Nutrition in the Middle and Later Years
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Aging leads to lower activity levels and a further narrowing of physical activity options. Recent cross-sectional data from the Aerobics Center Longitudinal Study showed that older adults expended significantly less energy on exercise than did younger adults Walking was the most common physical activity reported by adults Older adults in the United States were more likely to report lower-intensity activities such as walking, gardening, or golf, rather than running, aerobics, or team sports Although the time spent on bicycling and gardening showed a significant drop with age in the Zutphen cohort, the time spent on walking was not affected Significant disparities in activity levels by sex and ethnicity were also noted.
Reported levels of leisure-time physical activity were lowest for minority respondents and for older women.
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Data from the Coronary Artery Risk Development in Young Adults study showed that important ethnic differences in physical activity patterns remained even after adjustments were made for important demographic factors such as education or income Significantly, unfavorable perceptions of one's own health were associated with lower participation in a cardiac rehabilitation program In contrast, perceived enjoyment and satisfaction were positive predictors of physical activity in men and women of all ages These data suggest that psychosocial rather than biomedical variables may influence continued participation in exercise programs.
The recommendation that every American accumulate at least 30 minutes of exercise on most—and preferably all—days 25 26 is based on evidence that even moderate physical activity is associated with a substantial drop in all-cause mortality Although there is evidence that current activity is more protective than past activity, cumulative lifetime activity pattern may be the most influential factor of all The question remains as to whether a sustained active lifestyle can delay the age-associated changes in body composition and decline in lean body mass.
Studies of physical activity and aging, including some outlined in this volume, suggest that fat-free mass and body composition of active elderly subjects are not very different from those of inactive elderly subjects In contrast to younger subjects, the effect of exercise programs on total activity of elderly subjects was minimal because elderly subjects compensated for exercise training by reducing their spontaneous physical activity.
However, exercise training did have a positive effect on muscle function and may have contributed to the activities of daily living. Continuing to function without assistance may be the most salient outcome variable. Some 7 million Americans over age 65 depend on others for help with some basic task of daily living 2. The Activities of Daily Living score includes capacity for daily self-care as well as other functions related to cooking, eating, and access to food. Such activities are essential for ensuring independent living and contribute importantly to overall quality of life.
Physical activities that improve muscular strength, endurance, and flexibility also improve ability to perform the tasks of daily living. For example, strength training can result in substantial improvements in muscle size and strength in elderly men and women 28 and can also increase resting metabolic rate, resulting in increased energy requirements In addition, strength training improves balance and gait speed in very old and frail nursing home residents, improves bone health, and decreases many of the risk factors for an osteoporotic fracture Exercise programs for elderly adults can delay the age-induced impairment in personal mobility necessary for the performance of routine activities.
The definition of health used to be based on life expectancy, mortality, and morbidity statistics. Quality of life provides a validated approach for expanding the definition of health to include other domains of physical, mental, and social well-being HRQL measures reflect a personal sense of physical and mental health and the capacity to react to diverse factors in the environment.
Among measurement tools are years and days of healthy life and a self-rated index of overall health. HRQL indexes address broad aspects of physical, mental, and social functioning and their determinants at both individual and community levels 9 One important domain of quality of life is physical functioning, as assessed with the Activities of Daily Living score. Some researchers have argued that quality-of-life measures should go beyond biomedical and health outcomes and that global concepts such as life satisfaction and happiness also ought to be included 9.
In this view, quality of life is a multidimensional construct that addresses physical state, social functioning, and emotional well-being. Recent studies suggest that the key perceived dimensions of quality of life may be comparable across cultures and can be broadly grouped into health, psychological, social, and environmental domains 9. The item quality-of-life instrument developed by the World Health Organization lists physical health, psychological health, social relationships, and environmental issues as its four domains 9.
