December 2018 Issue

Individualized Diets for Older Adults
By Ginger Hultin, MS, RDN, CSO
Today's Dietitian
Vol. 20, No. 12, P. 36

Learn about their importance for improving overall health and quality of life in long term and postacute care.

Nutrition plays a critical role in rehabilitation and quality of life as people age. Dietitians from different specialties will encounter older adults in many clinical and community settings.1 The elder population may need nutrition adaptations, including supplements, texture and consistency modifications, and meal timing adjustments, in addition to therapeutic diets for a variety of health conditions. Balancing the need for diets to support longevity and health with dietary preferences and a sense of control and autonomy is critical when working with older adults.1 Therefore, individualizing diets for these patients, especially in long term and postacute care, is a place where dietitians can have the most impact.

New Guidelines for the Aging Population
In April 2018, the Academy of Nutrition and Dietetics (the Academy) published a new position paper, "Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings," by Becky Dorner, RDN, LD, FAND, and Elizabeth Friedrich, MPH, RD, CSG, LDN, FAND.2 This paper states that the quality of life and nutrition status of older adults in long term care, postacute care, and other settings can be enhanced by individualized nutrition approaches. These approaches take into account individual patient preferences, personal history, and culture, as well as health-related needs to create a dietary plan patients enjoy and are in agreement with. Baby boomers (the largest generation) started turning age 65 in 2011, beginning the boom in the percentage of those in the older adult age group. Currently, 15% of the population is aged 65 or older. By 2030, that number is expected to increase to 21%, or 74 million people.2,3 "As the population of older adults in the US grows rapidly, RDs are seeing older adults across the spectrum of care," explains Dorner, who's owner of Becky Dorner and Associates, a resource for healthy aging and nutrition care for older adults. Whether or not dietitians work specifically with older adults, RDs likely will encounter them in transitional care centers, nursing homes, assisted living, outpatient practice, Meals on Wheels and congregate meal programs, and home care and hospice, and will need to assess their needs to provide nutrition education.

Because of the rapid growth of this diverse population, all dietitians will benefit from learning how to individualize diets and prioritize its needs. Friedrich, owner of Friedrich Nutrition Consulting, which provides nutrition services for older adults and education for health care professionals, agrees that all RDs need to be educated on this subject. "Because dietitians (no matter their area of expertise) often serve as sources of information for friends and family, an understanding of the standard of care in these settings could be useful to all dietitians, no matter what their area of expertise is." Whatever clinical or community setting in which a dietitian is employed, understanding how to individualize diets to suit the needs of older adults, especially in transitional care, is a critical part of their education.

Age-Related Challenges in Nutrition
The term "older adults" includes a large age range. Older adults generally are considered to be the group aged 65 and older, but it can be further divided into ranges: 65 to 74 years (young old), 75 to 84 years (old), and 85-plus years (oldest old).2 Estimates from the 2010 National Health Interview Survey showed that 45.5% of older adults 65-plus years report having two to three chronic medical conditions, and 17.1% have four or more chronic conditions, an amount significantly higher than those in younger age groups.1-5

Some older adults face social factors that affect their dietary intake, such as food insecurity, lack of transportation, and the inability to purchase and/or prepare food.6,7 They may experience health problems, including cerebrovascular accidents, Parkinson's disease, cancer, diabetes, and dementia, and age-specific related factors such as difficulties with activities of daily living, anorexia of aging, and malnutrition.1-3 Yet some older adults remain vibrant, active, and healthy. Therefore, assessing older adults with a holistic, personalized approach to determine which dietary pattern may support them best as well as evaluating potential barriers to achieving optimal health is an important job for dietitians.

Nutrition Needs of Older Adults
There are several nutrients of concern in the older adult population. Older adults are at increased risk of developing protein-energy malnutrition in community living settings, hospitals, and other institutions. Negative energy balance and inadequate protein intake can lead to poor health outcomes, but these are modifiable risk factors that dietitians can address.8 Many older adults are insufficient or deficient in vitamin D, vitamin B12, and protein due to low intake or malabsorption. Studies show that micronutrient deficiencies in older adults tend to worsen with increasing age due to continued malabsorption and poor nutrient utilization (intrinsic factors), in addition to polypharmacy, decreased appetite, and the inability to perform activities of daily living such as meal preparation (extrinsic factors).7 It's ideal for older adults to obtain required nutrients such as vitamin D, the B vitamins, and minerals including potassium, calcium, magnesium, and selenium, in addition to dietary fiber and protein from the foods they eat. Dietitians should consider these unique needs when individualizing diets for older adults, as they change over time.8

