Unfortunately, these extra years added to our lifespan are not necessarily ‘healthy’, and this has a detrimental impact on the quality of life of older people.

For older adults and nutrition In the UK, life expectancy has doubled over the last 200 years and now around 16% of the population is aged over 65 years.General nutrient requirements and healthy eating guidelines apply to older people. However, energy requirements fall with advancing age due to a decrease in basal metabolic rate and often decreased levels of physical activity.

The ability to synthesise vitamin D by the skin decreases with age. Older people are therefore recommended to take a supplement containing 10g of vitamin D daily as well as regularly eating food sources of the vitamin (for example oily fish and fortified breakfast cereals). Some older people in the UK, especially those living in institutions, have been found to have low intakes and/or low blood levels of a range of micronutrients.

Good nutrition and regular physical activity play a protective role in a number of age-related conditions including cardiovascular disease and cognitive decline and can help to protect oral and dental health, and bone and joint health in later life.Both malnutrition and obesity are prevalent in the older population. Malnutrition is more prevalent in older people living in institutions, whereas overweight and obesity are more prevalent in free-living adults.

An ageing population

In the UK, life expectancy has doubled over the last 200 years, and now around 10 million of the population is aged over 65 years (16% of the population). Within the older age group, even greater population growth has been seen among those aged 85 years and over.

Unfortunately, these extra years added to our lifespan are not necessarily ‘healthy’, and this has a detrimental impact on the quality of life of older people.

Energy requirements

For healthy people, energy requirements decrease with advancing age. This is due to changes in body composition; a decrease in lean body tissue (muscle) and an increase in fat tissue. This means that, for a given bodyweight, older people tend to have less muscle and more fat, leading to a fall in basal metabolic rate (BMR). Many people also become less active as they get older. In the UK (as in other countries) the estimated average requirement (EAR) of energy for older adults has been set at a lower level than for younger adults.

Dietary recommendations

In the UK, dietary recommendations for fat, carbohydrate and dietary fibre are the same for older people as for the rest of the population and similar healthy eating guidelines apply. 

As for the general population, it is advised that older people of all ages consume two portions of fish each week, one of which should be oily. Oily fish contains long chain omega-3 fatty acids which can help protect against heart disease and have been shown to be particularly important for those who have already had a heart attack. In older people, omega-3 fatty acids may also help to alleviate some of the symptoms of rheumatoid arthritis, with beneficial effects on swollen and tender joints, grip strength and mobility. There is some evidence that these fatty acids may also help to preserve eye health, prevent cognitive decline and improve immune function. But because oily fish may contain contaminants (such as dioxins and PCBs), it is not advised to eat more than 4 portions per week (a portion is 140g).

There is a lack of specific recommendations for older people for many of the vitamins and minerals. But we do know that the ability to digest, absorb, metabolise and excrete nutrients changes with age (e.g. vitamin B12 absorption is decreased because levels of the intrinsic factor needed for its absorption are thought to decrease with age). Older people should eat a varied diet containing plenty of fruit and vegetables, and include some fortified foods such as bread or fat spreads, which are often voluntarily fortified by manufacturers, as well as breakfast cereals with added vitamins and minerals such as iron, some B vitamins and calcium. Some functional foods may also be of benefit for particular health conditions. Examples include probiotic drinks and yogurts, and foods with added fibre or prebiotics for gut health; and cholesterol-lowering spreads (with stanols and sterols) and soya containing products for heart health.

There are, however, specific recommendations for vitamin D for older people. Vitamin D is synthesized in the skin via the action of sunlight. But older people typically go out of doors less than younger age groups and their skin is less efficient at producing vitamin D from sunlight. It is therefore recommended that all adults over the age of 65 take a supplement containing 10g of vitamin D daily and regularly eat foods containing vitamin D (e.g. oily fish and fortified breakfast cereals). 

A range of factors may influence the nutritional status of older people. This might include ill health and other medical conditions, drug-nutrient interactions, lack of mobility, low incomes, social isolation or bereavement and poor dentition.

