Nutritional Considerations For Healthy Aging and Reduction in Age-Related Chronic Disease

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REVIEW

Nutritional Considerations for Healthy Aging and


Reduction in Age-Related Chronic Disease1,2
Julie Shlisky,3* David E Bloom,4 Amy R Beaudreault,5 Katherine L Tucker,6 Heather H Keller,7 Yvonne Freund-Levi,8–10
Roger A Fielding,11 Feon W Cheng,13 Gordon L Jensen,14 Dayong Wu,12 and Simin N Meydani12
3
The Sackler Institute for Nutrition Science at the New York Academy of Sciences, New York, NY; 4Department of Global Health and Population,
Harvard TH Chan School of Public Health, Boston, MA; 5World Food Center, University of California, Davis, Davis, CA; 6Department of Clinical
Laboratory and Nutritional Sciences, University of Massachusetts Lowell, Lowell, MA; 7Schlegel-UW Research Institute for Aging, Applied Health
Sciences, University of Waterloo, Ontario, Canada; 8Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics,
Karolinska Institutet, Stockholm, Sweden; 9Department of Geriatrics, Karolinska University Hospital, Huddinge, Sweden; 10Department of
Psychiatry, Tiohundra Hospital, Stockholm, Sweden; 11Nutrition, Exercise Physiology and Sarcopenia Laboratory and 12Jean Mayer USDA Human
Nutrition Research Center on Aging, Tufts University, Boston, MA; 13The Pennsylvania State University, University Park, PA; and 14University of
Vermont College of Medicine, Burlington VT

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).

ã2017 American Society for Nutrition. Adv Nutr 2017;8:17–26; doi:10.3945/an.116.013474. 17


Age is a major risk factor for noncommunicable chronic
diseases (NCDs)15 such as chronic obstructive pulmonary
disease, cardiovascular disease (CVD), type 2 diabetes, cog-
nitive decline, dementia, and cancer (6), all of which have
high associated costs of diagnosis, treatment, and care.
Therefore, the aging of the population raises serious con-
cerns about the fiscal integrity of health care systems (7). Es-
timates also suggest that the economic burden is currently
skewed toward wealthy industrial countries, due to their rel-
atively high incomes, high levels of health care spending, and
rapidly aging population over the past half century. Mean-
while, middle-income countries in the near future will expe-
rience the sharpest increase in the economic burden of
NCDs compared with other income groups (7).
To collectively quantify the burden of age-related NCDs
and other age-related disease is, however, difficult. Many
NCDs apparent in industrialized countries by middle age
only become clinically identified once an individual reaches
an advanced age, having taken many years to develop. Fur-
thermore, the overall economic burden of NCDs and spe-
cific age-related chronic disease is magnified by disabilities
and death, reducing labor contribution and potentially re-
ducing productivity due to time taken to care for ill family or
parents (8).
Although much of the resources necessary to support the
aging population are economic, a reorganization of health
systems and an increased emphasis on preventive, lifestyle-
choice approaches to NCDs and other age-related diseases
and care are needed for a sustainable, feasible, and affordable
health care system (9). Therefore, we review current evi-
dence in nutrition science to identify promoters of healthy
aging, defined as increased healthy active years of life, and FIGURE 1 Factors that positively and negatively influence
nutritional health which affect healthy aging. aIncludes lack of
focus on nutrition-related disease in the older population
social interaction, economic factors leading to food insecurity;
(Figure 1). Although not a comprehensive review of age- b
includes age-associated biological and physiologic changes,
related chronic disease, this review focuses on several specific such as loss of appetite, dentition, loss of smell, and changes in
nutrition-related conditions with advancing age. Nutrition ex- cognitive function.
perts from a variety of disciplines were part of discussions to
narrow topics for review, and the authors contributed individ-
ual sections on the basis of their expertise, which were then of inadequate practice of important health behaviors. The
revised by the full group. Approaches to preventing age- WHO estimates that the elimination of the major risk fac-
related nutritional frailty, as defined below, and chronic dis- tors for chronic disease (smoking, lack of exercise, and
ease are imperative to healthy aging. The identification of poor diet) would reduce the risk of CVD, stroke, and type
research priorities (10) will move the aging nutrition and 2 diabetes by 80% (11).
public health fields forward to prepare for the global “silver Energy intake and body weight also have bearing on lon-
tsunami” expected by 2050 (Table 1). gevity and quality of old age. Caloric restriction, as a reduc-
tion in ad libitum energy intake, increases life span in many
species (12), whereas implications for humans are less clear.
Role of Nutrition in Healthy Aging Long-term randomized studies with caloric restriction in
The goal of healthy aging is not only to increase years of life
humans are unfeasible and unlikely based on ethical princi-
but also, and importantly, to extend healthy active years. Un-
ples; however, studies spanning several years have been at-
fortunately, chronic diseases become increasingly common
tempted with somewhat promising outcomes. For example,
with age and are often considered an inevitable part of aging.
>2 y of caloric restriction in young- and middle-aged non-
However, accumulating research shows that the increasing
obese adults led to relative reductions in cardiometabolic
prevalence of many of these conditions at younger ages is
risk factors (13). In contrast, however, there is also research
not a normal function of aging, but rather a consequence
that suggests that overweight and mild obesity are associated
15
Abbreviations used: AD, Alzheimer disease; CVD, cardiovascular disease; NCD, noncommunicable with the lowest all-cause mortality in older individuals (14).
chronic disease; RDN, registered dietitian nutritionist. This controversial area is in need of additional research to

