Final Flashcards
1
Q
Definition of Adulthood in the Life Cycle: Young Adult Years
A
◦Growth and maturation typically complete
◦Shift in focus to maintain health and physical activity to avoid weight gain
◦Bone density and muscle mass continue to grow
2
Q
Definition of Adulthood in the Life Cycle: Middle Adult Years (31-50)
A
-physiologic functions that impact mobility begin to decline 1% per year
◦Body composition begins to shift, fat increases and LBM decreases
3
Q
Definition of Adulthood in the Life Cycle: Older Adult Years
A
◦Typically have more time to enjoy life with less responsibility; more disposable income
-muscle mass and strength decreases but can be offset with exercise
◦Immune system weakens with age
-changes in ability to taste and smell food
◦Saliva decreases, gastric secretions decline, and constipation, gas and bloating can become more problematic
4
Q
Physiological Changes in Adulthood
A
Growing stops by the 20’s
Bone density continues until 30-35
Muscular strength peaks around 25 to 30 years of age
Decline in size and mass of muscle and increase in body fat
Dexterity and flexibility decline
5
Q
Hormonal and Climacteric Changes: Women
A
◦Decline of estrogen –> menopause
- increase in abdominal fat
- increase risk of cardiovascular disease and accelerated loss of bone mass (estrogen protects)
6
Q
Hormonal and Climacteric Changes: Men
A
-gradual decline in testosterone and muscle mass
7
Q
Body Composition Changes in Adults
A
◦Bone loss begins around age 40
◦Positive energy balance resulting in increase in weight and adiposity; decrease in muscle mass
◦Fat redistribution- gains in the central & intra-abdominal space, decrease in subcutaneous fat
◦Associated with increased risk of chronic disease:
◦hypertension
◦Insulin resistance
◦Diabetes (type ll)
◦Stroke
◦Gallbladder disease
◦Coronary artery disease
8
Q
The span of years between ages 20 and 64 is a time when the future course of health & wellness are influenced by:
A
◦Diet
◦Physical activity
◦Smoking
◦Body weight
9
Q
DRIs for adults
A
- Follow dietary pattern guidelines
- Emphasis on good nutrition/provision of required nutrients and wellness/prevention of chronic disease
10
Q
Dietary Recommendations-Total Diet Approach:
A
◦Use 2015 Dietary Guidelines and MyPlate
◦Follow a healthy eating pattern across the lifespan
◦Focus on variety, nutrient density and amount
◦Limit calories from added sugars and sat. fat and decrease sodium
◦Shift to healthier food and beverage choices
◦Support healthy eating patterns for all
11
Q
Dietary guidance systems focus on:
A
◦Consuming greater amounts of fruits, vegetables, fiber and low fat dairy
◦Limiting saturated fat intake, trans fats
◦More nutrient rich foods, less sugar
◦Keeping sodium low
◦If consumed, moderate alcohol: 1 standard drink per day for women, 2 for men
◦Regular physical activity
-energy intake= energy expenditure
12
Q
Health Promotion and Chronic Disease Prevention- Target diseases:
A
◦Atherosclerotic heart disease - narrowing of blood vessels bc of plaque buildup= increased risk of heart disease (leading cause of death)
◦Hypertension- high blood pressure, increases with age (1/3 of adults)
◦Overweight and obesity - 2/3 of adults
◦Cancer
-Diabetes mellitus- high blood sugar, 10% but is declining
-about 50% of our population has a chronic disease (our guidelines are for healthy individuals)
13
Q
Four Common Causes of Chronic Disease
A
Lack of physical activity
◦ 1/3 of all adults do not meet recommendations for aerobic physical activity and 23% report no leisure-time physical activity
Poor nutrition
◦ 24% of adults report eating 5 or more servings of fruits and vegetables per day
Tobacco use
◦20% still smoke
Excessive alcohol consumption
◦Contributes to over 54 different diseases and injuries ◦Binge drinking is reported by 17% of US adults, averaging 8 drinks per binge
◦3rd leading preventable cause of death in the U.S.
14
Q
Wellness versus health
A
Wellness: development of maximal potential
Health: absence of disease or dysfunction
15
Q
Approaches to Health and Well-being:
A
Traditional: Change when symptoms of illness exist
Preventive: identify risk factors and then minimize risks
Wellness: positive lifestyle choices
16
Q
Determinants of Health Status
A
Heredity Environment Health outlook Health care Lifestyle
17
Q
Healthcare Reform
A
- many americans have limited access to health care
- Postponement of care worsens many conditions
- Limited attention to health promotion
- Health care costs increasing fast
- prevention will save money and increase quality of life
18
Q
Components of a Healthy Lifestyle
A
Diet
Physical Activity
Stress Management
19
Q
Healthy Diet
A
Assess risks and benefits
Use Food and Nutrition Board recommendations
20
Q
Physical Activity- positive benefits
A
◦Energy balance ◦Body composition ◦Improved cardiovascular efficiency ◦Improves serum lipid levels ◦Lowers disease risk Exercise program must be developed - 30 mins per day of moderate intensity
21
Q
Stress Management
A
Stress is a specific reaction to a life event
◦new job, death in the family, new baby, etc.
