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Advice on Healthy eating for older people.

VOL: 101, ISSUE: 48, PAGE NO: 47

Karen Fisher, BSc, is chief dietitian, Whiteabbey Hospital, Newtownabbey, Northern Ireland

There has been a steady increase in life expectancy during and since the 20th century. In 1981, the life expectancy of women was 76 years and 70 years for men, but by 2001 this had increased to 80 and 76 years respectively. However, 'healthy life expectancy' (expected years of life in good health) has not increased at the same rate. This has meant that the number of years a person can expect to live in poor health has increased from 6.5 years for men in 1981, to 8.7 years in 2001, and 10.1 to 11.6 years for women for the corresponding time (Office for National Statistics, 2004a).

There has been a steady increase in life expectancy during and since the 20th century. In 1981, the life expectancy of women was 76 years and 70 years for men, but by 2001 this had increased to 80 and 76 years respectively. However, 'healthy life expectancy' (expected years of life in good health) has not increased at the same rate. This has meant that the number of years a person can expect to live in poor health has increased from 6.5 years for men in 1981, to 8.7 years in 2001, and 10.1 to 11.6 years for women for the corresponding time (Office for National Statistics, 2004a).

Between 1971 and 2002, the percentage of people in the UK who were aged 65 years and over increased from 13 per cent to 16 per cent, a figure that is projected to rise to 23 per cent by 2031 (Office for National Statistics, 2004b).

Health professionals can help older people to maintain their health for longer by encouraging them to modify risk factors for disease and disability by improving their diet. The Nutrition of Elderly People report (Department of Health, 1992) recommended that the majority of people over the age of 65 years who are fit and active, not classified as frail or underweight and do not have a chronic debilitating disease, should follow eating and lifestyle patterns similar to those of younger adults.

The Health Education Authority (1994) has published a summary of the guidelines for healthy eating. The advice for healthy eating that is discussed below relates to fit, older people who are not frail or underweight, who do not have debilitating chronic disease or major problems with mobility.

Modifiable Risk factors
Weight

According to Finch et al (1998), 65 per cent of men and women over 65 years of age who are living independently in the community are obese or overweight, a figure that has increased steadily over the past three decades. Weight gain is associated with the ageing process, and may be exacerbated when older people are less physically active than they used to be. The aim of treatment for obese patients is to encourage them to lose 10 per cent of the weight they were at the start of a weight-reducing programme.

A programme such as this involves a combination of the following: l Dietary modification; l Increased physical activity; l Cognitive behaviour therapy (Scottish Intercollegiate Guidelines Network, 1996).

Dietary modification
The diet used for weight reduction should be nutritionally complete in all nutrients except kilocalories (kcal).

A reduction of 500kcal a day from the usual energy intake will usually lead to a weight loss of 0.5kg a week.

Physical activity
Moderate aerobic physical activity should be undertaken for 30 minutes five days a week. The white paper, Choosing Health (DoH, 2004), endorses the use of a pedometer to monitor exercise levels, aiming for a minimum of 10,000 steps a day, increasing to 15,000 if the goal is to achieve weight loss. The British public walk an average of 3,000 to 5,000 steps a day (Northern Partnership for Physical Activity, 2005).

Cognitive behavioural therapy
Cognitive behavioural therapy encourages patients to set their own achievable goals for weight loss and helps them consider the personal benefits of losing weight along with the sacrifices that they will have to make to do so. The aim is to allow patients to 'talk themselves' into losing weight. This form of therapy encourages patients to use a food diary to identify triggers (emotions and situations) that may cause overeating, and is a means of empowering them, as they create their own solutions. For example, they might not keep certain food in the house, or wait 30 minutes between being tempted to eat and actually eating the food, so increasing self-control.

Cognitive behavioural therapy should be carried out by health professionals experienced in using the technique, and patients must be able to understand what they need to do to lose weight so that they can set achievable goals.

Hypertension
As part of the ageing process, heart muscle is gradually replaced by fibrous connective tissue, which reduces its contractility and elasticity. This, coupled with reduced elasticity of the arteries and the onset of atherosclerosis, means that hypertension is common in older people.

Weight - Patients with a body mass index above 25 are classified as overweight. (Body mass index is a measure derived from the weight and height of an individual.) Increased body weight and limited physical activity will exacerbate high blood pressure.

Treatment for hypertension that is associated with being overweight and inactive involves a weight management programme, as discussed above. These patients should be advised to have five portions of fruit and vegetables, as this may help to lower their blood pressure and to reduce oxidative damage, which is thought to be associated with the development of atherosclerosis or cancer.

Salt intake - There is a link between high salt intake and hypertension. Salt intake in the UK on average exceeds the 6g per day suggested by the Department of Health (2004) because it is added to processed foods and to food cooked at home for flavour. The Food Standards Agency is working with the food industry to try to get a voluntary agreement to reduce by 2006 the salt content of their products by 10 per cent. The Food Standards Agency has a useful website about salt intake for the general public (www.salt.gov.uk/ index.shtml).

Taste sensation - Attempts to reduce salt intake can be hampered by the effects of ageing. Age reduces the number of taste buds on the tongue and the amount of saliva produced, which means that food can lack taste (Carson and Gormicon, 1976). In addition, some common drugs, for example, aspirin, reduce sensitivity to salt.

Because the taste buds become accustomed to excess salt, food without it tastes bland. However, pepper, herbs, spices, vinegar and lemon juice can be added to foods to enhance their flavour. It should be remembered, though, that it may be several weeks before the taste buds adjust to dietary changes.

