Ggeriatric Foods: A Novel Food for Elderly

Sanjeev Kumar

The word geriatrics is derived from the Greek word ‘gerios’ meaning old age and ‘eatron’ meaning medicine. An American doctor Nascher coined it in 1914. The British geriatrics society defines geriatrics as “that branch of general medicine concerned with the clinical, preventive, medical and social aspects of illness in the elderly.” There is an interrelationship between ageing and nutrition. Good nutrition helps in maintaining functional status and prevents the onset of disability. The benefit of good nutrition to health is considered as important to elderly as it is to younger people. Conversely nutritional deficiency has been associated with numerous health problems in the elderly involving anemia, anorexia and weight loss, constipation, dehydration, gastric atrophy, cancer, vision disorders, coronary heart disease, diabetes, obesity, osteoporosis, hypo tension, frailty, pedal edema, infections and adverse drug reaction. There is good scope for geriatrics foods as a baby eats baby food for only about 2 years whereas an oldster could be a consumer of the new product for 15 year or more.

There are challenges involved in developing geriatrics foods due to following reasons:

  • The elderly persons are a heterogenic group
  • Ageing affects gastrointestinal function like sensory perception (food choice), food digestibility, gut function.
  • Elderly persons require less energy due to decreased physical activity and slower metabolism
  • Some of the elderly are malnourished, obese or in malnutrition, have many diseases and a lot of medication, and have decreased function ability while others are active, energetic and healthy.
  • Dietary status and general capability are interrelated
  • Interaction between medication, diseases and nutrition
  • Social background, such as living alone influences eating habits.
  • Geriatrics foods provide opportunity to food industries for product development and marketing.

Types of Malnutrition in Elderly

Protein-Energy Malnutrition

Protein-energy malnutrition results from a deficient supply or absorption of nutrients or an excessive utilization of nutrients by the body. In addition, protein requirements for older adults exceed current RDA (1.0 to 1.25 vs. 0.8 g/kg body weight, respectively). Morbidity and mortality rates increase with protein-energy malnutrition, low serum levels of albumin and/or thyroid hormones, and hypothermia. Marasmus and kwashiorkor are two forms of protein-energy malnutrition.

Marasmus is a condition of borderline nutritional compensation in which a patient has a marked depletion of muscle mass and fat stores but has normal visceral protein and organ function. Because the patient has depleted nutritional reserves, any additional metabolic stress (e.g. surgery, infection, or burn) may rapidly lead to kwashiorkor (hypoalbuminemic protein-energy malnutrition). Characteristically, elderly patients come to this state more rapidly than young patients. Usually, susceptible elderly patients are underweight, but even those who appear to have ample fat and muscle mass are susceptible if they have a recent history of rapid weight loss.

About 16% of elders living in the community consume < 1000 kcal/day, an amount that cannot maintain adequate nutrition. Malnutrition also occurs in 3%-12% of older outpatients, 17%-65% of older persons need acute care in hospitals, and 26%-59% of older persons need long-term care in institutions.

Vitamin Deficiencies

Physiological and functional changes during aging result in changes in nutrient needs. Altered ability to taste and smell, poor oral health, dysphasia, and failure-to-thrive syndrome (i.e., nonspecific symptoms associated with deteriorating mental status and functional ability, social isolation, and decreased food intake) can contribute to decreased nutrient intake, involuntary weight loss, and malnutrition.

Mild vitamin deficiencies are very common in older persons, particularly those in institutions, and have been associated with cognitive impairment, poor wound healing, anemia, bruising, and an increased propensity for developing infections and certain types of cancers. Therefore, it is important for them to take a multi-vitamin supplement.

