HM Medical Clinic

Table of Contents Introduction . . . . . . . . . . . . . . . . 37
Aging and Nutritional Well-Being . . . . . . . 38
Good Nutrition for Seniors . . . . . . . . . 39
Determining Nutritional Risk . . . . . . . . . 39
Nutritional Risk Checklist . . . . . . . . . . 40
Promoting Fluid Intake . . . . . . . . . . . 42
Nutrient and Calorie Needs . . . . . . . . . 43
Chronic Diseases . . . . . . . . . . . . . . 44
44 . . . . Heart Disease 46 . . . . High Blood Pressure 47 . . . . Diabetes 51 . . . . Osteoporosis Food Allergies and Intolerances . . . . . . . 52
Dietary Supplements . . . . . . . . . . . . 54
Medicines and Older Adults . . . . . . . . . 55
Barriers to Healthy Eating . . . . . . . . . . 57
57 . . . . Poor Appetite 57 . . . . Dental Problems 58 . . . . Swallowing Problems 59 . . . . Sensory Impairments 60 . . . . Cognitive Impairments Massachusetts Department of Education Child and Adult Care Food Program Developed for the Massachusetts Department of Education Child and Adult Care Food Program by the University of Massachusetts Extension Nutrition Education Program. 2006 Massachusetts Department of Education. Permission is hereby granted to copy any or all parts of this document for non-commercial educational purposes. Please credit the "Massachusetts Department of Education." Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS This section will cover the following topics:
Now that you have learned the basics of Aging and Nutritional Well-Being good nutrition, you can learn How does the aging process affect nutritional health?about some special nutrition needs that older adults Good Nutrition for Seniors What are some goals for good nutrition? Determining Nutritional Risk How can you identify adults at risk of poor nutrition? Fluid, Nutrient, and Calorie Needs Why do older adults need plenty of fluids? How can older adults meet their nutrient needs? What causes some older adults to gain excess weight? Which chronic diseases have a link to nutrition? Food Allergies and Intolerances What are some examples of food allergies or intolerances? What are the symptoms of a serious allergic reaction? Dietary Supplements Should older adults use vitamin, mineral, or herbal supplements? Caution: Adult day health staff
should never diagnose health Medicines and Older Adults conditions; prescribe supplements; What are some common side effects of medicines? put participants on special diets; How do medicines affect the nutritional status of older adults? nor revise, change or interpret diet orders. These roles are the responsibility of your participants' Barriers to Healthy Eating What barriers might prevent older adults from eating well? health care providers.
How can you address these barriers to promote healthy eating? Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Aging and Nutritional Well-BeingMany older adults face changes that can affect their food intake and nutritional status. The changes may be physical, health-related, social, or psychological. The nature and extent of these changes will vary among adults. Good nutrition can help older adults to improve their health and maintain their quality of life, in spite of these changes.
• Older adults may need fewer calories to maintain their weight, but still need the same amounts (or even more) of vitamins and minerals as they did in their younger years. • Changes in vision, taste, or smell can affect appetite or enjoyment of foods. • Dental problems may limit intake of certain foods. • Digestive changes can affect the way the body absorbs certain nutrients. • A decreased sense of thirst can raise the risk of dehydration.
• Immune function may decline and prolong recovery from illness.
• Aging can affect how medicines work in the body, and how they interact with foods.
Medicines can alter appetite or taste. • Acute illness can lead to decreased appetite.
• Older adults are at increased risk for chronic diseases such as obesity, diabetes, heart disease, high blood pressure, cancer, or osteoporosis.
• The loss of a spouse or partner can lead to changes in eating patterns.
• Less income after retirement may lead to cutting nutritious foods from the budget. • A reduced ability to drive may make it hard to buy food from the grocery store.
• Cognitively impaired adults are less able to buy foods, prepare meals, or use utensils. Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS Good Nutrition for SeniorsThe following are goals to help maintain the health and nutritional status of older adults. By following the advice of the Dietary Guidelines and USDA Pyramid, along with additional advice in this manual, you can plan meals and strategies to help meet these goals: • Meet nutrient needs on fewer calories.
• Increase the appeal of meals.
• Eat a variety of nutritious foods.
• Address any barriers to healthy eating.
• Eat more dietary fiber.
• Stay physically active, if possible.
• Consume enough fluids.
• Prevent or treat chronic diseases.
• Maintain health and nutritional status.
• Minimize food/drug interactions.
Determining Nutritional RiskOlder adults who consume low levels of nutrients may be at risk for poor nutrition. The risk may be compounded by self-medication, alcohol, disease, dental problems, or physical limitations. Identifying problems early may help older adults to live longer, healthier lives.
