10
Nutrition

Dietary status and nutritional status are not synonymous. Dietary status is a measurement of what an individual is eating; nutritional status is the state of an individual's health as it is influenced by what is eaten. Diet is only one of many factors that may influence nutritional status. Thus, to provide an estimate of an individual's nutritional status, other measures are also used, including biochemical measurements of body fluids, anthropometric measurements, clinical findings, and medical history.

When diet alone is responsible for deficits in an individual's nutritional status, the person is said to be suffering from primary malnutrition. The forms of primary malnutrition that may arise simply as a result of deficits in dietary intake are undernutrition or starvation, protein calorie malnutrition, and various vitamin and mineral deficiency disorders such as iron deficiency anemia, scurvy (from a deficiency of ascorbic acid), and osteomalacia (from a deficiency of vitamin D). Excesses in some categories of dietary intake may give rise to obesity, hypervitaminoses, alcohol intoxication, and various dietary imbalances that all have adverse health effects. Deficits, imbalances, and excesses in nutrients may all be present simultaneously in some individuals.

Other factors may also give rise to malnutrition—for example, the presence of disease, special physiological states, or inborn errors of metabolism. Moreover, although the biomedical model tends to concentrate on biological variables, social and psychological factors



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The Second Fifty Years: Promoting Health and Preventing Disability 10 Nutrition Dietary status and nutritional status are not synonymous. Dietary status is a measurement of what an individual is eating; nutritional status is the state of an individual's health as it is influenced by what is eaten. Diet is only one of many factors that may influence nutritional status. Thus, to provide an estimate of an individual's nutritional status, other measures are also used, including biochemical measurements of body fluids, anthropometric measurements, clinical findings, and medical history. When diet alone is responsible for deficits in an individual's nutritional status, the person is said to be suffering from primary malnutrition. The forms of primary malnutrition that may arise simply as a result of deficits in dietary intake are undernutrition or starvation, protein calorie malnutrition, and various vitamin and mineral deficiency disorders such as iron deficiency anemia, scurvy (from a deficiency of ascorbic acid), and osteomalacia (from a deficiency of vitamin D). Excesses in some categories of dietary intake may give rise to obesity, hypervitaminoses, alcohol intoxication, and various dietary imbalances that all have adverse health effects. Deficits, imbalances, and excesses in nutrients may all be present simultaneously in some individuals. Other factors may also give rise to malnutrition—for example, the presence of disease, special physiological states, or inborn errors of metabolism. Moreover, although the biomedical model tends to concentrate on biological variables, social and psychological factors

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The Second Fifty Years: Promoting Health and Preventing Disability can cause malnutrition as well. Food and eating have potent aesthetic and psychological attributes that are of great importance to maintaining the quality and enjoyment of everyday life. If a person's dietary intake is devoid of such characteristics owing to pathology arising from a physiological, psychological, or social cause, metabolism is deranged, appetites fall off, and eventually physical as well as emotional well-being may suffer. When malnutrition results from one or more of these causes, it is referred to as secondary malnutrition. Diet-drug or drug-drug interactions may also affect nutritional status adversely. Because this form of nutritional derangement is iatrogenic, it too is regarded as secondary malnutrition. NUTRITION AND QUALITY OF LIFE Favorable nutritional status throughout life can increase life expectancy. The increased expectation of life at birth that has taken place since 1900, as well as the growth in the expectation of life after 65 years of age, has been due in part to more favorable environmental conditions. Among these conditions has been an improvement in certain aspects of the food supply and dietary intakes, which have led to decreased prevalence of undernutrition and dietary deficiency diseases. Yet at the same time, other dietary factors have changed in the opposite direction—including several risk factors for chronic degenerative diseases (in particular, coronary artery heart disease, high blood pressure, and storke) and certain cancers, which now account for at least 75 percent of all deaths and half of all bed confinement days among the elderly.76 Common chronic degenerative diseases with diet-related components as well as other diseases and cognitive impairments prevent functional independence. In 1985, more than 5 million people 65 years of age and older needed special care to remain independent; by the year 2000, more than 7 million people are likely to need such care. Many of these same individuals will need assistance with shopping, meal preparation, and eating.34,87 The oldest old, that is, those over 85 years of age, are likely to be in special need of assistance in preparing food, eating, or planning their diets. Others, especially those with multiple, complex conditions, are also likely to require long-term care, either in or outside of institutions. Many residents of nursing homes and other long-term care facilities require therapeutic diets to deal with their health problems.76 However, a lack of choice, limited variety, and poor quality of food may limit the enjoyment an individual derives from eating, even though minimal standards for nutrient intake are met in such facilities, in boarding