1) Antioxidant Deficiency – The antioxidants a-tocopherol, beta carotene, and ascorbic acid benefit visual capacity and help to prevent cataract formation and macular degeneration.
2) Vitamin A Deficiency – Vitamin A deficiency is rarely a problem in older persons, however, its deficiency is associated with lung cancer. Excess vitamin A should be avoided because it can produce hypercalcemia, liver
3)Vitamin B1 (Thiamine) Deficiency – Thiamine deficiency occurs mainly in alcoholics. Glucose administration can precipitate acute thiamine deficiency and cause delirium, ataxia, and bilateral sixth nerve palsies (Wernicke's syndrome). Thus, thiamine and glucose should always be administered together.
4) Vitamin B2 (Riboflavin) and Vitamin B6 (Pyridoxine) Deficiency – Signs of vitamin B2 deficiency are cheilosis, glossitis, angular stomatitis, seborrheic dermatitis, and a magenta tongue. Signs of vitamin B6 deficiency are sideroblastic anemia.
5) Vitamin B3 (Niacin) Deficiency – Niacin deficiency occurs in older persons who are alcoholics, are receiving isoniazid, or have carcinoid syndrome. Characteristically, the patient develops pellagra, dementia, diarrhea, and constipation.
6)Vitamin B6 (Pyridoxin), Vitamin B12 (Cyanocobalamin) Deficiency – Metabolic and physiological changes that affect the status of vitamin B12, vitamin B6, and folate may alter behaviour and general health, whereas adequate intake of these nutrients prevents some decline in cognitive function associated with aging. Deficiencies of these nutrients, along with insufficient intake of vitamin C and riboflavin, may result in poor memory.
7) Vitamin B12 (Cyanocobalamin) Deficiency – Vitamin B12 deficiency can lead to dementia, megaloblastic anemia, incontinence, and orthostatic hypotension. Up to 5% of persons over age 80 have vitamin B12 deficiency. The most common cause is pernicious anemia, which results from a lack of intrinsic factor. Documenting a vitamin B12 level <200 µg/dL makes the diagnosis of vitamin B12 deficiency. However, 25% of persons with levels between 200 and 300 µg/dL are deficient, as demonstrated by elevated methylmalonic acid and homocysteine levels in the urine.
8) Vitamin C Deficiency – Vitamin C deficiency is associated with increased bruising, poor wound healing, and the development of pressure sores. Ingesting vitamin C at any dose results in false-negative fecal and urinary occult blood tests; ingesting megadoses can interfere with serum and urine glucose tests and may result in oxalate kidney stones, increased serum salicylate levels, and rebound scurvy (bleeding after withdrawal).
9)Vitamin D Deficiency – Vitamin D serum levels may be deficient even with adequate sunlight exposure. Deficiency may be exacerbated by homebound status, use of sun block, poor dietary intake, decreased capacity to synthesize cholecalciferol in the skin, and decreased number of gastrointestinal receptors. When vitamin D levels are low, fracture rates increase. Vitamin D and calcium supplementation may reduce the incidence of hip fractures and increase bone density.

Mineral and Trace Mineral Deficiencies

Mineral and trace mineral deficiencies are associated with immune dysfunction and many other disorders. Therefore, it is important to take a multi-mineral supplement, such as Daily Health.

1) Zinc Deficiency – Zinc deficiency is indicated by plasma zinc levels < 70 µg/dL, occurs mostly in institutionalized, shut-in, and ambulatory elderly persons. Zinc loss in the urine occurs in persons with diabetes, cirrhosis, and alcoholism and in those using a diuretic. Zinc deficiency is associated with poor wound healing, impaired immune function, night blindness, and hypogonadism. High doses of zinc have been reported to slow the progression of age-related macular degeneration.

2) Selenium Deficiency – It occurs in patients who receive long-term tube feedings. The major symptoms of selenium deficiency are muscle weakness and pain.

3) Copper Deficiency – It is associated with anemia and glucose intolerance.


Dehydration

Dehydration is a major problem for older adults. It results in death within a year of admission for nearly half of the elderly hospitalized Medicare patients. Dehydration risk increases because of the kidney's decreased ability to concentrate urine, altered thirst sensation, decreased renin activity and aldosterone secretion, relative renal resistance to vasopressin, changes in functional status, delirium and dementia, medication side effects, and mobility disorders. Fear of incontinence and increased arthritic pain resulting from numerous trips to the toilet may also interfere with consumption of adequate fluid intake.

