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FROM THE ACADEMY
Position Paper
Position of the Academy of Nutrition and Dietetics:
Food and Nutrition for Older Adults: Promoting
Health and Wellness
ABSTRACT POSITIONSTATEMENT
It is the positionoftheAcademyofNutritionandDieteticsthatallAmericansaged60 It is the position of the Academy of Nutrition
yearsandolderreceiveappropriatenutritioncare;haveaccesstocoordinated,com- and Dietetics that all Americans aged 60
prehensivefoodandnutritionservices;andreceivethebenefitsofongoingresearch years and older receive appropriate nutrition
to identify the most effective food and nutrition programs, interventions, and ther- care; have access to coordinated, compre-
hensive food and nutrition services; and re-
apies. Health, physiologic, and functional changes associated with the aging process ceive the benefits of ongoing research to
caninfluencenutritionneedsandnutrientintake.Thepracticeofnutritionforolder identify the most effective food and nutri-
adults is no longer limited to those who are frail, malnourished, and ill. The popula- tion programs, interventions, and therapies.
tion of adults older than age 60 years includes many individuals who are living
healthy, vital lives with a variety of nutrition-related circumstances and environ-
ments. Access and availability of wholesome, nutritious food is essential to ensure
successfulagingandwell-beingfortherapidlygrowing,heterogeneous,multiracial,
andethnicpopulation of older adults. To ensure successful aging and minimize the
effects of disease and disability, a wide range of flexible dietary recommendations,
culturally sensitive food and nutrition services, physical activities, and supportive
care tailored to older adults are necessary. National, state, and local strategies that
promote access to coordinated food and nutrition services are essential to maintain inde-
pendence, functional ability, disease management, and quality of life. Those working with
older adults must be proactive in demonstrating the value of comprehensive food and nu-
trition services. To meet the needs of all older adults, registered dietitians and dietetic
technicians,registered,mustwidentheirscopeofpracticetoincludeprevention,treatment,
andmaintenanceofhealthandqualityoflifeintooldage.
J Acad Nutr Diet. 2012;112:1255-1277.
EALTHY LIFESTYLES, EARLY Beginning early in life, eating a nutri- andreducingassociatedcomplicationsis
detection of diseases, imm- tious diet, maintaining a healthy body an essential strategy for keeping older
unizations, and injury pre- weight,andaphysicallyactivelifestyle adults healthy, independent, and com-
Hvention have proven to be arekeyinfluentialfactorsinhelpingin- munitydwelling.
effective in promoting the health and dividualsavoidthephysicalandmental
longevity of older adults. One in every deteriorations associated with aging. ROLE OF FOOD AND
eight people in America is an older Approximately one third of older NUTRITION IN AGING
adult, defined by the Older Americans adults are aging successfully based on Although health status has multiple
Act (OAA) as an individual who is aged objectivecriteria;however,agreatnum- contributing factors, nutrition is one of
1
60yearsolder. Theenjoymentoffood ber of older adults perceive themselves the major determinants of successful
and nutritional well-being, along with as aging successfully despite the pres- aging. Food is not only critical to one’s
otherenvironmentalinfluences,hasan 3
enceofillnessanddisability. Ofthemost physiological well-being but also con-
influence on health-related quality of commoncauses of death of adults aged tributes to social, cultural, and psycho-
life and the aging process (Figure 1). 65 years and older in the United States, logical quality of life. Primarily, nutrition
Qualityoflifeisdefinedinpublichealth fiveofeighthaveaknownnutritionalin- helps promote health and functionality.
and medicine as a person’s perceived 4
physical and mental health over time, fluence (Figure 2). Almost 80% of older As a secondary and tertiary strategy,
including factors such as health risks, adults have one chronic condition, and medicalnutritiontherapy(MNT)isanef-
halfofallolderadultshavetwoormore.5 fective disease management approach
andconditions,functionalstatus,social Morethan39%ofallnoninstitutionalized that lessens chronic disease risk,
support, and socioeconomic status.2 persons aged 65 years and older are in
slows disease progression, and re-
excellent health and only 6.4% of these duces disease symptoms. Thus, the
2212-2672/$36.00 adults needs help with their personal yearsattheendofthelifecyclecanbe
doi: 10.1016/j.jand.2012.06.015 daily care.6 Preventing chronic diseases healthful,enjoyable,andproductiveif
©2012bytheAcademyofNutrition and Dietetics. JOURNALOFTHEACADEMYOFNUTRITIONANDDIETETICS 1255
FROM THE ACADEMY
This Academypositionpaperincludesthe Americansaged65yearsandolderhas netic predisposition to long life for
authors’ independent review of the liter- morethantripled:from4.1%to13.1%of someindividuals, healthy dietary hab-
ature in addition to systematic review thepopulationin2010.7Thenumberof its, regular physical activity, avoidance
conducted using the Academy’s Evidence older Americans reached 40.4 million of tobacco products, and maintenance
Analysis Process and information from persons in 2010. By 2030, there will be of a healthy body weight all appear to
the Academy’s Evidence Analysis Library about72.1millionolderpersonsrepre- have a favorable influence on genetic
(EAL). Topics from the EAL are clearly de- senting 19.3% of the population—al- predispositions toward long life.