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The Second Fifty Years: Promoting Health and Preventing Disability homes, or even in the person's own home. Certain nutritional interventions among those aged 50 and older offer promise in helping meet national goals to reduce the number of days of restricted activity per year that result from acute or chronic conditions among the elderly.22 And at all ages, attention to nutrition can increase the quality of life. NUTRITION AND FUNCTION The critical factor in a diminished quality of life for U.S. residents over 50 years of age is impairment in functional independence. Thus, a major concern of most elderly people is related to dependency. The average 68-year-old man today has a life expectancy of 13 years, which includes 4 years of progressive incapacity and increasing dependence. The segments of the population over 75 and over 85 years of age, the groups most likely to suffer functional impairments, are growing rapidly.76 Therefore, the concerns of the elderly with respect to maintaining the activities of daily living, including those related to nutrition and foods, are likely to increase rather than decrease in the future. FUNCTIONAL INDICES OF NUTRITIONAL STATUS Functional assessments and indices in nutritional studies and in evaluations of service programs with a strong functional focus fell into disuse several decades ago, and renewed interest in them is only now beginning to surface. It is interesting to note that, in the earliest nutritional studies, a functional focus was often present. These early studies had a socioeconomic as well as a biological motivation and were usually concerned with the preservation or restoration of physical, psychological, social, or economic function by nutritional means. Many of the early justifications of the school milk, lunch, and breakfast programs for poor children were based on improvements in functionally related criteria (e.g., lowered absenteeism rates, greater alertness). The vitamin and mineral deficiencies that were common in the early part of this century were acute and could be clearly related to diet; if diet were altered, total cure could be expected. With certain other conditions, such as the associations between massive obesity, incidence of chronic diseases, and disabling conditions, functional indices of a crude sort (e.g., days of work lost, days of restricted activity) were used, and the effects of improved diet were also relatively easy to demonstrate.27 The range of available measures of physical, mental, and social

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The Second Fifty Years: Promoting Health and Preventing Disability function has expanded greatly.42 Such measures include the Activities of Daily Living scale, as well as assessments of social competence (the Instrumental Activities of Daily Living scale) and mobility measures. In the field of nutrition, however, none of these measures or any other measures of disability have been used frequently, especially in studies in highly industrialized countries.51 The effects of the diseases themselves and the treatments for the diseases (nutritional or other types) are rarely separated and measured. Thus, the effects of many nutritional therapies on function, quality of life, morbidity, and mortality are unavailable. Even more unfortunate, function in relation to eating is often not even considered in medical assessments. A recent survey revealed that the specifics of dietary history (either diet restrictions or details of food intake with respect to calories, the types of food actually eaten, and physical limitations on eating) and other functional measures were rarely found on standard history-taking forms used in hospitals and long-term care facilities.60 These forms also neglected subjective comments by patients on the degree of their health, specifics of home living arrangements, the supporting services they received, and their dietary histories.60 Currently, the most common type of nutritional assessment used for older individuals comprises a clinical examination and one or more objective indices of functional impairment. The major advantage of a clinical examination, if it truly involves an assessment of functional status, is that it can incorporate observations of the individual actually performing the activities essential to preservation of independent function. When clinical assessments are combined with functional assessments of an objective nature, using such instruments as mental status measures, dietary intake and nutritional status measurements, measures of visual acuity and gait, and the Activities of Daily Living scale, more moderate cases of functional impairment are often revealed.86 (A more typical clinical assessment that does not involve such functional assessments is useful in identifying severe impairments but may miss more moderate degrees of deficits in function.) Given the limited training most physicians, nurses, and dietitians receive in the specifics of functional assessment and, indeed, in many areas of care and assessment of the problems of the elderly, such care givers often find it difficult to assess the self-maintenance skills of elderly patients by clinical means. When fuller assessments of function or home visits to the elderly are conducted, however, they often reveal insights on function related to diet and eating.88 Such a complete geriatric assessment is often

