancy Chapman. R.D., M.P.H.
N. Chapman Associates, Inc.

   Ann Sorenson, H.S., Ph.D.
Health Scienriat Administrator, NIA

"The trick fs to live to be 100.  very few people die after that."

                                          George Burns

Aging is inevitable.  Health promotion.  including good nutrition.  can slov the rate of degeneration
and foiter the independence and well-being of older individuals.   For years,  health promotion
activities targeted only younger adults.  Health profes,ionaLs and adults over 65 simply accepted
the high rate of chronic disease and the concomitant physical and mental impairments.
Elealth-promoting dietary recommendations were generally vieved as useless.   Hovever, a
preponderance of evidence now suggests many potential benefits of good nutrition for older persons:

1)  Life expectancy after age 65 has increased in part because of an abundant food supply, which
   has eliminated most nutritional deficiencLes (1).
2)  Reducing body weight and excess intakes of sodium, sugars, fats, and cholesterol can lover the
  risk of developing hypertension, diabetes, and heart disease for many individuals and improve
  the management of these diseases for older as well as younger individuals (2).
3)  Nutritious diets that protect physical and mental health help older people to work longer and
   lead independent lives (1).
4)  Maintaining P reasonable weight, exercising regularly, and selecting a proper diet may retard
  the aging process and delay certain debilitating conditions common in old age (i.e..
  osterporosis, hypertension, dementia, and diabetes) (3).
5)  Preventing malnutrition can reduce the need for recurrent hospitalizations and prevent the
  occurrence of complicating conditions, thereby,  Lowering medical costs (3).
6)   Selecting the best, most economical foods to meet nutrlttonal needs and using appropriate
  nutrition programs can maxLmize Limited financial resources and permit Lndependent Living for
   the older population.
7)  Correcting poor dfets for healthy older persons eliminates the need for and avoids the hazards
  of high doses of expensive dietary supplements (4).

To de,Lgn appropriate nutrition strategies for those over 65, decision-makers need to 1) consider
the heterogeneous CharacteristLcs of the elderly population,  2) differentiate age-related changes
from effects of degenerative diseases, and  3) recognize the Limitations of the current research
base.  This paper discusses these factors as veil as other related areas -- problems in determining
nutritional status and nutrient requirements of older persons, emerging research  issues,  and the
effectiveness of current nutrition interventions.  Several links between nutrition and other health
promotion areas are identified.  The issues identified in this paper, though not exhaustive,
provide a starting point for developLng the strategies that wLLL  address nutrition concerns in the
rapidly groving, aging population in the U.S.

CHARACTERISTICS OF OLDER PERSONS

            ,
Older persons, generally defined as individuals over the age of 65,  represent a very diverse group
The sex and racial composition of specific cohorts change as the subgroup ages beyond 80 years.
The physical and mental capabilities of elders vithin and among older subgroups also vary widely:
thus the potential benefits of nutrition therapies are not uniform.  Attempting to foster
independence and veil-being in this heterogeneous popuLatLon vi11 require that policy makers and
health care professionals examine the distinct characteristics of two to three age strata over 65
before deveLopLng broad interventions or formulating policies.

The varlacions in physiological, physical, and mental functions are grearer among older persons
than among any yaunger cohort.  This heterogeneity reflects, in part, the diversity Ln lifestyles,
economic and social conditions, food supply, culture, education, and exposure to other
environmental factors experienced daring their graving and maturing years.  Genetics,  of course,
also plays a major role in the rate of functional loss in various organs and one's susceptibility
to chronic diseases (such as cancer, coronary heart disease, diabetes, and osteoporosis).   A Later
section describes more fully the differences in  age-related functional changes and occurrence of
chronic diseases.

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PsvchosocLal and economic determinants

Many psycho*ocLol factors affect the food habits and nutritional *r.atus of the old.  Depression,
loss of *elf-esteem, loss of *pou*e,  inability to live Lndependently, and loss of a sense of
purpose =nd motLvotLon adversely affect nutrLtiona1 status by decreasing appetite and Lnterest in
eating and food preparation (5).   Place of residence and economic *tatus can determine access to
food s~.,,,~cQs and health care services.

In 1985,  the majorlcy of those over 65 were vhite,  non-institutionalized women, either living in a
family setting (67%) or living alone (30~).  Few (5X) lived in nursing homes, and mo*t of these
vere over 85.  After age 80 to 85,  males and blacks are more likely to survive.   Although many
older persons maintain households,  many need help with personal care and food purchasing and
preparation.  Older persons tend to reside more frequently in central cities, small town*. and
rural areas where acce** to social and health services,  nutrition program*,  and food stoxes may be
limited.  Because older re*Ldents Ln urban and rural areas are often less educated and poores than
suburban residents,  their risk of nutritional problems increase* (6).  The dLetary parcerns of
these rural residents Lnclude large amounts of salty snacks,  heavy sweets-sugar desserts, and high
fat meat (7).

Older persons are more likely than younger adults to be poor or live an fixed Lncomes.   Federal
programs (Medicare, Medicaid.  Social Security) have slowed the onset of poverty for some, but more
than two out of every fLve of those over 65 are poor or economically vulnerable (8).   Those over
85,  nonvhltes, women,  and persons LLving alone experience the hLghest rate* of poverty (8, 9, 10).
As Lnflatlon increases,  those 1lvLng on fixed or low incomes fLnd that a larger portion of theLr
income is *pent for food.  The recent low Lnflation rate has partly eased this burden.
PartLcLpatlon in the food stamp program,  the nutrition program for seniors, and the commodity
supplemental food program has aiso Lmproved older persons access to food: but these safety-net
programs provide protection for only a small proportion of poor older persons (8).

The cultural and socfal influences on food habits are also important to consider In planning
nucr1tion strategies (10, 11, 12, 13).  DavLs and Randall (14) described trends In famLly
structures and gender roles,  in social LntegratLon,  in employment opportunities, in education and
in economic stability that affected the food habits and food choices of three subgroups of the
population vho would be over 65 by the year 2000.  For example,  individuals born betveen 1910-1930
experienced food shortages:  often Lived close to their food supply: and were less educated.   They
may require dLfferent food offerings and educationaL cools than persons born betveen 1940-1950.
NutrLtLonaL problems of the older cohort vha ate more complex carbohydrate* and Less fat may differ
from the younger cohort who were exposed to more processed foods with more fats and simple sugars.
A Lover fertLLlty.rate among those barn Fn 1910-30 could Limft family support a* they age compared
to those born ten to twenty years later.

NutrLtLonal status

The nutritional status of the older persons often reflects lifetime nutrient Lntakes and food
behaviors,  as well as age-related conditions and socioeconomic determinants.   ExperLence vith
chronic degenerative dLseases and conditions, drug regimens,  drug and dLet interactions, and
functLona1 *tiltus also influences   health.  To Lntecpret the nutrition data from surveys, caution
should be taken not to confuse cross-sectional data shoving secular trends Ln dietary patterns with
longLtudLna1 data showing vLthLn person change* over time (15, 16, 17).

The most recent survey data from NHANES II showed alder adults selecting mO*t frequently the
folloviyg foods from each specific group: whole and Lov fat milk and cheese (milk group),
grapefruit* and melon (fruLt group).  potatoes and tomatoes (vegetables), bread, biscuits, and
muffins (breads and cereals group),  and ground beef (meat group) (18).   The 1977-78 National Food
ConsumptLon Survey data showed that one-third of older adults used whole grain bread* and that
older persons were the highest users of eggs, skim milk, vegetable*, fruit*,  soups and lowest u*er*
of soft drLnks (19).

