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Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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10
Nutrition

Dietary status and nutritional status are not synonymous. Dietary status is a measurement of what an individual is eating; nutritional status is the state of an individual's health as it is influenced by what is eaten. Diet is only one of many factors that may influence nutritional status. Thus, to provide an estimate of an individual's nutritional status, other measures are also used, including biochemical measurements of body fluids, anthropometric measurements, clinical findings, and medical history.

When diet alone is responsible for deficits in an individual's nutritional status, the person is said to be suffering from primary malnutrition. The forms of primary malnutrition that may arise simply as a result of deficits in dietary intake are undernutrition or starvation, protein calorie malnutrition, and various vitamin and mineral deficiency disorders such as iron deficiency anemia, scurvy (from a deficiency of ascorbic acid), and osteomalacia (from a deficiency of vitamin D). Excesses in some categories of dietary intake may give rise to obesity, hypervitaminoses, alcohol intoxication, and various dietary imbalances that all have adverse health effects. Deficits, imbalances, and excesses in nutrients may all be present simultaneously in some individuals.

Other factors may also give rise to malnutrition—for example, the presence of disease, special physiological states, or inborn errors of metabolism. Moreover, although the biomedical model tends to concentrate on biological variables, social and psychological factors

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

can cause malnutrition as well. Food and eating have potent aesthetic and psychological attributes that are of great importance to maintaining the quality and enjoyment of everyday life. If a person's dietary intake is devoid of such characteristics owing to pathology arising from a physiological, psychological, or social cause, metabolism is deranged, appetites fall off, and eventually physical as well as emotional well-being may suffer. When malnutrition results from one or more of these causes, it is referred to as secondary malnutrition. Diet-drug or drug-drug interactions may also affect nutritional status adversely. Because this form of nutritional derangement is iatrogenic, it too is regarded as secondary malnutrition.

NUTRITION AND QUALITY OF LIFE

Favorable nutritional status throughout life can increase life expectancy. The increased expectation of life at birth that has taken place since 1900, as well as the growth in the expectation of life after 65 years of age, has been due in part to more favorable environmental conditions. Among these conditions has been an improvement in certain aspects of the food supply and dietary intakes, which have led to decreased prevalence of undernutrition and dietary deficiency diseases. Yet at the same time, other dietary factors have changed in the opposite direction—including several risk factors for chronic degenerative diseases (in particular, coronary artery heart disease, high blood pressure, and storke) and certain cancers, which now account for at least 75 percent of all deaths and half of all bed confinement days among the elderly.76

Common chronic degenerative diseases with diet-related components as well as other diseases and cognitive impairments prevent functional independence. In 1985, more than 5 million people 65 years of age and older needed special care to remain independent; by the year 2000, more than 7 million people are likely to need such care. Many of these same individuals will need assistance with shopping, meal preparation, and eating.34,87 The oldest old, that is, those over 85 years of age, are likely to be in special need of assistance in preparing food, eating, or planning their diets. Others, especially those with multiple, complex conditions, are also likely to require long-term care, either in or outside of institutions. Many residents of nursing homes and other long-term care facilities require therapeutic diets to deal with their health problems.76 However, a lack of choice, limited variety, and poor quality of food may limit the enjoyment an individual derives from eating, even though minimal standards for nutrient intake are met in such facilities, in boarding

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

homes, or even in the person's own home. Certain nutritional interventions among those aged 50 and older offer promise in helping meet national goals to reduce the number of days of restricted activity per year that result from acute or chronic conditions among the elderly.22 And at all ages, attention to nutrition can increase the quality of life.

NUTRITION AND FUNCTION

The critical factor in a diminished quality of life for U.S. residents over 50 years of age is impairment in functional independence. Thus, a major concern of most elderly people is related to dependency. The average 68-year-old man today has a life expectancy of 13 years, which includes 4 years of progressive incapacity and increasing dependence. The segments of the population over 75 and over 85 years of age, the groups most likely to suffer functional impairments, are growing rapidly.76 Therefore, the concerns of the elderly with respect to maintaining the activities of daily living, including those related to nutrition and foods, are likely to increase rather than decrease in the future.

FUNCTIONAL INDICES OF NUTRITIONAL STATUS

Functional assessments and indices in nutritional studies and in evaluations of service programs with a strong functional focus fell into disuse several decades ago, and renewed interest in them is only now beginning to surface. It is interesting to note that, in the earliest nutritional studies, a functional focus was often present. These early studies had a socioeconomic as well as a biological motivation and were usually concerned with the preservation or restoration of physical, psychological, social, or economic function by nutritional means. Many of the early justifications of the school milk, lunch, and breakfast programs for poor children were based on improvements in functionally related criteria (e.g., lowered absenteeism rates, greater alertness). The vitamin and mineral deficiencies that were common in the early part of this century were acute and could be clearly related to diet; if diet were altered, total cure could be expected. With certain other conditions, such as the associations between massive obesity, incidence of chronic diseases, and disabling conditions, functional indices of a crude sort (e.g., days of work lost, days of restricted activity) were used, and the effects of improved diet were also relatively easy to demonstrate.27

The range of available measures of physical, mental, and social

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

function has expanded greatly.42 Such measures include the Activities of Daily Living scale, as well as assessments of social competence (the Instrumental Activities of Daily Living scale) and mobility measures. In the field of nutrition, however, none of these measures or any other measures of disability have been used frequently, especially in studies in highly industrialized countries.51 The effects of the diseases themselves and the treatments for the diseases (nutritional or other types) are rarely separated and measured. Thus, the effects of many nutritional therapies on function, quality of life, morbidity, and mortality are unavailable. Even more unfortunate, function in relation to eating is often not even considered in medical assessments. A recent survey revealed that the specifics of dietary history (either diet restrictions or details of food intake with respect to calories, the types of food actually eaten, and physical limitations on eating) and other functional measures were rarely found on standard history-taking forms used in hospitals and long-term care facilities.60 These forms also neglected subjective comments by patients on the degree of their health, specifics of home living arrangements, the supporting services they received, and their dietary histories.60

Currently, the most common type of nutritional assessment used for older individuals comprises a clinical examination and one or more objective indices of functional impairment. The major advantage of a clinical examination, if it truly involves an assessment of functional status, is that it can incorporate observations of the individual actually performing the activities essential to preservation of independent function. When clinical assessments are combined with functional assessments of an objective nature, using such instruments as mental status measures, dietary intake and nutritional status measurements, measures of visual acuity and gait, and the Activities of Daily Living scale, more moderate cases of functional impairment are often revealed.86 (A more typical clinical assessment that does not involve such functional assessments is useful in identifying severe impairments but may miss more moderate degrees of deficits in function.) Given the limited training most physicians, nurses, and dietitians receive in the specifics of functional assessment and, indeed, in many areas of care and assessment of the problems of the elderly, such care givers often find it difficult to assess the self-maintenance skills of elderly patients by clinical means. When fuller assessments of function or home visits to the elderly are conducted, however, they often reveal insights on function related to diet and eating.88 Such a complete geriatric assessment is often

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

helpful and should be mandatory when nonspecific failure to thrive with unexplained deterioration in nutritional status is evident.7

DIETARY INDICES

An assessment of dietary intake is another useful but often neglected tool for determining the nutritional status of the aging. Dietary status indices provide information that helps a clinician make the differential diagnosis between primary malnutrition owing to inadequate dietary intake and malnutrition resulting from other causes. They can also offer some estimate of the patient's habitual diet, foodways, and abilities to purchase, prepare, serve, and clean up after meals, as well as any special restrictions or food prohibitions. Once these data have been collected, dietary intake is then assessed against some standard for nutrition, which, in the United States, is most commonly the Recommended Dietary Allowances (RDAs). The RDAs are commonly agreed upon standards for planning and assessing nutrient intake at various ages that are published periodically by the National Research Council. At present, there are no separate recommendations for those over 55 years of age for most nutrients, owing to the absence of evidence on nutrient requirements among older individuals; however, there is some information on useful alterations in nutrient recommendations for older individuals, and these data have recently been summarized.106 The most striking alteration in nutrient requirements for those over the age of 50 is the reduction in energy needs, which decreases by 6 percent from ages 51 to 75 and another 6 percent after 74 years of age. There are strong data to support the recommendations for decreased energy needs;13,83,95,113 what is not so clear is whether the decreases in lean body mass that account for much of this decrease are inevitable with advancing age or simply an artifact of inactivity. Exercise programs and more physically active lives among those over 50 might preserve lean body mass and thereby increase resting metabolic rates (and consequent energy needs). Increasing physical activity also increases energy expenditures in discretionary physical activity, further increasing energy outputs.

Additional standards have been developed by a large number of expert bodies, including the National Research Council (NRC) for other substances in food such as cholesterol or dietary fiber that are not dealt with in the RDAs. One NRC committee recently published an authoritative report on diet and health that makes recommendations regarding a number of dietary constituents for which the RDAs

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

do not provide quantitative guidance.17 These recommendations were promulgated for all healthy adults, including the elderly.

ANTHROPOMETRY

Anthropometric indices of nutritional status such as weight, stature, and skinfolds, as well as changes in these indicators, correlate well with clinical and laboratory markers, at least in young and middle-aged adults. They pose difficult problems for use in the elderly, however, because there are no norms for body composition in older individuals. Some of the usual anthropometric measures (e.g., stature) may be difficult to obtain, especially in the very old; as a result, substitutes such as segmental measurements of the head to the knee may be more useful. Also, special equipment and extensive training in its use may be required for some of the more elaborate measurements. Yet despite these limitations, even simple, standardized measurements of weight can be helpful in monitoring nutritional status and are easy enough to be performed by anyone, given minimal training.

Because most anthropometric measurements of body composition are rather nonspecific, they are best utilized in combination with other measurements. Indeed, the combination of clinical observations with biochemical, anthropometric, and dietary indices is thought by nutritional scientists to best reflect the specific physiological ''functions" of interest for nutritional research purposes. For example, functional tests of light adaptation coupled with clinical and dietary data may be used as measures of vitamin A nutrition. Whether a diet is adequate to rehabilitate a starved individual can be assessed by its ability to generate weight gain. For clinical purposes, however, these standard assessment methods are less useful than feeding evaluations to determine by observation whether individuals are able to and actually do eat unassisted. Finally, it is necessary to assess the effects on functioning that may arise from nutritional or other treatments (for example, home internal feeding by pump, which is a complex, time-consuming procedure).