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The Second Fifty Years: Promoting Health and Preventing Disability helpful and should be mandatory when nonspecific failure to thrive with unexplained deterioration in nutritional status is evident.7 DIETARY INDICES An assessment of dietary intake is another useful but often neglected tool for determining the nutritional status of the aging. Dietary status indices provide information that helps a clinician make the differential diagnosis between primary malnutrition owing to inadequate dietary intake and malnutrition resulting from other causes. They can also offer some estimate of the patient's habitual diet, foodways, and abilities to purchase, prepare, serve, and clean up after meals, as well as any special restrictions or food prohibitions. Once these data have been collected, dietary intake is then assessed against some standard for nutrition, which, in the United States, is most commonly the Recommended Dietary Allowances (RDAs). The RDAs are commonly agreed upon standards for planning and assessing nutrient intake at various ages that are published periodically by the National Research Council. At present, there are no separate recommendations for those over 55 years of age for most nutrients, owing to the absence of evidence on nutrient requirements among older individuals; however, there is some information on useful alterations in nutrient recommendations for older individuals, and these data have recently been summarized.106 The most striking alteration in nutrient requirements for those over the age of 50 is the reduction in energy needs, which decreases by 6 percent from ages 51 to 75 and another 6 percent after 74 years of age. There are strong data to support the recommendations for decreased energy needs;13,83,95,113 what is not so clear is whether the decreases in lean body mass that account for much of this decrease are inevitable with advancing age or simply an artifact of inactivity. Exercise programs and more physically active lives among those over 50 might preserve lean body mass and thereby increase resting metabolic rates (and consequent energy needs). Increasing physical activity also increases energy expenditures in discretionary physical activity, further increasing energy outputs. Additional standards have been developed by a large number of expert bodies, including the National Research Council (NRC) for other substances in food such as cholesterol or dietary fiber that are not dealt with in the RDAs. One NRC committee recently published an authoritative report on diet and health that makes recommendations regarding a number of dietary constituents for which the RDAs

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The Second Fifty Years: Promoting Health and Preventing Disability do not provide quantitative guidance.17 These recommendations were promulgated for all healthy adults, including the elderly. ANTHROPOMETRY Anthropometric indices of nutritional status such as weight, stature, and skinfolds, as well as changes in these indicators, correlate well with clinical and laboratory markers, at least in young and middle-aged adults. They pose difficult problems for use in the elderly, however, because there are no norms for body composition in older individuals. Some of the usual anthropometric measures (e.g., stature) may be difficult to obtain, especially in the very old; as a result, substitutes such as segmental measurements of the head to the knee may be more useful. Also, special equipment and extensive training in its use may be required for some of the more elaborate measurements. Yet despite these limitations, even simple, standardized measurements of weight can be helpful in monitoring nutritional status and are easy enough to be performed by anyone, given minimal training. Because most anthropometric measurements of body composition are rather nonspecific, they are best utilized in combination with other measurements. Indeed, the combination of clinical observations with biochemical, anthropometric, and dietary indices is thought by nutritional scientists to best reflect the specific physiological ''functions" of interest for nutritional research purposes. For example, functional tests of light adaptation coupled with clinical and dietary data may be used as measures of vitamin A nutrition. Whether a diet is adequate to rehabilitate a starved individual can be assessed by its ability to generate weight gain. For clinical purposes, however, these standard assessment methods are less useful than feeding evaluations to determine by observation whether individuals are able to and actually do eat unassisted. Finally, it is necessary to assess the effects on functioning that may arise from nutritional or other treatments (for example, home internal feeding by pump, which is a complex, time-consuming procedure). PROGNOSTIC INDICATORS OF MORBIDITY OR MORTALITY Another approach to assessing "functional" nutritional status is to develop a battery of biochemical and clinical tests that serve as predictors of morbidity and mortality and assist clinicians in determining the appropriate course of further treatment for the patient.

