Nutrition Challenges and the Older Adult

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1 Sponsor Disclosure: Support for this presentation was provided by the Foodservice Express division of Med-Diet, Inc. The material herein is for educational purposes only. Reproduction or distribution of these materials is prohibited except as expressly provided by Med-Diet, Inc. or the presenter. Copyright 2015 Med-Diet, Inc. All rights reserved. 1 Nutrition Challenges and the Older Adult 1

2 Session Objectives The participant will be able to: Explain issues that interfere with older adults consuming an adequate diet. Identify 4 key nutrient deficiencies for older adults and gain ideas for addressing them. Describe the signs, issues and treatments of frailty, sarcopenia and failure to thrive. Copyright 2006 The NY Times Company 2

$Rheumatoid Arthritis Chronic Obstructive Pulmonary Disease Chronic renal failure Chronic heart failure 10%-25% Stroke Dementia Hip fracture Up to 50% Prevalence of Malnutrition 26%-71% not seen in$

3 Multiple Medical Conditions* *Among fee -for -service Medicare Beneficiaries, 2010 Prevalence of Malnutrition in Disease States and Conditions likely to affect the Elderly Disease State/Condition Rheumatoid Arthritis Chronic Obstructive Pulmonary Disease Chronic renal failure Chronic heart failure 10%-25% Stroke Dementia Hip fracture Up to 50% Prevalence of Malnutrition 26%-71% not seen in younger people 20%-70% highest in emphysema 30%-76% higher in elderly and when second to diabetes 8%-16% at hospitalization; 22% at discharge 12-50% institutionalized; esp. Alzheimer s Akner G and Cederholm T. Am J Clin Nutr. 2001;74:

The Role of Nutrition Nutrition Intervention Opportunities: Prevention encouraging healthy eating & fitness to maximize health Risk Reduction slowing progression of chronic nutrition related diseases

4 The Role of Nutrition Nutrition Intervention Opportunities: Prevention encouraging healthy eating & fitness to maximize health Risk Reduction slowing progression of chronic nutrition related diseases to maintain functionality and QOL Therapy nutrition becomes part of treatment for many chronic disease Krause s Food & Nutrition Therapy 12 th Edition It is never too late to eat healthy and be active. 4

5 Healthy Eating Interferences Physical Psychological Social Economic Mobility to shop/cook Home bound Chair/bed bound Chronic diseases Aches / pain Alzheimer s / Dementias Alcoholism Substance abuse Medications Stubborn, denial Anger, anxiety Depression / loneliness End-of-life; no will and/or fear No cooking knowledge Restrictive diet Loss of spouse/partner Loss of friends Isolation Moving from home to alternate care Neglect and abuse Poverty Access to food Access to care Lack of support and help >70% of older Americans would benefit from improved eating habits. White JV et al. Nutr Clin Pract. 2003;18:

6 Energy (kcal/day) Intake of Adults Usual Intake from Food y y >70 y Males Females Source: What We Eat in America National Health and Nutrition Examination Survey (NHANES) Carbohydrate (g/day) Intake of Adults Usual Intake from Food y y >70 y Males Females Source: What We Eat in America National Health and Nutrition Examination Survey (NHANES)

7 Fat (g/day) Intake of Adults Usual Intake from Food y y >70 y Males Females Source: What We Eat in America National Health and Nutrition Examination Survey (NHANES) Protein (g/day) Intake of Adults Usual Intake from Food y y >70 y Males Females Source: What We Eat in America National Health and Nutrition Examination Survey (NHANES)