The Nutrition Screening Initiative has developed a screening tool called Determine Your Nutritional Health (see an adapted version titled Nutritional Risk Checklist on the next two pages) to assess nutritional risk in older adults. The goal of the checklist is to identify potentially high-risk adults before the appearance of any signs or symptoms of poor nutrition. This tool helps to determine whether an older adult might need medical or nutritional assistance. You should refer any high-risk older adult to a dietitian, physician, or other heath care professional.
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Nutritional Risk Check ListKnow the warning signs of poor nutritional health. Use this checklist to learn whether you, or someone you know, is at risk for poor nutrition.
Read the statements below. For each YES answer, circle the number in the "yes" column.
Then total the score.
I have an illness or condition that has made me change the amount or kind of food that I eat.
I eat fewer than 2 meals each day.
I have 3 or more drinks of beer, liquor, or wine, almost every day.
I eat few fruits, vegetables, or milk products.
I have tooth or muscle problems that make if hard to me to eat.
I don't always have enough money to buy the food I need.
I eat alone most of the time.
I take 3 or more different prescription or over-the counter medicines each day.
In the last 6 months, I've lost or gained 10 pounds without wanting to. I am not always physically able to shop, cook, or feed myself.
GOOD! Re-check your score in 6 months.
You are at MODERATE nutritional risk. Try to improve your eating habits and lifestyle. Seek advice from your office on aging, senior nutrition program, senior center, or health department.
You are at HIGH nutritional risk. Bring this checklist to your next appointment with your doctor, dietitian, or other qualified health professional. Tell them about any problems you may have. Ask for help to improve your nutritional health.
Note: These warning signs suggest risk, but they are not meant to diagnose any condition.
Turn the page to learn more about the warning signs of poor nutritional health.
Adapted from: Determine Your Nutritional Health, developed by the Nutrition Screening Initiative. A project of the American
Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging. Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS USE THE WORD D E T E R M I N E TO REMIND YOU OF THE WARNING SIGNS.
Disease, illness, or chronic conditions affect the way that people eat. Confusion or memo- ry loss can make it hard to remember what, or whether, they have eaten a meal. Feeling depressed can affect appetite, digestion, energy level, weight, and well-being.
Poor nutritional health can be caused by eating too little, eating too much, skipping meals, or eating the same foods day after day. It can also be caused by eating too few fruits, vegetables, or milk products.
Missing or loose teeth, or poor-fitting dentures, can make it hard to eat.
People on a reduced income may find it hard to afford the foods they need.
Having fewer contacts with other people can have a negative effect on morale, well-being, and appetite.
Growing old may change the way that older adults respond to these medicines.
The more medicines that they take, the greater the risk for side effects such as constipation, diarrhea, drowsiness, nausea, or a change in appetite or taste.
This is an important warning sign that should not be ignored. N EEDS ASSISTANCE IN SELF-CARE
Some older adults have trouble walking, shopping, or buying or cooking food.
Most older people lead full and productive lives. But as age increases, the risk of frailty or health problems increases.
Adapted from: Determine Your Nutritional Health, developed by the Nutrition Screening Initiative. A project of the American
Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging.
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Fluids play important roles in the body. They prevent constipation, regulate body temperature, carry nutrients to cells, and regulate the balance of fluids in body cells. They also make it easier for people to chew and swallow foods. Every day, people lose fluids when they sweat, breathe, urinate, and have bowel movements. Thus, they need to replenish fluids to prevent dehydration and help their bodies function smoothly.
As adults get older, they continue to need about 11⁄2 to 2 liters of fluids each day.
However, older adults may find it harder to maintain fluid balance, for several reasons: • They may have a reduced sense of thirst, leading them to drink less fluids.
• They may drink less fluids due to poor bladder control, poor mobility, or illnesses.
• Their bodies may have lost water due to diarrhea or poor intestinal absorption.
• They may use diuretics and laxatives that raise the risk for dehydration.
• They may be using other medications that increase fluid needs.
Dehydration can be a serious health problem for older adults. To prevent dehydration, many experts recommend consuming at least 8 cups of fluids each day. Fluids are not limited to water! Fruit juice, milk, soup, fruit, and decaffeinated coffee and tea also count. Your day health program can help promote fluid intake by offering fluids every 2 or 3 hours, including with meals and snacks. Encourage older adults to drink fluids regularly, since they may fail to recognize their thirst.
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS Nutrient and Calorie Needs AGING AND CALORIE NEEDS

Compared to their younger years, older adults need fewer calories to maintain their weight.
This is because their metabolism tends to slow down, and because they may be less physically active. The chart at right lists the estimated daily calorie needs for older adults based on Source: Dietary Guidelines for Americans, 2005.
their level of physical activity.
