CHAPTER 19: Nutrition and Older Adults
Heart Disease: Coronary Heart Disease, Cerebrovascular Disease,
Peripheral Artery Disease
• Cardiovascular disease (CVD) is the leading cause of death in older adults, but is
potentially reversible by adopting a healthy lifestyle.
• Heart disease varies by race and gender
• CVD prev. raises with age
• The American Heart Association statistic
o Age 60-79; men 73.3%, women 72.6%
o Age 80; men 79.3%, women 85. 9%
• Risk factors in old age remain the same as in younger adults, except factors have
less predictive value
• Of adults aged 65+, 86% had one or more risk factors
• These include;
o Elevated LDL cholesterol
o Diabetes mellitus
• Race associated, older African Americans nearly 3X more likely for risk than average
Nutritional Remedies for Cardiovascular Disease
• Day to day context for adopting therapeutic lifestyle changes is likely quite different
• Nutritional habits alter progression only if individual adheres to eating plan
• Intensive LDL-lowering therapy is used for older adults with established CVD
• Consumption of fish, fish oils and omega-3 polyunsaturated fatty acids for cardio
protection. Associated with significant reduction in deaths from cardiac causes.
Definition CHAPTER 19: Nutrition and Older Adults
• Stroke and TIA’s (transient ischemic attack) are serious conditions involving reduced
cerebral blood flow (brain ischemia)
• TIA’s brief episode of neurological dysfunction; sudden confusion, trouble
speaking/understanding, sudden dizziness, trouble walking. Often precede a stroke.
• During ischemic stroke; obstruction clogs a blood vessel and prevents oxygen and
other nutrients from reaching parts of the brain
• Hemorrhagic stroke occurs when a weakened blood vessel breaks, such as rupture of
an aneurysm. Leaking blood accumulates, putting pressure on the surrounding tissue
and eventually destroys brain cells.
• Adults 65+, 8% female, 10% males have had stroke.
• 6 months after stroke 36% females, 16% males were disabled.
• At younger ages, incidents higher for men. At age 85 incidents greater in women.
• Individuals with first stroke at age 70+, approximately 1/4 (22-27%) die within a
• Factors that lead to stroke; blocked arteries, easily clotting blood cells, and weak
heartbeats that are unable to circulate blood through body (pools form and clot).
Hypertension contributes b/c force of blood may break weak vessels.
Effects of Stroke
• Deprive brain of needed oxygen/nutrients causing brain/nerve cells to die
• Leads to loss of function for parts of the body (ex. either left or right side, unable to
speak walk or swallow. Nutrition also likely to be affected)
• Nutrition likely affected
• Although dead brain cells cant be replaced, new nerve pathways in grey matter can
• Long term high blood pressure (systolic/diastolic)
• Family history
• African American, Asian, Hispanic ethnicity
• Physical inactivity
• Cigarette smoking doubles risk
• Comorbid conditions; diabetes mellitus, carotid artery disease, atrial fibrillation, CHAPTER 19: Nutrition and Older Adults
transient ischemic attacks (TIAs), sickle cell anemia and depression.
• Living in poverty
• Excessive use of alcohol (more than 70g/day=2.5x more likely); use of cocaine and
illicit intravenous drugs
• Focus of dietary advice is to normalize blood pressure. Medical nutritional therapy
used to promote rehabilitation
• High blood pressure (HBP) defined as “untreated systolic pressure of 140mm Hg or
higher, or diastolic of 90mm Hg or higher, or taking antihypertensive meds”.
• Prehypertension increases risk of CVD (systolic 120-139mm Hg/ diastolic 80-89mm
• Puts more force on potential vessel blockages and increases chances of blood vessel
• Only chronic condition that has higher prevalence in older adults than arthritis.
Western societies prevalence rises with age.
• Before 45, men more likely. Evens out again and then woman more likely at age 64+
• Death rates much higher for blacks than whites. Hispanics similar or lower than
• Uncontrolled hypertension is major public health challenge: prevalence high,
consequences serious but manageable. However only 34% of individuals with it, have
it under control.
• Family history/ ethnic background increases risk.
• Salt intake can contribute, 20% of hypertension in Western societies is attributed to
Effects of Hypertension
• Prolonged high bp puts extra pressure on blood vessels and organs in the body,
wearing them out before natural aging process. Damaged kidneys are common sign
• Nutritional; drinking alcohol to excess, high-saturated-fat diets leading to
dyslipidemia and atherosclerosis, lifestyles resulting in overweight and obesity and
diet low in calcium CHAPTER 19: Nutrition and Older Adults
• Weight management, moderation of alch, limiting sodium while maintaining
adequate potassium magnesium and calcium.