National survey data (20) also shov that estimated food energy Lncakes decline vLth age; the Lowest
mean intakes are for those 75 years and over (about 1850 kcal for males and 1400 kcal for females).
Adults generally gain weight untL1 age 50; then,  relative weights decline.  The variance for energy
intakes of those over 65 years of age Is great,  due to the small numbers in this subset.
Assessments of caloric intake adequacy require data on body size and physical activity.

For some older persons, having been obese and consuming inappropriate Levels of sodium and perhaps,
calcium, protein, and fat earlier Ln life may have raised their chances of developing hypertension,
cardiovascular disease (CVD), diabetes, and cancer.  DLetary cholesterol Lntakes for many over 65
(means are 461 mg for males,  316 mg for females) rematn above recommended levels for lowering the
rL*k of CVD.

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Intakes of most nutrlenrs except vitamin C and vitamin A also appear to decrease vlth age.   Foods
consumed by most older adults provided adequate levels of protein, preformed niacin, viramin C,
folate,  and phosphorus.  Intakes of calcium iron, vitamin A, thiamin, rLboflavin, and potassium for
most adults either approached or failed to meet the RDAs.  In general,  biochemical or clinical
markers of defictency were rarely found (<5x on average) Ln the older persons (21).   Of concern are
older women who have hFgh rates of bone fractures and related lover intakes of calcium and vitamin
D-rich milk products (22, 23).

Usage of dietary supplements. drugs, and alcohol

An approprLate assessment of nutritional status cannot overlook the population's use of dietary
supplements, drugs, and alcohol.   In turn,  additional data on the nutritional status and
requirements may stimulate promotfon of more dietary  supplement use by older persons.   [Ihe
elderly as targets of health fraud are discussed later.]

Usage of supplements by older persons has increased from an estimated 1 percent in 1975 (24) to
estimates of 40 percent narFonvLde in 1980 (25).  Analysis of n-tlonal survey results s"ggests that
chose vho use supplements may not be the individuals most Ln need of them (4, 22, 26, 27).
Approximately half of those who use supplemental vitamins take multivitamins,  Ln particular vitamin
C and E (22, 28, 29).  Dietary supplementation does not appear to routinely improve nutritional
status for older persons.  It may even lead to nutrient imbalances,  toxicities and/or interactions
with drugs.  especially if megadoses (10 times the RDAs) are taken (4, 22, 30).

Although older AmerLcans constitute about 10 percent of the population,  they use about 25 percent
of all prescription drugs.   This 1s not surprising since many chronic diseases are managed vith
prescription drugs.  Over half of older people take at least one medication daily and many take six
or more a day for multiple diseases.   The drug-drug and drug-nutrient interactions may affect body
composition,  nutrient balance, or appetite,  as discussed later (31).

ExcessFire alcohol intakes may also advance nutrient deficiencies (i.e., thiamin, niacin and other
vacer soluble nutrients),  may damage organs and tissues important to nutrient utillzacion, and may
depress appetite and the desire and ability to eat.   The result can be poor nutritional status.
Older persons have a lower tolerance for alcohol which becomes more concentrated as body water
declines with age.  Approximately 30X percent of those 65 and over consume alcohol on a regular
basis (at least one time/week).  About 15% of this cohort are considered 1Lght drinkers, 11%
moderate drinkers, and 6X heavy (32).  If the older persons'  drinking habits are reflective of the
adult population,  then the 5 percent of the population vhLch drinks most heavily, accounts for
about 50 percent of the total alcohol consumption.   Since alcohol is a risk factor for diabetes,
hypertension, cancer, and liver disease,  moderation of intake is advisable at axy age.

EFFECTS OF AGING AND CHRONIC DEGENERATIVE DISEASES

Normal aging changes body composition, physical performance,  organ system function and condition in
all individuals if they live long enough: hovever, changes   occur at different rates in differenr
people.   Even wLthin the same Individual,  degeneration of various tissues and organs occurs at
different rates   (33).  There are some 60- or 70-year-olds with organ function tests equivalent to
SOmeone 30 or 40 years younger.   Conversely,  there are some younger individuals vith physiological
capacities in the range of an average elder (34).

Age-related chanxes

Physiological changes in many organ systems naturally accompany the aging process. Examples of
various age-related conditions that can affect the nurritlonal status of older persons include
sensory impairments, altered endocrine, gastrointestinal,  and cardiovascular functions, and changes
in the renal and musculo-skeletal systems (35).

During the aging process,  changes in dentation and in the oral cavity (recession of gums and
decreased salivary flov) can occur.  These conditions are exacerbated by some medications.   Dental
caries,  periodontal disease,  and trauma have Led to the Loss of natural teeth in approximately 29X
of those over 65 and 50% of individuals over 80.  Being toothless or having ill-fitting dentures
can reduce chevfng abilFty and raise the risk of choking.   Well-fitting dentures are essential for
chewing high fiber,  nutritionally-rich foods,  such as raw fruits and vegetables, vhole grain
products, and nuts.  The use of fluoridated water, fluoride treatments, regular dental care, and
improved diet may decrease dental problems for the next generation of older persons.   Less is knovn
about prevention of periodontal disease,  especially the potential role of nutrients (e.g., sucrose,
fluoride,  and calcium). [These Lssues ~111 be consLdered in background papers prepared for other
vorking groups.J

Decreased organ or tissue function can be accelerated by anorexia or nutrient imbalances or
deficiencies related to chronic illness,  use of therapeutic regimens,  or lack of proper medical
care.  Many age-related conditions affect the older person's ability to ingest, absorb and utilize

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esssntill nufrlcnts.  1s well PJ obtaL" and prepare fhod.  AddLcional age-related changes are
di,cus,sd under emcr8i"g research issues.

Chronic discnse-related channes

The prevalence of hypertension, diabetes, CVD, cancer, osteoporosis,  and arthritis increases with

age.  Four out of five older persons have at leasr one chronic condition and many have multiple
problems.  Obesity, affeCti" approximately 28% of older persons,  is also related to many chronic
diseases.  Hnny of these conditions require special diets, drugs.  or other therapeutic regimens
that could further compromlsc nutritio"ol status.

nortnlity and morbidity rates for diseases differ by gender and race.  This may reflect genetic
differences,  lifestyle habits,  or differences in access to health care.  Therefore, when planning
nutrition strategies, special diet-related problems should be considered by race and sex.  Briefly,
1982-84 data (36, 37) show that reported rates of CVD, stroke, and cancer are higher for maLes than
females, with the highest incidence =mo"g black males.  Hypertension and arthritis rates are
highest stmong females, especially blacks.  The prevalence of diabetes is comparable for vhite males
and females, but about 50X higher for black females than for white females (36, 38).  This may be
due to the high prevalence of obesity among older black females (37).

osteoporosis. generally affects more "omen than me", measured by the higher proportion (four to
one) of bone fractures in "omen than me", and more vhites than blacks (36) and Mexican AmerLca"s
(39) .  Eigher bone density initially explains part of these differences; but the potential for
obesity may explain the racial difference and should also be explored.  Associated immobility
ha"dicaps a" older P~*SOII'S ability to purchase and prepare food and thus Limits food selections
and independent 1iVi"g.   Similarly, resorption of the residual alveolar ridge (bony ridge in which
teeth are positioned) reduces the retention of dentures (40,  41) and may limit food selections.

MAJOR POLICY ISSUES

The previous descriptions of the socioeconomic factors, nutritionaL status, usage of drugs, alcohol
and dietary supplements, and specific health problems, serve as background to the major policy
issues.  This section highlights the following areas to explore in developing nutrition policies
for the agfng:

1)  Nutrition surveillance and monitoring
2)  Emerging research issues
3)  Nutrlrlon services for older persons
4)  Technology advances
5)  Food assistance and nutrition programs
6)  Nutrition education and information

This Listing does not order the importance of these issues,
information gathering to dissemination.             but rather the logical progression from
                            For the public, the value of research is best realized
when people learn the co"se"sus on the findings through the mass media or nutrition education
programs.