Physiologic and psychologic reaction
Poorly managed stress detrimental for physical and mental health
Stress management involves cognitive and behavioral approaches
22
Q
Addictive Behaviors Harming Health
A
Cigarette smoking: free radicals, toxins - increased risk of heart disease and cancer
Alcohol abuse: increased risk of cancer and cardiovascular diseases
23
Q
Primary prevention
A
◦Promote health
◦Provides specific protection against onset or incidence of a health problem (don’t actually have yet)
◦i.e. “Five a Day” for cancer prevention
◦Family Health history risk identification
24
Q
Secondary prevention
A
Early diagnosis and treatment of health problems
◦Screening
◦Early diagnosis
◦Treatment Follow-up
25
Tertiary prevention
Minimizing existing disability through treatment and rehabilitation efforts
ex: diabetes management
26
Individual-based interventions
◦Creates changes in the knowledge, behavior, or health outcomes of individuals, either singly or in small groups ◦Direct client service
27
Community-based interventions
Focus on creating changes in populations
◦Directed toward groups or sub-groups or persons within a community
◦i.e. immunization clinics, health fairs
28
Systems-based Interventions
Focus on creating change in organizations, policies, and laws or structures
◦Focus is not on people or communities but on the systems that serve them
◦i.e. food labeling laws, revised school lunch recipes to reduce fat content, etc.
29
Characteristics of Aging
In “normal” aging, inevitable, & irreversible physical changes occur over time
The pattern and sequence of changes associated with normal aging are the same
Rate at which they occur will be different from one person to another
Decrease in the rate of cell division which leads to a progressive decline in organ function
Decrease in the ability to maintain homeostasis and ability to respond to different environmental stimuli
30
Characteristics of Aging: Changes in body composition
Changes in body composition – decrease in LBM, H2O and bone density with an increase in fat
◦Muscle mass decline in an almost linear fashion at the rate of 2-3% per decade after age 30
◦22% for women and 23% for men from age 30 to 70 without exercise
◦Resistance training in elderly has been shown to improve muscle strength and gait velocity and enhance thigh muscle area
◦LBM has been shown to improve with physical activity, and weight loss
◦Also a shift from subcutaneous to truncal body fat ◦Associated with insulin resistance
◦Less LBM leads to decreased BMR and lower energy requirements
◦As LBM is lost and fat increase, total body water decreases which leads to faster dehydration
31
Decrease in bone density
◦Bone mass is achieved in the third decade of life and then plateaus
◦Bone loss begins in the 4th or 5th decades and continues until death
◦ Greater risk of fracture due to loss of bone mineral coupled with less muscle strength
32
What Causes Aging?
Environmental
| Genetics (35%)
33
Theories of Aging: Programmed Theories
Programmed longevity- sequential switching on and off of genes and age associated deficits
Endocrine theory- biological clocks act through hormones to control pace of aging
Immunological- programmed decline in immune system function
34
Theories of Aging: Error Theories
Wear and Tear
Rate of Living: Increased BMR = shorter life span
Crosslinking
◦An accumulation of crosslinked proteins damages cells and tissues, slowing down bodily processes
Free radicals = accumulated damage
Somatic DNA Damage
◦Genetic mutations occur and accumulate with increasing age
◦Causes cells to deteriorate and malfunction
◦Damage to mitochondrial DNA might lead to mitochondrial dysfunction
35
Longevity Genes
◦Fruit flies (INDY gene) and SOD
◦C. elegans (daf-2 activity reduction)
◦Human studies using microarrays for gene activity now being studied
- proteins are made that limit lifespan
36
Cellular Senescence
◦Hayflick limit: number of times a cell can divide (at least 4 genes involved)
◦Most aging cells are not dead or dying – responsive but don’t proliferate and continue to work
◦Causes changes in gene expression
◦may promote unregulated growth and tumor formation
◦“antagonistic pleiotropy ” – genes that have beneficial effects early in life can also have detrimental effects later
◦However, no feature of aging has been explained by in vitro cellular senescence
37
Proliferative and Anti-proliferative Genes
◦Promotion and suppression of proliferation
◦Tumor suppressor genes when inactivated leads to tumor formation
◦Replicative senescence appears to have evolved as a defense against cancer
38
Telomeres
◦Chromosome tails shorten as a cell divides
◦Protective covering with no vital genetic information
◦Shorten with age to point where function is disrupted and cell stops proliferating
◦Telomerase restores telomeres so reproduction continues
◦Suspected to be activated in cancer cells
◦Immortal cancer cells have telomeres that do not shrink
