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Nutritional Care of Older Adults
Laurie B. Steenwyk M.Ed, RD, LDN Laurie B. Steenwyk, M.Ed., RD/LDN 1 1
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Class Overview Assessing Nutritional Status
Nutritional Needs of the Elderly Nutrition Interventions Eating Lifestyles Meal planning for optimal health Laurie B. Steenwyk, M.Ed., RD/LDN
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Assessing Nutritional Status
Laurie B. Steenwyk, M.Ed., RD/LDN
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Factors Impacting Nutritional Status in the Elderly
Poly pharmacy Chronic /acute illness: Diabetes, COPD, CHF Macular degeneration Arthritis limits function and mobility Laurie B. Steenwyk, M.Ed., RD/LDN
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Assessing Weight Status
Nutrition 101 Assessing Weight Status BMI <23 considered underweight >65 yrs Percent Weight Loss (unintended) >5% in 1 month (quadruples risk of death) > 7.5% in 3 months >10% in 6 months Cachexia Severe wasting accompanying diseases such as cancer Normal age related weight changes: 0.3 kg LBM per year after age 30. Usually replaced by fat so weight stays the same Laurie B. Steenwyk, M.Ed., RD/LDN
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Mini Nutrition Assessment
6 question screening tool Complete in <5 minutes Validated for age >65 More sensitive than BMI Available at: The site also has a version that can be self administered by patients or family members. Laurie B. Steenwyk, M.Ed., RD/LDN
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Sarcopenia Sarcopenia Sarcopenic Obesity
Nutrition 101 Sarcopenia Sarcopenia Loss of skeletal muscle associated with aging Affects 8-40% of adults >60 yrs 50% of adults >75 yrs Sarcopenic Obesity Coexisting loss of skeletal muscle mass and strength with excess body fat Laurie B. Steenwyk, M.Ed., RD/LDN
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Nutritional Needs of the Elderly
Laurie B. Steenwyk, M.Ed., RD/LDN
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Nutrition 101 Energy Energy (calorie) needs decrease with age, mostly due to decreased physical activity LBM declines with age and influences energy needs Protein and vitamin/mineral needs remain the same or increase Challenge: adequate micronutrients within caloric requirement Requires limiting discretionary calories from fat and sugar Laurie B. Steenwyk, M.Ed., RD/LDN
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Nutrients of Concern Risk for deficiency with age Water Fiber Protein
Nutrition 101 Nutrients of Concern Risk for deficiency with age Water Fiber Protein Calcium and Vitamin D Vitamin B12 Vitamin C and E – antioxidants Laurie B. Steenwyk, M.Ed., RD/LDN
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Water Dehydration is a form of malnutrition
Kidneys’ decreased ability to concentrate urine Adverse effects of medication Mobility disorders Fear of incontinence 25-30 mL/kg actual body wt 20-25 mL/kg: CHF, renal failure, edema, liver disease with ascites 30-35 mL/kg: Constipation, dehydration, fever, diarrhea, fistulas, draining wounds, dry/hot environment, diuretic use Laurie B. Steenwyk, M.Ed., RD/LDN
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Fiber Fiber Goals for adults over 50:
Nutrition 101 Fiber Fiber Goals for adults over 50: Men: 30 g per day Women: 21 g per day Insoluble: Tough, fibrous plant material that does NOT absorb water Most grains and vegetables Soluble: Plant fibers capable of absorbing water and become gummy or gel-like Oats, fruit, legumes, pectin, inulin, psyllium Insoluble: think of a scrub brush keeping you cleaned out Soluble: bulking You need both types of fiber Laurie B. Steenwyk, M.Ed., RD/LDN 12 12
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Sources of Fiber Bran Legumes Seeds Fruits Oats Vegetables Barley
Nutrition 101 Sources of Fiber Bran Legumes Seeds Fruits Vegetables Oats Barley Wheat Quinoa Flax Brown Rice Laurie B. Steenwyk, M.Ed., RD/LDN 13 13
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Protein Muscle mass (LBM) decreases 15% per decade after age 70