• Dietary Approaches to Stop Hypertension (DASH diet) is effective in decreasing bp
and risk of stroke in adults under 65over age 50 participants benefit more than
under 50. Benefits of DASH;
o Other non drug interventions; using weight reduction and/or reducing sodium
o Greatest overall reduction was from reducing sodium to 1500 mg/day
o Choosing foods with less processing can help limit sodium intake (approx..
75% of dietary sodium attributed to manufacturing/preservation
o DASH combined with exercise allowed patients significant weight loss
maintained for at least 2 years
o Significant diastolic blood pressure reduction also seen
• Dietary/lifestyle changes that address hypertension also likely to have beneficial
effect on atherosclerosis.
Special Concerns for Older Adults
• Nearly 1 in 5 adults aged 65+ report have diabetes (primarily type 2)
• Native American, Latino, African American, Asian American and Pacific Islander adults
face higher risks than Caucasians.
• Greater risk for heart disease, also risk factor for atherosclerosis
• Diagnosis criteria and management are same for older as younger, using
individualized treatment plans that assessment of functional status, cognitive
capacities and motivation.
• Hyperglycemia and risk of complications ‘should be avoided in all patients”
• For older adults, diabetes may exacerbate declining organ functions=less resilient.
Effects of Diabetes
• Leads to tenfold greater risk of amputations, muscular degeneration, visual loss,
cataracts, glaucoma and neuropathies (nerve damage, pain or tingling).
• Alcohol and drugs such as aspirin contribute to drops in blood sugar
• Hypoglycemia in older adults may lead to weakness, confusion and possible falls and
fractures. 22-31% of older adults with diabetes reported falling within 12 month span.
Increase in falls are attributed to reduced peripheral nerve function, renal function
and vision; all are diabetes complications. CHAPTER 19: Nutrition and Older Adults
• Diabetes self-management training works alongside medical nutrition therapy to
achieve glycemic control.
• Tight control of blood sugar can lead to better quality of life for older adults with
diabetes and can result in fewer long-term complications.
• Special concerns include;
o Where nephropathy (chronic kidney disease) is present, limit protein intake
o Assess dietary adequacy and supplement with vitamins and minerals to meet
age appropriate DRI
o Monitor functional status, modify care plan as appropriate. Ex. carb counting
harder to achieve because of; altered senses, decreased mobility, trouble
buying, etc. Providers must attend to psychological and physical needs of
o Ask about special foods/alternative and complimentary therapies. Clarify
confusing food terms so they better understand what they are trying to
o Sugar alcohols in candies/gums are sweeter than sucrose/fructose and provide
little energy. High doses lead to diarrhea.
o Older adults with constipation or diarrhea may need potential benefits of fiber
for glycemic control. Moderate carb increases have been well tolerated with
diabetes. High fiber intake significantly associated with reduced inflammation.
Eating at least 20g/day of fiber has been associated with less hepatic fat,
lower levels in markers of inflammation and decreased risk of developing
• A BMI of 30 or higher, extreme obesity BMI of 40 or higher
• In older adults, BMI alone is not adequate indicator of excess body fat associated with
morbidity and mortality
• Population mean body weight and BMI tend to peak at 60. As people pass 70, obesity
rates tend to decline.
• However, obesity rates in older adults has climbed along with the rest of the country.
Etiology, Effects and Risk Factors of Obesity
• Decreased functional status may inter with fitness. Approx. 1/4 adults over 75 found
it difficult to walk a ¼ mile or climb 10 steps without resting.
• Need fitness programs designed for these people with limitations CHAPTER 19: Nutrition and Older Adults
• Cardiorespiratory fitness contributes to longevity
• Healthy BMI for older adults 18.5-30= lowest mortality. Death associated with 35 and
above. Although not an entirely good measure of fatness (does not assess fat or lack
of fat). Sometimes higher BMI can mean lower morbidity.
• Measuring excess body fat is better. Study found that abdominal obesity is better
measure of premature death than BMI
• Markers of waist circumference, waist-to-stature ratios and waist-to-hip ratio
predicted stroke cases better than BMI
• Sometimes extra weight during illness (hospitalizations) seem to be protective.
