Nutrition and the elderly a global perspective
Mark L Wahlqvist, BMed Sc, MDBS, MD
Antigone Kouris-Blazos, BSc Hons, Grad Dip Diet, PhD
Irene Darmadi, MD
Martalena Purba, BSc, MCN
International Health and Development Unit, Monash University, Melbourne, Australia

S A J Clin Nutr 2000 February Vol. 13 No 1.

Few will doubt the worldwide documented trend toward increased life expectancy, and equally few will question the significant and multifaceted implications of this trend. It is generally accepted that within the framework of the changing demographics of the elderly optimal nutrition is of paramount importance, not only in improving health and general wellbeing, but also in reducing the use of ever-diminishing health care resources. As such, there are many challenges ahead that need to be addressed if we are to be successful in meeting the needs of this increasing section of the world population

Problems and potential
Demographic
As a species, Homo sapiens is living longer than ever before with several population life expectancies at birth exceeding 80 years, and increasing by approximately 1 year every 3 years for the last 30 years, with part of this increased longevity occuring from ages 60 and 70 onwards (Fig. 1).1 At the moment, although the proportion of centenarians is also increasing (upwards of 1 in 1 000 of the population in economically advantaged countries), individuals do not appear to exceed a maximal life span of about 120 years. This may change as biotechnology, lifestyle and health care develop in favour of greater longevity.

Again, age-specific morbidity rates among the aged, reflected in disability indices, are decreasing,2 suggesting that biological age is younger for a given chronological age.3 This phenomenon represents an important trend towards compression of morbidity nearer to death. The problem is that the same morbidity and longevity gains are not being seen globally, with exceptions related to:

• poverty (Third-World, urban poor)
• educational disadvantage
• ethnicity (e.g. African and Hispanic Americans compared with whites)
• status of women (who generally live longer than men)
• food security
• health services
• status of aged
• cultural resilience (e.g. indigenous people overpowered by dominant immigrant or colonial cultures)
• housing
• community support and organisation
• substance abuse (tobacco, alcohol, self-medication)
• opportunity for and interest in physical activity.

Frailty among the aged is defined as ‘a condition or syndrome which results from a multi-system reduction in reserve capacity to the extent that a number of physiological systems are close to, or past, the threshold of symptomatic clinical failure. As a consequence, the frail person is at an increased risk of disability and death from minor external stresses’.4 Whether or not it is the most prevalent, it is arguably the most consequential problem among the aged because it affects independence and survival. Its measurement and surveillance is of growing importance in the demography of the aged.5

Figure 1. International comparison of life expectancy at birth. (Source: Department of statistics and information, ministry of health and welfare, Japan. Abridged life table, 1996)

Societal
Being old is not simply a chronological issue – it may be biological or societal. The notion of Bismark, the German Chancellor (1883 - 1887), that retirement was appropriate at age 65 led to a century of preconception that people should be treated as old from this age onwards.6 The reality is that biological heterogeneity in later life increases relative to early life, and a ‘cut-off’ at which one is aged is not easily amenable to biological definition. A growing proportion of ‘retirees’ are physically, mentally and socially active. They may therefore continue to make significant contributions to society and to their own welfare. The social engagement of elderly people will become increasingly critical to the sustainability of communities. Indeed, social activity itself may be one of the most important determinants of longevity.7 The role of social activity in encouraging healthful food patterns, notably food variety, and of eating in encouraging social activity, is increasingly understood. 8-13

Cultural
Where the aged are accorded respect, their wellbeing is more assured. Additionally, they then provide an opportunity for the transmission to younger generations of knowledge and wisdom, including that pertaining to food and health. While it may be that transmission of adverse beliefs is also possible, where the aged are well connected to the young a culturally dynamic society can modulate the belief system in a critical way. It is difficult to substitute for the absence of older people and what they can relate. The potential of today’s youth to interact with all four grandparents has never been greater. At a time of considerable pressure on young people to conform to a global fast food culture, the championing of food cultural roots by grandparents may be invaluable – a contribution to self respect and its favourable impact on behaviour.

Monitoring and surveillance
Cost-effective methods for measuring what older people eat and have eaten are part of quality health surveillance in this age group. This view is predicated on a growing body of evidence that many health problems among the aged are nutritionally dependent. To this end several descriptive studies of food and health among the aged have been attentive to methodology that might be rapidly and reliably applied. Ultimately the need for such information is to predict health outcomes and to facilitate food interventions that are culturally-sensitive and healthful. There are a number of studies of elderly people of this type. 14-17

These studies are also prospective in mode and provide information on food patterns and health outcomes.18 The world 18 Health Organisation (WHO) and Food and Agriculture Organisation (FAO) have now applied the Food-based dietary Guidelines (FBDG)19 framework to the nutritional and health needs of the aged.20

