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Later Life

Introduction

Over the last 100 years, the life expectancy of people living in the United States has increased substantially, from 47 years at the beginning of the 20th Century to over 70 years by the end of the 20th Century.

Advances in medical care, an increase in the standard of living, and improved nutrition have all contributed to the greater life expectancy. This combined with the aging Baby Boomers segment of the United States population has resulted in a substantial increase in the number of persons over 65 years of age. From 4% of the United States population in 1900 to 13% in 1990, the over-65 group is expected to reach 20% by the year 2030.

Our obsession with youth has spurred a huge amount of research about how to live a long healthy life. Although there are many factors, nutrition seems to be one of the most important. Most of the leading causes of death are closely associated with diet or alcohol consumption.

Unfortunately, Aging is associated with a variety of physiologic changes that affect nutritional status. In addition, changes in social, economic, and medical conditions often impact the amount and quality of food that elderly people have available to them.

As a result, elderly people are at increased risk for nutrient deficiencies, and should ensure adequate intake of calcium, vitamin D, folic acid, vitamin E, vitamin C, vitamin B12, vitamin B6, magnesium, potassium, and fiber.

Fortunately, all these nutrients'and many more'are well supplied by Mediterranean-style diet, which is likely why two studies published April 2005: the EPIC-elderly prospective cohort study of initially healthy subjects published in the British Medical Journal, and a study of patients with coronary heart disease published in the Archives of Internal Medicine, show that eating a Mediterranean-style diet extends life expectancy.

Characterized by a high intake of plant foods (legumes, vegetables, fruits, and whole grains) a moderate to high fish intake, a low intake of saturated fat and high intake of unsaturated fats (particularly olive oil), a low to moderate intake of dairy products (cheese and yogurt), a low intake of meat, and a modest intake alcohol (mostly wine), a Mediterranean diet increases survival among older people, whether healthy or living with heart disease.

Led by Dr Antonia Trichopoulou from the University of Athens Medical School in Greece, the EPIC study followed more than 74,000 healthy men and women (without heart disease, stoke or cancer when the study began) aged 60 years or more in 9 European countries. Information on diet, lifestyle, medical history, smoking, physical activity levels and other variables that could potentially affect results was analyzed. Participants were recruited from 1992 to 2000 with follow until 2003 when they were classified as alive, dead, emigrated, refused to participate further and unknown.

The extent to which participants followed a modified Mediterranean diet (modified to include other unsaturated fats since non-Mediterranean populations consume less olive oil) was scored on a 10-point scale. A higher Mediterranean diet score was linked to a significant reduction in mortality: a two point increase corresponded with an 8% reduction in mortality, while a three or four point increase reduced total mortality by 11% and 14% respectively.

Eating a Mediterranean-style diet, according to the EPIC study, translates into an extra year of life for a healthy 60-year-old man compared to one who did not follow a Mediterranean diet. The EPIC International Study is the European Prospective Investigation of Cancer and is the largest study of diet and health ever undertaken. If you'd like to learn more about the study, including links to individual country contributions, click Epic International Study.

The second study, also led by Dr. Trichopoulou, focused on Greek men and women with coronary heart disease. Again using a 10-point scale to assess adherence to a Mediterranean diet, researchers found that a two point increase in an individual's score was associated with a 27% lower mortality rate among persons with coronary heart disease. When only death from cardiovascular disease was considered, the reduction in mortality was even higher'31%. A more recent 2008 study has confirmed the benefits of a Mediterranean approach to eating in individuals older than 65 years of age. In this study conducted by investigators at the Cardiovascular Risk and Nutrition Research Group in Barcelona, Spain on 2,244 adults with an average age of 71 years, A focus on fruits, vegetables, legumes, low-fat dairy products, low intake of red meat, low intake of refined grains, and avoidance of fried foods was found to be most closely associated with the ability to meet a wide variety of nutrient needs in this age group. By focusing on the foods above, men and women in this age group were able to increase their chances of meeting dietary recommendations for total fat, saturated fat, cholesterol, total fiber, vitamin C, vitamin E, thiamin, riboflavin, vitamin B-6, folate, calcium, and magnesium.

Physical Factors

As we age, we may experience a variety of physiologic changes affecting the mouth and gastrointestinal tract that negatively impact our desire to eat and/or our body's ability to absorb and assimilate nutrients. As a result, even healthy elderly people are at increased risk for certain nutrient deficiencies.

Statistics predict that the older we get, the greater our risk of developing certain diseases, including cancer, heart disease, obesity, osteoporosis, hypertension, and diabetes mellitus, all of which can affect our nutritional status. With the onset of such diseases, elderly people are treated with a host of prescription and over-the-counter medications, some of which contribute to poor absorption of nutrients and/or reduced appetite.