PROGNOSTIC INDICATORS OF MORBIDITY OR MORTALITY

Another approach to assessing "functional" nutritional status is to develop a battery of biochemical and clinical tests that serve as predictors of morbidity and mortality and assist clinicians in determining the appropriate course of further treatment for the patient.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

In comparison to the more global indices of functioning in daily life, these indices have a more narrow focus of morbidity and function; thus, quality of life may be de-emphasized. Another limitation is that prognostic indicators tend to focus on prognoses for specific types of patients who either suffer from certain diseases or are candidates for risky or expensive procedures (e.g., surgery, chemotherapy for advanced cancers).

Several indices have shown some prognostic significance for morbidity and mortality. One such popular index is the Prognostic Nutritional Index, or PNI, developed by Mullen and colleagues.75 The PNI consists of 16 nutritional and immunological variables that are used to predict subsequent morbidity and mortality patterns in surgical patients with various cancers and other conditions. In Mullen's original research, the 3 (of the 16) variables that correlated most closely with outcomes were serum transferring, serum albumin, and delayed hypersensitivity reaction from skin test antigens. Patients who had poor scores on these three major factors usually had poorer prognoses than other patients; however, the association may have been due not to their poor nutritional status but to their poor general health status.

The PNI is efficient in discriminating populations at high risk of morbidity and mortality, but it is not as effective in selecting individuals who are at risk when only one of the risk factors is abnormal. In addition, the index provides no estimate of the severity of the individual's malnutrition problem. Thus, the prognostic indices are of little use for decisions about whether to proceed with a surgery immediately or to wait until a patient can be nutritionally rehabilitated. The risks of withholding surgery are usually well known, particularly when cancer has been diagnosed; there are no similar quantitative estimates of the risks posed by malnutrition (i.e., the failure to wait and rehabilitate the patient).

A second prognostic index quite similar to the PNI was developed a decade ago by another group at the New England Deaconess Hospital, also to assess risks of later morbidity and mortality in surgical patients.42 In addition, other risk indices have been developed by other investigators as nutritional prognostic indicators in medical conditions. All have failings similar to those discussed for the PNI, however, and none are presently viewed as acceptable for all patients in all circumstances. Only recently have indices been developed that include age-related criteria.4

Theoretically, it should be possible to develop prognostic indicators that have a rehabilitative focus instead of concentrating solely on morbidity and mortality. The techniques for such efforts have

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

been available for many years in the rehabilitation medicine and occupational therapy literature.66,103 An investigator observes as many as 100 different activities, many associated with food and eating, and records whether the patient can perform the task either independently, only with adaptive devices, with supervision, with assistance, or not at all. It is from such longer inventories that the few key activities thought to be most highly associated with a lack of functional disability for independent living were originally developed. After these activities were identified, arbitrary scores were assigned and a numeric score calculated for each patient from which progress or deterioration in self-care could be determined.103

Many different indices are available, including the Barthel index,72 the Kenney system,94 and the Katz index of active life expectancy.55 The Katz index classifies patients into one of seven groups and avoids arbitrary point systems. Class A refers to a patient who is independent in feeding, continence, transferring, toileting, dressing, and bathing. Class B patients are independent in all but one of these areas. Class C patients are independent in all but bathing and one additional function, and so on. The underlying assumption of the Katz method is that there is an order of maintenance of function, which proceeds in chronological fashion; consequently, feeding ability is maintained longer than the ability to bathe independently. When this is not true, the patient must be classified as "other." Because the ability to self-feed is lost relatively late in many cases, the index does not discriminate among nuances of function in eating and feeding, which would argue for development of more sensitive indicators. (The many problems of developing systems de novo have been well reviewed, however.57) Nevertheless, these indices in general are highly correlated in predicting self-care ability and are accurate in about two-thirds of all cases. Of the existing indices, the Barthel index is considered to be the most sensitive and the Katz index the least sensitive.26,37

NUTRITIONAL RISK SCREENING INDICES

Another approach that attempts to measure both social and biological functioning is the Nutritional Risk Index (NRI) for morbid and disabling conditions associated with nutrition. The NRI is an easily administered screening test developed by Wolinsky and colleagues120 that attempts to tap five factors often associated with poor nutritional health: (1) existing illness in the digestive system, (2) the use of medications associated with that system, (3) the use of dentures, (4) smoking, and (5) bowel-related problems. The Wolinsky

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

group developed a short, 16-item test to tap various aspects of these problems; items include the use of prescribed or self-prescribed medications in the past month, previous abdominal problems or operations, trouble with eating or with foods "not agreeing" with the individual, special diets, stomach pains, bowel trouble, diarrhea or constipation over the past month, anemia, presence of illness cutting down on appetite, smoking, trouble swallowing, and gain or loss of weight over the past month. The test-retest reliabilities of the instrument were .5 to .6. The investigators assessed the validity of the instrument using factor analysis and comparisons on outcome measures between those at risk and those not at risk. These analyses showed that individuals with higher risk scores had poorer health and consumed more health services than those with lower risk scores. Although there was no apparent relationship between the NRI and the informal use of health services (e.g., restricted activities, bed disability days), the NRI did predict formal health services utilization quite well.

Much work needs to be done before the NRI or any other index of nutritional risk is widely accepted. Any broad-scale use of such an index must recognize that, at any given level of nutritional status, individuals vary greatly in their functional status with respect to daily living and coping. Not only nutrient intake but the social aspects of food and eating are important to consider, and the need for assistance in food- and diet-related activities depends on both biological and social circumstances. Clearly, it is important to assess all of these aspects, and work is continuing on questionnaires to assess aspects of functional status that are associated with nutritional risk.121,122,123 As yet, however, correlations of nutritional risk indices with clinical status or nutritional status are low or remain unproven. More thorough means of assessing the activities of daily living with special attention to nutrition are needed.29 These assessments can supplement and augment other routinely collected information on function.76

NUTRITION IN A FUNCTIONAL PERSPECTIVE

In this report, impairment is considered to be the condition involved in causing the loss or abnormality of psychological, physiological, or anatomical structure and function. Among the impairments that may be associated with malnutrition-related diseases and that are relatively common among aging adults, visceral, skeletal, intellectual, and other psychological impairments are most prominent. The most common categories of disability associated with malnutrition are

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

probably physical disabilities affecting the use of the hands, arms, and legs and thus movement of the individual; that is, upper body and hand function but lower body and mobility problems may be involved in some cases—for example, massive obesity or complications of cardiovascular disease. These problems (e.g., lack of cardiovascular fitness or muscle strength) can reverse themselves quickly if active lifestyles are adopted.

Handicaps in the nutritional realm consist of the disadvantages that result from an impairment or disability that limit or prevent fulfillment of an individual's normal roles. Malnutrition can lead to handicaps related to physical independence and mobility and occupational and social integration, as well as difficulties and handicaps involving economic self-sufficiency.

BURDEN

Prevalence

The prevalence of various forms of malnutrition differs depending on the type, stage, and condition being considered. Each of the dietary components to be discussed in this report are dealt with separately below or in the chapters devoted to risk factors that include a nutritional component.

Costs

There have been several attempts over the past two decades to estimate the cost of diet-related diseases. There is no consensus on these estimates, however, because of the different definitions used and uncertainties regarding the proportion of total risk for a disease or condition attributable to diet or to other aspects of diet-related health risks. Furthermore, the synergistic effects of these various risk factors on the chronic degenerative diseases that are thought to involve diet are difficult to quantify. For example, it is well known that the addition of hyperlipidemia to other cardiovascular risk factors raises morbidity and mortality considerably, but these relationships are often unclear or based only on limited data after ages 50 or 60.35 Today, reanalyses of diet-related interventions to decrease coronary artery disease risks appear to indicate benefits in decreased medical expenditures (by decreasing morbidity), even late in life.32 However, estimates of cost-benefit ratios and cost-effectiveness of dietary interventions after the age of 50 are not yet available.

One set of costs that are clear are the losses of time, money, and

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

happiness associated with the nutritional remedies that carry exaggerated, unproven claims of efficacy for the ills often associated with aging. The elderly are particularly susceptible to such claims, the economic consequences of which are enormous.110 The health consequences of nutritional quackery and fraud include the failure to seek conventional and more effective care for illnesses and the rejection of legitimate medical advice. Moreover, the practice of inappropriate self-medication may itself give rise to illness, especially as some dietary remedies are potentially toxic in and of themselves, particularly if the elderly individual is already ill.45

PREVENTABILITY OF BURDEN

This section reviews selected interventions in the area of nutrition, including screening and case-finding strategies that have not been previously discussed. Particular attention is given to interventions that are likely to have positive interactions with other factors singled out for attention in this report.

Table 10-1 describes various forms of malnutrition that may be secondary to other disease processes and the kinds of effects they are likely to have, particularly in terms of nutritional status with respect to function. Table 10-2 briefly summarizes possible interventions that might be considered. Some of these selected options are discussed in the following sections under the risk factor most relevant to a particular disease process.

Table 10-3 shows how diet and nutritional status may alter other risk factors among individuals over the age of 50. Much effort is being devoted to developing better evidence that dietary counseling, food programs, and related nutritional interventions can change food habits and that these altered food habits in turn decrease risk factors and thereby bring about desirable health and economic benefits.23,24,69,92,100 Until very recently, however, the relative costs and benefits of nutritional counseling and interventions were virtually unknown. Now, as evidence is rapidly becoming available, new studies are being planned.2,77

High Blood Pressure

The burden imposed by high blood pressure on aging individuals is well documented in Chapter 3. In addition to its close association with mortality from stroke, high blood pressure is also a major cause of morbidity. Stroke may give rise to physical difficulties in walking, lifting, and moving the upper extremities; all of these limitations

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

TABLE 10-1 Malnutrition That is Secondary to Disease, Physiological State, or Medication Use

Disease or Condition

Effects on Nutritional Status

Atherosclerosis

This condition may increase difficulties in regulating fluid balances if disease is caused by congestive heart failure. Also, if the individual is incapacitated, energy needs decrease.

