College of Our Lady of Mt.

Carmel
Bachelor in Science of Nursing III

Nutrition

Nutrition plays in important role in health maintenance, rehabilitation, and prevention and control of
disease.

 ASSESSMENT

When dealing with nutritional issues, nurses who work with older adults must consider the following:

(1) the basic components of a well-balanced diet for older adults

(2) how the normal physiologic changes of aging change nutritional needs

(3) how the normal physiologic changes of aging may interfere with the purchase, preparation, and
consumption of nutrients

(4) how cognitive, psychosocial, and pathologic changes commonly seen in aging impact one’s
nutritional status.

To assess nutritional adequacy and select interventions that promote good nutrition, nurses must be
knowledgeable about basic nutrition and diet therapy.

 Barriers

NUTRITION AND AGING

Nutritional needs do not remain static throughout life. Like other needs, older adults’ nutritional needs
are not exactly the same as those of younger individuals.

CALORIC INTAKE

Calories are units of heat that are used to measure the available energy in consumed food.

Because people’s energy requirements differ widely, the number of calories they require also differs
significantly.

When determining the adequacy of caloric intake, disease processes must be considered. Diseases that
result in restricted mobility and physical activity (e.g., arthritis and stroke) are likely to decrease caloric
needs. Other disease processes (e.g., cancer and critical illness) can greatly increase the body’s calorie
requirements,

because illnesses increase metabolism. Individuals suffering from diabetes mellitus require special
prescribed diets to control and treat the disease. This diet normally includes consistent carbohydrate
intake and balanced amounts of fats and proteins.

Many factors influence how many calories will be used by a person:

activity patterns, gender, body size, age, body temperature, emotional status, and the temperature of
the climate in which the person lives.

 Studies have shown that caloric needs in healthy individuals decrease gradually with age, as
there is a decrease in muscle and lean tissue mass and an increase in adipose tissue. With these
muscle and fat changes, the basal metabolic rate (the rate at which the body uses calories)
decreases.
 Body mass index (BMI) is a number calculated using a person’s weight and height that is a
reliable way to measure body fatness for most people. Using the BMI chart, you can determine
if someone is under-weight, within normal weight parameters, or obese
 College of Our Lady of Mt. Carmel
Bachelor in Science of Nursing III

NUTRIENTS

Although caloric needs often decrease with age, the need to include all of the various nutrients does
not. Therefore, foods high in nutritional value (nutrient dense) and relatively low in calories must be
selected to maximize the amount of nutrients the body receives while reducing the number of calories.

General recommendations from the U.S. Department of Agriculture (USDA) (2011) for the general
population include:

• Enjoy food but eat less of it

• Avoid oversized portions

• Increase intake of fruits, vegetables, and whole grains

• Choose low-fat or fat-free dairy products

• Reduce intake of sodium

• Drink water instead of sugary beverages

• Make physical activity an everyday occurrence

dietary reference intakes (DRIs) - More precise standards for measuring the nutritional adequacy of a
diet are found. These references contain specific recommendations for calories, macronutrients
(protein, carbohydrate, fat), water, fiber, minerals (iron, magnesium, manganese, zinc, etc.), vitamins,
and electrolytes.

Use of the DRIs requires careful weighing and measurement of portions and use of nutritional
references or complete nutrition labels that list every ingredient in detail.

Carbohydrates

Carbohydrates include sugars and starches that comprise approximately half of the standard American
diet. Carbohydrates provide a ready source of energy for the body and are divided into two categories:
simple and complex.

Simple carbohydrates are used most readily by the body because their bonds are easily broken. Table
sugar, honey, syrup, and candy are examples of simple carbohydrates.

Complex carbohydrates must be broken down into simple sugars before they can be used by the body.
This breakdown requires time and energy. Foods such as vegetables, whole grains, and fruits contain
complex carbohydrates.

The Institute of Medicine recommends that 45% to 65% of calories should come from carbohydrates,
with an emphasis on complex carbohydrates (USDA, 2010).

Proteins

Proteins are composed of amino acids, which are essential for tissue repair and healing.

According to Dietary Guidelines for Americans (2010), the DRI of protein for adult women is 46 g/day;
for adult men, the RDA is 56 g/day. Data from the National Health and Nutrition Examination Survey
reveal that 10% to 25% of women older than age 55 consume less than half of the recommended daily
amount of protein.

Increasing protein consumption has been linked with a lower incidence of frailty among older women
(health in Aging, 2014).

