Aging @)

living necessarily induces depression, but such life changes may be associ-
ated with poor self-esteem, which, in turn, can lead to significant changes
in eating patterns (Letsov and Price 1987). Depression is one psychiatric
disorder that can be treated successfully, but recent advances in therapy
are not disseminated to health professionals widely or rapidly enough to
make maximum impact (NIA 1987).

Economic and Social Changes

Older Americans as a group have a lower economic status than other adults
in the United States (U.S. Census Bureau 1977; U.S. Senate 1987/88).
Although the percentage of older individuals living below the poverty level
(12.4 percent in 1984) has decreased substantially over the past two dec-
ades and is now less than the percentage of those under 65 living in poverty
(14.7 percent in 1984), poverty continues to be too high. The decline in
income most often results from retirement from the workforce, the effects
of inflation on fixed incomes, death of a wage-earning spouse, or failing
health (U.S. Senate 1987/88). Income and health status have been found to
be important determinants of life satisfaction in the older population (Chat-
field 1977). Low income is also a major risk factor for inadequate nutrition
in older individuals (DHEW 1974; Guthrie, Black, and Madden 1972).

Most older people do not live in institutions, but older Americans as a
group are more likely to be institutionalized temporarily or permanently
(Kane 1984). Although institutional food is likely to meet minimal stan-
dards for nutrient content, factors such asa lack of choice or limited day-to-
day variety may increase the risk of inadequate consumption. Many resi-
dents of nursing homes consume a therapeutic diet (NCHS 1981) that may
further discourage adequate intake. An important issue for demented
institutionalized individuals is that they may not consume the food, not that
the menu is inadequate (Sandman et al. 1987).

Evaluation of the Nutritional Status of the Older Population

Methodological Issues

Assessing the nutritional status of the older population—and other popula-
tions—requires clinical studies to evaluate physical signs of nutritional
health or disease, dietary studies to evaluate nutrient intakes with accepted
standards, and laboratory investigations to provide data about quantities of
particular nutrients in the body or to evaluate certain biochemical functions
that are dependent on an adequate supply of a particular nutrient. Because
use of a single measure is rarely sufficient to establish the level of malnutri-
tion in a population, nutritional assessment is best accomplished using a

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ie Nutrition and Health

combination of these methods. The greater the number of measurements
yielding values below standard, the more likely a population is to suffer
from poor nutritional status.

Nutritional status evaluation of older people is complicated, and a number
of methodological caveats should be kept in mind when evaluating the
results. Clinical and dietary standards for younger adults may not be
appropriate for older persons, yet few data are available on nutritional
requirements or recommended intakes of older adults. The Recommended
Dietary Allowances (RDA’s), for example, were developed largely from
research on the nutrient needs of young healthy people. The present
standards for adults over age 50 are, for the most part, identical to those for
people ages 23 to 50 (NRC 1980). Because these standards fail to consider
the great heterogeneity of adults whose ages may differ by as much as 50
years (Schneider et al. 1986) and because they were often not developed
from actual measurements on older populations, their appropriateness for
older Americans is not known (Suter and Russell 1987).

Collection of dietary data in older individuals based on recording or recall-
ing food eaten over a specified period of time is complicated by an in-
creased prevalence of dementia and forgetfulness in older persons, which
may result in underreported nutrient intakes (Beaton 1985; Hunt et al.
1983). It has also been difficult to separate behavioral changes in dietary
intakes from the effects of aging processes on dietary and nutritional status.
For example, 70 percent of a sample of older subjects indicated some
change in food habits in recent years for health reasons, changes in living
status, beliefs, or finances (Todhunter 1976). The Ten State Nutrition
Survey found that two-thirds of the older population had changed their
diets in the 4 years before the study (DHEW 1972). Male participants in the
Baltimore Longitudinal Study of Aging reduced their cholesterol intake
significantly during the period 1961-75 (Elahi et al. 1983). Whether advice
from health professionals is responsible for such changes has not been
established. However, these changes need to be considered when making
inferences about the effects of aging processes on nutrition in older persons
taken only from surveys conducted at a single point in time.

Similar issues apply to use of laboratory tests, body measurements, and
body weights to assess the older population’s nutritional status. Evaluation
of height and weight measurements to define obesity, for example, is
complicated by the loss of stature that accompanies aging (Bowman and
Rosenberg 1982). Measurements of actual heights, weights, and body
skinfolds in older populations have led to the development of standards
substantially different from those for younger adults (Frisancho 1984).

602
Aging O

Health status also affects such measurements; nutritional measures of
older homebound individuals differ significantly from those of younger and
less restricted groups (Sherman et al. 1983).