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

Nutrition for healthy aging 19


much of this vitamin should be avoided (37). Iron, a short- nutrient density. However, it is worth noting the appropri-
fall nutrient in earlier life-cycle phases, accumulates with ateness of current BMI guidelines because measures of
age, and high intakes of heme-iron (from meat or supple- body composition and adiposity in older adults have re-
ments) at older ages have been associated with the risk of cently come into question, challenging the prudence of lim-
heart disease; therefore, excess intakes of this nutrient should iting energy intake to reduce body weight for otherwise
also be avoided (38). Furthermore, some nutrients, and es- healthy older adults. For example, some research (14) sug-
pecially minerals, have a small window between requirement gests that overweight and mild obesity are associated with
and Tolerable Upper Intake Level, meaning that global sup- the lowest all-cause mortality in older individuals. In addi-
plementation is not a panacea to this issue due to the risk of tion, those older individuals with overweight and mild
toxicity; judicious use of supplements on the basis of their obesity who exhibit survival advantage do not manifest sar-
identified or likely deficit is required. copenia (52). Recent findings suggest that this observation
Longstanding poor food intake may result in undernutri- may be partially explained by the inclusion of metabolically
tion or malnutrition, defined as deficient energy and macro- healthy overweight and obese older individuals, who do not
and/or micronutrient status (due to inadequate food intake, have elevated mortality risk, in population studies of BMI
malabsorption, and/or increased metabolism often associ- and mortality (53).
ated with inflammation), which may result in measurable
biological changes and loss of tissue and/or functional ability Diet Resilience
(39, 40). Undernutrition is diagnosed by identifying long- More than 2 decades ago, Payette et al. (54) developed a con-
standing inadequate intake; loss of weight, body fat, and ceptual model to describe the material, physical, psycho-
muscle mass; or loss of functional capacity (41). Thus, un- logical, and social factors that influence food purchase,
dernutrition occurs in older adults when they do not con- preparation, and consumption to better understand why
sume enough protein to retain skeletal muscle; have a lack poor food intake occurs in older adults (54). A more recent
of vitamin B-12, resulting in neurological deterioration; or model, called “Making the Most of Mealtimes,” is used to
have low vitamin D intakes resulting in decreased calcium frame determinants of food intake with the domains of
storage in the bone. Nutritional risk is commonly defined meal quality (e.g., cultural preferences, nutrient interactions
as the presence of factors that impair food intake and thus with medications), meal access (e.g., lack of transportation),
eventually lead to malnutrition if not ameliorated (42, 43). and mealtime experience (e.g., eating alone) (55). Epidemi-
Low appetite and inadequate intake contribute to nutri- ologic studies focused on healthy and more vulnerable
tional frailty, sarcopenia, and physical frailty. Regardless community-living older adults have identified various fac-
of the terminology used (nutrition or malnutrition risk, tors that show the utility of these and other models for un-
mal- or undernutrition, or nutritional frailty), the key is derstanding why nutritional frailty, undernutrition, and/or
that undernutrition is preventable (21); however, if left un- poor food intake occurs. These factors include disease states,
treated, further negative functional, health, and quality-of-life self-reported health and medication use, widowhood, low in-
outcomes occur (16, 44–48). come or food insecurity, food skills, isolation or low social
For community-living older adults, the inadequate intake connectedness, lack of transportation, inadequate community
of nutrient-dense foods is the primary mechanism for this supports for food, cognition and dementia, depression, be-
undernutrition (43, 49). Prevalence estimates of undernutri- reavement, anxiety or stress, poor appetite, dentition and
tion and nutrition risk depend on the measurements used oral health, swallowing problems, sensory and functional def-
and whether upstream approaches are considered in select- icits, recent hospitalization, and polypharmacy (16, 49, 50, 54,
ing risk factors to include in screening instruments (43, 50). 56, 57–59). Diet resilience is defined as having or developing
Upward of 35% of community-living seniors have been adaptive strategies to maintain a nutrient-dense diet sufficient
found to have undernutrition (49, 50). Despite the consider- to meet requirements, despite challenges (60). Additional
able interest recently shown in nutrition risk and/or under- work in larger samples and with the use of a framework to
nutrition, these conditions remain underdiagnosed and -treated identify, a priori, several potential determinants and media-
in older adults living in the community (16, 43), potentially tors is needed to further clarify potential determinants of
promoting the high prevalence of malnutrition identified at diet resilience and thus areas for intervention (50, 57).
admission to the hospital (49, 51). In addition to further epidemiologic evidence to map the
Although many nutrients are deficient in the diets of potential causal pathways for poor food intake and/or un-
older adults (26), other nutrients are consumed in excess, dernutrition and thus find solutions, identifying how older
contributing to overnutrition and the risk of obesity and adults overcome challenges and remain diet resilient is re-
chronic conditions. The latter include saturated fats from quired. It is proposed that the motivation to eat well is the
fatty meats, processed meat, and whole-fat dairy products; foundation for diet resilience and that pleasure and health
trans fats from margarine, shortening, and processed baked are key drivers of this motivation (60). Education programs
products; refined carbohydrates from soft drinks, white that focus on good-tasting, easy-to-prepare food, that em-
bread, and white rice; and sodium in canned and processed phasize the importance of nutrition to health, and that
foods (26). An important approach to nutrition in healthy help older adults understand their challenges to resiliency
aging is to limit energy-dense foods while maximizing and how they can use community resources to promote

