O Nutrition and Health

Studies of the relationship between maternal nutritional supplementation
and the behavioral development of offspring have produced inconsistent
results. In some studies, no differences in cognitive function occurred
among offspring of women who did or did not receive nutritional supple-
ments (Rush, Stein, and Susser 1980a, 198Ob; Higgins 1976), but others
have reported significant benefits of improving prenatal nutritional status
(Villar et al. 1984).

As discussed in the anemia chapter, lower mental and behavioral test scores
improved relative to controls among iron-treated iron-deficient infants only
when the amount of iron administered corrected both the anemia and
biochemical indices of iron deficiency (Lozoff et al. 1987). Short-term
studies on the effects of omitting breakfast on cognitive performance have
reported that adequate nutrition benefits learning (Pollitt, Leibel, and
Greenfield 1981, 1983; Conners and Blouin 1982/83). Well-nourished chil-
dren ages 9 to 11 who skipped breakfast displayed higher rates of inaccurate
responses to problem solving.

Inborn Errors of Metabolism

Early identification and nutrition intervention can help prevent subsequent
mental retardation in infants born with many kinds of metabolic disorders.
All States have screening programs to detect newborns with inborn meta-
bolic disorders (Infant Metabolic Diagnostic Laboratory 1987). Such chil-
dren require long-term dietary management. One example of such a disor-
der is phenylketonuria (PKW) (AAP Committee on Genetics 1982).

PKU results in excessive and potentially toxic blood levels of the amino
acid phenylalanine. The goals of therapy are to provide adequate intakes of
energy and nutrients but only enough phenylalanine to maintain normal
growth and development. Meeting these goals requires special formulas
and food products with reduced phenylalanine content, as well as consider-
able support from health professionals (Trahms 1984). Current recommen-
dations are to continue the phenylalanine-restricted diet throughout the
reproductive years, because experience with its discontinuation at ages
ranging from 4 to 10 years indicates progressively decreasing cognitive
functioning, learning difficulties, poor attention span, and behavioral dfi-
culties (Smith et al. 1978; Koch et al. 1982; Holtzman et al. 1986). Evidence
suggests also that phenylalanine restriction during pregnancy improves the
outcome for women with PKU and their infants (Mabry, Denniston, and
Coldwell 1966; MacCready and Levy 1972; AAP Committee on Genetics
1985; Drogari et al. 1987).

576


Maternal and Child Nutrition O

Implications for Public Health Policy

Dietary Guidance

General Public (Including Children and Pregnant Women)
Assessment of nutritional status is an integral part of maternity care at the
beginning of pregnancy and periodically throughout pregnancy and lacta-
tion to provide continuing monitoring and recommend appropriate inter-
vention.

Evidence related to the role of diet in maternal and child health indicates
that well-nourished mothers produce healthier children. Intake of sufftcient
energy and nutrients to attain optimal nutritional status, including appro-
priate weight before pregnancy and adequate weight gain during pregnan-
cy, improves infant birth weight and reduces infant mortality and mor-
bidity. Avoiding potentially toxic substances such as alcohol or drugs
during pregnancy seems to improve infant birth weight and health, but the
evidence regarding low exposures to these agents is not conclusive. Infor-
mation on appropriate dietary intake, with consideration of ethnic and
cultural food habits, should be provided as early as possible to pregnant
women and to women expecting to become pregnant.

Evidence related to the role of diet in infancy indicates that breast milk is
the optimal food for infants. Whenever possible and as early as possible,
health professionals should provide guidance and support to pregnant
women and new mothers on the importance of breastfeeding and on meth-
ods for its initiation and maintenance. Mothers who cannot or choose not to
breastfeed should receive information about appropriate formulas.

Consuming the appropriate amount and form of energy and nutrients for
developmental age is important for good health, as is early education about
lifelong dietary patterns that help prevent disease. Parents should guide
their children in developing positive eating behaviors and on age-appropri-
ate food patterns that meet nutritional requirements but avoid excessive
intake of fat, sodium, and sugar. Parents should also help adolescents
develop healthy eating habits and should emphasize the importance of
including sufftcient quantities of low-fat, nutritious foods in meals and
snacks.

