Alexis is an RD who works with older adults of varying ages in numerous settings including private practice, outpatient counseling, and a skilled nursing facility with 60 long term care beds (mainly comprising complex medical issues), and 40 short-term rehabilitation beds. She has noticed a trend toward patients/residents wanting to eat more plant-based, vegetarian, and even vegan diets. Alexis needs to educate herself on these dietary patterns so she can revise the menus in her facilities to meet her patients’ needs and provide education and counseling as needed.
Individuals adopt a vegetarian or vegan diet for reasons that include religious convictions, personal preferences, and health, ethical, and/or environmental concerns. Vegetarians can be lacto-ovo (includes eggs and dairy foods), lacto (includes dairy but not eggs), ovo (includes eggs but no dairy), and vegan (excludes all animal products). Pescatarians are those who abstain from eating meat and animal flesh with the exception of fish. “Flexitarian” is a relatively new term and refers to those who consume mainly vegetable foods but eat meat, fish, or poultry occasionally.
A 2019 online survey conducted by The Harris Poll and the Vegetarian Resource Group found that even though only 2% of people aged 65 and older are vegetarian or vegan, 37% sometimes or always eat vegetarian or vegan, and 16% sometimes or always eat vegan. So it appears that the demand for plant-based diets is growing.
According to the Academy of Nutrition and Dietetics, well-designed vegetarian diets can provide adequate nutrients for all stages of the life cycle, including older adulthood. Protein, omega-3 fatty acids, iron, zinc, iodine, vitamin D, vitamin B12, and calcium are all potential shortfall nutrients for vegetarians and vegans.
That said, vegetarians have a lower risk of all-cause mortality and cardiovascular mortality, and vegetarian diets can be beneficial for prevention and/or therapeutic management of obesity, CVD, diabetes, and certain types of cancers. Although bone health can be compromised with a diet low in calcium, vitamin D, vitamin B12, and protein, a vegetarian diet high in magnesium, potassium, vitamin K, and vitamin C, and a low acid load can promote bone health.
Are older adults more vulnerable than younger people to nutrient shortfalls that could result if a vegetarian diet isn’t well planned or executed? There are some considerations unique to this demographic. Aging results in decreased calorie needs and an increased need for calcium, vitamin D, vitamin B6, and protein. Most older adults, even those who consume animal foods, have a decreased ability to absorb vitamin B12. For these reasons, an adequate intake of nutrient-dense foods is probably even more critical for older adults who are vegetarian than for their younger vegetarian counterparts.
In addition, some older adults have difficulty chewing or swallowing, limiting their ability to consume foods like nuts, seeds, certain whole grain foods, and raw vegetables and fruits. Community-dwelling older adults may have mobility issues, vision problems, or medical conditions that make food shopping and meal preparation difficult.
Fruits, vegetables, legumes, nuts, seeds, whole grains, and calcium- and/or vitamin D–fortified foods and beverages should be included in the diet of vegetarian older adults as long as they’re not contraindicated. Dairy and/or eggs are good sources of protein and other nutrients and should be encouraged if they’re accepted. Individual nutrition assessment can help identify potential shortfall nutrients and help RDs develop a plan of care for each person following a vegetarian diet. Vitamin B12 or other supplements may be needed, particularly for vegans or vegetarians with poor food and/or fluid intake.
Postacute care facilities that admit Medicare and Medicaid patients must assure that their residents who follow vegetarian diets receive appropriate meals to meet regulatory requirements. Nursing homes under Centers for Medicare & Medicaid Services regulations must “provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.” Food preferences and cultural norms for residents (vegetarians and omnivores alike) always should be honored to the extent possible.
Where to Begin?
Alexis should start by using the vegetarian menu patterns available in the 2015–2020 Dietary Guidelines for Americans as a template for providing a well-balanced and varied diet. These guidelines can help individuals and professionals plan menus to meet dietary guidelines and food preferences.
Alexis is excited about increasing the availability of plant-based foods for residents in her facilities. She discusses the benefits and risks of vegetarian diets for older adults with the director of food and nutrition services so they can formulate a plan. They decide to add more fruits, vegetables, whole grains, and vegan options to the facility’s “always available” menu, and they plan to update the regular and therapeutic diets to a Mediterranean-style diet to provide more healthful eating patterns for all their patients/residents.
More information on plant-based eating for a variety of vegetarian diets can be found in Becky Dorner & Associates’ 2019 Diet and Nutrition Care Manual.
— 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 continuing education, nutrition resources, and creative solutions. Visit www.beckydorner.com to sign up for free news and information.