with each cell division
39
Oxygen Radicals
◦Released from mitochondria as well as produced by environmental factors such as tobacco smoke and sun exposure
◦Cause damage to proteins, membranes, DNA and mitochondria
◦Oxidative damage accumulates over time
◦Implicated in both aging and degenerative disorders
-Antioxidants and cellular repair mechanisms counteract
40
Protein Crosslinking
◦Glycation of glucose to proteins resulting in crosslinking that alters biologic and structural roles
◦Process slow and complex but accumulates over time
◦Accelerates formation of free radicals
◦Results in stiffening of tissues
◦Macrophage defense system (declines with age also)
41
DNA Repair and Synthesis
-enzyme systems detect and repair
◦Ability to repair certain types of damage is directly related to lifespan of the species
◦Mitochondrial DNA damage increase with age
42
Heat Shock Proteins
◦Produced when cells exposed to stresses (not just heat)
| -help cells dismantle and dispose of damaged proteins and make and transport new proteins
43
Hormones
```
◦Estrogen
◦Growth hormone
◦Melatonin
◦Testosterone
◦DHEA
-Growth Factors ◦IGF-I/hGH -decrease w age and affect cognition
```
44
Physiologic Clues
Normal Aging
◦Variable so looking for biomarkers
The Immune System
◦Research focusing on T-cells and products
-cal restriction may counteract some natural declines in the immune system
◦Caloric Restriction
-slows metabolism, decreases body temp and blood glucose levels
◦Behavioral Factors
-Diet and exercise
45
WILL IMPROVED NUTRITIONAL STATUS AND INCREASED EXERCISE DECREASE FURTHER LOSS OF TISSUE FUNCTION OR DELAY THE ONSET OF AGE RELATED DISORDERS?
Antioxidants/fruit and vegetable consumption seem to protect against certain chronic diseases (cancer, atherosclerosis, cataracts
– Low saturated fat diet can delay CHD by delaying or lessening atherosclerosis
Exercise
– less loss of muscle strength, less of a decline in cardiac output with age
46
Conclusion
Appropriate nutrition along with exercise may increase life expectancy
Probably a combination of things (multifactorial) – genetics may be modified by environmental conditions
CDC Conclusion:
◦Longevity depends on:
◦ 19 % genetics
◦ 10 % access to high-quality healthcare
◦ 20 % environmental factors (i.e. pollution)
◦ 50 % lifestyle factors
◦Not smoking ◦Diet ◦Exercise
47
Will nutritional manipulation and/or exercise increase the maximum lifespan?
So far, the only intervention shown to increase the MLS is caloric restriction studies done in animals – 30 to 50% less kcal than controls; lifespan increased about 35%
Less kcal, but adequate protein, vitamins and minerals, so not malnourished
MLS increase along with delay of age related changes – healthier longer
◦NIA study showed healthier but not longer lived
48
CNS- Brain and Spinal Cord
30-50% decrease in neuron number
Decrease in the activity of enzymes participating in neurotransmitter synthesis – less dopamine, epinephrine, serotonin, and acetyl choline produced
Increase in the activity of epinephrine and norepinephrine degradative enzymes
15% reduction in nerve conduction velocity
Reduction in brain blood flow with CVD
Dementia – 20% above age 80 (not normal)
49
Renal System
30-40% fewer nephrons by age 80
Decreased cardiac output lead to ~30% decline in renal blood flow
Net effect of less nephrons and less blood flow is decreased GFR (less filtration of drugs) (can't conc. urine and can't eat high protein diets)
Bladder capacity declines
50
Pulmonary System
Decrease in effective surface area of lungs for gas exchange – loss of elasticity and reduced blood flow Oxygen transfer to the tissues is decreased- amount of Hgb saturated with oxygen is less with increasing age
– Increase in shortness of breath with exercise due to decreased vital capacity
51
Immune System
The mass of immune tissue declines throughout adult life Becomes less effective
Leads to increases susceptibility to illness
Most immune parameters were not compromised with aging in well-nourished women in one study
52
Cardiovascular System
- The work load of the heart increases and its effectiveness as a pump decreases
- Increase in PVR due to atherosclerosis and the loss of elasticity in the arteries causes increased work load
- Effectiveness of the heart muscle as a pump is reduced as the strength of contraction is diminished
- All contribute to age-related changes in other tissues such as the kidney
- CO may decline by as much as 30% with aging
- Change is from increased rigidity of arterial walls, decreased blood flow to tissues and decreased oxygen uptake
- Overall decrease in the size of the heart muscle and cavity of the ventricle and an increase in the size of the left atrium
- Heart valves become more rigid because of thickening from increased collagen
- There is calcification in the aortic valve
- Hypertrophy of some heart muscle fibers compensates for others that have been lost
53
Cardiovascular System equations
