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Contemporary Nutrition
Contemporary Nutrition Nutrition and Aging Myron Winick Currently, more than 20 million Americans are 65 years of age or older. There are nearly 25,000 nursing homes in the United States containing almost a million and a half bedsmore nursing home beds than hospital beds. This population-our' 'senior citizens" -is growing rapidly every day. If aging is a problem, then, it is increasing in magnitude; and society, by focusing on health issues at younger ages, is trying to lengthen life. Thus, we have within our society, as well as in many other so-called advanced societies, what has become a contradiction which is often difficult to deal with: more elderly people and, therefore, more problems of the elderly. There are two ways in which we may deal with this problem: (1) reducing the burdens that the elderly must bear and (2) curtailing the process during the early and middle years that leads to the physiologic state that we presently define as "old age." In a sense, we must seek ways of not slowing, but actually changing, the aging process, as well as methods to structure the environment of those reaching old age to provide them with optimal health and well-being. Nutrition is an important component of both these approaches. Feeding the Elderly A number of physiologic changes that occur with aging should be understood before an adequate nutritional program can be rationally developed. From a nutritional standpoint, the most important of these changes relate to the renal, neuromuscular and gastrointestinal systems. Under resting steady-state conditions, most of the components of the "internal environment" are maintained at fairly normal levels even at a quite advanced age; however, renal function clearly deteriorates with age. The major renal changes which occur with aging are: a. In humans, the renal blood flow and glomerular filtration rate decline. b. In humans, the T M for glucose and PAH declines. c. In humans, the ability to form either a concentrated or dilute urine decreases.
Myron Winick, MD, is Director, Institute of Human Nu-
trition, College of Physicians and Surgeons, Columbia University, New York, New York 10032.
Vol. NS 17, No.9, September 1977
d. In rats, there is a decline in the number of nephrons. Most of the functions above decrease about 0.6 percent per year in adults. Gastrointestinal function also declines with age in the following ways: a. In humans, the ability of parietal cells to secrete hydrochloric acid declines. In general, there is a reduction in the secretory ability of the digestive glands. b. In humans, xylose absorption is normal until 80 years of age. c. In humans, calcium absorption decreases beyond 65 years of age. Therefore, a number of processes basic to the digestion and absorption of nutrients are impaired during aging, whereas others, such as glucose absorption, are unaffected. The motor function of humans also declines with age. There is a generalized weakness probably due to both a decline in the number of functioning muscle fibers and in the contractile process itself. In addition, body composition also changes during aging. Bone loss is a general phenomenon beginning by the fifth decade in both men and women. This condition progresses more than twice as fast in the female as in the male. Although it has been generally believed that there is a loss in lean body mass and in increase in the adipose tissue mass with age, the data have been gathered in cross-sectional studies. Recent data from longitudinal studies (Le., collected on the same patient over a period of time) suggest that lean body mass does not decline with age but rather that individuals with a smaller lean body mass tend to live longer. Finally, in a series of interesting studies in rats, it has been shown that the adipocyte number actually increases very late in life. The significance of these findings remains unknown but the suggestion is that old age is accompanied by relative obesity, due to an actual hyperplasia within the adipose depot. These changes suggest the need for careful evaluation of nutritional requirements , for the elderly, especially in relation to certain specific nutrients. For example, the decrease in muscle mass suggests that protein and amino acid requirements may change. The reduced calcium absorption coupled with bone resorption suggests a reevaluation of the calcium and phosphorus requirements. The decreased secretion of hydrochloric acid coupled with general gastric atrophy suggests an increased iron and perhaps vitamin B12 requirement. Unfortunately, careful research aimed at determining requirements
of most nutrients specifically for the elderly is just beginning. At present, neither current United States nor international dietary allowances ,have included separate recommendations tor a single nutrient for the elderly. Recently, studies have begun to determine the protein and amino acid requirements of the elderly. In humans, the amount of total body protein synthesized daily declines with age. In addition, the relative amounts of protein synthesized by various organs are redistributed. Visceral tissue makes a greater overall contribution to total body protein synthesis in the elderly than in young adults. From these observations we are tempted to predict that the total protein requirement for the elderly should be less per unit of body weight. Actual measurements of protein requirements using a variety of techniques suggest that the minimum protein needs of