Older adults need the right balance between eating too many calories or too few calories. Too many calories can lead to obesity, which raises the risk for high blood pressure, diabetes, heart attack, and stroke. Too few calories can lead to weight loss, frailty, or fatigue, and can prevent adequate intake of essential nutrients. MEETING NUTRIENT AND CALORIE NEEDS
While calorie needs decrease with aging, vitamin and mineral needs remain the same. In fact, the need for some nutrients (such as vitamin B6, vitamin D, and calcium) increases. Thus, older people face the challenge of meeting their nutrient needs on fewer calories. For this reason, they should choose a variety of nutrient-dense foods each day. Nutrient-dense foods are rich in vitamins and minerals and relatively low in calories. Examples are whole grain breads, fortified cereals, fruits and vegetables, lean meats, and low-fat dairy products.
Because each food group provides a variety of nutrients, it is important to include all food groups in the daily diet. It is also important to vary choices within each food group. Foods with a low nutrient density provide calories but few vitamins and minerals. They have added sugars, saturated fats, trans fats, and alcohol. Regularly eating these foods makes it hard to get enough nutrients without gaining weight, especially for people with sedentary lifestyles. Many Americans (including older adults) consume more calories than they need without getting enough nutrients. They should choose foods and beverages that are high in nutrients, but low to moderate in calories. Overall, they should eat more fruits, vegetables, whole grains, legumes, and low-fat milk and milk products. They should eat less refined grains, cholesterol, saturated fats, trans fats, salt, and added sugars.
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
The prevalence of obesity in the U.S. has doubled Coronary heart disease involves a progressive in the past two decades. Obesity raises the risk for blockage of coronary arteries that reduces blood premature death, type 2 diabetes, high blood flow to the heart. This can raise the risk of chest pressure, stroke, heart disease, gall bladder disease, pain, heart attack, and death. Coronary heart gout, osteoarthritis, and some types of cancers.
disease is the leading cause of death among older adults.
There are many possible causes of weight gain If too much cholesterol circulates in the blood, in older adults. The major cause is being less it can build up in the walls of the arteries.
physically active. Other possible causes are Over time, the arteries become narrow and slow burning fewer calories with age due to a slower down the blood flow to the heart. Since blood metabolism; having an underactive thyroid or carries oxygen to the heart, chest pains can occur other medical disorder; or taking medications when less oxygen is available. If no oxygen gets with a side effect of promoting weight gain.
to the heart, a heart attack can happen.
Risk Factors for Heart Disease
Ideally, adults should achieve and maintain a body • Some risk factors are beyond control.
weight that is good for their health. For obese They include age (45 or older for men; adults, even losing as little as 10 pounds provides 55 or older for women) and family history health benefits. Reducing caloric intake by as little of early heart disease.
as 50 to 100 calories per day may help prevent weight gain. Eating 500 fewer calories per day is a • Other risk factors can be controlled through common goal in weight-loss programs. Strategies diet and lifestyle changes. These include high to reduce calories include serving smaller portion blood pressure, high blood cholesterol, high sizes, and serving foods with fewer calories, such LDL ("bad" cholesterol), low HDL ("good" as low-fat foods and foods without added sugars.
cholesterol), cigarette smoking, diabetes, overweight, and lack of exercise.
Treating obesity requires the advice and supervision of a participant's health care providers (doctor, registered dietitian, and nurse). It may involve a supervised program of diet and exercise.
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS What do the Numbers Mean?
Different types of cholesterol and fat travel • HDL cholesterol (high-density lipoprotein) is
through the body. the "good" cholesterol. It prevents • LDL cholesterol (low-density lipoprotein) is
cholesterol from building up in the arteries; called the "bad" cholesterol.
therefore, it protects against heart disease.
It is the main cause of cholesterol build-up • Total cholesterol is the sum of LDL, VLDL
and blockage in arteries.
and HDL cholesterol levels.
VLDL cholesterol (very low-density lipoprotein)
Triglyceride is a type of fat in the blood that
is also called "bad" cholesterol because it acts can raise the risk of heart disease.
in much the same way as LDL cholesterol.

Blood Level:
Total Cholesterol Less than 200 mg/dL LDL Cholesterol• Low risk patients . . . . . . . . . . . . . . Less than 160 mg/dL• Moderately high risk patients . . . . . . . . . Less than 130 mg/dL• High risk patients . . . . . . . . . . . . . . Less than 100 mg/dL• Very high risk patients . . . . . . . . . . . . Less than 70 mg/dL More than 60 mg/dL Less than 150 mg/dL Source: National Cholesterol Education Program Adult Treatment Panel III, 2004.
