How to eat for better aging?


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Eating constitutes the first pleasure of the newborn. This act can remain a pleasure until the end of life provided that particular attention is paid to the quality of the meal and the environment in which it is eaten. »

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How to eat for better aging?

  1. 1. « Eating constitutes the first pleasure of the newborn. This act can remain a pleasure until the end of life provided that particular attention is paid to the quality of the meal and the environment in which it is eaten. » All individuals are not equal towards aging. Many genetic and environmental factors as well as lifestyle may influence aging. Diet in particular plays an important role in orienting towards successful aging. If not yet done, the fifty year old must adopt adequate behaviours in order to best manage the multiple evolutions associated with aging. This will help entering into the thrid and fourth age with all the necessary assets to avoid undernutrition, a plague for aging people living at home or in institution. The Louis Bonduelle Foundation summarizes for you in a few pages the key nutrition recommendations to successful aging while dispelling the spectrum of undernutrition. A ll specialists are today convinced: good eating habits contribute to successful aging. This concept, first described in 1987 by Rowe and Kahn, refers to aging without pathologies nor handicap, while maintaining a high level of physical activity, cognitive function and autonomy1. The aging population includes heterogeneous subjects for which age does not necessarily constitute the most pertinent criterion when evaluating the general state of health, most often influenced by the quality of aging. Hence, geriatrics specialists and gerontologists classify people over 60 into three categories1, 2: those aging in good shape (successful aging), those that are described as frail, not presenting any pathology but having a risk of developing diseases (normal aging) and those presenting several risk factors, pathologies, and/or early disabilities (pathological aging). However, two age groups reflecting very different realities from a nutritional standpoint must be distinguished when describing aging: young seniors around sixty with good eating habits delaying the onset of pathologies and the fourth age whom major preoccupation is to prevent undernutrition.z © Monkey Business - How to eat for better aging?
  2. 2. Sustainable evolution of eating habits In theory Managing evolutions associated to aging The links between aging and nutrition are com- plex: the diet may influence the quality of the process of getting older which in conjunction to aging evolutions modify the way individuals are eating. Physiological changes (loss of appetite, reduced taste sensitivity, early satiety, etc.) as well as lifestyles modifications (retirement, widowhood, etc.) may alter the nutritional status. Declining sensory perceptions From a sensory standpoint, aging is linked to the greater or lesser capacity of the elderly to perceive organoleptic properties of food, especially aroma, flavour and texture. The elderly may experiment a reduction of their ability to detect, discriminate and identify aromas and flavours3, 4. However, there exists a wide interindividual variability: some aging individuals present a severe alteration of olfaction, others may maintain intact their chemicosensory capacities. In between these two situations, there are people with altered olfaction or taste perception responding positively to increased intensity of sensory stimuli5. In any case, taste reduction acts specifically: it’s more significant for bitter and salty tastes than for sour and sweet6. Sensory losses associated to normal aging must be considered carefully. They are due to a progressive decline and a sort of permanent reset of internal food representations and food memories without explicit perception of smell and taste loss. Studies show that increasing Fruits & vegetables in the elderly’s diet The consumption of fruits & vegetables tend to decrease among the elderly because of their reduced ability to chew15. Eating cooked vegetables (preferably steamed, cooked in a pressure cooker or microwave to preserve nutrients) and consuming ripened fruits may allow to remedy this situation and increase intakes of foods usually appreciated by the elderly. A French consumer survey (Inca) shows that fresh fruits & vegetables consumption is higher among the elderly compared to young adults12, 19. These findings are attributable to a generational effect (present elderly are more familiar with preparation techniques and the consumption of a variety of fruits & vegetables) and to the evolution of preferences linked to age20. Although this trend is observed in other European countries such as the UK and Sweden, it cannot be generalized. In Belgium, the 2004 Belgian consumption survey shows that fruits & vegetables intakes tend to decline among the elderly over 75 compared to adults (120 g/d vs 141 g/d)21. taste concentration in a food or in a meal does not affect its consumption7, 8. In consequence, increasing taste concentration does not constitute a high interest to the