HANDBOOK OF CLINICAL NUTRITION AND AGING

NUTRITION � AND � HEALTHAdrianne Bendich, Series Editor

Handbook of Clinical Nutrition andAging,Second Edition, edited byConnieWatkins

Bales and Christine Seel Ritchie, 2009

Handbook of Nutrition and Pregnancy, edited by Carol J. Lammi-Keefe, Sarah

Collins Couch, and Elliot H. Philipson, 2008

Nutrition and Health in Developing Countries, Second Edition, edited by

Richard D. Semba and Martin W. Bloem, 2008

Nutrition and Rheumatic Disease, edited by Laura A. Coleman, 2008

Nutrition in Kidney Disease, edited by Laura D. Byham-Gray, Jerrilynn D.

Burrowes, and Glenn M. Chertow, 2008

Handbook of Nutrition and Ophthalmology, edited by Richard D. Semba, 2007

Adipose Tissue andAdipokines inHealth andDisease, edited byGiamila Fantuzzi and

Theodore Mazzone, 2007

Nutritional Health: Strategies for Disease Prevention, Second Edition, edited by

Norman J. Temple, Ted Wilson, and David R. Jacobs, Jr., 2006

Nutrients, Stress, and Medical Disorders, edited by Shlomo Yehuda and David I.

Mostofsky, 2006

Calcium in HumanHealth, edited byConnieM.Weaver and Robert P. Heaney, 2006

Preventive Nutrition: The Comprehensive Guide for Health Professionals, Third

Edition, edited by Adrianne Bendich and Richard J. Deckelbaum, 2005

The Management of Eating Disorders and Obesity, Second Edition, edited by David

J. Goldstein, 2005

Nutrition and Oral Medicine, edited by Riva Touger-Decker, David A. Sirois, and

Connie C. Mobley, 2005

IGF and Nutrition in Health and Disease, edited by M. Sue Houston, Jeffrey M. P.

Holly, and Eva L. Feldman, 2005

Epilepsy and the Ketogenic Diet, edited byCarl E. Stafstrom and JongM. Rho, 2004

Handbook of DrugNutrient Interactions, edited by Joseph I. Boullata and Vincent T.

Armenti, 2004

Nutrition and Bone Health, edited by Michael F. Holick and Bess Dawson-Hughes,

2004

Diet and Human Immune Function, edited by David A. Hughes, L. Gail Darlington,

and Adrianne Bendich, 2004

Beverages in Nutrition and Health, edited by Ted Wilson and Norman J. Temple,

2004

HANDBOOK OF CLINICAL

NUTRITION AND AGING

Second Edition

Edited by

CONNIE WATKINS BALES, PhD, RD,

FACNDurham VAMedical Center and Duke University Medical Center,Durham, NC

and

CHRISTINE SEEL RITCHIE, MD,MSPHBirmingham VA Medical Center, University of Alabama atBirmingham, Birmingham AL

Foreword by

Former Director, National Resource Center on Nutrition, PhysicalActivity and Aging, Florida International University, Miami, FLPast President, The American Dietetic Association

NANCY S.WELLMAN,PhD,RD,FADA

Editors

Connie Watkins BalesDurham VA Medical Center and DukeUniversity Medical CenterDurham, NC

Christine Seel RitchieBirmingham VA Medical CenterUniversity of Alabama at BirminghamBirmingham, AL

Series Editor

Adrianne BendichGlaxoSmithKline Consumer HealthcareParsippany, NJ

ISBN 978-1-60327-384-8 e-ISBN 978-1-60327-385-5DOI 10.1007/978-1-60327-385-5

Library of Congress Control Number: 2009920207

# Humana Press, a part of Springer ScienceþBusiness Media, LLC 2004, 2009All rights reserved. This work may not be translated or copied in whole or in part without the written permission ofthe publisher (Humana Press, c/o Springer ScienceþBusiness Media, LLC, 233 Spring Street, New York, NY10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with anyform of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilarmethodology now known or hereafter developed is forbidden.The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are notidentified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietaryrights.

Printed on acid-free paper

springer.com

Dedications

Connie Watkins Bales dedicates this volume to her children, Audrey Ashburn BalesBritton and William Brittain Bales, in appreciation of all the ways they have enriched

her life and with enthusiastic anticipation of all they are becoming.

Christine Seel Ritchie dedicates this volume to the memory of her father, David JohnSeel, MD, FACS, a man of compassion who was devoted to life-long learning.

Acknowledgements

CWB would like to recognize and thank Tien Thi Ho who, as a Duke student assistant,worked tirelessly for two academic years on the management and copy editing of this text,contributing substantially to its quality. Thanks also to Justin (Cody) Maxwell and CarolineFriedman for their contributions to this project. CWB and CSR thank our series editor,Dr. Adrianne Bendich, for her encouragement to begin what has become an ongoing andexciting set of encounters with critical clinical issues in geriatric nutrition and the gifted anddedicated scientists who study them. Without the creative contributions of these scientist-authors, this book would not have been possible.

vii

Series Introduction

The Nutrition and Health series of books have, as an overriding mission, to providehealth professionals with texts that are considered essential because each includes (1) asynthesis of the state of the science, (2) timely, in-depth reviews by the leading researchers intheir respective fields, (3) extensive, up-to-date fully annotated reference lists, (4) a detailedindex, (5) relevant tables and figures, (6) identification of paradigm shifts and the con-sequences, (7) virtually no overlap of information between chapters, but targeted, inter-chapter referrals, (8) suggestions of areas for future research and (9) balanced, data-drivenanswers to patient/health professionals questions that are based upon the totality of evidencerather than the findings of any single study.