Nutrition surveLllance

Several national and state surveys have been conducted on, or include, the older population.   These
surveys are designed to determine the amounts and types of foods consumed,  the nutrient co"te"t of
intakes, the existence of cLinLca1 signs of nutritional problems,
biochemic?..l evidence of sub- clinical nutritional deficiencies.   and the hercatologlcal or
                                                   A limited number of
cross-sectional population studies supplement these national data: hovever,  there is almost as much
variability between individuals within a" age group as betveen group averages of age decade groups
(42).  The NIA Baltimore Longitudinal Study of Aging provides the only data to assess individual
variations Ln intake, biochemical, anthropometric, and functional parameters.

Many surveys lack documentation of dietary supplement usage.  There has also been minimal nutrition
surveillance and monitoring among institutionalized elders (those in ambulatory care centers and
Long-term care facilities), homebound, or homeless older persons.  Likewise,  little Is known about
older persons in defined ethnic groups such as Asian Americans,
recently,                                     native Americans, and, untL1
       Hispanics.
of age,        Nutritional data on subgroups of older persons,
    in vhom malnutrition may be more comma", are also missing.   such as those over 80 years
                                                It is often diffLcuLt to

compare nutritional surveys which include or focus on older persons because of differences in
dietary methodology and standards (43).

To date, the nutrition surveys of older persons in the U.S. have been very Limited in scope,  have
frequently excluded the oldest old age groups. and have used varying standards of comparison in
presenting the frequencies of nutrient deficiencies (33).  In the NHANES I and NHANES II, adults
ages 65-74 years comprised approximately 6-8X of the sample.  The USDA Nationvide Food Consumption
Surveys (NFCS) also collects data on the food intakes of individuals ages 65-74, representing

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approximately 10% of the 1977-78 NFCS. ~~ Lnformarton on individuals older than 75 was gathered
from eLther survey.

.  Comparisons of independently-living ond institutionalized older persons
The nutritional status of long-term instltutionalired =nd Independently living older persoys needs
to be compared.  Older persons in institutions are usually subject to fixed meals vhich may not
accommodate their individual food preferences, though they often adhere to specified dLetary
regimens.   Often, individuals in these ,etting, lose interest in foods and eat sparingly. A
national survey of geriatric patientr in institutions in the U.S. and of homebound individuals
would be instructive.  Halor areas to research Lnclude (44):

1.
2.


3.

4.


5.

Food-energy and nutrient needs of sedentary and bedridden patients:
The means to best carry out nutritional screening and a~~ts+menf of geriatric patients in
these facilities:
The interpretation of clinical, anthropometric, hematologfcal, and biochemical indices of
nutritional stat"3 in chronically sick older patients,  with or without age-related conditions
(i.e.,  skin disease, renal dysfunction, anemia, and muscle wasting):
The responsiveness of patients shoving one or more indices of malnutrition to nutrient
.upplementatlon: and
Acceptable values for nutrit~0~~1 status indicators in nursing home patients.

.  Methods of nutritional assessment

Dietary Fntakes documented Later in Life may not correlate vith anthropometric. biochemical
measurements.  or clinical evaluations taken at the same time.   Often these measurements more
closely describe a myriad of historical experiences and long-term food intakes.  Longitudinal
studies provide information that begins to explain possible relationships of intakes to other
measurements.   To standardize  the result.3 of geriatric nutrLtiona1 studies, a core set of
assessment tools needs to be identified and then used routinely (as a minimum) for all studies or
surveys.

Nutrient and energy intakes are determined using 24-hour recalls, food records, food frequencies
and dietary hlatorles.  Interpretation of the histories requires standards.  Appropriate standards
for various age-subgroups of older persons do not exist.  ComparLsons are made to nutritional data
from NEIANES I and II and the 1977-78 NECS despite limitations identified earlier. Reliability of
Lnformation in these dietary histories has also been questioned.  Memory, vision,  and hearing may
decline vith age. making it more difficult to recall accurately foods previously eaten.  Likevise,
arthrlcfs may impede record keeping.

AnthropometrLc measurements (e.g., height, weight,  and skinfolds) are affected by aging.   for
example, height decreases over time due to changes in the integrity of the skeletal system.
Measurements are often hard to obtain because of poor posture,  or the LnabLlLty of the older
persons to stand erect unassisted. For these LndivLduals, recumbent length, total arm length, knee
height and arm span have been proposed as alternative methods to estimate stature (45, 46).   More
research on the reliability of these measurements Is needed before they can be recommended as
routine clinical practice.

Actual weight is less difficult to measure than height.  For ambulatory people, a calibrated
balance beam scale is used.  For the non-ambulatory,  wheel chair or bed balance beam scales are
available.  Beforjz weighing, the patient's hydration state should be noted, as severe edema or
dehydration can distort actual velght and anthropometric measurements (47).   Skinfold measurements
are also affected by the age-related decrease in lean body mass that results in a larger proportion
of body weight aa fat.  Fat stores are also redistributed truncally.  Changes in skin
compressibility and elasticity hinder interpretation of sklnfold measurements (33).
Biochemical parameters may be affected by an age-related decline in renal function, by shifts in
fluid balance, by drug-drug or drug-nutrient interactions, by the long-term effects of chronic or
coexisting disease,  and by malnutrition.  For example,  low serum albumin levels often indicate poor
nutritional status: however, kidney and Liver disease, cancer,  congestive heart failure, and other
diseases (common among older persons) cause marked reductions in serum albumin (37).   Ruling out
chcse conditions muSt be done before lov serum albumin concentration is associated vlth
malnutrition alone.  ~~~ accurate results, bLochemicaL analysis should use several blood and void
samples (48, 49, 50).

The moat effective clinical methods of nutritional assessment are based on physical examinations
and observation, and reflect long-term nutritional status.  Clinical evaluations must be highly
3crutlnized because of the potential for human error, especially vhen large numbers are evaluated.
For example, several age-related changes In clinical appearance--dry skin, sensory loss, and sparse
hair -- may appear to be representative of one or more nutrient deflcLencles (47). Other
limitations in assessment methodology are  discussed later.

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EmerRinR research isSUeS

Nutrition and aging research focuses on two general areas: issues related to interaction of diet
and aging functions (i.e., physiological, psychological,  sociological) and dietary relationships
with pathological conditlon3 common to old age.  More specifically,  much of the current research is
directed tovard the following topics:

1)


2)

3)


4)

5)


6)


7)


8)


9)

The effects of aging on nutrient digestion,  absorptton and utilization and the relationship
between these effects and nutrient requirements.
The role of dietary restriction in modifying age-related physiological changes or the role of
diet in treating conditions associated vith changes in immune and endocrine functions and
changes in body composition.
The influence or effects of neurological, environmental,  and dietary factors on senile
dementia or sensory deficits in older persons.
The  influence of physiological, behnvloral,  and environmental factors (e.g., sensory function,
dental status, culture, cognition,  and economics) on the quality and quantity of food eaten by
older individuals,  and on the relationship betveen various patterns of dietary intake and
nutritional and health status.

The nutritional changes including changes in food intake vhich accompany chronic diseases
common In the older person.
The role of nutrition and nutritional status during adult years in the etiology and
prthogenesis of diseases and problems of older persons.
The effect of therapeutic regimens (i.e., drugs,  surgery) on nutritional status and the
effects of nutritional status on the efficacy of therapeutic agents.
The associetion betveen nutritional status and morbidity and mortality -- examining patterns
of dietary intake and mortality.
Valid methodologies for use in assessing nutritional status in older persons and in
establishing age-appropriate norms.