Preventing and Treating Heart Disease
To help prevent heart disease, adults should work with their health care providers to change their diets and lifestyles. A heart-healthy eating plan can help control the risk factors of high blood pressure, high cholesterol levels, overweight, and diabetes.
Serving heart-healthy meals and incorporating physical activity into the daily routine can help older adults lower their risk of heart disease. A heart-healthy eating plan provides less than 30% of calories from fat. It includes foods low in saturated fat, cholesterol, and sodium. It also includes fiber from whole grains, fruits, and vegetables. Treating heart disease may involve a prescribed diet, medications, and a supervised physical activity program. It also may require surgery.
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Blood pressure is the force that blood exerts against the artery walls. It is measured in two numbers. The top number is systolic pressure (as the heart beats). The bottom number is diastolic pressure (as the heart relaxes between beats).
Blood pressure is affected by several factors and Source: Your Guide to Lowering Blood Pressure,
can vary over the course of a day. Therefore, National Institutes of Health, 2003.
blood pressure measures should be repeated over a few days to get an accurate reading.
High blood pressure, or hypertension, is blood
Guidelines to Help Prevent High Blood Pressure
pressure that remains elevated for a long time.
• Maintain a healthy weight.
It is prevalent in older adults, and often has no • Include fruits, vegetables, low-fat dairy foods.
warning signs or symptoms. It can be dangerous because it makes the heart overwork and raises • Choose foods with less salt and sodium.
the risk of atherosclerosis (buildup of fat in • Limit alcohol intake.
arteries). It can also lead to kidney disease or • Be physically active.
congestive heart failure.
Treating High Blood Pressure
Sodium and Blood Pressure
Treating high blood pressure may involve Sodium plays a major role in controlling blood following the guidelines above, along with stricter pressure, since it helps maintain fluid pressure sodium restrictions. People unable to control within the blood. For some people, consuming their high blood pressure with diet and lifestyle foods high in salt can lead to elevated sodium changes alone may also require medications such levels in the body, which can result in high as diuretics and other drugs. This may especially blood pressure.
be true if they have a strong family history of high blood pressure.
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS Focus on Sodium
• According to the Dietary Guidelines, most Type 2 diabetes is most prevalent in adults.
people should aim for less than 2,300 mg of The body makes insulin, but cannot use it sodium per day. This is about 1 teaspoon of properly. Risk factors include age over 40 years, salt. Older adults and people with high blood overweight (more than 20% of ideal body pressure should aim for less than 1,500 mg of weight), and having a closely related family sodium per day.
member with diabetes. It can often be treated with diet and exercise (exercise helps muscles • High amounts of sodium (as salt) are often use glucose for energy). Treatment may also added to processed and prepared foods.
• Most unprocessed foods are naturally low in sodium. These include fruits; fresh or frozen Possible Complications
vegetables; and fresh or frozen fish, fish, poultry, and meat.
Diabetes can cause some serious problems over time. It can lead to blindness, kidney • Read food labels for sodium content.
damage, heart disease, nerve damage, and Avoid adding salt in recipes or at the table. other health problems.
• Use spices and herbs for seasonings.
Signs and Symptoms
The signs and symptoms of diabetes may include: Diabetes is a disease that affects how the body • Feeling hungry or thirsty all the time.
uses carbohydrates (sugars and starches) from foods. Usually, the sugars and starches that • Urinating more than usual.
people eat are broken down into a sugar called • Feeling tired more than usual.
glucose, and their blood carries the glucose to • Blurred vision.
cells in the body. A hormone called insulin helps move glucose from the blood into the • Cuts or bruises that won't heal.
cells for fuel and storage.
• Tingling or numbness in hands and feet.
People with diabetes either cannot make insulin or cannot use it properly, depending on what type of diabetes they have. Either way, the glucose stays in the blood longer and cannot be used properly by the cells. The result is a high blood glucose level.
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Diabetes and Older Adults
Many older adults may have type 2 diabetes without even knowing it. They may be surprised to be diagnosed with diabetes, because they haven't noticed any symptoms or felt sick. Therefore, it is extremely important that older adults have their blood glucose checked on a regular basis.
If they have diabetes, they should see their doctor and a licensed registered dietitian to design a meal plan that best fits their needs.
Preventing Type 2 Diabetes
Goals for People with Diabetes
• Maintain a healthy weight.
• Follow special dietary advice from your doctor and a licensed registered dietitian.
• Consume plenty of fiber.
• Take insulin or diabetes medications • Eat appropriate portion sizes.
if prescribed.
• Be physically active, if possible.
• Be physically active, if possible.
• Maintain a healthy weight.
• Aim for blood glucose levels within the recommended range.
