Nutritional Considerations For Healthy Aging and Reduction in Age-Related Chronic Disease
Nutritional Considerations For Healthy Aging and Reduction in Age-Related Chronic Disease
Nutritional Considerations For Healthy Aging and Reduction in Age-Related Chronic Disease
ABSTRACT
A projected doubling in the global population of people aged $60 y by the year 2050 has major health and economic implications, especially in
developing regions. Burdens of unhealthy aging associated with chronic noncommunicable and other age-related diseases may be largely
preventable with lifestyle modification, including diet. However, as adults age they become at risk of “nutritional frailty,” which can
compromise their ability to meet nutritional requirements at a time when specific nutrient needs may be high. This review highlights the role
of nutrition science in promoting healthy aging and in improving the prognosis in cases of age-related diseases. It serves to identify key
knowledge gaps and implementation challenges to support adequate nutrition for healthy aging, including applicability of metrics used in
body-composition and diet adequacy for older adults and mechanisms to reduce nutritional frailty and to promote diet resilience. This review
also discusses management recommendations for several leading chronic conditions common in aging populations, including cognitive decline
and dementia, sarcopenia, and compromised immunity to infectious disease. The role of health systems in incorporating nutrition care
routinely for those aged $60 y and living independently and current actions to address nutritional status before hospitalization and the
development of disease are discussed. Adv Nutr 2017;8:17–26.
Keywords: nutrition, aging, chronic disease, cognitive decline, health care, risk factors, sarcopenia, age-related disease
Background adults outnumber young children for the first time in history,
By the year 2050, the global population of older adults (de- but most of this population increase will occur in devel-
fined as those aged $60 y) is projected to double from 841 oping countries (2). During 2013–2100, half of the in-
million (2013) to 2 billion, or 21% of the world’s population crease in the world’s population will occur in Nigeria,
(1). Moreover, the elderly population is living longer: by India, the United Republic of Tanzania, the Democratic
2050, the number of individuals aged $80 y will be 3 times Republic of Congo, Niger, Uganda, Ethiopia, and the United
the 2013 population, reaching 392 million (1). This change States (3). Because developing countries experience demo-
in demography is a global challenge that can affect econom-
graphic and epidemiologic transitions more rapidly, many
ics, politics, labor, and public health. Not only will older
regions are not equipped to meet the demands of an aging
1
The authors reported no funding received for this study.
population.
2
Author disclosures: J Shlisky, DE Bloom, AR Beaudreault, HH Keller, Y Freund-Levi, FW The prevalence of obesity is also increasing globally, es-
Cheng, GL Jensen, and D Wu, no conflicts of interest. KL Tucker is the editor of Advances in pecially in urban settings within developing countries,
Nutrition. RA Fielding receives grant support from the USDA, the NIH, Astellas Pharma,
Nestlé, and Axcella Health; receives honoraria/consultation fees from Astellas, Nestlé, with older adults being no exception (4). As people live
Axcella Health, and Biophytis; and has equity in Axcella Health and Inside Tracker. SN longer and age distribution shifts toward a greater number
Meydani serves on the scientific advisory board of Nestlé Health Institute and on the
Dannon-Yakult Scientific Advisory Board.
of older adults, the number of obese older adults will also
*To whom correspondence should be addressed. E-mail: jshlisky@gmail.com. grow (5).
18 Shlisky et al.
TABLE 1 Key knowledge gaps and research priorities
Randomized controlled trials that include older adults with disease and medication use to make nutrient recommendations within these altered
metabolic states
Randomized controlled trials in various life stages for prevention of mild cognitive decline and in different stages of Alzheimer disease with
patient-tailored lifestyle nutrition treatments for evidence to support individual or broad recommendations on diet, lifestyle, or nutrient
supplementation
Studies examining other biomarkers beyond nitrogen balance to fully understand the impact of advancing age on protein requirements and skeletal
muscle protein turnover
Evidence for which nutritional factors (e.g., fruit and vegetable intake, vitamin D status, presence of obesity) may further modulate age-associated
declines in skeletal muscle mass
Clinical trials to establish optimal nutrient requirements and to identify food components for older adults to improve immune function and reduce
inflammatory diseases
Design of an effective, interoperable electronic medical record, integrated across health care settings, to promote improved documentation and
communication across health care providers, enhance care coordination, and facilitate continuity in nutrition care as an older individual transitions
between health care settings
Re-evaluation of how the current BMI guidelines are used in older adults and incorporation of nutrition screening and assessment into general practice
and community settings
clarify the roles of both energy intake patterns and weight vitamin D, dietary fiber, and potassium, with protein noted as a
status in optimal aging. nutrient of concern (26). In addition, commonly used medica-
tions for chronic conditions can alter nutrient requirements by
Key Nutrition Considerations interacting in ways that may affect absorption or metabolism
The term “nutritional frailty” has been used to describe a (27). For example, long-term use of acid-blocking medica-
state commonly seen in vulnerable older adults, character- tions may contribute to the development of vitamin B-12
ized by sudden significant weight loss and loss of muscle deficiency (28). There is a potential need for adapted nutri-
mass and strength, or an essential loss of physiologic re- ent requirements with disease and medication use. Evidence
serves, making the individual susceptible to disability (15, 16). from randomized controlled trials that include older adults
More recently, it has been recognized that increasing num- with diseases is necessary to make nutrient recommenda-
bers of older adults are frail but also obese (17). Nutritional tions within these altered metabolic states.
