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Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111
* To whom correspondence should be addressed. E-mail: alice.lichtenstein{at}tufts.edu.
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ABSTRACT |
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 TOP ABSTRACT IntroductionLITERATURE CITED |
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Introduction |
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TOPABSTRACTIntroductionLITERATURE CITED |
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The >70-y-old group can be vulnerable to compromised nutrient status. Traditionally, food intake tends to decrease with advancing age to compensate for the diminished energy needs associated with lower energy expended in physical activity and basal metabolic rate (7). Nonetheless, vitamin and mineral needs either remain constant or increase (8). In a seeming paradox, new nutritional concerns for older adults have recently been raised about energy (9,10) and nutrient (11) overconsumption. To address this latter concern for the whole population, the DRI committees added a new category of recommendations, tolerable upper intake levels (UL), defined as the highest average daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population.
In 1990 the Food Guide Pyramid for Americans was first introduced by the USDA (12). The intent was to translate the RDA values and United States Dietary Guidelines for Americans into an actionable educational tool for individuals over the age of 2 y. In 1999 we developed the Modified Food Guide Pyramid for 70+ y. Adults to reflect and emphasize the unique nutrient needs of the older U.S. population (13). The prototype of the pyramid figure was drawn in black and white. Soon thereafter, the figure was redrafted in color and renamed the Food Guide Pyramid for Older Adults. Since then, the figure has been widely used as an illustrative icon in textbooks and manuals, informational material prepared by the Departments of Elder Affairs in a number of states, newsletters intended for older Americans, and educational presentations for seniors. It also serves as the basis for the development of supplemental material for elders to educate them about nutrition and healthier techniques in food preparation and help them make informed food choices. Unique aspects include an emphasis on fiber and fluid intakes, and the potential need for dietary supplementation of shortfall nutrients.
In 2005 the USDA released a revamped Food Guide Pyramid, termed MyPyramid, and expanded its scope (Fig. 1). In addition to this new pyramid icon, integral to the system is an Internet-based program that allows for the calculation of individualized, food-based dietary guidance based on sex, body weight, height, and level of physical activity (14). The advantages of MyPyramid compared with the original Food Guide Pyramid are that the guidance is delivered in terms of household measures, is accompanied by tips on how to achieve the recommended goal, presents food group serving suggestions in terms of total intake per day, and provides tips on altering standard recipes to limit added sugars, utilizing the information available on food labels and adhering to food safety standards.
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70 y who are active and living independently. It continues to be based on the principles of the U.S. Dietary Guidelines for Americans and those of other health organizations: diets high in fruits, vegetables, whole grains, low- and nonfat dairy products, legumes, fish, and lean meats (18–21). At the base of the pyramid, a row of glasses is included to represent the importance to older adults of meeting their fluid needs (22,23) and a second row depicting a variety of physical activities is included to emphasize the importance of regular physical activity for this age group. The latter is particularly important given the high prevalence of physical inactivity in older adults (10,24).
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Current data for mean nutrient intakes suggest that as a group, older adults are at risk for not meeting the RDA or adequate intake (AI) values for calcium, vitamins D, E, and K, and potassium and fiber (Table 2) (25). The mean intake for these shortfall nutrients ranges from 33 to 50% of the RDA or AI values for individuals over the age of 70 y. These data highlight the benefit for incorporating targeted advice in the Modified MyPyramid for Older Adults graphic.
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Vitamin D.
Older adults are at increased risk for not meeting their AI for vitamin D (30). It is currently estimated that no more than 2% of the elderly (70 y) met the vitamin D AI from food sources (30). The ability of the skin to synthesize vitamin D declines with age (31). Limited sun exposure due to latitude or concern about sun exposure and skin cancers can minimize endogenous vitamin D synthesis (32). Additionally, with increasing rates of overweight and obesity in the older population, there is a further concern for vitamin D inadequacy due to deposition in body fat compartments and subsequent compromised bioavailability (33). Until recently, fluid milk was the only reliable food source of vitamin D in the United States (30). The intake of fluid milk has been on the decline. In 1980 per capita consumption was 27.9 gallons, whereas in 2003 per capita consumption declined to 22.5 gallons (34).
