Alice, aged 86, looked up from her plate filled with food and said, “Bill didn’t even eat this much when he was farming full time.” Not unlike many elderly clients who have their meals prepared for them, Alice is overwhelmed by the amount of food she’s served and told me that “they said it is required to give me this much.”
Many aging clients feel they cannot eat as much food as they’re asked to eat, and this feeling can result in reduction of overall consumption and potential undernutrition. As nutrition practitioners, often we’re faced with the dilemma of how to meet minimum requirements while serving (or recommending) reasonable portions to our senior clients. To do the right thing, we must consider what the science says; what the Centers for Medicare & Medicaid Services, The Joint Commission, or the Older Americans Act requires; and what Alice really wants.
Decreased appetite in the elderly is the result of many normal changes. As people age, they become less active, their metabolisms slow, and their biological and physiological functions decline—resulting in cytokine and hormonal level changes and reduction of lean body mass. For a variety of reasons, even healthy older folks are less hungry before meals, consume smaller portions, eat more slowly, and are more rapidly satiated after a meal.
The Dietary Reference Intakes and Recommended Dietary Allowance guidelines from the Food and Nutrition Board of the Institute of Medicine of the National Academies, outline nutrient requirements for a broad age range of people, with >70 years of age as the last grouping. Our US population is living longer than ever, but this internationally recognized tool doesn’t give guidance for those living into their 80s, 90s, or even 100s.
The current daily calorie standard is 1,600 kcal for a sedentary female and 2,000 kcal for a sedentary male. However, the planned menus in assisted living facilities, nursing homes, or congregate meal sites often provide 700 to 1,000 kcal per meal for everyone. Unfortunately, the menus also are frequently heavy on white bread and other nutrient-weak carbohydrates.
Digna Cassens, MHA, RDN, author of Food First!: Enhancing the Nutritional Value of Meals with Fortified Foods, says, “Individuals with poor appetites can ingest sufficient calories and protein without being overwhelmed with bigger portions.” Studies published in Clinical Nutrition and The Journal of Nutrition Health and Aging support this statement, showing seniors consumed 25% to 37% more calories and increased intake of protein and other nutrients on a smaller-portion fortified menu.
RDs can help improve food intake, increase nutrients in a meal, and alleviate the overwhelmed feeling our older clients often experience when served a huge meal by adopting a few of the following practices:
- Assess estimated nutrient needs, and customize meals to meet those needs. Consider the use of a multivitamin with minerals if micronutrient needs aren’t met.
- Be a diligent menu writer/reviewer, and don’t be afraid to make changes as needed. Visualize the meal on a 10-inch dinner plate. Is there a lot of space between the food? Does each food maximize nutritional density? Does the menu significantly exceed the Dietary Reference Intakes for an average elderly individual?
- Avoid serving soup before a meal; it reduces hunger and overall calorie consumption.
- Incorporate nonfat dry milk powder, peanut butter, cheese, pumpkin or sweet potatoes, eggs, full-fat yogurt, tofu, olive oil, avocado, and other nutrient- and calorie-rich foods into meals. (Refer to Cassen’s book for more ideas, recipes, and implementation guidelines.)
- Enhance food flavors and aroma with herbs, spices, and sauces.
- Keep the table setting simple. Limit the number of plates, cups, and bowls, and consider small portions on a color-contrasting plate.
- Encourage nutrient-rich beverages at meals—extra tea, coffee, and water can be saved for between meals.
- Make desserts count by using recipes that incorporate fruit or even vegetables, whole grains, and dairy products. A small scoop of ice cream or frozen yogurt on top is a bonus.
- Encourage exercise throughout the day.
- Capitalize on breakfast, as the elderly typically have a better appetite and consume more at this meal.
- Let older individuals serve themselves whenever possible.
- Encourage eating in the company of others (preferably those with good appetites).
- Engage in discussions with regulators and researchers. Encourage collaboration to ensure individualized needs are addressed and all seniors aren’t served the same large portions. This age group deserves further study to determine actual nutrient requirements. We must be their advocates.
— Sue Stillman Linja, RDN, LD, has 29 years experience working in nutrition and the aging. She has built a business that employs more than 50 dietitians in nine states—providing much needed nutrition services to a wide variety of health care clients. Sue is a researcher, author, and sought-after speaker in the area of nutrition and longevity. She recently published The Alzheimer’s Prevention Food Guide and presented a TEDx Talk titled The Road to 100.