elderly9. However, smell and taste do contribute for a large part to the pleasure associated to food ingestion. Even if no correlations between food intake, smell and taste malfunctioning have been found, the reduction of chemicosensory capacities is often found to reduce appetite in the elderly. A French multidisciplinary survey showed that individuals presenting a high smell alteration had frail nutritional status compared to others5. Factors such as poor dental status and psychological or sociological changes also play a role in food pleasure and appetite in the elderly. Changing lifestyles habits Throughout aging, the quality of dietary habits tends to deteriorate. Food variety decreases as well as intakes in foods such as: bread, meat, cheese and fresh vegetables10, 11 . When individuals are getting older, they have less ability to shop for food which leads to reduced food supply: intakes of perishable foods decrease12. The elderly’s life may also be punctuated by breakdowns susceptible to affect their dietary habits13. Food behaviours do not refer solely to the ingestion of food to fulfill a need. They are governed by complex inter-relations of motivations, feelings and pleasures. Hence, it is necessary to considerate the individual in its social aging context evolving through life events. Retirement highly modifies food habits14. Different food typologies may be identified for retired people based on their link to health, commensality and sociologic profile. Philippe Cardon, lecturer at University of Lille, France, has identified 5 profiles: the disinterested, the lonely, the greedy, the cooks and the nutritionists. Nonetheless, food patterns of retired people are not immovable since other life events such as widowhood, diseases, hospitalization can affect the elderly. Cooking dependency appears during this period and the delegation of all or part of food activities such as shopping or meal preparation to a third party (family, friend, househelp) may be necessary. The consequences of this dependency vary according to the family structure, the gender, whether the elderly is living alone or not, the type of deficiency (psychological or physical) and the status of the house-help. The most important changes are usually observed when the person in charge of food shopping or meal cooking is touched by a psychological deficiency within the couple. The surviving spouse, who is not familiar with these tasks, often needs to simplify these activities. In any case, cooking delegation always leads to a reduction in food variety and such food degradation is often perceived as an aging fatality15. >> p. 2 - How to eat for better aging ?
  3. 3. © Alexander Raths - Fotolia >> Life breakdowns, including those not necessarily linked to cooking dependency like widowhood or progressive social isolation, favor undernutrition16, 17. Widowhood implies changes in usual dietary habits previously established among the couple. Foods with high symbolic value such as homemade pastries, typical family meals (roast, pot-au-feu, etc.) are neglected. This situation is generating a succession of learning phases and trials, mostly for men than women, to help rediscover old preferences forgotten over a long time12. In the case of isolation or monotony, elderly’s appetite often decreases. For all these reasons, food sociologists specialised in aging recommend to look beyond nutritional aspects. Social practices associated to food intake (shopping, cooking practices, frequency and meal composition) are equally important to ensure nutritional balance. z In theory Undernutrition, a reality among the elderly The loss of sensory perceptions, dental health degradation, psychological and sociological changes... All these factors are contributing to decrease appetite and nutritional status. This is why the fight against under-nutrition must be at the heart of the elderly’s preoccupations. Nutritional situation and state of the elderly in Europe In Europe, the Euronut Seneca Survey (Survey in Europe on Nutrition and the Elderly, a Concerted Action) conducted between 1988 and 1991 with 2856 individuals, aged between 70 and 75 at the beginning of the recruitment, indicates a marked energy intake reduction correlated with age: 2 to 4% of men at 70 and 10 to 20% of women at 75 years old do not eat enough22, 23. For instance, individuals over 80 have energy intakes below 1500 kcal/day. In France, according to the 2007 HAS report (French national authority for health), the prevalence of proteinenergy undernutrition is 4 to 10% among the elderly How to eat for better aging ? - p. 3 living at home, 15 to 38% among those living in institution and 30 to 70% in hospitalized patients24. In Belgium, according to a prevalence study conducted in 2007 among more than 80% of geriatrics departments, 35% of individuals over 75 are undernourished25. The Solnut study, conducted in 2001 in France in the south-east department of Drôme, shows that 43% of individuals over 70 have inadequate energy intakes which are gone unnoticed26. These results are alarming knowing that figures are usually based on average data. In the UK, BAPEN (British Association for Parenteral and Enteral Nutrition) reported in 2007 and 2010 that there were over 3 million people undernourished in the UK, 93% of whom are living in community health services. This represents 5% of the population and this incidence increases to 14% for those over 65 years of age. Around 30% of patients admitted to hospital as well as 10-14% of the 700,000 people living in institution27, 28. The more the individuals are getting older, the more undernutrition becomes prevalent. This is why it is >>