The Dietary Approaches to Stop Hypertension (DASH) diet advocates high intakes of fruit and vegetables, with moderate intakes of low-fat dairy products (two to three portions daily) and sodium restriction, as a means of reducing blood pressure (Bray et al, 2004).

Regular consumption of alcohol is associated with significant rises in blood pressure, and patients should be encouraged to avoid binge drinking and to limit their intake of alcohol - two units a day for women and up to three for men.

[h2] Hyperlipidaemia and the prevention of thrombosis Reducing blood cholesterol by 10 per cent has been associated with a 19 per cent reduction in coronary heart disease at 80 years of age (Law, 1994).

The National Diet and Nutrition Survey (Finch et al, 1998), highlighted that while older people were meeting the Department of Health's target for total fat intake (DoH, 1992) their intake of saturated fat remained excessive. The government target for fat intake is less than 35 per cent of total calories from fat and 10 per cent from saturated fat. The high intake of fat by older people could be reduced by encouraging them to eat leaner, unprocessed cuts of meat, fewer cakes, biscuits and pastries, low-fat dairy products only, and to use olive or rapeseed oil products as spreads or for cooking.

Plant stanol spreads have been shown to reduce total cholesterol by 10 per cent and low-density lipoprotein (LDL) cholesterol by 15 per cent. However, they are expensive, which may be a problem for many older people (Miettinen and Gylling, 2004).

Eating fish should be encouraged twice a week as part of the cardio-protective diet, and should include at least one oily fish portion, as the omega-3 fatty acids in oily fish reduce the risk of thrombosis formation. Five portions of fruit and vegetables a day are also recommended as part of this type of diet.

Bone health
Bone resorption (a process eliminating old bone) increases with age, resulting in osteoporosis. As the mechanical strength of bone reduces, relatively minor trauma can cause a fracture, often of the femur, wrist or vertebra.

The disease affects one in three women and one in 12 men above 50 years. Half of all patients who have had a fracture associated with osteoporosis will no longer be able to live independently (DoH, 2001). A fractured femur is associated with 33 per cent mortality within one year (Swift, 2001).

The Nutrition Survey (Finch et al, 1998) highlighted that the average (mean) intake of vitamin D in people over 65 years was 3.5mcg daily compared with the target of 10mcg daily. Dietary sources, such as oily fish and fortified spreads, should therefore be encouraged. However, many people will require supplementation (DoH, 1998). To prevent vitamin D toxicity, it is important to ensure that patients are not taking another supplement containing vitamin D, such as multivitamin tablets or cod liver oil.

Although calcium intake was not highlighted as a problem in the Nutrition Survey (Finch, 1998), patients should be encouraged to take two to three portions of low fat calcium-containing foods daily. They should also be encouraged to keep as active as possible, as reduced physical activity is a risk factor for increasing bone resorption. High alcohol intake also reduces bone resorption, so patients should be encouraged to keep within the recommended daily intake (see above).

Other nutritional issues associated with ageing
Fibre
The Nutrition Survey (Finch et al, 1998) highlighted that non-starch polysaccharide (fibre) intake of people over 65 was only about two-thirds of that recommended by the Department of Health (1992). This has important implications for older people, as muscular atrophy reduces peristaltic movement in the large bowel, causing constipation and diverticular disease.

The general advice is to increase non-starch polysaccharide intake from wholegrain cereal, fruit and vegetable sources (but not from raw bran, as this can reduce the absorption of calcium, iron and zinc); ensure adequate fluid intake (which may be further hampered by the loss of thirst sensation and/or fear of incontinence), and to try to keep as active as possible.

This advice should not be given to those who have regular episodes of diarrhoea.

Older people may suffer from malabsorptive diarrhoea owing to a combination of factors. These include:

- Atrophy of the villi in the small intestine, so reducing the surface area for absorption;

- Reduced amounts of intestinal digestive enzymes.

Altered bowel habits should be reported to the patient's GP, who may refer the patient for further investigations.

Anaemia
The Health Survey for England (DoH, 2000) found that 16 per cent of men and 11 per cent of women aged 65 and over living in their own homes were anaemic. This results from the decreased gastric acid secretion associated with ageing, which reduces iron absorption.

The Nutrition Survey (Finch et al, 1998) did not highlight poor iron intakes in this age group, but it would be prudent to encourage the inclusion of haem (an easily absorbed form of iron) in the form of lean red meat at least one to three times a week. Vegetarians can obtain iron from eating a fortified breakfast cereal daily. Slimming varieties, such as Fitnesse and Special K have three times the amount of iron that is in ordinary fortified cereals.

Other iron-rich sources for vegetarians are eggs, beans, peas and lentils and dark, green, leafy vegetables. For those who eat fish, oily fish is a good source.

Dental health
Steele (1998) noted in the part of the National Diet and Nutrition Survey that dealt with oral health that 50 per cent of older adults do not have any natural teeth. It is essential to check that false teeth fit and are comfortable.

The survey also noted that those with natural teeth had better nutritional status, as they found it easier to chew their food. Patients with dental problems should, therefore, be encouraged to eat soft, pureed or tinned fruit, homemade vegetable soups and casseroles. Older people should be encouraged to visit the dentist regularly.

Conclusion
Many older people are at risk of poor nutrition owing to physical factors associated with ageing or ill health, or for psychological and economic reasons. It is important to assess the nutritional status of older people while they are receiving health care in order to identify nutritional problems, for which they could be offered help and advice.

Resources
- Food Standards Agency

The website includes a useful section for the public on salt intake:

www.food.gov.uk

- Department of Health

The Department of Health website has a link to the Food and Health Action Plan:

www.dh.gov.uk

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