healthy adults do not change significantly with advan(;;ing age. Thus, on the basis of current knowledge, the recommended intake for healthy males is 56 g and for females, 46 g. This appears to be adequate for most healthy elderly individuals. Even less is known about amino acid requirements than about total protein requirements. At present, preliminary data suggest that the requirements for the amino acids, threonine and tryptophan, are similar to those for young aduits when expressed per unit of body weight. Literally nothing is known about the other amino acids. Medical and health professionals are then left to make decisions about protein and amino acid requirements for the elderly based on limited data. Therefore, our decisions at best can only be "educated guesses." Based on our present state of knowledge, I would recommend that protein intake for the elderly consist of amounts adequate to meet the minimum daily requirement of the healthy young adult but not a great deal above this. In addition, the quality , of the protein should be such that it is rich in the essential amino acids and should be supplied in a form that is easily digestible. Thus, fish, soft cheese, lean meats and fowl, as well as certain vegetable proteins, would be good choices. Since hydrochloric acid in the stomach may not be secreted properly and the intrinsic factor may be low, the elderly may be more prone to anemia because of poor iron absorption and poor absorption of vitamin B 12. Therefore, foods rich in iron and vitamin B12 are indicated. These include red me'at, liver and fortified cereals. Requirements for other vitamins and minerals have 585
Contemporary Nutrition
not been established for the elderly; therefore, we can only provide what is adequate for the young adult. Calcium, however, may be chronically deficient in older individuals. At present, there are two schools of thought as to the nature of osteoporosis and periodontal disease, two extremely common and often debilitating diseases of older people. One group of investigators believes that they are two totally different diseases, osteoporosis being a slowly progressing degenerative disease of bone and periodontal disease being a chronic infection of the gums with erosion of the underlying bone, loosening and finally loss of teeth. A second group of investigators feels that they are both the same disease arising from a chronic, long-term calcium deficiency which slowly drains both the long bones and the jaw bones and results in a propensity toward long bone fractures and loss of teeth from their bony sockets. Both groups agree that calcium treatment alone will do little for the patient with osteoporosis. However, those espousing the chronic calcium deficiency etiology believe that supplemental calcium before osteoporosis develops will prevent or at least delay the process. They eel that the Recom-
Dean-College of Pharmacy and Allied Health Professions Northeastern University The University is the largest cooperative education institution in the United States with broad academic offerings and extensive research and community oriented programs. The College offers both undergraduate and graduate degrees in accredited health related programs. Candidates should have an earned doctorate or its equivalent, an appreciation of clinical health programs and an established scholarly background to qualify for a professorial appointment. Administrative and teaching experience in an academic setting is preferred. Applications and nominations, including a detailed resume, should be sent to Dr. A. H. Taubman, Room 113 Mugar (J), Northeastern University, 360 Huntington Avenue, 80ston, MA 02115, by November 15, 1977. Equal opportunity/ affirmative action, Title IX employer
mended Dietary Allowance is much too low and that adults should take in a minimum of one gram of calcium daily and preferably more than that. In addition, based on experiments with periodontal disease in horses and with limited trials in humans with periodontal disease, these individuals feel that calcium therapy in high doses will reverse the process in the jaw bones and lead to the healing of the periodontal tissues and strengthening of the teeth within their sockets. My feeling, based on my understanding of the data, is that osteoporosis may in part be due to a chronic calcium deficiency because of the low intake of calcium by modern society. I WOUld, therefore, suggest that foods rich in calcium be recommended during childhood as well as adult life and that patients who are mi9dle-aged and who have symptoms and 1or x-ray findings of osteoporosis be supplemented with one gram of calcium a day in the form of gluconate. While I am not convinced that this will prevent progression of the disease, I feel that the risk of this form of "prophylaxis" is minimal and the potential benefits are high enough to warrant this approach. With periodontal disease, the data are difficult to interpret. I feel that this is a disease of multiple etiology and that some forms may respond to calcium treatment. Since calcium has been reported in some cases to have considerable benefit with x-rays showing objective changes, I recommend short-term treatment (three to six months) . Certain diseases associated with the gastrointestinal tract are more common in the elderly-especially in the elderly of more affluent societies. Diverticulitis, gall bladder disease and cancer of the colon are among these diseases. Evidence suggests that all three of these may be related to the amount of fiber in the diet.