  4. 4. Sustainable evolution of eating habits >> particularly important to monitor people over 75. One significant figure shows that two thirds of undernourished seniors with no sign of disease die within the next 5 years29. Moreover, undernutrition at the hospital increases the risk of complications, morbidity and mortality as well as the average length of hospitalization and global treatment cost. Micronutrient deficiencies (vitamins, calcium, iron…) associated with inadequate dietary intake must also be taken into account. Studies confirm that these results are common facts among older people at risk of undernutrition22 26. Key points in prevention Undernutrition appears when energy and protein intakes are lower than needs. Hence, the more people are aging the more the appetite becomes difficult to regulate. The basis for prevention consists in limiting appetite loss in order to avoid anorexia to install. Eating must remain a pleasure. Increasing the organoleptic quality of meals, encouraging food diversity to avoid monotony, ensuring exchange moments and conviviality around the meal are ways to be explored as well. It is also important to fight the idea that energy and protein needs are reduced among the elderly due to lower physical activity level. This is false! An aging metabolism is less efficient in transforming ingested food into nutrients and energy. Hence, the body needs more nutrients to obtain the same results. Even though the body is less active, more calories are required to meet basal metabolism needs when aging. This is all the more important when pathologies appear6. If the quantity of food eaten constitutes a priority for the elderly, its quality is also important: only a varied diet rich in fruits & vegetables will provide the required amount of nutrients to the aging organism. It is necessary to avoid deficiencies installing because metabolic dysfunctions may appear and become difficult to restore. Sarcopenia, characterized by progressive loss of mass and muscular functions, must also be prevented29. Reduced protein anabolism is often combined to increased catabolism leading to a high risk of fractures and falls. In Europe, EFSA (European Food Safety Authority) Panel Whatever age, physical activity is essential Practicing physical activity on a regular basis (30 minutes per day of endurance and/or resistance exercise) provides many benefits to the elderly34, 35 such as: slowing down bone loss associated to osteoporosis and helping preventing falls, stimulating protein anabolism, slowing down sarcopenia, decreasing the prevalence of cardiovascular disease and type 2 diabetes, reducing abdominal fat mass as well as blood pressure and increasing cardiopulmonary capacity. The cherry on the cake: when done in the morning or in the afternoon, physical activity stimulates hunger between meals. on Dietetic Products, Nutrition and Allergies considers that the value of 0,66 g/kg body weight per day can be accepted as the Average Requirement (AR) and the value of 0,83 g/kg body weight per day as the Population Reference Intake (PRI) derived for Dietary Reference Values for protein. For older adults, the protein requirement is considered to be equal to that for adults. However, countries such as France have set greater requirements for elderly: protein intakes for the elderly should be 1g/  g body weight per day compared to 0,7 to 0,8  /  g k g k body weight per day in the younger adult30-33. These recommendations are difficult to achieve when appetite is decreasing. One solution consists in encouraging the elderly to maintain appropriate physical activity level to favor protein synthesis and in turn stimulate appetite. Anabolism increase helps fighting against bone loss and osteoporosis as well. Calcium and vitamin D intakes must be monitored. In parallel to undernutrition, dehydration must be taken into account due to lower body reserve and decreased taste perception. The elderly must drink regularly (hot drinks, cold drinks, aromatic water, jellified water,..), in order to maintain daily intakes of 1 to 1,5 liters and consume a diet rich in water (fruits, vegetables, dairy products…)6. z In practice Seniors, home-helps, health professionals... Take action against undernutrition Undernutrition is the main nutritional challenge facing the elderly, especially over 75. Metabolic changes (recurring infections, dehydration, healing problems) become only visible at advanced stage36. Health professionals, househelps, the elderly himself should pay attention to weight and its evolution. It is essential to quickly identify weight loss since every kilogram or pound lost by the elderly is very difficult to regain. Abnormal fatigue, decline in muscle strength, clothes getting too big, etc. are all signs of possible undernutrition and should be taken care of early. p. 4 - How to eat for better aging ?