Although recent estimates suggest that 20X of the population in the year 2010 vi11 be over 60, and
that one half of those will be at least 75 years of age,  much of the research base on nutrition,
ag*ng,  and health is quite immature.  An increase in the understanding of these dynamic
interrelationships can improve the quality of life of the aged,  provide more effective health care,
and lessen the impact of aging on the health of older persons.

A balance of animal experiments,  epidemiologic research,  and clinical trials is needed to study the
nutritional status and requirements of geriatrics.   To assess nutritional status Ldeally requires
1) determining daily consumption of energy and nutrients,  2) measuring tissue levels of nutrients,
3) clinical examinations including anthropometric measurements,  and 4) evaluating physical and
mental   function.  Current assessments of older persons are handicapped by a lack of  appropriate
age-related biomarkers and valid standards for intake and biochemical and anthropometric values to
vhlch survey results can be compared.  The related limitation in methodology and gaps in research
knowledge were discussed under the nutrition surveillance section.

Many of the gaps in our knowledge about nutrition and aging are being investigated by NIA-supported
researchers and by researchers at the NIA,  the USDA Human Nutrition Research Center on Aging, and
other government and private research centers around the country.

.  Effects of aging on dietary intakes and eating patterns

The need for research on socioeconomic influences on eating behaviors of older persons and the
biopsycho#ocial antecedents of age-related changes in eating habits will be discussed in this
section.  There is a need to clearly differentiate generational patterns in selection and eating of
foods from changes in eating habits which are age-specific.  Since previous educational, social,
economic,  and cultural erperlences vary widely among various cohorts of individuals over age 65
y.ZZlrs,  these influences on food use and preparation patterns need to be separated from late life
modifications in eating habits that result from age-related physical changes, chronic diseases, and
lifestyle changes (51).  Little is knovn about the diets and nutritional status of individuals 75
years of age and older,  who are part of the most rapidly graving and frailest segment of the U.S.
population.

Future research also needs to address the differences in dietary patterns associated with various
stages in the late life cycle and with the variety of settings vithin which older persons Live
(i.e., alone, with family,  or institutionalized).   In addition,  the effects of interventions.
social or nutritional,  at these various stages and in these settings need to be evaluated (51).

Among the socioeconomic factors, the type and level of income are particularly important.  Poverty,
for example, can restrict the amount and frequency of food purchases and also influence housing,
cooking facilities,  and overall health (3).  Eating patterns and food choices are also determined
by family structure, social situations, emotional statu,,  cultural and religious beliefs, and
living arra.ngements.  Therefore,  retirement,  children leaving home,  divorce or death of spouse, a

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move to an institution, P new community, or p resLdence with limited cooking facilities. or
entering or ix-entering the labor force later in Life can introduce changes in the food purchases,
food preparation methods,  and eating environment.   These change*.  along with social isolation and
psychological problems, may cause nnorexin or disinterest in food.  Boredom can lead to over eating
or snacking.  LCVin'S (52) SOCial net,,ork analyses and Gifft's (53) exam*n=ti*n *f nutr*t**n.
behavior, and change provide approaches to determine "hat social interactions change vith age and
hov these changes effect nutritional statUs.  Research that has identified food- and
nutrition-related ottttudes and knovledge of older persons will be discussed Ln the last section.

Age-related sensory impairments and prescriptions for special diets further affect food choices.
Loss of vision may restrict ability to prepare food or obtain food.  Loss of hearing may constrain
socializing at mealtime or may make it dif- ficult to get information on menu items or food
products.  Loss of smell and taste acuity may directly affect appetite and decrease the desire to
eat (54, 55).  Professionally prescribed diets such as lov sodium, lov fat, and low sugar may
further depress appetite and increase anorexia.  -future research should investigate the effect of
special diets on food intakes and nev vays to formulate appetizing foods lover in specific
nutrients, yet acceptable to the target population.  Answers to these questions vi11 certainly
require cooperation among gerontologists, physiologists, and food scientists.

.  Aging, and energy and nutrient requirements

The nutritional requirements of those over 65 are difficult to determine and are largely unknown.
Undetected disease and use of dietary supplements or medication complicate the task of defining
population samples that are representative of various strata of older persons.  In addition, there
are fev controlled metabolic studies in humans related to micronutrient metabolism in aging (21).
An examination of long-term diets of very old people who have remained healthy until an advanced
age may shed light on nutrient needs of older persons.

At present, most nutrienr requirements are generally age invariant. However, RDAs for all persons
over 51 are extrapolated from data collected painly on males ages 20 to 30 years of age (48, 56).
Current research on the vitamin nucriture of older persons may provide data to modify the current
recommendations, especially as the relationships betveen specific nutrients and chronic diseases
unfold or if never RDAs optimize health and tissue function.

Energy needs decline vith age because of decrease in metabolism related to a decrease in physical
activity and loss of lean body mass.  Since energy needs decline vhile nutrient needs remain stable
or perhaps increase, recommending nutrient levels in terms of veight of the nutrient per 1000 kcal
or per unit of lean body mass may be particularly useful for those over age 65 years.   Conversely,
energy intake restriction and exercise affect aging.  This topic ~111 be addressed later.

Protein synthesis appears to decline with age (44, 57),  as does the synthesis of muscle tissues,
organ tissue, and other protein moieties (e.g., collagen,  immune system components, and enzymes)
(33).  Declining protein intakes do not appear to affect deleteriously older populations vho have
no evidence of wasting diseases (57).  Nitrogen and dietary protein requirements may, however, be
increased in response to physiological stress common in older persons (i.e., infections, fractures,
surgery and burns) (56).  Preventing protein deficiency with attendant hypoalbuminemia is most
important in older persons when protein-bound drugs are taken (44).  Patients with renal or hepatic
disease may require protein restrict- Lens.   Hovever, the quantity and type of protein best able to
meet the needs of older people has not been ascertained,  even for healthy populations.

Present evidenc&indicates that vitamin A and ribaflavln absorption or tissue levels do not decline
vith age, despite intakes that are lover than the present RDA (17).   Research on the role of
carotenoids in cancer etiology may indicate advantages of increased intakes.  Age does not appear
to affect folate absorption and/or metabolism, except in individuals vith atrophic gastritis (58).
Individuals vith hypo- and acholorhydria may compensate for the malabsorption through increased
bacterial folate synthesis.

Some research suggests that the RDAs for viramin D. B6,  and B12 might be too Low, at least for
certain groups of older persons (21).  Reduced vitamin D synthesis in the skin,  lack of sun

exposure,  lav intakes, and impaired l-a hydroxylation depress vitamin D production in older persons
(59).   For nav. increased sun exposure combined vith low-dose supplementation (i.e., 10 ug/day)
(21) or tvice-per- year regimen of 2.5 mg vitamin D2 (60)  are recommended for housebound older
persons to maintain adequate serum vitamin D.  Both human and animal research suggest age-related
seductions in vitamin 86 absorption and metabolism (e.g.   impaired pyridoxal phosphate formation
or increased urinary excretion), but more conclusive data are needed to suggest changes in the RDA
(21).  Serum vitamin 812 levels appear to decline vith increasing age, perhaps because of
pernicious anemia and/or atrophic gastritis-related malabsorption (21).  Negative health
consequences of these changes have not been documented (61).

There is no consistent evidence for linking vitamin E, chiamin, or vitamin C  requirements vith
age.  The effect of increasing dietary vitamin E levels on tissue lipid peroxidation and platelet

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vit;lmin E Levels (and function) needs further exploration (21).  Age-related changes in thiamin
absorption vary depending  on the a**es*ment method used: however, it is veil knovn that alcohol
interferes vith thlamfn absorption and phosphorylation.  Age-related declines in vitamin C Levels
in the blood, plasma,  and Leukocytes are reported in most studies: hovever, changes in tissue
Levels are less canalstent (21).   Smoking (62),  medication (63).  and environmental stress (64)
combined vlth Lov intake*,  can compromise vLtamLn C Status,  but the health consequences of these
observations are not veil-estnbilshed (34).