8 Vitamins & Minerals Over 40% of adults don t meet the daily recommended intakes for vitamins & minerals through diet alone Calcium, Potassium, Magnesium, Vitamins A, C, & E For older adults also: Vitamin B 12 & D Older adults have increased need for: Vitamin D & B 12 Calcium &?Zinc Women have need for iron after menopause Position of the American Dietetic Association: Nutrient Supplementation J Am Diet Assoc. 2009;109: Foote JA, et al. J Am Coll Nutr. 2000;19: Prevalence of Protein - Energy Malnutrition in the Geriatric Population 6-15% in LTC Fazia M et.al. JAMDA 2013; 14: % Community Dwellers 60% Hospitalized 35-85% in LTC Furman EF. J Gerontol Nurs 2006;32: % Community Dwellers 39% Hospitalized 51% Rehab 14% in LTC Kaiser MJ et al. J Am Geriatr Soc. 2010;58: % >65y in ER malnourished or at-risk Pereira GF et al. Ann Emerg Med. 2014;x:1-7. (in press) 8

system Assist with normal cell repair Promote wound healing Promote

9 Nutrients of Concern Protein Vitamin B12 Calcium & Vitamin D Protein Needs with Aging Preserve and/or replace lean body mass Maintain healthy immune system Assist with normal cell repair Promote wound healing Promote functional independence Protein is fundamental to every system and function in the body. 9

Fig. 1 Protein Needs Don t Change with Age Protein metabolism is less efficient in older adults Journal of the American Medical Directors Association 2013 14, 542-559DOI: (10.1016/j.jamda.2013.05.

10 Fig. 1 Protein Needs Don t Change with Age Protein metabolism is less efficient in older adults Journal of the American Medical Directors Association , DOI: ( /j.jamda ) Copyright 2013 American Medical Directors Association, Inc. Protein Needs of Older Adults Current requirements based on N-balance and not optimizing muscle mass or functionality 0.8 g/kg PRO is not enough for >65 y [Healthy] elderly require g/kg BW high quality protein daily to maintain / gain muscle Requirement may be g/kg BW for repletion Adequate [quality] protein intake per meal is important gram / meal target / threshold Bauer J, et al. JAMDA 2013;14: Praddon-Jones D, et al. Am J Clin Nutr 2008;87(suppl):1562S-1566S. 10

Benefits of Higher Protein Intake Correlates to: Bone mass density Slower rate bone loss Slower loss of muscle mass and strength Health ABC Study: subjects in highest quintile of protein intake lost

11 Benefits of Higher Protein Intake Correlates to: Bone mass density Slower rate bone loss Slower loss of muscle mass and strength Health ABC Study: subjects in highest quintile of protein intake lost ~40% less LBM than those in lowest quintile Bauer J, et al. JAMDA 2013;14: Houston DK, et al. Am J Clin Nutr. 2008;87: All Proteins are Not Equal Two considerations: Quality [essential amino acid content; esp. leucine] Digestibility and bioavailability Good, Better, Best but any protein better than none Plant proteins (soy) Egg Dairy (whey, casein) & (lean) Meat Higher in key amino acid leucine Praddon-Jones D, et al. Am J Clin Nutr 2008;87(suppl):1562S-1566S Symon TB, et al. Am J Clin Nutr. 2007;86:

$? Condition Protein Energy Hospitalized 1.2-1.7 g/kg 25-30 kcal/kg Frailty No specifics Hip fracture Met 80% target Met 50% target Use ONS Osteoporosis >0.$ 8 gm / kg or 24% of kcal Higher BMD Stroke 1 g/kg Intake at 80-90% of target Pressure ulcers Up to 1.3 g/kg Meals covered only 76% of energy need.

8 gm / kg or 24% of kcal Higher BMD Stroke 1 g/kg Intake at 80-90% of target Pressure ulcers Up to 1.3 g/kg Meals covered only 76% of energy need.