  5. 5. © contrastwerkstatt - Detect signs early Detection by general practitioners of undernutrition for all seniors is recommended at least once a year. Monitoring weight, calculation of Body Mass Index (BMI) based on reported height in adulthood using the identity card (not the current one) and evaluating the dental health status are actions to be implemented systematically on a regular basis. The Mini Nutritional Assessment (MNA) constitutes a simple and reliable tool to detect undernourished individuals or being at risk of undernutrition37. This test is used to assess nutritional status by asking six simple questions in less than five minutes. To asses nutritional status more precisely, blood tests (albumin, prealbumin, C-reactive protein) may also be advised6, 38. Albumin is a good indicator to detect undernourished overweight people for which weight loss may be a sensitive criterion. Lastly, it is useful to question elderly people about their food intake, meal composition and portion size, for the last 24 hours. The loss of muscle function, an indicator of sarcopenia, is detected by clinical tests measuring strength (grip strength test, extension test) or performance (4-meter walking speed, sit down and stand up test, etc.). Stimulate appetite Whatever the elderly is undernourished or not, the priority remains to stimulate their appetite. Encouraging family or friendly conviviality around the meal as much as possible (eating should remain a social act) and presenting appetizing dishes adapted to suit individual tastes, are the main actions to be put in place. Eating must remain a pleasure! When the elderly is living at home, it is crucial that family members or house-helps regularly ensure the refrigerator, freezer and cupboards are filled, taking into account two points: firstly, checking that products are not expiHow to eat for better aging ? - p. 5 red, indicator of poor dietary intake and secondly, integrating tastes of the moment, knowing that perceptions can change. Another point: nothing beats homemade meals. The house-help can prepare a variety of meals in small portions (single or double), clearly labeled with date and be placed in the freezer. The meals could then be heated in the microwave and eaten alone or with company. Conviviality is important and it is necessary to encourage the elderly in that sense: participation in clubs (some cities offer several activities for seniors and meals at moderate price), listening networks, maintaining relationship with neighbours, etc. When a specific diet is medically required - recommended by health professional (diabetes, hypertension, swallowing or chewing disorders, etc.), it is necessary to consider individual food preferences and eating habits. Otherwise, there will be a risk of non-coverage of nutritional needs. Taking time to laying the table is important for the elderly (tablecloth, dishes, flowers), presenting catering foods in a nice plate are all little things that count to increase meal palatability. Encouraging the elderly to walk a few minutes before meals, for getting bread for example, can contribute to stimulate appetite. Optimize dietary intakes In the case the elderly do not eat enough, despite efforts, they must be advised to adopt a fortified and varied diet which meets, as much as possible, daily nutritional recommendations (3-4 dairy products per day, 2 portions of meat, fish or eggs rich in proteins, one vegetable portion and one starchy food per meal and at least one daily serving of raw vegetables or fruits, etc.). Products high in proteins and/or energy can be recommended to boost meals for example: adding an hard-boiled egg or bacon, sardines, surimi, cheese cubes to the