UntLL improved method* for biochemical evaluations of vitamin K and nLacLn nutriture are available,
Lt Ls difficult to determine changes in nutrient requirements for these vitamins.  Incomplete food
tables handicap studies on zinc, copper, chromium,  and selenium *tat"* of the older persons.   Fluid
intake.  especially vater,  declines in older persons along with a age-related Loss of body vater.
Adequate vater intake (e.g.,  30 ml/kg of body weight) or approximately 1 ml of water for each
calorie ingested) (64) Is reasonable and important to normal renal and hovel function (5, 65).

Several questfons are important to consider in setting nutritional requirement* for the aging (44):

1.   Can ve formulate dietary recommendations that mitigate against development of aging changes in
   body composition?

2.   Since diseases such as o3ceoporo*is, atherosclerosis,  and cancer are in part age-related and
   appear to have Long Latency periods,  can ve offer guidelines for the diets of younger people
   vhich vi11 protect them from the development of these disease*?

3.    What crLteria should ve use to determine the nutrient needs of elders?
4.   What are the specially formulated preventive health goals for the elderly?  Should they change
   with successLve age strata over 65 years?

.  Effects of energy intake and expenditures on the aging process

Although some older persons seek the "fountain of youth"  in dietary supplements, the ansver to
deceleration of the aging process may be found in caloric deprivation  or increased energy
expenditure.  Energy intake restriction (ER) vithout essenttal nutrient deficiency has been the
only intervention in animals that extends maxLmum Lifespan in all species tested and across wide
phylogenetic differences.  Long-term national studies of persons on Lov calorie diets are often
confounded by Low Levels of nutrients and/or poor personal health habits.

UaLford et al. (66)  d escribed four phases that trace the hLstory of ER in the study of aging.
Initial vork shoved that ER slovs the biological aging process and favorably affects the incidence
and age of onset of malignancies, arthritis, renal disease,  and osteoporasis in animals.   Secondly,
animal studies demonstrated that ER animals had slowed age-related changes (not necessarily disease-"'
related) in the immune system. Liver enzymes, age pigment*,  behavioral and psychomotor pattern*.
The third phase is P search for mechanisms that suggest causality that might Lnclude altered gene
eXpreSSiOn,  thymic hormone Levels,  protection against free radical injury, and DNA repair.
Descriptions of the effect of ER on cLrcuLatLng levels of in+uLLn, somatostatin, thyroxine, and
other hormones are needed.  Exploring energy restriction in humans is the next phase.

Increasing energy expendLture through exercise also appears to influence mortality and morbidity
through a number of complex physLoLagLca1 mechanisms.  The effect* of inactivLty mimic the effect*
of aging (67):  almost 5OZ of the functional decline attributed to aging may in fact be related to
inactivity (68).  Combined with a calorie-appropriate diet,  exercise maintains a reasonable body
veight,  Lean body  ma** and good physical performance.  This combination also helps to prevent or
reduce fat cell hypertrophy,  production of high density Lipoproteins (HDLs), hypertension,
osteoporosis and insulin resistance.   [A separate background paper  explores exercise in more
detail.1

With the increasing interest in the effects of peroxidation processes on aging, intervention vith
various antioxidant*, including vitamins A, C,  and E and selenium has been tried in both animal and
human trials but the results have been mixed or inconcLusive.   More research is needed in this
area.

.  Drug and nutrient/food interactions

The high use of drugs among the aging may further compromise their health.  The average older
person receives more than 13 prescriptions a year and may take a* many as 6 drugs at a time.
Cardiac drugs (e.g., diuretics) are most videly used by the aging population, folloved by drugs to
treat arthritis.  psychic disorders,  and respiratory and gastrointestinal conditions.  Uany of these
diseases are diet- related, and the use of drugs may complement, supplement, or supplant diet
therapy.

Long-term use of a variety of drugs (often at high doses) raises the risk of drug-nutrient
interact ions.  Individuals with nutrLtionaLly inadequate intakes and impaired nutritional Status
are at the highest risk.  Use of high-potency nutrient supplements may also affect drug efficacy.

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Physician, need to cxplaln carefully the potential side-effects vhen certain drugs and
food./$oppLements are taken together.  For some older persons, altering the drug therapy may be
more appropriate than recommending dietary changes or food restrictions.  Periodic assessments can
ide,,tify borderline nutritionrl status that require appropriate dietary recommendations, nutrient
supplementation. or change in drug regimen.

Roe (44, 69) has detailed several areas of drug-nutrient interactions.  Thele include 1) diet
effects on drug disposition,  2) drug disposition in malnourished subjects, 3) drug induced
mrlnutrition, and 4) drug-food and drug-nutrient incompatibilities.  Key Lntcrnction3 relevant to
the aging population are discussed belov and more detail on drug use is provided in a separate
background paper.  More research la needed to explain these interactions and to determine their
clir,icrL Si&`nifiC-Cc in the aging Population.

Foods component, and nutrients can affect drug absorption and metabolism. Heavy metals, high fat
intakes and,  to P Lesser extent, high protein foods delay gastric emptying and, thus, delay the
passage of drugs into the small intestines. Kigh protein diets may also accelerate hepatic drug
mcraboLism.  A fasting state may hasten drug absorption from an empty stomach.
Malnutrition also alters drug absorprLon, protein binding, drug metabolism and drug clearance.
Protein-bound drugs such as varfarin and diazepam may be more toxic in patients vith
hyponlbuminemlo.  On the other hand, some drugs decrease absorption of nutrients or cause mineral
depletion.  Such drugs include Laxatives, antacids, anti-inflammatories (e.g., asptrin), diuretics,
antibiotics, analgesics (e.g., Lndomethacin), and hypocholesterolemics (e.g., cholestpramine).
Appetite can be enhanced by tricyclic antidepressants, reserpine, antihistamines, and anabolic
steroids, vhereos amphetamines and related drugs depress the appetite.  But the aging process can
reverse these effects.   Phenothlazine,  a psychotropic agent, that usually increases food intake may
decrease oppetlte in older persons whose race of drug metabolism Is slaved.  Specific foods or
alcoholic beverages can precipitate adverse reactions to drugs.  Some reactions such as the
tyrnmine rcaccions with monoamine oxidase inhibitors may be Life-threatening,  while others such as
the reactions caused by disulfiram and hypoglycemic agents to alcohol are extremely unpleasant.

Guidelines for drug development are needed that include studies In the elderly and consideration of
various drug and food/nutrient interactions.  Initially,  research must determine hov much drug
efficacy and safety might improve with proposed guidelines (70).  The quality of such research
depends 1x1 part on the reltability of nutritional status assessments conducted and nutritional
standards applied.  Education-information transfer about drug-nutrient interactions for the public
and the caregivers also needs consideration (70).

.  Diet and chronic degenerative conditions

The prevalence of chronic conditions, such as osteoporosis, gastrointestLna1 disorders, diabetes,
cardiovascular disease, and central nervous system disorders, increases with age.  Questions about
the role of nutrition in delaying  the onset or mitigating the consequences of these conditions are
the focus of NIA-sponsored research and conferences.  The following examples are illustrations of
aging and nutrition research topics:

Osteoporosis:  Osteoporosis 1s defined as an absolute decrease in the amount of bone, Leading to
fracture, after minimal trauma.  Although age-related bone Loss is common, certain older persons
are at higher risk of developing fractures than others.  Riggs (71,  72) suggests that osteoporosis
may be two distinct bonethinning  syndromes: I) a "postmenopausal" form (Type I), associated wLth
estrogen deficiancy and 2) P "senile" form (Type II). highly correlated vlth aging.  Type 1,
occurring predominantly In females 15-20 years after menopause,  thins trabecular bones (e.g..
vertebral bodies,  ultradistal radius (forearm), and mandibles) that Lead to fractures and tooth
loss.  Type 11, occurring mainly in persons of both sexes over 75 years, thins both the cortical
bone and trabecular bones proportionately, Leads to fractures of hip, femur, tibia, and pelvis.