Tissue replacement and repair continue throughout life. Any condition in which tissue integrity is altered
(e.g., surgery and pressure ulcers) increase the amount of protein needed to aid in tissue repair. Red
meats, poultry, fish, eggs, and dairy products are good sources of complete proteins, which contain all
 College of Our Lady of Mt. Carmel
Bachelor in Science of Nursing III

of the amino acids necessary for making and repairing tissues. Plant foods, such as legumes (peas and
beans), nuts, and cereals (whole grains and rice), contain smaller amounts of incomplete proteins, which
do not individually contain all of the necessary amino acids.

Complementary proteins consist of two or more incomplete proteins that together provide adequate
amounts of essential amino acids.

Some foods that are high in protein, such as steak, ham, organ meats, egg yolks, hard cheese, and whole
milk, also contain large amounts of fats.

Excessive consumption of proteins with a high fat content can contribute to elevated blood levels of
cholesterol and triglycerides, which, in turn, contribute to plaque formation and atherosclerotic changes
in the blood vessels.

Atherosclerosis often results in hypertension and heart disease. For this reason, many physicians and
dietitians recommend that high-fat protein foods be restricted.

A person who is on a fat-restricted diet should consume low-fat proteins, such as fish and lean poultry,
as well as protein from plant sources, such as peas and beans.

Fats

It is recommended that fats be limited to approximately 20% to 35% of the total daily caloric intake.

This recommendation does not change with aging.

Fat is desirable because it adds flavor to food and provides a sense of fullness with a meal. Foods with
no fat would be unappealing, poor tasting, and not very satisfying.

The body incorporates fats into substances called lipoproteins, which contain cholesterol and proteins.

There are three important types of lipoproteins:

high-density lipoprotein (HDL), low-density lipoprotein (LDL), and very low-density lipoprotein (VLDL).

 LDL is primarily composed of cholesterol and is believed to contribute to blood vessel disease.
 VLDL is primarily composed of triglycerides and may contribute to vessel disease but to a lesser
extent.
 HDL, the so-called healthy fat, is primarily composed of protein that appears to protect against
blood vessel disease.

Vitamins

Vitamins are organic compounds found naturally in foods.

The fat-soluble vitamins include vitamins A, D, E, and K. Vitamin C and the B-complex vitamins are
water-soluble.

• Vitamin A deficiency: Poor wound healing, dry skin, and night blindness.

• Vitamin B6 deficiency: Neurologic and immunologic problems, elevated homocysteine levels (risk
factor for cardiovascular disease). Clinical manifestations of B6 deficiency may include nausea, vomiting,
loss of appetite, dermatitis, motor weakness, dizziness, depression, and sore tongue. Supplements of
vitamin B6 help reverse these problems.

• Vitamin B12 deficiency: Neurologic changes that affect sensation, balance, and memory; elevated
homocysteine levels. B12 deficiency can be related to inadequate protein consumption or physiologic
changes in digestion. Normal aging changes result in the decreased production of gastric acid and
pepsin, which are necessary for protein digestion. When less protein is digested, less B12 is available
 College of Our Lady of Mt. Carmel
Bachelor in Science of Nursing III

for absorption. Clinical manifestations of B12 deficiency can include vomiting, fatigue, constipation,
anemia, decreased memory, and depression. If detected early and treated with supplements, symptoms
may be reversible.

• Vitamin C deficiency: Weakness, dry mouth, skin changes, delayed tissue healing, atherosclerosis, and
decreased cognitive function.

• Vitamin D deficiency: Bone demineralization or osteoporosis, because it is essential for calcium

absorption; depression; immune system dysfunction. Vitamin D deficiency is more common in older
adults because of less exposure to the sun, reduced capacity of the skin to synthesize the vitamin, and
decreased dietary intake. Clinical symptoms include weakness, gait disturbance, and pain. Adequate
intake of vitamin D and calcium supplements can help prevent or even reverse the severity of this
problem. Research in Great Britain showed a 19% to 26% decrease in falls by older individuals taking
vitamin D in doses between 700 IU and 1000 IU daily.

• Vitamin K deficiency: Increased risk of fractures.

• Vitamin E deficiency: Immune dysfunction, memory problems. Vitamin E recently has been connected
to delaying the onset of symptoms in Alzheimer disease. The exact dose required to obtain maximal
benefits is under study.

Minerals

Minerals are inorganic chemical elements that are required in many of the body’s functions. Minerals
make up a small proportion of total body weight, yet a slight mineral imbalance can have serious effects.