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As shown in Table 1 , neither the domains nor facets incorporated within domains directly assess food, eating habits, or physical activity issues. Much current research on quality of life has come from clinical studies. The usual focus has been on quality-of-life indexes after surgery or some major health trauma. Studies of quality of life of cancer patients have focused on physical functioning, psychological distress, pain and pain relief, fatigue and malaise, nausea and vomiting, symptoms, and toxic effects.
Social support, economic disruption, and global quality of life were also measured. A number of disease-specific tools were outlined by Amarantos and colleagues One such instrument assessed HRQL specific to obesity and included general health, distress, depression, and self-esteem among its key domains The benefits of diverse medical treatments and interventions are often measured with regard to quality-of-life outcomes 9.
Additional studies on quality of life come from the broader arena of research on social indicators. In studies of developing nations, quality of life is being increasingly used to determine stages of social development in preference to strictly economic indicators such as income or the gross national product. Quality-of-life indexes are a compelling dependent variable, one that is broadly based and well-suited for studies of diet, activity, and health in elderly adults. Increasing physical activity is a viable strategy for improving both health and quality of life of older adults However, the two sets of outcome measures may not be exactly the same.
Stewart and King 35 proposed two outcome categories—functioning and well-being—to measure the effect of physical activity on the overall quality of life.
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Functioning included physical ability and dexterity, cognition, and activities of daily living; well-being included not only symptoms and bodily states but also emotional well-being, self-concept, and global perceptions related to health and overall life satisfaction The basic question was whether outcome measures would best be served by symptom-driven HRQL measures or whether quality of life was more of a psychological construct that included conscious cognitive judgment of satisfaction with one's life.
Physical activity improved HRQL measures regardless of age, activity status, or health of participants However, the relationship between physical activity and quality of life largely depended on what outcome was of greatest concern to the elderly individual.
The effect of fitness on HRQL was less dramatic when the person was already functioning above the norm. In other words, disability and dysfunction were far more salient and far more detrimental to quality-of-life measures than were reductions in the general level of fitness. How does physical activity improve health and quality of life?
Rejeski and Mihalko 34 suggested that perceived control and mastery and overall satisfaction and enjoyment may be key variables. Self-esteem and positive feelings may mediate the effect that physical activity has on life satisfaction. However, as Rejeski and Mihalko 34 noted, the current guidelines for exercise prescription offer little advice for outcomes other than improved physical health When quality of life becomes the primary outcome, the focus shifts to areas that are most relevant and most valued. Continued independent physical functioning is one such area. Furthermore, physical activity programs involve more than performance of a simple act.
The input that participants may have in the design or running of a program may be more important to quality-of-life outcomes than meeting specific criteria for frequency intensity and duration. Virtually no research has been done on how nutrition and dietary variables can best be integrated in the quality-of-life concept. The focus has been mostly on biomedical measures and health outcomes.
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For example, clinical assessment of nutritional status in elderly adults is commonly based on dietary intake assessments, anthropometric measures, and plasma chemistry values Such measures have been used to document the prevalence of malnutrition in elderly adults, assess the degree of nutritional risk, and compare dietary intakes with recommended dietary allowances.
Epidemiological studies of diet and chronic disease risk have focused on the relationship between a single nutrient and the relevant health outcome. The traditional approach has been to examine the consumption of fats, saturated fats, or cholesterol in relation to morbidity and mortality data for coronary heart disease or cancer.
Other studies have explored the consumption of specific foods or food groups, such as legumes or vegetables and fruits, always relating estimated consumption to plasma biomarkers, disease risks, or some other biomedical endpoint.
Assessing the quality of the total diet is a promising new approach to nutritional epidemiology. Earliest measures of diet quality were mostly concerned with malnutrition and nutrient deficiency diseases. Current measures of diet quality, such as the Diet Quality Index and the Healthy Eating Index, are more concerned with issues of overnutrition and focus on dietary moderation, variety, and balance 38 Studies conducted with the Healthy Eating Index suggested that elderly women had the highest scores, reflecting high consumption of grains, vegetables, and fruits. Healthy Eating Index scores increased with age, education, and income, again showing that the quality of the diet is largely determined by social and environmental variables The success of dietary strategies for health promotion is commonly measured in terms of compliance with Dietary Guidelines for Americans or with the U.
