Nutrition and the Elderly 
by Alexandra Greeley

    We all know a Norma Kramer--an older person whose life has slowly 
started to come apart--a widow living alone who in her depression eats
sparsely. Her adult son drops by for dinner one night a week, but that may
be her only substantial meal until his next visit. Finally, because she can 
no longer live well enough alone, Norma Kramer moves into a senior citizen's
residence.
    Outgoing now and healthy except for painful arthritis--72-year-old
Kramer lives at the Har Sinai West senior high-rise in Baltimore, Md. She 
looks forward each day to the Eating Together in Baltimore breakfast and
lunch program at the residence--for there, not only can she gossip with 
friends, she also can eat wholesome, hot meals that fortify her.
    Kramer's story is true, and altogether too common, repeated in varying
versions everywhere by people who worry about aging relatives or friends. 
Without proper supervision, many millions of older Americans exist in a 
nutritional twilight zone, grappling with the daily challenge of eating--and
often not eating well-balanced meals or any meals at all. 
    A recent survey completed for the new Nutrition Screening Initiative
(sponsored by Ross Laboratories)--targeted at improving the nutritional 
health status of the aging--shows that while 85 percent of seniors surveyed 
believe nutrition is important for their health and well-being, few act on
their beliefs. Further, 30 percent admit they skip at least one meal a day. 
These numbers may well soar, as America continues to gray at an escalating
rate. 
    "Twelve percent of the population of the United States is now age 65 or 
older," says Jeffrey Blumberg, Ph.D., associate director of the USDA Human
Nutrition Research Center of Aging at Tufts University. "But in 30 years, 
the figure will be closer to 20 percent." 

                         Higher Risk of Malnutrition
    Sound nutrition plays a major role in good health for people of any age.
But, says Paul Kerschner, senior vice president of the National Council on
the Aging in Washington, D.C., seniors tend to be at a disproportionate risk
of poor nutrition that can adversely affect their health. He describes the
unacceptably high levels of poor nutrition and malnutrition among the 
elderly, which range from 15 to 50 percent. He says the problem is
particularly pronounced among those living in institutional settings. 
    To make matters worse, often the signs and symptoms of malnutrition can 
baffle and mislead even the professionals. For example, weight loss,
lightheadedness, disorientation, lethargy, and loss of appetite are often 
diagnosed as illness, says Colleen Pierre, American Dietetic Association
ambassador and director of the Eating Together in Baltimore program. "What
the person really needs is to eat better," she says.
    Responding to the widespread gap in nutrition knowledge, the American 
Academy of Family Physicians, the American Dietetic Association, and the
National Council on the Aging have joined forces to promote the Washington, 
D.C.-based Nutrition Screening Initiative.
    Kerschner says that the hoped-for goal of this five-year initiative is
to "start good nutritional habits that will forestall inappropriate acute 
and institutional care and will help people age well and keep in better 
health." The campaign was initiated, he continues, because the nutritional
status of older people was being ignored, not only by older people
themselves, but also by the health-care community.
    One other goal of the program, he continues, is to point out to 
institutions that eating is a major part of people's lives. "Even 
institutions that serve good meals don't present them as part of therapy,"
Kerschner says. Dietitians and nurses need to realize that meals at any age 
are an important part of daily life, whether people live at home or in an 
institution. So just presenting food, then taking it away when a person is
finished, doesn't help the person learn good nutritional habits, he says. 