Calcium, the most abundant mineral in the body, is necessary for bone and tooth formation, nerve
impulse transmission and conduction, muscle contraction (including cardiac function), and blood
clotting. The main dietary sources of calcium are milk and dairy products. Calcium is normally retained in
bone, with only a small amount (1%) found in the tissues and blood. With aging and with immobility, the
bones tend to lose calcium, resulting in osteoporosis.

abnormal amounts of calcium leave the bone, enter the bloodstream, and cause hypercalcemia, which is
an elevated level of calcium in the blood.

Hypercalcemia is seen with hyperparathyroidism, disuse atrophy, metastatic bone tumors, and vitamin
D excess.

Phosphorus is needed for normal bone and tooth formation, activation of some B vitamins, normal
neuromuscular functioning, metabolism of carbohydrates, regulation of acid-base balance, and other
physiologic processes.

Iron is found in the center of the heme portion of hemoglobin. Hemoglobin in the red blood cells
transports oxygen to and removes carbon dioxide from the cells. Without adequate amounts of iron,

the body cannot produce enough hemoglobin (6-2). Two forms of nutritional anemia are commonly
seen in older adults: iron-deficiency anemia and pernicious anemia.

Pernicious anemia is caused by a deficiency in intrinsic factor secreted by the stomach.

Sodium is a commonly occurring mineral and is one of the important elements in the body.

Potassium is the major intracellular ion in the body. Potassium ions play an important role in acid-base
balance, fluid and electrolyte balance, and (with sodium) normal neuromuscular functioning.

Zinc is a trace mineral that plays a role in protein synthesis. In adults, insufficient zinc may result in
delayed wound healing, impaired immune function, lethargy, skin changes, diminished sense of smell
and taste, and decreased appetite.
 College of Our Lady of Mt. Carmel
Bachelor in Science of Nursing III

FUNCTIONAL FOODS

Functional foods are foods that have been found to have overall health benefits and reduce risk factors
for chronic diseases or enhance body processes that benefit health (Woo, 2011). Most have cultural
origins and include soy, mushrooms, green tea, and black rice.

• Soy has been shown to decrease LDL and total cholesterol, increase HDL, increase bone density,
stabilize blood glucose, and reduce breast cancer risk.

• Mushrooms can enhance immunity, guard against tumors, decrease inflammation, and improve blood
lipid profiles.

• Green tea can reduce risk of cardiovascular disease and stroke, possibly guard against cancer and
Parkinson disease, and stabilize blood sugar. Even drinking 3 cups of ordinary tea daily has been shown
to decrease stroke risk.

• Black rice is rich in phenolic compounds (antioxidants) and minerals. It has been shown to reduce body
mass index (BMI) and body fat and increase HDL cholesterol.

WATER

Water is essential for life. Humans can survive for many days without food but not without water.

Water is normally lost through urination, perspiration, respiration, and defecation. Abnormal fluid loss
occurs with diarrhea, vomiting, diaphoresis, gastric suctioning, and wound drainage; essential minerals
are often lost along with the water. The amount of fluid taken into the body should be in balance with
the amount eliminated from the body. This is referred to as fluid balance.

MALNUTRITION AND THE OLDER ADULT

In America, where obesity is an increasing problem, undernutrition and malnutrition are significant
problems for the older adult population.

Malnutrition is defined as a disorder of nutrition resulting from unbalanced, insufficient, or excessive

diet or from impaired absorption, assimilation, or use of food.

The risk for developing nutritional deficiencies increases with aging, but determining nutritional status
can be challenging. Older adults who appear to be healthy may have unhealthy nutritional practices.

An obese older adult may be malnourished, whereas someone thin may be well nourished.

Estimates of the number of malnourished older adults vary depending on the screening tool used, but
generally fall within the following ranges:

• Older adults in the community: 45%

• Older adults cared for at home: 45% to 51%

• Hospitalized older adults: 54% to 82%

• Older adults in residential care facilities: 84% to 100%

Frailty syndrome in older adults, a syndrome characterized by increased susceptibility to stressors that
can lead to negative health outcomes and functional impairment.
 College of Our Lady of Mt. Carmel
Bachelor in Science of Nursing III

 FACTORS AFFECTING NUTRITION

IN OLDER ADULTS The nutritional status of older adults living in the community is affected by
physiologic, economic, and social factors. Lack of appetite is commonly reported. The reasons for this
are multiple and form the basis of risk assessment. The more risk factors present, the greater the
likelihood of the older person experiencing nutritional inadequacy. Overall nutritional status will be
affected if any of these problems persists for a significant period of time.

Physiologic risk factors include the following:

• Chronic health factors such as chronic obstructive pulmonary disease, chronic heart failure, arthritis,
dementia, and many others can interfere with obtaining and preparing adequate nutritional food.