The potential increasing importance of vitamin D in maintaining optimal health has met with a groundswell of concern (35,36). Recent amendments to the vitamin D fortification regulation resulted in approval of the addition of vitamin D to calcium-fortified juices and juice drinks, nutrient supplemented meal replacements, and a wide range of dairy products (37–39).
Vitamins E and K, and potassium. Vegetables and fruits are nutrient rich. Depending on the individual food, they can be good sources of vitamins E and K, and potassium. Higher fruit and vegetable intakes and concomitant nutrients have been associated with a number of positive health outcomes, including bone health, blood pressure, metabolic syndrome, stroke, and cardiovascular disease (40–46). Within the Modified MyPyramid for Older Adults, the food icons emphasize deeply colored vegetables and fruits, those that (for the most part) are richer per serving in shortfall nutrients. Also emphasized is the wide range of food-packaging forms available. Resealable bags of frozen vegetables and fruits are particularly good choices for older individuals, because they allow for easy apportioning of single or double servings, minimize pre-preparation that can be difficult or even painful with advanced years, eliminate waste due to spoilage, reduce the need for frequent trips to the market, and provide variety during winter months. Vegetable oils, especially soybean and canola, are an important source of vitamins E and K. Icons in the fats and oils segment of the Modified MyPyramid for Older Adults highlight vegetable oils in the liquid state and soft spreads that are rich in vitamins E and K and also low in saturated and trans fatty acids.
Fiber. High-fiber foods are plant-based foods low in energy and rich in vitamins, minerals, and phytochemicals (5). The AI level set for fiber includes dietary and functional fiber, summed together and expressed as total fiber. Dietary fiber is defined as "nondigestible carbohydrate and lignin that are intrinsic and intact in plants," and functional fiber as "isolated, nondigestible carbohydrates that have been shown to have beneficial physiological effects in humans" (5). Dietary fiber aids laxation in older adults. According to the NHANES III, data dietary fiber intake for men >70 y is only 50% of the recommended intake; for women >70 y, it is 67% (Table 2) (5). The Modified MyPyramid for Older Adults recommends achieving dietary fiber intake by choosing whole grains, whole fruits and vegetables, and legumes.
Fiber supplements are not routinely recommended. Excessive intake of dietary fiber can decrease gut mineral absorption of calcium, iron, zinc, copper, and magnesium (47,48). In some elderly, chewing and swallowing fibrous foods may be difficult due to poor dentition and may prevent older adults from selecting better food choices, resorting instead to soft foods that are highly processed and lower in fiber (49). As part of our effort to encourage all older adults to increase fruit and vegetable intake, the Modified MyPyramid for Older Adults graphic displays stewed and canned food items as well as fresh examples.
Dietary supplement/fortification (flag)
Despite dietary advice, some older adults will not or cannot consume adequate amounts of calcium- and vitamin D-rich foods to meet their nutrient requirements. Limitations in the bioavailability of vitamin B-12 occur due to an increased prevalence of atrophic gastritis with advancing age. It is conservatively estimated that atrophic gastritis affects 10–30% of the U.S. population >60 y (50). In these individuals, protein-bound vitamin B-12 is not freed to bind to intrinsic factor for absorption. Atrophic gastritis can also result in bacterial colonization of the upper gastrointestinal tract and further compromise vitamin B-12 status by utilizing the small amounts of vitamin B-12 available (51). A flag at the top of the Modified MyPyramid for Older Adults graphic is included to indicate that a supplement containing calcium and vitamin D or vitamin B-12 or specific foods fortified with these target nutrients may be needed.
Potentially overconsumed nutrients for individuals 70 y and older
The high prevalence of dietary supplement use in older adults and the increased availability of fortified foods makes this group particularly vulnerable to overconsumption (11,52–54).
Folate. Current data for mean nutrient intakes suggest that adults 70 y and older are at risk for overconsumption of folate (Table 3). The widespread and relatively unregulated fortification of foods and beverages, and the high rates of nutrient supplement use among older women in the United States contribute to this problem (11,52). One serving of fortified cereal (100% daily value) and 1 multivitamin supplement per day can provide 80% of the UL for folic acid alone.