It is also difficult to make generalizations about clinical signs of undernutri-
tion in older persons. For example, changes in subcutaneous tissue and
skin that occur normally with age may mask clinical signs of vitamin
deficiency (McClean, Dodds, et al. 1976). However, NHANES did not find

high percentages of older people with biochemical indications of nutrient
deficiencies.

Perhaps the most serious problem in nutritional status assessment of older
people is the lack of correlation between dietary intake data and clinical and
laboratory assessment methods. For example, over the past 20 years,
several comprehensive nutritional surveys that included persons over age
60 have been performed in this country (DHEW 1972, 1974; Agricultural
Research Service 1972; USDA 1980; DHHS 1983). All of these studies have
identified a substantial proportion of older men and women who fell below
the RDA for calories—as well as for protein, vitamins, calcium, and iron
(Bidlack, Kirsch, and Meskin 1986; Young and Rivlin 1982). However,
estimates of obesity from anthropometric (body) measurements generally
show an increase in percent of body fat for both sexes as age increases
(Schlenker et al. 1973). NHANES I (DHEW 1974) and the Ten State
Nutrition Survey (DHEW 1972) found obesity to be a substantial problem
in the aged, especially in women. The findings of diminished calorie intake
and increased obesity are difficult to reconcile. The contradiction may
result from differences in criteria for evaluating the adequacy of dietary
versus biochemical data (DHHS/USDA 1986), the diversity of the study
populations, diminished physical activity among many older persons, or as
yet unknown metabolic factors. However, it is well established that body
composition changes in older people: the extremities lose fat that is re-
distributed to the trunk, and lean body mass is lost. Thus, the term obesity
in older populations may need redefinition.

Energy and Nutrient Status of the Older Population

Bearing in mind the methodological considerations discussed above, this
section highlights results from clinical, laboratory, anthropometric, and
dietary assessments of energy and nutrient status of the older population.

Energy. The national dietary and food consumption surveys conducted

during the 1970’s reported lower energy intakes among older persons than
among younger adults (DHEW 1979a; DHHS 1983; USDA 1984), a finding

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CO) Nutrition and Health

that has been supported by smaller studies. A study of male executives in
the Baltimore Longitudinal Study of Aging, for example, found a Steady
decline in average energy expenditure from 2,700 kcal/day at age 30 to 2,100
kcal/day at 80 years of age. The decline in energy expenditure was at-
tributed to reduced physical activity (400 kcal) and to a 200 kcal decline in
basal energy metabolism as a result of a reduction in lean body mass with
age (McGandy et al. 1966). Aging was also inversely associated with energy
intake among 180 male participants (35 to 74 years old) in the same study of
aging (Elahi et al. 1983). A 4-year longitudinal study of free-living healthy
older men and women whose average age was 71 showed a decline in energy
intake of 162 and 152 kcal, respectively, to an average energy intake of 2,118
kcal/day for men and 1,545 kcal/day for women (Garry, Goodwin, and Hunt
1985). These levels of energy intake were determined from 3-day diet
records and were substantially higher than those recorded for older sub-
jects between 65 and 74 years of age in NHANES I and II and in the 1977-78
NFCS (DHEW 1979a; DHHS 1983; USDA 1984).

NHANES I reported lower caloric intake among older black Americans
than among white Americans (DHEW 1979a), as did the 1977-78 NFCS for
older black versus white men (USDA 1984). NHANES II did not present
data by race within age, sex, and income groups because the number of
black persons within those groups was too small to provide reliable esti-
mates (DHHS 1983). However, NHANES II indicates that the percentages
of overweight women are greater than men, although both sexes increase in
weight until late mid-life when rates plateau and then decline into old age.
Black women become overweight earlier in life than whites, but weight
patterns of black males are similar to their white counterparts. Of the ap-
proximately 3,500 older persons examined in the NHANES I sample,
which is representative of the U.S. civilian, noninstitutionalized popula-
tion between 65 and 74 years of age, the mean energy intakes for the white
and black males were 1,828 and 1,571 kcal/day, respectively; for white and
black older females, the mean energy intakes were 1,319 and 1,186 kcal/day
(NCHS 1977). These energy intakes represented 77 percent of the RDA’s
for white females and 69 percent for black females. The percents of the
RDA standard were 75 and 64 for white and black males, respectively. Even
when a conservative estimate of the 67 percent of the RDA standard is
used, about 50 percent of the individuals 65 years and older met this level of
intake. These levels were related to income: energy intake for those with
income below the poverty level was less than the population mean regard-
less of sex and race. These surveys were conducted on healthy free-living
individuals; most surveys of institutionalized older individuals have re-
ported even less energy intake than that of individuals living at home
(Stiedemann, Jansen, and Harrill 1978; Harrill and Cervone 1977; Jordan
1976).