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The Second Fifty Years: Promoting Health and Preventing Disability In comparison to the more global indices of functioning in daily life, these indices have a more narrow focus of morbidity and function; thus, quality of life may be de-emphasized. Another limitation is that prognostic indicators tend to focus on prognoses for specific types of patients who either suffer from certain diseases or are candidates for risky or expensive procedures (e.g., surgery, chemotherapy for advanced cancers). Several indices have shown some prognostic significance for morbidity and mortality. One such popular index is the Prognostic Nutritional Index, or PNI, developed by Mullen and colleagues.75 The PNI consists of 16 nutritional and immunological variables that are used to predict subsequent morbidity and mortality patterns in surgical patients with various cancers and other conditions. In Mullen's original research, the 3 (of the 16) variables that correlated most closely with outcomes were serum transferring, serum albumin, and delayed hypersensitivity reaction from skin test antigens. Patients who had poor scores on these three major factors usually had poorer prognoses than other patients; however, the association may have been due not to their poor nutritional status but to their poor general health status. The PNI is efficient in discriminating populations at high risk of morbidity and mortality, but it is not as effective in selecting individuals who are at risk when only one of the risk factors is abnormal. In addition, the index provides no estimate of the severity of the individual's malnutrition problem. Thus, the prognostic indices are of little use for decisions about whether to proceed with a surgery immediately or to wait until a patient can be nutritionally rehabilitated. The risks of withholding surgery are usually well known, particularly when cancer has been diagnosed; there are no similar quantitative estimates of the risks posed by malnutrition (i.e., the failure to wait and rehabilitate the patient). A second prognostic index quite similar to the PNI was developed a decade ago by another group at the New England Deaconess Hospital, also to assess risks of later morbidity and mortality in surgical patients.42 In addition, other risk indices have been developed by other investigators as nutritional prognostic indicators in medical conditions. All have failings similar to those discussed for the PNI, however, and none are presently viewed as acceptable for all patients in all circumstances. Only recently have indices been developed that include age-related criteria.4 Theoretically, it should be possible to develop prognostic indicators that have a rehabilitative focus instead of concentrating solely on morbidity and mortality. The techniques for such efforts have

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The Second Fifty Years: Promoting Health and Preventing Disability been available for many years in the rehabilitation medicine and occupational therapy literature.66,103 An investigator observes as many as 100 different activities, many associated with food and eating, and records whether the patient can perform the task either independently, only with adaptive devices, with supervision, with assistance, or not at all. It is from such longer inventories that the few key activities thought to be most highly associated with a lack of functional disability for independent living were originally developed. After these activities were identified, arbitrary scores were assigned and a numeric score calculated for each patient from which progress or deterioration in self-care could be determined.103 Many different indices are available, including the Barthel index,72 the Kenney system,94 and the Katz index of active life expectancy.55 The Katz index classifies patients into one of seven groups and avoids arbitrary point systems. Class A refers to a patient who is independent in feeding, continence, transferring, toileting, dressing, and bathing. Class B patients are independent in all but one of these areas. Class C patients are independent in all but bathing and one additional function, and so on. The underlying assumption of the Katz method is that there is an order of maintenance of function, which proceeds in chronological fashion; consequently, feeding ability is maintained longer than the ability to bathe independently. When this is not true, the patient must be classified as "other." Because the ability to self-feed is lost relatively late in many cases, the index does not discriminate among nuances of function in eating and feeding, which would argue for development of more sensitive indicators. (The many problems of developing systems de novo have been well reviewed, however.57) Nevertheless, these indices in general are highly correlated in predicting self-care ability and are accurate in about two-thirds of all cases. Of the existing indices, the Barthel index is considered to be the most sensitive and the Katz index the least sensitive.26,37 NUTRITIONAL RISK SCREENING INDICES Another approach that attempts to measure both social and biological functioning is the Nutritional Risk Index (NRI) for morbid and disabling conditions associated with nutrition. The NRI is an easily administered screening test developed by Wolinsky and colleagues120 that attempts to tap five factors often associated with poor nutritional health: (1) existing illness in the digestive system, (2) the use of medications associated with that system, (3) the use of dentures, (4) smoking, and (5) bowel-related problems. The Wolinsky