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Sodium. High sodium intakes are a population-wide problem and current data indicate that this is particularly so in older adults (Table 3) (60). As individuals age, sodium sensitivity increases and renal function, which limits the ability of the kidney to excrete sodium, decreases (61,62). About 55% of women and 49% of men aged 55–64 y are reported to be hypertensive. These values increase to 74 and 64% by age 65–74 y and 84 and 70% by age 75 y and over, respectively (63). Reduction in dietary sodium in older adults lowers blood pressure (64) and has been associated with reduced incidence of stroke and heart disease (65). Increased availability of reduced and low-sodium canned and prepared foods affords a feasible approach to reducing sodium intake in older adults. Raising awareness to their availability should be stressed.
Fluid
Fluid intake is critical for maintaining vascular volume, regulating body temperature, removing waste from the body, and supporting cellular homeostasis. Fluid needs in healthy older people are variable and greatly influenced by level of physical activity, ambient temperature, and medication use. It is assumed for the individuals for whom the Modified MyPyramid for Older Adults is intended, renal function is in the normal range. Fluid intake is more important to emphasize in older than in younger adults, because compromised homeostatic mechanisms such as loss of the thirst sensation can result in dehydration (22,23,66). This is of particular concern during periods of increased ambient temperature or physical activity. There are a number of ways to meet fluid needs: water derived from drinking water, water in other beverages, and water in foods. Data from NHANES III indicate that for adults 70 y, 
81% of their daily fluid intake came from beverages and 19% from food. The current AI (mean intake of the U.S. population) for total water (beverages and food) as established by the Institute of Medicine (6) for 70-y-old adults is 2.7 L (12 cups)/d for women and 3.7 L (16 cups)/d for men. At the base of the Modified MyPyramid for Older Adults, we have incorporated fluid as an integral part of the icon, depicted as glasses of water.
Physical activity
The foundation of the Modified MyPyramid for Older Adults is formed by a panel illustrating various types of physical activity. The individual segments of the panel are intended to serve as examples rather than to be comprehensive. In the United States, physical activity declines with advancing age (10,24,67). This is particularly unfortunate because regular physical activity has been associated with reduced fatigue, elevated mood and reduced depression symptoms, improved physical functioning, reduced physical role limitations, decreased falls, attenuated loss in bone density, decreased risk of cardiovascular disease and osteoporosis, improved insulin sensitivity and glucose tolerance, decreased blood pressure, and improved exercise capacity (68–74). In addition, it has been shown to be helpful in achieving and maintaining a healthy body weight (75).
Overweight and obesity
In our original Modified Food Guide Pyramid for 70+ Adults, it was noted that 40% of those surveyed in NHANES III consumed below two-thirds of the RDA for energy (13). Thus, the focus of our original report targeted individuals who were vulnerable to compromised nutrient status based on inadequate energy intakes. Indications are that adults approaching 70 y will more likely be faced with problems of calorie excess, leading to overweight or obesity (34,76). Additionally, underreporting of energy intake is pervasive among all age categories and thus the validity of self-reported energy intake is questionable. Our main platform in promoting special nutrient considerations for those over age 70 y is still predicated on the concept of emphasizing foods with a high nutrient density (a high ratio of nutrients to energy). In this advanced life stage, increased physical activity notwithstanding, energy needs decline and necessitate decreased food intake, but this decrease should not be at the expense of nutrient-rich food choices.
Both weight loss and gains in the elderly are challenging situations. Unintended weight loss in an older adult is associated with impaired immunity, muscle wasting and cognitive function deficits (77). The causes of weight loss in an older adult are complicated and multidimensional, and include such factors as poor dentition, impaired taste and smell, polypharmacy, chronic illness, digestive disorders, and early stages of cognitive impairment. It has been estimated that caloric intake decreases 800 and 1200 kcal/d for women and men, respectively, between the ages 20 to 80 y (77).
The prevalence of obesity has grown worldwide and affects morbidity and mortality in those in the later decades of life. One of the physiological changes that occur over time is the loss of lean body mass and increased in fat mass (78). This body composition change is particularly challenging for individuals who have higher body mass indices because of the increased risk for diabetes, heart disease, high blood pressure, arthritis and other disabilities (79). Since the 1960's the percentage of the adult population classified as obese has risen from 13.3 to 33.1% (80).