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Aging e

Although it is Jifficult to interpret dietary intake studies of older Americans
because of methodological problems, existing studies almost always reveal
decreases in energy intake with age that may also be influenced by income,
race, food preference, and drug use. A low-calorie diet may not impair
health as long as the nutrient density of the diet is high and can provide
adequate amounts of essential nutrients. However, this issue has not been
examined in great detail because nutrient requirements in old age remain
largely unkown.

Consequently, the increasing level of obesity among older persons, as
indicated by higher weight-for-height with age (Frisancho 1984), requires
explanation. Whether the inconsistency between reported low energy in-
take and increasing body weight is due to measurement errors, inappropri-
ate standards, loss of height with age (Bowman and Rosenberg 1982), or
lack of physical activity has not been established.

Protein. A 30-day continuous metabolic balance study of seven men and
eight women over 70 years of age who consumed RDA levels of protein and
energy found that about half were unable to maintain nitrogen balance on
this level of protein (0.8 g of protein/kg/day). The results suggested that
higher intakes were required (Gersovitz et al. 1982) to meet protein require-
ments. Other studies that examined protein requirements of older persons
have also concluded that protein requirements may be higher (Munro 1983)
even though mean protein intake usually exceeds the RDA (Brown et al.
1977; Jordan 1976; McClean, Weston, et al. 1976; Grotkowski and Sims
1978; Garry, Goodwin, Hunt, Hooper, et al. 1982; McGandy et al. 1986).
Other studies reported lower protein intakes: at least 24 percent of the
women in nursing homes and 29 percent in private homes consumed less
than the RDA for protein (Jansen and Harrill 1977; Justice, Howe, and
Clark 1974), and in another study, 12 percent of the men and 40 percent of
the women living at home failed to meet this criterion (Jordan 1976).
Because the RDA for protein includes a substantial safety margin and
because clinical measurements have rarely found signs of protein deficien-
cy among healthy older persons, it is not possible to conclude from these
data that persons with intake below the RDA are protein deficient or that
they would benefit from additional protein intake.

Calcium. Older people, especially Caucasian women, lose bone mineral
and have a higher incidence of fractures than younger persons (Seeman and
Riggs 1981). The mechanism behind the age-related loss of bone calcium is
discussed in the chapter on skeletal diseases. Metabolic and absorptive
factors as well as low intake may contribute to chronic negative calcium
balance (Heaney, Recker, and Saville 1978; Horsman et al. 1980; Spencer,

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OQ Nutrition and Health

Kramer, and Osis 1982). Reduced efficiency of intestinal calcium absorp-
tion (Avioli, McDonald, and Lee 1965; Gallagher et al. 1979; Alevizaki,
Ikkos, and Singuelakis 1973; Bullamore et al. 1970; Ireland and Fordtram
1973) may be due to inadequate dietary intake (Heaney, Recker, and Saville
1977; Vinther-Paulsen 1981; Garry, Goodwin, Hunt, Hooper, et al. 1982.
Omdahl et al. 1982; Koplan et al. 1986), age-related changes in gastric
acidity, and/or interactions of intestinal constituents such as fiber, bacteria,
and other nutrients. Perhaps in some individuals a negative effect on
calcium nutriture may be caused by age-related changes in hormonal
control (parathyroid hormone, calcitonin, prolactin, steroids, growth hor-
mones), aberrations in vitamin D metabolism, and imbalances of protein,

phosphorus, alcohol, and electrolytes with calcium (Riggs and Melton
1986).

The RDA for calcium of 800 mg/day (NRC 1980) may not be sufficient to
maintain calcium balance in populations consuming Western-type diets
(Heaney, Recker, and Saville 1978; Matkovik et al. 1979; Recker and
Saville 1977; Recker and Heaney 1985; Consensus Development Panel
1984),

NHANES and NECS reported mean intakes of about 700 to 720 mg for
older men and 540 to 590 mg for older women (DHEW 1979a; DHHS 1983;
USDA 1984). Other surveys have also reported that dietary calcium intake
by older people is often marginal. For example, 43 percent of women in
nursing homes failed to get two-thirds of their calcium requirement
(Stiedemann, Jansen, and Harril 1978; Brown et al. 1977). Women living at
home consumed even less calcium than those in nursing homes (Brown et
al. 1977). One study reported that women, on the average, consumed only
two-thirds of the RDA for calcium (Grotkowski and Sims 1978). Whereas
some studies have reported similarly low calcium intakes among men (660
mg/day) (Brown et al. 1977; McClean, Weston, et al. 1976), others have
found that intakes among older males equaled or exceeded the RDA of 800
mg/day (Stiedemann, Jansen, and Harrill 1978: Grotkowski and Sims
1978). Older people may have reduced calcium intake because they avoid
dairy products containing lactose, to which they are intolerant (Goodwin,
Hunt, et al. 1985; Heaney et al. 1982).