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The Second Fifty Years: Promoting Health and Preventing Disability group developed a short, 16-item test to tap various aspects of these problems; items include the use of prescribed or self-prescribed medications in the past month, previous abdominal problems or operations, trouble with eating or with foods "not agreeing" with the individual, special diets, stomach pains, bowel trouble, diarrhea or constipation over the past month, anemia, presence of illness cutting down on appetite, smoking, trouble swallowing, and gain or loss of weight over the past month. The test-retest reliabilities of the instrument were .5 to .6. The investigators assessed the validity of the instrument using factor analysis and comparisons on outcome measures between those at risk and those not at risk. These analyses showed that individuals with higher risk scores had poorer health and consumed more health services than those with lower risk scores. Although there was no apparent relationship between the NRI and the informal use of health services (e.g., restricted activities, bed disability days), the NRI did predict formal health services utilization quite well. Much work needs to be done before the NRI or any other index of nutritional risk is widely accepted. Any broad-scale use of such an index must recognize that, at any given level of nutritional status, individuals vary greatly in their functional status with respect to daily living and coping. Not only nutrient intake but the social aspects of food and eating are important to consider, and the need for assistance in food- and diet-related activities depends on both biological and social circumstances. Clearly, it is important to assess all of these aspects, and work is continuing on questionnaires to assess aspects of functional status that are associated with nutritional risk.121,122,123 As yet, however, correlations of nutritional risk indices with clinical status or nutritional status are low or remain unproven. More thorough means of assessing the activities of daily living with special attention to nutrition are needed.29 These assessments can supplement and augment other routinely collected information on function.76 NUTRITION IN A FUNCTIONAL PERSPECTIVE In this report, impairment is considered to be the condition involved in causing the loss or abnormality of psychological, physiological, or anatomical structure and function. Among the impairments that may be associated with malnutrition-related diseases and that are relatively common among aging adults, visceral, skeletal, intellectual, and other psychological impairments are most prominent. The most common categories of disability associated with malnutrition are

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The Second Fifty Years: Promoting Health and Preventing Disability probably physical disabilities affecting the use of the hands, arms, and legs and thus movement of the individual; that is, upper body and hand function but lower body and mobility problems may be involved in some cases—for example, massive obesity or complications of cardiovascular disease. These problems (e.g., lack of cardiovascular fitness or muscle strength) can reverse themselves quickly if active lifestyles are adopted. Handicaps in the nutritional realm consist of the disadvantages that result from an impairment or disability that limit or prevent fulfillment of an individual's normal roles. Malnutrition can lead to handicaps related to physical independence and mobility and occupational and social integration, as well as difficulties and handicaps involving economic self-sufficiency. BURDEN Prevalence The prevalence of various forms of malnutrition differs depending on the type, stage, and condition being considered. Each of the dietary components to be discussed in this report are dealt with separately below or in the chapters devoted to risk factors that include a nutritional component. Costs There have been several attempts over the past two decades to estimate the cost of diet-related diseases. There is no consensus on these estimates, however, because of the different definitions used and uncertainties regarding the proportion of total risk for a disease or condition attributable to diet or to other aspects of diet-related health risks. Furthermore, the synergistic effects of these various risk factors on the chronic degenerative diseases that are thought to involve diet are difficult to quantify. For example, it is well known that the addition of hyperlipidemia to other cardiovascular risk factors raises morbidity and mortality considerably, but these relationships are often unclear or based only on limited data after ages 50 or 60.35 Today, reanalyses of diet-related interventions to decrease coronary artery disease risks appear to indicate benefits in decreased medical expenditures (by decreasing morbidity), even late in life.32 However, estimates of cost-benefit ratios and cost-effectiveness of dietary interventions after the age of 50 are not yet available. One set of costs that are clear are the losses of time, money, and