Definitive etiologies for either the early deficit in trabecular bones in Type I or gradual
thinning in Type II need to be determined.  Pharmacokinetic studies using calcitonin and
dlphosphonates have begun to explain the ceLluLar mechanisms of bone resorption.   Other studies
(73, 74) have suggested risk factors including insufficient bone density at maturity, lov levels of
endogenous estrogen and other hormones, prolonged immobility and weightlessness, Long term use of
corticosteroids, family history, impaired intestinal or renal function, and diet.    Prevention of
osteoporosis has become a public health concern and has brought the promotion of foods high in
c.alcium (e.g., milk products), calcium fortified foods (e.g., cereals, breads, and sofr drinks),
high potency calcium supplements,  and other nutrient supplements.  NIB Consensus Conference (75)
recommended calcium Lntakes at P Level of 1000 to 1500 mg, estrogen therapy, and exercise for

Questions remain about 1) what Levels of calcium intakes are most protective against age-related
bone Loss and do these Levels vary with age or sex of individual.  2) do calcium requirements vary
with the Level and type of physical activity, 3) hov does calcfum intake/supplementation interact

G-9


vith estrogen status, 4) do calcium, fluoride,  and vitamin D metabolltes protect bones
independently or in conjunction vlth estrogen therapy,  veight-bearing exercise, or other
approaches,  and 5) how do vitamin D, protein, phosphorus,  and even alcohol affect calcium

requirements.  Lastly. designing precise methods for measurement of bone mass 1s critical for
dererminlng relationships becveen diet and bone loss for the population or assessing the risk of
bone fractures in individuals so as to use prophylactic therapy most effectively (76).

Osteoarthritis (OA) also causes great pain, Lmmobility,  and loss of independence  for many aging
individuals.  Although nutrient deficiencies or excesses have not been implicated in this disease,
obesity has been found to be associated vlch OA of the knee and hip but not of the sacroiliac joint
(77).

Glpcation in diabetes and cardiovascular disease:  Glycation or non-enzymatic  glycosylation may
well be involved in the etLology of a number of age-related diseases.  GLycosylation describes the
process whereby glucose, fructose,  or galactose react vith proteins or nuclerc acids to form a
Schiff base.  The Schlff base undergoes further changes to form advanced glycosylation end (AGE)
products.  The excessive accumulation of AGE products in the tissues,  especial1y in the arterial
valls,  acceIerates progressive stiffening or rigidity of these tissues.  This rigidity may be
caused by the cross-linking of proteins (e.g.,  collagen) and increases vith age.

Elevated glucose concentrations characteristic of diabetes promote advanced glycosylation, thus
accelerating stiffness of the tissues.  Such rigidity may Lead to reduced elasticity in the
cardiovascular system.   As a result,  cardiac function declines,  renal blood flow decreases, and
vital lung capacity and oxygen uptake also decline.  Further studies on advanced glycation may
elucidate the mechanisms involved in the formation of senile cataracts,  aging peripheral nervous
system,  and etiology of atherosclerotic plaques.

apochlorhydria:  New research lnitlatives are studying the effects of aging on gastric secretions
and the subsequent impact on nutritional stat"s of the older persons.  Hypochlorhydria incidence
increases with age and may affect up to one-third of those people over 60 years of age.   women are
more often affected than men.  but the current extent of the problem and those at highest risk for
disease are not knovn.  Future epidemiologic studies of hypochlorhydria must be based on a common
standardized case definlrion in order to assess the impact of aging on the disease.   The causes of
hypochlorhydria and the commonly associated atrophic gastritis are also largely unknovn, yet these
disorders have far reaching implications for health maintenance in the older population.

The major clinical implications of hypochlorhydrla are altered absorption of nutrients and drugs in
the upper gastrointestinal tract,  bacterial over grovth resulting in infections and changes in the
immune response,  and the predisposition  to other diseases and disorders.  Defective absorption of
calcium,  iron,  folate,  and vitamin B12 and the related deficiency diseases are of particular
concern in hypochlorhydric patients.  Reduced production of hydrochloric acid may affect the
development of gastric cancer.

B-vitamins and central nervous system function:   Current knovledge of the extent of interactions of
nutrition and neurology is limited.   The effect of B viramlns and other nutritional factors on
brain function,  including dementia and motor  control,  is better established.   Deficiencies of
various nutrients,  particularly vitamin 812, thiamln, niacin.  and folate fmpair cognition.
Rigorously controlled,  double-blind, prospective trials may elucidate the cognitive effects of
malnutrition,  especially subclinical,  or multiple deficiencies of B-vitamins.  To date, much
information in this field is based on anLmaL studies that may have limited applicability to human
conditions,or on clinical pathology complicated by advanced   age,  alcoholism,  and disease.

In addition,  analytical methods specific and sensitive enough to measure the Levels and metabolism
of B vitamins are only beginning to be developed.   HOVeVeK,  still mo+e basic methodological
research is needed before further refinement in study design can be attempted.  For example, based
on nev evidence using updated technology,  it appears that folic acid as a naturally occurring
excitatory agent found in the brain may have a mechanistic relationship to neuropathological
conditions such as epilepsy-related bratn damage, lithium neurotoxicity, tardive dyskinesia, and
neuronal degeneration associated with aging.

The study of nutrients'  effect on brain function has not received vldespread attention because it
vas commonly belLeved that the brain vas well protected from fluctuating plasma levels of dretary
nutrients by the blood-brain barrier (BBB).   Now,  it appears that  food constituents affect the
synthesis of brain neurotransm1tter and thereby modify brain functfon (e.g., alertness or
depression) and behaviors (e.g., sleep).   Fernstrom (78) and Wurtman (79) have shovn that the
levels of rrerotonin,  an appetite-controlling neurotransmltter, can be increased by a
high-carbohydrate,  protein-poor meal that elevates brain tryptophan,  accellerating serotonin
synthesis.  They report similar regulation of brain acetplcholine by ingestion of
choline-containing compounds and of brain dopamlne by  tyrosine-containing compounds.   Besides
mPcron"trlents,  levels of trace minerals in the brain affect formation of synapses, nerve impulses,
and other brafn activity in neurotransmitter systems (80).  Sl nce  the blood-brain barrier serves as

G-10


the interface bctveen brain metabolism and diet.  understanding the BBB nutrient transport processes
provldc insights into the mechanlsml by which dleC may influence brain functions (81).   Research in
this area is still too young Co atcrlbute altered behavior solely to nutrient-induced changes in
neurotransmitter Levels. Improved study designs are needed chat use standardized methods for
measuring behavioral responses and that adequately evaluate the dietary components and nutritional
status of subjects and controls (82).

Although clinical research has not associated the severe senile dementia in  AlzheFmer's disease
with aluminum coxlcity (83) or other nutritional imbalances,  future research in this area may be
p*0lU2*i*g.  Approprlnce biochemical testing of individuals suffering mental loss or other central
nervous system dysfunction may be required for differential diagnosis of these probiems.

Also of research interest is the effect of aging on the interaction of B vitamfns vLth ocher
nutrients in the brain and nervous system.  For example,  alcohol consumption vhich can cause
Uernicke's encephslopachy compromises thiamin  pyrophosphate-dependent enzymes and interferes with
Chiamin nbsorptlon and phos- phorylation.  The drug, DFlantin, can increase folate requirements and
Si*elllet ,  used to treat Parkinsonlsm,  can cause niacin deficiency.