lineated. The use of an evidence-based most twice the number there was in
approach provides important added ben- 2007. The 85 years and older popula-
efits to earlier review methods. The major tion is expected to increase to 6.6 mil- HEALTH DISPARITIES AND
advantage of the approach is the more NUTRITION-RELATED HEALTH
rigorous standardization of review crite- 7
lion in 2020. CONDITIONS
ria, which minimizes the likelihood of re-
viewer bias and increases the ease with Minority Aging Manyolder adults have at least one or
which disparate articles may be com- more chronic health condition. The
pared. For a detailed description of the Theracial/ethniccompositionofAmer- most frequently occurring conditions
methods used in the Evidence Analysis icansaged65yearsandolderisalsoex-
Process, go to www.andevidencelibrary. pected to continue to grow and diver- amongolderadultsareshowninTable
com/eaprocess. sify. Minoritypopulations,estimatedat 2. The main goal for older adults in
Conclusion Statements are assigned a 8.1 million in 2010 (20.0% of older HealthyPeople2020isto“improvethe
grade by an expert work group based on 12
adults), are projected to increase to health, function and quality of life.”
the systematic analysis and evaluation of Disparities in health are believed to
the supporting research evidence. Grade 13.1 million in 2020 (24% of older be the result of complex interaction
IGood; Grade IIFair; Grade III adults).7 Table 1 shows projected pop-
Limited; Grade IVExpert Opinion Only; ulation growthdatafrom2010to2050 amonggeneticvariations,environmen-
and Grade VNot Assignable (because by race for persons ages 65 years and tal factors, and cultural and health be-
there is no evidence to support or refute 7 haviors. Inequities in access to health
the conclusion). See grade definitions at older and ages 85 years and older. care, income, and poverty, as well as
www.adaevidencelibrary.com/grades. food security also contribute to health
Recommendations are also assigned a Life Expectancy disparities among older adults. Differ-
rating by an expert work group based on Persons living to age 65 years have an ences in rates of physical activity also
the grade of the supporting evidence and average life expectancy of 18.8 more exist,withminoritypopulationsengag-
the balance of benefit vs harm. Recom- 8 inginlowerratesofphysicalactivity.12
mendation ratings are Strong, Fair, Weak, years. Menandwomenwhoreachage
Consensus, or Insufficient Evidence. Rec- 85 years can expect to live more than However,despiteimprovementsinthe
ommendations can be worded as condi- 5.7 and 6.8 additional years, respec- overall health of the US population, ra-
tional or imperative statements. Condi- tively.8 Along with general trends for cial and ethnic health disparities con-
tional statements clearly define a specific theUSpopulation,theHispanic,Amer- tinuetopersistbetweenwhitesandAf-
situation and most often are stated as an ican Indian and Alaskan Native, African rican Americans,forexample(Table2).
“if, then” statement, while imperative American,Asian,andHawaiianandPa- The ability of RDs to effectively reduce
statements are broadly applicable to the the burden of illness among older ra-
target population without restraints on cific Islander populations are also now
their pertinence. Evidence-based infor- 7 cial/ethnic minority adults will depend
living longer.