Iron. As with people of all ages, the frequency with which anemia occurs in
the older population and determination of its etiology depend on the
criteria used for diagnosis (see chapter on anemia). Few data on the iron
status of older persons in the United States are available, and most studies
report conclusions based on hemoglobin and hematocrit values with, at
most, only one other index of iron nutrition (Lynch et al. 1982). One

606
Aging O

national study—-NHANES I (DHEW 1979b) and three regional studies
(O’Neal et al. 1976; Fisher, Hendricks, and Mahoney 1979; Htoo, Kofkoff,
and Freedman 1979), for example, found that more than 10 percent of older
white men were anemic (when a hemoglobin level less than 14 g/dl was
considered diagnostic). When a hemoglobin level less than 12 g/dl was used
to identify anemia in women, these same studies found older white women
to have a lower prevalence of anemia than men. These studies included
oider men who were not screened for diseases that can greatly reduce red
blood cell production, such as chronic infections, renal disease, and neo-
plasms that result in chronic blood loss. Such data may indicate that the
standard for low hemoglobin levels for men are too high, although age-
related lower testosterone levels may reduce hematopoiesis and might also
account for this difference (Lipschitz, Mitchell, and Thompson 1981).

Another study examined biochemical measures of iron status in healthy
older persons and concluded that anemia or impaired iron status was no
more prevalent in this population than in younger healthy adults when
identical criteria were used to assess iron nutritional status (Garry, Good-
win, and Hunt 1983). A later longitudinal study revealed significant vari-
ability in the population mean values for all biochemical measures of iron
nutriture except plasma iron; however, none of the changes suggested an
increased risk of anemia. Comparison of older subjects who took iron
supplements with those who did not showed no clinically significant differ-

ences in the biochemical measures of iron status (Garry, Goodwin, and
Hunt 1985).

Because iron stores or reserves, as determined by plasma ferritin measure-
ments, increase with age, studies that examine only dietary intake of iron in
older people need to be interpreted cautiously (Casale et al. 1981). Low
dietary iron intake at one point in time does not necessarily increase the
risk for anemia because iron may still be available from body stores and
because absorption increases when intake and stores are low. In addition,
the type of iron and other components of a meal such as ascorbate also
influence the amount absorbed (see anemia chapter).

Some clinicians believe that an increased incidence of anemia in some
older people, compared with younger groups, is a direct and common
physiologic response to aging (Lipschitz, Mitchell, and Thompson 1981).
Evidence that bone marrow erythroid precursors are reduced in some
anemic older individuals supports this theory; whether this reduced blood-
forming capacity is due to aging per se or to some age-associated phenome-
non such as chronic disease or use of medications is not certain (Lipschitz
et al. 1984). Studies of very old healthy individuals find little evidence of

607
e Nutrition and Health

anemia and, therefore, support the contention that this condition iS rare in
healthy older people (Zauber and Zauber 1987).

Data from NHANES II are illustrative here. The mean iron intakes for men
ages 65 to 74 years were 14.1 mg (about 1.4 times the RDA) and the
prevalence of impaired iron status correspondingly low. The values for
women of the same age were 10.2 mg, or about equal to the RDA for women
age 55 and over, with a corresponding low prevalence of impaired iron
status (DHHS 1983; LSRO 1984).

B Vitamins. Vitamin deficiency may be a result of decreased dietary intake,
absorption defects, decreased hepatic avidity for folate in Laennec’s cir.
rhosis, decreased storage and conversion to active metabolic forms, or
excessive utilization, destruction, or excretion (Cherrick et al. 1965).

No comprehensive study of all the vitamins and their related enzyme
systems has been conducted, perhaps because laboratory facilities and
analytical technology are not sufficient to do all the necessary biochemical
evaluations (Brin and Bauernfeind 1978). Most studies have examined the
status of one or two vitamins. For example, a Boston study of older
subjects reported that 37 percent had inadequate blood levels of riboflavin
and 21 percent had low thiamin levels (Davidson et al. 1962). Biochemical
pyridoxine deficiency in older individuals has also been noted in enzyme
functional tests (Hoorn, Filkweert, and Westerink 1975). A number of
studies have indicated a great risk for vitamin deficiencies in older persons
on the basis of low dietary intakes, but such deficiencies are not always
confirmed by biochemical or clinical results (Garry and Hunt 1986). In
addition, interpretation of biochemical parameters is hampered by lack of
data on normal standards for the older population (Kirsch and Bidlack
1987). For example, a New Mexico study revealed that more than one-
fourth of the older population consumed less than 75 percent of the RDA’s
for folate and vitamins B, and B,, from diet alone (Garry, Goodwin, Hunt,
Hooper, et al. 1982). However, biochemical studies failed to confirm that
these individuals were at risk for developing clinical symptoms associated
with low intakes of these vitamins (Garry, Goodwin, and Hunt 1984).
Intake of vitamin supplements may explain part of this apparent discrep-
ancy, although analysis showed little statistical difference in mean dietary
intake for those individuals taking a specific supplement compared with
those who did not take the supplement (Garry, Goodwin, Hunt, Hooper, et
al. 1982).