Decreased CO = HR X ↓SV
◦↓strength of contraction and coronary blood flow
◦The CO falls as the volume of blood pumped with each stroke falls (SV)
◦As SV falls, amount of blood flow through the coronary arteries is less
◦With exercise, CO may not ↓ as much
Increased BP = CO X ↑PVR
◦Blood pressure tends to rise with age
◦Even though CO falls, the PVR rises due to atherosclerosis and loss of elasticity of the vessels, so BP goes up
◦The workload of the heart increases with age resulting in:
◦Exercise poorly tolerate by aged heart, so medical evaluation before exercise program initiation is needed ◦Emotional stress – reaction to SNS detrimental
54
Compression of Morbidity
Delaying onset of disabilities caused by chronic disease
Goals:
◦Compress significant sickness related to aging into the last few years or months of life
◦Change how quickly a person ages based on healthy lifestyle
55
Baltimore Longitudinal Study
Ongoing study of the SAME men for the past 50 years, women for the past 30
Established that energy intake and expenditure actually being to decline at about age 35 to 45 and then stabilize until age 75 and after
Is evaluating the effect of the aging process on body composition with longitudinal changes observed in the same individual as well as effect of food on health
56
Baltimore Longitudinal Study- findings
◦loss of hearing is normal
◦Declines earlier and faster in men
◦Personality does not change much after age 30
◦Contrary to belief that people become cranky, depressed and withdrawn as they age
◦Relationships to CVD, PSA and Alzheimer’s disease in relationships to normal aging found
57
Michigan Study
Longitudinal study of 103 older women in Michigan over a 24 year period
*Suggests that diet influenced both well-being and length of life
After 7 years, mortality was higher in those women containing diets of <40% RDA for one or more nutrients - most frequent Calcium, Vitamins A and C
At the 24 year mark, survivors (ages 64-90) had reduced the quantity and improved the quality of the food they ate ◦Amount of protein didn’t change
◦Bakery items eaten less often
◦Fruits, vegetables, breads, cereals and low-fat dairy food emphasized
◦Fat decreased from 40% to 35%
58
Alameda Health Study
Longitudinal study begun in 1965 with nearly 7,000 residents of Alameda County California
7 health-related practices found to decrease risk of death in middle and advanced age not only increased length of life but also significantly reduced physical disability Suggests patterns of mortality and morbidity not a random process - lifestyle choices play a role in exacerbating or reducing risk
59
The 7 Health-Related Practices
1. Not smoking
2. Drinking no or moderate amounts of alcohol
3. Regular physical activity
4. Seven or eight hours of sleep a night
5. Appropriate relative weight (not more than 10% under or 30% over average weight for height)
6. Not eating between meals
7. Regularly eating breakfast
- People who had 6-7 of the health-related practices were 50% as likely to have physical disability as those with 3 or less
- Those with 4 to 5 of the health practices had 2/3s the risk of disability of those with 3 or less
60
Georgia Centenarian Study
- Collected nutrition and diet information from 22 centenarians who were living in the community and mentally able to participate
- Most reported eating breakfast every day
- On average met the 5-a-day program
- Low intake of alcohol (1 per WEEK)
- By recall had a reasonably stable body weight over their adult life with < a 50 lb difference between minimum and maximum
- Average intake was 1,581 kcal with 37% as fat and 13% as saturated fat
- Stable body weight may have decreased risk of chronic disease or helped avoid illness associated with weight loss
61
Stanford University Medical School Study
- Longitudinal study of 1741 university alumni first surveyed in 1962 (avg. age 43) and then annually starting in 1986
- Strata of high, moderate, and low risk were defined on the basis of smoking, BMI, and exercise patterns
- Onset of disability was postponed by more than 5 years in the low-risk group
- Disability index for the low-risk subjects who died was half that for the high-risk subjects in last 1 or 2 years of observations
- Conclusions: “Smoking, body-mass index, and exercise patterns in midlife and late adulthood are predictors of subsequent disability. Not only do persons with better health habits survive longer, disability is postponed and compressed into fewer years at end of life
62
Other Cultures- Japan
- highest life expectancy in the world in 1990
◦Compared food intake in villages with shortest and longest life expectancy, results revealed that those living longer consumed:
◦3 times more meat but still <50 gm /day
◦about 150 gm of dairy
◦1 ½ times more vegetable protein
◦3 times more green vegetables
◦½ the amount of salt
63
Other cultures- China
supplement program yielded drop in esophageal and stomach cancer incidence
64
