Chances are you are either entering the last decades of your life or are caring for someone who is. Between 2019 and 2020 the number of people over age 55 grew by 27%. This increase is due to the baby boomer generation who are in the 65-74 year-old age group (1). The Older Americans Act (OAA) defines “older Americans” as age 60 or older, however this age range can reflect many different health statuses and nutrition needs (2). During the elderly years, we often see many health-related changes such as development of chronic diseases, that can impact nutrition status or vise versa. Older Americans diets often lack quality nutrition and at times are packed full of empty calorie foods which can contribute to malnutrition and the consequences that come along with that. Many older adults are entering these years in the obese category with depleted nutrient stores and suboptimal fitness levels putting them behind the eight ball. Many external and internal factors can contribute to poor nutrition and nutrition changes in the elderly.
Decreased Appetite and Unintended Weight Loss
Food intake declines as age advances with this being even more exaggerated in the very old and the frail elderly living in institutional settings. In addition to this decrease in food intake, the food that is chosen is often nutrient depleted. The US Healthy Eating Index showed that older people’s food consumption was lowest for whole grains, dark green and orange vegetables, legumes and milk (3). The 2020-2025 Dietary Guidelines for Americans showed that older women’s intake of all food groups was suboptimal while males intake only met recommendation for total grains and protein. More than 50% of older Americans overconsumed added sugars and more than 75% overconsumed saturated fats and sodium- all which contribute to chronic diseases and displacement of calories that provide much needed nutrients (4). There is not one answer to why the elderly population as a group appetites starts to decrease but many contributing factors may be playing a role such as poor dentition, decline in sense of taste and smell, altered GI function, age related changes in hormones, depression and anxiety among many others. With all these factors you can see how unintended weight loss can become a problem.
Changes in Body Composition
As we age, our body composition starts to change. Because many people begin the older years in the overweight and obese categories, we often see unintended weight loss putting the elderly person in a healthy body weight or even underweight. Event though they may be in a healthy body weight range, their body composition is often not ideal. The older adult often losses muscle mass and gains fat mass- with weight loss exaggerating the muscle loss. Sarcopenia is a progressive loss of muscle mass, function and quality and strength that happens as we age. This term is so important to remember even before we are in those “older” years because sarcopenia begins at age 30! Yes you heard me! We start naturally losing muscle mass around age 30 and if we are not doing things to actively try to prevent this, then we will continue to lose muscle mass year after year. Studies show that between the ages of 30 and 60, the average adult will gain one pound of fat and lose ½ pounds of muscle yearly. This equates to a total gain of 30 pounds of fat and a loss of 15 pounds of muscle. The rate of muscle loss skyrockets after age 70 with a loss of 15% per decade (5). I am sure you have seen the elderly population who have trouble standing, walking, going up steps and have an increased number of falls- sarcopenia plays a large role in this. The greatest predictor of mobility later in life is EXERCISE! Building and maintaining your muscle mass from a young age right into your elderly years is a big predictor of how mobile you will be in your elder years. Nutritionally, protein-energy malnutrition can contribute to a rapid decrease in lean body mass. Consuming a diet that is not providing adequate protein, carbohydrates as well as micronutrients can contribute to this rapid decline of lean body mass and can result in weakness, gait instability, balance disorders, falls and fractures, functional decline, and ultimately an increase in morbidity and mortality.
Change in Micronutrient Composition
As we age, because of the change in our body composition (decrease in lean body mass and increase in fat stores), and decreased physical activity, the elderly body requires a much lower calorie level. A popular saying is that muscle burns more calories than fat- so the elderly population who have low amounts of muscle will have a lower caloric need. The problem here is that their micronutrient (vitamins and minerals) needs do not decline and often actually increase due to impaired absorption of these nutrients in the body. The struggle is that these people who require a low number of calories need to consume very nutrient dense foods to make sure they are getting the micronutrients they need. Nutrient dense foods are foods that are low in calories but pack a high number of vitamins and minerals. These foods include fresh fruits and vegetables, lean meats, low fat dairy products and whole grains. As the body’s GI system beings to change, we often see nutrients not being absorbed well. Older adults are at risk for decreased absorption in carbohydrates, protein, folate, vitamin B12, Vitamin D and calcium.
Complex Medical History and Polypharmacy
Studies have found many factors influence an older person’s nutritional status, among them are living alone, difficulty swallowing, higher BMI, depression, frailty and multiple medication use- AKA, polypharmacy (6). As we age, we develop more chronic diseases and therefore may be taking any number of medications to maintain our quality of life and extend our lifespan. Along with medications come side effects and drug nutrient interactions. Among these side effects, ones related to nutrition include appetite changes, weight changes, dry mouth, increased thirst, altered taste, and altered GI tract functioning such as nausea, vomiting, diarrhea and constipation- all of which can contribute to a decrease in food intake. In addition to medications affecting a person’s intake, it can also affect how the body metabolizes foods which can impair absorption of nutrients. Medications can have alterations in the GI tract such as antibiotics wiping out the GI tract flora (healthy bacteria), antacids reducing the amount of hydrochloric acid in the stomach and laxatives speeding transit of food through the GI tract – all of which can impair nutrient absorption.