                             A Complex Challenge
    Unfortunately, encouraging older citizens to eat well and to pay serious
attention to sound nutrition is a complex challenge with no single, simple
solution. For one thing, the aging process itself becomes a real barrier, 
explains Blumberg. As many people age, he says, their biological clock winds
down and they also start to lose lean body mass.
    Consequently, their interest in food--and their appetites for it --tends
to diminish so people cut back on calories. But that's not okay, says 
Blumberg. "Requirements for many nutrients don't diminish," he says, "and 
they may even increase with age. Eating less presents real problems leading 
to deficiency." For example, he says, requirements for vitamin B6 actually
increase for older people. "We find that when people are in a depleted but
not a deficiency state, there are cognitive changes, changes in the immune
systems, and deficits in sensitivity to insulin," he says. But an increase
in B6 intake corrects the problems. 
    Health declines have "a cascading effect," says pathologist Philip
Garry, professor at University of New Mexico School of Medicine. But after
studying 300 older adults from the ages of 65 to 93, Garry has concluded
that even the process of aging itself may be retarded through behavioral
changes.
    "You really can slow aging down through eating well, exercising 
properly, keeping positive, and staying active," he says. "We don't see much
change in them [the people in the study] due to aging," he continues, 
because very few of the people in his New Mexico Aging Process study are
sedentary, have memory loss, or are on medications or overweight. "So they
are going on in life like they did when they were much younger," he says, 
telling of a spry 80-year-old man in the study who works as a ski 
instructor. "The only time we see a dramatic change in someone is when
something acute happens, such as a fall. That may precipitate a change in 
the dietary lifestyle," he says.
    The reasons seniors shun balanced fare results from more than natural 
metabolic changes, of course: Some of these other factors are not so
obvious. Loneliness, for example, can cripple the person who has always 
lived with a spouse or other family members, and it seems to hit older men
particularly hard, reports Suzanne Murphy, nutritionist at University of
California at Berkeley, and co- researcher of a study on the living 
arrangements and dietary quality of older adults in the United States,
funded by the National Institute on Aging.
    Without cooking or shopping skills, men may eat less or skip meals
altogether. Women living alone may simply grow tired of kitchen duty and
lose interest in eating. "Older Americans are at risk," she says, "but
single older Americans are at greater risk." Depression--often linked to
loneliness--may likewise curtail a person's interest in food. 

                               Sensory Decline
    Another roadblock to eating well is the decline in the sense of smell 
that directly affects a person's ability to taste--and enjoy--food. "We once
believed that older people didn't eat well because of their decline in taste
and taste buds," says James Weiffenbach, Ph.D., research psychologist,
Clinical Investigation and Patient Care Branch, National Institute of Dental
Research, National Institutes of Health in Bethesda, Md. "Taste and smell as
a sensory system do affect eating. But the ability to taste remains fairly
intact with age. It's the decline in the ability to smell that seems to be
responsible for 'taste' complaints," he says. 
    Weiffenbach points out that older people have trouble identifying pur}ed
foods. Though younger people do much better under usual circumstances, when 
holding their noses while eating, they are no better at identifying foods 
than older people. In essence, he says, you can't taste if you don't
smell--smell is the real factor in the enjoyment of food. 
    Money worries play a large role, too. After people retire, their incomes
often dwindle, forcing them to make some hard cutbacks in their budgets. The
one area that usually cuts most easily is the food allowance. 
    In addition, certain medications can kill appetites or taste sensations.
Or people may wear ill-fitting dentures that make chewing meats and fibrous 
vegetables difficult. Perhaps failing eyesight causes meals to look less
appealing and makes reading food labels difficult. Perhaps, too, disease or 
broken bones limit mobility so that shopping or cooking becomes an unwelcome
chore.
    Weakness is another factor. How, asks Gail Martin, assistant
administrative director of the National Association of Meal Programs (which 
represents Meals on Wheels), Washington, D.C., can a frail elderly person 
carry home a heavy bag of groceries, particularly if that home is six blocks
away and that person has no cab fare? 
    Unlike years ago, when all tradesmen came to the door, she continues, 
shopping today is more difficult. Shoppers generally must leave home, 
usually by car, to buy their provisions. "If you are 85 years old and have a
car," she says, "you must be able to drive it and handle it well enough to
maneuver shopping mall parking lots. And you'll probably have to park at a
distance from the store. There are obstacles for those even in the best of
health. Our society has not thought through how older people are going to 
live and make it."