Special Populations

Some factors present at the onset of pregnancy place women at increased
nutritional risk. These include: adolescence, short interconceptional peri-

577


0 Nutrition and Health

od, poor reproductive performance, economic deprivation, food faddism,
substance use, chronic systemic disease, and inadequate or excessive
prepregnant weight (below 85 percent or above 120 percent of standard
weight for height). Other nutritional risk factors such as anemia and inade-
quate or excessive weight gain may develop during pregnancy.

Attaining appropriate prepregnancy body weight and nutritional status,
gaining adequate body weight, and avoiding alcohol during pregnancy are
important for all women. Qualified health professionals should provide
close nutritional monitoring and individualized counseling to women ap-
propriate to their educational level and cultural food habits before and
throughout pregnancy.

Specialized professional counseling on feeding should be provided to par-
ents of LBW infants, other infants at high risk, and infants who require
special formulas. Parents of children who are at high risk because of
developmental disorders, inborn errors of metabolism, physical dis-
abilities, or chronic disease should also receive ongoing professional ad-
vice on appropriate diets and feeding methods. Because children from
families with a history of diet-related chronic disease have a high risk for
such conditions, they should be evaluated for these conditions. Children of
families whose blood cholesterol, blood sugar, or blood pressure exceed
appropriate levels should be advised on dietary and other means to reduce
these risk factors.

Physicians, nurses, and other health professionals caring for children and
women of childbearing age should receive education and training in nutri-
tion assessment, nutrition intervention for prevention of disease, and pro-
motion of maternal and child health.

Nutrition Programs and Services

Nutrition Services

Evidence related to the role of nutrition in maternal, infant, and child health
suggests that all health care programs for these groups should provide
nutrition services, especially to those people at special health or economic
risk. Such services include nutrition assessment, dietary counseling, nutri-
tion education, and referral.

Food Products
Evidence related to the role of dietary factors in maternal and child health
suggests that food manufacturers should develop nutritious, low-fat, low-

578


Maternal and Child Nutrition O

salt, low-sugar snack food products for children and adolescents. Quality
and safety of infant formulas and other infant foods require continued
monitoring to prevent untoward health consequences.

Special Populations

pregnant women, infants, and children with diet-related disease conditions
and physical disabilities that impair food intake should receive counseling
and assistance in dietary management. Low-income families should have
access to an adequate diet. Those with poor education, limited understand-
ing of English, and different cultural patterns require nutrition education
approaches appropriate to their needs.

Research and Surveillance

Research and surveillance issues of special priority related to the role of
diet in maternal, infant, and child health should include investigations into:
o The amounts of energy and essential nutrients pregnant women must
consume to achieve optimal birth outcome and promote long-term
  maternal health.

0 The optimal weight gain during pregnancy.
0 The diet during pregnancy that best prevents complications of chronic
disease conditions in the mother.
0 The effects of potentially toxic dietary factors such as alcohol on fetal
health.

0 The optimal feeding methods and diet for improving growth and devel-
opment of LBW infants.

o The diet in childhood that will best prevent later development of
chronic disease conditions.

0 The influence of nutritional status on teratogenic outcomes, particu-
larly neural tube defects.

o Nutritional care for optimal development of infants and children with
special health care needs due to chronic illness or developmental
disorders.

o Effective educational methods to teach parents how to develop good
dietary practices for themselves and their children.
0 Effective educational methods for teaching good nutritional practices
to children and adolescents.

579


O Nutrition and Health

0 Effective strategies to integrate nutrition screening, education, and
intervention services into health care programs.
o The impact of social changes on nutritional status, including those
related to meal sources and eating patterns.

580


Maternal and Child Nutrition O

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Jones, K.L. 1973. Pattern of malformation in offspring of chronic alcoholic mothers. Lancer
i:l267-71.

Jones, C.T., and Rolph, T.P. 1985. Metabolism during fetal life: a functional assessment of
metabolic development. Physiologicnl Reviews 65:357430.

Kalhan, S.C., and Hertz, R.H. 1985. Diabetes in pregnancy. In Principles of medical therapy
in pregnancy, ed. N. Gleisher, pp. 239-63. New York: Plenum Medical.

Keen, D.V., and Pearse, R.G. 1985. Intrauterine growth curves: problems and limitations.
Acta Paediatrica Scandinavica 319(suppl.):52-54.

