Geriatric Medical Nutrition Therapy Education

By, Lindsay K. Johnson, RD, LDClinical Registered Dietitian, BJEC

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What you will learn

How nutritional needs change as we age Common disease process that effect nutrition Liberalized diets Weight management as we age Nutritional supplements Fortified foods Appetite stimulant Heart Disease, low salt diet Kidney Disease, lower potassium diet Diabetes, consistent carbohydrate (lower sugar diet) Social activities and affects on wellness Take – home tips

As we age, the rate at which we burn calories (our metabolism) slows down. We naturally lose muscle mass and some organ systems also slow leading to new diseases.

Lack of protein can lead to bone density loss (osteoporosis) and weaken the immune system. As we age it can be harder to process heavy meats, for example a steak. The stomach produces less acid making it harder to break down well cooked animal proteins. This can result in less vitamin B12 being absorbed and potentially anemia even though the same amount of meat is being consumed in the diet as when you were younger.

Dehydration is also more common in seniors due to a reduced sense of thirst. The part of the brain (hypothalamus) which controls our thirst mechanism slows as we age. While some overconsume water thinking “more water is better” causing an imbalance in the nerves, muscles, and bodily tissues which can be dangerous.

An average older female that requires 1,600 calories per day would need about 6.5 cups of water each day. For a man burning 2,200 calories per day the requirement would be around 8 cups. Physical activity, hot environments, radiation therapy or having a fever can add an addition 2-4 cups of water needed per day.

Nutritional Needs

Fiber

Regulates the digestive system, can lower cholesterol, and help control blood pressure. Sources of fiber: fruits, vegetables, whole grains, and legumes.

Omega-3

Foods rich in omega-3 can lower elevated triglyceride levels, and help with stiffness and joint pain. Sources include: salmon, halibut, herring, sardines, tuna, walnuts, flaxseed, and canola oil.

Folate/folic acid Is a B vitamin that helps maintain your metabolism and creates energy for your body.

Many breakfast cereals are fortified with folic acid and other key vitamins and minerals. Folate is also found in leafy greens “think foliage.”

Calcium Vital to maintaining bone density, calcium is particularly important for women as their

bones thin with age. Some sources include milk (fortified OJ or almond milk), kale, broccoli, sardines, edamame, tofu and fortified nutritional supplements.

Vitamin D Vitamin D aids in the absorption of calcium. Food sources include: milk or fortified

almond milk, yogurt, kale, or broccoli. Sunlight on the skin for 15 - 30 minutes per day, can also help provide a natural source of vitamin D.

Nutritional Needs continued

Potassium

• Aids in maintaining muscle tissue and facilitates heart and kidney functions. It also helps lower blood

pressure and decreases the risk of stroke.

• Food sources include: avocados, bananas, spinach, and sweet potatoes

• If you are taking a diuretic, you may be vulnerable to potassium loss through frequent urination. Often a

potassium supplement is prescribed by your physician to counter this effect.

Magnesium

• Can be very calming for the body. If sleeping problems and sore achy muscles are common an increase in

magnesium in the diet may help. Food sources include: pumpkin seeds, sunflower seeds, whole grains,

oatmeal and bananas.

Seniors and alcohol?

• If you’re drinking alcohol with a meal, it is competing with B vitamins for absorption. This can lead to anemia

over time.

• Other risks include: liver damage, balance problems which can lead to a fall, and mixing medications and

alcohol can be deadly (talk to your doctor).

• While some health benefits are noted with moderate consumption of alcohol:

• Women: one standard can of beer OR one 4-6 oz. glass of wine OR 1.5 oz. of hard liquor

• Men: two standard cans of beer OR two 4-6 oz. glasses of wine, OR 3 oz. of hard liquor

Nutritional Needs continued

Heart disease, kidney disease, chronic obstructive pulmonary disease, obesity and diabetes are common conditions that manifest as we age.

Research supports following diets similar to DASH (Dietary Approach to Stop Hypertension) or Mediterranean to aide in heat disease management

Lower in sodium and saturated/trans fats from packaged processed foods

Higher in potassium, fiber, antioxidants, and heart healthy fats

Fluid restrictions are ordered by your Physician as needed in some cases of congestive heart failure to aide in decreased edema (fluid retention on the body) and potential shortness of breath

Lower potassium and salt diets are often recommended if you have kidney disease. With less urine output, more fluids can buildup.

Exercise has heart healthy cholesterol lowering benefits and can help reduce obesity related risk factors. However, as we age we are often less ambulatory with arthritis and decreased bone density, osteoporosis.

Disease Processes as We Age

Liberalized Diets Research supports a more liberal approach to diets when you are 65 years old and greater. The

benefits included: lower mortality rates, better management of blood sugar levels with diabetes, improved appetite with more pleasurable foods which helped prevent unplanned weight loss and pressure ulcers.