                            Practical Suggestions 
    While most experts express dismay at the situation, they all offer
practical suggestions that almost every aging American can follow. For one, 
Blumberg suggests, simply taking supplements can help. "By the time someone 
is old, the consequences of inappropriate nutrition are hard to void," he 
explains. "But it's not too late to start to reduce the risk. I know of only
one ready alternative, and that's to take supplements. Others talk about
fortifying foods. But if the vitamin D requirement for an older person
really is two to three times higher than the current allowance, it may not
be realistic to tell a 65-year-old woman to drink five glasses of milk a
day." Of course, he cautions, supplements in large amounts can be toxic.
    Another expert, however, does not advise the use of supplements. "I hate
to make a recommendation for supplements," says Jean Pennington, associate
director for dietary surveillance at the Food and Drug Administration's 
Center for Food Safety and Applied Nutrition, "unless in special cases when 
there is an illness or a physiological reason. Then a supplement might be 
indicated." 
    Generally, she adds, most people get adequate nutrients from the food 
supply. But if they can't or don't, she says, then supplements taken should 
not be greatly in excess of the RDA for that nutrient. Or, she continues, 
people should pay much closer attention to what they are eating and should
select the most nutritious foods possible. "People should make the proper 
selection from the four basics," she says, "and should place more emphasis
on grains and vegetables."
    Enhancing food aromas is another way to stimulate appetite. "The parts
of the brain for taste and smell are also connected to hunger/satiety," says
Susan Schiffman of the Duke University Medical Center, Department of
Psychology. "For example, if you stop eating a meal, you do so because your 
sense of taste and smell are satisfied; it's not that you feel full yet," 
she says. 
    Schiffman's research has enabled her to help dieters by finding ways to 
enhance food aromas that can also increase the taste experience. Dieters may
eat less if their food has more flavor. But the same principle works in 
reverse for older people: Better-tasting food sparks appetites. She has 
found that enhancing food flavors will increase the consumption of the foods
to which flavors have been added-- and the increase in intake is greater for
the people who have a greater loss of smell.
    She explains that seniors can intensify tastes by adding flavors and
sweeteners, like herbs (not spices, which may irritate), maple syrup, bacon 
bits, and butter flavoring. They also can heighten the appeal of their foods
by "switching from food to food while eating. That keeps up sensory 
interest," she says. And when preparing meals, she suggests that seniors
combine different textures to make food more appetizing--for example, 
putting crunchy Grapenuts on smooth frozen yogurt . 
    "Make eating a joyous experience," advises Martin. She describes how
simple tricks can turn mealtimes into treats. For starters, she suggests
shopping at convenient times when stores are likely to be uncrowded. Then 
she advises learning to make food budgets stretch by checking unit
pricing--that way, people can afford to buy extras. She advises taking a
creative approach to meal planning by experimenting with one new food or
flavor a week, and to cooking by preparing meals that appeal to the senses. 
"We eat with our eyes," she says, "so meals should have color and texture 
and, of course, have taste sensations." 
    But perhaps the key to better eating lies not so much with the mechanics
of food preparation as with the social aspects of eating. As most experts 
agree, mealtimes should be social occasions, spent eating in the company of 
others, whenever possible. If need be, senior citizens, particularly those
living alone, should join a community group-dining program. 
    "An older person's loss of interest in eating is like a failure to
thrive," says Pierre. "He or she is not getting enough stimulation or social
interaction to feel life is worth living. But generally, once that person is
in a social situation, the interest in food returns." 
    Pennington adds that using a feeding service to bring meals in to 
homebound seniors would ensure better nutrition--and presumably provide some
mealtime socialization. 
    Until the problem hits home, most people may not worry about how an 
older person eats. But research confirms that we really are--at least to a
large degree--what we eat. If older people have not laid a good nutrition 
foundation early in life, says Blumberg, they may be at risk for various
chronic diseases, including heart attacks, artherosclerosis, cancer,
diabetes, and osteoporosis. And if they continue to subsist on less than
wholesome foods, they jeopardize quality of life. "Nutrition," concludes
Blumberg, "must be a lifelong process." n 

Alexandra Greeley is a freelance writer in Reston, Va., who has written on
nutrition for Time-Life Books, The New York Times, Newsday, and the South 
China Post. 