• Alcoholism is suspected to be a risk factor in a larger percentage of older adults than is commonly
recognized.

• Sensory changes can cause problems with safe preparation and storage of food.

• Pain, whether it is chronic or acute, can interfere with an older person’s appetite and desire toprocure,
prepare, and consume food.

• Medications can cause an unpleasant change in the taste of food; suppress appetite; or cause nausea
and vomiting. Many older adults complain of a “metallic taste” that interferes with the enjoyment of
food.

• Problems with chewing, swallowing, or digesting are common causes of impaired nutrition.

• Malabsorption caused by decreased production of digestive enzymes can interfere with protein
breakdown and absorption of vitamin B12, calcium, and folate.

Economic risk factors include the following:

• Cost of food is a concern for many older adults with limited income.

• Difficulty getting transportation to obtain food is a serious problem for older adults, particularly those
who live alone.

• Obtaining an appropriate variety and sufficient amount of food can be difficult for older adults. Most
foods are packaged in sizes appropriate for families of four or more.

Social risk factors include the following:

• Depression is a common reason for decreased appetite in older adults. Grief, failing health, loss of
independence, and many other factors can cause depression.

Loneliness or social isolation is one of the more common risk factors for nutritional problems in older
adults.

• Lack of motivation to cook is commonly an issue for older adults. Preparing food for one or two people
can be more difficult.
 College of Our Lady of Mt. Carmel
Bachelor in Science of Nursing III

ASSESSMENT/DATA COLLECTION

• Does the person appear noticeably overweight or underweight?

• Does clothing appear abnormally loose or tight?

• What are the person’s current height and weight?

• Is the BMI within normal limits? (See Figure 6-1.)

• Has the weight significantly increased or decreased

in the past 3 to 6 months? If so, how much has it

changed?

• How long has this weight change been occurring?

APPETITE CHANGES

• How does the person describe his or her appetite?

• Does the person feel that his or her appetite has

changed? If yes, why does the person think this is happening?

• How does food taste to the person?

• What does the person like or dislike about the meals he or she eats (or is served)?

• What would the person prefer to eat?

• Are there any cultural food preferences that are not being recognized?

• Are there any dietary restrictions? Are they understood?

• Does the person complain of any of the following before, during, or after meals: nausea or
hyperacidity? Strange taste in the mouth? Eructation or flatulence? Chest pain?

• Does the person show an unusual reaction to any foods (e.g., dairy products, nuts, and shellfish)? Is
the person depressed?

NUTRITIONAL INTAKE

• Are the hemoglobin, hematocrit, and RBC parameters within normal limits?

• Has the blood sugar level been taken? Was this a fasting blood sugar? If taken at a non-fasting time,
was it before or after a meal? How long before or after?

• Are electrolyte levels (e.g., sodium, potassium, and calcium) within normal limits?

• Is the serum albumin level within the normal range?

 College of Our Lady of Mt. Carmel
Bachelor in Science of Nursing III

 HEALTH CARE TEACHING PLAN

• Serve meals in an attractive manner. Foods that are well prepared and served in an attractive manner
are more appealing.

• Ask family members to bring the person’s favorite dishes from home. Family favorites are rarely on the
menu in an institutional setting.

• Provide a social environment for meals by encouraging older adults to eat in the dining room. The
nature of meals tends to be social.

 Prepare food by opening cartons, buttering toast, or performing other activities that may be
difficult for the older person. Problems setting up food and opening cartons may lead older
adults to skip or avoid certain foods.

• Avoid hurrying the individual during meals. If an older person eats too rapidly, indigestion, heartburn,
or regurgitation may result. If rushed, many older individuals stop eating before they are truly satisfied.

 Time medication administration to not interfere with meals. Some medications leave a bad taste
in the mouth or otherwise upset the individual. Refer individuals for special counseling if
emotional difficulties are interfering with appetite. Individuals with extreme grief and emotional
disturbances may require special nutritional approaches. Consult therapists trained to deal with
eating disorders to determine the most effective interventions.

• Assist in the selection of low-calorie foods. Decreasing caloric intake helps the person lose weight.
Foods high in bulk and low in calories, such as fresh fruits and vegetables, provide a sense of fullness
without a sense of deprivation.

• Plan low-calorie snacks into the daily routine. Snacks such as diet beverages and unbuttered popcorn
are appropriate for older individuals unless they have a medical condition that contraindicates their
inclusion.

• Increase diversional activities to decrease snacking. Some older and younger people snack when they
are bored.

• Encourage increased activity levels. Increased activity helps burn calories. Walking is an exercise
tolerated well by most older individuals, and it is effective as a means of weight reduction.