Starting at about the age of 60, some people begin to lose their sense of taste and smell. Specifically, they lose the ability to distinguish between sweet, salty, sour, and bitter, which makes food less appealing and reduces appetite. Inadequate taste and smell sensations may also negatively impact the digestion of food, as the taste and smell of food stimulates the secretion of digestive enzymes in the mouth, stomach and pancreas.

As we age, we may also experience loss of hearing, impaired vision, and/or loss of coordination, which can make it difficult to shop for food, prepare meals, and to feed one's self. All of these factors reduce the amount of nutrients that are available to the body.

A large percentage of elderly people (more than 70%) do not produce enough saliva, a condition called xerostomia. This condition is considered to be part of the normal aging process, but it is also caused by several commonly prescribed medications including antidepressants, blood pressure medications, diuretics, and sedatives.

Saliva is manufactured by glands located in the mouth, and plays an important role in the digestive process. Without adequate saliva, appetite and digestion are compromised. In addition, a majority of elderly people have untreated cavities and gum disease, which can lead to loss of teeth and the need for dentures. People who wear dentures chew less efficiently, which makes eating a frustrating and laborious task, and may ultimately lead to decreased food consumption. This problem is intensified in people with poorly fitting dentures, as eating can become extremely painful.

Hypochlorhydria, or lack of stomach acid, contributes to a variety of nutrition-related problems in the elderly. During digestion, hydrochloric acid is secreted into the stomach, which lowers the pH of the stomach, a condition necessary for the breakdown of protein and the absorption of several minerals including iron, calcium and zinc. People with hypchlorhydria, therefore, have poor digestion and poor absorption of minerals. In addition, insufficient stomach acid allows the overgrowth of bacteria in the small intestine, a condition that can reduce the absorption of vitamin B12.

Many elderly people suffer from chronic constipation. Constipation may be caused by poor muscle tone in the digestive tract (a physiological change that is seen with aging), inadequate fluid intake and/or lack of physical activity. Often, people with constipation do not feel hungry and may skip several meals in a row. Such individuals are at risk for nutritional deficiencies.

In the normal course of aging, many people also experience a decline in the function of the immune system, making them more susceptible to viral and bacterial infections. For an elderly person, catching the common cold or a flu bug can have devastating consequences, keeping them in bed for days, or resulting in a hospital stay. A nutrient-dense diet, and perhaps nutritional supplementation, is necessary to prevent chronic infections and to support immune system functioning.

Another consequence of aging is the gradual loss of muscle tissue throughout the body and the replacement of this tissue with fat. The loss of muscle tissue causes weakness and instability, and increases the chance that the elderly person will fall, causing a bone fracture or other injury. A healthy, well-balanced diet and regular exercise can help prevent the loss of muscle tissue.

Nutrient Needs

The recommendations for calorie, protein, fat, and fiber intake for the elderly do not differ significantly from the recommendations for younger adults. Although it is true that calorie requirements decrease slightly with age due to loss of muscle tissue and reduced physical activity, many elderly people struggle to take in enough calories to meet their nutritional needs.

If you're over 70, it is not important to deliberately restrict calories unless you are severely overweight. And if you do restrict calories, take care to include a variety of foods to ensure that you take in enough protein, fiber, vitamins and minerals.

Protein requirements are typically calculated based on body weight. For most people, protein intake of 0.8 -1 gram of protein per kilogram of body weight (or approximately 70 grams of protein per day for a 150 pound person) is sufficient to maintain lean body mass and support the functions of the immune system.

Like all Americans, the elderly are encouraged to limit dietary fat intake to no more than 30% of total calories, to avoid saturated fats and hydrogenated fats, and to include good sources of omega-3 fats (flaxseeds, tuna fish, and salmon) in their diet.

Elderly individuals should consume a minimum of 25 grams of dietary fiber per day. If constipation is a problem, fiber intake should be increased by consuming more fiber-rich whole grains and vegetables.

Osteoporosis, or porous bones, causes more than 1.5 million bone fractures each year. For an elderly individual, a bone fracture often results in hospitalization and nursing-home care. It is important, therefore, for elderly people to consume nutrients important for bone health, including calcium, vitamin D, and vitamin K. Calcium is important for maintaining the strength and density of bones. Inadequate intake of calcium in elderly individuals may lead to more rapid breakdown of bone, resulting in osteoporosis. Many elderly individuals may not absorb calcium because they lack stomach acid, which is necessary for calcium absorption.