                      Recipes for a Long, Healthy Life

    The Dietary Guidelines for Americans established by the Food and
Nutrition Board of the National Research Council, National Academy of 
Sciences, in Washington, D.C., include the basic food groups that supply
people with an adequate diet of minerals, proteins, vitamins, and energy. 
While no guideline can guarantee perfect health, people who follow these
recommendations will give themselves a good foundation for health.
    In general, people should eat a variety of foods, maintain a desirable
weight, and avoid fried and fatty foods in order to cut down intakes of fat,
saturated fat, and cholesterol; eat an adequate amount of fiber-rich foods; 
avoid too much sugar and starch; and drink alcohol only in moderation.
    The Recommended Dietary Allowances established for the 51 and older age 
group, says Gail Martin, assistant administrative director of the National
Association of Meal Programs, provide a framework around which older
Americans should base their diets. If they wish to increase calorie intake, 
they should select extra portions of food from one of the following 
categories: 

Daily regimen:
* 2 to 3 half-cup servings of milk, cheese or yogurt for men
* 4 half-cup servings of milk, cheese or yogurt for women 
* 6 or more servings of whole-grain breads or cereals 
* 2 to 4 half-cup servings of fruit 
* 3 to 5 half-cup servings of vegetables
* 2 to 3 servings, or 5 to 7 ounces, of protein (lean meat, poultry, fish,
and alternates such as eggs, nuts, and dried beans and peas)

    The following recipes, provided by Martin, are balanced, nutritious and 
wholesome. The dishes also provide a variety of flavors, colors and textures
with a minimum of fat and no extra salt.

Aunt Louise's Chicken 
1 whole chicken breast
1 can stewed tomatoes 
1 green pepper, cut into chunks 
1 medium onion, cut into chunks 
1 clove garlic, minced
1/4 tsp. curry powder 
1 bay leaf
1 cup chicken stock 
    Simmer chicken breast in 2 cups of water with bay leaf for 20 minutes.
Remove and cool in refrigerator. Skim the fat from top of the stock when it 
is solidified.
    Bone the chicken and combine with the chicken stock, stewed tomatoes, 
green pepper, onions, garlic, and curry powder. Simmer for 20 minutes.
Thicken slightly with cornstarch and water. Serve with rice, three-quarters 
of a cup per person. (Suggestion: Prepare the rice using leftover chicken 
stock.) Serves 2. 

Orange Carrots
    Cook fresh carrot slices until slightly crisp. Instead of butter and/or 
salt, spoon desired amount of concentrated frozen orange juice over the hot 
carrots.

Bran Cereal Muffins 
1 cup whole bran cereal 
1 cup milk
1 egg 
1/4 cup corn oil
1/4 cup honey 
2 tsp. baking powder
1/4 tsp. baking soda
1/2 tsp. salt 
1 1/4 cups whole-wheat flour, unsifted
    Preheat oven to 400 degrees Fahrenheit. Mix bran cereal and milk in a 
bowl, and let stand 1 or 2 minutes. Add egg, oil and honey. Beat well.
Combine remaining ingredients and stir until well mixed. Add to liquid
mixture and stir only until mixed. Spoon into 12 greased muffin tins. Bake
about 20 to 25 minutes. Makes 12 medium-sized muffins.

    Conclude dinner with fresh seasonal fruit.

    Colleen Pierre of the American Dietetic Association and director of 
Eating Together in Baltimore observes that many senior citizens prefer to 
snack rather than sit down to a full, prepared meal. To assure them an
adequate intake of all nutrients each day, she recommends the following 
snack plan--which is a very basic, balanced program that "meets the caloric 
and nutritional needs of a sedentary woman in the 60-to-75-year age range 
without cooking a major meal. Add the starred items to meet the caloric 
needs of the sedentary man the same age," says Pierre.

One-day snack plan: 
* 1 cup of hot chocolate with whole-wheat toast and 1 teaspoon margarine
* 1 hard-boiled egg and glass of orange juice 
* a half cup of low-fat vanilla yogurt with 4 ounces crushed pineapple and 2
tablespoons wheat germ
* 2 graham crackers with 2 tablespoons peanut butter and a half cup of
low-fat milk
* 1 small banana* 
* unsalted pretzels*
* 5 pitted prunes 
* 1 two-ounce piece of cold chicken, 1 slice rye bread, 1 teaspoon
margarine, and a half cup of mixed vegetables (a light meal/snack)
* 1 cup split pea soup and 4 unsalted shredded wheat crackers 
* 1 cup whole-grain cereal with a half cup of low-fat milk, 1 teaspoon
sugar, and a serving of fruit*

--A.G.