Cancer

In metastatic disease, increased emaciation is common owing to lack of appetite. Secondary malnutrition is common.

Dental and oral disease

This type of disease may alter the ability to chew and thus reduce dietary intake; if severe it may give rise to digestive problems if large food boluses are swallowed. It may also increase the likelihood of choking or aspirating large food boluses.

Depression and dementia

Increased or decreased food intakes are common. In dementia there may be decreased ability to get food for oneself, or the appetite may be very small or very great. Judgment and balance in meal planning are generally absent.

Diabetes mellitus (insulin dependent)

Increased risk of undernutrition results if untreated, and there is increased risk of other diet-related risk factors such as hyperlipidemia, and decreased resistance to infections. Therapeutic diets limited in type and amount of carbohydrates and fats that are timed to coincide with insulin doses are essential to avoid ketoacidosis and losses of nutrients in urine, as well as shock and other acute and possibly longer-term complications.

Diabetes mellitus (non-insulin dependent)

This condition brings increased risk of other diet-related diseases such as hyperlipidemia. Weight loss is needed to control acute complications if obesity is present. Risk of alcohol intoxication is increased among dependent elderly at home.

End-stage kidney disease

This conditions often alters fluid and electrolyte needs. Uremia may alter appetite and increase consequent risks of malnutrition. Infections and low-grade fever may increase energy output and weight loss because appetite is often poor. Special diets low in protein and phosphorus may be needed to control symptoms.

Gastrointestinal disorders

Such disorders increase the risk of malabsorption of nutrients and consequent undernutrition, as well as other forms of malnutrition.

High blood pressure

Hyper- or hypokalemia can be increased by dietary means; weight gain may exacerbate high blood pressure.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

Disease or Condition

Effects on Nutritional Status

Osteoporosis

Osteoporosis limits the ability to purchase and prepare food if mobility is affected. If severe scoliosis is present, the appetite may be altered.

Osteoarthritis

This condition makes motion difficult, including those activities related to purchasing, serving, eating, and cleaning up after meals. It predisposes people to a sedentary lifestyle and may give rise to obesity. Drug-nutrient relationships are common.

Smoking

Smoking may alter weight status. It also alters serum levels of some nutrients such as ascorbic acid and carotenes although the health significance of such alterations is unknown. Chronic smoking gives rise to emphysema and chronic obstructive pulmonary disease (COPD), which makes it difficult to eat owing to breathing problems.

Stroke

Paralytic stroke may alter abilities in the cognitive and motor realms related to food and eating. If the individual is incapacitated, his or her energy needs decrease.

TABLE 10-2 Nutrition-related Interventions for Elderly Individuals

Domain

Intervention

Education

Educational programs involving food and nutrition education for the aging and elderly

Food

Nutrient recommendations and food guidance; food programs including commodities, food stamps, congregate meals, and others

Health

Nutritional assessment services; Nutritional counseling services; Short-term, intermediate, and long-term care services; Help with food purchasing, preparation, eating, clean-up, and foodways; Medical care and assistance for nutrition-related health problems and health problems with nutritional implications

Social welfare

Income support for elderly adults (both general and targeted support) Enhancement of community socioenvironmental and socioeconomic influences on older adults

Well elderly

Food, nutrition, and health services

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

TABLE 10-3 Potential Effects of Diet and Nutritional Status on Risk Factors for Disability Among the Elderly

Risk Factor

Alterations and Effect on Risk Factor

High blood pressure

Increased risk: Obesity and high levels of sodium and alcohol intake appear to increase risk. If diabetes, atherosclerosis, or kidney disease are present and uncontrolled by diet or drugs, the risk of sequelae increases.

Decreased risk: Weight loss (if overweight) and decreased sodium and alcohol intake all decrease risks and may in turn lead to decreased drug dosages to control the condition.

Mental indolence

Increased risk: Undernutrition and starvation, protein calorie malnutrition, and other vitamin and mineral deficiencies decrease attention and performance if very severe. Alcohol abuse also contributes to mental indolence. Certain vitamin deficiencies (e.g., vitamin B12 deficiency) may be associated with degeneration of the spinal cord and confusion. Unwise use of unproven dietary remedies may cause otherwise preventable cases of depression and mental inactivity to go untreated.

Decreased risk: Good nutritional status provides the individual with sufficient energy so that inanition is not a contributory cause to mental inactivity.

Physical inactivity

Increased risk: Extreme obesity decreases physical activity and makes falls or other movement-related injuries more difficult to treat. Extreme emaciation and most severe vitamin and mineral deficiencies also decrease physical activity. Alcohol abuse increases physical inactivity and also the likelihood of falls or movement-related injuries.

Decreased risk: Normal weight status does not hinder physical activity.

Polypharmacy

Increased risk: Undernutrition, emaciation, and protein calorie malnutrition all alter the metabolism and disposition of drugs and the risk of overdoses. Alcohol abuse alters the likelihood of drug-nutrient interactions. Normal changes associated with aging such as decreased lean body mass, decreased total body water, and decreased resting metabolic rate increase the likelihood of drug-related overdoses.

Decreased risk: Use of nonpharmacologic measures to control high blood pressure, hyperlipidemia, adult onset diabetes, and other conditions that respond to dietary alterations may decrease the risk of polypharmacy or the doses needed.

Poor oral health

Poor nutritional status owing to emaciation, undernutrition, vitamin and mineral deficiencies (especially ascorbic acid), and poor control of diet-related diseases such as diabetes may lead to oral lesions and failure of wounds to heal (as in scurvy or uncontrolled diabetes). Diets high in sticky, fermentable

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

Risk Factor

Alterations and Effect on Risk Factor

 

carbohydrates may increase the risks of root as well as crown caries in remaining teeth. Chronic alcohol abuse, especially among heavy smokers, increases the risks of oral and head and neck cancers.

Decreased risk: Diets low in sticky, fermentable carbohydrates decrease the risk of root and crown caries, as does good oral hygiene. Diets containing adequate intakes of nutrients minimize risks to oral tissues as a result of dietary deficiency disease.

Osteoporosis

Increased risk: Inadequate intakes of calcium and vitamin D, especially early in life during the time of accretion of peak bone mass as well as in the premenopausal period, increase risks of osteoporosis, especially if estrogen replacement therapy is absent. Caffeine intake may also increase osteoporosis risks, as may highly acid diets. Malnutrition secondary to untreated gastrointestinal disease increases risks because absorption of calcium and vitamin D may be affected, especially if steatorrhea is present. Sedentary lifestyles with little physical activity increase risk, especially if there is little physical exercise involving weight bearing. Alcohol abuse or its consumption in large amounts may increase risks.

Decreased risk: Adequate intakes of calcium throughout life with estrogen replacement therapy after menopause and exercise involving weight bearing decrease risks.

Smoking

Increased risk: Smoking plus chronic alcohol intake increases head and neck cancer risks. Low intakes of caratenoids and of other, as yet poorly characterized constituents of vegetables and fruits may increase smoking-related cancer risks.

Decreased risk: Possible slight (but relatively insignificant) decrease could be achieved for certain forms of cancer from intakes of vegetables and fruits that are high in ascorbic acid, carotenoids, and other vitamin A precursors.

Social isolation, low socioeconomic status, and false stereotypes of aging

Increased risk: Undernutrition, emaciation, insufficiencies of vitamins and minerals, and excessive intakes of fat, salt, sugar, and energy are often associated with these in low-income groups. In fact, these nutritional problems may be due in part to lack of income. Those suffering from any form of malnutrition have increased risk of being socially isolated, and the process is likely to be self-perpetuating. Alcohol abuse may be especially important in causing social isolation. Malnutrition reinforces the stereotype that being old is being sick.

Decreased risk: Good nutrition in all respects minimizes the above barriers.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

make food getting and eating difficult. High blood pressure is also a major cause of multiinfarct dementia and may be responsible for milder and more subtle losses of intellectual capacity that occur occasionally with older people and are probably due to subclinical cerebrovascular disease.41,46,82

Treatment for high blood pressure has potent effects on the risk of stroke and of cardiovascular disease. It is likely that, in both middle-aged and older people, reductions in moderate or severe high blood pressure add more to life expectancy than most other interventions.62,108,119 Indeed, because many elderly people are already taking medications for other reasons, there are distinct advantages to treating high blood pressure by nonpharmacological means. Diet and exercise constitute two such means that are given particular emphasis in this report.

The effectiveness of altering high blood pressure and subsequent mortality and morbidity from cardiovascular and renovascular disease is well documented. Among the measures for achieving such control are dietary counseling to bring about weight reduction, sodium restriction, and in some cases abstinence from alcohol.

There is good reason to think that weight control and moderation in sodium intake are reasonable health measures for all aging adults. Studies have shown that weight loss per se decreases blood pressure by about 1 to 2 mmHg systolic and 1 mmHg diastolic per pound lost.17,44,48,102,115 Restriction of sodium also appears to be effective in some persons who are sodium sensitive, although such individuals cannot be identified in advance.50 Data on the efficacy of increasing the intake of other nutrients (e.g., calcium and magnesium) to lower blood pressure are more controversial. These findings have been reviewed in another recent Institute of Medicine report.17

The costs and effectiveness of various dietary therapies to control high blood pressure have been well reviewed by Disbrow.23 Few of these studies involved individuals over 65 years of age. At present there is too little age-specific information to determine the effectiveness of nonpharmacologic therapies for hypertension in the elderly. Theoretically, they offer three potent advantages: a low cost in comparison with the sometimes expensive antihypertensive drug therapies that are often used, decreased side effects, and avoidance of drug-drug interactions common in the elderly. Indeed, studies have shown that blood pressure control can often be maintained by dietary means even after medications are withdrawn or reduced.65,101,102,114 Therefore, tests of the effectiveness of nonpharmacologic therapies, including but not limited to diet, should be encouraged in the elderly.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Hypercholesterolemia

Several of the modifiable risk factors for cardiovascular disease involve diet. They include high blood pressure, hypercholesterolemia, diabetes mellitus of the adult onset type, and physical inactivity.52 Screening for these conditions may be useful for behavioral reinforcement and education. It may also allow monitoring of individuals at risk of hyperlipidemias because of other problems such as diabetes, hypothyroidism, nephrotic syndrome, or heredity. In addition, screening permits the identification and treatment of otherwise asymptomatic adults so as to improve their health and prolong their lives.