The series volumes are not the outcome of a symposium. Rather, each editor has thepotential to examine a chosen area with a broad perspective, both in subject matter as well asin the choice of chapter authors. The international perspective, especially with regard topublic health initiatives, is emphasized where appropriate. The editors, whose trainings areboth research and practice oriented, have the opportunity to develop a primary objective fortheir book; define the scope and focus; and then invite the leading authorities from aroundthe world to be part of their initiative. The authors are encouraged to provide an overview ofthe field, discuss their own research and relate the research findings to potential humanhealth consequences. Because each book is developed de novo, the chapters are coordinatedso that the resulting volume imparts greater knowledge than the sum of the informationcontained in the individual chapters.

‘‘Handbook of Clinical Nutrition and Aging, Second Edition’’ edited by Connie WatkinsBales and Christine Seel Ritchie fully exemplifies the Nutrition and Health Series’ goals. Thefirst volume of the handbook, published in 2004, was acknowledged by reviewers as the mostcomprehensive volume available concerning the role of clinical nutrition in preserving thehealth of older adults – especially those suffering from established chronic disease. The secondedition is very timely as the fastest growing population in the US as well as globally is thoseover 60 years of age and especially the oldest-old, those over 80 years of age. This importanttext provides practical, data-driven options to enhance this at-risk population’s potential foroptimal health and disease prevention with special emphasis on secondary disease preventionand therapeutic nutritional interventions. The overarching goal of the editors is to providefully referenced information to health professionals, so that they may enhance the nutritionalwelfare and overall health of their older adult clients and family members. This excellent, up-to-date volume will add great value to the practicing health professional as well as thoseprofessionals and students who have an interest in the latest information on the science behindthe aging process, and the potential for nutrition to modulate the effects of chronic diseasesand conditions that are widely seen in the geriatric population.

ix

Drs. Bales and Ritchie, who have edited the first and second editions, are internationallyrecognized leaders in the field of clinical nutrition and aging. Both editors are excellentcommunicators and they have worked tirelessly to develop a book that continues to be thebenchmark in the field because of its extensive, in-depth chapters covering the mostimportant aspects of the complex interactions between cellular functions, diet and nutrientrequirements and their impact on the chronic diseases as well as the acute conditions that canadversely affect the quality of life and health of older individuals. The editors have chosen 40of the most well-recognized and respected authors, internationally distinguished researchers,clinicians and epidemiologists, who provide a comprehensive foundation for understandingthe role of nutrients and other dietary factors in the clinical aspects of nutritional manage-ment of the elderly.

Hallmarks of all the 29 chapters include complete explanations of terms, with theabbreviations fully defined for the reader, and consistent use of terminology betweenchapters. Key features of this comprehensive volume include the informative bulletedsummary points and key words that are at the beginning of each chapter and appendicesthat include a detailed list of relevant nutrition resources, including lists of books, journalsand websites. Glossaries of terms and abbreviations are provided as needed and recommen-dations for clinicians are included at the end of relevant chapters. The volume contains morethan 45 detailed tables and informative figures, an extensive, detailed index and more than1100 up-to-date references that provide the reader with excellent sources of worthwhileinformation about nutrition options to help maintain the health of seniors.

The first section of the volume contains three chapters that examine overarching issues fornutritional well-being in later life. The first chapter examines the complex factors that affectfood choices. As one ages, the social interactions at mealtimes greatly affect food choices andintake. Also relevant is where the meals are consumed – in the home, in a hospital or nursinghome or other type of institution, as examples. National feeding programs available in theUS are described and relevant details about how these affect the access to food for the elderlyare reviewed. The second chapter reviews the role of behavior modification in assuring thebenefits of therapeutic nutritional changes. Two major determinants of success in adherenceto dietary compliance are enhancement of patient knowledge and understanding of the valueof the change for their own health and secondly, enhancement of patient confidence thatthey can make the changes and maintain them over the long term. Six behavioral theories arediscussed in detail and helpful educational materials are also provided in this informativechapter. The third chapter highlights changes in population demographics in both thedeveloped and developing world, the so-called ‘‘global graying’’ attributed to the combina-tion of lower birth rates and increased longevity. A detailed discussion of demographics, dietand disease trends in China serves as an example of the potential effects of the Westernizeddiet on causes of death as they shift from infectious to chronic diseases associated withobesity. As in 36 other developing countries, in China overweight exceeds underweight as anutritional problem. Although population growth has been curtailed due to the one child/family policy, lifespan has increased dramatically in the past 40 years. There are currentlymore than 100 million Chinese who are 65 years or older, and that number is increasingannually (from 8% now to 24% of the population by 2050). At present, China has morepeople 65 and older than all European countries combined. Family care of elderly parentsremains the norm in China and may be a major factor that differentiates elder care in China

x Series Introduction

from that seen in the US and other Western cultures. However, urbanization and smallerliving spaces may lead to changes in the care of older family members in future generations.