Department of Agriculture Food Guide Pyramid 38 Few attempts have been made to relate diet quality indexes to quality-of-life measures. In the sense that quality of life reflects a general sense of happiness and satisfaction with our lives and environment, it has not been a part of mainstream research on nutrition and diet of elderly adults.
Physical health and psychological well-being are among the key domains of quality of life.
Nutrition for Older Adults
Only published data are presented here. Fontana et al. Insulin is a risk factor for cardiovascular disease and cancer, and it has been implicated in aging. However, when challenged with a glucose load, the athletes did much better than the CR individuals, suggesting that exercise is much more powerful than CR in preventing type 2 diabetes. Fontana remarked that clearly hormones and growth factors play a major role in modulating aging in humans. The same changes that have been observed in humans i. IGF-1 is a risk factor for premenopausal breast cancer, prostate cancer, and colon cancer, so the higher the IGF-1 concentration, the greater the risk of developing these cancers Chan et al.
Not only is IGF-1 a major player in cancer, Fontana said that it is also probably important in the aging process itself. Fontana and his colleagues realized this when they observed that a group of strict vegans in the study described in Fontana et al. The average American obtains about 15 to 16 percent of calories from protein. People on the CR diet had a very high protein diet, obtaining about 24 percent of calories from protein. The vegans obtained only about 10 percent of calories from protein. During the course of the study, Fontana asked some of the CR individuals to go on reduced protein diet, after which their IGF-1 serum levels dropped 25 percent, suggesting that protein restriction is more important than calories in reducing IGF Fontana and colleagues are currently studying protein restriction not just CR in both animals and humans.
In conclusion, Fontana stated that other factors besides CR , and possibly protein restriction, also affect aging. For example, exercise is very important.
Likewise, phytochemical intake may impact antiaging pathways independent of CR and other interventions. Moreover, CR is not necessarily always beneficial. Too much restriction can have detrimental effects and may even lead to death. Plus, various factors such as age, sex, and genetic predisposition might also make a difference. For example, Fontana said that starting a CR diet at the age of 65 is probably not a good idea. CR should be started at an earlier age to control body weight and avoid increased abdominal fat, though Fontana did not specify an age range.
Kirkwood began by describing his role at General Mills as somebody who connects the science with something that people actually want to eat. Aging consumers are very important to General Mills because of the fast rate of growth in the aging population. Kirkwood said that 65 percent of the estimated future growth for General Mills will come from aging boomer consumers. Several people raised their hands. When asked if old age starts at 55, a few more people raised their hands. When asked if it starts at 65, many more people raised their hands.
At 75, everybody had their hands raised.
He said that if General Mills were to build food products for aging consumers, nobody would buy them, because nobody is aging in his or her own mind. He and his team have identified five key areas of concern among aging boomer consumers: 1 physical vitality; 2 mental acuity; 3 legacy i.
Of these, mental acuity is the biggest consumer worry. People assume that medicines would be available for physical health problems and that family and other sources would be available for financial assistance, if necessary, but it would be very difficult to deal with loss of mental acuity. If we can tie food to what matters, then we will be able to inject good things into their lives. For boomers in particular, compromise is not an option. They want it all. Kirkwood then showed a short film, Project Goldie , describing the results of ethnography studies that General Mills has conducted as a way to understand baby boomer consumer values.
In particular, there are six key needs of aging consumers: 1 health and wellness, 2 care for others, 3 grandchildren, 4 connections, 5 life experiences, and 6 small households. Kirkwood used the Fiber One bar as an example of a product developed for aging boomer consumers.