Vitamin C. Studies have shown that the total body pool of ascorbic acid
reaches a maximum of approximately 20 mg/kg and that this level can be

608
Aging )

achieved at a steady state plasma concentration of 1.0 mg/dl (Kallner,
Hartman, and Hornig 1979). Women require an intake of 75 mg/day and
men require an intake of 150 mg/day to achieve this ascorbic acid level in
plasma (Garry, Goodwin, Hunt, and Gilbert 1982). This finding was sup-
ported by a clinical trial that showed that a daily intake of 60 mg was
insufficient to maintain this plasma concentration (VanderJagt, Garry, and
Bhagavan 1987). The clinical significance of maintaining maximal plasma
ascorbic acid levels, however, has not been determined.

Some studies have reported low vitamin C intake and blood levels in both
institutionalized and free-living older persons (Leevy et al. 1965; Davidson
et al. 1962). Other studies reported intakes significantly greater than RDA
levels and very few individuals with clinical symptoms of hypovitaminosis
C (Garry, Goodwin, Hunt, and Gilbert 1982; Garry, Goodwin, Hunt,
Hooper, et al. 1982). For instance, one study found that less than 2 percent
of 270 free-living and healthy older persons over 60 years of age were at risk
for developing clinical symptoms of hypovitaminosis C, as measured by
plasma vitamin C concentrations below 0.2 mg/dl (Garry, Goodwin, Hunt,
and Gilbert 1982). The mean steady state plasma vitamin C level for
persons not taking supplemental vitamin C was 1.02 mg/dl—a level re-
po-ted to be sufficient to maintain a maximal body pool. Additional supple-
mental intake had little effect in raising plasma levels. Mean intakes of
vitamin C from the diet in that population were 137 mg/day and 142 mg/day
for women and men, respectively—approximately 2.4 times the RDA
(Garry, Goodwin, Hunt, Hooper, et al. 1982). In addition, over half were
taking supplemental vitamin C—mean levels of approximately 600 mg/day.

Vitamin A. Vitamin A deficiency does not seem to be a particular problem
in older persons. Although NHANES I and NHANES II reported that
about half the study population over age 65 had vitamin A intakes at or less
than two-thirds of the RDA, only 0.3 percent of the NHANES I older
population had low vitamin A blood levels (Bowman and Rosenberg 1982;
DHHS 1983), Serum vitamin A was not available for adults from NHANES
Il (LSRO 1985). Whether vitamin A supplement use can account for the
observed discrepancy is unknown, but similar data suggest that older
individuals can maintain normal vitamin blood levels even with reportedly
low dietary intakes (Yearick, Wang, and Pisias 1980, Garry et al. 1987).

Vitamin D. Previous studies have revealed a generally lowered vitamin D
Status in older people, chronically ill individuals (Petersen, Hall, and
Briges 1981: Weisman et al. 1981), and those living in institutions (Weisman
etal. IORI - Corless et al. 1979; Vir and Love 1978) with little or no exposure
to sunlight (Lund and Sorensen 1979; Baker, Peacock, and Nordin 1980;

609
ie Nutrition and Health

Lawson et al. 1979). Because the vitamin D endocrine system is the major
regulator of intestinal calcium absorption (Christakos and Norman 1978), a
reduced vitamin D status might promote a negative calcium balance in
older people (see chapter on skeletal diseases).

Two recent studies in the United States have found dietary intake of
vitamin D to be approximately 50 percent of the RDA for older subjects
(Garry, Goodwin, Hunt, Hooper, et al. 1982; Lee, Lawler, and Johnson
1981), and inadequate intake (especially of vitamin D-supplemented dairy
products) was well correlated with low blood levels of 25-hydroxyvitamin
D (Omdahl et al. 1982). However, ultraviolet light induced endogenous
production of vitamin D is the main external factor in maintaining adequate
vitamin D status. Because sunlight exposure activates vitamin D precur-
sors in skin, it has been recommended that older people obtain at least
minimal sunlight exposure (10 to 15 minutes) two or three times a week
(Holick 1986). Increased sun exposure may help compensate for aging
skin’s decreased capacity to produce these precursors (MacLaughlin and
Holick 1985; Holick 1986). Supplements may be necessary to compensate
for inadequate sunlight exposure due to seasonal variation in northern
latitudes (Bouillon et al. 1987). Moderation in sun exposure should be
recommended because overexposure to the sun is a strong risk factor for
skin cancer.