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

Nutrition for healthy aging 21


function, and infection is key in determining the risk of diseases. The use of naturally occurring infection as the primary
susceptibility to and morbidity from infectious disease outcome would require a much larger sample size than that
(99–102). needed when established immunologic markers are used.
As indicated earlier, older adults are at higher risk of in-
adequate consumption of nutrients and nutrient-rich foods A Role for Health Systems
than are younger adults, and both undernutrition (e.g., nu- Health care systems play a key role in integrating nutrition
trient deficiencies) and overnutrition (obesity) are prevalent care for older individuals across primary, acute, subacute,
among older adults. Age-associated biological changes occur chronic care, and home settings. Primary care refers to the
in multiple organs, tissues, and cell types, altering their abil- initial care contact with a health provider where the majority
ity to absorb or uptake and metabolize essential nutrients of health problems are addressed. As part of a primary care
and other food components; thus, the current RDA may regimen, nutrition screening and dietary assessment are in-
need adjustment for those aged >70 y. Furthermore, the tegral to the prevention and diagnosis of many conditions
RDAs are not based on specific requirements of the immune common in older adults, such as CVD, gastrointestinal con-
system and its ability to fight infection or control inflamma- ditions, diabetes, unexplained weight loss, and cancer. Due
tion. Therefore, these requirements, in the case of several to the increased vulnerability of this life stage, a greater focus
nutrients, might actually be higher for other body systems on dietary intake may be warranted during routine care
and cell types (33, 34, 99, 103–111). For example, higher- (118).
than-recommended intakes of vitamin E (200 mg/d), vita- In an acute care setting, the Joint Commission, a non-
min B-6, and zinc are required for optimal function of the profit organization that accredits and certifies health care or-
immune system and, in some cases, resistance to infection ganizations and programs in the United States (119), requires
in older adults (33, 108, 111–114). The dose of micronutri- that nutrition screening be completed within 24 h of hospital
ents is an important consideration: for example, dose- admission (120). The screening process identifies risk factors,
response studies indicate that there is no additional benefit such as unintentional weight loss, low BMI, compromised di-
from increasing vitamin E intakes >200 mg/d for immune etary intake, alterations in swallowing ability, use of enteral or
response in older adults (35). Furthermore, zinc supplemen- parenteral nutrition, and the presence of pressure ulcers
tation is most effective in those with low serum zinc concen- (120). The finding that a patient is “at nutritional risk” triggers
trations, who represent ;20–30% of older adults in the a nutrition consultation with a registered dietitian nutritionist
United States (113, 115). (RDN), which includes a comprehensive nutrition assessment
Future studies, including adequate clinical trials, are re- in accordance with the Nutrition Care Process that consists of
quired to determine the optimal level of nutrients and 4 individual but interdependent steps: nutrition assessment,
food components with immune-modulating effects—such nutrition diagnosis, nutrition intervention, and nutrition