The data are strongest with diverticulitis. Low fiber intake increases the prevalence of this disease. This is probably because of the decreased transit time it produces and the subsequent hardening of stools and constipation which follows. Since constipation is a serious problem in many older people, an increase in the fiber content of their diet is suggested. This is probably best accomplished by increasing their bran intake. Summary There is much we still must learn about nutrition and aging, but there are certain practical things which we can do now to improve the nutrition of the elderly. These include eating a balanced diet relatively low in fats, high in fiber and, particularly, rich in iron, vitamin B12 and calcium. References Winick, M. : Current concepts in nutrition, Vol. '4, Nutrition and aging, John Wiley and Sons, New York, New York 1976. Kritchevsky, D., and Story, J. A.: Dietary fiber and cancer, in: Current concepts in nutrition, Vol. 6, Nutrition and cancer, John Wiley and Sons, New York, New York (in press) . Wynder, E. L., and Reddy, B. S.: Diet and cancer of the colon, in: Current concepts in nutrition, Vol. 6, Nutrition and cancer, John Wiley and Sons, New York, New York (in press).
This department of the Journal is intended to assist practicing pharmacists in fulfilling their responsibilities in health education and patient counseling. It provides concise, well-documented, objective literature reviews, prepared by recognized experts, on current topics concerning nutrition and health. Some of the topics are related to drug therapy. Contemporary Nutrition is reproduced or adapted with permission from a newsletter of the same name published by the Nutrition . Department of General Mills, Inc. and edited by A. Elizabeth Sloan, PhD.
Most people in the world have never heard of acetylsalicylate. Those in medically deprived areas have never heard of aspirin. Think of what your skills and knowledge could mean to them ... Write today for our catalogue of short- and long-term medical opportunities in areas of need, foreign and domestic.
Optl·on
a nonprofit placement service for health care professionals.
3502 Hancock St., P.O. Box 81122, San Diego, CA 92138 714/299·1531 586
Journal of the American Pharmaceutical Association
Myron Winick, MD, is Director, Institute of Human Nu-
trition, College of Physicians and Surgeons, Columbia University, New York, New York 10032.