Changes in Taste and Smell
Those who experience a change in their sense of taste and smell often experience fewer food cravings and have less involvement with food. It is understandable if food doesn’t taste the way it used to, or you can’t taste at all that you would not want to eat. The enjoyment that food provides has now been taken away. As we age, the amount of taste buds we have decrease and become less sensitive naturally. In addition to that, we see additional changes with taste and smell often due to medications, cancer, those with dry mouth, poor oral hygiene, periodontal disease, cigarette smoking and with Alzheimer’s.
Think about the last time you ate a meal. Did you eat alone? Did you eat with your family? Did you seek out someone to eat with? When you eat alone do you eat more or less than if you ate with others? Socialization can impact food intake greatly. People tend to eat more when in the company of others. Throughout our lives, we tend to surround ourselves with friends and family and in many cultures, food is always present for every occasion. In some households dinners are a time to come together and share what our days were like. The elderly population often lacks socialization and eat alone. Their families they have raised have grown up and created families of their own, moved away and are busy with their lives. Spouses and friends have at times passed away leaving them alone. Eating in isolation can have a negative impact on food intake and nutrition. In addition, the ability to shop for and cook food often become a challenge. Driving to the store, walking the long distance of the grocery stores and standing long enough to prepare a meal all can become a challenge. With this often comes depression which in itself is a common cause of weight loss. Other mental changes often seen in the elderly population are dementia and Alzheimer’s which can cause confusion to the point of impairing an adult’s desire to eat and their ability to feed themselves.
Decrease in Body Water
Total body water decreases as we age in relation to the changes in our body composition. The majority of our body water is stored in our lean body mass, so when we have a decrease in muscle mass, then we see a decrease in body water. This makes it extremely easy for the elderly population to become dehydrated quickly. Adequate and consistent hydration is essential to prevent dehydration. Water is always the best source of hydration however, in instances where we are sweating profusely, having diarrhea or are vomiting, replacing electrolytes in addition to water is essential. You can do this by drinking an electrolyte drink such as Gatorade or Pedialyte.
Inability to Swallow or Chew
Did you know that the act of swallowing involves more than 30 muscles and nerves! Just like all the other muscles in the body, as we age these muscles become weak and so our ability to swallow can become impaired. An impairment in the ability to swallow is called dysphagia and can lead to dehydration, malnutrition, respiratory infections, weight loss, and depression. Dysphagia may occur due to normal aging or may be a result of a medical problem such as a stroke. In addition to swallowing changes, dental changes such as missing or broken teeth and ill-fitting dentures can impair an older adult’s ability to eat as well. The older adult experiencing these problems may need an altered consistency diet. For instance, foods may need to be chopped up or pureed into a baby food like consistency and liquids may need to be thickened to decrease transit time and reduce the chance of food entering the airways and causing aspiration pneumonia. Those experiencing swallowing problems may benefit from seeing a speech therapist that can provide exercises to strengthen the muscles involved in swallowing.
Slowed Down Gastrointestinal (GI) Tract
Do you ever hear the elderly in your life talk about their bowel movements constantly? It’s a running joke that the elderly become “bowel obsessed”. Well one of those reasons for this is that as we age, we often have GI related changes. Constipation is very common among the older population. In addition to the naturally slowing down of the GI tract, medications can contribute to these changes as well. Medications that often induce constipation are analgesics (narcotics), antidepressants, antihistamines, calcium channel blockers, anti-Parkinson drugs, iron and calcium. With the decrease in appetite and in overall food intake discussed earlier, we often see a decrease in dietary fiber and water intake as well further contributing to constipation. There are lifestyle changes that can help with this including consuming more dietary fiber, drinking more water, going to the bathroom after a meals, and getting regular exercise.
If you or anyone you know are experiencing these nutrition related changes and would like help. Reach out to a Registered Dietitian Nutritionist (RD/RDN) who specializes in Gerontological nutrition who can help you make some lifestyle changes to prevent or slow the effects of malnutrition.
1-Bureau, U. S. C. (2020, December 14). National Demographic Analysis Tables: 2020. The United States Census Bureau. https://www.census.gov/data/tables/2020/demo/popest/2020-demographic-analysis-tables.html.
2- Older Americans Act. ACL Administration for Community Living. (n.d.). https://acl.gov/about-acl/authorizing-statutes/older-americans-act.
3-Healthy Eating Index (HEI). USDA. (n.d.). https://www.fns.usda.gov/healthy-eating-index-hei#:~:text=The%20Healthy%20Eating%20Index%20(HEI,the%20Dietary%20Guidelines%20for%20Americans.
5- Nutrition’s Role in Sarcopenia Prevention. Today’s Dietitian. (n.d.). https://www.todaysdietitian.com/newarchives/090112p62.shtml.
6- Burgos, R., Joaquin, C., Blay, C., Ledesma, A., Figueiras, G., Pérez-Portabella, C., Granados, A., Gómez, M. D., González, A., Sarquella, E., Amil, P., & Vaqué, C. (2016). Strategy to fight against malnutrition in chronic patients with complex health needs. International Journal of Integrated Care, 16(6), 161. https://doi.org/10.5334/ijic.2709