Other cultures- Mediterranean
Mediterranean diet with high level of physical activity have lower death rate than those who “Westernize” their diets
65
Dijon, France study
unhealthy lifestyle associated with increase in disability
66
Age classifications
```
65-74= young old
75-84 = old
85 and above = oldest old
“Elderly” usually refers to over 65
AARP membership begins at age 50
PC Term: Older Americans
```
67
Demographics
Currently 13% of Americans are > 65 (39 million people)
By the year 2030 estimated to be 72 million or 20% of the population
◦“Oldest Old” numbers rose 274% from 1960 to 1974
◦In 2010 = 6 million people
◦Expected to be 21 million in 2050
Trends in birth rates and aging –
◦Baby Boomers 75 million babies born between 1946 and 1964 (majority between 1945 and 1955)
◦>70% more than were born in the 20 previous years ◦Between 2010 and 2020 many will be 65
68
Life expectancy
Definition: average remaining years of life for a person of a given age
Infant girl born in 2010 had a life expectancy of 81.1 years ◦76.2 years for a boy
65 year old American male has life expectancy of 17.2 more years and female 20
Largely a reflection of the environment
◦Has increased due to less infant and childhood mortality, better medical care, public health (sanitation and vaccinations)
◦Causes of death now from chronic diseases
◦US life expectancy lower because of higher infant mortality
69
Life Span
Definition: absolute maximum number of years possible
A greater number of people >65 does not reflect an increase in maximal life span
Maximal life span of humans is ~110 years
Only way to increase life span would be to slow down aging
70
Changes in GI Tract and Accessory Organs
Taste and smell
Dentition and swallowing
Digestion and absorption of macronutrients
Change in the unstirred water layer
71
Taste and Smell changes
Taste ( dysgeusia ) and smell ( hyposmia ) dysfunction begins around age 60 and becomes more severe in those > 70 years
Odor detection threshold increased
Number of taste buds decreases
Saliva production low in >70% of elderly causing difficulty tasting, chewing and swallowing
Over 400 different medications have dry mouth listed as a side effect
72
Dentition and Swallowing changes
Dry mouth can make swallowing difficult = avoidance of crunchy, dry and sticky foods
People who wear dentures chew 75-85% less efficiently than those with natural teeth
Swallowing process changes in older people ◦Approximately 15% of people >60 have dysphagia (~6 million people)
Presbyphagia: old yet healthy swallowing ◦Oropharyngeal swallowing changes with healthy aging: slower, delayed onset of airway protection and upper esophageal sphincter (UES) opening, bolus adjacent to airway longer, reduced lingual pressures
73
Esophageal swallowing changes with aging:
◦Duration of esophageal peristalsis is prolonged and amplitude decreases (60–80 years)
◦Esophageal contraction amplitude diminishes, but function remains intact (80-90 years)
◦Reduced frequency of secondary peristalsis
◦Increased reflux events
74
Digestion and Absorption of Macronutrients Changes
Stomach - acid production does not decrease as a normal function of aging...
Pancreas - small decrease in bicarb and enzyme secretion, but not clinically significant
Liver - no changes in function relative to nutrient metabolism, but ability to metabolize drugs seems to be affected
Intestine- decreased gut motility
75
Digestion and Absorption of Macronutrients: Intestinal Absorption
```
Fat
◦Normal digestion and absorption with normal intakes ◦With large intakes see more fecal fat
Protein
◦Normal with normal intakes
◦More fecal N on high protein diets
Carbohydrate
-ability to digest lactose is affected
Bioavailability of vitamins and minerals
-lack of research
```
76
Changes in the Unstirred Water Layer
UWL overlays the intestinal epithelium some changes/thinning with aging
More easy penetration of certain fat soluble substances (i.e. Vit. A)
Barrier function of gut might be reduced with aging
77
Common Problems Related to GI Tract Changes in the Elderly
```
Reflux esophagitis and GERD
Constipation
Atrophic Gastritis
Lactose Maldigestion
Normal aging is not associated with dysfunction like these just an increase in discomforts
```
78
Reflux Esophagitis
Commonly called heartburn
-inflammation of esophagus
Delayed gastric emptying and/or weakened lower esophageal sphincter pressure (LES) leads to Gastro-esophageal Reflux Disease (GERD)
79
GERD Treatment
Avoid foods that decrease LES
-fried fatty foods, chocolate, alcohol, coffee
Avoid foods that would irritate inflamed lining of esophagus
-citrus, tomato, pepper
Eat smaller meals
Lose weight if overweight
Drugs to block stomach acid secretion or to increase LES
Remain upright after meals
80
Constipation
Definition: fewer than 3 bowel movements per week on a high-residue diet; more than 3 days go by without the passage of stool; the weight of the stool passed in 1 day total less than 35 gm (normal 100-200 per day)