problems and increased risk of malnutrition, including obe- Although supplements may be helpful in the case of nutri-
sity, contribute to frailty via the culmination of sociologic, ent deficiencies, or when health conditions or medications
biological, and cognitive issues. interfere with absorption or effective nutrient utilization of
Recent changes in the environment and in lifestyle make specific nutrients, trials of specific nutrient supplements
following dietary recommendations for many older adults have generally been disappointing, emphasizing that whole
difficult. Changing family dynamics means that older adults foods are important (29). Exceptions include vitamin B-12,
have less support, while facing substantial challenges in ob- supplements of which may correct deficiency associated with
taining recommended nutrient-dense diets, because many atrophic gastritis and use of acid-blocking medication,
experience changes in taste and smell (18), loss of appetite metformin, or other interfering medications (30), and
(19), dental and chewing problems (20), and limitations vitamin D for individuals who receive inadequate sun ex-
in mobility and access to high-quality fresh food (21). This posure and during the winter months in northern latitudes
is of particular concern because older individuals require (31). Higher amounts of vitamin E might also be needed to
even more nutrient-dense foods to meet their changing re- maintain an optimal immune response and to enhance resis-
quirements. Aging-related inefficiencies in absorption and tance to respiratory infections (32–35). The lack of rigorous
utilization mean that the requirement for some essential nu- assessment of individual nutritional status to identify those
trients increases, despite lower energy needs (22–24). Further- in need of specific supplementation might explain the failure
more, older adults commonly fall below recommendations of some of the nutrient supplementation trials. Still, al-
for intake. National surveys and observational cohort studies though supplements are useful in the face of inadequate intakes
have identified several nutrients that may be inadequately of some nutrients, the promotion of food-based approaches to
consumed in relation to health risk among older adults, includ- meeting nutrient requirements is needed as a first approach.
ing protein, n–3 FAs, dietary fiber, carotenoids (vitamin A pre- Older adults tend to report inadequate intakes of fruit, vegeta-
cursors), calcium, magnesium, potassium, and vitamins B-6, bles, legumes, whole grains, nuts or seeds, fish, lean meat, poul-
B-12, D, and E (25). Furthermore, it is important to con- try, and low-fat fluid dairy products but excess intakes of
sider that even RDA intake levels may not always provide op- refined grain products, processed and fatty meats, fried
timal intake for the older population because, generally, foods, solid fats, and added sugars (36).
RDAs were determined on the basis of studies conducted In contrast to the increased requirement for many nutri-
in younger, healthy populations. Nutrients specifically iden- ents, some nutrients may accumulate in the body and con-
tified by the 2015 Dietary Guidelines report as particular tribute to chronic disease through excess. The body is less
“shortfall nutrients” for US adults aged $70 y include calcium, able to excrete preformed vitamin A as retinol, and too
20 Shlisky et al.
food intake are needed. Evergreen Action Nutrition, which is et al. (79) reported from the Health, Aging, and Body Com-
provided in a recreation center for seniors, is a feasible and position Study that a 3-y loss of lean mass was associated
sustainable model for nutrition education in community- with average dietary protein intake and that this association
living older adults. This community-based program, devel- persisted even when adjusted for daily energy intake and
oped with older adults at the center, included cooking change in body mass. Subsequent analyses that used the In-
groups, food workshops and demonstrations, and nutrition Chianti and Women’s Health Initiative cohorts confirmed
information in the form of newsletters, recipes, and tailored these findings and suggested a relation between protein in-
fact sheets. This program, initiated by research funding take and the development of the frailty syndrome, a condi-
(2000–2003), continued activities for several years through tion typically associated with sarcopenia (80, 81).