Nutrition 101 Protein Muscle mass (LBM) decreases 15% per decade after age 70 Needs increase with illness, injury Surgery, wounds, CHF, COPD, Cancer Optimal intake: gm/meal Even distribution most effective in preventing muscle loss during illness 1-1.6 gm/kg IBW may prevent sarcopenia Laurie B. Steenwyk, M.Ed., RD/LDN
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PROTEIN Sources: Animal Proteins Dairy Legumes and Nuts
Nutrition 101 PROTEIN Sources: Animal Proteins Egg, Turkey, Fish, Beef… Dairy Milk, Cheese, Yogurt, Cottage Cheese… Legumes and Nuts Black Beans, Red Beans, Lentils, Walnuts… Some from grains/breads/plants Quinoa, Greens, Broccoli, Oats, Pasta… Laurie B. Steenwyk, M.Ed., RD/LDN 15 15
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Vitamin D 800 IU >70 years Safe upper limit 4000 IU
Nutrition 101 Vitamin D 800 IU >70 years Safe upper limit 4000 IU Supplements are recommended for older adults Sources Fortified milk Fatty fish, fish oil Liver Egg yolk Some enriched beverages Exposure to sunshine during Spring, Summer, early Fall Laurie B. Steenwyk, M.Ed., RD/LDN
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Calcium 1000 mg Men <70 years 1200 mg Men >70
Nutrition 101 Calcium 1000 mg Men <70 years 1200 mg Men >70 1200 mg Women >50 Safe upper limit 2000 mg/day A large recent study suggests that calcium supplements don’t prevent hip fractures Take calcium separately from iron by 2 hrs Take smaller doses of supplemental calcium Take calcium citrate if you take a PPI Laurie B. Steenwyk, M.Ed., RD/LDN
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Calcium Dairy Sources 1 cup milk – 300 mg 4 oz yogurt – 200 mg
Nutrition 101 Calcium Dairy Sources 1 cup milk – 300 mg 4 oz yogurt – 200 mg 1 oz cheese – 200 mg ½ cup cottage cheese – 65 mg ¼ cup ricotta cheese mg Laurie B. Steenwyk, M.Ed., RD/LDN
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Non-Dairy Calcium Sources
Understanding the Gluten-free Diet Non-Dairy Calcium Sources 1 cup Calcium fortified orange or apple juice (240 mg) Enriched, GF almond, soy or rice milk – 300 mg 3 oz Sardines – 370 mg 3 oz Canned Salmon w/ bones – 180 mg Almonds ½ cup Broccoli (90 mg) 2 oz Tofu (made w/ calcium sulfate Firm Tofu (385 mg) Regular Tofu (200 mg) 1 T Blackstrap Molasses – 135 mg 1 T Tahini – 65 mg Laurie B. Steenwyk, M.Ed., RD/LDN
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Other Nutrients in Bone Health
Vitamin K Leafy greens, broccoli, soybean oil Manganese Spinach, peanuts, almonds, brown rice, green tea Excesses of sodium, protein and phosphorus decrease calcium availability. Large intake of soft drinks provides excess phosphorus.
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Vitamin B-12 6-15% of older adults are deficient
Nutrition 101 Vitamin B-12 6-15% of older adults are deficient Another 20% have marginal status Compromised absorption Pernicious anemia Lack of intrinsic factor Atrophic gastritis Long-term use of PPIs Eldery can be prone to overconsumption of folate. High folate intake can mask vitamin B12 deficiency. Since 1998 grain products have been fortified with folic acid in the drive to decrease birth defects. (neural tube defects). Laurie B. Steenwyk, M.Ed., RD/LDN
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Vitamin B-12 Deficiency Symptoms Sources Supplement Recs:
Folate Deficiency Numbness, tingling of arms, legs Difficulty walking Memory loss Disorientation Dementia Sore tongue Poor appetite Constipation Possibly depression Sources Meat Poultry Fish Dairy Products Supplement Recs: Adults 2.4 mcg/day >50 yrs should take supplement >65 yrs mcg/day As many as 20-25% of adults over 65 have B-12 deficiency. Many cannot absorb B-12 from food and thus need a supplemental form. B-12 injections bypass the gut entirely. High oral doses of 1 mg/day allow 10 mcg (10%) to be absorbed by passive diffusion. No known toxicity. B-12 deficiency is often masked as Folic Acid Deficiency. Anyone with Folic Acid Deficiency should also be tested for B-12 deficiency before treatment with Folic Acid. Also people taking folic acid, should not take more than 1000 mcg a day so as not to mask a developing B-12 deficiency.