The second section deals with the fundamentals of nutrition and geriatric syndromes in10 chapters. The first chapter in this section reviews the majority of nutrition screening toolsavailable for dietary intake assessment geared to seniors and examples are included in thenine tables. Tools for assessment of frailty are also discussed. The most critical informationfor assessment of overall nutritional status remains body mass index and recent weight loss.Sensory signals, including taste and smell, are key factors affecting the nutritional status ofseniors and we are reminded in Chapter 5 that many of the medications that are commonlytaken as we age affect these senses negatively. Visual and auditory losses also affect responsesto food and eating experiences. There are somatosensory changes with aging that result inlowered oral, touch and other temperature-related sensations. A separate chapter reviews therole of certain environmental factors, such as smoking and sunlight exposure, in increasingthe risk of vision loss. The latest data on the potential for essential nutrients to preventcataracts and age-related macular degeneration – the two major causes of blindness in theelderly – are included in detailed tables. Nutrients reviewed include vitamins C and E,carotenoids including lutein and zeaxanthin, zinc and omega-3 fatty acids. The recommen-dation is to consume diets that are rich in these micronutrients. To this end, extensive tableslisting foods that contain these nutrients are included.

The important changes that occur throughout the gastrointestinal tract, beginning in themouth, are outlined in the seventh comprehensive chapter. Topics such as dysphagia,gastroesophageal reflux disease (GERD), gastritis, ulcers, diarrhea, fecal incontinence,constipation, colitis, inflammatory bowel disease, lactose intolerance, GI bleeding, anemiaand hepatitis are all discussed and clinical recommendations are provided. There is animportant chapter on the changes in the stimulus for thirst and potential for dehydration inthe elderly. Deficiencies in sodium and certain trace minerals and electrolyte imbalances thatmay be drug, illness or age induced are reviewed.

Nutritional frailty, which is characterized by the loss of both muscle and fat, is often theconsequence of unintentional progressive decreases in food intake in the elderly. Nutritionalfrailty differs from sarcopenia and cachexia, and, thus, each of these conditions thatsignificantly affect health in the aging population is given its own in-depth chapter. Incontrast to the loss of weight in the overweight or obese adult <65 years that is associatedwith reduced mortality risk, even a small loss of weight over age 65 is associated with anincreased risk of death. The difference may be due to the change in body composition inolder adults with the replacement of muscle with fat and the loss of bone. There may also bea loss of appetite and hormonal changes may also increase the potential for unintendedweight loss. Information is given about the interactions between physiological, psychologicaland socioeconomic factors that may increase the risk of weight loss. Guidance is alsoprovided on the introduction of nutritional supplements and drugs that may enhanceappetite, and enteral and parenteral nutrition options in older adults who continue to loseweight. Sarcopenia, which is defined as age-related loss of skeletal muscle mass, is mostprevalent in individuals who consume low protein diets and who are sedentary, but occursalmost universally as adults grow older. Lower body exercises that include resistanceactivities and protein-rich diets may help to avert the loss of muscle, functional impairmentsand loss of mobility seen in those with muscle loss. Cachexia includes sarcopenia and,because of its relevance to aging, is discussed in Chapter 11. Cachexia, the wasting of skeletal

Series Introduction xi

muscle and loss of protein and energy stores resulting from disease, is directly related toinflammatory states such as seen in immune-related diseases and cancer. In contrast tostarvation, which can be reversed with increased intake, cachexia is driven by inflammatorycytokines that reduce hunger that is not abated with provision of food. The use of anti-inflammatory agents is discussed. An often seen consequence of cachexia in bed-riddenelderly is pressure sores. The chapter on pressure ulcers documents the strong associationbetween nutritional status and incidence, progression and severity of these sores. The reviewof macronutrient and micronutrient interventions to prevent and/or treat pressure soresconcludes that general nutritional support can help to prevent diet deficiencies and this mayor may not affect the progression of pressure sores. The final chapter in this section addressesthe sensitive issue of provision of nutrients at the end of life. Careful consideration must begiven by family members in consultation with health providers concerning the legal andethical distinction between acts of omission and acts of commission with regard to terminalnutrition and hydration. Religious considerations may also affect decisions about initiatingartificial nutrition and hydration. Nutritional support for end-stage cancer patients withcachexia has not yet been shown to improve survival. Some studies have found thatterminally ill patients are neither hungry nor thirsty and small amounts of food and liquidsatisfy their needs. However, decisions about tube feeding for patients with terminal stagesof Alzheimer’s or other dementias may have more emotional than objective considerations.The chapter provides valuable guidance to attending physicians as well as caregivers of theterminally ill.

The third section of the volume relates to common clinical conditions seen in the geriatricpopulation. The first chapter in this section looks at the importance of dental health to theoverall nutritional status in the elderly. The major issues are dental and root caries, period-ontal disease and tooth loss; loss of saliva (xerostomia) impacts these factors as well asaffecting the ability to swallow food. Survey data confirm that about 1/3 of adults 75 yearsand older have no teeth (edentulous). The incidence of oral cancers and consequentmortality increases above age 65. Diet is implicated in all aspects of oral health and diet-related diseases such as diabetes increase the risk of tooth loss whereas lifestyle habits, such assmoking, increase the risk of head and neck cancers and are linked to lowered diet quality;oral cancer therapies also can further decrease nutritional status.

Obesity is a common global clinical condition and is also seen in the elderly. Obesity isassociated with increased risk of mortality and morbidity, including decreased mobility anddecreases in other activities of daily living. Gradual, modest weight loss is recommended inChapter 15; however, this should include an exercise program to preserve muscle mass andsufficient calcium and vitamin D to help counteract any attendant bone loss. Along with theincreased prevalence of obesity in the elderly, we see increased prevalence of diabetes; almosthalf of individuals with self-reported diabetes are 65 years or older. Over 40% of US adultsover 70 years have been diagnosed with metabolic syndrome. Diabetes, and its co-morbid-ities, such as decreased vision and depression, can adversely affect diet quality. Both type 1and type 2 diabetes diagnoses, treatments, and dietary and lifestyle approaches are welldescribed in Chapter 16. Detailed information is also provided about the metabolicsyndrome as well as identification and treatment of hypoglycemia and co-morbidities inthe aged.