Recommendations vary with respect to cholesterol screening and dietary modifications for lowering serum cholesterol. One group of experts recently concluded that screening and treatment plans for treatment of hyperlipidemias needed to be individualized and that for the elderly (e.g., those over 70 years of age) the predictability of risk was not well defined; thus, the efficacy of cholesterol reduction remained unproven.35 The analyses and criteria they employed in their study for assessing intervention benefits, however, focused on cost and increased mortality rather than improved function. Moreover, studies on outcomes from dietary and drug treatment among postmenopausal women at various serum cholesterol levels are only now becoming available.

Other experts take a more optimistic view and suggest that prudence dictates attempting to reduce serum cholesterol and other risk factors among aging adults as well as the middle-aged.52 Gordon and Rifkind,39 for example, argue for an aggressive posture based on their analysis of the Multiple Risk Factor Intervention Trial (MRFIT) and Framingham longitudinal data. They argue that attenuation of the cholesterol/coronary heart disease relationship among the elderly clearly exists but that because more coronary events are likely, the number of events that might be prevented annually might be very much greater between 56 and 74 years of age than at younger ages. In addition, the effects of earlier screening efforts in the 40- to 50-year-old age group and any ensuing preventive action may not show up until later in life; consequently, these results have not yet been factored into the analysis.

Recommendations for screening from other groups vary. In 1988, the National Cholesterol Education Program Adult Treatment Panel recommended cholesterol screening once every five years. It also advocated repeated testing for high-risk persons and those whose cholesterol levels were more than 200 milligrams per decaliter (mg/dl (5.17mmol/L).

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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In summary, those who appear to benefit most from screening are high-risk populations—for example, those individuals who already have marked hypercholesterolemia or who have other risk factors that place them at high risk (e.g., smokers, hypertensives, etc.). Those for whom screening offers morbidity reductions (even if mortality and life expectancy are not affected) include persons who have a family history of hypercholesterolemia, who are not being treated with lipid-altering medications, or who have secondary hyperlipoproteinemias arising from diabetes or other causes.35

There is little doubt that initial reductions in serum cholesterol can be accomplished by dietary means. The problem is that long-term adherence to dietary regimens is difficult to achieve, and without sustained counseling, serum cholesterol levels are likely to drift upward again.10,25,89 It may be, however, that the elderly are more likely to comply with dietary regimens than younger adults and that the appeal of avoiding medications may further increase adherence to dietary treatment strategies by the aging.

It is important to note that the relationship between serum cholesterol levels and cardiovascular risk changes with age. Thus, in asymptomatic elderly persons, the association between serum cholesterol levels and later risk for mortality from coronary artery disease is in fact weaker than that in younger adults. Moreover, low cholesterol values in the elderly (e.g., below 150 mg/dl) appear to be associated with excess mortality, independent of cancer incidence.31 Although there is no clear cause-and-effect relationship, the association of low cholesterol levels with mortality has raised concern in the minds of some experts about the advisability of oversensitizing aging adults to the importance of low serum cholesterol levels. Finally, the treatment of hypercholesterolemic patients in elderly age groups may not reduce mortality rates to those of untreated patients with lower cholesterol levels. All of these questions should be settled by additional research.

The reasons for the differing associations among serum cholesterol, morbidity, and mortality in aging individuals are still unknown. In part, the differences may be due to genetically high HDL cholesterol levels among some of the surviving elderly.1,93 The menopause also leads to increases in serum cholesterol in females. Current recommendations are to screen for serum cholesterol in asymptomatic adult men at least every five years and more frequently in symptomatic men. At least one group still regards screening in such asymptomatic adults as optional for women and the elderly.35 Others suggest that screening is warranted for all individuals on the five-year schedule. Various intervention studies have shown that, in younger individuals

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

when serum cholesterol decreases by 2 to 13 percent, coronary artery disease mortality also decreases, whereas all-cause mortality exhibits relatively few changes.35,70,79 However, for the very old and especially for middle-aged and older women, the effectiveness of interventions involving dietary change on serum cholesterol lowering is unknown because relatively few interventions have been instituted in these groups. Gordon and Rifkind39 recently concluded that treatment of hypercholesterolemia in the elderly might bring about a greater reduction in absolute risk than in younger persons, even though the strength of the cardiovascular disease/cholesterol relationship decreases with age. The decreased strength of that relationship may be due to the increasing influence of age-related changes in the arterial wall, to selective survival, to faulty attribution of causes of death on death certificates (leading to underreporting of the true number of deaths from cardiovascular causes), to confounding factors causing low serum cholesterol levels that are a sign of other underlying diseases, or to some other factor. In fact, it is clear that a series of factors are involved. For example, healthy octogenarians do not all appear to have very high HDL cholesterol levels or very low LDL cholesterol levels (as those who favor a solely genetic basis for a weakened cholesterol/coronary artery disease relationship sometimes used to argue).93 Such patterns may be present in more instances in certain families;36 however, other influences are probably also involved in the attenuation of the relationship between serum cholesterol and heart disease in the elderly.117

The cost-effectiveness of lowering serum cholesterol by diet appears to be greater than by other means.5,62,81,108 For example, Berwick and coworkers' best estimate was that the cost was about $11,000 in 1975 dollars per year of life saved.5 Taylor and colleagues108 used a 7 percent effect of diet on serum cholesterol lowering to estimate that, at age 60, 13 months for females and 2 months for males were added to life expectancy. Using a larger serum cholesterol-lowering effect (20 percent), 36 months for women and 5 months for men were added to life expectancy. These effects were much less than those experienced from decreasing blood pressure or from quitting smoking, but they nevertheless amounted to one or two years.101 These results have been challenged and rebutted.33 In summary, however, the analyses seem to favor positive effects from the lowering of serum cholesterol and suggest that underestimates of life expectancy are not large. Nevertheless, it is useful to remember that the life-prolonging effects of any intervention may be small for the individual but much greater for the population at large.

Lowering of serum cholesterol may be efficacious, but most

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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studies agree that it results in very few and rather small effects on medical care costs, at least in younger men.62,81 Yet because the absolute risk of myocardial infarction rises with age (even if the cholesterol/coronary artery disease relationship is weaker in older people), the benefits from treatment could still be considerable on a population basis. Diet therapy was the least expensive option of those assessed.62 Estimates of days of work lost, measures of health care use, and activity limitations other than those mentioned above were not available.

Hypertriglyceridemia

Screening for high serum triglycerides (and subsequent interventions to lower triglycerides if they are elevated) is more controversial than screening for serum cholesterol, even at younger ages. Serum triglycerides are not consistent, independent predictors of cardiac risk, nor does serum triglyceride lowering lead to diminished mortality among healthy individuals.3 Therefore, triglyceride screening is not generally recommended for the healthy. Individuals at higher risk, however, including those with familial combined hyperlipidemia and those with secondary hypertriglyceridemia resulting from diabetes or obesity, may benefit.35

Renal Disease-related Risks

The three nutrition-related causes of kidney disease that are thought to be avoidable or at least partially treatable by diet are high blood pressure, diabetic nephropathy, and renal artery atherosclerosis. Dietary factors may hasten the progression of renal deterioration. Brenner9 and others have postulated that modification of protein and phosphorus intake early in the course of chronic renal insufficiency can slow or stop the progression of the disease.9,112 This theory is now being tested in a large-scale randomized clinical trial. If in fact it is found that dietary therapy can slow renal disease progression, the cost of dialysis will be much reduced. Moreover, the functional abilities of patients with renal disease might be improved if dialysis were delayed. Among individuals suffering from renal disease, including the elderly, nutritional counseling has proven helpful in decreasing hospitalizations, especially among individuals who have lost a large amount of weight.58,71 Home hemodialysis coupled with dietary modifications has also resulted in somewhat greater freedom for patients. Other advantages over hospital dialysis include considerable cost savings, fewer clinical complications, and greater comfort for many patients.74

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Diabetes Mellitus

Several severe disabling conditions among older individuals may arise from diabetes mellitus. For example, one of the four leading causes of blindness in those over the age of 40 is diabetic retinopathy.61 In addition, other vascular complications of diabetes (e.g., vascular disease in the lower extremities) may inhibit walking. Diabetic vascular disease in the legs, especially when combined with smoking, is a major cause of amputation among the elderly.64,104 Finally, the elderly with diabetes, especially uncontrolled diabetes, are also more likely than the nondiabetic to develop cognitive impairments, a probability that applies to those with Type II diabetes.85 Yet diabetes mellitus is another common cardiovascular disease risk factor that can be controlled in part by dietary interventions. Diabetic control in adult onset diabetes (Type II, or non-insulin-dependent diabetes mellitus) can often be achieved without the use of insulin or oral hypoglycemic agents using dietary manipulation and adjustments in exercise. Patients who suffer from insulin-dependent diabetes (Type I) generally require extensive dietary counseling.