12 Optimal Feeding of Protein gm / meal (w/ gm leucine OR, at minimum Main high-protein meal at midday Litchford, MD. Nutr Clin Pract. 2014;29: High Protein, What About.? Condition Protein Energy Hospitalized g/kg kcal/kg Frailty No specifics Hip fracture Met 80% target Met 50% target Use ONS Osteoporosis >0.8 gm / kg or 24% of kcal Higher BMD Stroke 1 g/kg Intake at 80-90% of target Pressure ulcers Up to 1.3 g/kg Meals covered only 76% of energy need. ONS needed COPD 20% of kcal from protein Use ONS Cardiac-critical g/kg kcal/kg DM w/o kidney dz 20-30% of kcal DM w/ kidney dz low 0.8 gm/kg Renal trumps DM For obese or underweight; use ideal body weight ONS = oral nutrition supplements Bauer J, et al. JAMDA 2013;14:

High Protein, What About Renal Disease? Condition Protein Severe CKD, GFR <30 0.8 g/kg BW /d Moderate CKD, GFR >30 <60 >0.8 g/kg BW / d Monitor GFR Mild CKD, GFR >60 Protein per needs Hemodialysis >1.

13 High Protein, What About Renal Disease? Condition Protein Severe CKD, GFR < g/kg BW /d Moderate CKD, GFR >30 <60 >0.8 g/kg BW / d Monitor GFR Mild CKD, GFR >60 Protein per needs Hemodialysis >1.2 g/kg BW /d Ideally 1.5 g/kg Peritoneal dialysis >1.2 g/kg BW /d Ideally 1.5 g/kg Consider nutrition status 1) prior to the disease, 2) the disease, and 3) the impact the disease will have on nutrition status. Bauer J, et al. JAMDA 2013;14: Fig. 2 As able min. / day of endurance exercise Resistance training 2-3 x/wk for min. Frail individuals can gain muscle strength and function! Journal of the American Medical Directors Association , DOI: ( /j.jamda ) Copyright 2013 American Medical Directors Association, Inc. 13

14 Vitamin B 12 DRI 2-3 mcg /day New data suggests 4-7 mcg/day (for 4 yrs. and up) Role: Nervous system health Red blood cell formation DNA Synthesis Cell metabolism Fatty acid / amino acid metabolism 1.5%-15% of pop. deficient Supplement at mcg/day 2000 mcg/day titrated down 14

15 Sources of Vitamin B 12 Micrograms (mcg) per serving Percent DV* Clams, cooked, 3 ounces ,402 Liver, beef, cooked, 3 ounces Breakfast cereals, fortified with 100% of the DV for vitamin B12, 1 serving Trout, rainbow, wild, cooked, 3 ounces Salmon, sockeye, cooked, 3 ounces Trout, rainbow, farmed, cooked, 3 ounces Tuna fish, light, canned in water, 3 ounces Cheeseburger, double patty and bun, 1 sandwich Micrograms (mcg) per serving Percent DV* ,178 Haddock, cooked, 3 ounces Breakfast cereals, fortified with 25% of the DV for vitamin B12, serving Beef, top sirloin, broiled, 3 ounces Milk, low-fat, 1 cup Yogurt, fruit, low-fat, 8 58 ounces Cheese, Swiss, 1 ounce Beef taco, 1 soft taco Ham, cured, roasted, ounces Egg, whole, hard boiled, 1 large Chicken, breast meat, roasted, 3 ounces Continued Vitamin B 12 Deficiency Deficiency < pg/ml (< picomol/l ) B12 serum concentration might be suspect? >13 micromol/l homocysteine maybe an indication >4 micromol/l methylmalonic acid highly probable Symptoms: extreme fatigue, confusion, tingling and weakness in arms/legs, unsteady gait, tinnitus, pernicious anemia, GI disturbances, inflammation of tongue, urinary incontinence, loss of appetite 15

Why Older Adults Need B 12 Supplementation

Early satiety absorption efficiency 10-30%

help Medications Decreased resistance to

chronic conditions Antrum Pyloric sphincter

16 Why Older Adults Need B 12 Supplementation Potential Problems food intake; vegetarian Early satiety absorption efficiency 10-30% have stomach acid Fortified w/ B12 sources help Medications Decreased resistance to ulcers, cancers, and infection Existing chronic conditions Antrum Pyloric sphincter Fundus Older Adults need Calcium & D Drink milk! (or have something dairy ) 16