Geriatric Nutritional Needs

The benchmark of nutrient needs for healthy persons is the set of Recommended Dietary Allowance (RDAs) established by the Food and Nutrition Board of the National Academy of Sciences. RDAs have been issued for protein, 11 vitamins, and 7 minerals. These recommendations are for all healthy people over the age of 51. However, when calculating the nutrient requirements of the elderly, the RDA guidelines have several limitations:

1) They are aimed at preventing nutritional deficiency, not preventing disease. They do not cover nutritional needs that have been altered by disease, stress, chronic use of drugs, etc.
2) RDA guidelines are recommendations for healthy population groups. They do not take into account differences between individuals.
3) RDAs have not been established for all essential nutrients.
4) Diet-drug and food-nutrient interactions were not considered in setting these levels.
5) RDAs for older persons were extrapolated from studies of younger population.
It is important to be aware of the truth about RDA guidelines for the elderly. with adequate knowledge, geriatric malnutrition can be properly diagnosed and treated. If both the patient and health care professional understand the entire spectrum of nutrition and food care, these RDA guidelines will serve only as a helpful overview of the essential nutrients. As every person is different, the body's needs are also different. With proper knowledge correct guidelines can be prescribed and used to meet specific individual's needs.

Protein

Protein is essential for building and maintaining body tissues. It is a source of amino acids that function in muscles, organs, hormones, nervous system, and immune system. If the body is not receiving enough calories it will burn protein for its energy needs. Protein needs are 0.8 - 1.0 g protein/kg body weight for healthy elderly, about 12-14% of total calories, and this amount increases when the body is stressed by injury, infection, surgery, or illness.

Fat

A small amount of fat is necessary for life. Fats are highly concentrated sources of energy. They transport fat-soluble vitamins (A, D, E, and K), if flavour is added to food, it enhances its satiety value. Fat digestion is inhibited with aging. Saturated fats are harmful to the body. They are found in butter, cheese, cream, lard, salt pork, meat fat, coconut oil, palm oil, and hydrogenated margarine or shortenings. Polyunsaturated fats tend to lower blood cholesterol. These oils are liquid at room temperature. Examples of oils high in polyunsaturated fats are corn, cottonseed, safflower, sunflower, sesame, and soybean. The amount of fat per day should be no more than 30% of total calories, and only l0% of calories should come from saturated fat. Dietary cholesterol should be limited to 300 mg or less per day.

Carbohydrates

The minimum daily carbohydrate intake should be 50-100 g/day. At least 50% of total calories should come from complex carbohydrate sources. Daily recommended fiber intake is 20-35 grams.

Calories

Calories come from proteins, carbohydrates, and fats. The body's caloric needs are about 1.5 times the basal energy expenditure (BEE). There is a 10% reduction of caloric need between ages 51-75 with an additional 10-15% reduction after age 75 depending on individual activity. Most foods contain calories from more than one source.

  • Each gram of Protein = 4 calories
  • Each gram of Carbohydrate = 4 calories
  • Each gram of Fat = 9 calories

Energy needs decrease with age because lean body mass (LBM) decreases and the overall level of activity also usually decreases. Calorie needs are dependent on activity level, as well as on body composition. Therefore, caloric requirements for a person who is bedridden is less than for someone who is mobile and active.

Exercise helps active older people maintain lean body mass, although lean body mass decreases somewhat even in those who exercise extensively. The higher the LBM, the more a person can eat without gaining weight and the more likely he or she will obtain an adequate supply of all nutrients. 

Vitamins and Minerals

Although older adults need fewer total calories, they have an increased need for certain vitamins and minerals. This increased need must therefore be satisfied with a lower overall intake of food. Thus, it is especially important for the elderly to eat foods rich in nutrients: fruits, vegetables, sea vegetation, whole grains, lean meat, fish, and legumes. Nutrient-poor foods like sweets and alcohol should be limited.