  6. 6. Sustainable evolution of eating habits vegetable-based starter. Many different ingredients could be added or topped to soups such as: tapioca, croutons, cream, milk powder, ham, etc. Vegetables are more caloric when prepared with bechamel sauce or enriched with milk powder or served with mashed potatoes, pasta or rice, added cheese, cream, butter, egg or minced meat. Dairy products and desserts could be fortified with milk powder, condensed milk or cream but also products such as: jam, honey, chestnut cream puree, caramel, chocolate, fruits in syrup, etc. Finally, drinks may be enriched with milk or milk powder, served hot or cold, plain or flavoured (chocolate, coffee, fruit syrup). Eggnog (beaten egg with milk, sugar and other flavourings) and milkshake (beaten with ice cream or fresh fruit and milk) could also be tasty alternatives. In order to meet dietary requirements, the elderly must take the necessary time to eat. The 2005 National Food Council recommendations (NAC) encourage the elderly to spend at least 30 minutes for breakfast, an hour for lunch, and 45 minutes for dinner. In order to maximize food intake, meals should be split during the day and eaten within a maximum interval of three hours including several healthy snacking between meals and by reducing to 12 hours night fasting. z In practice home, in institution, at the hospital: At Proposing an adapted food offer The food offer plays an essential role in managing undernutrition in many ways: by providing a varied and wellbalanced diet among healthy seniors, by being pro-active to help undernourished people or those at risk of undernutrition. Meals must be adapted to the elderly whether they are living at home, in institution or as patients at the hospital. In order to compensate the decline of chemico-sensory abilities, meals can be enhanced with spices or herbs. Garlic and parsley are usually appreciated among seniors. Other spices can be used (curry, soy sauce, coriander, ginger, etc.). Never forget to ask for feedback after meals. Including palatable foods such as cold cuts or sweet desserts could Workshops dedicated to residents of Marpa Professionals working with French’s rural homes adapted to the elderly (Marpa) know the magnitude of the challenge and the interest of motivating elderly residents about their diet. The Louis Bonduelle Foundation knows it as well. This is why the Foundation is supporting the national federation of Marpa in the conduction of a national and innovative operation with the objective of developing food pleasure and relationship-building among the elderly. Two different workshops have been developed: the first one, “Art nature” is encouraging the elaboration of short-lived creations using vegetables and the second one, “Art flavours”, involves blind tests stimulating sensory perceptions where foods have to be identified through smell or taste and encouraging as well the creation of simple recipes. These workshops get residents to meet each other and arouse their curiosity about food. In that, they are contributing to maintain elderly’s autonomy. be an interesting alternative. However, specific attention should be paid to the volume of the food. Although portions should be increased to cover daily needs, older people can be discouraged in front of a plate judged too full. Thus, proposing small portions of fortified meals constitutes a more efficient strategy. At home As discussed previously, nothing beats homemade meals. When it is not feasible, ready-made dishes could be a good alternative. The most suitable products for this age-group are: individual portions at reasonable prices, easy-to-open packagings, information on how to prevent food poisoning, etc. Food poisoning is a major concern among the elderly because they often forget how long products have been stored in the refrigerator. Several studies (Euronut-Seneca22, 23 and Solinut26) have shown how important the support provided to elderly people living at home when preparing, delivering and/or consuming meals is. In Institution In institution, problems are different40. Food intakes are part of the medical treatment and the input of health professionals is key to contribute to meal quality. The dietician can provide valuable help to kitchen staff and train them about elderly’s requirements (well-balanced menus, texturemodified or enriched foods etc.). However, nutritional and sensory qualities of the plate are not always enough. People removed from their familiar environment must be given back the desire to eat. One suggestion could be to involve seniors in meal organization and food choices. Studies show that such participation can increase food intake up to 25%. If one looks at the substance (of the plate), it is also important not to neglect form (meal): eating remains a social act and the conditions under which it takes place are crucial. p. 6 - How to eat for better aging ?