Weight loss alone can often bring satisfactory control of non-insulin-dependent diabetes. In a recent study of elderly individuals suffering from Type II diabetes, a combination of dietary counseling and peer support resulted in weight loss and improved diabetic control as measured by glycosylated haemoglobin.118 Four months later, however, most of the elderly participants had returned to their original weight, pointing to the need for continued dietary counseling and assistance. In addition, even after weight loss, some elderly non-insulin-dependent diabetics continue to require drugs to achieve satisfactory glycemic control or to achieve better values on other risk factors that may also need modification (e.g., serum cholesterol). At present, estimates of the effectiveness of nutritional interventions are optimistic, but there are too few data to make definitive judgements.54

Most studies of interventions for diabetes involve young and middle-aged populations rather than the elderly. Nevertheless, some generalization is possible. The effects of diabetes education programs on subsequent hospitalization for diabetes, especially those admissions related to a lack of diabetes self-management skills, have been the subject of several studies; it appears that hospital admissions do decrease following such programs, although the programs usually involve some form of residence in a hospital for training and therefore are rather costly.30 Other programs that have a similar goal—to help patients manage their diets and medications more completely—but that involve ambulatory care also appear to be effective and are less expensive than programs with a hospital training component.20,105,116

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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These ambulatory programs generally include several counseling visits with a registered dietitian; they too appear to decrease hospitalizations. Other positive outcomes, such as better metabolic control as measured by glycosylated haemoglobin and blood sugar levels, also appear to be moderately affected by dietary education programs.23,49 In addition, there is some evidence that nutritional counseling services can help reduce the number of amputations resulting from diabetic vascular disease and achieve substantial cost savings.20

Weight Reduction

The effectiveness of interventions involving weight reduction in managing several chronic degenerative diseases is well demonstrated.23,78 Very little information is available, however, regarding the specific benefits of weight reduction in individuals over age 50. One study, conducted in the late 1950s by the Anticoronary Club of New York City, involved middle-aged men in a weight loss program that divided participants into treatment and control groups. The program was able to achieve much lower obesity rates among those individuals who were provided with treatment and given ongoing help to maintain weight loss than among controls.15 The problem was not the short-term efficacy of weight loss efforts but the need to include long-term maintenance as part of the therapeutic program. Quite apart from the effect of obesity on chronic degenerative diseases is the direct functional effect on activities of daily living—transferring, toileting, stooping, and climbing stairs.

The type, length, and location of weight loss programs for the elderly vary. Because many of the elderly are already taking several different drugs, there may be particular advantages to using diet and physical activity programs to bring weight into line instead of relying on anorectic or other drugs. In general, control of obesity is of particular importance among elderly persons who suffer from high blood pressure. Indeed, the positive effects of weight reduction in this group may be greater than the effects observed in younger populations.19 Of particular salience from the functional standpoint are the benefits weight loss brings in improving mobility and decreasing pain in osteoarthritis affecting weight-bearing joints.8 In addition, weight reduction may improve—in some cases, quite dramatically—ischemic and hypertensive cardiac disorders that decrease work performance. In many instances, when weight is brought to normal, symptomatology (including excessive urination and other annoying problems owing to poor glucose tolerance) may also come under control.52

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Physical Activity

Disuse atrophy or marked decline in physiological function because of lack of physical activity is more common than might be supposed in persons over the age of 50, and it becomes increasingly common with advancing age. Fortunately, the condition is partially reversible with increased physical activity.6 There is good evidence that rather large improvements can be made in muscle strength, lean body mass, and oxygen consumption,104 as well as somewhat smaller increments in glucose tolerance, blood pressure, and blood lipid control.12,47 If sedentary lifestyles in middle age can be avoided, the risks of obesity, high blood pressure, and eventual cardiovascular disease may also be lowered by increased physical activity after age 50.53,84,109 Finally, flexibility and physical activity may retard osteoporosis (see Chapter 6).

Polypharmacy: Controlling Side Effects

Individuals over 50 years of age use more prescribed and over-the-counter drugs than younger people. Drug use among the elderly averages more than two drugs a day in most studies.14 Drug-nutrient interactions are quite common. Patients on multiple drug regimens often suffer from dysgeusia and changes in salivation that may adversely affect their appetite. Diet can also affect drug metabolism.91 Therefore, all elderly patients who receive long-term drug therapies, especially drugs that cause diarrhea, appetite change, or other symptoms that affect the gut or appetite, should be carefully monitored for drug-nutrient interactions.14 In addition, effective nutritional therapies warrant careful consideration in aging populations, as they offer the advantage of keeping drug therapies to a minimum.

Nutrition Fraud

More than a quarter of all Americans have used questionable health care products and treatments, according to a recent survey conducted by the Food and Drug Administration.40 Many of these individuals were elderly, and many of the products they used were dietary supplements.

Advances in nutritional science and the still poorly understood possible role of dietary factors in chemoprevention of certain disorders have increased attention and interest in nutrition. At the same time such attention has also provided new and fertile ground for false and misleading promotional efforts. The 1984 report of the Select

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Committee on Aging placed health quackery costs at $10 billion.110 Other, more recent reviews document the fact that diet-related nostrums and homeopathic remedies of unproven effectiveness account for substantial unnecessary expenditures by the elderly (total costs may exceed $40 billion or more for all forms of fraud).2,110 Indeed, the Select Committee estimated that the elderly accounted for more than 30 percent of the fraud victims in this country, a burden particularly heavy in that such losses by older individuals are disproportionate because the elderly are slower to recover physically, financially, and mentally than younger, more affluent victims.

Common among the frauds perpetrated on the elderly are the so-called nutritional therapies for various chronic degenerative diseases and conditions. The extensive use of vitamin and mineral supplements is well documented.63 Overreliance on such remedies often means that diseases or impairments that might otherwise be prevented or assisted by medical means (e.g., arthritis) may become both economically and medically handicapping. Elderly individuals with chronic degenerative diseases such as cancer, heart disease, arthritis, and gastrointestinal disturbances are especially at risk. Even those who do not have overt signs and symptoms of these diseases often assume themselves to be at special risk of vitamin or mineral deficiencies, although they may not necessarily be so.28

At the federal level, the Food and Drug Administration has major enforcement responsibilities to prevent health fraud by regulating health claims for the efficacy of nutrients and other substances in the prevention, cure, and treatment of disease. The agency is also responsible for other measures to assure that the food supply is safe. In addition, the U.S. Postal Service, the Federal Trade Commission, and other federal agencies act to ensure that the mails and communications media are not used to aid and abet fraudulent sales of products.

The education of consumers on the steps they can take to avoid nutritional and other types of fraud is crucial. By assisting individuals to avoid inefficacious or fraudulent remedies and by helping them obtain appropriate medical help, many conditions that would otherwise lead to severe losses of independent function can be identified and treated. The American Association of Retired Persons, the American Cancer Society, the American Arthritis Foundation, and other groups such as the Council on Health Fraud all have a role to play in educating consumers on these issues.

Oral Health

The oral health of aging individuals often influences their nutritional status. For example, in one study, elderly veterans with self-perceived

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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chewing problems had lower protein and calorie intake than control subjects who did not perceive that they had such problems. Indeed, perceptions of this kind may be a useful indicator of an individual's nutritional state, even more so, in fact, than actual dental status.38 The loss of teeth can also contribute to poor appetite and to social isolation. Finally, the dentate elderly who have retained their teeth are vulnerable to crown or root caries, and diet is a significant risk factor for the development of either. Further discussion of this issue is provided in Chapter 8.

Nutritional Support: Food Programs

Nutritional support is a term that covers a variety of different types of alimentation of patients. It includes meeting nutritional needs by the usual oral, enteral, and parenteral routes, as well as social support. It also covers instances in which social and physiological types of problems may be involved simultaneously.

The living arrangements of the elderly are such that the social aspects of eating are often ignored or are difficult to sustain, especially for those who are confined to their homes, among whom nutrient deficiencies may be present.96 Such problems were described in the first National Health and Nutrition Examination Survey (NHANES 1). They also surfaced in NHANES 2; for example, those data showed that elderly individuals who lived alone were more likely to eat alone, to eat away from home, and to skip meals than their peers of the same age who lived with one or more persons.21 Most of the well elderly, however, maintain a good nutritional status, although there are some differences between the younger and older well elderly, the older elderly generally being less well nourished.11,73 Among elderly women, limited intake of some nutrients is thought to contribute to poor nutritional status, for which diet interventions may bring improvements.73

A number of meal programs are available to assist the elderly. In fact, those who participate in the elderly meal programs are generally in good health. As the elderly age, however, the very old, that is, those over age 80 or 90 who are living at home, are at special risk, and they may be unable to attend aging programs18 (although the effectiveness of such programs is still unproven owing to a lack of evaluation). Some of those at special risk among the elderly who participated in meal programs, such as recipients of the Meals on Wheels programs, and who were found to be nutritionally deficient responded with weight gain. However, there was no improvement in hematologic or immunological responses from supplementing the program for several months with high-calorie nutrients.67 Some housebound

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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elderly who receive Meals on Wheels services exhibit negative nitrogen balances, but this deficit may be due to disease rather than diet. It is clear that as larger numbers of the very old continue to live at home, better food and nutritional support services will be needed in the community.

In addition to the actual provision of food, some elderly people need ambulatory nutritional services of other sorts, such as dietary counseling and help in meal planning. The costs and benefits of ambulatory nutrition care for senior adults have been reviewed recently by Disbrow.23 There appear to be positive benefits of ambulatory nutritional services for the elderly, but more studies are needed. Benefits are concentrated in four areas: reduced health care costs, reduced needs for long-term care, improved health status and quality of life owing to better self-management of chronic disease, and subsequent reduction of related complications.22 In addition, several studies indicate that there were positive associations between nutritional status and participation in the Nutritional Programs for Older Adults Congregate Meal Services.67 The clearest benefits come as a result of screening and the referrals generated by such programs, but other benefits have also been observed as a result of diet counseling, exercise, adult education, and other classes and activities associated with the congregate meals services. Additional possible benefits from such interventions include retention of mobility, sustained quality of life through improved socialization, and positive self-perceptions of health. Ambulatory nutrition counseling may also be of benefit in helping the elderly with meal planning and food purchasing and in coping with disabilities. At present, however, these benefits are not well documented and await further study.