Vol. NS 17, No.9, September 1977
d. In rats, there is a decline in the number of nephrons. Most of the functions above decrease about 0.6 percent per year in adults. Gastrointestinal function also declines with age in the following ways: a. In humans, the ability of parietal cells to secrete hydrochloric acid declines. In general, there is a reduction in the secretory ability of the digestive glands. b. In humans, xylose absorption is normal until 80 years of age. c. In humans, calcium absorption decreases beyond 65 years of age. Therefore, a number of processes basic to the digestion and absorption of nutrients are impaired during aging, whereas others, such as glucose absorption, are unaffected. The motor function of humans also declines with age. There is a generalized weakness probably due to both a decline in the number of functioning muscle fibers and in the contractile process itself. In addition, body composition also changes during aging. Bone loss is a general phenomenon beginning by the fifth decade in both men and women. This condition progresses more than twice as fast in the female as in the male. Although it has been generally believed that there is a loss in lean body mass and in increase in the adipose tissue mass with age, the data have been gathered in cross-sectional studies. Recent data from longitudinal studies (Le., collected on the same patient over a period of time) suggest that lean body mass does not decline with age but rather that individuals with a smaller lean body mass tend to live longer. Finally, in a series of interesting studies in rats, it has been shown that the adipocyte number actually increases very late in life. The significance of these findings remains unknown but the suggestion is that old age is accompanied by relative obesity, due to an actual hyperplasia within the adipose depot. These changes suggest the need for careful evaluation of nutritional requirements , for the elderly, especially in relation to certain specific nutrients. For example, the decrease in muscle mass suggests that protein and amino acid requirements may change. The reduced calcium absorption coupled with bone resorption suggests a reevaluation of the calcium and phosphorus requirements. The decreased secretion of hydrochloric acid coupled with general gastric atrophy suggests an increased iron and perhaps vitamin B12 requirement. Unfortunately, careful research aimed at determining requirements
of most nutrients specifically for the elderly is just beginning. At present, neither current United States nor international dietary allowances ,have included separate recommendations tor a single nutrient for the elderly. Recently, studies have begun to determine the protein and amino acid requirements of the elderly. In humans, the amount of total body protein synthesized daily declines with age. In addition, the relative amounts of protein synthesized by various organs are redistributed. Visceral tissue makes a greater overall contribution to total body protein synthesis in the elderly than in young adults. From these observations we are tempted to predict that the total protein requirement for the elderly should be less per unit of body weight. Actual measurements of protein requirements using a variety of techniques suggest that the minimum protein needs of healthy adults do not change significantly with advan(;;ing age. Thus, on the basis of current knowledge, the recommended intake for healthy males is 56 g and for females, 46 g. This appears to be adequate for most healthy elderly individuals. Even less is known about amino acid requirements than about total protein requirements. At present, preliminary data suggest that the requirements for the amino acids, threonine and tryptophan, are similar to those for young aduits when expressed per unit of body weight. Literally nothing is known about the other amino acids. Medical and health professionals are then left to make decisions about protein and amino acid requirements for the elderly based on limited data. Therefore, our decisions at best can only be "educated guesses." Based on our present state of knowledge, I would recommend that protein intake for the elderly consist of amounts adequate to meet the minimum daily requirement of the healthy young adult but not a great deal above this. In addition, the quality , of the protein should be such that it is rich in the essential amino acids and should be supplied in a form that is easily digestible. Thus, fish, soft cheese, lean meats and fowl, as well as certain vegetable proteins, would be good choices. Since hydrochloric acid in the stomach may not be secreted properly and the intrinsic factor may be low, the elderly may be more prone to anemia because of poor iron absorption and poor absorption of vitamin B 12. Therefore, foods rich in iron and vitamin B12 are indicated. These include red me'at, liver and fortified cereals. Requirements for other vitamins and minerals have 585
Contemporary Nutrition