Nutritional services in the health care of the older persons

About 85% of older persons have one or more chronfc, porentially debilitating diseases and could
benefit from nutrition services.  Up to half of older individuals have cLfnicaLLy Identifiable
nutrition problems requiring professional intervention (3).  If the goal of health promotion is Co
assure the older persons' health, independence, and quality of life,  incorporation of nutritional
services into the.conCinuum of health care -- instltutlon, ambulatory, and home-based care -- for
older persons IS paramount.  Since older persons are more susceptible to foodborne poisoning than
younger people, proper sanitation practices are needed in food preparation and service in all these
health care   settings.

0  Nutritional Assessments

Nurrltlonal services. vhether therapeutic, rehabilitative, or maintenance services, include
clinical,  educational and foodservice components.  As part of clinical services, nutritional
assessments should become routine parts of physical examinations for all older residents of health
care frcllities, nursing  homes,  or community health centers (84).   In turn,  the findings of these
assessments should guide medical orders tncluding drug regimens, scheduling surgery, dietary
guidance,  and other nutritional therapy.  (The Limitations of assessmenrs were discussed earlier.)

Complete diet histories provide information on eating habits that can identify  nutrient
inadequacies early.  Since the food habits of the older persons reflect long-term patterns, special
attention to the food preferences,  cultural and religious beliefs, economic status, drug and
supplement use, and lifestyles can enhance compliance with specific dietary regimens, while
enStIring they obtain enough food and enough of the food they like.

For hospitalized or insritucionalized patients,  regular documentation of food  intake may alert
health professionals to potential nutritfon problems (5).   A*OreXia ,  induced by drug or radiation
therapies or resulting from surgery or chronic conditions,  can quickly lead to nurrient
deficiencies,  especially in frail older persons.  Nutritional therapies, either enteral or
parenteral,  formulated feedings, have minimized attendant medical complications (e.g., Infection),
improved therapeutic responses,  and sped recovery in some patients.   Rowever,  the prospective
payment systempf financing health care (discussed below) may be a disincentive to use of
nutritional support in hospitals.

For the hospitalized or frail older persons vho cannot eat, providing adequate nutrition support
through tube or intravenous catheter can contribute to regaining  health and independence.   Enteral
and parenteral feedings can sustain Life for patients who are physically unable Co swallow, digest,
or absorb food and fluids taken by mouth and for patients vho refuse to eat.

The efficacy of these therapies is not universal across all diseases.   Little is known about the
efficacy in older persons, partly because of the lack of information on the nutritional
requirements and standard+ for the older persons.   NutrLtionists and ocher health care
professionals vi11 more frequently participate in debates about vithholding and vithdraving
nutritional support and hydradration`from terminally ill, comatose,  and severely debilitated
people.  In addition, health care providers vi11 be faced with questions about'vhen and if to use
these treatments vich severely demented persons who cannot decide on the course of their therapy
and may need to be physically restrained (85).

.  Education and training for varktng vith older p-sons

Uith the emergence of diverse health problems among the fast-graving numbers of older persons, the
number of education and training prOgramS on aging and geriatric  nutrition have gro"n.   NIA sets

G-11


as two high priorities: 1) training of clinicians  and biomedicaL researchers to specialLze in
n"trLtion and aging i,s"es and 2) deveLopment of centers of excellence In nutrition and aging
research.

Professional societies (86), research centers (87)  and programs for medical, nursing, and nutrition
students (88,  89) have offered courses or seminars to address ethical concerns in nutrition for
Long-term care patients and to encourage posrtive attitudes toward the older persons.   Although It
may be necessary to train some health professionals to be geriatric specialists, the benefits of
'main-streaming" older persons into generic health care services outveLgh the hazards of
stigmatlting and stereotyping their health problems (89).  Appropriate funding for ambulatory and
health care services for older persons may also change the perception of students that these jobs
are often lov paying.

.  Impact of health care fLnancLng on nutritional care of older persons

As the population ages and individuals live longer,  health care expenditure vi11 increase.   The
major reason for this increase is that health care utilization is greatest among the older persons.
especLally the oldest old -- the segmeat of our population that is growing the fastest.   To date
(1984) major sources of fFnancfng the health care of older persons in the UnLted States are: 1)
medfcare (49%).  2) out-of-pocket (25X), 3) medicaid (13X), 4) Lnsurance (7X), and 5) other
government BOUKCPS (6X).  The federal government pays for about 68% of all health care expenditures
(90).

Government expenditures are dispersed as follows: 39% to hospital costs,  20% to personal health and
physician services expenditures,  and 21% to nursing home and other expenditures.   In 1983, due to
escalating health care erpendltures,  Congress and the Administration proposed reform -- the
prospective payment system (PPS) for Hedicare reimbursement of hospitals.

Under the PPS,  Medicare pays for each hospital admission,  a rate predetermined on the basis of the
patient's principal diagnosis and certain other factors.  Each admission is assigned to one of 468
diagnosis related groups (DRGs) for payment.  PPS is intended to discourage extended inpatient
stays and encourage the substi- tution of less expensive care outside of the hospital (91).   As a
result of the PPS there has been a decline in the average length of stay for Medicare patients, and
therefore an increased demand for postdischarge services.  The prospective payment system provides
a financial incentive for hospitals to c"t costs belov the reimbursable level and adjust inputs,
such as teses,  personnel time,  and special procedures (92).  Studies are determining the impact of
PPS on the quality of care (92) and on access to in-hospLta1 nutritional support services (93).

The Lmpact of PPS on the nutritional status of Post discharge patients also needs examining.
PatLents are discharged early in what appears to be poorer states of health and needing extensive
care (94).  Health providers are finding it harder to retain patients requiring long term
nutritional support for a long enough time to monitor their status and train them before discharge.
Since October 1983 greater numbers of these patlents (402 increase in discharges) are being
transferred to skilled-nursing homes or requiring home health care (95).   Often these facilities do
not have the proper equipment,  supplies or trained personnel to deliver safe and appropriate tube
or intravenous catheter feeding (5).  Hospice Programs and some home health care programs include
nufrltional services: hovever,  the majority of alternatLve community-based services do not include
nutrLtionaL services (3).  The costs of nutrition services provided by hospice programs are
absorbed under the organlzatioa's administrative overhead (3) because medicare and most third party
payment services do not reimburse nutrition services dLrectly.

Cost cont%inment pressures are projected to shift more demand from the hospital to the community,
especially to home care services traditionally provided through the nonprofit sector.   The number
of Hedicare certified home health agencies increased from 2,212 in 1972 to 5,755 in 1985.   The
growth has primarily taken place In facility-based and for-profit home health agencies, vhile the
number of more traditional nonprofit providers -- visitLug nurse associations and government
agencies -- has declined slightly (96).  Questions arise as to hov the communitycare nonprofit
sector vi11 cope vith the increasing demands for delivering of hLghly technical in-home health care
that drains reso"rces from delivery of more traditional, community-decided,  multi-services (e.g.,
transportation,  food preparation assistance,  primary health care) (97).

Technological advances and feeding the older persons

Changes in the physiology and organ systems of older persons challenge the food industry as Lt
attempts co serve the growing market of elders.  CreativLty will be needed to formulate products
that are flavorful,  visually attractive,  and have high nutrient densities.   Products vi11 need to
supply high nutrient levels for theFr caloric value.  Fortified products need to assure high
bioavailabilf'cy of the added nutrients.  For several years,  food manufacturers have been gradually
lovering the salt, fat,  and sugar content of food,  while retaining good flavor in most products.
Manufacturers have al30 addressed Current n"tritLon research concerns by increasing the fiber,
calcium,  and vitamin D content of cereals and other foods.  Special diet products that are low

G-12


pr*te in,  cholesterol-free, lactose-free, or very low in sodium are also available (35, 98). An
earlier section also discussed the "se of parenteral and enteral feedings.