Home health services and food delivery for the elderly constitute another set of services in the spectrum of social interventions designed to maintain independent function among the elderly to the greatest extent possible. Although home health care for the elderly is not necessarily less costly than hospital or clinic care, it may nevertheless do a great deal to preserve an individual's independence if the alternative is the disruption that often accompanies hospitalization. Home health and nursing care costs are roughly similar.67 Home-delivered meals, on the other hand, are usually much more expensive than the congregate meals programs. These cost differences and the stress on volume of meals served make it difficult for all those who need home meal delivery services to obtain them. Homemaker services, hospital-based home health care visits, and nutritionist visits have all been described in the literature. It is not yet clear whether the benefits of these home services exceed their

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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costs, although clearly, for some patients who wish to avoid institutionalization and still maintain acceptable levels of quality of life and health, there is no other alternative.43,73

Increasing numbers of the very old are institutionalized during their final years of life, and in such settings the adequacy and appropriateness of the food served to them vary greatly. The simple fact of residence in a long-term care facility does not imply immunity from malnutrition or undernutrition. Indeed, several studies show that the nutritional status of residents of long-term care facilities leaves much to be desired.98 It is difficult to evaluate these groups, however, because some of the supposed indicators of nutritional status among elderly patients may be altered for nonnutritional reasons (e.g., disease).96 In addition, although biochemical tests of malnutrition are useful, they vary greatly in their specificity and sensitivity, especially in the elderly. There is as yet no generally agreed upon battery of tests that will provide accurate assessments of risk.59

The benefits of inpatient nutritional care have recently been reviewed.23 Among the most cost-effective strategies are weekly nutrition rounds, made with the dietary supervisor, a consultant dietitian, and a registered nurse, to assess patient status. The results of such sessions have been generally positive and include improved dietary intake, weight status, bowel status, and skin health; the costs associated with the sessions were less than those associated with conventional procedures. Other studies have shown that the use of high-fiber (bran) diets among elderly institutionalized patients can dramatically decrease laxative abuse. Because the amount of time presently devoted to dietetic surveillance is only 10 minutes or less per patient per month, efficient means for nutritional care assessment, intake evaluations, counseling, and documentation need to be found. It is also essential that dietitians develop more services in these areas and that funding be made available to investigate the cost-effectiveness of such services.

The nutrient intake of elderly long-stay hospital patients is often inadequate; in fact, those patients whose healing is the most retarded often prove to have the poorest intake. Attention to dietary intake may be particularly helpful in some cases to stimulate healing postsurgery. For example, malnutrition adversely affects the prognosis for lower limb amputations, but it seems to have less effect on more proximal amputations.56 Similarly, certain biochemical parameters associated with malnutrition (e.g., reduced serum albumen, transferring, absolute lymphocyte count, energy) are associated with both morbidity and mortality. Furthermore, patients judged to be malnourished at

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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admission had longer stays in the same DRG (diagnostic-related group) category than those judged to be well nourished.90

A barrier to more widespread use of nutritional support measures in the elderly involves various clinical issues surrounding the use of special nutritional support measures, such as total parenteral nutrition and enteral nutrition using nasogastric or other tube feedings and pumps. Ethical and legal questions further complicate this issue. In fact, in some cases such measures are clinically justified for use even in the very old, and they may improve quality of life as well.16,68

RECOMMENDATIONS

Services

  1. Using current knowledge, consensus recommendations should be developed for nutritional screening and monitoring and for nonpharmacologic interventions, including diet, in asymptomatic individuals of both sexes over the age of 50. The age ranges considered should include the following: from 50 to 64, 65 to 74, and 75 and over. Nonpharmacologic intervention should be considered for persons with atherosclerosis, high blood pressure, diabetes mellitus, physical inactivity, and osteoporosis.

  2. Methods should be explored for maintaining independent functioning with respect to nutrition among individuals living at home. Methods of particular interest include participation in meals programs (e.g., Meals on Wheels) and congregate dining.

  3. Methods are needed to screen older populations for nutritional risk. Such methods must be reliable, valid, and predictive of later maintenance of independent function.

  4. Model standards should be developed for the nutritional component of food services, including functionally oriented nutritional assessments, for use in nursing homes and long-term care facilities. The means for reimbursement of these assessments and services under Medicare should also be devised.

  5. The regulatory authority of the Food and Drug Administration should be extended to deal adequately with health claims on food products and to guard against nutritional fraud.

  6. Mechanisms should be developed to assess problems and assist the families of cognitively impaired elderly people, as well as other older individuals who have difficulty eating.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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  1. Functional assessments and nutritional care plans should be required in federally funded hospitals, nursing homes, and extended care facilities. Such plans should emphasize independent function, minimization of polypharmacy, and maximization of physical activity while maintaining good nutritional status.

Research

  1. The association of serum cholesterol lowering and alterations in other risk factors for cardiovascular disease should be determined. Special attention should be paid to clarifying the associations and trade-offs among serum cholesterol lowering, the use of postmenopausal estrogen replacement therapy with progestins, physical activity, and other interactive interventions in the sixth through ninth decades of life.

  2. A major research effort should be mounted to clarify the associations between nutritional requirements and function.

  3. Common drug-diet interactions among the elderly should be studied, and alternative pharmacological or nonpharmacological therapies should be developed to reduce functional difficulties.

Education

  1. Courses of study for students in dietetics, the nutritional sciences, nursing, dentistry, and medicine should include an emphasis on functional assessments of nutritional status and the preservation of independent functioning.

  2. Mass media and other educational presentations should be developed to assist elderly individuals in self-care, especially in the area of nutrition. Advice should include attention to problems that arise when commonly coexisting diseases are present.

  3. More complete, easy-to-read food labels should be developed for those who have common dietary restrictions.

  4. The recommendations provided in the 1989 National Research Council report on diet and health17 should be implemented. Although the evidence is definitive in only a few areas (e.g., coronary artery disease), there is reason to suspect that benefits will result and that risks are few.51 There is also evidence to suggest that dietary moderation should be coupled with a physically active life to the greatest extent possible, given the disabilities of aging. There is no need for vitamin and mineral supplements if healthful diets in line with these recommendations are followed.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

REFERENCES

1. Abbott, R. D., Wilson, P. F., Kannel, W. B., and Castelli, W. P. High density lipoprotein cholesterol, total cholesterol screening and myocardial infarction: The Framingham study. Arteriosclerosis 1988; 8:207-211.

2. American Dietetic Association. Costs and Benefits of Nutrition Care: Phase I. Chicago: American Dietetic Association, 1979.

3. Barrett-Connor, E., and Khaw, K. T. Borderline fasting hypertriglyceridemia: Absence of excess risk of all cause and cardiovascular disease mortality in healthy men without hypercholesterolemia. Preventive Medicine 1987; 16:1-8.

4. Bernard, M. A., and Rombeau, J. C. Nutritional support for the elderly patient. In: E.A. Yong (ed.), Nutrition, Aging and Health. New York: Alan A. Liss, 1986, pp. 229-258.

5. Berwick, D. M., Cretin, S., and Keller, E. B. Cholesterol, Children and Heart Diseases: An Analysis of Alternatives. New York: Academic Press, 1979.

6. Bortz, W. A. Disuse atrophy and aging. Journal of the American Medical Association 1982; 248:1203-1208.

7. Braun, J. V., Wykle, M. W., and Cowling, W. R. Failure to thrive in older persons: A concept derived. Gerontologist 1988; 28(6):809-812.

8. Bray, G. A. Complications of obesity. Annals of Internal Medicine 1988; 103:1056-1062.

9. Brenner, B. M., Meyer, T. W., and Hostetter, T. H. Dietary protein intake and the progressive nature of kidney disease: The role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation and intrinsic renal disease. New England Journal of Medicine 1982; 307:652.

10. Brown, H. B. The National Diet Heart Study: Implications for dietitians and nutritionists. Journal of the American Dietetic Association 1968; 52:279.

11. Burns, R., Nichols, L., Calkins, E., Blackwell, S., and Pragay, D. Nutritional assessment of community living well elderly. Journal of the American Geriatrics Society 1986; 34(11):781-786.

12. Cade, R., Mars, D., Wagemaker, H., et al. Effect of aerobic exercise training on patients with systemic arterial hypertension. American Journal of Medicine 1984; 77:785-790.

13. Casanova, C., Agarwal, N., and Cayten, C. G. Basal energy expenditures in the elderly (abstract). Journal of Parenteral and Enteral Nutrition 1987; 11:205.

14. Chan, L. H., Liu, S., Newell, M. E., and Barnes, K. Survey of drug use by the elderly and possible impact of drugs on nutrition status. Drug-Nutrient Interaction 1985; 3(2):73-86.

15. Christakis, G., Kinzler, S.H., Archer, M., and Kraus, A. Effect of the Anticoronary Club program on coronary artery disease risk factor status. Journal of the American Medical Association 1966; 198:129.

16. Clark, N. G., Rappoport, J. I., DiScala, C., et al. Nutritional support of the chronically ill elderly female at risk for elective or urgent surgery. Journal of the American College of Nutrition 1988; 7:17.

17. Committee on Diet and Health, National Research Council. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, D.C.: National Academy Press, 1989.

18. Czajka Narins, D. M., Kohrs, M. B., Tsui, J., and Nordstan, J. Nutritional and biochemical effects of nutrition programs in the elderly. Clinics in Geriatric Medicine 1987; 3:275-287.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

19. Dahms, W. T., Molitch, M. E., Bray, G. A., Greenway, F. L., Atkinson, R. L., and Hamilton, K. Treatment of obesity: Cost benefit assessment of behavioral therapy, placebo and two anorectic drugs. American Journal of Clinical Nutrition 1978; 31:774.

20. Davidson, J. K., Delcher, H. K., and England, A. Spin off cost benefits of expanded nutritional care. Journal of the American Dietetic Association 1979; 75:250.

21. Davis, M. A., Murphy, S. P., and Neuhaus, J. M. Living arrangements and eating behaviors of older adults in the U.S. Journal of Gerontology Social Sciences 1988; 43(3):S96-S98.

22. Department of Health, Education and Welfare, Public Health Service. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. DHEW Publ. No. 79-55071. Washington, D.C.: Department of Health, Education and Welfare.

23. Disbrow, D. Ambulatory nutrition care: Adults weight reduction and management . Journal of the American Dietetic Association 1989; 89(4):530-534.

24. Disbrow, D., and Bertram, K. Cost-Benefit and Cost Effectiveness Analysis: A Practical Step by Step Guide for Nutritional Professionals. Modesto, Calif.: Bertram Nutrition Associates, 1984.

25. Dolecek, T. A., Milas, N. C., VanHorn, L. V., Farrand, M. E., Gorder, D. D., Dyer, J. R., and Randall, B. C. A long-term nutrition intervention experience: Lipid responses and dietary adherence patterns in the MRFIT trial. Journal of the American Dietetic Association 1986; 86:752.