Alcohol
One-third of the U.S. elderly population reports regular consumption of alcohol (81). In older individuals, moderate alcohol intake has been associated with lower risk of coronary heart disease (82), and U-shaped relationships with stroke (83), bone mineral density, and hip fracture (84). Further complicating the picture, alcohol use in older adults, especially as they advance in years, is of concern with respect to physical or emotional illnesses (such as depression), drug interactions, limitations in physical functioning (such as mobility and self-care), and smoking and driving after drinking (85–87). Among adults aged 60 y and older, drinking >7 drinks per week has been associated with impairment in instrumental activities of daily living, while drinking >14 drinks per week has been associated with impairment in advanced activities of daily living (85). Accurate identification of alcohol use disorders in older individuals is difficult (86,87). Therefore, we did not include alcohol as an integral component of the Modified MyPyramid for Older Adults. If an alcoholic beverage is regularly consumed by an older adult, it is recommended that this be done in only moderation (
1 drink per day for women 2 drinks per day for men) and this information be shared with all healthcare providers so that if medication use changes, this information will be readily available.
Commentary
In 1999 we proposed a Modified Food Guide Pyramid for 70+ Adults (13). The major modifications to the original USDA Food Guide Pyramid were to narrow the base to reflect lower energy needs of older adults due to changes in body composition and metabolic rate and, hence, the amount of food needed to maintain a stable body weight; replace selected food icons with nutrient dense examples to help the elderly reconcile decreased food intake with unchanged or increased RDAs; add a fiber icon in appropriate food categories to emphasize the need for and provide guidance toward achieving Adequate intakes to promote optimal bowel function; include a row of glasses at the base of the pyramid to reinforce the importance of maintaining adequate fluid intakes at a stage in life when some individuals experience a disassociation between hydration state and the thirst sensation; and add a flag to the top to indicate that some elders, due to changes associated with aging, may need to consult with their healthcare provider to determine whether they should take vitamins B-12 or D or calcium supplements.
The goal of the current modification and embellishment of the MyPyramid graphic is to provide older people with an alternate to the Web-based version that is an easily understood graphic that, in conjunction with supplemental material, can be used in print format for education and demonstration purposes. The MyPyramid Web dietary guidance program could have enormous value if its potential use is maximized and if there is a dedicated outreach to make all older adults "Internet fluent." Pedagogic issues regarding literacy, clarity, and relevance with Web-based nutrition and dietary information need to be continuously examined. We do not intend the graphic to accomplish all the functions that the interactive computer program does or substitute for it. The intent is to incorporate icons within the graphic that serve to raise awareness of the unique needs of older adults and how to meet them. These include an emphasis on whole grains and variety within the grain group; variety and nutrient density in the vegetable and fruit groups; in the milk group, low-fat and nonfat forms of dairy products, including reduced lactose; low saturated and trans fatty acid types of oils in the fats group; and low saturated fat animal and vegetable choices in the meat and bean group. An underlying theme is emphasis on fiber-rich sources within each group. Also incorporated as an integral part of the pyramid are fluid and physical activity icons.
It is important to communicate to older adults that eating should remain an enjoyable experience. Drawing public attention to this issue provides an opportunity for those educating the public regarding optimal nutrition, not just for those >70 y. The guidance provided can be used as a road map and should be adaptable so it can accommodate many different dietary preferences, patterns, and lifestyles. It is also important to communicate to older adults that the basic message in the Modified MyPyramid for Older Adults is that is it preferable to get essential nutrients from food rather than supplements. Deriving the majority of nutrients from foods rather than supplements makes overconsumption less likely. The flag on the top of the pyramid is intended only to alert older adults that they may need to augment food sources of nutrients with either specially fortified food products or a nutrient supplement containing vitamins D or B-12, not that it is necessary for all individuals.
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FOOTNOTES |
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2 Author disclosures: A. H. Lichtenstein, H. Rasmussen, W. W. Yu, S. R. Epstein, and R. M. Russell, no conflicts of interest.
3 Abbreviations used: AI, adequate intake; DRI, dietary reference intake; RDA, recommended dietary allowance; UL, upper intake level.
Manuscript received 20 August 2007. Initial review completed 18 September 2007. Revision accepted 22 October 2007.
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