~54 million Americans have Osteoporosis Osteoporosis = Bone disease loss or too little Peak bone mass at 18-25 years Mid-life = increasing bone loss Post-menopause women can lose up to 20% of bone

17 ~54 million Americans have Osteoporosis Osteoporosis = Bone disease loss or too little Peak bone mass at years Mid-life = increasing bone loss Post-menopause women can lose up to 20% of bone density A break is often first hint of problem 1 in 2 women and 1 in 4 men will break a bone Bone make-up: Collagen Calcium-phosphate mineral Bone cells Bone loss not normal part of aging National Osteoporosis Foundation Bone Health & the Calcium Connection Protecting bone health: Proper diet; including Calcium and Vitamin D And protein Exercise (strength) Avoid smoking Limit alcohol Calcium deficiency bone loss Absorption efficiency with age Btw yr. absorb ~1/3 less calcium than younger Diets (usually) inadequate supplement as needed National Osteoporosis Foundation 17

Daily Calcium Intake Target Recommended Dietary Allowances (RDAs) for Calcium Age Male Female Pregnant Lactating 0 6 months* 200 mg 200 mg 7 12 months* 260 mg 260 mg 1 3 years 700 mg 700 mg 4 8 years

18 Daily Calcium Intake Target Recommended Dietary Allowances (RDAs) for Calcium Age Male Female Pregnant Lactating 0 6 months* 200 mg 200 mg 7 12 months* 260 mg 260 mg 1 3 years 700 mg 700 mg 4 8 years 1,000 mg 1,000 mg 9 13 years 1,300 mg 1,300 mg years 1,300 mg 1,300 mg 1,300 mg 1,300 mg years 1,000 mg 1,000 mg 1,000 mg 1,000 mg years 1,000 mg 1,200 mg 71+ years 1,200 mg 1,200 mg * Adequate Intake (AI) National Institutes of Health Calculating Calcium Intake Estimated Food Intake + Supplements (if taken) - Daily target +/- Calcium Goal National Osteoporosis Foundation 18

Don t Forget the (Vitamin) D Adequate D is needed to absorb Calcium Vitamin D Recommendation Under age 50 Age 50 and older 400-800 international units (IU) daily** 800-1,000 IU daily** **Some people

19 Don t Forget the (Vitamin) D Adequate D is needed to absorb Calcium Vitamin D Recommendation Under age 50 Age 50 and older international units (IU) daily** 800-1,000 IU daily** **Some people need more vitamin D. According to the Institute of Medicine (IOM), the safe upper limit of vitamin D is 4,000 IU per day for most adults. Calcium absorption compromised when 25-hydroxy vitamin D blood levels are <30 nmol/l AGS recommends level of >75nmol/L Best Sources of D: Fortified foods (e.g. milk) Supplement AND sunlight! Litchford MD. Nutr Clin Pract. 2014;29: Top Foods for Calcium & Vitamin D Calcium Milk (fortified milks like soy or rice) Other Dairy (cheeses, yogurt, pudding) Dark Greens (spinach, kale, collards, turnip) Some fish, (sardines, salmon, perch, trout) Soybeans White beans Almonds Foods that are calcium-fortified, such as some orange juice, breakfast cereals Vitamin D Cod Liver Oil Fortified Milk (& other dairy) Fatty fish, (swordfish, tuna, salmon, sardines) Foods fortified with vitamin D, (orange juice, soy milk, and cereals Beef liver Egg yolks 19

Avoiding the Worst Scenarios Sarcopenia, Frailty and Failure to Thrive Sarcopenia Age-related loss of muscle mass AND strength Not specific to frail

tissue Presents as: physical disability, functional impairment, decreased physical performance, loss of independence, falls Diet helps; strength training is

20 Avoiding the Worst Scenarios Sarcopenia, Frailty and Failure to Thrive Sarcopenia Age-related loss of muscle mass AND strength Not specific to frail individuals Observed in healthy ; well-nourished elderly Lean mass >2 SD below the young normal mean Sarcopenic obesity loss of lean muscle with excess adipose tissue Presents as: physical disability, functional impairment, decreased physical performance, loss of independence, falls Diet helps; strength training is key Hormone therapy?...mixed results Thomas, DR. Asia Pacific Geriatric Congress Hong Kong October 2012 Praddon-Jones, D et al. Am J Clin Nutr. 2008;87(Suppl):1562S-1566S. 20

Frailty Syndrome Prevalence: 3-6% of 65 70 yrs. and >16% aged 80+ Fried s Frailty Syndrome Phenotype: Weight loss >4.