Weight Changes in Older Adults
In addition to developing unique nutrition needs, older adults also experience weight changes as they age. Sedentary older adults are more likely to experience a precipitous loss of lean body mass and increased fat mass leading to overweight and obesity. And many older adults who are overweight or obese may be malnourished in micronutrients due to overeating foods that are calorie dense and nutrient poor.3

Research suggests that helping overweight or obese older adults lose clinically significant amounts of weight could be beneficial to health but to use caution because weight loss in this population may do more harm than good. During the aging process, older individuals often experience age-related weight loss-induced sarcopenia and bone loss as well as changes in body composition, which can accelerate disability.9 Because of this, many older adults require fewer calories to maintain a healthy weight. Older adults become at risk of undesired weight gain if they continue consuming the same number of calories they did as younger adults. Some patients, as they attempt to restrict calories and reduce portion sizes to maintain a normal weight, risk improper nutrient intake with their decreased intake. So when considering counseling this population on weight loss, make sure to assess mobility, quality of life, and physical function—factors that aren't usually considered in younger adults.6 Friedrich explains, "As the number of obese adults in our country continues to grow, it is most critical that dietitians (and other professionals) understand the risks vs benefits of weight loss for older adults. That includes the role of honoring individual preferences and choices and maximizing quality of life. This overlaps with the issue of providing diets that are as liberal as possible." It's important for dietitians to help older clients maintain a healthy weight but in ways that support their health and well-being. MyPlate guidelines suggest making small adjustments to help patients enjoy their foods and beverages such as adding sliced fruits and vegetables they enjoy to meals and snacks, choosing ones that are prepared or presliced for ease if dexterity or eyesight is a challenge.8

In one large systematic review of randomized controlled trials on weight loss interventions in older adults with obesity, researchers observed greater weight loss in groups that had a dietary component than in those with exercise alone. Exercise alone led to better physical function but no significant weight loss. However, the combination of diet and exercise yielded the greatest improvement in physical performance and quality of life, and it reduced the loss of muscle and bone mass that occurred in the diet-only groups.9

With this in mind, RDs can help plan physical activities or encourage other qualified health professionals to do so. Being physically active can help older patients stay strong and independent as they age. Adults at any age need at least 2 1/2 hours or 150 minutes of moderate-intensity physical activity at least three days per week.8 Sedentary older adults who get approval from their doctors to exercise can begin walking or riding a stationary bike, aiming for at least 10 minutes of exercise at a time. Older adults should include activities that improve balance and reduce their risk of falling, such as strength training with light weights two times per week.8

While many older adults struggle with overweight and obesity, others suffer from malnourishment and underweight as a result of food insecurity, lack of transportation, and/or the inability to prepare food on their own. In addition, psychosocial factors including lack of independence, social isolation, and depression can make food less appealing and lead to decreased consumption and undesired weight loss.2

The consequences of malnutrition include loss of strength and function, increased risk of falls, depression and lethargy, decreased immune function leading to greater risk of infection and delayed recovery from illness, pressure injuries, poor wound healing, higher risk of hospital admission and readmission, additional medical costs, and increased mortality. Of course, if weight loss is an individual's choice, dietitians can develop a nutrition care plan that includes adequate protein and calories to meet nutrient needs and prevent malnutrition.2

Chronic Disease and Therapeutic Diets
Healthful diets tailored to patients' preferences and lifestyles can help them reduce the risk of developing high blood pressure, type 2 diabetes, hypertension, and heart disease, or at least help them better manage these conditions.8 One of the easiest dietary changes patients can make is to increase the use of herbs and spices to reduce sodium intake. Other changes, such as counting carbohydrates or restricting sweets for older patients with type 2 diabetes, especially in long term care facilities, may reduce quality of life and lead to decreased food intake, and even put patients at risk of hypoglycemia. Often, chronic diseases in older adults are medically managed to enhance the joy of eating and improve quality of life while lowering risk of malnutrition.2

Other Dietary Considerations

Polypharmacy
In addition to meeting dietary requirements and managing chronic disease, there's the issue of multiple medication use. However, dietitians can help assess the use of medications and supplements that may be compounding eating challenges. Many medications have side effects that affect the gastrointestinal tract and appetite, so it's important for older adults to work with their doctors and pharmacists to ensure medications aren't inhibiting food and nutrient intake.8 "When providing a list of medications, people may only provide their prescription medications, so we need to ask the right questions to get the information we want and need," Dorner says. "For example, I talked with an RDN just last week who discovered her patient was taking a supplement that was causing an interaction with one of her prescription medications and creating a negative side effect for the patient. Once they stopped the supplement, the side effect disappeared."