Cardiovascular disease remains the leading cause of death in older adults, and twoimportant chapters review the nutritional aspects of heart disease in particular. In the chapter

xii Series Introduction

on cardiac rehabilitation, emphasis is placed on the multidisciplinary team that includesnutrition counseling with emphasis on lipids, antioxidants, salt reduction and increasedwhole grains, fruits and vegetables. The chapter on heart failure documents its effects onnutritional requirements, which are often dependent upon the types and dosages of medica-tions given to treat the disease. Two of the major causes of heart failure are hypertension andcoronary heart disease. Heart failure is the number one cause of hospitalization in theMedicare population, and hospitalization affects food intake and nutritional status, usuallyadversely. Activity levels are greatly reduced in heart failure and, in the end stage, cachexia iscommon. Nutritional interventions are complex and described in detail and recommenda-tions are included.

Cancer is a disease of aging and the development of cancer as well as its treatment greatlyimpacts the nutritional status of the senior patient. The type of cancer and its stage arerelevant factors in the development of malnutrition in the cancer patient regardless of age,but aging adds to the potential severity of the nutritional deficits. Specifically, by usingassessment tools such as the comprehensive geriatric assessment, often there is the findingthat protein intake, vitamins D, B6, B12, calcium and iron status may be reduced and furtherdecreased with cancer treatments.

The next four chapters deal individually with chronic conditions and diseases includingchronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), osteoporo-sis and osteoarthritis. Each of these chronic conditions is characterized by a decrease inmobility, significant changes in lifestyles and frequent pain. Chapter 20 describes theconsequences of COPD that include a loss of weight and increase in basal metabolic rate.Use of multiple drugs is common and adverse drug/nutrient interactions can be found in allof these complex conditions. CKD is often a consequence of long-term hypertension,obesity and diabetes. At end stage, dialysis requires careful monitoring of mineral andprotein intakes. A useful summary table of diet recommendations through the stages ofCKD is provided. Osteoporosis is defined by the WHO as a loss of bone mineral density(BMD) greater than 2 standard deviations below the mean compared to the BMD seen inyoung adults. Lower than optimal intakes of calcium and vitamin D, as well as several otherkey essential nutrients, over the lifetime significantly increases the risk of low BMD andfractures. Of importance, and not well known, even during treatment with drugs to treatosteoporosis, there is a continued need for optimal intake of calcium, vitamin D and proteinto help maintain bone strength and density. Osteoarthritis is the most common arthritis seenin seniors and is often the reason behind joint replacement operations. Osteoarthritis isassociated with damage to the cartilage at joints. Anti-inflammatory drugs are commonlyused to treat the pain associated with osteoarthritis. The 23rd chapter contains an extensivereview of the clinical studies with dietary supplements including glucosamine, chondroitin,omega-3 fatty acids, avocado and soybean unsaponifiables, iodine and antioxidants includ-ing selenium, vitamins C and E and the bone-related nutrients, vitamins D and K.

The last three chapters in this section emphasize the role of nutrition in brain function.The separate chapters emphasize the effects of stroke, Alzheimer’s disease, Parkinson’s diseaseand other neurodegenerative disorders, and late-life depression on nutritional status andprovide relevant dietary recommendations. Specifically, in stroke patients, changes in brainfunction often include dysphagia with consequent decreased consumption of foods thatrequire chewing and, in some cases, swallowing. Stroke-related neurological deficits mayinclude an inability to feed oneself, shop for food, carry food packages, cook, etc.

Series Introduction xiii

Malnutrition is frequently seen following stroke and is related to the level of impairment.Swallowing assessment tools are described in detail and have been shown to be helpful inpatient evaluations. A major risk factor in stroke patients is aspiration of food into the lungsand subsequent development of respiratory tract infections. The use of enteral and parent-eral nutrition options is also discussed.

In contrast with many stroke patients, those suffering from Alzheimer’s disease havesignificant mental deterioration and those with Parkinson’s disease have progressive loss ofvoluntary movements, but neither may include dysphagia. However, all of these patientsmay become malnourished over time for different reasons. Dietary factors that have beenassociated with decreased risk of developing the neurological diseases include higher intakesof omega-3 fatty acids, B vitamins, antioxidants and lowered intakes of saturated fats, totalcalories and sugar. Once the neurological disease is documented, weight loss is often seen. Infact, retrospective data suggest that weight loss precedes diagnosis of Alzheimer’s as well asParkinson’s diseases. All of these conditions and diseases that are seen in the elderly can easilyresult in depressing thoughts about the future for the aging person. When the depressivemood overtakes activities of daily living and the individual becomes vegetative and with-drawn, a clinical mental condition may have developed. Factors that may result in late-lifedepression are reviewed and the potential for dietary factors to reduce the risk of depressionis included. Dietary constituents, such as omega-3 fatty acids and folic acid, associated withreduced risk of neurological diseases, are also linked to reduced risk of depression. VitaminB12 deficiency may also result in symptoms of depression.