26. Donaldson, S. W., Wagner, C. C., and Gresham, G. E. A unified ADL evaluation form. Archives of Physical Medicine and Rehabilitation 1973; 54:175.

27. Downes, J. Association of the chronic diseases in the same person and their association with overweight. Milbank Memorial Fund Quarterly 1955; 31:124.

28. Expert Scientific Working Group. Summary of a report on assessment of the iron nutritional status of the U.S. population. American Journal of Clinical Nutrition 1985; 42:1318-1330.

29. Fillenbaum, G. G. The Well-being of the Elderly: Approaches to Multidimensional Assessment. World Health Organization Offset Publ. No. 84. Geneva: World Health Organization, 1980.

30. Fishbein, H. A. Precipitants of hospitalization in insulin dependent diabetic mellitus: A statewide perspective. Diabetes Care 1985; 8(Suppl.):61.

31. Forett, B., Tortrat, D., and Wolmark, Y. Cholesterol as a risk factor for mortality in elderly women. Lancet 1989; 1(8643):868-871.

32. Fries, J. Aging, illness and health policy: Implications of the compression of morbidity. Perspectives in Biology and Medicine 1988; 31:407-428.

33. Frommer, P. L., Verter, J., Witters, J., and Castelli, W. Cholesterol reduction and life expectancy. Annals of Internal Medicine 1988; 1908:313-314.

34. Gaffney, J. T., and Singer, G. R. Diet needs of patients referred to home health. Journal of the American Dietetic Association 1985; 85:198-202.

35. Garber, A. M., Sox, H. C., and Littenberg, B. Screening asymptomatic adults for cardiac risk factors: The serum cholesterol level. Annals of Internal Medicine 1989; 110:622-639.

36. Glueck, C. J., Gartside, P. S., Steiner, P. M., et al. Hyperalpha and hypobeta lipoproteinemia in octogenarian kindreds. Atherosclerosis 1977; 27:387-406.

37. Gresham, G. E., Phillips, T. E., and Labi, M. L. C. ADL status in stroke: Relative merits of 3 indices. Archives of Physical Medicine and Rehabilitation 1962; 61:355.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

38. Gordon, S. R., Kelley, S. L., Sybyl, J. R., Mill, M., Kramer, A., and Jahnigen, D. W. Relationship in very elderly veterans of nutritional status, self perceived chewing ability, dental status and social isolation. Journal of the American Geriatrics Society 1985; 33(5):334-339.

39. Gordon, D. J., and Rifkind, B. M. Treating high blood cholesterol in the older patient. American Journal of Cardiology 1989; 63:48H-52H.

40. Grigg, W. Quackery: It costs more than money. FDA Consumer, July-August 1988, pp. 30-31.

41. Haccinski, V. C., Lassen, N. A., and Marshall, J. Multiinfarct dementia: A cause of mental deterioration in the elderly. Lancet 1974; 2:207-210.

42. Harvey, K. B., Ruggiero, J. A., Regan, C. S., Bistrian, B. R., and Blackburn, G. L. Hospital morbidity mortality risk factors using nutritional assessment. Clinical Research 1978; 26:581A.

43. Hatten, A. M. The nutrition consultant in home care services. Journal of the American Dietetic Association 1976; 68:250.

44. Havlik, R. J., Hubert, H. B., Fabsitz, R. R., and Manning, F. Weight and hypertension. Annals of Internal Medicine 1983; 98:855.

45. Herbert, V., and Barrett, S. Vitamins and Health Foods: The Great American Hustle. Philadelphia: Stickley, 1981.

46. Hertzog, C., Shaie, K. W., and Gribbin, K. Cardiovascular disease and changes in intellectual functioning from middle to old age. Journal of Gerontology 1978; 33:872-883.

47. Holloszy, J. O., Schultz, J., Kusnierkiewicz, J., Hagveeg, J. M., and Ehsani, A. A. Effects of exercise on glucose tolerance and insulin resistance. Acta Medica Scandinavica (Suppl.) 1986; 711:55-65.

48. Hovell, M. F. The experimental evidence for weight loss treatment of essential hypertension: A critical review. American Journal of Public Health 1982; 72:359.

49. Jacobson, J. M., O'Rourke, P. J., and Wolf, A. D. Impact of a diabetes teaching program on health care trends in an Air Force Medical Center. Military Medicine 1983; 148:46.

50. Jeffrey, R. W., Gillum, R., Gerber, W. M., Jacobs, D., Elmer, P. J., and Prineas, R. J. Weight and sodium restriction for the prevention of hypertension: A comparison of group treatment and individual counseling. American Journal of Public Health 1983; 73:691.

51. Kane, R. A., and Kane, R. L. Assessing the Elderly. Lexington, Mass.: Lexington Books, 1981, pp. 25-67.

52. Kannel, W. B. Nutritional contributions to cardiovascular disease in the elderly. Journal of the American Geriatrics Society 1986; 34(1):27-36.

53. Kannel, W. B., and Sorlie, P. Some health benefits of physical activity: The Framingham study. Archives of Internal Medicine 1979; 139:857-861.

54. Kaplan, R. M., and Davis, W. K. Evaluating the costs and benefits of outpatient diabetes education and nutrition counseling. Diabetes Care 1986; 9:81.

55. Katz, S., Branch, L., Branson, M. H., et al. Active life expectancy. New England Journal of Medicine 1983; 309:1218-1224.

56. Kay, S. P., Morland, J. R., and Schmitter, E. Nutritional status and wound healing in lower extremity amputations. Clinical Orthopedics 1987; 217:253-256.

57. Kellman, H. R., and Willner, A. Problems in measurement and evaluation of rehabilitation. Archives of Physical Medicine and Rehabilitation 1962; 43:172.

58. Kelly, M. P., Gettel, S., Gee, C., Meltzer, L., Yamaguchi, J., and Aaron, M.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

Nutritional and demographic data related to the hospitalization of hemodialysis patients. CRN Quarterly 1987; 2:16.

59. Kergoat, M. J., Leclerc, B. S., Petit Clerc, C., and Imbach, A. Discriminant biochemical markers for evaluating the nutritional status of elderly patients in long-term care. American Journal of Clinical Nutrition 1987; 57:376-379.

60. Kerzner, L. J., Greb, L., and Steel, K. History taking forms and the care of geriatric patients. Journal of Medical Education 1982; 57:376-379.

61. Kini, M. M., Liebowitz, H. M., Colton, T., Nickerson, R. J., Galey, J., and Dawber, T. R. Prevalence of senile cataract, diabetic retinopathy, senile macular degeneration and open angle glaucoma in the Framingham study. American Journal of Ophthalmology 1978; 895:28-34.

62. Kinosian, B. P., and Eisenberg, J. M. Cutting into cholesterol: Cost effective alternatives for treating hypercholesterolemia. Journal of the American Medical Association 1988; 259:2249-2254.

63. Krasinski, S. D., Russell, R. M., Otradovec, C. L., Sadownski, J. A., Hartz, S. C., Jacob, R. A., and McGandy, R. B. Relationship of vitamin A and vitamin E intake to fasting plasma retinol, retinyl binding protein, retinyl esters, carotene, alpha tocopherol and cholesterol among elderly people and young adults: Increased plasma retinyl esters among vitamin A supplement users. American Journal of Clinical Nutrition 1989; 49:112-120.

64. Kreines, K., Johnson, E., Albrink, M., et al. The course of peripheral vascular disease in non insulin dependent diabetes. Diabetes Care 1988; 8:235-243.

65. Langford, H. G., Blaufox, D., Oberman, A., Hawkins, C., Curb, J. D., Cutter, G. R., Wassertheil-Smoller, S., Pressel, S., Babcock, C., Abernathy, J. D., Hotchkiss, J., and Tyler, M. Dietary therapy slows the return of hypertension after stopping prolonged medication. Journal of the American Medical Association 1985; 253:657.

66. Lawton, E. B. Physical Rehabilitation for Daily Living. New York: McGraw-Hill, 1952.

67. Lipschitz, D. A., Mitchell, C. O., Steele, R. W., and Milton, K. Y. Nutritional evaluation and supplementation of elderly subjects participating in a Meals on Wheels program. Journal of Parenteral and Enteral Nutrition 1985; 9(3):343-347.

68. Maslow, K. Total parenteral nutrition and tube feeding for elderly patients: Findings of an OTA study. Journal of Parenteral and Enteral Nutrition 1988; 12(5):425-432.

69. Mason, M., Hallahan, I. A., Monsen, E., Mutch, P. B., Polobo, R., and White, H. S. Requisites of advocacy: Philosophy, research, documentation. Phase II of the costs and benefits of nutritional care. Journal of the American Dietetic Association 1982; 80:213.

70. McCormick, J. S., and Krabanek, P. Coronary heart disease is not preventable by population interventions. Lancet 1988; 2:839-841.

71. Mitch, W. E., and Sapir, D. G. Evaluation of reduced dialysis frequency using nutritional therapy. Kidney International 1980; 20:122.

72. Moheney, F. I., and Barthel, D. W. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1985; 14:61.

73. Morgan, D. B., Newton, H. M., Schorah, C. J., Jewitt, M. A., Hancock, M. R., and Hullin, R. P. Abnormal indices of nutrition in the elderly: A study of different clinical groups. Age and Aging 1986; 15(2):65-76.

74. Muehrcke, R. C., Sheehan, M., Lawrence, A., Moles, J. B., and Mandel, A. K. Home hemodialysis. Medical Clinics of North America 1971; 55:1473.

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

75. Mullen, J. L., Buzby, G. P., Waldman, M. T., Gertner, M. H., Hobbs, C. L., and Rosato, E. F. Prediction of operative morbidity and mortality by preoperative nutritional assessment. Surgical Forum 1979; 30:80-82.

76. National Center for Health Statistics. Characteristics of nursing home residents, health status and care received: National Nursing Home Survey. PHS Publ. No. 81-11712. National Center for Health Statistics, Vital and Health Statistics, Series 13, No. 51, 1981.

77. National Center for Health Statistics (Lin, B. M., Kovar, M. G., et al). Health statistics in older people: U.S. 1986. Vital and Health Statistics, Series 3, No. 25, June 1987.