The Adequate Intake level of calcium for men and women above the age of 70 is 1200 mg. Postmenopausal women who do not take hormone replacement therapy require additional calcium, and should strive to take in at least 1500 mg of calcium per day. Excellent food sources of calcium include turnip greens, mustard greens, and tofu. Vitamin D plays an important role in the absorption and utilization of calcium. As a result, vitamin D deficiency negatively impacts calcium status and bone health. The elderly may be at increased risk for vitamin D deficiency due to inadequate sun exposure and the decreased capacity of the kidneys to convert this vitamin to its active form. Salmon, sardines, milk, tuna, eggs, and shiitake mushrooms are concentrated sources of vitamin D.

Vitamin K levels appear to decrease with age and because vitamin K is important for maintaining the strength of bones, the elderly should include foods containing vitamin K in their diet. Excellent food sources of this vitamin include kale, spinach, mustard greens, collard greens, broccoli, Brussels sprouts, and asparagus.

To help prevent heart disease, age-related macular degeneration, cataracts, and cancer, elderly people may need additional antioxidant nutrients, including vitamin E, vitamin C and the carotenoids, to protect their cells from free radical damage. Food sources of these nutrients include dark green leafy vegetables and a variety of fruits.

The incidence of type 2 diabetes mellitus increases with age. Although many dietary and lifestyle factors contribute to the development of diabetes, some scientists believe that a natural consequence of aging, regardless of diet and lifestyle, is a decreased ability of the body to metabolize blood sugar (called glucose) efficiently.

As a result, elderly individuals may need additional chromium in their diet. Chromium facilitates the movement of glucose from the bloodstream into the cells, thereby lowering blood sugar levels. Food sources of chromium include brewer's yeast, oysters, liver, onions, whole grains, bran cereals, tomatoes, and potatoes

High dietary intake of folic acid, vitamin B6, and vitamin B12 is known to lower blood levels of homocysteine, a by-product of metabolism that can cause damage to artery walls, setting the stage for the development of atherosclerosis. A high blood homocysteine level (called hyperhomocysteinemia) is associated not only with with increased risk of cardiovascular disease, but Alzheimer's disease; low intake of folic acid, vitamin B6 and vitamin B12 are key risk factors for hyperhomocysteinemia.

Research featured in the first issue of Alzheimer's & Dementia: The Journal of the Alzheimer's Association, found that adults over age 60 who consume at least 400 μ/day of folate could be as much as 55% less likely to develop Alzheimer's disease.

Recent animal studies have suggested that low folic acid and high homocysteine levels make brain cells more vulnerable to damage from beta amyloid. Plus, homocysteine is now thought to be directly toxic to brain cells.

Along with vitamins B12 and B6, folate (the form in which folic acid is active in the body), is needed to convert homocysteine into methionine in an important cellular process called the methylation cycle. When folate supplies are inadequate, homocysteine levels build up.)

Researchers at the University of California examined data on 579 adults over age 60 who participated in the Baltimore Longitudinal Study of Aging. Participants joined between 1984 ' 1991, provided detailed 7-day diet diaries, and were followed for an average of 9 years, during which time, 57 developed Alzheimer's disease.

Results showed that participants who consumed at least 400 micrograms of folate reduced their risk of developing Alzheimer's disease by 55%.

Participants' intakes of vitamins E, C, B6 and B12, and carotenoids were also assessed, but no significant association was found for these nutrients and reduction in Alzheimer's disease risk.

Study authors think that folate may reduce Alzheimer's disease risk by lowering levels of homocysteine. But, they also note that people who have a high intake of a nutrient like folate, which is found in a variety of whole foods, are more likely to be eating well, and thus have high intakes of other nutrients and a healthier lifestyle in general.

Furthermore, study authors also caution that taking a supplement of any one of the B vitamins (including folate) for long periods of time may produce an imbalance of other B vitamins, so it is important to take a B complex with any single B vitamin supplement.

We have a much tastier suggestion—just enjoy a healthy way of eating based on the World's Healthiest Foods. You'll be richly supplied with all the B vitamins and all the other vitamins, minerals, and wide array of phytonutrients needed for a vibrantly healthy old age. Many of the World's Healthiest Foods are well supplied with folate. Some of the richest sources of folate include lentils, asparagus, spinach, broccoli, and beets.

Elderly people may need to pay special attention to their intake of vitamin B12 because the production of hydrochloric acid (stomach acid) which is necessary for the absorption of vitamin B12 declines with age. Excellent sources of folic acid include spinach, parsley, broccoli, beets, turnip greens, asparagus, romaine lettuce, yeast, calf's liver, and lentils.