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The Second Fifty Years: Promoting Health and Preventing Disability happiness associated with the nutritional remedies that carry exaggerated, unproven claims of efficacy for the ills often associated with aging. The elderly are particularly susceptible to such claims, the economic consequences of which are enormous.110 The health consequences of nutritional quackery and fraud include the failure to seek conventional and more effective care for illnesses and the rejection of legitimate medical advice. Moreover, the practice of inappropriate self-medication may itself give rise to illness, especially as some dietary remedies are potentially toxic in and of themselves, particularly if the elderly individual is already ill.45 PREVENTABILITY OF BURDEN This section reviews selected interventions in the area of nutrition, including screening and case-finding strategies that have not been previously discussed. Particular attention is given to interventions that are likely to have positive interactions with other factors singled out for attention in this report. Table 10-1 describes various forms of malnutrition that may be secondary to other disease processes and the kinds of effects they are likely to have, particularly in terms of nutritional status with respect to function. Table 10-2 briefly summarizes possible interventions that might be considered. Some of these selected options are discussed in the following sections under the risk factor most relevant to a particular disease process. Table 10-3 shows how diet and nutritional status may alter other risk factors among individuals over the age of 50. Much effort is being devoted to developing better evidence that dietary counseling, food programs, and related nutritional interventions can change food habits and that these altered food habits in turn decrease risk factors and thereby bring about desirable health and economic benefits.23,24,69,92,100 Until very recently, however, the relative costs and benefits of nutritional counseling and interventions were virtually unknown. Now, as evidence is rapidly becoming available, new studies are being planned.2,77 High Blood Pressure The burden imposed by high blood pressure on aging individuals is well documented in Chapter 3. In addition to its close association with mortality from stroke, high blood pressure is also a major cause of morbidity. Stroke may give rise to physical difficulties in walking, lifting, and moving the upper extremities; all of these limitations

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The Second Fifty Years: Promoting Health and Preventing Disability elderly who receive Meals on Wheels services exhibit negative nitrogen balances, but this deficit may be due to disease rather than diet. It is clear that as larger numbers of the very old continue to live at home, better food and nutritional support services will be needed in the community. In addition to the actual provision of food, some elderly people need ambulatory nutritional services of other sorts, such as dietary counseling and help in meal planning. The costs and benefits of ambulatory nutrition care for senior adults have been reviewed recently by Disbrow.23 There appear to be positive benefits of ambulatory nutritional services for the elderly, but more studies are needed. Benefits are concentrated in four areas: reduced health care costs, reduced needs for long-term care, improved health status and quality of life owing to better self-management of chronic disease, and subsequent reduction of related complications.22 In addition, several studies indicate that there were positive associations between nutritional status and participation in the Nutritional Programs for Older Adults Congregate Meal Services.67 The clearest benefits come as a result of screening and the referrals generated by such programs, but other benefits have also been observed as a result of diet counseling, exercise, adult education, and other classes and activities associated with the congregate meals services. Additional possible benefits from such interventions include retention of mobility, sustained quality of life through improved socialization, and positive self-perceptions of health. Ambulatory nutrition counseling may also be of benefit in helping the elderly with meal planning and food purchasing and in coping with disabilities. At present, however, these benefits are not well documented and await further study. Home health services and food delivery for the elderly constitute another set of services in the spectrum of social interventions designed to maintain independent function among the elderly to the greatest extent possible. Although home health care for the elderly is not necessarily less costly than hospital or clinic care, it may nevertheless do a great deal to preserve an individual's independence if the alternative is the disruption that often accompanies hospitalization. Home health and nursing care costs are roughly similar.67 Home-delivered meals, on the other hand, are usually much more expensive than the congregate meals programs. These cost differences and the stress on volume of meals served make it difficult for all those who need home meal delivery services to obtain them. Homemaker services, hospital-based home health care visits, and nutritionist visits have all been described in the literature. It is not yet clear whether the benefits of these home services exceed their

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The Second Fifty Years: Promoting Health and Preventing Disability costs, although clearly, for some patients who wish to avoid institutionalization and still maintain acceptable levels of quality of life and health, there is no other alternative.43,73 Increasing numbers of the very old are institutionalized during their final years of life, and in such settings the adequacy and appropriateness of the food served to them vary greatly. The simple fact of residence in a long-term care facility does not imply immunity from malnutrition or undernutrition. Indeed, several studies show that the nutritional status of residents of long-term care facilities leaves much to be desired.98 It is difficult to evaluate these groups, however, because some of the supposed indicators of nutritional status among elderly patients may be altered for nonnutritional reasons (e.g., disease).96 In addition, although biochemical tests of malnutrition are useful, they vary greatly in their specificity and sensitivity, especially in the elderly. There is as yet no generally agreed upon battery of tests that will provide accurate assessments of risk.59 The benefits of inpatient nutritional care have recently been reviewed.23 Among the most cost-effective strategies are weekly nutrition rounds, made with the dietary supervisor, a consultant dietitian, and a registered nurse, to assess patient status. The results of such sessions have been generally positive and include improved dietary intake, weight status, bowel status, and skin health; the costs associated with the sessions were less than those associated with conventional procedures. Other studies have shown that the use of high-fiber (bran) diets among elderly institutionalized patients can dramatically decrease laxative abuse. Because the amount of time presently devoted to dietetic surveillance is only 10 minutes or less per patient per month, efficient means for nutritional care assessment, intake evaluations, counseling, and documentation need to be found. It is also essential that dietitians develop more services in these areas and that funding be made available to investigate the cost-effectiveness of such services. The nutrient intake of elderly long-stay hospital patients is often inadequate; in fact, those patients whose healing is the most retarded often prove to have the poorest intake. Attention to dietary intake may be particularly helpful in some cases to stimulate healing postsurgery. For example, malnutrition adversely affects the prognosis for lower limb amputations, but it seems to have less effect on more proximal amputations.56 Similarly, certain biochemical parameters associated with malnutrition (e.g., reduced serum albumen, transferring, absolute lymphocyte count, energy) are associated with both morbidity and mortality. Furthermore, patients judged to be malnourished at