Vitamin E. There is no evidence that older individuals are deficient either
in dietary intake or tissue levels of vitamin E (Kelleher and Losowsky
1978; Vatassery, Johnson, and Krezowski 1983; Garry and Hunt 1986),
despite statements that megadose vitamin E supplements retard the aging
process and prevent atherosclerosis and cancer (Bieri, Corash, and Hub-
bard 1983). Therapeutic doses of vitamin E have prolonged survival of red
blood cells in some inherited hemolytic anemias (Corash, Spielburg, and
Bartsocas 1980), but its use to treat or prevent other conditions has not
been established (Bieri, Corash, and Hubbard 1983).

Nutritional Supplements. It has been estimated that 37 percent of Ameri-
can adults consume a daily multivitamin preparation, fueling a more than
$2 billion per year industry (the Gallup Organization 1982; Herbert 1980;
Koplan et al. 1986). NHANES II indicated that the persons most likely to
take supplemental nutrients are less likely to need them, and those most in
need of them are least likely to take them (Koplan et al. 1986). In older
persons, vitamin use has increased dramatically in the past decade (Garry,
Goodwin, Hunt, Hooper, et al. 1982; Scheider and Nordlund 1983).
Whether such supplements improve the health of these people cannot be
determined from existing data (Mann et al. 1987), but it is clear that

610
Aging Q

excessive supplementation may be harmful. High doses of the fat-soluble
vitamins A and D are toxic.

Drug-Nutrient Interactions

Although older Americans constitute about 12 percent of the U.S. popula-
tion, they use about 25 percent of all prescription drugs (Lecos 1984/85).
This is not surprising because many chronic diseases associated with aging
are managed with prescription drugs. Over half of the older people take at
least one medication daily and many take six or more a day for multiple
diseases (Lecos 1984/85). Cardiovascular drugs (e.g., diuretics) are most
widely used by the aging population, followed by drugs to treat arthritis,
neurologic disorders, and respiratory and gastrointestinal conditions.
Many unwanted drug-nutrient interactions in older persons have been
documented (see chapter on drug-nutrient interactions). The drug-nutrient
interactions outlined in another chapter of this Report apply to the older
person. However, this population requires special consideration because
aging per se changes the absorption, disposition, and elimination of drugs.
The older person with multiple diseases is at risk for additional drug-
nutrient interactions linked to separate drug therapies for primary and
secondary health problems. Even over-the-counter antacids, laxatives,
analgesics, and vitamin and mineral supplements may result in unwanted
drug-nutrient side effects in the older person (Roe 1985).

Effects of Nutritional Deficiencies on the Older Population

Morbidity and Mortality

Severe malnutrition—protein, calorie, vitamin, or mineral—is associated
with increased morbidity and mortality, and the relationship of malnutri-
tion to morbidity and mortality in older persons is of current interest. While
less severe forms of malnutrition may be detrimental to health, the evi-
dence has been more difficult to establish. Among severely ill or injured
hospital patients of any age, protein-energy malnutrition greatly increases
the risk for postoperative complications and overall morbidity and mor-
tality (Mullen et al. 1979; Kaminski, Fitzgerald, and Murphy 1977). This
association between nutritional status and survival does not prove a causal
relationship because poor nutritional status may be the result of the illness
or injury and not its cause. It is also difficult to demonstrate that moderate
nutrient deficiencies increase morbidity and mortality.

Several investigators have tried to correlate blood levels of vitamin C, for

example, with morbidity and mortality in an aging population. Among
patients admitted to an acute care geriatric unit, those with low ascorbate

él!
C Nutrition and Health

levels had a significantly higher mortality, but vitamin C supplements did
not improve survival in these patients (Wilson et al. 1972, 1973). One
prospective study reported dietary intake of vitamin C to be a significant
predictor of mortality in an aging population (Hodkinson and Exton-Smith
1976), although it was not possible to separate cause from effect in this
instance. Some older subjects with low vitamin C levels in blood exhibit
clinical signs of scurvy (Andrews and Brook 1966), but some do not
(McClean, Dodds, et al. 1976). Signs of scurvy may be slow to resolve with
supplementation in older subjects (Andrews, Letcher, and Brook 1969).
The clinical significance of this observation has not been established.

