When working with older adults who have chronic diseases such as CVD, physicians often prescribe strict diets. While these diets may help control symptoms of chronic diseases and conditions, they may not enhance quality of life for older adults. In fact, they may reduce the joy of eating, and they do nothing to encourage food intake for people with poor appetites. In these cases, it might be best to say, “Ditch the diet!” Here are a few examples.
Glen is happy to have made it to 90, but he suffers from heart failure, COPD, and emphysema. His doctor has had him on a strict 2,000 mg sodium per day diet for over a year. Since then he has lost 45 lbs, from 145 to barely 100 lbs on his 5’4” frame. He eats fairly well when meals are prepared and someone sits and eats with him. He recently was placed on home hospice, but his attitude is generally good, and with a reduction of his medications from 22 pills a day down to about nine, he seems to be fairly stable. His caregivers worry about his salt intake since the doctor said he needed to follow a strict low-sodium diet. As his RD, what advice should you give them? I’d say, “Ditch the diet!”
Doctors often order a 2,000 mg sodium diet with a 2,000 mL fluid restriction per day, but evidence indicates decreased hospital readmissions and mortality in patients with compensated congestive heart failure consuming 2,000 to 3,000 mg sodium a day.1,2 And since Glen is on hospice care, diet rules go out the window. Generally, patients on hospice are encouraged to eat whatever they want, and symptoms are controlled with medications. Since Glen is so emaciated, this likely would be the best approach to take with him at this point. Encourage him to eat the foods he loves, along with a high-calorie/high-protein supplement if he’ll take it. Cream soup, pudding, cream pie, milkshakes, ice cream, and other similar foods would provide needed calories and protein if acceptable to Glen. At the end of life, as long as the hospice nurses continue to monitor his breathing, blood pressure, and edema, let him eat whatever he is willing to eat.
Glen’s wife, Mary, is 89. She has hypertension and had a myocardial infarction with stent placement at age 80. She has been following a low-fat, low-cholesterol, 2,000 mg sodium per day diet ever since. She has developed moderate cognitive impairment with unintended weight loss in the past year as her husband’s illness has taken its toll on her. Mary is still fairly independent with her activities of daily living and gets around fairly well. She needs someone to prepare her meals and clean the house, but she still likes to make herself useful. She has no swelling in her lower extremities and doesn’t exhibit any other symptoms of hypertension or cardiac distress. What would you recommend for Mary’s diet? Since she has also experienced weight loss and is frailer now than she was a year ago, at 89 Mary should probably also ditch the diet!
Be aware of cardiac problems while balancing clinical status, prognosis, and risk of malnutrition. If blood pressure control and lipid reduction are goals for Mary, monitor her blood pressure frequently and encourage her to take her medication to achieve these goals and still allow her to enjoy personal food choices.3 Physical activity based on Mary’s abilities, along with a liberalized diet encouraging a variety of healthful foods with moderate sodium levels may be the best approach.4 The 2015–2020 Dietary Guidelines for Americans and the Dietary Approaches to Stop Hypertension (DASH) diet also can help.5 The DASH eating pattern is known to reduce blood pressure.1,6
Remember to assess for malnutrition with interventions as appropriate to improve nutritional status.4 Ensure that Mary gets plenty of protein in her diet. Older adults should strive for 30 g protein per meal. In combination with weight-bearing exercise, this can help Mary maintain her muscle mass and strength.
Glen and Mary’s son John also is an older adult at 70 years of age. He is overweight and has hypertension and hypercholesterolemia with multiple risk factors for CVD. John lives independently and is very active. He travels a number of times a year, golfs, putters around with wood crafts, and has a healthy social life. John loves a good meal as well as a good cocktail every evening. He also loves to snack and attend parties with friends and family, where he tends to overeat and -drink. For the “young older adult” like John whose goal it is to prevent CVD and dementia, you might recommend he follow a Mediterranean-style eating pattern or the MIND Diet. There are many sources of information on these diets, but here is a sample diet guideline on the Mediterranean-style option.
Every individual is unique, and our advice should be tailored to individual needs. When it comes to older adults, it’s important to keep in mind that conventional dietary guidelines might not always be the best approach. Sometimes enhancing older adults’ quality of life requires changing the rules and ditching the diet.
— Becky Dorner, RDN, LD, FAND, is widely known as one of the nation’s leading experts on nutrition and long term health care. Her company, Becky Dorner & Associates, Inc., is a trusted source of valuable resources dedicated to improving quality of life for older adults. For valuable resources for health care professionals, visit www.beckydorner.com and sign up for the free membership.
- Academy of Nutrition and Dietetics Nutrition Care Manual website. www.nutritioncaremanual.org. Accessed September 30, 2017.
- Academy of Nutrition and Dietetics. Heart failure (2017) evidence-based nutrition practice guideline. https://www.andeal.org/topic.cfm?menu=5289. Accessed September 30, 2017.
- Pioneer Network Food and Dining Clinical Standards Task Force. New dining practice standards. https://www.pioneernetwork.net/wp-content/uploads/2016/10/The-New-Dining-Practice-Standards.pdf. Published August 2011. Accessed December 15, 2016.
- Goldberg JP, Chernoff R. Cardiovascular disease in older adults. In: Chernoff R, ed. Geriatric Nutrition: The Health Care Professional’s Handbook. 4th ed. Burlington, MA: Jones & Bartlett Learningl; 2014:277-296.
- US Department of Health and Human Services; US Department of Agriculture. Dietary Guidelines for Americans 2015–2020, Eighth Edition. http://health.gov/dietaryguidelines/2015/guidelines/. Published January 7, 2016.
- Salehi-Abargouei A, Maghsoudi Z, Shirani F, Azadbakht L. Effects of Dietary Approaches to Stop Hypertension (DASH)-style diet on fatal or nonfatal cardiovascular diseases — incidence: a systematic review and meta-analysis on observational prospective studies. Nutrition. 2013;29(4):611-618.
* For more information on this topic, refer to Diet and Nutrition Care Manual: Comprehensive Edition from Becky Dorner & Associates, Inc.