  • Vitamin A Needs Decrease; they should avoid supplements containing vitamin A
  • Vitamin D Needs Increase;they should include vitamin D-rich foods, such as fish liver oil, foods fortified with vitamin D, egg, alfalfa, cod liver oil, egg yolk (moderately), fruit, most nuts, oatmeal, salmon, sardine, sweet potato, tuna, vegetable and vegetable oil.
  • Vitamin B12 Needs Increase; the elderly persons should eat vitamin B12-rich foods such as egg (moderately), certain soy products (miso, tamari, soy sauce, natto and tempeh), fish, hijiki, kumpo, mackerel, nori, seafood and tofu
  • Folate Needs Decrease; no recommended changes.
  • Chromium Needs Increase; they should consume foods high in chromium such as brown rice, meat (moderately), whole grain, dried bean, corn, corn oil, mushroom and potato.
  • Zinc Needs Increase; they should eat foods rich in zinc, such as beef (moderately), egg yolk (moderately), fish, legumes, lima bean, meat, mushroom, peach, pecan, pumpkin seed, sardine, sea cucumber, seafood, seeds, soy lecithin, soybean, sunflower seed, tourla and whole grain.

Water

Water is an important nutrient that is frequently overlooked. The thirst response decreases with age so the elderly persons should be encouraged to make a habit of drinking water and other fluids throughout the day. The elderly needs at least 6 to 8 cups (48-64 oz.) of water daily.

Dietary Intervention

Dietary advice is most effective when tailored to the individual’s personality, living situation and body’s needs, and when offered in small increments. Changes should not be pushed too rapidly. The skills used by older adults to reach the later stages of life may serve them better than any changes recommended to them.

Good eating habits are based on moderation and variety. The Daily Food Guide provides a simple plan for everyday eating. It separates food into four groups according to their nutritional contribution, and it specifies the number of servings necessary to meet nutritional needs. Eating foods from each food group every day will provide the protein, vitamins, minerals and calories needed for a healthful diet.

Using Nutritional Supplements

Supplements are needed especially if the individual cannot or will not eat enough food to meet nutrient needs. This may be due to poor eating habits, a medical condition, a diet restriction, or food/drug interactions. Doctors and other health professionals should discuss supplement use with their patients and provide appropriate guidelines for their use. Families of such patients should be included in these discussions

Consult a Qualified Doctor and Nutritionist

It is strongly encouraged for cancer patients to seek the help and advice of a healthcare provider who has achieved proven methods of success in the area. Geriatric patients are generally weaker and present more physiological imbalances. Therefore, they need to pay special close attention to their bodies and if certain symptoms develop, to approach it directly, effectively and knowledgeably. The essential nutrients needed by the individual body should be recommended. The patient should be educated on proper food care for recovery and healing.

Proper Healthcare

It is essential for geriatric patients to receive the proper health care. Natural medicine treatments are therefore, strongly recommended. Acupuncture, herbal medicine, and food therapy all help to treat diseases and balance vital internal organ systems. These treatment methods help improve circulation, benefit respiration, nourish the bone, nervous, kidney and bladder systems, strengthen immunity, and improve memory.

Choosing Foods Low in Fat and Cholesterol

About 35-40% of average daily caloric intake comes from fat. This type of high-fat diet needs to change because it has been linked with cancers of the breast, colon and prostate. A reduced intake of fat helps control weight and lower the risk of heart disease. Because serum cholesterol levels tend to increase with age, choosing low-fat, low-cholesterol foods is particularly important for the elderly. Broiling, poaching, stir-frying, steaming, are low-fat methods of food preparation.

Low density lipoprotein (LDL) sticks to the inside of arteries, impeding blood flow. High density lipoprotein (HDL) removes LDL from the blood. Monounsaturated oils (canola, olive) can help lower LDL and raise HDL. Desirable lipid profile results are total cholesterol level below 200 mg/dl, LDL below 130 mg/dl, HDL above 45 mg/dl. The ratio of total cholesterol to HDL should be less than 4.5.