The final section of this volume looks at new frontiers in preventive nutrition andincludes separate chapters in the areas of long-term living arrangements for older adults, anin-depth examination of dietary supplements and the effects of complex health emergencieson nutritional status in the geriatric population. As the number of older adults increasesexponentially over the next decades, planning by insurance and government agencies for eldercare has included greater emphasis on home and community care rather than nursing facilities.However, it is critical to assure that disease condition needs as well as dietary needs are met.Education is important for the family caregiver so that dietary requirements through foodsand/or supplements are met and drug–nutrient interactions are avoided. The importance ofdieticians and nutritionists will be even greater as the level of care provided by non-specialistsincreases. Another option for preventing essential nutrient deficiencies is the use of dietarysupplements. More than half of US adults over age 50 take a dietary supplement daily. Dietarysupplements include those containing vitamins and minerals as well as herbal supplements.The in-depth chapter on dietary supplements includes a discussion of the regulatoryenvironment as well as the scientific data supporting the use of certain supplements forchronic disease prevention and detailed tables that contain critical information about themost widely used ingredients in non-essential nutrient-containing dietary supplements. Thefinal chapter in this comprehensive volume deals with responses to complex emergenciessuch as environmental or man-made disasters that can acutely affect the elderly, especiallythose who are infirmed. Even without the occurrence of an emergency, many elderly who arehome bound are malnourished and are on waiting lists to receive Federally funded meals.Nevertheless, this chapter reviews examples of the state and local plans that are being made tocope with emergencies that include help for the elderly. Basic recommendations, such asalways having on hand a 2-week supply of water, food and medicines as well as sources ofpower, are suggested for each senior whether at the individual, community or state-wide level.

xiv Series Introduction

Understanding the complexities of the aging process, drug use, physical debilities andmental changes that also affect nutrient status is not simple and the technologies used canoften seem daunting. However, the volume’s editors and authors have focused on assistingthose who are unfamiliar with this field in understanding the critical issues and importantnew research findings that can impact the field of senior nutrition. The editors have takenspecial care to use the same terms and abbreviations between chapters, and provide guidanceon the location of relevant material between chapters. Moreover, the Foreword by the well-acknowledged leader in the field, Dr. Nancy S. Wellman provides a clear overview of thevalue of this volume for increasing the understanding of the importance of clinical nutritionto the health of the aging population.

In conclusion, ‘‘Handbook of Clinical Nutrition and Aging, Second Edition’’, edited byConnie Watkins Bales and Christine Seel Ritchie provides health professionals in manyareas of research and practice with the most up-to-date, well-referenced volume on theimportance of nutrition in determining the potential for chronic diseases to affect overallhealth of the aging population. This volume will serve the reader as the benchmark in thiscomplex area of interrelationships between the senses, immune function, heart, lungs,kidney, muscle, bone, cartilage, brain and other relevant organ systems in the humanbody and the substances that we consume. Moreover, the interactions between geneticand environmental factors and the numerous co-morbidities seen as the aging processprogresses are clearly delineated so that students as well as practitioners can better under-stand the complexities of these interactions. Drs. Bales and Ritchie are applauded for theirefforts to develop the most authoritative resource in the field to date and this excellent text isa very welcome addition to the Nutrition and Health Series.

Adrianne Bendich, PhD, FACN

Series Introduction xv

Foreword

Aging, a multifaceted natural phenomenon, is dramatically changing the landscape of ourcountry. We have not only the opportunity but also the obligation to broaden the nutritionservices available to older persons. This book will help make that happen. It substantiates theconnections between nutrition and successful aging. While comprehensively and convin-cingly focusing on nutrition’s vital role in preventing, delaying onset, and managing costlyand debilitating chronic diseases, the book explains the nutrition services and interventionsthat evidence shows work to keep older Americans more independent with a good quality oflife.

As our nation addresses not only its obesity epidemic, but its impending age wave, alarmsare sounding as Medicare and Medicaid costs for the poor and the old explode. Ourskyrocketing health-care costs have resulted in a greater emphasis on the importance ofhealthy diets. Nutrition has become part of or has received increased emphasis in all majorhealth promotion and risk reduction initiatives. The Dietary Guidelines for Americans nowrecognize people over age 50 as one of the ‘‘Specific Population Groups’’ that need specialconsideration. Steps to a HealthierUS, a US Department of Health and Human Servicesinitiative, encourages Americans to live longer, better, and healthier lives by eating anutritious diet as one of its four focal points. The Older Americans Update 2006 and2008: Key Indicators of Well-Being list dietary quality as one of the 7 modifiable ‘‘HealthRisks and Behaviors.’’ The most recent White House Conference on Aging included a‘‘Healthy Nutrition’’ recommendation for the first time in decades. Among its suggestedstrategies is greater access to nutrition therapy and education, as well as healthy diets, in anyand all aging-related settings. As nutrition services for older adults move out of hospitals andinstitutions and into homes and communities, the new and updated chapters in this bookare key to understanding cost containment trends where nutrition should play an essentialrole but does not yet – for example, nursing home diversion efforts dictated by the federalDeficit Reduction Act. Appropriately, the information in this book can be used to justifythe need for greater availability of bona fide nutrition expertise in all programs and settingsthat serve older adults.

Clinicians, policymakers, faculty, and graduate and undergraduate students will find thatthis book fills practice and education gaps. As the most youth-obsessed, death-denying nationin the world, our culture’s negative attitude qualifies as ‘‘ageist.’’ It is based primarily on myths,stereotypes, and misinformation. It is therefore not surprising that some of our colleagues andmany of our students have little interest in nutrition and aging. Geriatricians and gerontol-ogists alike will find that the evidence in this book obligates them to include the nutritionalstatus of older persons in comprehensive care management. It will help dietitians and otherhealth professionals value the importance of healthy diets. For those new to aging, the book

xvii

includes the many important approaches to improving the nutritional status of those theyserve – from setting up screening programs, to recognizing when to make referrals to dietitiansfor individualized assessments and chronic disease management, to connecting older personswith community nutrition assistance ‘‘safety net’’ programs.