as vitamins A, D, E, and C; selenium and zinc; and essential monitoring and evaluation (121).
FAs—needed to support proper immune system function Adopted by the Academy of Nutrition and Dietetics in
and leading to a reduction in the risk of, and morbidity 2003, the Nutrition Care Process aims to improve both in-
and mortality from, infection. Results obtained on the basis tra- and interorganizational communication and patient
of optimization of immune and inflammatory responses outcomes through application of a standardized process
(key players in determining quality of life for older adults) and language (122). The nutrition assessment is intended
could then be used to develop older adult–specific recom- to be incorporated into the medical record (123), which is
mendations for these nutrients. increasingly an electronic medical record. The use of elec-
Although the immune system clearly plays an important tronic medical records should promote improved documen-
role in the defense against infection, few established immu- tation and communication across health care providers to
nologic markers, such as delayed-type hypersensitivity skin enhance care coordination and facilitate continuity in nu-
response and vaccine efficacy, are readily available to use trition care as an older individual transitions between health
in clinical trials. Thus, a need exists for research into more care settings (124). However, implementing truly interoper-
defined immunologic markers of the aging immune system able health information technology “ecosystems” remains a
and their clinical value for assessing the risk of infections considerable challenge, because such systems are rarely inte-
and the associated morbidity and mortality. Most studies re- grated across diverse health care settings (125). The resulting
lated to nutrition and infection in older adults were con- poor communication and gaps in nutrition care often com-
ducted in animal models, whereas, with a few exceptions, promise transitions out of acute care.
human studies typically use immune function readouts as As an older individual transitions back to the home setting,
surrogate indicators for infection (116, 117). However, in fully coordinating nutrition services with other services are
both cases, depending on the model or the immune markers necessary to promote improved outcomes and independent
used, the applicability to clinical infection may be limited. living. Krumholz (126) described “post-hospital syndrome”
Therefore, well-designed clinical trials are needed to estab- as an “acquired, transient condition of generalized risk.”
lish the optimal requirement for nutrients in older adults Compromised nutritional status is a potent predictor of risk
and to identify food components that are particularly beneficial of early readmission to the hospital (127), with limited reim-
in improving immune function and reducing inflammatory bursement for the RDN to provide services in the community

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
funding for these programs is inadequate for the number of 1. UN Department of Economic and Social Affairs, Population Division.
older individuals who need them (128). Moreover, as men- World population ageing 2013 [Internet]. 2013. ST/ESA/SER.A/348.
[cited 2016 Jun 24]. Available from: http://www.un.org/esa/socdev/
tioned previously, some evidence casts doubt on the appro- documents/ageing/Data/WorldPopulationAgeingReport2013.pdf.
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