Excellent sources of B6 include bell peppers, turnip greens, cauliflower, garlic, tuna, mustard greens, and kale. Excellent sources of B12 include sardines, salmon, tuna, cod, lamb, scallops, shrimp, and beef.

Elderly individuals may require additional amounts of three more important minerals: zinc, magnesium, and potassium. Zinc absorption is impaired when secretion of stomach acid is not sufficient, and, as a result, zinc deficiency is fairly common among the elderly.

Low intake of zinc is associated with decreased function of the immune system, loss of appetite, loss of taste, delayed wound healing, and development of pressure sores. Very good sources of zinc include beef, spinach, asparagus, shiitake mushrooms, and crimini mushrooms.

Certain diuretics, which are commonly prescribed for the treatment of high blood pressure, increase the excretion of magnesium and potassium, increasing the risk of developing a deficiency of these minerals. In addition, a diet high in sodium and low in potassium can negatively impact potassium status. Excellent sources of potassium include beet greens, Swiss chard, spinach, and bok choy. Excellent sources of magnesium include spinach, Swiss chard, and beet greens.

Adequate intake of fluids, most notably water, by elderly individuals is necessary to maintain health. Dehydration is common among the elderly, and may lead to uncomfortable physical problems including constipation and kidney stones.

The following table lists the Dietary Reference Intakes, established by the Institute of Medicine at the National Academy of Sciences, for men and women over the age of 70.

NutrientM 70+F 70+
Vitamin A (mcg RE)900700
Vitamin D (mcg)1515
Vitamin E (mg alpha-TE)1515
Vitamin K (mcg)12090
Thiamin (mg)1.21.1
Riboflavin (mg)1.31.1
Niacin (mg NE)1614
Pantothenic Acid55
Vitamin B6 (mg)1.71.5
Folate (mcg)400400
Vitamin B12 (mcg)2.42.4
Choline (mg)550425
Biotin (mcg)3030
Vitamin C (mg)9075
Calcium (mg)12001200
Phosphorus (mg)700700
Magnesium (mg)420320
Iron (mg)88
Zinc (mg)118
Iodine (mcg)150150
Selenium (mcg)5555
Copper (mcg)900900
Manganese (mcg)2.31.8
Chromium (mcg)3020

Dietary Choices

Although many elders recognize that good nutrition contributes to their health and quality of life, many simply do not eat enough food to obtain the necessary nutrients to keep healthy. Many elders are cooking and eating alone, which, for some, lessens the desire to eat. In addition, prescription medications may decrease appetite.

While a variety of community nutrition programs serve elders by providing inexpensive, home-delivered meals and by providing transportation to and from senior centers and other organizations that provide community meals, we hope the information we provide at the World's Healthiest Foods will help inspire you to prepare some easy but delicious Mediterranean-style meals yourself. If you're living on a fixed income, it's good to know that not only are the World's Healthiest Foods less expensive than most prepared foods, but they are also much more flavorful and nutritious.

Now that you have the time, treat yourself, experiment. Try George's quick, easy recipes, and you'll soon be dishing up wonderful, fresh meals that will delight your tastebuds and those of your friends, children and grandchildren.

References

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  • Evans WJ. Exercise and nutritional needs of elderly people: effects on muscle and bone. Gerodontology 1998;15(1):15-24. 1998. PMID:19680.
  • Gariballa SE. Nutritional support in elderly patients. J Nutr Health Aging 2000;4(1):25-7. 2000. PMID:19660.
  • Guigoz Y, Vellas BJ. [Malnutrition in the elderly: the Mini Nutritional Assessment (MNA)]. Ther Umsch 1997 Jun;54(6):345-50. 1997. PMID:19720.
  • High KP. Nutritional strategies to boost immunity and prevent infection in elderly individuals. Clin Infect Dis 2001 Dec 1;33(11):1892-900. 2001. PMID:19610.
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  • Seshimo A, Shirotani N, Kameoka S. [Nutritional assessment in the elderly]. Nippon Rinsho 2001 May;59 Suppl 5:829-32. 2001. PMID:19640.
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  • Trichopoulou A, Orfanos P, Norat T, Bueno-de-Mesquita B, Ocke MC, Peeters PH, van der Schouw YT, Boeing H, Hoffmann K, Boffetta P, Nagel G, Masala G, Krogh V, Panico S, Tumino R, Vineis P, Bamia C, Na. Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. BMJ. 2005 Apr 30;330(7498):991. Epub 2005 Apr 8. 2005. PMID:15820966.
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