Catering to Diverse Populations
As baby boomers age, the older adult population will become more generationally diverse, causing dietitians to counsel older adults based on not only individual needs but also generational preferences. Dorner explains the differences between the generations. For example, baby boomers (born between 1946 and 1964) tend to expect more than the Silent Generation (born between 1925 and 1945). "They're used to little luxuries like fancy coffee and greater variety in meal choices," she says. "Gen X (born between 1965 and 1980) tends to be more health conscious, demanding farm-to-table options, and fresher, healthier food options. They also may choose vegan diets [or] gluten-free [foods], or follow other trends or food fads." The more dietitians can individualize diets for the unique desires of each generation, or subgeneration, the better the health outcomes.10

Dorner also suggests RDs keep up with the latest consumer trends and consider the communication preferences of each generation. Some generations may prefer group or in-person meetings, phone conversations, or e-mail, while others may prefer texting and using social media for nutrition messaging. Providing patient-directed care along with food choices that reflect the culture of the individuals they serve will be a critical piece of promoting individualized diets for older adults.

Moreover, Dorner and Friedrich encourage RDs to learn about their patients' cultural and ethnic heritage to better individualize diets. "RDNs need to understand the populations they're serving and learn about their ethnic heritage and cultural traditions," they say. RDs who work in long term care facilities should take personal preferences into consideration and incorporate appropriate daily menu options to serve the needs of older adults.

Liberalizing Diets
As part of taking personal preferences into account, it's important for dietitians to enable older adults to eat a wide variety of the foods they desire. The Academy advocates that as part of the interprofessional team, dietitians play a role in assessing, evaluating, and recommending appropriate nutrition interventions according to each individual's medical condition, desires, and rights to make health care choices.2 Critical to caring for this population is suggesting and advocating for the least-restrictive diet possible given each individual's unique needs and preferences, and assessing risks vs benefits of therapeutic diets, especially for frail older adults. Among nutrition professionals, it's well understood that food is essential to quality of life. An unpalatable diet can lead to poor food and fluid intake, resulting in malnutrition, frailty, and other related negative health outcomes.2 So it's important for dietitians to support older adults by including them in decisions about their food, which can increase their desire to eat.2 Involving them in diet and supplement orders, texture and consistency modifications, menu selections, dining locations and atmosphere, and meal/snack times, can help older adults maintain a sense of dignity, control, and autonomy in any care setting, and dietitians play an important role in achieving these results.

Recommendations for RDs
The bottom line for dietitians is to treat each older adult as a unique individual and create a diet as personalized and as liberalized as possible for their health and enjoyment. "In general, older adults have some different nutrient needs than younger adults, but there's such a wide range of needs based on health, personal preferences, goals for care, quality of life, and so many other issues," Dorner explains. "Even in nursing home settings, there's no 'typical' nursing home resident. A lot of nursing facilities offer rehab for baby boomers who have had knee replacement or hip replacement. These could be active runners or tennis players. They want to know how to get back in the game and continue to live healthy lives. On the other side of the health spectrum, many facilities also offer palliative care and hospice care for older adults who may be at the end of life. These older adults may be looking for quality of life for the time they have left. The approach to their care is very different." So as the older adult population continues to increase and become more diverse, ensure that facilities and staff are providing culturally and ethnically appropriate dietary options that appeal to their unique community needs and requests.

— Ginger Hultin, MS, RDN, CSO, is a nutrition and health writer and certified specialist in oncology nutrition based in Seattle. She's past-chair of the Vegetarian Nutrition Dietetic Practice Group, past president of the Chicago Academy of Nutrition and Dietetics, and author of the blog Champagne Nutrition.

References
1. Ward BW, Schiller JS. Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chronic Dis. 2013;10:E65.

2. Dorner B, Friedrich EK. Position of the Academy of Nutrition and Dietetics: individualized nutrition approaches for older adults: long-term care, post-acute care, and other settings. J Acad Nutr Diet. 2018;118(4):724-735.

3. US Department of Health and Human Services, Administration for Community Living, Administration on Aging. 2017 profile of older Americans. https://www.acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2017
OlderAmericansProfile.pdf
. Published April 2018. Accessed July 1, 2018.

4. Porter Starr KN, McDonald SR, Bales CW. Nutritional vulnerability in older adults: a continuum of concerns. Curr Nutr Rep. 2015;4(2):176-184.

5. Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat 10. 2012;10(252):1-207.

6. Hengeveld LM, Wijnhoven HA, Olthof MR, et al. Prospective associations of poor diet quality with long-term incidence of protein-energy malnutrition in community-dwelling older adults: the Health, Aging, and Body Composition (Health ABC) Study. Am J Clin Nutr. 2018;107(2):155-164.

7. ter Borg S, Verlaan S, Hemsworth J, et al. Micronutrient intakes and potential inadequacies of community-dwelling older adults: a systematic review. Brit J Nutr. 2015;113(8):1195-1206.

8. Older adults. United States Department of Agriculture, ChooseMyPlate.Gov website. https://www.choosemyplate.gov/older-adults. Updated July 17, 2018.

9. Batsis JA, Gill LE, Masutani RK, et al. Weight loss interventions in older adults with obesity: a systematic review of randomized controlled trials since 2005. J Am Geriatr Soc. 2017;65(2):257-268.

10. Fredriksen-Goldsen KI, Kim HJ. The science of conducting research with LGBT older adults — an introduction to aging with pride: National Health, Aging, and Sexuality/Gender Study (NHAS). Gerontologist. 2017;57(Suppl 1):S1–S14.

DISEASE-SPECIFIC CONSIDERATIONS

Obesity/weight loss. Overweight and mild obesity status may have some benefit in the older adult population, exerting a protective effect for some people in regard to mortality and survival. If weight loss is appropriate and desired by the patient, ensure adequate protein, calories, and nutrients in the diet and monitor weight loss closely.

Diabetes mellitus. Hypoglycemia is the most important factor in determining glycemic goals, which may need to be readjusted to an A1c of <8% to 8.5% in some patients. Dietary restriction isn't an important part of diabetes management for older adults; it's generally managed with medications.

Chronic kidney disease. Because of shifts in body weight due to fluid status changes, malnutrition may be more difficult to assess. Liberalize protein restrictions to ensure older adults get adequate intake. For those on dialysis, protein needs are greater, so work to ensure needs are being met. Sodium, potassium, phosphorus, and fluid restrictions should be individualized for each patient based on clinical judgment on a case-by-case basis.

CVD. Goals for blood pressure control in the older adult population may be set to <150 mm Hg systolic and <90 mm Hg diastolic (140/90 for people with diabetes and chronic kidney disease). Sodium restriction in this population may not be indicated depending on intake and food preferences. Serum lipid goals for the older adult population don't yield a clear benefit in current research. Instead, guidelines suggest assessing a collection of risk factors and continuing to provide a diet as liberalized as possible. Healthy US-Style, Healthy Vegetarian, and Mediterranean-Style Eating Patterns, in addition to the Dietary Approaches to Stop Hypertension, or DASH, diet may be appropriate for some patients.

Cognitive impairment. Because unintended weight loss is common in those with moderate to severe Alzheimer's disease and other types of dementia, diets also should be as liberalized as possible considering the patient's food preferences with a focus on nutrient-dense foods while offering feeding assistance, if needed.

Undesired weight loss. Consider social support, feeding assistance, mealtime ambiance, and environment and a liberalized diet factoring in food preferences.

— GH


CASE STUDY

Dana, aged 67, is admitted to postoperative care in the hospital after undergoing a bilateral full knee replacement necessitated by severe osteoarthritis, limiting movement and causing pain. Dana lives alone and needs help with activities of daily living and pain management while recovering. She has a BMI of 24.5, prehypertension, and low serum vitamin D status, and is a lacto-ovo vegetarian. Dana says her goal is to rejoin her swimming group and play recreational tennis. She has a trip to Italy planned in eight months and is motivated to recover quickly.

Her physician orders a sodium-restricted, 1,500-kcal vegan diet, but she has requested a dietitian because she doesn't care for the food options at the facility. Because Dana is a lacto-ovo vegetarian, the RD suggests liberalizing her diet to include eggs and dairy as sources of protein and dietary vitamin D to provide more options for her to enjoy. Dana is health conscious and says she follows the MyPlate guidelines to make one-half of her meals fruits and vegetables. Given Dana's dietary preferences and health literacy, the RD suggests lifting the sodium restriction while monitoring her blood pressure daily. The RD suggests increasing the calorie range to 1,800 given Dana's previous level of physical activity and the work she'll be doing with physical therapy in the hospital. Dana's protein and calorie intake improves to support healing, and she says she now enjoys the options offered at the hospital.

— GH
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