78. National Institutes of Health Consensus Conference. Lowering blood cholesterol to prevent heart disease. Journal of the American Medical Association 1985; 253:2080-2090.

79. Oliver, M. F. Reducing cholesterol does not reduce mortality. Journal of the American College of Cardiology 1988; 12:814-817.

80. Oster, G., and Epstein, A. M. The cost effectiveness of antihyperlipemic therapy in the prevention of coronary heart disease: The case of cholestyramine. Journal of the American Medical Association 1987; 258:2381-2387.

81. Oster, G., and Epstein, A. M. Primary prevention of coronary heart disease: The economic benefits of lowering serum cholesterol. American Journal of Public Health 1986; 76:647-656.

82. Ostfeld, A. M. A review of stroke epidemiology. Epidemiologic Reviews 1980; 2:136-152.

83. Owen, O. E., Holip, J. L., D'Alesso, D. A., et al. A reappraisal of the calorie requirements of men at different ages. Journal of Gerontology 1986; 21:581.

84. Paffenbarger, R. S., and Hale, W. E. Work activity and coronary heart mortality. New England Journal of Medicine 1975; 292:545-550.

85. Perlmutter, J., Hakani, M. K., Hodgson, H. C., et al. Decreased cognitive function in aging non insulin dependent diabetic patients. American Journal of Medicine 1984; 77:1043-1048.

86. Pinholt, E. M., Kroenke, K., Hanley, J. F., Kussman, M. J., Twyman, P. L., and Carpenter, J. L. Functional assessment of the elderly: A comparison of standard instruments with clinical judgment. Archives of Internal Medicine 1987; 147:484-488.

87. Posner, B. M., and Krachenfels, M. M. Nutrition services in the continuum of health care. Clinics in Geriatric Medicine 1987; 3(2):261-274.

88. Ramsdell, J. W., Swart, J. A., et al. The yield of a home visit in the assessment of geriatric patients. Journal of the American Geriatrics Society 1989; 7(1):17-24.

89. Remmell, P. S., Casey, M. P., McGrandy, R. B., and Stare, F. J. A dietary program to lower serum cholesterol. Journal of the American Dietetic Association 1969; 54:12.

90. Robinson, G., Goldstein, M., and Levine, G. M. Impact of nutritional status on DRG length of stay. Journal of Parenteral and Enteral Nutrition 1987; 11(1):49-51.

91. Roe, D. A. Drug nutrient interactions in the elderly. Geriatrics 1986; 41(3):57-59, 63-64, 74.

92. Ross Laboratories. Benefits of Marketing Services: A Costing and Marketing Approach. Report of the Seventh Annual Ross Roundtable on Medical Issues. Columbus, Ohio: Ross Laboratories, 1987.

93. Schaefer, E. J., Moussa, P. B., Wilson, P. W. F., McGee, D., Dallal, G., and Castelli, W. P. Plasma lipoproteins in healthy octogenarians: Lack of reduced

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
×

high density lipoprotein levels; results from the Framingham heart study. Metabolism 1989; 38:293-296.

94. Schoening, H. A., and Iversen, I. A. Numerical scoring of self care status: A study of the Kenney self care evaluation. Archives of Physical Medicine and Rehabilitation 1968; 49:221.

95. Scultz, Y., Bray, G., and Margen, S. Postprandial thermogenesis at rest and during exercise in elderly men ingesting two levels of protein. Journal of the American College of Nutrition 1987; 6:497.

96. Sherman, M. N., Lechich, A., Brickner, P. W., Greenbaum, D., Kellogg, F. R., Scharer, L. K., Starita, L., and Daniel, B. L. Nutritional parameters in homebound persons of greatly advanced age. Journal of Parenteral and Enteral Nutrition 1982; 7(4):165-177.

97. Simko, M. D., and Conklin, M. T. Focusing on the effectiveness side of cost effectiveness equations. Journal of the American Dietetic Association 1989; 89:485-488.

98. Smith, J. L., Wickiser, A. A., Korth, L. L., Granjean, A. C., and Schaefer, A. E. Nutritional status of an institutionalized aged population. Journal of the American College of Nutrition 1984; 3:13-20.

99. Smith, F. A., and White, H. S. Intervention in an elderly population. In: Costs and Benefits of Nutritional Care, Phase 1. Chicago: American Dietetic Association, 1979.

100. Splett, P., and Caldwell, M. Costing Nutrition Services: A Workbook. Chicago: Department of Health and Human Services Region 5, November 1985.

101. Stamler, R., Stamler, J., Grimm, R., Dyer, A., Gosch, F. L., Berwin, R., Elmer, P., Fishman, J., Van Heel, N., Civinelli, J., and Hocksma, R. Nonpharmacologic control of hypertension. Preventive Medicine 1985; 14(3):336-345.

102. Stamler, R., Stamler, J., Grimm, J. R., Gosch, F. C., Elmer, P., Dyer, A., Berwin, R., Fishman, J., Van Heel, N., Civinelli, J., and McDonald, A. Nutrition therapy for high blood pressure. Final report of a 4 year randomized controlled trial: The Hypertensions Control Program. Journal of the American Medical Association 1987; 257:1484.

103. Steinberg, F. U. Care of the Geriatric Patient, 6th ed. St. Louis: C. V. Mosby, 1983.

104. Steer, H. W., Cuckle, H. S., Frankling, P. M., and Morris, P. J. The influence of diabetes mellitus on peripheral vascular disease. Surgery, Gynecology and Obstetrics 1983; 157:64-72.

105. Strock, E., Spencer, M., Sandell, J., and Hollander, P. Reimbursement of an ambulatory insulin program. Diabetes 1987; 36:33A.

106. Suter, P. M., and Russell, R. M. Vitamin requirements of the elderly. American Journal of Clinical Nutrition 1987; 45:501-512.

107. Sydenstricker, E., and Wiehl, D. G. A study of the incidence of disabling sickness in South Carolina cotton mill villages in 1918. Public Health Reports 1924; 39:17-23.

108. Taylor, W. C., Pass, T. M., Shepard, D. S., and Komaroff, A. L. Cholesterol reduction and life expectancy: A model incorporating multiple risk factors. Annals of Internal Medicine 1987; 106:605-614.

109. Tuxworth, W., Nevill, A. M., White, C., and Jenkins, C. Health, fitness, physical activity and morbidity of middle aged male factory workers. British Journal of Industrial Medicine 1986; 43:733-753.

110. U.S. Congress. Quackery: A $10 Bullion Scandal: A report by the Chairman

Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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of the Subcommittee on Health and Long-Term Care of the Select Committee on Aging. 98th Cong., 2d sess. Committee Print No. 98-435. Washington, D.C.: U.S. Government Printing Office, 1984.

111. Vallbona, C., and Baker, S. B. Physical fitness prospects in the elderly. Archives of Physical Medicine and Rehabilitation 1984; 65:194-200.

112. Walser, M. Does dietary therapy have a role in the predialysis patient? American Journal of Clinical Nutrition 1980; 33:1629.

113. Warnold, I., Falkheden, T., Hulten, B., and Isaksson, B. Energy intake and expenditure in selected groups of hospital patients . American Journal of Clinical Nutrition 1978; 31:742.

114. Wasserthiell Smoller, S., Langford, H. G., Flaufox, M. B., Oberman, A., Hawkins, M., Levine, B., Cameron, M., Babcock, C., Presel, S., Caggiula, A., Cutter, G., Curb, D., and Wong, R. Effective dietary intervention in hypertensives: Sodium restriction and weight reduction. Journal of the American Dietetic Association 1980; 85:423.

115. Weinsier, R. L., Johnston, M. H., and Doleys, D. M. Time calorie displacement diets for weight control. Evaluation of safety and efficiency. American Journal of Clinical Nutrition 1980; 33:950.

116. Whitehouse, F. W., Whitehouse, I. J., Cox, M. S., Goldman, J., Kahkonen, D. M., Partamian, J. O., and Tamayo, R. T. C. Outpatient regulations of the insulin requiring person with diabetes (an alternative to hospitalization). Journal of Chronic Disease 1983; 36:433.

117. Wilson, P. W. F., Garrison, R. T., Castelli, W. F., et al. Prevalence of coronary heart disease in the Framingham offspring study and the role of lipoprotein cholesterols. American Journal of Cardiology 1980; 46:649-664.

118. Wilson, W., and Pratt, C. The impact of diabetes education and peer support in weight and glycemic control of elderly persons with noninsulin dependent diabetes mellitus. American Journal of Public Health 1987; 77:6234.

119. Winkelstein, W. Some ecological studies of lung cancer and ischemic heart disease mortality in the United States. International Journal of Epidemiology 1987; 14:39-57.

120. Wolinsky, F. D., Coe, R. M., Chavez, M. N., Prendergast, J. M., and Miller, J. Further assessment of reliability and validity of a nutritional risk index: Analysis of a 3 wave panel to study elderly adults. Health Services Research 1986; 20:977-990.

121. Wolinsky, F. D., Coe, R. M., Miller, D. E., et al. Measurement of global and functional dimensions of health status in the elderly. Journal of Gerontology 1984; 39:88-92.

122. Wolinsky, F. D., Prendergast, J. M., Miller, D. E., Coe, R. M., and Chavez, N. M. Preliminary validation of a nutritional risk index. American Journal of Preventive Medicine 1985; 1:53-59.

123. Wolinsky, F. D., Coe, R. M., et al. Further assessment of reliability and validity of a nutritional risk index. Health Services Research 1986; 20(6, Pt. 2):977-990.

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Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Suggested Citation:"Nutrition." Institute of Medicine. 1992. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: The National Academies Press. doi: 10.17226/1578.
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Taking its title from the second 50 years of the human life span of about 100 years, this book presents wide-ranging and practical recommendations for health care providers, policymakers, and other sectors of society. These recommendations range from setting new national policies to changing the way elderly patients are interviewed in the doctor's office and from what exercises older persons should do to how city planners should design our urban environment.

The bulk of this volume presents the latest research on 13 major health threats to the elderly, covering prevalence, impact on the older person's life, cost, and intervention.

In addition, the authors provide a detailed analysis of why older people often do not receive the benefit of prevention programs.

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