Immune Status

Considerable evidence documents an age-related decline in immune com-
petence, characterized by losses in T-lymphocyte and other functions.
Certain of these changes resemble those induced by malnutrition
(Thompson, Robbins, and Cooper 1987), but whether malnutrition is a
significant cause of depressed immune function in large numbers of older
individuals is uncertain. The large number of rodent studies that describe
well-nourished old animals regularly displaying weak immune responses
argues against the hypothesis that immunosenescence is due to malnutri-
tion (Shock et al. 1984).

As described in the chapter on infections and immunity, protein-energy
malnutrition in individuals of any age alters the proportion of T cell types,
depresses T cell function, impairs delayed hypersensitivity reactions, and
impairs thymic factor activity. Such changes are strongly associated with
increased susceptibility to infectious diseases (Mullen et al. 1979: Falchuk
et al. 1977). Impairment of delayed hypersensitivity and thymic factor
activity have also been documented for deficiencies of single nutrients
(Beisel 1982). Severe malnutrition is clearly related to impaired immune
function in some older people, and improved dietary intake can at least
partially correct these impairments. Current evidence is insufficient, how-
ever, to decide which, if any, age-related losses in T cell function are caused
by nutritional deficiencies or some other physiologic or environmental
factor (Thompson, Robbins, and Cooper 1987). The possible role of zinc
deficiency in loss of immune function in older people has received consid-
erable attention (Sandstead et al. 1982; Gershwin, Beach, and Hurley
1983).

If nutritional deficiencies are related to impaired immune function in older

people, correcting the deficiencies should improve this function. Among
hospitalized patients, intensive nutritional support does increase immu-

612
Aging OC

nocompetence (Law, Dudrick, and Abdou 1973). Among older people,
dietary supplements have been associated with improved antibody re-
sponses to viral vaccines (Chandra and Puri 1985), and several studies have
reported improved immune function as a result of zinc supplementation
(Duchateau et al. 1981; Thompson, Robbins, and Cooper 1987); others
have not (Brader et al. 1988). Whether these effects represent correction of
nutrient deficiencies or are secondary to some nonspecific effect of supple-
mentation is uncertain (Goodwin and Garry 1983).

Nervous System and Cognitive Function

Whether mental functions necessarily decline with age is questionable, and
whether dietary factors can influence mental status in older persons is also
uncertain. Results of psychometric testing in older people vary depending
on the group studied. Although large population studies have reported
gradual decreases in many mental functions with age (Nandy and Sherwin
1977), healthy, active older subjects do not display significant decrements
(Botwinick 1977). This discrepancy suggests that the reported decrements
in mental function are not inevitable age-associated events, rather, such
changes are secondary to the various diseases and physical conditions that
frequently accompany aging (Palmore 1974).

Alzheimer’s Disease

Alzheimer’s disease affects between 2 and 3 million Americans. The preva-
lence of this disease increases with age; while only 5 to 8 percent of people
age 65 and over are affected, 35 percent of those over age 85 are affected.
The cost of institutional care alone for Alzheimer’s disease patients is
estimated to exceed $38 billion per year in direct costs and up to $80 billion
per year if indirect costs are considered (Huang, Cartwright, and Hu 1988).

The causes of Alzheimer’s disease have not been established, but potential
risk factors include age, family history of Alzheimer’s disease, and head
injuries. Further studies are needed to determine the validity and reliability
of these risk factors. Whether nutritional factors can alter the risk for this
condition is not known. High concentrations of aluminum have been found
in the neurofibrillary-containing neurons of deceased patients, suggesting a
relationship between aluminum and Alzheimer’s disease. Such foci are not
observed in the brains of people who die from other causes (Perl and Brody
1980). Despite these observations, there is no evidence that renal dialysis or
use of aluminum antacids, antiperspirants, or cookware increases the risk
for Alzheimer’s disease (Katzman 1986), and the significance of the in-
creased brain aluminum concentrations is unknown. The roles of certain

613
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dietary antioxidants and toxic amino acids (Spencer et al. 1987) are under
study.

Because Alzheimer’s disease is a neurodegenerative syndrome involving
cell loss and dysfunction, and because there is evidence that nutrient
variables can affect brain metabolism, it might be speculated that neurotox-
ins acquired through the food chain may be involved in brain cell death.
Therefore, researchers and clinicians should consider nutritional factors in
the etiology of Alzheimer’s disease.