A major complaint in the elderly which may be real or perceived
A factor in the development of diverticuli
81
Factors Contributing to Constipation
```
Decrease in gut motility and reduced innervation to colon
Dentition
Low fiber intake
Medications
Low fluid intake
```
82
Recommendations- constipation
Educate about what constipation really is reassure that daily bowel movement is not necessary
Food - more fruits, veges, whole grains, cereals and fluids
Increase physical activity
83
Atrophic Gastritis (AG)
20% of those > 60 and 40% by age 80
Very slow to develop, therefore age of onset hard to tell
Atrophic: a loss of glandular tissue that produces acid and intrinsic factor
Gastritis: an inflammation of the lining of the stomach (glands lost as a result)
84
Consequences of Atrophic Gastritis
Hypochlorhydria
Decreased acid-pepsin digestion of proteins and lack of B12 cleavage from proteins
Bacterial overgrowth of the small intestine with positive effects of nutrient production and negative of vitamin B12 utilization
Increase in the pH in the proximal duodenum
85
Iron bioavailability in AG
Acidic environment promotes conversion of ferric to ferrous, so this is reduced
Decrease in iron chelate formation
Probably does not contribute significantly to anemia, however
86
Calcium bioavailability in AG
Less disassociation of calcium from calcium-fiber complex
| Decreased solubility of calcium carbonate supplements (other forms of calcium not acid dependent on acid for release)
87
Folic Acid bioavailability in AG
Higher pH in small intestine decrease uptake of folic acid into the mucosal cell
However, bacteria can make folate and this is available, so AG probably does not affect folic acid status
88
Vitamin B12 bioavailability in AG
Lack of cleavage of vitamin B12-food protein complex
Reduced but adequate intrinsic factor production
Bacterial use of vitamin B12
Lower levels of vitamin B12 seen in people with AG
Free vitamin B12 can be absorbed (adequate IF), so dont need shots unless achlorhydria
89
Lactose Sensitivity
70% of world’s population has some degree of intolerance to lactose with onset being after childhood
About 50 million Americans affected
Elderly need more calcium in diet but they are less tolerant to lactose
90
Lactose Digestion
Lactose - disaccharide of glucose and galactose
| ß-galactosidase or lactase - enzyme in brush border of jejunum that cleaves lactose of glucose and galactose
91
Types of Low Lactase Activity
Adult lactase deficiency, aka lactase non-persistence:
Permanent and most common
◦Secondary lactase deficiency: lactase expression will return upon recovery from a GI illness
◦Congenital lactase deficiency:
◦Genetic absence, seen immediately in infants
92
GI Symptoms of Lactose Malabsorption
Bacteria in large intestine metabolize lactose to lactic acid, carbon dioxide, hydrogen, and short chain fatty acids
Results in cramping, gas, bloating, and diarrhea
93
Dietary Treatment for lactose deficiency
Slow gastric emptying
◦i.e. milk with meals, higher fat and/or sugar dairy products Small amounts of lactose containing food at any one time
Use of low lactose dairy products
94
Lactose in Common Dairy Foods
```
Whole cow’s milk
Skim cow’s milk
Yogurt, low-fat
Cream
Cottage Cheese
Hard Cheese I
ce cream - 14% fat
Milk chocolate
4.7%, 5.0% 4.0-4.6% 3.0% 1.4%Trace3.6% 8.1%
```
95
Nutrient Recommendations
Nutrient recommendations change as scientists learn more about effects of foods on human functions
◦Specific DRI for those >51 yrs were 1st established in 1997
Estimating Energy Needs
decrease in PA and BMR from early to late adulthood results in 70-100 fewer calories needed
96
Energy
DRI same for all above 19 yrs
See decreased energy needs in some older adults due to decrease in lean body mass and activity
“for each year above 30, subtract 7 kcal/day for women and 10 kcal/day for men” – DRI EERs
97
Carbohydrate and Fiber
Carbohydrate
◦AMDR between 45-65%
Fiber
◦Minimum of 22 to 28 grams of dietary fiber daily for older females and males
98
“Discretionary Calories
A review of NHANES data
Snacks provide nearly 1/4 of cals
Snacks make up ◦14% of protein ◦12% of alcohol
-older eats less sugar
99
Protein
Inactive, older adults living alone may have low protein intakes
Several researchers report protein needs for older adults are 1 to 1.3 g/kg body wt (higher than the DRI of 0.8 g) Nitrogen balance is easier to achieve when:
◦Protein is a high quality
◦Adequate calories are consumed
◦Individuals participate in resistance training
DRI-RDA remains the same for all adults .8gm/kg/day
-based on protein turnover- obligatory N loss
Protein intake greater than 2x RDA should be avoided due to decreased renal function
100
Protein and Sarcopenia
Sarcopenia: gradual loss of skeletal muscle after 50 with:
◦Sedentary lifestyles
◦Malnutrition
◦Loss of anabolic and anti-catabolic responsiveness to changes in extracellular amino acid concentrations ◦Increase in abnormal reactive oxygen species