Unless one is symptomatic, with biochemical lab results indicating the need for a dietary restriction, medical nutritional therapy is now recommending a “regular diet.”

Unintended weight loss is linked to increased mortality in long-term-care facilities. Weight loss of 5% or more within 30 days is correlated with a tenfold increase in the risk of death. A loss in appetite is related to increased protein-energy undernutrition with side effects: loss of lean muscle mass, increased skin breakdown, infections, lower immune system, anemia, falls and bone fractures.

Registered Dietitians specialize in nutrition assessments to help prevent sig unplanned weight loss or gain:

Review of food/nutrition related history, preferences, emotions and eating patterns

Biochemical data, medical tests, prescribing diets/nutritional supplements

Anthropometric measurements (height, weight, BMI, nutrient needs, wellness goals)

Typically a safe weight gain rate is 0.5-2.0 pounds per week however should be customized to

meet your unique needs, measurements based on your usual body weight (UBW) are preferred.

Many factors can effect your weight trends: time of day you weigh yourself, clothing worn, if you

have used the restroom recently, or consumed a large meal and/or a salty meal, medications

and health conditions that include heart and kidney disease or use of diuretic therapy.

It is best to weigh yourself at the same time of the day, after using the restroom and wearing

the same clothing.

If you have a history of heart or kidney disease, keep in mind it is normal for you to have larger

weight fluctuations , however talk to your doctor about what is a safe weight fluctuation specific

to your conditions.

If you have been told you need a specific texture or thickened liquids in your diet, please check

with your Speech Therapist regarding safety of certain foods.

Weight Management in Seniors

Research suggest a BMI >18.45 provides reduced health risk related to being underweight.

Safe weight gain can be achieved by consuming an extra 500-750 calories (kcal) per day.

It is helpful to work with a Dietitian to learn how many calories per day are recommended

to achieve your specific health goals and what nutritional supplements can meet your

unique needs while honoring your food preferences.

Commercial supplements help provide more protein and calories in the diet for example:

Ensure, Boost, Thrive ice cream, lower sugar Boost (glucose control) or Glucerna. These

supplements range from 250-500 calories per severing added to your day.

Some may prefer a more natural approach or a “fortified foods first approach” where extra

calorie dense foods are added with meals (ie. olive oil, cream, butter, smoothie).

Nutritional Supplements

Nutritional Supplements cont.

At BJEC the following supplements are offered:

Thrive ice cream supplement (No Sugar Added option as well)

Boost (Boost glucose control, option for diabetic blood sugar management)

Boost Breeze (juice-like supplement with added protein)

Novasource Renal (special formula for kidney disease)

Resource 2.0 (a very high “calorie dense” supplement)

Arginaid (special formula for wound healing)

Fortified foods diet:

Our fortified foods protocol offers an additional (150-450 calories) per meal, the higher

range includes our fortified muffin (which can be added with breakfast).

The other fortified food items offered on this diet include: super-cereal (oatmeal, butter,

syrup), fortified vegetables (a blend of olive/canola oil), or extra sauce/gravy/butter.

Fortified Foods

Food Item Portion Size Calories per portion

Avocado 2 medium slices 80-100

Canola oil 1 Tablespoon 125

Olive oil 1 Tablespoon 125

Half and half ¼ cup 80

Butter 1 Tablespoon 100

Nut butters 1 Tablespoon 100Nuts/seeds (*chopped/ground) ¼ cup 150-200Chocolate 2 squares 80-100Mayonnaise 1 Tablespoon 100Cheese 1 slice, ¼ cup 80-120Gravy sauce ¼ cup – ½ cup 60-120Salad dressings 1-2 Tablespoons 60-180

A “fortified foods diet” takes extra time and planning ahead. Sometimes commercial

nutritional supplements are better because of their convenience and ease of drinking

when weakness and loss of appetite are a common side effects of the aging process.

If you want to try a fortified foods diet at home, here are some suggestions: Add one

food item from the list below at every meal/snack to promote gradual weight gain:

Appetite Stimulant

Remeron (Mirtazapine) Appetite Stimulant, Weight Gain Goals

Remeron is most commonly prescribed as an antidepressant, however research shows it can also

help improve a poor appetite.

• It is usually taken one time a day, at bedtime, without food. You should follow the prescribed dose

of your doctor to help meet your specific health goals with the least potential for side effects.

How Remeron Causes Weight Gain (Theories)

• Increased appetite: Some doctors prescribed Remeron for underweight and/or under-eating patients. This drug is very effective at improving appetites within the first month of treatment. Approximately 17% notice an increased appetite.

• Social eating: With improved mood, one is more likely to hang out with friends and participate in social activities that include food.

• Side effects: If you feel fatigued, you are less likely to participate in active activities. With more food intake and less movement, weight gain occurs.