This book can help rectify longstanding educational gaps in nutrition and aging. Ournational research found that knowledge about aging was lower in nutrition curricula than insome other disciplines and more than half of nutrition students had negative views aboutolder adults. Students ranked working with them as their least preferred choice. Our reviewof curricular content nationally found relatively few undergraduate and graduate courses inaging compared to maternal and child courses. Rightfully, more than half of the programdirectors were not satisfied with the aging content in their curriculum, citing ‘‘curriculumalready full’’ and ‘‘lack of faculty expertise in aging’’ as common obstacles. Our nationalreview of nutrition textbooks identified problems that other disciplines had also found intheir textbooks. Overall, nutrition textbooks generally fail to present aging comprehensively,across topics, or positively.

In contrast, this book is a standout. It provides an ideal structure for designing a coursesyllabus; it is a rich resource for faculty interested in strengthening components in their othercourses such as aging in nutrition therapy, nutrition in geriatrics, and diet and health ingerontology; and it is useful for special topics or contemporary issues courses. It can be usedin internships to amplify students’ understanding of nutrition in aging. As such, this bookwill help today’s students overcome their aging apathy. It tunes them into today’s agingreality: most older Americans are living longer, healthier, and more actively. Older persons’determination to live independently makes them the most receptive and attentive to ourguidance. They want to lessen their potential for illness, speed their recovery, shorten theirhospital stays, and stay out of nursing homes. Students, both graduate and undergraduate,will value this book not only in their courses but as a ‘‘keeper’’ resource for their professionallibrary. It may be just the antidote against deterring students and others from wanting towork with older adults. The rewards of working with older persons are real indeed!

Older people want to hear the good news about nutrition—that it is indeed never too lateand that even small steps can make a difference at any age. The new aging reality says boththe quantity and quality of life count. A healthy lifestyle and being active leads to greaterlongevity, adds more years of independence, and compresses morbidity in later years.However, people do not want to live longer to have more years of illness and unhappiness;the added years must be healthier ones. Good nutrition not only adds years to life, but life toyears. This book has all the information needed to make universal access to quality nutritionservices a reality for older Americans today. Doing so will positively improve their longevityand quality of life, prolong their independence in later years, and conserve the health careresources of our nation. Nutrition as depicted in this book fits a life-affirming view ofaging—one that is long overdue in America.

Nancy S. Wellman PhD, RD, FADA

xviii Foreword

Preface

We opened the first edition of this handbook with a preface highlighting the uniquechallenges of the new millennium resulting from ‘‘successful aging’’ and reduced birth ratesof the twentieth century. We emphasized, along with the ‘‘graying globe’’, the diversities ofaging with regard to the influence of geographic location, gender, economic status, and evenage (younger versus older old age). During the intervening years, we have come to under-stand that the majority of the health-related challenges faced by older adults, be theyphysical, social, or economic, are globally relevant. This is thanks in large part to incrediableadvances in telecommunication, along with a growing understanding of the nature of thefininte resources of the planet.

In this context, it is clear that geriatric health issues and the behaviors that shape ourresponses to them (Chapters 1 and 2) are universal concerns, shared by the majority of olderadults and their health-care providers. The same often applies to concerns about lifethreatening chronic diseases (Chapters 14–26), complex emergencies (Chapter 29), andrelated challenges for older citizens of the world (Chapter 3). With the inevitable graying ofthe globe, there will be exponential increases in expenditures for health care, increasing needsfor long-term care services, and a demand for more focused health-care services for olderadults living at home (Chapter 27). Concurrently, we expect an unfortunate shortage ofgeriatricians, especially in the US. Thus, understanding the unique interactions of geriatricsyndromes (Chapters 4–13) with nutritional factors will be increasingly important for allhealth care givers attending to older patients.

We are indebted to many individuals who contributed as we put together this edition ofthis Handbook. Our sincere thanks and congratulations on a job well done go to ThuytienThi Ho, a Duke senior who has worked tirelessly for most of the past two academic years onthe management and copy editing of this text. Dr. Bales also thanks Justin (Cody) Maxwelland Caroline Friedman for their contributions to this project. We also thank Paul Dolgert,Richard Hruska, and the rest of the Humana staff for their support and offer a special tributeto the late Tom Lanigan and Julia Lanigan, whose vision and creativity gave us, throughHumana, a unique opportunity to publish on a topic very dear to us. Finally, we offer warmwishes and sincere gratitude to our series editor, Dr. Adrianne Bendich, for her encourage-ment to begin what has become an ongoing and exciting interaction with some of the mostcritical clinical issues in geriatric nutrition and the gifted and dedicated scientists who studythem. Without the creative contributions of these scientist-authors, this book would nothave been possible.

A Pulitzer Prize winning author in the field of aging, Dr. Robert Butler predicts that whathe terms ‘‘the Longevity Revolution’’ will become a worldwide geopolitical issue in the 21st

century, with the need for global adaptations to accommodate the extension of human

xix

lifespan. The challenge is a formidable one but we propose that state-of-the-art nutritionalinterventions can help to meet it. This Handbook was written to assist health care givers forolder adults by providing strategies for effective secondary interventions for establisheddiseases and conditions amenable to dietary modulation. We believe it is a uniquelycomprehensive resource and hope that it will be a valuable guide to all (including physicians,nurses, dietitians, and speech language and occupational therapists) who provide care for thishigh-risk population. It is our sincere intention that the nutritional welfare and overallhealth of older adults be enhanced at a global level through the application of the informa-tion contained here.