Sarcopenia
◦Characterized by selective atrophy and loss of type II myofibers
◦Associated with ◦Decrease in strength ◦Greater potential of disability and functional impairment in activities of daily living ◦Insulin resistance ◦Increased incidence of fall and hip fractures
101
Sarcopenia reversement
Resistance training exercise combined with an increase in leucine can help reverse sarcopenia
◦Combination increases muscle fiber area significantly more than just RET
-essential AA supplementation following RET reverses blunted protein synthetic response to RET in the elderly
When insulin is greatly increased, elderly have a blunted protein synthetic response
◦Study showed protein supplement with 7 g of CHO showed increase in fiber area whereas study using 70 g of CHO with protein showed a decrease in skeletal muscle hypertrophy
102
Implications for Protein Intake
Increasing high-quality protein in the diet may increase protein synthesis and lower protein degradation in the muscle of older adults
Combining protein with RET most efficient - protein immediately after
Indications from studies are that protein above 30 gm per feeding (from meat) does not increase protein synthesis Short term protein recommendations of 1.6 to 1.8 g/kg and then increasing RDA to 1.0 to 1.2 g/kg has been recommended
103
Fats and Cholesterol
Minimize saturated fat & keep total fat between 20 to 35% of calories
Even though eggs are high in cholesterol, they are a nutrient-dense, convenient, & safe food for older adults that do not have lipid disorders
104
Fluids
The total amount of water decreases with age, resulting in a smaller margin of safety for staying hydrated
>6 glasses
To individualize fluid recommendations, 1 mL of fluid/kcal consumed, with a minimum of 1500 mL
Fluid Requirements:
◦30 ml/kg with 1500 ml minimum
◦Approximate needs best in institutionalized
◦1 ml per calorie consumed
◦100 ml/kg for first 10 kg plus 15 ml/kg for remainder of weight
◦Enough to cover normal losses and more with illness
105
Issues with Hydration
Adequate intake in older adults challenging
Thirst sensitivity goes down due to changes in control mechanisms, especially a decrease in osmoreceptors and baroreceptors and secretion of vasopressin
Fever, infection, institutionalization, immobility, dementia, coma, excess loss or acute illness can lead to chronic dehydration
Decreased ability of kidney to concentrate urine or conserve water may affect hydration
Risk of: hypotension, constipation, nausea, vomiting, mucosal dryness, decreased urine, elevated temp, mental confusion, and medication toxicity
106
Assessing Adequacy
Intake and output
Changes in body weight
Lab tests ◦Serum osmolality greater than 296 mOsm ◦BUN:creatinine ration > 20
◦Serum sodium > 145 mg/dl
◦Urine specific gravity, Osmolality, conductivity
Urine color
107
Age-associated Changes: Nutrients of Concern- A
Vitamin A
◦Plasma levels & liver stores ↑ with age
◦May be linked to ↓ clearance from the blood
◦Older adults more vulnerable to toxicity & possible liver damage than deficiency
◦Beta-carotene will not damage the liver
108
Age-associated Changes: Nutrients of Concern- D
Vitamin D, Calciferol
Factors that put older adults at risk for deficiency:
◦1. Limited sun exposure
◦2.homebound or institutionalized
◦3. Certain medications (barbiturates, cholestyramine, Dylantin, laxatives)
Elderly have low dietary intake and typically have low sun exposure
Biologically active 1,25(OH)2D3 is made in the kidneys ◦The older kidney is less responsive to PTH which activate the conversion of 25- to 1,25D3 - may be less conversion to active form
Increasing vitamin D has been shown to improve bone health in older adults
600 IU for 51-70 and 800 for over 70
109
Age-associated Changes: Nutrients of Concern- E and K
Vitamin E, Vitamin K
◦Interaction with each other
◦Antioxidant properties of vitamin E
◦Blood coagulation, bone health – vitamin K
110
Age-associated Changes: Nutrients of Concern- B12
Vitamin B12
◦Despite adequate intake, ~30% of older adults have ↓ serum vitamin B12 levels
◦↓ vitamin B12 linked to ↓ levels of HCL & pepsin (from atrophic gastritis) in aged persons resulting in inability to split vitamin B12 from protein carriers
◦Synthetic or purified vitamin B12 is not protein bound and is much better absorbed
111
Age-associated Changes: Nutrients of Concern- B6, Folate and Vitamin B12
Vitamin B6, Folate and Vitamin B12
◦All involved in homocysteine metabolism - the indicator for the DRI for these vitamins
◦New DRI for vitamin B6 increased relative to younger people
◦Folate and vitamin B12 increased for all adult age groups but same for younger and older
◦Folic acid fortification now a concern with vitamin B12 deficiency masking in older adults
◦Synthetic vitamin B12 recommended for older adults
112
Age-associated Changes: Nutrients of Concern- Iron
Iron
Iron needs ↓ after menopause
◦DRI 8 mg/day for men and women > 51 yr.