Sense of taste and smell can alter with age, and this can affect appetite and enjoyment of food. Older people tend to eat less and the body’s ability to absorb some nutrients also becomes less efficient with age so it can be harder to get all the necessary nutrients for good health. It is important for older people to eat a varied diet to ensure an adequate supply of all the essential vitamins and minerals, and enough food to cover their energy requirements.

Current intakes

National survey data show that average daily energy intakes are below the estimated average requirements for older adults. For older adults, intakes of fibre are also below the population recommendation, whereas average daily protein intakes are well above the recommendation (as is the case for the general population). The average intake of total fat is similar to recommended daily intake for the general population; but intakes of saturated fatty acids remain above recommended levels (again in line with the general population).

A proportion of older people, especially those living in institutions, also have low intakes or low blood levels of a range of vitamins and minerals 

Nutrition and health in older people

Cognitive decline and stroke

Stroke, dementia, Parkinson’s disease and depression are common diseases affecting the brain of older people and they can have a severe impact on a person’s quality of life and independence. High intakes of sodium (salt), fat, energy and alcohol are linked with high blood pressure, which is a major risk factor for cognitive decline and stroke.

There is now some evidence that fatty acids in the diet may be important in determining the risk of developing dementia. Some emerging research suggests a protective role for omega-3 fatty acids.

Low status of folate, vitamin B12 and vitamin B6 has been associated with elevated levels of homocysteine, which is linked with increased risk of stroke and an increased risk of dementia. Low

vitamin B12 status affects 5-10% of people over the age of 65 years and low folate status affects 16% of older people living in institutions, so it is important that steps are taken to improve deficiencies in dietary intake of these vitamins.

Physical activity is thought to have a protective role against cognitive decline in later life; but results have not yet been adequately supported by data from randomised controlled trials.

Bone and joint health

It is estimated that 1 in 3 women and 1 in 12 men over the age of 55 years will suffer from osteoporosis in their lifetime. Adequate intakes of calcium and vitamin D are key to ensure that optimum peak bone mass is attained in early adulthood and to reduce postmenopausal bone loss and prevent osteoporotic fractures.

Low vitamin D status has also been shown to increase risk of falls. Vitamin D insufficiency is widespread in older people in the UK, particularly among those in residential care (see table 1). People aged 65 years and over should take a vitamin D supplement (10?g), and eat food sources such as oily fish, and fortified breakfast cereals.

Table 1: Proportion of people aged 65 years and over in the UK with low vitamin D status

 

Free living

Living in institutions

Men

6%

38%

Women

10%

37%

Low vitamin K intake and/or status are associated with low bone mass and increased fracture risk. A diet that contains adequate protein and vitamin K and is rich in fruit and vegetables and low in salt, may also help to delay bone ageing. Conversely, a high intake of vitamin A (retinol) may be associated with low bone mineral density and increased risk of fractures in certain populations; so high doses should be avoided. Groups at increased risk of osteoporosis, such as older people, should limit consumption of liver and supplements containing retinol (e.g. cod liver oil).

Weight-bearing exercise also plays a crucial role in maintaining a healthy skeleton. Being active can protect against osteoporosis via its effects on muscle strength, coordination, flexibility and balance. Involvement in a range of activity types is also important as we get older, for strength and flexibility. Arthritis is very common in older people, particularly osteoarthritis, which is age-related and causes disability in over 10% of those over the age of 65. It is clear that avoiding obesity can help to prevent osteoarthritis but the role of popular dietary supplements remains unclear. Some findings suggest that fish oils may provide symptom relief for some sufferers of rheumatoid arthritis, but evidence for benefits of other supplements including glucosamine and chondroitin, especially regarding the more common osteoarthritis, remains weak.

Oral and dental health

One of the key determinants of dietary variety in later life is retention of natural teeth, so good dental health throughout life is very important. In the UK, 58% of adults aged 75 years and over have no natural teeth and rely on dentures: these people tend to eat less fruit and vegetables and have lower intakes of some micronutrients such as vitamin C.