Implications for Public Health Policy
Dietary Guidance

General Public

Aging is accompanied by a variety of physiologic, psychologic, economic,
and social changes that may compromise nutritional status. However, ways
in which the aging process affects energy balance, specific nutrient require-
ments, and nutrient status remain to be fully elucidated. Older adults may
not necessarily have the same nutritional requirements as younger adults,
yet current estimates of the nutrient requirements of older persons are
based almost entirely on values extrapolated from data from studies of
younger adults. The ways in which nutritional status might influence
changes in tissue and organ function change with age and may influence the
relationships between dietary components and the occurrence of chronic
diseases of old age. Until more appropriate age-specific RDA’s are estab-
lished, the current RDA’s should continue to be used as standards for
nutrient intake of healthy older persons.

Until more is known, older Americans should consume sufficient nutrients
and energy and maintain levels of physical activity that maintain desirable
body weight and may prevent or delay the onset of chronic disease.
Because it is often difficult to maintain adequate nutrient intake on low-
calorie diets, older people should be advised to maintain at least moderate
levels of physical activity so as to increase caloric needs. Recommenda-
tions to the general population about calcium intake (see chapter on skel-
etal diseases) are true for older Americans. Because many of the chronic
diseases common to older persons may originate earlier in life (see chapter
on maternal and child nutrition), dietary guidance to prevent them should
be provided throughout life (as discussed in other chapters).

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Aging O

Health promotion messages from the public and private sectors should
utilize advanced communication techniques, recognizing different life-
styles, decrements in vision and hearing, different cultural experiences,
and different learning styles that may be common to older people. Federal
and State agencies should provide information about successful public-
private sector models for nutrition, health promotion, and education for
older adults—for example, Healthy Older People, Age Well, and OASIS
(Older Adult Service Information System).

Special Populations

Sedentary older individuals should be counseled on appropriate methods
to increase caloric expenditure. Older persons who do not (or cannot)
consume adequate levels of nutrients from food sources and those with
dietary, biochemical, or clinical evidence of inadequate intake should
receive advice on the proper type and dosage of nutrient supplements.
Such supplements may be appropriate for some older persons, but self-
prescribed supplementation, especially in large doses, may be harmful and
should be discouraged. Older people who suffer from diet-related chronic
diseases should receive dietary counseling from credentialed health profes-
sionals, and those who take medications should be given professional
advice on diets that minimize food-drug interactions.

Nutrition Programs and Services

Food Labels

Evidence related to the role of diet in the aged currently holds no special
implications for change in policy related to food labeling, although the size
of the type on the label is a factor for most older consumers. Information
provided on food labels should be scientifically sound, understandable,
and nonmisleading.

Food Services

Food services, especially those receiving Government funds, should be
required to pay special attention to meeting the caloric and nutrient needs
of older clients. Nutritional assessment and guidance should be done at
hospital admission or enrollment in or discharge from institutional or
community-based services for older adults (e.g., acute and long-term care
inpatient services, hospital-based outpatient services, alcohol and drug
treatment programs, community health services, and home-delivered
meals programs).

615
ie Nutrition and Health

Food Products

Evidence suggests that older people would benefit from food products that
provide a high proportion of available nutrients to calories, that have taste
appeal, and that are easy to prepare.

Special Populations

Older people who are homebound, who live in isolation, or who suffer from
chronic disease have special needs for nutrition services that are tailored to
their particular conditions. Considerable evidence supports the nutritional
and health benefits of dietary, economic, and social support programs for
the older population.

Research and Surveillance

Research on nutrition and aging currently focuses on two general areas—
the nutritional requirements and status of aging people and the influence of
diet on aging processes and related pathologies. Psychosocial interactions
with nutrition cut across both areas.

Research and surveillance issues of special priority related to the role of
nutrition in the aged should include investigations into:

® The nutrient and energy requirements of older adults, currently ex-
trapolated from younger age groups.

© The effects of dietary restriction and overconsumption on longevity
and age-related pathology. -

© The interactions among nutritional status, lifestyle and behavior, and
the environment in older Americans.

®@ The effects of nutrition on age-related impairment of the cardtovascu-
lar, gastrointestinal/oral, immune, musculoskeletal, and nervous SYS-
tem functions and on prevention and treatment of disorders of those
systems.

© The effects of marginal nutrient and energy deficiencies on the mental
and physical health of older persons.

©@ Interactions among nutrients and between nutrients and drugs in older
adults.

© Development of data bases for use by pharmacists and dietitians in
counseling older persons on drug-nutrient interactions.

© Age-specific methods and standards to assess the nutritional status
and body composition of older adults.

616
Aging @

@ The educational methods and program strategies that best promote
adequate food consumption by older persons.

e Improved methods to monitor the nutritional status of older popula-

tions and individuals, including institutionalized older adults, over
time.

© The educational and public health strategies that can be used to elimi-
nate nutrition-related health fraud directed toward older citizens.

617
ie Nutrition and Health

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