The chart below shows general goals for most people with diabetes who self-test their blood glucose levels. An individual's health care team should determine specific target goals and develop a program of regular glucose monitoring to manage his/her diabetes.
Time of Check
Whole Blood Values
Before Meals
Source: If You Have Diabetes, Know Your Blood Sugar Numbers.National Diabetes Education
Program, National Institutes of Health and the Centers for Disease Control and Prevention, 2002.
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS Hypoglycemia in People with Diabetes
a diabetes meal plan. Examples are following Hypoglycemia is low blood sugar. It can occur in the USDA Pyramid, rating your plate, exchange someone with diabetes who is taking medications.
lists, and carbohydrate counting. Check with Be alert to the signs and symptoms, which your participant's heath care provider for include feeling weak, feeling hungry, sweating more, or having sudden changes in heartbeat.
Immediately test the blood glucose level of a Tips for Feeding Participants with Diabetes:
person with these symptoms. If his/her glucose • Follow scheduled eating times. Serve meals level is below 70 mg/dL, the person should and snacks at about the same time each day immediately consume one of the following: to maintain a consistent supply of sugar in the blood. Eating too much food at one time • 1⁄2 cup fruit juice can raise blood glucose to dangerous levels.
• 1⁄2 cup regular soft drink Skipping a meal can cause the blood glucose (not diet or sugar-free) to drop too low, resulting in hypoglycemia.
• 5 or 6 pieces of hard candy • The Idaho Plate Method provides a quick and • 1 or 2 teaspoons of sugar or honey easy way to know how much space each food • 2 or 3 glucose tablets group should occupy on a dinner plate (fill 1⁄2 After 15 minutes, retest the blood glucose level of the plate with bright, colorful vegetables, and see if it has returned to a more acceptable ⁄4 of the plate with a starchy food, and the level. After the blood glucose level stabilizes, other 1⁄4 with a protein food). You can order offer the person a snack if it will be at least this guide from the Idaho DCE Plate Method, 1 hour until the next scheduled meal.
PO Box 441, Rexburg, Idaho 83440-0441, website:, phone:
Diabetes Meal Plan
Following a proper meal plan is important in • See the next page for a sample diabetic menu controlling blood glucose levels. Along with with different amounts of food at different exercise and medications (insulin or oral diabetes calorie levels. Observe how small changes or pills), eating well-balanced meals in the correct additions in foods bring the menu up to a amounts can help keep blood glucose levels as higher calorie level. Note that serving sizes close to normal as possible.
and food items are not necessarily those A diabetes meal plan tells how much and what creditable by CACFP. kinds of food a person can eat at meals and snack • Check with the participant's healthcare times. It should fit in with the person's schedule provider for individual recommendations.
and eating habits. There are many ways to follow Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Sample Diabetic Menu
Note: This is only a sample of a menu for people with diabetes. It is NOT designed specifically for your program's participants
with diabetes. Serving sizes and food items shown below are not necessarily creditable by CACFP. Any meal or menu
substitutions that vary from CACFP regulations require documentation from a medical authority.
Whole-wheat toast Graham cracker squares Tuna sandwich/sandwiches Water-packed tuna Low-fat mayonnaise Whole-wheat bread Chicken breast (skin removed) Gingersnap cookies Adapted from: Diabetes and Your Diet: Using the Dietary Guidelines for Americans as a Guide to Healthy Eating;
University of Wisconsin Extension – Cooperative Extension, publication NCR 576, 2004.
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS • Older adults need 1,200 mg of calcium each day. Low-fat milk, cheese, and yogurt are Osteoporosis is a gradual process of bone loss great sources of calcium.
that results in weak, brittle bones. It is a major cause of bone fractures of the hip, spine, and • Older adults also need extra vitamin D to help wrist. Every year, over 25 million people in the their bodies absorb calcium. Vitamin D is United States are afflicted with this disease.
found in fatty fish and fortified milk. Osteoporosis is called a "silent disease" because • Calcium supplements with vitamin D may be a often people are not diagnosed until they have necessary addition to the meal plans of older broken a bone. As people get older, the risk of adults who do not consume enough calcium- rich foods and vitamin D-fortified milk.
• Physical activity, especially weight-bearing Who Has the Greatest Risk for Osteoporosis?
exercise such as walking, lifting, or dancing, Women make up 80% of people with osteo- can strengthen bones and actually reverse porosis. Women are especially at risk if they: the effects of osteoporosis.
• Are past menopause.
• Have a small body frame.
The following are good sources of calcium: • Have a family history of osteoporosis.
Amount of
Food Source
• Are Caucasian or Asian.
• Don't exercise (since exercise leads 350-375 mg
• 1 cup soy milk, to stronger bone).