Connie Watkins Bales, PhD, RD, FACNChristine Seel Ritchie, MD, MSPH

xx Preface

Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Series Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Part I: Over-Arching Issues For Nutritional Well-Being in Late Life

1 An Ecological Perspective on Older Adult Eating Behavior . . . . . . . . . . . . . . . . 3

Julie L. Locher and Joseph R. Sharkey

2 Behavioral Theories Applied to Nutritional Therapies for Chronic Diseasesin Older Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

James M. Shikany, Charlotte S. Bragg, and Christine Seel Ritchie

3 Global Graying, Nutrition, and Disease Prevention: An Update on Chinaand Future Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Yanfang Wang and Connie Watkins Bales

Part II: Fundamentals of Nutrition and Geriatric Syndromes

4 Update on Nutritional Assessment Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

John E. Morley

5 Sensory Impairment: Taste and Smell Impairments with Aging. . . . . . . . . . . . . 77

Susan Schiffman

6 Nutrition and the Aging Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Elizabeth J. Johnson

7 Common Gastrointestinal Complaints in Older Adults . . . . . . . . . . . . . . . . . . . 121

Stephen A. McClave

8 Hydration, Electrolyte, and Mineral Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Robert D. Lindeman

9 Redefining Nutritional Frailty: Interventions for Weight Loss Dueto Undernutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Connie Watkins Bales and Christine Seel Ritchie

10 Sarcopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Ian Janssen

xxi

11 Cachexia: Diagnosis and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

David R. Thomas

12 The Relationship of Nutrition and Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . 219

David R. Thomas

13 Nutrition at the End of Life: Ethical Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Christine Seel Ritchie and Elizabeth Kvale

Part III: Common Clinical Conditions

14 Nutrition and Oral Health: A Two-Way Relationship . . . . . . . . . . . . . . . . . . . . 247

Kaumudi Joshipura and Thomas Dietrich

15 Obesity in Older Adults – A Growing Problem. . . . . . . . . . . . . . . . . . . . . . . . . . 263

Dennis T. Villareal and Krupa Shah

16 Nutrition and Lifestyle Change in Older Adults with Diabetes Mellitusand Metabolic Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Barbara Stetson and Sri Prakash Mokshagundam

17 Cardiac Rehabilitation: The Nutrition Counseling Component . . . . . . . . . . . . . 319

William E. Kraus and Julie D. Pruitt

18 Chronic Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

Christopher Holley and Michael W. Rich

19 Nutrition Support in Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

Elizabeth Kvale, Christine Seel Ritchie, and Lodovico Balducci

20 Nutrition and Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . . . . . 373

Danielle St-Arnaud McKenzie and Katherine Gray-Donald

21 Nutrition and Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403

Srinivasan Beddhu

22 Nutritional and Pharmacological Aspects of Osteoporosis. . . . . . . . . . . . . . . . . 417

David A. Ontjes and John J.B. Anderson

23 Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

Paola de Pablo and Timothy E. McAlindon

24 Post-stroke Malnutrition and Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479

Candice Hudson Scharver, Carol Smith Hammond, andLarry B. Goldstein

25 Alzheimer’s Disease and Other Neurodegenerative Disorders . . . . . . . . . . . . . . 499

Ling Li and Terry L. Lewis

26 Nutrition and Late-Life Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523

Martha E. Payne

Part IV: New Frontiers in Preventive Nutrition

27 Providing Food and Nutrition Choices for Home and CommunityLong-Term Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539

Dian O. Weddle and Nancy S. Wellman

xxii Contents

28 Dietary Supplements: Current Knowledge and Future Frontiers . . . . . . . . . . . . 553

Rebecca B. Costello, Maureen Leser, and Paul M. Coates

29 Minimizing the Impact of Complex Emergencies on Nutrition and GeriatricHealth: Planning for Prevention is Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635

Connie Watkins Bales and Nina Tumosa

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655

Contents xxiii

Contributors

JOHN J.B. ANDERSON, PHD �Departments of Medicine and Nutrition, School of Medicine andSchool of Public Health, University of North Carolina, Chapel Hill, NC

LODOVICO BALDUCCI, MD �Moffitt Cancer Center, Tampa, FLCONNIE WATKINS BALES, PHD, RD, FACN �Department of Medicine, Geriatrics Research,

Education, and Clinical Center, Durham VA Medical Center, Duke University MedicalCenter, Durham, NC

SRINIVASAN BEDDHU, MD � Salt Lake Veterans Affairs Healthcare System; Division ofNephrology & Hypertension, University of Utah School of Medicine, Salt Lake City, UT

CHARLOTTE S. BRAGG, MS, RD �Division of Preventive Medicine, School of Medicine, Universityof Alabama at Birmingham, Birmingham, AL

PAUL M. COATES, PHD �Office of Dietary Supplements, National Institutes of Health, Bethesda,MD

REBECCA B. COSTELLO, PHD �Office of Dietary Supplements, National Institutes of Health,Bethesda, MD

PAOLA DE PABLO, MD, MPH �Division of Rheumatology, Tufts-New England Medical Center,Boston, MA

THOMAS DIETRICH, DMD, MD, MPH � School of Dentistry, University of Birmingham,Birmingham, UK; Health Policy and Health Services Research, Boston University GoldmanSchool of Dental Medicine, Boston, MA

