The Second Fifty Years Promoting Health and Preventing Disability (1992) / Chapter Skim
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Nutrition
Nutrition
Pages 157-192
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From page 157... ...
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)
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From page 158... ...
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 stroke)
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From page 159... ...
The average 68-year-oic! man today has a life expectancy of 13 years, which includes 4 years of progressive incapacity and increasing dependence.
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From page 160... ...
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 selfmaintenance skills of elderly patients by clinical means.
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From page 161... ...
. Increasing physical activity also increases energy expenditures in discretionary physical activity, further increasing energy outputs.
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From page 162... ...
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.
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From page 163... ...
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. 1 ~ 1 1 1 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.
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From page 164... ...
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.
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From page 165... ...
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. ~22 ~23 As yet, however, correlations of nutritional risk indices with clinical status or nutritional status are low or remain unproven.
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From page 166... ...
For example, it is well known that the addition of hyperTipidemia 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 Iby 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.
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From page 167... ...
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 id 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 indivicluals is well documented in Chapter 3.
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From page 168... ...
Diabetes mellitus iron-insulin dependent) End-stage kidney disease Gastrointestinal disorders High blood pressure This condition brings increased risk of other dietrelated diseases such as hyperlipidemia.
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From page 169... ...
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 in cluding 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)
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From page 170... ...
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.
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From page 171... ...
Alcohol abuse or its con sumption 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.
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From page 172... ...
It is likely that, in both mic34le-aged and older people, reductions in moderate or severe high blooc! pressure add more to life expectancy than most other interventions.62 i08 ii9 Indeed, because many elderly people are already taking medications for other reasons, there are distinct advantages to treating high blood pressure by nonpharmacological means.
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From page 173... ...
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 Rifkinc3,39 for example, argue for an aggressive posture based on their analysis of the Multiple Risk Factor Intervention Trial {MRFIT) and Framingham longitudinal data.
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From page 174... ...
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 cholestero} levels and later risk for mortality from coronary artery disease is in fact weaker than that in younger adults.
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From page 175... ...
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 (lisease in the elderly.~7 The cost-effectiveness of lowering serum cholesterol by diet appears to be greater than by other means.5 62 8i i08 For example, Berwick and coworkers' best estimate was that the cost was about $11,000 in 1975 dollars per year of life savec3.5 Taylor and colleaguesi°8 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.
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From page 176... ...
Nypertriglyceridemia 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.
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From page 177... ...
In addition, even after weight Toss, 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)
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From page 178... ...
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.
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From page 179... ...
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 50.53~84~09 Finally, flexibility and physical activity may retard osteoporosis See Chapter 61. Po~ypharmacy: Con trolling Side Effects Individuals over 50 years of age use more prescribed and overthe-counter drugs than younger people.
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From page 180... ...
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.
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From page 181... ...
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 Toss of teeth can also contribute to poor appetite and to social isolation. Finally, the dentate elclerly who have retained their teeth are vulnerable to crown or root caries, and diet is a significant risk factor for the development of either.
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From page 182... ...
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 neecled.
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From page 183... ...
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 reviewecI.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.
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From page 184... ...
Nonpharmacologic intervention should be considered for persons with atherosclerosis, high blood pressure, diabetes mellitus, physical inactivity, and osteoporosis.
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From page 185... ...
The association of serum cholesterol Towering 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 Towering, the use of postmenopausal estrogen replacement therapy with progestins, physical activity, ant!
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From page 186... ...
Costs and Benefits of Nutrition Care: Phase I Chicago: American Dietetic Association, 1979.
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From page 187... ...
Screening asymptomatic adults for cardiac risk factors: The serum cholesterol level. Annals of Internal Medicine 1989; 110:622-639.
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From page 188... ...
L Hospital morbidity mortality risk factors using nutritional assessment.
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From page 189... ...
Phase II of the costs and benefits of nutritional care. Journal of the American Dietetic Association 1982; 80:213.
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From page 190... ...
M Primary prevention of coronary heart disease: The economic benefits of lowering serum cholesterol.
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From page 191... ...
L Cholesterol reduction and life expectancy: A model incorporating multiple risk factors.
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From page 192... ...
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.
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