300-350 mg
• 3 oz sardines, with bones • Eat diets low in calcium and vitamin D.
• 1 slice (1 oz) Swiss cheese 200-225 mg
• Smoke or drink more than 3 glasses • 1 slice (1 oz) Cheddar cheese • 1 cup cottage cheese of alcohol per day.
• 1 cup baked beans 125-150 mg
Older men are also at risk for osteoporosis.
• 1 piece pumpkin pie (1⁄8 of 9" pie) • 1 slice (3⁄4 oz) Maintaining Bone Health
100-125 mg
• 1⁄2 cup vanilla pudding Osteoporosis can be prevented or delayed by • 1 cup cooked broccoli consuming vitamin D and calcium and taking 50-100 mg
• 1 cup ice cream part in regular physical activity. Following the • 1 cup soy milk, unfortified CACFP pattern and offering milk with each meal Source: USDA National Nutrient Database for Standard
will help provide calcium and vitamin D.
Reference, Release 17 (2004).
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Food Allergies and Intolerances A food allergy or intolerance is an improper reaction by the body to a food or additive. Although there is a difference between food allergies and intolerances, they both cause problems in susceptible people. Symptoms may include wheezing, bronchitis, runny nose, vomiting, diarrhea, rashes, itching or headaches. Some reactions can cause discomfort, while others can be life-threatening. It is important to: (1) learn about any food allergies or intolerances that your participants may have, (2) recognize the symptoms, and (3) minimize the chance of exposure to foods or additives that reactions when eating certain foods such as bananas, kiwi, avocados, or chestnuts Anaphylaxis is a sudden, severe, potentially fatal,
(or less commonly, potatoes, tomatoes, or pitted systemic allergic reaction that can involve the fruits such as peaches, plums, or cherries). Some skin, respiratory tract, gastrointestinal tract, and people are so sensitive that even a trace amount cardiovascular system. It can involve a reaction to of a problem food can cause a reaction.
a food, medication, insect sting, or latex. Anaphylactic reactions can range from mild to life-threatening. Symptoms occur within minutes to 2 hours after contact with the allergy-causing Lactose, or "milk sugar," is found in food products
substance. In rare instances, they may occur up containing milk or milk solids. It is also found as to 4 hours later. Life-threatening reactions may an ingredient in some non-dairy foods, baked progress over hours.
foods, and processed foods. Lactose is digested in the body by the enzyme lactase. People with Symptoms may start with a tingling sensation, lactose intolerance have too little of this enzyme, itching, or metallic taste in the mouth. Other and cannot properly digest lactose. They may symptoms can include hives, a warm feeling, experience gastrointestinal discomfort such as swelling of the mouth and throat area, difficulty stomach cramps, gas and diarrhea. Native breathing, vomiting, diarrhea, cramping, a drop Americans and people from Africa and Asia are in blood pressure, and loss of consciousness. If particularly susceptible to lactose intolerance.
you see someone experiencing an anaphylactic Some people with lactose intolerance may be reaction, seek professional medical help quickly.
able to tolerate certain dairy foods such as Peanuts, tree nuts, shellfish, fish, milk, and eggs yogurt and some cheeses. Lactase pills and commonly cause anaphylactic reactions. Some lactose-free milk products are available for people with latex allergy may also develop people who cannot tolerate any lactose.
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS FISH OR SHELLFISH
Allergic reactions to fish and shellfish can be severe. Shellfish allergies appear to be more common in adults than fish allergies. Shellfish known to cause allergic reactions include shrimp, crab, oysters, clams, scallops, mussels, squid, crayfish, and snails. These allergies usually last a lifetime, and the reactions become more severe as the frequency of exposures increases.
Nuts or peanuts can cause severe allergic reactions in susceptible people. These people should avoid nuts or peanuts, and any products that contain even small amounts of these foods (such as cookies, crackers, chocolate candy, or certain flavors of ice cream). Read the ingredient lists of products carefully to ensure that you are preventing exposure to these foods in susceptible people.
Soybeans are becoming more common as an ingredient in processed food products. Soybeans and soy products are sometimes found in baked goods, canned tuna, cereals, crackers, infant formulas, sauces, and soups. Some people have allergic reactions to soybeans and soy products.
Gluten is a protein found in wheat, oats, rye and barley. These grains and their byproducts should be carefully watched in people with gluten intolerance, and strictly avoided by people with celiac disease.
Casein is a milk protein that may be found in non-dairy creamers and baked goods such as crackers.
Some people are sensitive to casein.
Sulfites are often added to dried fruit and vegetables. People with asthma may be sensitive to sulfites.