Most older adults consume more iron than needed
Excess iron contributes to oxidative stress
Reasons that some older adults may have iron deficiency include:
◦Iron loss from disease (GI cancer) or medications (i.e. aspirin)
-decreased acid secretion
-decreased cals
113
Age-associated Changes: Nutrients of Concern: Niacin, Riboflavin and Thiamin
Niacin, Riboflavin and Thiamin
◦Function as cofactors in energy and protein metabolism reactions
◦Requirements do not decline with age
◦Riboflavin intake low in US due to low dairy intake ◦Laboratory studies suggest 20-30% of older population has values suggestive of deficiency but reported intake is not correlated with the lab results
114
Age-associated Changes: Nutrients of Concern: Calcium and magnesium
Calcium
◦Need adequate intake for bone health and to reduce hypertension
◦UL has been lowered because of toxic effects
Magnesium
◦Need adequate intake for bone health, nerve activity, glucose utilization
◦Excessive intake from supplements can cause overdose
115
Calcium RDA
Men 51-70: 1000 rest 1200
116
Bottom Line
Nutrient requirements stay approximately the same as those for younger adults
Energy needs decrease
requires a nutrient dense diet
117
Food Selection Patterns
Influence - old patterns, current food supply
Intake - decreased energy intake
Patterns - same types of foods, just less; choose nutrient dense foods
- Women have more fruits and vegetables than younger groups
Health Considerations
Ethnicity
118
Physiologic Factors Influencing the Nutritional Status in the Elderly
Changes in body composition and organ function
Loss of appetite - taste and smell
Dentition - can reduce intake of certain nutrients
Physical disability
Medications and prescribed diets
High supplement use
Alcohol consumption
119
Psychosocial Aspects Affecting Nutritional Status
```
Low income
Mental disorders
Loneliness
Food aversions
Limited nutrition knowledge
Level of social interaction
Changing household roles
Food preferences
```
120
Failure to Thrive – “Frailty”
Decline in biologic, psychologic (esp. depression) and social function
Loss of weight (decreased food intake) or undernutrition
No immediate explanation
121
Socioeconomic Factors
Low income
Lack of access to transportation
Lack of adequate cooking facilities
Income very important factor for determining nutritional risk
122
DETERMINE Checklist
```
Developed by the:
◦American Academy of Family Physicians
◦Academy of Nutrition and Dietetics
◦National Council on Aging
Integrates a list of warning signs of poor nutritional health in older adults
```
123
National Screening Initiative DETERMINE checklist
Designed to create awareness about warning signs of potential nutrition problems - risk assessment tool
Further assessment and referral if at risk
Simple self-administered questionnaire
124
Mini-Nutritional Assessment
The MNA short form uses six screening items
More extensive than the NSI & includes:
◦Dietary intake
◦Anthropometrics
◦Blood chemistries
125
Malnutrition Universal Screening Tool
The MUST was developed for institutional and community use
Assessment is a five-step process
◦Height and weight measurement to calculate BMI
◦Scoring unplanned weight loss
◦Assigning an acute disease effect score
◦Summing scores to determine overall risk of malnutrition
◦Using the score to plan management
126
Senior Nutrition Program
Funds appropriated under Title VII of the Older Americans Act of 1965
Created to alleviate poor nutritional intake & reduce social isolation among older adults
Based on evidence that older adults do not eat adequately because of:
◦Lack of income
◦Lack of skills
◦Limited mobility
◦Feelings of isolation & loneliness
127
Older Americans Act Nutrition Program
Administered by Administration on Aging
- $522 million program (2010) in all states and territories
- Provides community-based services to the ambulatory older population and services to frail, homebound elderly
- Services emphasize preventive nutrition intervention but also offer other support
- Available to all >60 but targeted in areas of greatest need
- Provides congregate and home-delivered meals to about 7% of older population, including an estimated 20% of the nation’s poor elders
- Participants are better nourished and achieve higher levels of socialization
- Federal funding is efficiently leveraged by other sources to double the nutrition services it provides