Multiple issues increase the complexity Prevention: Strength training Adequate protein and iron Staying generally active Fried LP, et al. J Gerontol Med Sci. 2001;56A:M416-M156. Same or Different?

21 Frailty Syndrome Prevalence: 3-6% of yrs. and >16% aged 80+ Fried s Frailty Syndrome Phenotype: Weight loss >4.5 kg in past year Exhaustion often or most of the time Very low to no physical activity Low walking speed (<15 in >6-7 sec) Low hand grip strength Etiology many Treatable? Or, GFTT? Multiple issues increase the complexity Prevention: Strength training Adequate protein and iron Staying generally active Fried LP, et al. J Gerontol Med Sci. 2001;56A:M416-M156. Same or Different? Sarcopenia vs. Frailty Common and overlapping in older adults Frail person may not be sarcopenic Sarcopenic person is often, but not always, frail Sarcopenia -muscle loss - muscle quality Physical Function - muscle strength -slow gait speed -poor balance Frailty -fatigue - activity - weight -cognitive impairment -social isolation Cesari M et al. Frontiers in Aging Neuroscience. 2014;6:Article

22 Geriatric Failure to Thrive (GFTT) Prevalence: GFTT is not normal ~5%-35% community Recognize & Intervene dwelling elders Late-life syndrome defined by: ~25%-40% nursing home Wt. loss >5% of baseline residents appetite.dehydration.poor nutrition Inactivity Depression Impaired immune function Low cholesterol levels (<160 mg/dl and declining) 4 common syndromes; predictive of adverse outcomes: impaired physical function malnutrition depression cognitive impairment Robertson RG, Et al. Am Fam Physician. 2004;70: Assessing Geriatric Failure to Thrive Indications: Depression Cognitive Impairment Malnutrition Functional Impairment Failure to Thrive Investigation Lab / diagnostics MMSE, ADL, IADL, Up & Go Test Geriatric depression scale MNA Rx review Chronic disease evaluation Assess environment Adapted from Robertson RG, Et al. Am Fam Physician. 2004;70:

23 Assessing Geriatric Failure to Thrive Depression Malnutrition Cognitive Impairment Functional Impairment Psychotherapy Antidepressants Modify environment SLP Eval Treat oral pathology Review diet restrictions Inc. feedings Nutr. Supplements Tube feed? Optimize living conditions Treat depression Treat malnutrition Treat infection Dementiadelaying Rx PT OT Modify environment With results, continue to treat. If no/ minimal result conduct care planning. Repeat evals/end-of-life / hospice Top Chronic Health Concerns Over 65 The one (or two) nutrition points to remember. 6. Stroke 5. Diabetes 4. Cancer 3. Heart Disease 2. Arthritis 1. Hypertension CDC National Center for Health Statistics. National Vital Statistics System, CDC State of Aging in America Leading cause of functional impairment and dysphagia. 5. No standard diet - BG control important; HHS is a concern 6. Diet per assessment, tx goal & pt wishes 3. Restricting dietary cholesterol has little impact on coronary events 2. Impacts nutrition via physical function access to food may be the bigger concern 1. #1 issue but low sodium diets may not be helpful 23

Healthy aging involves interaction between genes, environment & lifestyle choices.

acute] medical conditions Medications / therapies Psycho-social changes Socio-economic status Aging

Your Special Diet Partner Thank you for participating in today s session!