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Deceptive advertising and the large variety of Ideally, people should be able to meet their supplements on the market may lead older nutrient needs from food sources alone.
adults to buy supplements that are unnecessary However, older adults may find it challenging to or in potentially harmful doses. Taking high obtain enough vitamins and minerals from their amounts of some nutrients (such as vitamin A, diets, especially during illness and other times of iron, and zinc) can lead to toxic levels in their low food intake. bodies. Low-dose supplements are less likely to have adverse side effects. A daily multivitamin-mineral supplement can be one way to help older adults meet their nutrient needs. However, they should first consult a physi- cian to be sure that supplements are appropriate Herbal supplement use has grown dramatically in for them. The decision to use supplements should recent years. Examples are ginkgo biloba, ginseng, be based on their unique needs and dietary St. John's wort, and Echinacea. The health claims intake. It should not be a substitute for proper for these supplements may make them particularly eating or seeking appropriate medical care.
appealing to older adults. However, the jury is Supplement
Health Claim
Possible Harmful Effects
• Enhanced memory • Gastrointestinal disturbances • Improved circulation • Headaches, allergic skin reactions • Antioxidant function • Interactions with anticonvulsants• Bleeding if combined with certain medications • Enhanced memory • Interactions with medications • Increased energy (Coumadin, Digoxin, MAO inhibitors) St. John's wort
• Enhanced mood • Interactions with medications • Reduced depression (Coumadin, Mevacor, cancer drugs, • Improved sleep anticonvulsants, immunosuppressants) • Sensitivity to sunlight • Enhanced immunity • Not for use in autoimmune or systemic • Cold & flu protection diseases (lupus, scleroderma, HIV, multiplesclerosis, tuberculosis) Source: Nutrition and Aging – Herbal Supplements: Facts for Professionals. Pennsylvania State University Nutrition and Extension
Partnership Project, 2001.
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS still out on their effectiveness. Some studies As with medicines, herbal supplements can have have shown potential benefits, while others have potentially harmful side effects. Some can also shown no demonstrable results. Currently, large- interact with certain drugs or nutrients.
scale studies are underway to further test their Therefore, older adults should always discuss any effectiveness. Until the results are in, it may be current or planned supplement use with their too soon to justify any recommendations. health care providers.
Medicines and Older Adults Older adults consume a high proportion of THE RISK OF OVERMEDICATION
prescription and nonprescription medicines Older adults are sometimes at risk for being compared to the rest of the population.
overmedicated. Risk factors include: Compared to younger adults, they are more • Increased age.
likely to experience adverse effects of medicines.
This may be due to interactions between medi- • Female gender.
cines, interactions between foods and medicines, • A history of adverse drug reactions.
or age-related changes that affect the way their • The use of multiple medicines, especially if bodies use medicines. prescribed by more than one doctor or if prescriptions are filled at more than one COMMON SIDE EFFECTS
At times, it may be hard to tell whether a • Failure to follow prescriptions properly.
symptom is due to disease or is a side effect of • Reduced blood flow and less efficient kidneys, one or more medicines prescribed. Common side which may allow medicines to remain in the effects may include: body for a longer time. • Upset stomach, diarrhea, or constipation To reduce the risk of overmedication, older adults • Blurred vision should take medicines only as prescribed. They or their caregivers should keep all physicians • Decreased appetite and pharmacists informed of all medicines (over-the-counter and prescription) that the older adult is taking.
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Medicines can potentially affect a person's nutritional status.
• They can affect appetite or alter how foods taste or smell.
• Some medicines can cause nausea or vomiting.
• Side effects of some medicines can interfere with food intake.
Examples are dizziness, sleepiness, confusion, shaking, or agitation. • Medicines can change the way the body absorbs or uses nutrients.
Foods, in turn, can affect the way that medicines work.
• Some foods can reduce, delay, or increase the absorption of medicines. • Some medicines are better absorbed on an empty stomach.
Others are better absorbed with a meal. • Some foods can interact with medicines.
For example, grapefruit juice can increase the potency of certain medicines.
• Some foods can change the amount of acid in urine, which can affect the rate at which the body eliminates medicines.
To reduce the risk of adverse effects from medicines, older adults or their caregivers should communicate with doctors and pharmacists. They should inform them about all the prescription and over-the-counter medicines, vitamin-mineral supplements, or herbal supplements that the older adult is taking. Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS Barriers to Healthy Eating Poor appetite can be common in older adults.
Chewing problems may cause older adults to Possible causes include:
overly restrict foods important for proper health.
Poorly fitting dentures and missing teeth may • Grief or bereavement.
cause older people to avoid fresh fruits and • Fewer social contacts for meals.
vegetables, which are important sources of • Acute or chronic illness.
vitamins, minerals and fiber.