mation for this and other topics can be onanincreasedunderstandingofenvi-
found at www.andevidencelibrary.com The Genetics of Longevity ronmental and lifestyle factors in indi-
and subscriptions for non-members are viduals of various races and ethnicities
purchasable at www.adaevidencelibrary. In 2001 there were 48,000 individuals andhowthosefactorsinteractwithbi-
com/store.cfm. intheUnitedStateswhowereaged100 ological and physiological aging pro-
yearsorolder.By2009thereweremore 13
than 64,000 persons aged 100 years or cesses. Interventions tailored to the
chronic diseases and conditions can more, accounting for 0.2% of the popu- culture, language, and age group of the
be prevented or effectively managed. lation older thanage65years.7Genetic target population are key strategies to
Registered dietitians (RDs) and di- research has identified the presence of increase the effectiveness of programs
etetic technicians, registered (DTRs), designed to improve food security of
are uniquely qualified to provide a genes and combinations of genes in older adults with limited resources.14
broad array of culturally sensitive centenariansthatcontributetoprotec-
food and nutrition services in addi- tion from age-related diseases, healthy
9,10 Health Care, Income, and Poverty
tion to encouraging physical activity aging, and longevity. Some longe-
and other supportive care for older vity-enabling genes are thought to Inequalities in access to medical care
Americans. function by offering protection against resources, income, and poverty can re-
10
chronic diseases; other evidence, sultinhealthdisparities.Minoritiesare
THE GROWING AGING however, has not confirmed an associ- morelikelytoreportthattheyhaveno
POPULATION ation between specific genes and lon- usual source of medical care or that
gevity or suggests that the relationship theywereunabletoobtainorwerede-
11 layed in receiving needed medical
ThedemographicsoftheagingUSpop- is small. In addition, longevity genes
7
ulation is changing and growing dra- mayfunction in combination with en- care. In 2010, an estimated 3.5 million
matically as baby boomers reach older vironment and lifestyle choices. Al- elderly persons (9.0%) were below the
ages. Since 1900, the percentage of though the possibility exists for a ge- povertylevel;another2.1millionolder
1256 JOURNALOFTHEACADEMYOFNUTRITIONANDDIETETICS August 2012 Volume 112 Number 8
FROM THE ACADEMY
Figure 1. Factors that influence health-related quality of life and the aging process. Figure from reference 24: Bernstein MA,
Luggen AS. Nutrition for Older Adults. 2010: Jones & Bartlett Learning, Sudbury, MA. www.jblearning.com. Reprinted with
permission.
adults were considered “near poor” ciallyacceptedways,isinadequateorun- Body Composition study found that in
17
(125% of the poverty level). Rates certain. The level of food insecurity older adults a diet consistent with cur-
were higher among minority older amongolder adults in the United States rent guidelines, including relatively
7 18 high amounts of vegetables, fruits,
adults, and older women. Almost 16% varies considerably. Food insecurity is
ofpersonsaged65yearsandolderwere more prevalent in older adults with in- wholegrains, poultry, fish, and low-fat
poor in part due to medical out-of comes below the poverty line, popula- dairy products may be associated with
pocket expenses.15 In general, popula- tion subgroups such as blacks and His- superiornutritionalstatus,qualityoflife,
21
tion groups with the worst health sta- panics and those who live in rural areas, and survival. Food habits of older
tusarealsothosewiththehighestpov- rent their homes, are less educated, are adults are determined not only by life-
16 disabled, have a grandchild living in the
erty rates. This can be attributed to time preferences and physiologic
food insecurity, limited access to med- house, and participants in the Supple- changesbutalsobysuchfactorsasliving
ical care, and decreased opportunity to mental Nutrition Assistance Program arrangements, finances, transportation,
19
engage in health-promoting behaviors (SNAP). anddisability.Thepositivepsychological
suchasphysicalactivity. andsocialaspectsofeatingareimportant
FOOD AND NUTRITION IN pleasuresoflife.Whenplanningthecare
Hunger and Food Insecurity HEALTH AND DISEASE of older adults, RDs and DTRs must ac-
Hunger and food insecurity are definite Food is an essential component of ev- knowledge that food habits make a sig-
issues for a portion of community-resid- eryday life. Meals add a sense of secu- nificantcontributiontowell-being.