LARRY B. GOLDSTEIN, MD, FAAN, FAHA �Duke University Medical Center, Durham, NCKATHERINE GRAY-DONALD, PHD � School of Dietetics and Human Nutrition, McGill

University, Quebec, CanadaCAROL SEEL HAMMOND, PHD � Audiology, and Speech Pathology, Nutrition, and Radiology

Services, Durham VA Medical Center; Department of Medicine, Duke Medical Center,Durham, NC

CHRISTOPHER HOLLEY, MD, PHD �Washington University School of Medicine, St. Louis, MOIAN JANSSEN, PHD �Department of Community Health and Epidemiology, School of Kinesiology

and Health Studies, Queen’s University, Kingston, Ontario, CanadaELIZABETH J. JOHNSON, PHD � Jean Mayer USDA Human Nutrition Research Center on Aging

at Tufts University, Boston, MAKAUMUDI JOSHIPURA, BDS, SCD � School of Dental Medicine, Medical Sciences Campus, Center

for Clinical Research and Health Promotion, University of Puerto Rico, San Juan, Puerto RicoWILLIAM E. KRAUS, MD, FACC, FAHA, FACSM �Duke University Medical Center, Durham, NCELIZABETH KVALE, MD �Division of Gerontology, University of Alabama at Birmingham,

Geriatrics and Palliative Medicine and Birmingham VA Medical Center, Birmingham, AL

xxv

MAUREEN LESER, MS, RD �NIH Clinical Center Nutrition Department, National Institutes ofHealth, Bethesda, MD

TERRY L. LEWIS, BS �University of Alabama at Birmingham, Birmingham, ALLING LI, DVM, PHD �University of Alabama at Birmingham, Birmingham, ALROBERT D. LINDEMAN, MD �University of New Mexico School of Medicine, Albuquerque, NMJULIE L. LOCHER, PHD, MSPH �Division of Gerontology, Geriatrics, and Palliative Care,

Department of Health Care Organization and Policy, Center for Aging and Lister HillCenter for Health Policy, University of Alabama at Birmingham, Birmingham, AL

TIMOTHY E. MCALINDON, MD, MPH �Division of Rheumatology, Tufts-New England MedicalCenter, Boston, MA

STEPHEN A. MCCLAVE, MD �Division of Gastroenterology/Hepatology, Department of Medicine,University of Louisville School of Medicine, Louisville, KY

SRI PRAKASH MOKSHAGUNDAM, MD �Division of Endocrinology, Department of Medicine,University of Louisville, Louisville, KY

JOHN E. MORLEY, MB, BCH �Division of Geriatric Medicine, GRECC, VA Medical Center,Saint Louis University School of Medicine, St. Louis, MO

DAVID A. ONTJES, MD �Departments of Medicine, School of Medicine, University of NorthCarolina, Chapel Hill, NC

MARTHA E. PAYNE, PHD, MPH, RD �Department of Psychiatry and Behavioral Sciences, TheNeuropsychiatric Imaging Research Laboratory, Duke University, Durham, NC

JULIE D. PRUITT, MS, RD, LDN �Duke University Medical Center, Durham, NCMICHAEL W. RICH, MD � Cardiovascular Division, Washington University School of Medicine,

St. Louis, MOCHRISTINE SEEL RITCHIE, MD, MSPH �University of Alabama at Birmingham; Birmingham-

Atlanta VA Geriatric Research, Education, and Clinical Center (GRECC), Birmingham, ALCANDICE H. SCHARVER, MA � Audiology and Speech Pathology, Durham VA Medical Center,

Durham, NCSUSAN SCHIFFMAN, PHD �Department of Psychiatry and Behavioral Sciences, Duke University

Medical Center, Durham, NCKRUPA SHAH, MD �Division of Geriatrics and Nutritional Science, Center for Human

Nutrition, Washington University in St. Louis, St. Louis, MOJOSEPH R. SHARKEY, PHD, MPH, RD �Department of Social and Behavioral Health, School of

Rural Public Health, Texas A&M Health Science Center, College Station, TXJAMES M. SHIKANY, DRPH �Division of Preventive Medicine, School of Medicine, University of

Alabama at Birmingham, Birmingham, ALDANIELLE ST-ARNAUD MCKENZIE, PHD �Departement des sciences de la sante communautaire,

Universite de Sherbrooke, Sherbrooke, Quebec, CanadaBARBARA STETSON, PHD �Department of Psychological and Brain Sciences, University of

Louisville, Louisville, KYDAVID R. THOMAS, MD, FACP, AGSF, GSAF �Division of IM-Geriatric Medicine, Saint Louis

University Health Sciences Center, St. Louis, MONINA TUMOSA, PHD, GRECC �Department of Internal Medicine, St. Louis VA Medical Center,

Saint Louis University, St. Louis, MODENNIS T. VILLAREAL, MD, FACP, FACE �Division of Geriatrics and Nutritional Science, Center

for Human Nutrition, Washington University in St. Louis, St. Louis, MO

xxvi Contributors

YANFANG WANG, MD, PHD, MHS � Academy of Health and Development, Health andDevelopment Foundation, Beijing, China

DIAN O. WEDDLE, PHD, RD, FADA �National Policy and Resource Center on Nutrition, PhysicalActivity and Aging, Florida International University, Miami, FL

NANCY S. WELLMAN, PHD, RD, FADA �National Policy and Resource Center on Nutrition,Physical Activity and Aging, Florida International University, Miami, FL

Contributors xxvii