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The Second Fifty Years: Promoting Health and Preventing Disability admission had longer stays in the same DRG (diagnostic-related group) category than those judged to be well nourished.90 A barrier to more widespread use of nutritional support measures in the elderly involves various clinical issues surrounding the use of special nutritional support measures, such as total parenteral nutrition and enteral nutrition using nasogastric or other tube feedings and pumps. Ethical and legal questions further complicate this issue. In fact, in some cases such measures are clinically justified for use even in the very old, and they may improve quality of life as well.16,68 RECOMMENDATIONS Services Using current knowledge, consensus recommendations should be developed for nutritional screening and monitoring and for nonpharmacologic interventions, including diet, in asymptomatic individuals of both sexes over the age of 50. The age ranges considered should include the following: from 50 to 64, 65 to 74, and 75 and over. Nonpharmacologic intervention should be considered for persons with atherosclerosis, high blood pressure, diabetes mellitus, physical inactivity, and osteoporosis. Methods should be explored for maintaining independent functioning with respect to nutrition among individuals living at home. Methods of particular interest include participation in meals programs (e.g., Meals on Wheels) and congregate dining. Methods are needed to screen older populations for nutritional risk. Such methods must be reliable, valid, and predictive of later maintenance of independent function. Model standards should be developed for the nutritional component of food services, including functionally oriented nutritional assessments, for use in nursing homes and long-term care facilities. The means for reimbursement of these assessments and services under Medicare should also be devised. The regulatory authority of the Food and Drug Administration should be extended to deal adequately with health claims on food products and to guard against nutritional fraud. Mechanisms should be developed to assess problems and assist the families of cognitively impaired elderly people, as well as other older individuals who have difficulty eating.

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The Second Fifty Years: Promoting Health and Preventing Disability Functional assessments and nutritional care plans should be required in federally funded hospitals, nursing homes, and extended care facilities. Such plans should emphasize independent function, minimization of polypharmacy, and maximization of physical activity while maintaining good nutritional status. Research The association of serum cholesterol lowering and alterations in other risk factors for cardiovascular disease should be determined. Special attention should be paid to clarifying the associations and trade-offs among serum cholesterol lowering, the use of postmenopausal estrogen replacement therapy with progestins, physical activity, and other interactive interventions in the sixth through ninth decades of life. A major research effort should be mounted to clarify the associations between nutritional requirements and function. Common drug-diet interactions among the elderly should be studied, and alternative pharmacological or nonpharmacological therapies should be developed to reduce functional difficulties. Education Courses of study for students in dietetics, the nutritional sciences, nursing, dentistry, and medicine should include an emphasis on functional assessments of nutritional status and the preservation of independent functioning. Mass media and other educational presentations should be developed to assist elderly individuals in self-care, especially in the area of nutrition. Advice should include attention to problems that arise when commonly coexisting diseases are present. More complete, easy-to-read food labels should be developed for those who have common dietary restrictions. The recommendations provided in the 1989 National Research Council report on diet and health17 should be implemented. Although the evidence is definitive in only a few areas (e.g., coronary artery disease), there is reason to suspect that benefits will result and that risks are few.51 There is also evidence to suggest that dietary moderation should be coupled with a physically active life to the greatest extent possible, given the disabilities of aging. There is no need for vitamin and mineral supplements if healthful diets in line with these recommendations are followed.

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