  7. 7. ©Monkey Business - The environment and the table - including decoration, guests and pleasant ambience - must stimulate the desire to share the meal with others. Specific factors linked to aging (swallowing disorders, tremor, noise sensitivity, etc.) do not justify the exclusion of these moments of conviviality. A meal spent in the dining room could increase food intake from 20 to 30% compared with the same meal served in the patient’s room. It is everyone's responsibility to find solutions41. Multiple actions could be put in place in order to increase the interest of the elderly for food and stimulate their appetite: participation to menu task force, therapeutic culinary workshops, themed meals, special events, etc. A little imagination and a lot of goodwill can do miracles! At the hospital In the case of exceptional dietary conditions further to long-term hospitalization or serious illness, it is essen- Senior' Act a food offer adapted to seniors In 2011, Vitagora - an independent innovation “TasteNutrition-Health” network based in Dijon – in conjunction with the interregional division of gerontology (PGI) of Burgundy, France, have initiated the “Senior'Act” project. This project consists in a collective effort to provide guidance, to the industry, on business innovation and development about the senior market: nutrition, packaging, food equipment, distribution or marketing. Through this research, the network helps better understand the food environment and the culinary patterns of the elderly. Objective: to offer products and services tailored to the needs and expectations of older people. How to eat for better aging ? - p. 7 Cold vegetables even in case of chewing disorders The introduction or reintroduction of vegetables, especially cold vegetables, among the elderly having been deprived for a long time - due to chewing problems for example - requires some hints and tips. Vegetables with a soft texture should be preferred: avocado, corn salad, beets, asparagus and artichoke. If tomatoes are used, serve them peeled, seeded and cut into tiny cubes rather than sliced. tial to take the necessary time to encourage the elderly to eat their meal at their own pace. Lack of personnel or logistical constraints should never justify removing patients’ tray before it is finished. The hospital environment with its own rotating shifts and procedures can have negative impact on patient’s nutritional intakes42. In order to reduce the risk of undernutrition, special attention must be paid to mealtime. In addition, cooperation between care teams and kitchen staff is essential. In summary, at all ages and especially over fifty, good health is favored by a well-balanced diet combined to regular physical activity (to be maintained as much as possible even for very old people). Throughout aging, many factors lead to the reduction of food intake whereas metabolic changes are increasing nutritional needs. Undernutrition is the enemy to fight among the elderly. Using useful weapons such as adding nutrients-rich ingredients or spices to the meal combined to appropriate listening and empathy are the key components contributing to the independence of the elderly.z
  8. 8. © Ioana Davies (Drutu) - References [1] Rowe JW, Kahn RL. Human aging: usual and successful. Science. 1987;237(4811): 143-9. [2] Ministère de la Santé et des Solidarités, ministère délégué à la Sécurité Sociale, aux Personnes âgées, aux Personnes handicapées et à la Famille, 2007. Plan National Bien Vieillir”, 2007-2009. [3] Larsson M. Odor and source remembering in adulthood and aging: influences of semantic activation and item richness. 1996. Thesis report, Karolinska Institute, Stockholm, Sweden. [4] Murphy C. Taste and smell in the elderly. 1986. In Meiselman ML Rivlin RS (eds), Clinical measurement of taste and smell. New York, Macmillan (343-369). [5] Sulmont-Rossé C, Maître I, Van Wymelbeke V. Aupalesens: improving pleasure of elderly people for fihgting against malnutrition. 20-21 March 2012. Vitagora, Congrès International Goût Nutrition Santé, Dijon, France. [6] Ferry M, Alix E, Brocker P, Constans T, Lesourd B, Mischlich D, Pfitzenmeyer P, Vellas B. 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Serum albumin level and physical disability as predictors of mortality in older persons. JAMA. 1994; 272(13):1036-42. [39] Conseil National de l'Alimentation. Avis sur les besoins alimentaires des personnes âgées et leurs contraintes spécifiques. Avis n°53, 15 décembre 2005. p. 1-24. [40] Recommandation nutrition. Groupe d’étude des marchés de restauration collective et de nutrition (GEMRCN). Ministère de l’Économie, des Finances et de l’Industrie. France, juillet 2011. [41] The Caroline Walker Trust. Eating well for older people. Practical and nutritional guidelines for food in residential and nursing homes and for community meals. Report of an expert working group. Second edition. 2004. [42] O'Regan P. Nutrition for patients in hospital. Nursing Standard. 2009; 23(23):35-41.