Reducing Daily Sodium Intake

The body needs about 500 mg sodium per day (1/4 teaspoons of salt). High sodium levels can cause high blood pressure and heart disease. A small amount of sea salt may be used in cooking, but no salt should be added to food after it is prepared. For flavour, use vinegar, herbs and spices instead of table salt.

Increasing the Fibre Content

Fiber is the part of plant food that the body does not digest. It keeps bowel movements regular and prevents constipation. Because of the decrease in GI motility that occurs with aging and the constipating effects of some medications, boosting the fibre content of the diet is particularly important for older adults. The older adult who complains of constipation should be discouraged from overusing laxatives, but instead should be encouraged to eat more fibre and exercise more often.

The recommended daily intake of fibre is 25-35 grams. Whole grains, wheat bran, fruits, vegetables, legumes, nuts, and seeds are excellent sources of fiber. Fiber-rich foods are an essential part of a well-balanced diet. With the increase fibre in the diet, amount of water intake should also be increased. Adding too much fibre to the diet too quickly can however cause bloating, gas, and other uncomfortable symptoms. They should eat more fresh fruits and vegetables, which should be peeled. Instead, these should be cleaned thoroughly and steamed in a small amount of water to preserve fibre and nutrients. These should not be overcooked. Skins of potatoes, apples, and other fruits and vegetables should also taken along with them. The outer part of these foods contains the most fibre.

The elders should substitute whole-grain breads and cereals for white bread and sugary cereals. Instead of meat, they should eat more beans (navy, lima, kidney, pinto, and string beans are all high in fibre content and are an excellent source of protein.) Beans can be used in casseroles, soups, stews, and other dishes. They should eat fresh fruit, vegetables, and unbuttered air-popped popcorn for high-fibre, low-calorie snacks.

Increasing Nutrient Intake

The most nutritious meals are of no value if they are not eaten. It is important to know that older adults will eat the food provided to them.

  • Foods served warm (not too hot or too cold) may be more appealing to elders.
  • Having a well-balanced diet does not necessarily mean eating three meals a day. Adequate nutrition can be achieved by eating well-planned small meals throughout the day.
  • Eating is a social event and should be shared with family and friends.
  • Elders should share shopping and cooking duties.
  • The environment can affect one's appetite. It is therefore advised to have brightly lit, glare-free, uncluttered rooms accented in primary colours.
  • Cooking and eating utensils should be lightweight, colorful, and non-breakable.

Facilitating Weight Control

Though a less serious problem in older persons than protein-energy malnutrition, obesity can impair functional status, increase the risk of pulmonary embolus and heart disease, and aggravate chronic diseases such as diabetes mellitus and hypertension. To lose weight the body must burn more calories than it takes in. Each pound of fat equals 3500 calories. Selecting lower-calorie foods in smaller portions from all the food groups, in conjunction with increasing physical activity, will promote gradual weight loss. A sensible weight reduction is 1-2 pounds or 1% of total body weight per week.

Variety, moderation, portion control, and regular exercise are important in weight reduction and weight control. Diets that eliminate a food group or a nutrient are dangerous. Skipping meals is neither recommended nor effective; small, frequent feedings help the body burn more calories. Exercise increases the metabolic rate, increases or maintains lean body mass, and improves cardiovascular conditioning. Examples of aerobic exercise are walking, biking, swimming, jogging, and dancing. Contrary to common belief, exercise does not increase appetite.

To lose weight and to keep that weight off require permanent changes in eating and activity habits. Changing long-standing habits demands time, motivation, commitment, and persistence. It also requires patience-just as the excess weight was gained over a period of time, so losing it will take a long time.

Meeting the Nutritional Needs of the Impaired Elderly

A blender or food processor comes in handy for elders with chewing or swallowing problems. Meats and vegetables can be chopped or pureed with a small amount of gravy or broth to achieve the desired consistency. Soft foods, such as tuna, fresh fish, eggs, tofu, spirulina, and soybean spread, are good meat substitutes. Baby cereal can also be used to thicken pureed foods without changing the flavor.
People with physical disabilities may benefit from special feeding accessories, such as

  • non-skid place mats,
  • feeding cuffs that hold eating utensils,
  • plates with wide, curved lips that help keep food on the plate,
  • cups with special lids for sipping, and
  • weighted forks, knives, and spoons with wide handles for easy grasping.