The most significant effect of nutrition on teeth is in the development of dental caries, which can be affected by frequency of sugar intake especially in the absence of good dental hygiene. Root caries, in particular, occur more frequently in older people because they are more likely to have exposed tooth roots as a consequence of periodontal disease and gum recession. Dentists normally recommend limiting intake of sugar-containing foods and drinks to four to five occasions per day.

Dental erosion is associated with the regular consumption of acidic foods and drinks, particularly soft drinks and fruit juice. It is, therefore, important to look after teeth from early life into old age: this means brushing at least twice daily with fluoride toothpaste and regularly visiting a dentist.

Older people may also suffer from tooth decay as a result of taking medication; for example, drugs with prolonged oral clearance, high-energy syrup food supplements and other forms of between-meal snacks. However, chewing gum has a useful role in stimulating salivary flow and moderating the acidogenic response of dental plaque to sugars.

Cardiovascular disease

Cardiovascular disease (CVD), including coronary heart disease and stroke, is the main cause of morbidity and mortality in older people. The main risk factors for CVD that predict risk in middle-age also increase risk in later life. These include obesity, a high intake of saturates, hypertension, smoking, low levels of physical activity and diabetes. A diet that is energy-dense, high in saturated fatty acids and salt, and low in dietary fibre, wholegrains, and fruit and vegetables is generally associated with an increased risk of developing CVD and other chronic diseases.

Incorporating non-hydrogenated unsaturated fatty acids (monounsaturates and polyunsaturates) as the main form of fat (i.e. cutting back on saturates and avoiding trans fatty acids), choosing wholegrains as the main form of carbohydrate, eating an abundance of fruits and vegetables, adequate amounts of long chain omega-3 fatty acids (predominantly from oily fish) and not too much salt can together offer significant protection against CVD. Encouraging older people to improve their diets, together with taking regular physical activity, adopting sensible drinking habits, not smoking and maintaining a healthy bodyweight can together lead to lower CVD risk.

However, as the risk factors start to have their effect in earlier life, most benefit will be gained by adopting healthy lifestyle and dietary habits throughout the life course.

Healthy weight

Being a healthy weight is important for good health at any age. In the ageing population, a risk of malnutrition has been recognised in as many as 1 in 7 older people; the prevalence is even higher in people who are living in institutions. Being underweight and/or malnourished increases the risk of disease, delays recovery from illness and adversely affects body function, wellbeing and clinical outcome. 

However, there are also risks associated with excess bodyweight. Survey data suggests that a large proportion of older people are obese or overweight; 67% of free-living men and 63% of free-living women; and 46% of men and 47% of women living in institutions. Carrying excess weight, particularly around the waist, increases the risk of a number of chronic diseases including cardiovascular disease, stroke, cancer and type 2 diabetes.

Older people are at an increased risk of heart disease and type 2 diabetes if their waist circumference is:

  • Men - over 94cm (substantially increased risk over 102cm)
  • Women - over 80cm (substantially increased risk over 88cm)

The cut-offs are lower for Asian people: a waist circumference of more than 80 cm is a problem for a South Asian woman and 90cm for a South Asian man.

Physical activity

Regular physical activity benefits people of all ages including older people. It is important for maintaining a healthy weight by improving energy balance. Physical activities such as strength training that may increase muscle size, increase resting metabolic rate and therefore increase energy expenditure.

Physical activity also provides additional benefits to older people. The Department of Health recommends that adults (including older adults) in the UK do at least 30 minutes of moderate intensity activity at least five times a week to reduce the risk of cardiovascular disease and diabetes, and some cancers. Longer periods of activity may be required for weight control. Depending on the type of physical activity chosen, participation may provide some social interaction which can have a positive impact on quality of life. Keeping active also helps older people maintain mobility and therefore maintain their independence, which is very important for self esteem. Older people are encouraged to do activities that promote and improve balance, strength and coordination. These are particularly important for maintaining good bone and joint health and for reducing the risk of falls.

 Source British Nutrition Foundation, revised February 2016

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