Risky food patterns in later life
In order to minimise nutritional risk in later life, regular physical activity is crucial. Ideally, the exercise should be of different kinds to develop aerobic fitness, strength, balance and flexibility.21 From a nutritional point of view these exercise forms allow for greater energy throughput with easier-to- achieve energy balance; maintenance of lean mass and its various functions; reduced likelihood of falls and fractures where there is osteopenia; and the ability to move, with associated independence in relation to food requisition and habits. When older people are physically active, marginal food patterns are less likely to lead to problems of the aged such as:

1. frailty; 4
2. Protein energy dysnutrition;22
3. micronutrient and phytochemical deficiency 23 because greater amounts of nutritious food can be eaten without positive energy balnce;
4. chronic metabolic disease (non-insulin dependent diabetes mellitus (NIDDM), cardiovascular disease, osteoporosis)24,25 certain cancers (breast, colonic, prostate); 26
5. depression (there is growing evidence that omega-3 fatty acid deficiency can contribute to depression in some individuals and that exercise can alleviate it)27, and
6. cognitive impairment 28 - with the apoE4 genotype, excess dietary saturated fat is likely to increase risk of Alzheimer’s disease; 29 and some antioxidants like vitamin E30,31 and glutathione32 may reduce the risk.

Specific risk food patterns in later life include: (i) large rather than smaller frequent meals or snacks because of inability of insulin reserve to match the carbohydrate load in those proved to have impaired glucose tolerance (IGT) or in those with NIDDM; or because where appetite is impaired nutritious snacks can avoid chronic energy undernutrition; 33 (ii) alcohol excess, no alcohol-free days and/or alcohol without food (since food reduces the impact of alcohol ingestion on blood alcohol concentration and its consequences); (iii) eating alone most of the time, since social activity encourages interest in food, and usually healthful food preferences; and (iv) use of salt or salty food rather than intrinsic food flavour (especially as taste and smell tend to decline with age)34 as excess sodium contributes to hypertension through an increased Na/K molar ratio, salt and water retention in cardiac decompensation, and promotion of urinary calcium loss.

Protective foods
The most protective food pattern is one of food diversity – probably using 20 - 30 biologically distinct foods in a week. 35 At the same time, eating in the traditional food culture context can provide a measure of food security for the aged. This is one of the arguments for the FBDG for the aged. 19 The consumption of nutrient-dense foods reduces the risk of essential nutrient deficiencies. These include:

• Eggs (little if any effect on serum cholesterol if not eaten with saturated fat)
• Liver
• Legumes, especially traditional soya products such as tofu and tempeh
• Nuts
• Low-fat milk and dairy products
• Fish
• Lean meat
• Fruits, vegetables, plant shoots
• Wholegrain cereals
• Wheat germ
• Yeast
• Unrefined fat whole foods (nuts, seeds, beans, olives, avocado, fish)
• Refined fat from liquid oils (cold pressed, variety of sources, n-3, n-9).

The protective nutritional value of fruits and vegetabels derives especially from their content of phytochemicals, which are multifunctional compounds36 usually of health benefit (antioxidant, anti-mutagenic, anti-angiogenic, immunomodulatory, phyto-oestrogens).

Urban or rural
From the International Union of Nutrition Sciences (IUNS) Food Habits in Later Life study conducted in Tianjin, it is notable that rural people have a lower energy and overall food intake, especially of protective foods such as fish and fruits Rural Tianjinese also had lower BMIs than their urban counterparts (Table I). 14

In the same study series the more urbanised Greeks in Melbourne, compared with villages in Greece, actually adhered to a more traditional, and thereby more nourishing food pattern. 37 However, obesity prevalence (defined as a BMI above 30) was greater among elderly Melbourne Greeks (men 30%, women 45%) compared with elderly rural Greeks (men and women 15%),14 with its potential adverse mechanical and metabolic consequences. Nevertheless it is now known that among the aged, BMI up to 30 is not adverse for survival.38,39

Consequently, although rural food production and traditional knowledge must remain important along with environmental respect so that a sustainable food supply is available, older people seem to be nutritionally advantage by living in towns or cities. The overall health status of the aged is also likely to depend on readily available health care, which is easier to obtain in urban settings. The challenge, then, is to develop healthy urban environments for the aged and others In conclusion and in terms of health advancement in the aged, doing what we know to be nutritionally advantageous for the aged is of paramount importance. However, we must acknowledge that there is still much we do not know. Genetic predisposition, altered gene expression early in life (as early as in fetal life, and cumulative effects of adverse experiences ove a lifetime), may make nutritional approaches in later life difficult to implement beneficially. As such, food patterns in later life still determine health outcome. We are bound to monitor, evaluate and review public health nutrition practice in the aged for a long time to come.

Table I. Body mass index of Tianjin elderly (kg/m2)

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Last updated: 17-Feb-2004