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Anti-Oxidants (C and E)
Nutrition 101 Anti-Oxidants (C and E) Vitamin C Vitamin E RDI 75 mg females and 90 mg males 400 mg may be beneficial to older adults UL is 2,000 mg The role of anti-oxidants in macular degeneration and dementia is unclear RDI: 15 mg for adults UL is 1000 mg Supplements can increase risk of bleeding in patients on anti-coagulant therapy Sources: oils, nuts, peanuts, avocado Diarrhea and GI upset are the most common sx of toxicity Laurie B. Steenwyk, M.Ed., RD/LDN
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Nutritional Interventions
Laurie B. Steenwyk, M.Ed., RD/LDN
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Increasing Calories 5-6 small meals/between meal snacks
Calorically dense foods Nut butters, dried fruits, fruit purees, starchy vegetables, legumes, cheese, yogurt Drink calories Milk, juice, smoothies, soups Increase fats butter, sour cream, cream cheese, oils, mayonnaise, avocado
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Oral Nutrition Supplements
Use cal/mL Ensure Plus, Ensure Clinical Strength, TwoCal, Boost Plus, etc Serve 3-4 oz portions several times Use as a “med pass” Dilute with whole milk or serve frozen to reduce sweetness Encourage 1 sip every 5 minutes to reduce early satiety
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Texture Meats: chopped, ground, pureed
Use puree molds or small colorful dishes Piping soft foods, garnish with sauce Cut hard fruits, vegetables into bite sized pieces Finger foods work well with dementia or severe arthritis
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The Dining Experience Buffet service, family style service
Encourage selection Avoid social isolation Music Aroma Appearance and presentation
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Home Meals Financial limits Limited cooking ability
Eggs, peanut butter, canned beans, tuna, turkey, frozen veggies, rice Limited cooking ability Weight Watchers, Healthy Choice, Kashi Meals Precut fruits and veggies Prepared soups, crackers, whole grain bread, bagels, quick oatmeal, cheese, yogurt, cottage cheese, frozen veggies, bananas, grapes, hummus
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Appetite Stimulants Limited evidence of effectiveness in the elderly
Nutrition 101 Appetite Stimulants Limited evidence of effectiveness in the elderly Megace Remeron Eldertonic Marinol Periactin Oxandrin Megace and Marinol – shown to be effective in AIDS and Cancer patients Oxandrin –anabolic steriod used in AIDS patients Periactin – antihistamine that increases appetite Remeron – antidepressant that corrects chemical imbalances in the brain and may concurrently improve appetite Eldertonic – sherry based Laurie B. Steenwyk, M.Ed., RD/LDN
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Nutrition 101 Eating Lifestyles The Mediterranean Diet The DASH Diet The New American Plate MyPlate for Older Adults Laurie B. Steenwyk, M.Ed., RD/LDN
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Nutrition 101 2009 Version Fruits, Vegetables, grains, olive oil, beans, nuts and seeds are grouped together at the base Herbs and Spices are added at base Fish is promoted over poultry and dairy Laurie B. Steenwyk, M.Ed., RD/LDN
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Benefits 9% decrease in overall mortality
Merging Best Nutritional Practices with Your GF Diet Nutrition 101 Benefits 9% decrease in overall mortality 9% decrease in death from cardiovascular disease 6% decrease in death from cancer 13% decrease in incidence of Parkinson’s and Alzheimer’s Disease The cardiovascular health benefits of the Mediterranean Diet have been well established. What this study shoes is that the Mediterranean diet also reduces risk for cancer, degenerative diseases and overall mortality. Safi, F. et al, Adherence to Mediteranean Diet and Health Status: Meta-analysis. British Journal of Medicine, 2008: 337:a1344. Laurie B. Steenwyk, M.Ed., RD/LDN Laurie B. Steenwyk, M.Ed., RD/LDN 33 33
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Key Mediterranean Principles
Merging Best Nutritional Practices with Your GF Diet Nutrition 101 Key Mediterranean Principles Generous amounts of fruits and vegetables Healthy fats: olive oil Small portions of nuts Red wine in moderation, for some Very little red meat Fish on a regular basis We often think of pasta and bread as the mainstays of the Mediterranean diet. While these foods are included, whole grains are emphasized and consuming grains is not one of the strategic principles of the diet. Laurie B. Steenwyk, M.Ed., RD/LDN Laurie B. Steenwyk, M.Ed., RD/LDN 34 34
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DASH Diet Pyramid Dietary Approaches to Stop Hypertension
Nutrition 101 DASH Diet Pyramid Dietary Approaches to Stop Hypertension Laurie B. Steenwyk, M.Ed., RD/LDN
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DASH Benefits Reduces blood pressure, especially in older adults.