ing older adults, placing them at risk for rity, meaning, andstructuretoanolder Changes in Nutrient Needs with
poornutritional status and deteriorating adult’s day, providing feelings of inde-
17,18 Age
physical and mental function. Food pendence and control and a sense of
insecurityoccurswhenevertheavailabil- mastery over his/her environment.20 Health, physiologic, and functional
ity of nutritionally adequate and safe Assessment of dietary patterns from changes that occur with aging affect nu-
food,ortheabilitytoacquirefoodsinso- participants in the Health, Aging, and trient needs. Knowledge of the nutrient
August 2012 Volume 112 Number 8 JOURNALOFTHEACADEMYOFNUTRITIONANDDIETETICS 1257
FROM THE ACADEMY
requirements of older adults is growing,
yet in some instances inadequately in-
vestigated to establish standards. Spe-
cific dietary recommendations for en-
ergy and several essential nutrients and
food components, such as dietary fiber,
havebeendelineatedintheDietaryRef-
erenceIntakes(DRIs).22TheDRIsinclude
theagecategories51to70yearsand70
years, and although chronological age is
used as an indicator, actual nutrient re-
quirementsmaybewide-ranginginthis
population. Chronological age categories
maybeusefulformanypurposessuchas
assessing current and planning future
nutrient intakes related to both the diet
of an individual and of groups. The pre-
cise nutrition needs of an older adult at
anyagearemulti-factorialbecauseofthe
highdiversitywithinthispopulation.The
MyPlate for Older Adults icon illustrates
the recommendations of the 2010 Di-
etary Guidelines for Americans (DGA)
and MyPlate specially tailored to older
adultsbyemphasizingtopicssuchasad-
equatefluid;convenient,affordable, and Figure 2. Top eight leading causes of death for adults aged 65 years in 2009.
readily available foods; and physical ac- Adapted from reference 4: 10 leading causes of death by age group, United States—
tivity.23 2009. National Vital Statistics System, National Center for Health Statistics, Centers for
Adecreaseinfoodintakebyanolder Disease Control and Prevention website. www.cdc.gov/Injury/wisqars/pdf/10LCD-
adult can have overlapping causes and Age-Grp-US-2009-a.pdf. Accessed June 28, 2012.
far-reaching effects. Older adults often
have multiple medical conditions re- Energy nutrition requirements without ex-
quiring them to alter their dietary in- Total and resting energy requirements ceeding energy requirements poses an
take and use numerous prescription 25 additional challenge for older adults
decrease progressively with age. Al- andrequires limiting discretionary en-
andover-the-countermedicationsthat though the decline in energy require- ergyintake.Recentevidenceondietary
can impair food intake or alter diges- mentwithadvancingageismultifacto- trends is concerning. Usual intake for a
tion, absorption, metabolism, and ex- rial,itcanbeattributedinalargepartto largepercentageofolderadultsaged51
cretion. Barriers to the consumption of decreases in physical activity. Physical to 70 years and those 71 years was
ahealthydietcanbeattributedtosocial inactivity that accompanies advancing below the minimum recommended
factors, economichardships,functional age lowers energy requirements di- amounts, especially for the nutrient-
difficulties while shopping for or pre- rectly by reducing energy expenditure 30
paringfoods,changesinmentalability, andleadstoadeclineinbasalmetabolic rich food groups. More than 90% of
as well as physiologic alterations in rate due to losses of lean mass. Loss of persons aged 51 to 70 years and 80%
taste sensations, a decline in olfactory skeletalmuscle,aswellasgainsintotal of persons aged 71 had intakes of
body fat and visceral fat content con- emptyenergythatexceededthediscre-
function, difficulty chewing and swal- 30
tinueintolatelife.26Themaindetermi- tionary energy allowances. This im-
lowing, and changes in digestion and nant of energy expenditure is fat-free balance creates a nutritionally difficult
24
absorption. Physiologic changes may mass in sedentary individuals, which situation where food and dining expe-
occurnaturallywithaging,asaresultof declines by about 15% between the riencescontributesignificantlytoqual-
disease,orasasideeffectofmedication third and eighth decade of life. When ityoflifeandoverallhealthinolderage
use. Changes in body composition or energyneedsdeclinewithage,individ- yet may require more close attention
physiologic function that occur with uals often do not make a comparable than at any other stage of life. RDs
agemayalsohaveadirectinfluenceon reductioninenergyintakeleadingtoan working with this population have the
nutrient requirements. Reductions in increased body fat content.27 unique challenge to help older adults
muscle mass, bone density, immune A lower energy requirement repre- balance nutrient requirements for
function, and nutrient absorption and sents a challenging nutrition situation overall health and well-being.
metabolism may make it difficult for for older adults because vitamin and
older adults to meet nutrition require- mineralneedsoftenremainconstantor Other Nutrients
ments, especially when energy needs may even increase for many nutri- Fluid. The Adequate Intake for water
are reduced. ents.28,29 Consuming a diet that meets fromfoodandbeveragesissetatalevel
1258 JOURNALOFTHEACADEMYOFNUTRITIONANDDIETETICS August 2012 Volume 112 Number 8
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