With the advance in technology, geriatric patients with physical disabilities will have more and more eating aids to assist in dietary intake.These will be especially beneficial to ensure the consumption of essential nutrients and to prevent malnutrition for the physically impaired

Conclusion

Geriatric malnutrition is a very real and pertinent issue. It will affect us directly because each one of us will age and possibly come face to face with this health risk. It can affect us indirectly because we all have parents, grandparents, elderly friends, relatives, and loved ones. Therefore, it is important to be educated about geriatric malnutrition and learn how to use this knowledge for prevention and treatment.

With the proper education and knowledge about cause, diagnosis, treatment and intervention, we can all be better prepared. However, there is no promise and no guarantee that there will be an end to this health risk, because there are still new discoveries about health and treatment being made each day. But at least we do not have to be afraid of aging and afraid of this fatal possibility.

Age is not a negative thing, as long as one has good health and a strong body. But the key is to understand how to properly take care of the body, feed the body and balance the body. Often clinically, we encounter patients who do not like being old. They are depressed about their age and some even feel themselves useless and unproductive. We remind them that there is value is age and there is life to be enjoyed as long as the quality of life come together with the quantity. If the body is strong and healthy, age will only be a problem.Therefore, it is imperative to learn about the methods to take care of the body - about food, nutrition, diet, exercise, lifestyle, treatment, and environment. There are many factors that determine health and well-ness and with proper education, we can all be better prepared to diagnose and treat geriatric malnutrition.

 

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References

Potty, V. H.1996.Geriatric Foods- A fad or a need ?. Indian Food Industry,15:27.
Puranik, D.B.1999. Whey and whey proteins in geriatric nutrition.Indian Dairyman. 51(5):5-10.
Swamy,K., Jayaprakasha, H.M. 2002. Design consideration in formulation of geriatric foods. I. J. of Dairy & Biosciences. 13(1): 95-97.
Trugo C,Luiz,Finglas M.E.(2004).Elderly-Nutritional Status.In: Encyclopedia of Food Science and Nutrition,Vol.3,p2016-2033.
Food and Nutrition Board. 1989. Recommended Dietary Allowances. 10 th edition. Washington, DC: National Academy Press.
Nutritional needs for elderly. Detroit medical centre. Com.
Nayak, S. K., Pattnaik, P. And Mohanty, A. K. 2000. Dietary fibre: A low calorie adjunct. Indian Food Industry. 19(4): 268- 278.
Diet, Nutrition and the prevention of Chronic diseases. WHO, Geneva,2003.
DeVries, J. W. (2003). On defining dietary fiber. Proc. Nutr. Soc., 62: 37-43.
Dryer, J. (1992) Fiber: An idea whose time has come. Dairy Foods, 93 (1): 33.

 

Recommended Nutrients for Elderly

Nutrients Male Female
Calories(Kal) 1800 1400
Protein(gm) 60 50
Fat(gm) 50 40
Ca(mg) 400 4000
Fe(mg) 28 30
Vitamin A(I.U) 2400 2400
Thiamine(mg) 12 0.9
Niacin(mg) 16 12
Riboflavin (mg) 1.4 1.1
Vitamin C(mg) 40 40

 

 

 

Design consideration in product development of elderly:

Handicap How to Overcome
Poor Vision Colourful presentation
Poor sense Amplification of flavour
Less taste buds Mixture of KCl &NaCl
Loss of teeth Soft texture food
Less secretion of digestive juice Higher moisture & predigested food
Constipation High fibre food
Changes in colon microflora Dairy products
Reduced fat absorption & resynthesis Low fat products
Increased need of vitamins Fortified with micro-nutrients
Increased susceptibility to infections

Zn supplemented food

 

 

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