Kiilholma, P.; Paul, I?; Pakarinen, I?; and Gronroos, M. 1984. Copper and zinc in pre-
eclampsia. Acta Obstetricia et Gynecologica Scandinavica 63:629-31.

King, J. 1986. Obesity in pregnancy. In Dietary treatment and prevention of obesity, ed. R.
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Kleinman, J.C. 1987. Infant mortality trends. Provisional data, April 2, 1987. unpublished.
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Kleinman, J.C., and Kessel, S.S. 1987. Racial differences in low birth weight: trends and risk
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Kliegman, R.M., and Gross, T. 1985. Petinatal problems of the obese mother and her infant.
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Kliegman, R.; Gross, T.; Morton, S.; and Dunnington, R. 1984. Intrauterine growth and
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Koch, R.; Azen, C; Friedman, E.; and Williamson, M. 1982. Preliminary report on the effects
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Kurppa, K.; Holmberg, P.C.; Kuosma, E.; and Saxen, L. 1982. Coffee consumption during
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LaRosa, J., and Finberg, L. 1988. Preliminary report from a conference entitled "Prevention
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Lasky, R.E.; Klein, R.E.; Yarbrough, C.; E&e, PL.: Lechtig, A.: and Martorell, R. 1981.
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587


0 Nutrition and Health

Laurence, K.M.; James, N.; Miller, M.H.; Tennant, G.B.; and Campbell, H. 1981. Double-
blind randomized controlled trial offolate treatment before conception to prevent recurrence
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Lind, T. 1982. Iron supplementation during pregnancy. In Nutrition in pregnancy, ed. D.M.
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L&s, P.; Dewey, K.G.; and Poirier-Brode, K. 1985. Weight gain and dietary intake of
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588


Maternal and Child Nutrition O

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Romslo, I.; Haram, K.; Sagen, N.; and Augensen, K. 1983. Iron requirement in normal
pregnancy assessed by serum ferritin, serum transferrin saturation and erythrocyte pro-
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the prevention of hypoproteinemia without metabolic imbalance in breast milk-fed, very low
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relation to caffeine-containing beverages. Journal of the American Medical Association
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Rosett, H.L. 1983. Therapy of heavy drinking during pregnancy. Obstetrics and Gynecology
52:4146.

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Rosso, P. 1983. Nutritional needs of the human fetus. Clinical Nutrition 2(5):4-8

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66:65&57.

Saarinen, U.M. 1978. Need for iron supplementation for infants on prolonged breastfeeding.
Journal of Pediatrics 93: 177-80.

Saarinen, U.M.; Siimes, M.A.; and Dallman, P.R. 1977. Iron absorption in infants: high
bioavailability of breast milk iron as indicated by the extrinsic tag method of iron absorption
and by concentration of serum ferritin. Journal of Pediatrics 91:36-39.

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Maternal and Child Nutrition O

Saha, N. 1986. Energy equation in pregnancy. Lancer i: 102.

Sandstead, H.H.; Fosmire, G.J.; Halass, E.S.: Strobel, D.A.; and Marks, E.O. 1977. Zinc
deficiency effects on brain and behavior of rats and rhesus monkeys. Teratology 16:229-34.

Sandstead, H.H.; Strobel. D.A.; Logan, G.M.; Marks, E.O.; and Jacob, R.A. 1978. Zinc
deficiency in pregnant rhesus monkeys: effects on behavior of infants. American Journal of
Clinical Nutrition 3 I :844-49.

Sandstrom, B.; Cederbald, A.; and Lonnerdal, B. 1983. Zinc absorption from human milk,
cow's milk, and infant formula. American Journal of Diseases of Children 137:726-29.

Schanler, R.J., and Oh, W. 1980. Composition of breast milk obtained from mothers of
premature infants as compared to breast milk obtained from donors. Journal of Pediatrics
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Scherger, J.E., and Hudson, T.W. 1985. Routine screening for gestational diabetes reconsid-
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congenital malformations of the central nervous system in man? Teratology 7: 117-18.

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1984. Obesity prognosis: a longitudinal study of children from the age of 6 months to 9 years.
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Siimes, M.A.; Vuori, E.; and Kuitunen, P. 1979. Breastmilk iron-a declining concentration
during the course of lactation. Acta Paediatrica Scandinavica 68:29-31.

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Smith&, R.W.; Sheppard, S.; Schorah, C.J.; Seller, M.J.; Nevin, N.C.; Harris, R.; Read,
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Srisuphan, W., and Bracken, M.B. 1986. Caffeine consumption during pregnancy and asso-
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154:14-20.

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Paediutrica Scandinavicn (suppl.):29.

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and diet therapy, ed. M.V. Kraus and L.K. Mahan. Philadelphia, PA: Saunders.

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growth and mental development of intrauterine growth-retarded infants during the first three
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Paediatrica Scandinavica 68:33-37.

Weathersbee, P.S.; Olsen, L.K.; and Lodge, J.R. 1977. Caffeine and pregnancy: a retro-
spective survey. Postgraduate Medicine 625449.

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Circulation 67:A411-14.

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94: l-9.

West, G.; Sobotka, T.; Brodie, R.; Beler, J.; and O'Donnell, M. 1986. Postnatal neu-
robehavioral development in rats exposed in utero to caffeine. Neurobehnvioral Toxicology
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Medicine 112:72&tO.

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Chapter 16

Aging

If thou well observe

The rule of not'too much, by temperance taught
In what thou eat and drink, seeking from thence
Due nourishment, not gluttonous delight,
  Till many years over thy head return:
So may thou live, till like ripe Fruit thou drop
  Into thy Mother's lap, or be with ease
Gathered, not harshly plucked, for death mature.
          John Milton
    Paradise Lost, Book XI (1667)

Introduction

Life expectancy at birth is now 75 years, compared with about 47 years at
the beginning of this century (NCHS 1988). The average age and the
proportion of the older population are also increasing. Individuals over age
65 now comprise 12 percent of the population, compared with 4 percent in
1900. This percentage is expected to rise to 21 percent by the year 2030.
People who survive to old age are living longer. For example, persons
reaching age 65 in 1984 had an average life expectancy of an additional 17
years (19 years for women and 14.5 years for men), and life expectancy at
age 65 has increased 2.5 years just since 1960 (NCHS 1986). This increased
life expectancy for older Americans is resulting in an even more rapid
growth in the populations over age 75 and over age 85.

The lack of a satisfactory definition of old is a problem. What is old? Who is
old? When does one become old? Clearly, physiologic age is not the same
as chronologic age. On the other hand, numerous attempts to find a simple
and accurate indicator of physiologic age have not yet yielded a satisfactory
instrument. This discussion employs simple chronologic cutoffs, recogniz-
ing, however, that there is tremendous heterogeneity within the popula-
tions over 65, over 75, and over 85. The general term older will refer to
Americans over age 65.

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Historical Perspestive

Nutritional issues are prominent in the history of gerontology, and dietary
advice for the aged can be traced back as far as recorded history. The field
of nutrition and aging can be divided into studies in humans on dietary
adequacy, requirements, guidelines, etc. and studies in animal models
aimed at retarding the aging rate via diet. This chapter discusses the human
studies but does not examine in detail the large amount of literature on
animals.

Certain theories about the basic causes of aging are related directly to
nutrition. One theory proposed at the beginning of this century, for exam-
ple, was that the gradual accumulation of toxins secreted by intestinal
bacteria caused aging and that eating certain types of yogurt could prevent
this accumulation (Mechnikova 1921). Aldous Huxley satirized this theory
in his novel After Many a Summer Dies the Swan, in which a character eats
raw carp in an attempt to populate his intestines with the "good" micro-
organisms of this long-lived fish. More recent theories attribute aging to the
gradual oxidation of membrane lipids throughout life and promote con-
sumption of compounds with antioxidant properties (Harman 1982). Di-
etary caloric restriction without malnutrition in rodents and other diverse
animals substantially prolongs lifespan and retards most aspects of biologic
aging (Masoro 1985; Weindruch and Walford 1988). Dietary restriction is
effective in rodents when started in early life or mid-adulthood. This result
has been reproduced many times since it was first described in the 1930's
(McCay, Crowell, and Maynard 1935), but underlying mechanisms remain
vague. Dietary restriction is attracting broad attention because it provides
the best model now available to study the biology of decelerated aging.
How calorie-restricted regimens affect aging in primates is not well known.

Older persons are susceptible to` extravagant claims for the effects of
nutritional manipulations and supplements. Nutritional science provides
an important service by evaluating these claims and limiting the damage
resulting from such quackery (see chapter on dietary fads and frauds).

In the past two decades, the scientific community has increased attention
on the nutritional status of older people. Although specific nutritional
problems have been documented among older Americans, the relationship
of diet to morbidity and mortality in this age group is not always clear. What
is clear is that prevention of many of the health problems of old age must
necessarily begin much earlier in life.

5%


This chapter reviews age-related physiologic, psychologic, and socioeco-
nomic changes that can influence nutritional status of older Americans;
discusses issues related to the nutritional requirements of older persons;
and describes the effects of nutritional deficiencies on the health of the
older population.

Significance for Public Health

Although not inevitable, health and mobility often change and decline with
advancing age. The increasing life expectancy at age 65 observed through-
out this century suggests that diet, exercise, and other personal and socio-
economic factors can help prolong good health for most people (Rowe and
Kahn 1987). Nevertheless, the chances are great that an individual in the
eighth or ninth decade of life will be limited in activity and require health
and social services. Many older Americans suffer from arthritis, heart
disease, hypertension, hearing loss, diabetes, obesity, gastrointestinal
conditions, liver disease, and cancer and other chronic diseases. More than
60 percent of people over age 65 have high blood pressure and approximate-
ly 30 percent have heart disease. Heart disease, cancer, and stroke account
for over three-quarters of the deaths among older persons and 50 percent of
all days of bed confinement (U.S. Senate 1987/88; NCHS 1986).

Such chronic conditions as well as dementia prevent functional indepen-
dence and increase the need for dietary and other long-term care services.
In 1985, for example, more than 5 million persons over age 65 needed
special care to remain independent, and this figure is expected to exceed 7
million by the year 2000. Nearly 3 million older Americans residing outside
institutions have been estimated to require assistance with basic activities
related to food consumption such as shopping, meal preparation, or eating
(Posner and Krachenfels 1987). One survey has estimated that three-
fourths of all patients receiving home health care require therapeutic diets
and could benefit from the services of trained nutrition professionals
(Gaffney and Singer 385).

The total costs of health care for older persons are not known precisely. In
1986, health expenditures made up 29 percent of the nearly $270 billion paid
by the Government for programs and services for the older population, but
older Americans still disbursed an estimated average of 15 percent of their
personal income for health care (U.S. Senate 1987/88).

One difficulty in determining the effect of nutrition on the health of older
Americans is that there are no recent national food consumption and

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O Nutrition and Health

nutritional status data on this group, and hence no data on national trends.
Currently available national data come from the Nationwide Food Con-
sumption Survey (NFCS) conducted in 1977-78 and the National Health
and Nutrition Examination Surveys (NHANES I and II) conducted from
1971-74 and 1976-80 (see chapter on dietary patterns and practices). Some
of this information will be discussed below in the section on energy and
nutrient status of the older population. New national data on food con-
sumption and/or nutritional status of older individuals will be provided by
the U.S. Department of Agriculture's (USDA's) 1988 NFCS and DHHS's
NHANES III, which began data collection in 1988. In addition, plans are
being developed to conduct a special survey of food consumption of older
persons as part of USDA's Continuing Survey of Food Intakes by Individu-
als.

Policy Background

Nutrition Services and Programs

Until the early 1970's, nutrition services for the older population, with the
exception of food stamps, were based almost exclusively in hospitals and
long-term care facilities and included routine dietary screening, nutritional
status assessment, dietary counseling, oral or intravenous nutritional sup-
port, and food service. These services continue to be provided. Because
they are not usually reimbursable under current cost-containment guide-
lines, they are especially vulnerable to fiscal constraints (Posner and
Krachenfels 1987).

In 1973, in response to the growing population of older Americans, to rising
health care costs, and to greater interest in preventive health care, the
Nutrition Program for the Elderly was established under the Administra-
tion on Aging to expand food and nutrition services from the hospital to
include communities and homes. Current Federal programs support the
functional independence of older individuals in ambulatory care centers,
adult day care centers, hospices, and home settings. These food and
nutrition activities include the USDA's Food Stamp Program, which serves
more than 2 million older Americans, and two programs administered by
the Nutrition Program for Older Americans-Congregate Meals, which
also serves about 2 million individuals, and Home-Delivered Meals, which
serves 0.5 million, Despite limitations in size and scope, these programs
have been demonstrated to improve the dietary intake and nutritional
status of participants (Czajka-Narins et al. 1987).

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Aging O

Surgeon General's Workshop on Health Promotion and Aging
The 1988 Surgeon General's Workshop on Health Promotion and Aging
addressed nutrition and aging issues (DHHS 1988). The workshop report
regarding nutrition and aging was based on the premise that "good nutri-
tional status is essential for a high quality of life and food contributes to the
quality of life through psychological, social, as well as physical mecha-
nisms." This premise is based on the assumptions that older people vary
greatly in their social, economic, and lifestyle situations, functional capaci-
ty, and physical conditions; that nutrition policy should be crafted from a
multidisciplinary framework; that a critical shortage of knowledgeable
personnel in the areas of nutrition education, research, and service now
exists; and that because the research base for nutrition of older Americans
is evolving, specific recommendations must be periodically reviewed and
updated.

The workshop report identified priorities related to (1) sound public educa-
tion tailored to the special concerns of old age, such as multiple drug
regimens, appropriate energy intakes, and the effects of existing chronic
diseases on nutritional status; (2) professional education on geriatric con-
cerns integrated into the core curriculum, inservice training, and continu-
ing education of dietitians and other health care professionals; (3) counsel-
ing provided by credentialed nutrition professionals in institutional or
community-based programs providing health services to older adults; and
(4) appropriate financing for nutrition services delivered to older people as
part of routine and long-term care.

Key Scientific Issues

0 Effects of Aging on Nutritional Status
o Evaluation of the Nutritional Status of the Older Population
0 Effects of Nutritional Deficiencies on the Older Population

Effects of Aging on Nutritional Status

Aging is accompanied by a variety of physiologic, psychologic, economic,
and social changes that may compromise nutritional status. All of these
changes do not necessarily occur in all individuals, however, and many
older people remain in excellent health until very old age. Older persons
have a high prevalence of chronic disease, use medications heavily, and are
relatively sedentary. Many of the seemingly inevitable consequences of
aging may actually be caused by these other factors (Letsov and Price

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0 Nutrition and Health

1987). The role of exercise in the health of older tiersons has been reviewed
recently (Smith, Smith, and Gilligan 1988).

Physiologic Changes

Many physiologic functions, including the senses of smell and possibly
taste, decrease with age (Schiffman, Mors, and Erickson 1976; Kamath
1982; Smith, Smith, and Gilligan 1988; Chauhan et al. 1987). These changes
may result in decreased appetite as well as impaired utilization of nutrients
and limitations of function.

Dental problems, common in old age, decrease the ability to chew certain
foods (Albanese 1978). Physical disabilities such as diminution of vision
may make eating less pleasant (Roe 1985). Although the decreases in basal
metabolic rate and physical activity noted with increasing age in some
studies reduce nutrient needs, older people may still consume insufficient
calories and essential nutrients (McGandy et al. 1966; McGandy 1986).
Decreased physical activity also may predispose individuals to the devel-
opment of osteoporosis (see chapter on skeletal diseases).

Changes such as osteoarthritis, which affects 16 million people in this
country, can affect mobility and decrease an older person's ability to
purchase and prepare food (Garetz 1976). Another possible hindrance to
adequate nutrition in the aged is malabsorption, which can be caused by a
decrease or absence of gastric acid secretion and by interactions with
medications commonly prescribed for older persons (Butler and Lewis
1977; Russell 1986; Roe 1985; Hathcock 1987). Whether these changes
contribute to nutrient deficiencies in older people has not been established,
nor is it known whether such changes are related more to the use of
medications, to poor health, or to sedentary lifestyle than to age itself
(Letsov and Price 1987). Recent studies, for example, have demonstrated
that exercise prevents or delays the onset of musculoskeletal disabilities in
older adults (Lane et al. 1987).

Psychologic Changes

The most common psychologic factor affecting nutrition is depression
(Garetz 1976). Of all psychiatric diagnoses, depression is most strongly
correlated with increased morbidity and mortality, regardless of the age of
the subjects (Widgor and Morris 1977; Nielsen, Homma, and Bjorn-
Henriksen 1977), and is most often related to chronic disease and to
poverty, which are common among older persons. At least 30 percent of
noninstitutionalized men and women over the age of 65 live alone
(Todhunter 1976; AARP 1985). Neither institutionalization nor solitary

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