not been established for the elderly; therefore, we can only provide what is adequate for the young adult. Calcium, however, may be chronically deficient in older individuals. At present, there are two schools of thought as to the nature of osteoporosis and periodontal disease, two extremely common and often debilitating diseases of older people. One group of investigators believes that they are two totally different diseases, osteoporosis being a slowly progressing degenerative disease of bone and periodontal disease being a chronic infection of the gums with erosion of the underlying bone, loosening and finally loss of teeth. A second group of investigators feels that they are both the same disease arising from a chronic, long-term calcium deficiency which slowly drains both the long bones and the jaw bones and results in a propensity toward long bone fractures and loss of teeth from their bony sockets. Both groups agree that calcium treatment alone will do little for the patient with osteoporosis. However, those espousing the chronic calcium deficiency etiology believe that supplemental calcium before osteoporosis develops will prevent or at least delay the process. They eel that the Recom-
Dean-College of Pharmacy and Allied Health Professions Northeastern University The University is the largest cooperative education institution in the United States with broad academic offerings and extensive research and community oriented programs. The College offers both undergraduate and graduate degrees in accredited health related programs. Candidates should have an earned doctorate or its equivalent, an appreciation of clinical health programs and an established scholarly background to qualify for a professorial appointment. Administrative and teaching experience in an academic setting is preferred. Applications and nominations, including a detailed resume, should be sent to Dr. A. H. Taubman, Room 113 Mugar (J), Northeastern University, 360 Huntington Avenue, 80ston, MA 02115, by November 15, 1977. Equal opportunity/ affirmative action, Title IX employer
mended Dietary Allowance is much too low and that adults should take in a minimum of one gram of calcium daily and preferably more than that. In addition, based on experiments with periodontal disease in horses and with limited trials in humans with periodontal disease, these individuals feel that calcium therapy in high doses will reverse the process in the jaw bones and lead to the healing of the periodontal tissues and strengthening of the teeth within their sockets. My feeling, based on my understanding of the data, is that osteoporosis may in part be due to a chronic calcium deficiency because of the low intake of calcium by modern society. I WOUld, therefore, suggest that foods rich in calcium be recommended during childhood as well as adult life and that patients who are mi9dle-aged and who have symptoms and 1or x-ray findings of osteoporosis be supplemented with one gram of calcium a day in the form of gluconate. While I am not convinced that this will prevent progression of the disease, I feel that the risk of this form of "prophylaxis" is minimal and the potential benefits are high enough to warrant this approach. With periodontal disease, the data are difficult to interpret. I feel that this is a disease of multiple etiology and that some forms may respond to calcium treatment. Since calcium has been reported in some cases to have considerable benefit with x-rays showing objective changes, I recommend short-term treatment (three to six months) . Certain diseases associated with the gastrointestinal tract are more common in the elderly-especially in the elderly of more affluent societies. Diverticulitis, gall bladder disease and cancer of the colon are among these diseases. Evidence suggests that all three of these may be related to the amount of fiber in the diet.
The data are strongest with diverticulitis. Low fiber intake increases the prevalence of this disease. This is probably because of the decreased transit time it produces and the subsequent hardening of stools and constipation which follows. Since constipation is a serious problem in many older people, an increase in the fiber content of their diet is suggested. This is probably best accomplished by increasing their bran intake. Summary There is much we still must learn about nutrition and aging, but there are certain practical things which we can do now to improve the nutrition of the elderly. These include eating a balanced diet relatively low in fats, high in fiber and, particularly, rich in iron, vitamin B12 and calcium. References Winick, M. : Current concepts in nutrition, Vol. '4, Nutrition and aging, John Wiley and Sons, New York, New York 1976. Kritchevsky, D., and Story, J. A.: Dietary fiber and cancer, in: Current concepts in nutrition, Vol. 6, Nutrition and cancer, John Wiley and Sons, New York, New York (in press) . Wynder, E. L., and Reddy, B. S.: Diet and cancer of the colon, in: Current concepts in nutrition, Vol. 6, Nutrition and cancer, John Wiley and Sons, New York, New York (in press).
This department of the Journal is intended to assist practicing pharmacists in fulfilling their responsibilities in health education and patient counseling. It provides concise, well-documented, objective literature reviews, prepared by recognized experts, on current topics concerning nutrition and health. Some of the topics are related to drug therapy. Contemporary Nutrition is reproduced or adapted with permission from a newsletter of the same name published by the Nutrition . Department of General Mills, Inc. and edited by A. Elizabeth Sloan, PhD.
Most people in the world have never heard of acetylsalicylate. Those in medically deprived areas have never heard of aspirin. Think of what your skills and knowledge could mean to them ... Write today for our catalogue of short- and long-term medical opportunities in areas of need, foreign and domestic.
Optl·on
a nonprofit placement service for health care professionals.
3502 Hancock St., P.O. Box 81122, San Diego, CA 92138 714/299·1531 586
Journal of the American Pharmaceutical Association