senior champions, volunteers (students and seniors), and Despite conflicting reports from carefully controlled ni-
linking into and accessing other community and public trogen balance studies, observational studies in older people
health resources. The program showed that a modest invest- suggest a relation between lower dietary protein intake and
ment can have an important impact with respect to chang- loss of muscle mass (79–81). The discrepancy in findings
ing nutrition knowledge, attitudes, and behaviors (61–63). may relate to limitations in the ability of the nitrogen bal-
Promoting intergenerational activities and family and friend ance technique to detect subtle alterations in whole-body
gatherings around healthy food consumption will also go a protein metabolism and the selection of generally healthy in-
long way to address both nutritional and mental well-being dividuals in these intensive metabolic studies. Future studies
of older adults. should carefully consider target populations and outcomes
beyond nitrogen balance to fully understand the impact of
Nutrition in the Prognosis of Age-Related advancing age on skeletal muscle protein turnover. In addi-
Disease tion, other nutritional factors, such as fruit and vegetable in-
Sarcopenia. Robust skeletal muscle mass is essential for take (82), vitamin D status (83–86), and the presence of
maintaining whole body homeostasis and health (64). A obesity (87–89), may further modulate age-associated de-
characteristic hallmark of aging in humans is the well- clines in skeletal muscle mass.
described loss of skeletal muscle mass and function, which
has been shown to contribute to functional limitation, Cognitive decline and Alzheimer disease. Undernutrition
disability, and mortality (65, 66). This age-associated muscle is particularly common among people with cognitive decline
atrophy, termed “sarcopenia” (67), implicates a derangement and Alzheimer disease (AD). Cognitive decline is progress-
of the equilibrium between muscle protein synthesis and ive, with weight loss often preceding the onset of AD and
muscle protein breakdown as a major contributor to sarcopenia increasing over the course of the disease. Epidemiologic
etiology. studies showed that the Mediterranean diet, which includes
In particular, alterations in muscle protein synthesis dur- intakes of fruit, fish, vegetables, and olive oil, may lower the
ing anabolic conditions in aging populations have been im- risk of both mild cognitive decline and AD (90–94). How-
plicated as a significant contributor to this imbalance (68, ever, no consistent evidence exists that nutritional supple-
69). What remains unclear is the influence of aging and ments play a protective role (vitamins B-6, B-12, C, or E;
age-related changes in muscle mass on chronic protein turn- folate; or n–3 polyunsaturated fats) in randomized controlled
over and effects on dietary protein requirements (70–73). In trials (95–97), which suggests that a variety of nutrients is
addition, the role of supplemental protein intake has yet to important, likely including phytonutrients from foods, or that
be fully clarified with respect to promoting skeletal muscle earlier intervention is needed for nutrient supplementation
growth or attenuating the rate of skeletal muscle atrophy to be effective. Simple measurements, such as body weight
(74–78). over time, should be recorded in all patients with dementia
Although many older adults consume adequate protein at physical clinical visits. Special monitoring is needed,
on the basis of current standards, a subset of older individ- with a loss of >5 kg (10 pounds) over a 6-mo period in a
uals routinely have protein intakes below the current RDA person with dementia leading to intervention. Future research
(60), and thus, protein is considered a key shortfall nutrient areas should include more randomized controlled trials in
for aging populations. In addition, some suggest that the different life-stage periods of prevention for mild cognitive
current RDA for protein is inadequate for older adults (71, decline and in different stages of AD (mild, moderate, or
72), although consensus from the available data on protein severe) with patient-tailored treatments (98).
requirements for older adults is lacking (73). Furthermore,
most information on dietary protein requirements for older Infectious disease. Older adults have an increased incidence
adults derives from studies in healthy “disease-free” older of infectious and inflammatory diseases, with prolonged re-
individuals and thus the generalizability of these results to covery time and higher mortality from these diseases. These
the large number of older adults with comorbid conditions, changes are largely attributed to immune system dysregula-
functional limitations, and disability may be limited. tion—that is, increased inflammation and reduced cell-
Evidence from large epidemiologic cohort studies sug- mediated immune response, both of which are influenced
gests that the loss of lean mass with advancing age is, in by nutritional status and intake of particular bioactive
part, mediated by dietary consumption of protein. Houston dietary components. The interaction of nutrition, immune
22 Shlisky et al.
setting considered to be a substantial barrier to obtaining nu- care policy makers, health care providers, insurance
trition services (128). Some innovative health system models, companies, and nutrition experts are needed to develop com-
such as the community-based Care Transitions Program, man- prehensive preventive strategies based on individualized nutri-
dated by section 3026 of the Affordable Care Act, and the tional needs for older adults. Incorporation of “nutrition
patient-centered medical home, may contribute to potential so- physical” or screening into the yearly physical examination
lutions (129, 130). For example, community-based organiza- of older adults will provide the foundation for developing
tions, in partnership with hospitals, could include nutrition the preventive measures needed.
services by the RDN as part of their proposals to the Centers
for Medicare and Medicaid Services. Acknowledgments
In the community setting, title IIIC of the Older Ameri- All authors read and approved the final manuscript.
cans Act provides congregate and home-delivered nutrition
services for individuals >60 y of age (131). However, current References
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