24 Healthy aging involves interaction between genes, environment & lifestyle choices. Older adults are at greater risk of nutritional deficiencies due to : Aging processes Chronic [& acute] medical conditions Medications / therapies Psycho-social changes Socio-economic status Aging milestones can be managed or minimized and nutrition plays a key role. Your Special Diet Partner Thank you for participating in today s session! This presentation is intended to provide general information about geriatric nutrition issues but is not intended to provide medical advice. Presentation Author: Debra Zwiefelhofer, RDN, LD 24

25 Select References Books 1. L. Kathleen Mahan and Sylvia Escott-Stump. Krause s Food & Nutrition Therapy Elsevier, Inc. Journals 1. Ackner G and Cederholm T. Treatment of protein-energy malnutrition in chronic nonmalignant disorders. Am J Clin Nutr. 2001;74: American Diabetes Association. Clinical Practice Recommendations Diabetes Care 2014;37:S Bauer, J et al. Evidence-based recommendations for Optimal dietary protein intake in older people: a position paper from the PROT-AGE study group. JAMDA. 2013;14: Chernoff R. Normal aging, nutrition assessment, and clinical practice. Nutr Clin Pract. 2003;18: Cesari M, et al. Sarcopenia and physical frailty: two sides of the same coin. Frontiers in Aging Neuroscience. 2014;6:Article Fazia M, et al. Anorexia of aging: can we decrease protein energy undernutrition in the nursing home? JAMDA. 2013;14: Foote JA et al. Older adults need guidance to meet nutritional recommendations. J Am Coll Nutr. 2000;19: Select References *Recommended Journals (continued) 17. Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Gerontol. 2001;56A:M146-M Furman EF. Undernutrition in older adults across the continuum of care: Nutritional assessment, barriers, and interventions. J Gerontol Nursi 2006;32: Houston DK, et al. Dietary protein intake is associated with lean mass chance in older community-dwelling adults: the Health Aging and Body Composition (Health ABC) Study. Am J Clin Nutr. 2008;87: Jensen GL, et al. Nutrition in the elderly. Gastro Clin N Am. 2001;30: Kaiser MJ, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58: Kitabchi AE, et al. Hyperglycemia crises in adult patients with diabetes. Diabetes Care. 2009;32: Litchford MD. Counteracting the trajectory of frailty and sarcopenia in older adults. Nutr Clin Pract. 2014;29: Mozaffarian D, et al. Global sodium consumption and death from cardiovascular causes. N Engl J Med. 2014;371: Pereira GF, et al. Malnutrition among cognitively intact, noncritically ill older adults in the emergency department. Ann Emerg Med. 2014;x:1-7. (in press) 25. Position of the American Dietetic Association: Nutrient Supplementation J Am Diet Assoc 2009; 109:

26 Select References *Recommended Journals (continued) 25. Praddon-Jones, D. et al. Role of dietary protein in the sarcopenia of aging. Am J Clin Nutr. 2008;87(suppl):152S- 156S. 26. Robertson RG and Montagnini M. Geriatric failure to thrive. Am Fam Physician. 2004;70: Symons TB, et al. Aging does not impair the anabolic response to a protein-rich meal. Am J Clin Nutr. 2007;86: U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, th Edition, Washington, DC: U.S. Government Printing Office, December U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. National Institutes of Health. National Heart, Lung, and Blood Institute. Your guide to lowering blood pressure. May White JV, et al. Nutrition in chronic disease management in the elderly. Nutr. Clin Pract. 2003;18:3-11. POST-TEST 1. Identify a plan to assess intake adequacy for protein, B12, calcium and vitamin D in older adults. 2. Identify 2-3 ways to better meet protein, B12, calcium and vitamin D needs in older adults. 26

Nutrition Challenges and the Older Adult

Nutrition Challenges and the Older Adult Sponsor Disclosure: Support for this presentation was provided by the Foodservice Express division of Med-Diet, Inc. The material herein is for educational purposes only. Reproduction or distribution of