• Sensory changes (vision, taste, or smell).
To promote dental health:
• Medicines that affect appetite.
• Serve foods rich in calcium and phosphorus. Tips to help older adults with a poor appetite:
• Serve a variety of firm, fibrous foods • Offer beverages that increase calorie or to stimulate the release of saliva.
nutrient intake, such as milk, soup, or hot • Encourage or provide opportunities for chocolate, in place of coffee and tea.
brushing and flossing teeth daily.
• Enhance the flavor of meals with spices • Encourage older adults to brush their teeth or rinse their mouths with water after meals.
• Add variety and color to meals.
• Encourage regular visits to the dentist.
• Encourage them to eat smaller meals more To address chewing difficulties in older adults:
frequently, instead of large meals.
• Offer plenty of water or fluids with meals.
• Make eating a special occasion. Create a positive atmosphere for dining that includes • Offer foods that are soft and easy to chew.
attractive lighting, tablecloths, a nice table ✓ Tender cuts of meat setting, and appealing music.
✓ Soft protein foods: eggs, milk, cheese, yogurt • Make eating a social occasion. Create special ✓ Fruits and vegetables with peels removed "events" with themes that participants will enjoy together as a group.
✓ Fruit juices, canned fruits, and cooked ✓ Cooked cereals, rice, or pasta ✓ Mashed or pureed food, if needed Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
Swallowing is a complex act. It involves the Common causes of swallowing problems
mouth, throat area, and esophagus, which in in the esophagus:
turn are controlled by many nerves and muscles.
• Something that blocks the passage of food.
Swallowing is partly under conscious control.
Examples are tumors, foreign bodies, or a However, most of the swallowing process is narrowed esophagus caused by radiation, medication, or ulcers.
Someone with difficulty swallowing has the • Nerve and muscle problems resulting from sensation that food is stuck in the throat or certain diseases.
upper chest. This sensation may be felt high in the neck, or lower down, behind the breastbone To address swallowing problems in older adults:
(sternum). It may result from problems that arise in chewing food, moving it to the back of the • Chop foods in the blender.
mouth, or moving it through the esophagus • Avoid dry, chunky foods. Choose foods toward the stomach.
with a smooth texture.
• Add cream, gravy, or oil to foods.
Common causes of swallowing problems
• Avoid serving hot or cold foods.
in the mouth or pharynx:
• Avoid serving sticky foods.
• Something that blocks the passage of food or liquid. Examples are anxiety, a tumor, or • Encourage older adults to rinse their mouths cervical spine disease.
before and after eating.
• Nerve and muscle problems resulting from • Encourage them to eat in small bites, stroke, Parkinson's disease, Huntington's and to chew food well.
disease, multiple sclerosis, myasthenia gravis, • Refer them to their health care provider ALS (Lou Gehrig's disease), muscular dystrophy, if the problem continues, even if the polio, or syphilis.
symptoms are intermittent.
• If they suddenly show signs of choking and breathing problems, perform the Heimlich Source: Medline Plus Medical Encyclopedia: Swallowing
, website
Nutrition Resource Manual for Adult Day Health Programs SPECIAL NUTRITION NEEDS OF OLDER ADULTS As people get older, they become more likely to have sensory impairments (losses in vision, hearing,
smell, or taste). These impairments can limit their quality of life, and affect their appetite and interest Impaired vision can result from age-related eye changes or from diseases that affect the eyes
(cataracts, glaucoma, diabetes, or macular degeneration). Vision may become less sharp. Older adults may find it harder to judge distances, focus on objects at different distances, or see items on the outside edges of the visual field. Their eyes may need stronger light to recognize objects, along with more contrast between light and dark objects. They may find it hard to read recipes, food labels, and labels on medicines. Hearing problems can result from changes in the inner ear or from tinnitus (ringing or roaring
sounds). Older adults may be less able to understand conversations or hear announcements, particularly in noisy or crowded environments. They may withdraw from social interactions with others at group meals. A reduced ability to smell or taste can make it harder to discriminate between fine tastes, such as
between turkey and chicken. Older adults may find it harder to distinguish between sweet, sour, and salty flavors. This can make them lose their appetite or their interest in food, and reduce their ability to detect bad odors in spoiled foods. Tips for serving meals to adults with sensory impairments:
• Create a positive atmosphere for dining that includes attractive lighting, tablecloths, a nice table setting, and appealing music.
• Minimize distractive noises such as televisions and radios.
• Provide a strong contrast in color (such as cream of wheat in a dark bowl).
• Provide easy-to-grasp glasses and utensils. • Enhance the flavor of meals with spices and herbs.
• