Helping Older Adults Meet Nutritional Challenges

ABSTRACT

Prevention of premature chronic diseases is an important component of healthy aging. Nutrition education can help to reduce the risk of premature chronic diseases in some older adults. Home delivered meals and congregate dining services assist vulnerable elderly persons by providing opportunities for nutritional and social support. Screening and assessment tools identify factors affecting nutritional health and can also provide specific directions for planning, implementation, and evaluation of tailored interventions. Dietitians and allied health professionals are well positioned to assist a heterogeneous population of older adults in securing nutritional adequacy.

KEYWORDS:

• Congregate dining
• food and nutrition
• healthy aging
• Meals on Wheels
• screening

INTRODUCTION

Each generation of elderly persons is shaped by lifelong experiences within a changing environment. Under the umbrella of older adults, there are at least two distinct groups. The dividing period was around World War (WW) II when living conditions changed dramatically. There are still living centenarians who can reminisce about earlier times both before and after WW I, with each year marked by growing urbanization, a high birth rate, and extensive industrialization, when the population on the North American continent grew rapidly. Urbanization brought about socioeconomic and health problems. Living conditions were associated with unsafe water supplies, sewage, and waste disposal. Poverty, poor diet, unsafe food, and milk supplies were among the causes of the omnipresent communicable diseases and early death. Public health services were minimal. Food production and distribution were essentially unregulated from the health point of view. Health care services were rudimentary in range and sophistication. Specialists were few in numbers. In the early 20th century in North America, life expectancy averaged 47 years, and persons aged over 65 years represented 4% of the total population.

The younger generation of older adults, who are referred to as “Baby Boomers,” were born into times of economic growth and increasing prosperity after WW II between 1946 and 1964. The healthy economy had a positive impact on public health issues. Attention started to focus on important legislative, organizational, and financial decisions affecting the provision of health services. With the advent of antibiotics and the decline in communicable diseases, the number of older adults increased (Hastings, 1999). Life expectancy by the year 2000 was extended to 77 years, a large increase within one century. By 2005, adults older than 65 years comprised 13% of the American population (Administration on Aging [AoA], 2006). Those persons 85 years and older were the fastest growing age group in most industrialized countries, and the situation continues.

The extension of life expectancy mostly paralleled the economic status of societies. In rich countries, such as the United States and Canada, life expectancy is among the highest in the world while life expectancy in poor countries, such as those in Africa, has remained low, as illustrated in Table 1 (The Economist, 2007).

TABLE 1. Life Expectancy and Gross Domestic Product (GDP) per head of Selected Countries (Adapted from The Economist, 2007)

Country	Life Expectancy in years Projected 2005–2010	Gross Domestic Product (GDP) per head in US dollars in 2004
Swaziland	29.1 (World's lowest)	5,640
Malawi	41.1	650
Nigeria	44.2	1,150
Tanzania	46.6	670
United States	77.9	39,680
Canada	80.7	31,260
Japan	82.8	29,250
Andorra	83.5 (World's highest)	26,290

DIVERSITY AMONG OLDER ADULTS

The majority of older adults in Western society today live independently in their chosen communities. Nevertheless, they may be placed at nutritional risk at some stage of the aging process if food-related activities are disrupted. This may include factors such as living situation, socioeconomic status, and access to food-related support services. Independent elderly couples are the least at risk. Living alone increases the chance of not eating regularly, particularly among men, unless opportunities to socialize and share meals are available.

A recent prospective cohort study (Willcox et al., 2006) has identified certain midlife risk factors that decrease the probability of healthy aging among men. The greater the number or risk factors that could be avoided or modified in middle age the greater the probability of better health at older ages. Exceptional survival to 85 years occurred when participants maintained greater physical fitness, as evident by greater grip strength; avoided overweight, hyperglycemia, hypertension, smoking, and excess alcohol consumption; and were better educated. Men who had a marital partner in midlife survived longer but did not appear to be healthier in very old age. It was not possible to address nutritional issues in this long-term study of 55 years, but with dietary components associated with the risk of major chronic diseases, a relationship between disease prevention and healthful food choices would be anticipated.

Recent widowers rather than women living alone appear to be at greater nutritional risk with subsequent impact on their health. However, at highest risk are housebound elderly persons who are lacking family support. In a study of independently living older adults aged 60 to 94 years (Payette & Shatenstein, 2005) it was reported that when living situation produced social isolation and perceived loneliness, dietary adequacy was negatively related to degree of loneliness. It is important to differentiate between “aloneness” and “loneliness” since the quality of relationship may be more important than the number of social contacts. Social isolation may be a major contributor to emotional depression; this can result in deterioration of health, accelerated by decreased interest in food, which eventually results in loss of ability to manage self-care.

Research related to social factors and nutritional risks identified two poles. At one pole are widowed individuals in good health, irrespective of gender, in good health and without financial constraints, who continue to drive and remain independent in their dietary self-management. At the other pole are those in poor health with no adequate services or assistance, who experience difficulties obtaining appropriate home or health-care support, have little social contact, and are at great nutritional risk, since their food preparation abilities and dietary intakes could become limited.

Caregivers

Informal care giving remains the most prevalent source of care for the elderly in the community. Research on long-term care for the elderly indicated that two in five care recipients receive all care informally, and two in three receive some informal care. About 30% of persons caring for elderly long-term care users were themselves aged 65 years and older (Agency for Healthcare Research and Quality, 2001). By 2050, the number of individuals using paid long-term care services in any setting will likely double (Family Caregiver Alliance, 2007). Care giving for prolonged periods can be a burden and can cause depression in the caregivers when relief is not provided. When living at home is no longer possible, the option is institutionalization. In 2004, about 1.6 million nursing home residents were 65 years and older (National Centre for Health Statistics, 2006). The number increases drastically with advancing age (Table 2). Over half of the older residents of nursing homes were among the oldest old (He et al., 2005).

TABLE 2. Nursing Home Residents among People Aged 65 and by Age and Sex: 1999 (Adapted from He et al., 2005)

Age in years	Men	Women
65–74	10.3	11.2
75–84	30.8	51.2
85 and older	116.5	210.5

Living Location

Location is another issue of concern. Elderly persons residing in rural areas could be at greater nutritional risk, versus those in urban areas, because of isolation. Obtaining food requires transportation. Widowed women must be able to drive or have access to public transportation. Both of these conditions are not often met. Approximately 25% of adults aged 65 years and older in the United States live in rural areas; thus, the proportion of the population affected is large (McLaughlin & Jensen, 1998). However, it has been reported that rural elderly persons receive more support from family members and the community than do their urban counterparts. Opportunity to socialize and share meals can rekindle interest in eating and lead to greater variety in food use. Meal programs such as congregate dining and home-delivered meals are much needed for the older adults living in rural areas.

Socioeconomic Status

An individual's purchasing power is constrained by socioeconomic status. Older adults who are on fixed incomes may have to reduce the allocation of money for nutritious food. The relationship of income to food intake is complex. The use of cheaper brands and concern with food waste may precede limiting the amount of food. Compared with the average single living individual or childless married couples, the elderly tend to spend less money on food. Females spend less money than males. Of the total food expenditure, the elderly allocate less money to eating out than other lifecycle groups. This had been attributed to decreased mobility, reduced income, and fewer opportunities to purchase foods away from home (Krondl & Coleman, 1987).

Ethnicity

A fairly large proportion of older adults in the United States (US) and Canada are made up of immigrants. These older individuals of minority cultures are often at greater risk of poor health, isolation, and poverty (Garcia & Johnson, 2003; Johnson & Garcia, 2003; Jones, 2005). In the US, minority elders comprise over 16% of all older Americans aged 65 years and older in 2005; these numbers are expected to rise dramatically. The older minority population is projected to increase by 217% between 1999 and 2030, compared with only 81% for the older white population (AoA, 2006). The special needs of this growing minority population must be recognized. Interventions such as nutrition education and meal programs should include racially and culturally appropriate components to meet the requirements of this diverse population of older adults.

HEALTH AND NUTRITIONAL STATUS OF THEOLDER ADULTS

Chronic Diseases

Health status of older adults decreases with age. While 43% of Americans aged 65 years and older are in very good health, 33% of those between 75 and 84 years, and 28% older than 85 years subjectively considered themselves to be healthy (AoA, 2006). Some of the elderly are burdened with chronic diseases, including being overweight and obese. Obesity is one of the most common nutritional disorders in older adults. Nutritional factors are especially pronounced in increasing obesity among seniors 65 years and older from 12% in 1990 to 19% in 2002 (Lucas, Schiller, & Benson, 2004); undernutrition continues to be a pervasive problem in older adults with inadequate income and hunger.

The metabolic syndrome (MetS) is related to diet and lifestyle. MetS is a clustering of chronic disease risk factors, including abdominal obesity, dyslipidemia (elevated triglycerides and/or low levels of high-density lipoprotein cholesterol), elevated blood pressure, and elevated fasting glucose. Individuals with MetS are at high risk of developing type 2 diabetes and cardiovascular disease, and have greater mortality rates than those without the syndrome (Brien & Katzmarzyk, 2006). The chronic diseases diagnosed in the majority of older adults are included in the MetS cluster.

There may be a genetic predisposition to the metabolic aberrations in chronic diseases such as hyperlipidemia and diabetes. Technological advances in genomic research and nutrigenomics (Afman & Muller, 2006; Ordovas, 2006) will enable the development of customized designer foods based on an individual's genetic profile, with products to treat or prevent diseases earlier and better (Coulston et al., 2003; University of Toronto, 2006).

Nutritional genomics (nutrigenomics) is described as a combination of molecular nutrition and genomics. It is a relatively new area of study, but has far-reaching potential in the field of dietetics. Genetic information about individuals could lead to more specific dietary recommendations, and may further the prevention of diet-related disease (Debusk et al., 2005). An individual's personal genetic profile on a compact disc can be purchased for around half a million dollars (Elias, 2002). This information will allow personalized approaches to disease treatment and prevention (Coulston et al., 2003). Considerable research will be required to better understand complex diseases and to further identify the molecular pathways that are influenced by individual nutrients. Eventually, nutrigenomics will have practical applications that change generalized nutrition recommendation to targeted interventions to help consumers optimize their health potential (Debusk et al., 2005).

PREVENTION: NUTRITION EDUCATION, HEALTHY EATING, AND MEAL PROGRAMS

Nutrition Education

Reducing the risk of premature chronic disease in some older adults may be helped by the promulgation of accurate information through education programs and individual counseling, translating nutritional guidelines into manageable food use. Knowledge may not be reflected in actual practices without attention to the past experiences and perceptions of the target audience. The subgroup of “younger” older adults may be more receptive to knowledge-based intervention (DeWolfe & Millan, 2003). The future generation of the elderly is likely to be more health conscious and better educated; innovative approaches to nutrition education will be needed to keep pace with these changes (Krondl & Coleman, 1987). The message must be tailored to the target audience, and skill in selling the message is required (Gordon, 1983).

Healthy Eating

North Americans are confronted by an ever-increasing variety of food such as imported products, frozen meals, genetically modified foods, irradiated foods with prolonged shelf life, and organic foods. Fresh fruits and vegetables that were once considered exotic are available throughout the year. This food abundance did not seem to significantly effect the caloric consumption of elderly men and women in Canada, as shown from a comparison of two surveys by Health Canada (Garriguet, 2004) between 1970–1972 and 2004. In contrast, the caloric consumption of elderly persons aged 51 to 71 years in the US has increased over this same period. Despite easy and available access to fruit and vegetables, consumption of this food group by the elderly is below the recommended number of servings; the situation is worse for the 71 years and older-aged subgroup. Efforts must be made to improve the consumption patterns of older adults, in particular the intake of fruits and vegetables. The Transtheoretical or Stage of Change Model has been found useful in planning strategies to change the dietary behaviors of older adults (Greaney et al., 2004; Green et al., 2004).

The protective role of omega-3 fatty acids in reducing the risk of cardiovascular disease may be familiar but not incorporated into eating patterns. Preliminary evidence linking omega-3 fatty acids to reduction in risk of dementia and Alzheimer disease has been found but must be repeated in other studies before confirmation (Schaefer et al., 2006). A protective effect for more than one health condition would be advantageous.

Meal Programs: Meals on Wheels and Congregate Dining

Nutrition is recognized as one of the major determinants of successful aging, defined as the ability to maintain three key behaviors: low risk of disease and disease-related disability, high mental and physical function, and active engagement of life (Rowe & Kahn, 1998). As a primary prevention strategy, nutrition helps to promote health and functionality; millions of older Americans would benefit from nutritional services if they were broadly available (American Dietetic Association, 2005).

Meal programs for the elderly have a long history. The first organized meal delivery service to the elderly who had been displaced by the Blitz was established in Great Britain during WW II by the Women's Volunteer Services. The benefits of this delivery service gained recognition and continued as a peacetime effort. Later, the idea was carried across the Atlantic. The first Meals on Wheels program in the United States began in 1954 on a volunteer basis. The program was initiated by Margaret Toy, a social worker at the Lighthouse, a settlement house in northern Philadelphia (Lloyd, 1997). In Canada, the first Meals on Wheels program was introduced in 1963 by the Independent Order Daughters of the Empire (IODE) and the Red Cross in Brantford, Ontario. Many of the early programs in Ontario were sponsored and organized under the auspices of the Red Cross and IODE. In subsequent years, as the benefits of the program gained recognition, sponsorship extended to include the Victorian Order of Nurses, service clubs, churches, centers for elderly persons, hospitals, homes for the aged, and nursing homes with partial financial support from the provincial Ministries of Community and Social Services and Health (Meals on Wheels of Ontario, 1992).

Meal programs—both home-delivered meals and congregate dining—have been evaluated to be effective and efficient in delivering nutrient-dense meals, and demonstrated better food intake and improved nutritional risk in their participants; congregate meal programs also provided opportunity for socializing among high-risk older persons (Mathematica Policy Research, 1996; Millen et al., 2002; Wellman, Rosenzweig, & Lloyd, 2002; Kretser et al., 2003; Gollub & Weddle, 2004; Roy & Payette, 2006; Keller, 2006). Future efforts should focus on exploring additional funding sources from federal, state, or local agencies to increase program availability so that those elderly persons who are at low or moderate nutritional risk can also benefit from this preventive nutrition service.

FUTURE CHALLENGES

Screening and Assessment

Nutritional risk screening and health assessment for the general older adult population should be in place to identify the needs of the different elderly subgroups. Results from screening and assessment will enable the planning and implementation of tailored and appropriate programs such as meal service, congregate dining or home-delivered meals, group nutrition education or individual counseling, and special dietary prescriptions or nutrient supplements to meet the requirements of the individual. The necessity for nutritional risk screening and its usefulness in program planning and implementation is well documented (Sharkey, 2002, 2004; Weatherspoon et al., 2004; Lee, Frongillo, & Olson, 2005a, 2005b). Besides identifying needs, nutrition risk screening can raise awareness in the elderly regarding health issues, and can target limited resources (Rush, 1997; Chernoff, 2001). Several health and nutrition indices that are specific to older adults in the community have been developed. The most commonly used screening tool in the US is the Nutrition Screening Initiative Checklist, or the DETERMINE checklist (White et al., 1992). In Canada, two screening indices have been developed: The Elderly Nutrition Screen (ENS^©) is designed for use with older adults who require home support (Payette, 2005), and the SCREEN^TM is for use with older adults in the general population (Keller et al., 2000; Keller et al., 2001). Different screening instruments may be required for different segments of the older adult population because they may range from well and successfully aging to chronically ill and disabled (DeWolfe & Millan, 2003). Further research would be required in developing appropriate screening tools for a culturally and racially diverse population of older adults. At present, most nutrition and health prevention efforts have targeted those elderly persons that are at high health risk (Wellman et al., 2002); however, healthier and “younger” older adults should also be targeted for prevention of early onset of disease and declines in function (Drewnowski & Evans, 2001; Sahyoun, 2002).

Maintenance of Independence

A common goal for all older persons is to maintain independent living, especially for the Baby Boomers who have a goal of wellness. They want the health care system to keep them healthy and have no desire to go into nursing homes. The expected and most acceptable option is home care (Gendreau, 1997). In order to meet the needs of this heterogeneous group of older adults, expanded full-service community programs, including meal service, transportation, shopping assistance, wellness and exercise programs, medical and case management, respite care, and caregiver support, would have to be provided (Wellman et al., 2002). Community-based and cost-effective services, nutrition screening, and early intervention may enable the elderly to live independently and enjoy old age; intervention strategies have to take into account both physical and psychological well being and functional independence (Weatherspoon et al., 2004).

Increased Need for Geriatric Care

Since the eradication of infectious diseases as major causes of death in the general population, public health professionals have turned their attention to the diseases that affect middle and older age groups such as cardiovascular disease, stroke, type 2 diabetes, and cancer. Epidemiological studies led to education about preventive lifestyle practices, especially diet and exercise. Increased attention was turned toward the elderly as having special needs. The range of professionals and experts was broadened to include clinical dietitians, community nutritionists, and, later, gerontological nutritionists.

The older adults are the largest consumers of health care resources. Medication use by seniors accounts for 34% of prescription drugs. The adverse effects of some drugs may include dizziness, numbness, dehydration, loss of appetite, nausea, or diarrhea. Elderly persons taking multiple medications may be prone to falls, depression, confusion, hallucination, and malnutrition. The patient may be at risk of inappropriate drug dosage.

Unfortunately, specialization in geriatrics is not selected by many graduates in medicine; in Canada, with approximately four-million people older than 65 years, the number of geriatricians is 200. The same situation prevails in the US. A recent article (Gawande, 2007) describes the new demography and the difficulties that older adults will have in accessing appropriate health care to maintain well being in later years. Between 1988 and 2004, the number of certified geriatricians in the US decreased by a third, and few graduates in medicine opted for specialization programs in this area. In 2007, 300 doctors will complete geriatrics training in the US, while more than this number of persons will retire. A solution involves providing courses in geriatrics for primary care doctors. Another alternative is being studied in the Baltimore and Washington, DC area, where local nurses are being recruited for a highly compressed three-week course in how to recognize specific problems in the elderly and then determine appropriate solutions. It implies that registered dietitians could be the best qualified professionals to provide nutrition services to older adults in the community and be proactive in health promotion and risk reduction (Wellman, 2007).

Preventing disease and functional disability is a significant challenge for the public health system (Drewnowski & Evans, 2001). Improving the nutritional status of all elderly persons should be the ultimate goal of health prevention incentives and programs. However, most nutrition support for the elderly in the United States is targeted toward the high-risk elderly subgroups because of budget constraints (Millen et al., 2002; Wellman & Kamp, 2004) and there are no legislated meal programs for the elderly in Canada. Health prevention there is mostly targeted toward the adults and youths (National Research Council Committee on Diet and Health and Food and Nutrition Board Commission on Life Sciences, 1989). Additional research to develop better screening instruments and support from government to institute mandatory nutritional screening is required. The next challenge is to expand available resources, monetary and personnel, and coordinate operations between federal, state, or provincial and local community agencies for the provision of tailored interventions that are economical, easily accessible, and ethnically and culturally acceptable to meet the needs of the heterogeneous elderly population in maintaining health, independence, and quality of life.

SUMMARY

	Heterogeneity in the elderly population necessitates customized treatment and prevention measures.
	Prevention approaches have to be multifaceted, including nutrition education on healthy eating and provision of nourishment via food-based programs.
	Nutrition risk screening and health assessment should be in place to identify specific needs of the heterogeneous elderly subgroups.
	Registered dietitians can serve as expert consultants in coordinating nutrition services to older adults in the community and can be proactive in health promotion and risk reduction.

Additional information

Notes on contributors

Magdalena Krondl

Magdalena Krondl (PhD, RD) is Professor Emeritus, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Patricia Coleman

Patricia Coleman (MS) is research consultant in private practice.

Daisy Lau

Daisy Lau (PhD, RD) is research consultant in private practice.