Supermarkets and food stores are recognizing their responsibilities coward their axing clients.
Some grocery stores are establishing specific shopping hours for senior citizens complete vith bus
service,  bargain sales,  and refreshments.  Other uay* to reduce barriers to food shopping include:
1) sales on small packages and at off peak-hour times, 2) educational materials written in larger
print that suggest tips for meal planning, budgeting and food preparation for single-person
households: 3) take-home product listings to "se with telephone orders,  4) shelf-labels with large
print,  5) uncluttered aisles, and 6) convenient benches and rest rooms (81).

Nutrition and food assistance programs

Over the past 20 years, both the public and private sector have initiated and reformed food
assistance programs to respond to evidence that nutrltlonal deficiencies were prevalent in older
persons, especially those vith lov-income or vho are socially isolated.  A variety of services are
now available to elders with a continuum of functional capacity (99).  The Continuum of Community
Nutrition Services model developed by Balsam (100) describes this variety.

Federal nutrition programs include the food stamp program,  the commodity supplemental food program,
the congregate feedLnx program,  and the home-delivered meal program.  Private charities have teamed
vlth the public programs to expand food service to elders.  Soup kitchens offer breakfasts and
suppers and food pantries provide emergency food boxes.  Luncheon clubs (101) have permitted
seniors receiving home delivered meals to congregate ln neighbors' homes.   Restaurants have cut
prices for older persons and accepted their food *tamp*.  Food industries have designed packaging
and processing technique* to provide shelf-stable meals for evening and weekend "se.   VOlUntCCrS
offer escort services to supermarkets or deliver groceries to many home-bound persons (102).

Revisions to the USDA Food Stamp Program extended benefits to lov income elders by eliminating the
purchase requirement and increased their benefits by alloving  for medical and shelter deduction*
(103).   Nonetheless, many older persons still receive only minimal benefits  ($lO/month) and their
participation rates are lov (<50X of eligible) (90).  For lov-income, often frail, elders, vho were
uninterested in receiving food stamps and had difficulty in shopping,  Congress authorized delivery
of lov-cost commodity packages under the Commodity Supplemental Food Program.

The DBHS National Nutrition Program for Older Americans, as specified in Title III of the Older
Americans Act, includes food service for both the ambulatory old (congregate feeding) and the
home-bound old (home-delivered meals) (3).  Eval"atlon* (103, 104, 105,  106) of the congregate
feeding program and the home-delivered meals (107) generally shov that participants have higher
intakes of essential nutrients than nonparticipant*.

During recent hearing on program reauthorization,  the American Dietetic Association (ADA) (108)
raised concern that future program budgets must account not only for the annual inflation but also
for the annual rate of increase in the older population.  The flexibility in funding for Title III
concerns many because it permits shifting funds from meal programs to supportive services.
Currently, the congregate feedlnx program reaches only 10% of the eligible population. The need for
home-delivered meals has increased significantly (35% to more than 50% increase in persons
recefving meals) in the first year after the impLementatLon of the new prospective payment system
of health care financing (3).   As dietary  restrictions become more complex, especially for those
in their late 70s or 80s. demand for special meals and nutrition information vi11 increase,
requiring addLdona1 program resources and qualified professionals.

To formulate policies for food assistance programs requires attention to:

a.  Planning and conducting systematic evaluations of food programs to assure they meet the
   chanxLnx needs (nutritional, social, educational,  and economical) of the heterogeneous
   older population;
b.  ~evelopinx nev approaches to reach underserved groups of elders, such a* the hamele** and
   socially impaired elderly, minority and ethnic elders, and to extend food service beyond
   weekday lunches:
c.  Setting and revising (as needed) nutritional guidelines for meals served in senior
   citizen feeding programs;
d.  Establishing a clearinghouse for exchanging information on innovative programs that meet
   identified community needs:
e.  Assuring that educated and trained nutrition professionals assist vith planning and
   monitoring these programs at all  Levels of government.

G-13


Nutrition education and lnformrtion

The cool, that promote good nutritional health for older persons are most probably the nutrition
information gained from mass media or education programs.  Because of the myriad of nutrition
messages received.  sorting out consistent truth3 from half-truths or conflicting information
fru,trPtcs people at all ages.  Educators need effective ways to minimize the confusion and also to
trnnllate current.  relevant research into dietary advice applicable to elders.   The great
heterogeneity among older persons and the reality that life-long habits are resistant to change
make designing n"trLtFon messa8er a challenge for educators.

Key to appropriate,  effective nutrition education for this group is understanding the complexities
of aging,  applying knowledge of the change process,  and assessing cognitive, affective, and
nutritional status changes (109).  Effective nutrition education also requires knoving the
prrceptions older persons have tovord raflng and foods.  Many older persons,  relate food to social
interactions and entertainment and also recognize food as a source of nutrients that is important
to health (110).  More research on factors that facllitace learning and making dietary changes can
improve nutrlrion education efforts (111).

Applying communication theory (112) and marketing principles  (113) to nutrition education enhances
the chances that the consumer will act on the research-based dietary guidance.  Such an approach
allows the audience to identify vhat they want to know,  hov they want to receive information, vhere
they want to learn,  and how often they want follov-up.  For example,  older persons have sought a
uniform set of dietary guidelines,  appropriate for most chronic diseases.  They have also posed
questions about health fraud,  "se of vitamin and other dietary supplements, and drug and food
interactions (114).

Though not tailored specifically for older persons,  the DHEJSlUSDA Dietary Guidelines for Americans
provide essential information for motivating dietary changes that promote health.   Modifying the
text slightly to be more relevant for older persons,  printing copies vith large lettering, and
distributing them through Title III programs could permit wider "se.   The Eealthy Older People
program conducted by the Office of Disease Prevention and Eealth Promotion promotes good nutrition,
proper exercise,  and other health messages through the media and consumer education materials
(115).  Combatting health fraud is a priority of the FDA,  the Federal Trade Commission (FTC), and
COIIgl-eSS.  The two agencies have launched on educational/media campaign against health fraud, and
recently sought stronger court actions again- false advertisements for dietary supplements (115).
Since nutrition education ha3 been found to be negatfvely correlated vith misconceptions about
"vitamin/mineral supplements" (116),  informing older persons about the benefits and hazards of
dietary supplements could result in more prudent "se of these substances.  Food labels also provide
good sources of nutrition information:  but without close monitoring of the health claims on labels,
older persons could be deceived or adopt false expectations of the food.

Title III of the Older Americans Act is the only federal nutrition program for older people that
reimburses nutrition education.  Based on the recent National Association of Area Agencies on Aging
and the Administration on Aging's survey results (117). nutrition education, though often a high
priority for some program administrators,  is not routinely incorporated into all programs.   Three
reasons most frequently cited for lack of nutrition education are inadequate funds, the absence of
qualified nutrition educators,  and the lack of specific program standards and guidelines for
nutrition education (118).

Other nutrition policy considerations might include (119):

1.

2.


3.


4.


5.

What cerjtral nutritional message do seniors want - changing the amount of food eaten, eating
more nutrttious foods,  understanding drug and food interactions.  or learning about and "sing
community nutrition programs7
Elov can the messages delivered by the federal government be better coordinated, and how can
the government messages be coordinated with those of the private sector?
What format. language,  and style for educational materials are most useful and appealing to
older persons?
What medium (e.g., groups,  mass media) is most effective to "se in reaching older persons as a
group and the various subgroups over age 651
What should be done to assure that qualified nutritionists assist vith planning, coordinating,
evaluating,  and monitoring nutrition education programs at the federal, state, and local
level?

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.
10.

11.

12.



13.


14.

15

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17.

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22.

23.

24.

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