Individualized Diets for Older Adults
Learn about their importance for improving overall health and quality of life in long term and postacute care.
Nutrition plays a critical role in rehabilitation and quality of life as people age. Geriatricians from different specialties will encounter older adults in many clinical and community settings.1 The elder population may need nutrition adaptations, including supplements, texture and consistency modifications, and meal timing adjustments, in addition to therapeutic diets for a variety of health conditions. Balancing the need for diets to support longevity and health with dietary preferences and a sense of control and autonomy is critical when working with older adults.1 Therefore, individualizing diets for these patients, especially in long term and postacute care, is a place where practitioners can have the most impact.
New Guidelines for the Aging Population
Because of the rapid growth of this diverse population, all practitioners will benefit from learning how to individualize diets and prioritize its needs. Friedrich, owner of Friedrich Nutrition Consulting, which provides nutrition services for older adults and education for health care professionals, agrees that all practitioners need to be educated on this subject. “Because dietitians (no matter their area of expertise) often serve as sources of information for friends and family, an understanding of the standard of care in these settings could be useful to all dietitians, no matter what their area of expertise is.” Whatever clinical or community setting in which health care practitioners are employed, understanding how to individualize diets to suit the needs of older adults, especially in transitional care, is a critical part of their education.
Age-Related Challenges in Nutrition
Some older adults face social factors that affect their dietary intake, such as food insecurity, lack of transportation, and the inability to purchase and/or prepare food.6,7 They may experience health problems, including cerebrovascular accidents, Parkinson’s disease, cancer, diabetes, and dementia, and age-specific related factors such as difficulties with activities of daily living, anorexia of aging, and malnutrition.1-3 Yet some older adults remain vibrant, active, and healthy. Therefore, assessing older adults with a holistic, personalized approach to determine which dietary pattern may support them best as well as evaluating potential barriers to achieving optimal health is an important job for geriatricians.
Nutrition Needs of Older Adults
Weight Changes in Older Adults
Research suggests that helping overweight or obese older adults lose clinically significant amounts of weight could be beneficial to health but to use caution because weight loss in this population may do more harm than good. During the aging process, older individuals often experience age-related weight loss-induced sarcopenia and bone loss as well as changes in body composition, which can accelerate disability.9 Because of this, many older adults require fewer calories to maintain a healthy weight. Older adults become at risk of undesired weight gain if they continue consuming the same number of calories they did as younger adults. Some patients, as they attempt to restrict calories and reduce portion sizes to maintain a normal weight, risk improper nutrient intake with their decreased intake. So when considering counseling this population on weight loss, make sure to assess mobility, quality of life, and physical function—factors that aren’t usually considered in younger adults.6 Friedrich explains, “As the number of obese adults in our country continues to grow, it is most critical that geriatricians (and other professionals) understand the risks vs benefits of weight loss for older adults. That includes the role of honoring individual preferences and choices and maximizing quality of life. This overlaps with the issue of providing diets that are as liberal as possible.” It’s important for geriatricians to help older clients maintain a healthy weight but in ways that support their health and well-being. MyPlate guidelines suggest making small adjustments to help patients enjoy their foods and beverages such as adding sliced fruits and vegetables they enjoy to meals and snacks, choosing ones that are prepared or presliced for ease if dexterity or eyesight is a challenge.8
In one large systematic review of randomized controlled trials on weight loss interventions in older adults with obesity, researchers observed greater weight loss in groups that had a dietary component than in those with exercise alone. Exercise alone led to better physical function but no significant weight loss. However, the combination of diet and exercise yielded the greatest improvement in physical performance and quality of life, and it reduced the loss of muscle and bone mass that occurred in the diet-only groups.9
With this in mind, those in elder care can help plan physical activities or encourage other qualified health professionals to do so. Being physically active can help older patients stay strong and independent as they age. Adults at any age need at least 150 minutes of moderate aerobic activity such as cycling or brisk walking every week and strength exercises on two or more days a week that work all the major muscles (legs, hips, back, abdomen, chest, shoulders, and arms).8 Sedentary older adults who get approval from their doctors to exercise can begin walking or riding a stationary bike, aiming for at least 10 minutes of exercise at a time. Older adults should include activities that improve balance and reduce their risk of falling, such as strength training with light weights two times per week.8
While many older adults struggle with overweight and obesity, others suffer from malnourishment and underweight as a result of food insecurity, lack of transportation, and/or the inability to prepare food on their own. In addition, psychosocial factors including lack of independence, social isolation, and depression can make food less appealing and lead to decreased consumption and undesired weight loss.2
The consequences of malnutrition include loss of strength and function, increased risk of falls, depression and lethargy, decreased immune function leading to greater risk of infection and delayed recovery from illness, pressure injuries, poor wound healing, higher risk of hospital admission and readmission, additional medical costs, and increased mortality. Of course, if weight loss is an individual’s choice, practitioners can develop a nutrition care plan that includes adequate protein and calories to meet nutrient needs and prevent malnutrition.2
Chronic Disease and Therapeutic Diets
Other Dietary Considerations
Catering to Diverse Populations
Dorner also suggests practitioners keep up with the latest consumer trends and consider the communication preferences of each generation. Some generations may prefer group or in-person meetings, phone conversations, or e-mail, while others may prefer texting and using social media for nutrition messaging. Providing patient-directed care along with food choices that reflect the culture of the individuals they serve will be a critical piece of promoting individualized diets for older adults.