American Dietetic Association suggest BMI of 19-27
• 5 food clusters have been made in order to explain relationships of gradual weight
gain experienced with aging.
o Healthy (high in fruits, veg, whole grains and reduced-fat dairy, as well as low
in red/processed meats, fast food and soda).
o White bread
o Meat and Potatoes
• Meat and Potatoes cluster had highest increase of BMI
• Annual increase in waist circumference highest in white bread (compared to healthy
• Maintaining lean mass is important- DASH ensures adequate nutrient intake
• Sarcopenic Obesity- low lean body mass combined with excessive fat stores. (may
complicate weight loss in older adults)
• Healthy eating program based on;
o Sufficient nutrient-dense calories
o Balance nutrition priorities; sodium, protein and saturated fat restriction.
o Physical activity promotes functional independence (only way to prevent
• Means “porous bone”. Reduced bone mass and disruption of bone architecture can
result from imbalance of nutrients. CHAPTER 19: Nutrition and Older Adults
• Progression depends on homeostatic mechanism involved.
• Estrogen or testosterone loss.
• Bone mass loss greater for women, men develop later because of larger frames &
testosterone falls more slowly
• World Health Organization criteria for bone density= BMD.
o BMD that falls 2.5 or more standard deviations below values for healthy adults
o BMD 1-2.5 standard dev. below normal (osteopenia) precedes
osteoporosis/may lead to fractures.
• Up to 50% of trabecular bones (wrist vertebrae and end of long bones) and up to 35%
of cortical or compact bone (shafts of long bones) may be lost during a lifetime.
• 4x more common in woman than men
• Blacks/Hispanics greater BMD than whites.
• Osteoporosis has no symptoms, diagnosis relies on BMD or fractures
• Older adults are more likely to suffer disability from a bone fracture over prostate
cancer, rheumatoid arthritis, breast cancer and hypertension.
• Chance of osteoporosis related fracture approx. 1 in 2 for women and 1 in4-5 for men
• Bone mass gained primarily during growth periods (18-30)
• Remains stable until hormone decrease
• Inadequate bone mass coupled with significant bone loss leads to low bone density
and increase risk of fractures
Inadequate Bone Mass
• Risk for developing occurs during childhood and adolescence. Better if grow bigger
denser bones in youth. (**higher calcium intake important)
• Inactivity leads to bone mass. Weight bearing/resistance exercises needed for bone to
grow. More pressure put on the bones, the more minerals deposited into the bone
• Exercise also stimulates growth hormone, which in turn stimulates bone development.
“Use it or loose it”
Decreased Bone Loss
• Skeleton for structural support and calcium reservoir for body. (Bones/teeth contain
99%, 1% found in protein in blood, soft tissues and extracellular fluids). CHAPTER 19: Nutrition and Older Adults
• Reservoir needed for nerve transmission, muscle contraction and enzyme systems like
those that control blood clotting. Nerve transmission takes priority over bone structure.
• Calcium tightly regulated by hormone systems. When calcium levels fall, body secretes
more parathyroid hormone (PTH), which acts to raise blood calcium by increasing
dietary absorption, decreasing urinary excretion and releasing calcium from bone.
• Bone minerals dissolved and rebuild continuously, thus adequate calcium levels are
• Consistent supply of dietary supply of bone-building minerals/vitamins, coupled with
regular weight bearing exercise helps maintain skeletal mineral reserves.
• Bodies first priority is to maintain blood calcium levels for nerve, muscle and enzyme
• Osteoporosis can develop from shortage of phosphorus. Varied diet provides both
• Lack of sufficient phosphorus promotes release of calcium from skeleton
• Process of aging results in slow increase in PTH and decrease in skins ability to make
vitamin D; both lead to bone loss.
Effects of Osteoporosis
Falls and Fractures
• May make impossible for older adult to remain independent.
• Greater risk for those over 80 compared to those 65 and older.
• 10-20% of older who break a hip die within a year, due to complications of a
breakimpaired mobility which complicated all daily activities (eating & exercise)
• 50% of older who fracture hip have permanent functional disabilities.
Shrinking, Height, Kyphosis
• most vertebrae fractures (67%) are asymptomatic.
• Postmenopausal women with compression/bone fracture in spinal column have
condition known as “shrinking height”
• “Shrinking height” leads to dowager’s hump (aka kyphosis) meaning bent upper spine.
• Shrinking in height is slow and usually not painful.