Nutrition 101 DASH Benefits Reduces blood pressure, especially in older adults. Also protective against Osteoporosis Cancer Heart Disease Heart Failure Stroke Diabetes Laurie B. Steenwyk, M.Ed., RD/LDN
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Key DASH Principles Limits sodium to <2300 or <1500 mg/day
Merging Best Nutritional Practices with Your GF Diet Nutrition 101 Key DASH Principles Limits sodium to <2300 or <1500 mg/day Generous amounts of fruits & vegetables Whole Grains Emphasizes low fat dairy Monounsaturated Fats <27% of calories from fat Legumes, nuts or seeds daily Lean protein: fish, poultry, soy products High in calcium, potassium and magnesium Magnesium: Legumes, green leafy vegetables, nuts, seeds whole grains, lean meats Laurie B. Steenwyk, M.Ed., RD/LDN Laurie B. Steenwyk, M.Ed., RD/LDN 37 37
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New American Plate Proportions:
Nutrition 101 New American Plate Proportions: 2/3 plate should be plant based Whole grain Vegetables Fruit Legumes 1/3 from protein Fish Lean Beef Poultry Dairy 1/3 Laurie B. Steenwyk, M.Ed., RD/LDN
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2007 Expert Report on Cancer Prevention
Nutrition 101 2007 Expert Report on Cancer Prevention Joint effort of AICR and World Cancer Research Fund 7000 global scientific studies reviewed 10 lifestyle recommendations for cancer prevention Laurie B. Steenwyk, M.Ed., RD/LDN
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Diet Recommendations Limit sugary drinks and energy dense foods
Nutrition 101 Diet Recommendations Limit sugary drinks and energy dense foods Eat more of a variety of fruits, vegetables, grains, legumes Limit red meat and processed meats Limit salt and foods processed with sodium Laurie B. Steenwyk, M.Ed., RD/LDN
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MyPlate for Older Adults
Nutrition 101 MyPlate for Older Adults Laurie B. Steenwyk, M.Ed., RD/LDN
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MyPlate for Older Adults
Nutrition 101 MyPlate for Older Adults Bright-colored vegetables such as carrots and broccoli. Deep-colored fruit such as berries and peaches. Whole, enriched and fortified grains and cereals such as brown rice and 100% whole wheat bread. Low- and non-fat dairy products such as yogurt and low-lactose milk. Dry beans and nuts, fish, poultry, lean meat and eggs. Liquid vegetable oils, soft spreads low in saturated and trans fat, and spices to replace salt. Fluids such as water and fat-free milk. Physical activity such as walking, resistance training and light cleaning. Laurie B. Steenwyk, M.Ed., RD/LDN
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Resources Food & Nutrition Information Center
Tufts Human Nutrition Research Center on Aging
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Resources DASH Eating Plan Booklet, free on the web: Mayo Clinic Use their search engine and type in “DASH Diet” or “Mediterranean Diet” to view numerous consumer friendly articles. Oldways: Mediterranean diet info
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Resources AICR: The New American Plate Linus Pauling Institute
Printable brochures, Cookbook, recipes Linus Pauling Institute micronutrient information center
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Nutrition 101 Questions??? Laurie B. Steenwyk, M.Ed., RD/LDN
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