Moreover, Dorner and Friedrich encourage practitioners to learn about their patients’ cultural and ethnic heritage to better individualize diets. “People need to understand the populations they’re serving and learn about their ethnic heritage and cultural traditions,” they say. Those who work in long term care facilities should take personal preferences into consideration and incorporate appropriate daily menu options to serve the needs of older adults.
Recommendations for Practitioners
— Ginger Hultin, MS, RDN, CSO, is a nutrition and health writer and certified specialist in oncology nutrition based in Seattle. She’s past-chair of the Vegetarian Nutrition Dietetic Practice Group, past president of the Chicago Academy of Nutrition and Dietetics, and author of the blog Champagne Nutrition.
2. Dorner B, Friedrich EK. Position of the Academy of Nutrition and Dietetics: individualized nutrition approaches for older adults: long-term care, post-acute care, and other settings. J Acad Nutr Diet. 2018;118(4):724-735.
3. US Department of Health and Human Services, Administration for Community Living, Administration on Aging. 2017 profile of older Americans. https://www.acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2017
4. Porter Starr KN, McDonald SR, Bales CW. Nutritional vulnerability in older adults: a continuum of concerns. Curr Nutr Rep. 2015;4(2):176-184.
5. Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat 10. 2012;10(252):1-207.
6. Hengeveld LM, Wijnhoven HA, Olthof MR, et al. Prospective associations of poor diet quality with long-term incidence of protein-energy malnutrition in community-dwelling older adults: the Health, Aging, and Body Composition (Health ABC) Study. Am J Clin Nutr. 2018;107(2):155-164.
7. ter Borg S, Verlaan S, Hemsworth J, et al. Micronutrient intakes and potential inadequacies of community-dwelling older adults: a systematic review. Brit J Nutr. 2015;113(8):1195-1206.
8. Older adults. United States Department of Agriculture, ChooseMyPlate.Gov website. https://www.choosemyplate.gov/older-adults. Updated July 17, 2018.
9. Batsis JA, Gill LE, Masutani RK, et al. Weight loss interventions in older adults with obesity: a systematic review of randomized controlled trials since 2005. J Am Geriatr Soc. 2017;65(2):257-268.
10. Fredriksen-Goldsen KI, Kim HJ. The science of conducting research with LGBT older adults — an introduction to aging with pride: National Health, Aging, and Sexuality/Gender Study (NHAS). Gerontologist. 2017;57(Suppl 1):S1-S14.
• Diabetes mellitus. Hypoglycemia is the most important factor in determining glycemic goals, which may need to be readjusted to an A1c of <8% to 8.5% in some patients. Dietary restriction isn't an important part of diabetes management for older adults; it's generally managed with medications.
• Chronic kidney disease. Because of shifts in body weight due to fluid status changes, malnutrition may be more difficult to assess. Liberalize protein restrictions to ensure older adults get adequate intake. For those on dialysis, protein needs are greater, so work to ensure needs are being met. Sodium, potassium, phosphorus, and fluid restrictions should be individualized for each patient based on clinical judgment on a case-by-case basis.
• Cardiovascular disease. Goals for blood pressure control in the older adult population may be set to <150 mm Hg systolic and <90 mm Hg diastolic (140/90 for people with diabetes and chronic kidney disease). Sodium restriction in this population may not be indicated depending on intake and food preferences. Serum lipid goals for the older adult population don't yield a clear benefit in current research. Instead, guidelines suggest assessing a collection of risk factors and continuing to provide a diet as liberalized as possible. Healthy US-Style, Healthy Vegetarian, and Mediterranean-Style Eating Patterns, in addition to the Dietary Approaches to Stop Hypertension, or DASH, diet may be appropriate for some patients.
• Cognitive impairment. Because unintended weight loss is common in those with moderate to severe Alzheimer's disease and other types of dementia, diets also should be as liberalized as possible considering the patient's food preferences with a focus on nutrient-dense foods while offering feeding assistance, if needed.
• Undesired weight loss. Consider social support, feeding assistance, mealtime ambiance, and environment and a liberalized diet factoring in food preferences.
Her physician orders a sodium-restricted, 1,500-kcal vegan diet, but she has requested a dietitian because she doesn't care for the food options at the facility. Because Dana is a lacto-ovo vegetarian, the dietitian suggests liberalizing her diet to include eggs and dairy as sources of protein and dietary vitamin D to provide more options for her to enjoy. Dana is health conscious and says she follows the MyPlate guidelines to make one-half of her meals fruits and vegetables. Given Dana's dietary preferences and health literacy, the dietitian suggests lifting the sodium restriction while monitoring her blood pressure daily. The dietitian suggests increasing the calorie range to 1,800 given Dana's previous level of physical activity and the work she'll be doing with physical therapy in the hospital. Dana's protein and calorie intake improves to support healing, and she says she now enjoys the options offered at the hospital.