• Taste improvement: Some depressed persons report food doesn’t taste as good. Once depression was treated food began to taste better.

Heart Disease, Low Sodium Diet

One side effect of CHF is weight fluctuations because fluids build-up or “congest” in the body

Weight gain of 2-3 pounds in 24 hours

Weight gain of 5 or more pounds in 1 week

Call your Doctor or notify your clinical team immediately

Your Doctor may prescribe a diuretic to help remove excess

fluid from your body

Regular (NAS) Diet

This diet includes regular food items with salt added during the cooking process

You do not receive a salt packet on your tray

You can request Ms. Dash salt alternative with meals

Depending on what you order this diet may provide 2100-2800mg sodium per

day

Kidney Disease, Lower Potassium Diet

Depending on your unique needs, it may be helpful to limit sodium, potassium, and phosphorus in the diet.

Too much sodium can potentially affect blood pressure, increase thirst, and cause fluid retention (edema). Edema might be noticed in the lower legs, ankles, stomach or hands. If you notice edema, notify your nurse.

High Potassium can potentially affect your heart. Research suggests a liberalized renal diet prevents unplanned weight loss with more

favorite foods items still included in the daily diet. This can also help improve lab values that the dialysis center monitors routinely related to nutritional status and health.

Our Liberal Renal diet helps meet these recommendations by including the

following modifications:

No oranges or orange juice

No prunes or prune juice

No bananas

½ c milk per day or 1 small dairy serving/day

*No added salt (No salt packet served with the meal, option to add this to

the liberal renal diet)

Diabetes, Consistent Carbohydrate (lower sugar diet)

Research shows a carbohydrate consistent meal plan best manages diabetes:

This includes 3-4 servings of carbohydrates per meal or 45-60g per

meal.

This is a general guideline only and should be customized based upon

height, weight, activity levels and most recent A1C (lab test that show

how well you have been managing your blood sugars over the past 3-4

months).

Our diabetic diet helps meet these recommendations by including the

following modifications:

Juice only served at breakfast (4 oz)

Sugar free options, diet drinks, Splenda (artificial sweeteners)

Smaller dessert portions

No added bread rolls with meals

Social Activities and Affects on Wellness

According to the American Therapeutic Recreation Association: “Recreational therapy is a service used to restore, remediate and rehabilitate a person’s level of functioning and independence in life’s activities, to promote health and wellness as well as reduce or eliminate the activity limitations and restrictions to participation in life situations caused by an illness or disabling condition.”

At BJ Extended Care, our community members make dramatic improvements throughout their treatment plan when they rediscover their leisure interest.

Our Certified Therapeutic Recreation Specialists offer a variety of leisure resources and therapies for the community BJ Extended Care serves. • Fitness Programs – Improves Mental Health, produces optimal function of muscles,

bones and joints, creates social relationships • Deep Breathing – Alleviates stress, improves confidence, assists in blood circulation

and helps relaxes a person’s physical and mental well-being • Outdoor Socials – Eliminates fatigue, improves memory, boosts the immune system • Cooking Club – Expresses creativity, increases fine motor skills, reminiscing therapy

Take – Home Tips At BJEC we take into account the whole person and evidenced based research

when it comes to your nutrition and wellness plan of care.

Our Registered Dietitian conducts an initial nutritional assessment to best customize your food preferences and offers nutrition education as needed.

Our clinical team offers weekly weight monitoring to help reduce unplanned significant weight changes.

If weight loss does occur unplanned, the Dietitian can review nutritional supplement options and/or fortified foods with you.

Some research supports more liberalized amounts of salt in the diet and better management of symptoms related to heart disease.

If you have diabetes and need help managing your blood sugars and/or desire some weight loss a modification can be added to your diet order.

Staying involved with group activities and fitness can promote a healthy appetite and help manage a weight you feel your best at.

References1. Mahan, L. Kathleen., Escott-Stump, Sylvia., Raymond, Janice L. Krause, Marie V., eds. Krause’s Food & The Nutrition Care Process.

St. Louis, Mo. : Elsevier/Saunders, 2012. Print.

2. Simmons SF, Lim B & Schnelle JF. (2002). Accuracy of Minimum Data Set in identifying residents at risk for undernutrition: Oral

intake and food complaints. Journal of the American Medical Directors’ Association, 3 (May/June).

3. ADA Position Paper Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long-Term Care 2005.

4. Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC.

5. New Dining Practice Standards, Pioneer Network Food and Dining Clinical Standards Task Force Aug. 2011.

6. Academy of Nutrition and Dietetics. Adult Nutrition Care Manual, “Unintended Weight Loss,”

http://www.nutritioncaremanual.org.

7. Kaiser Permanente, Congestive Heart Failure, http://www.wa.kaiserpermanente.org.

8. Mayoclinic, Congestive Heart Failure, https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-

20373142; Sept., 11, 2017.

Thank you!

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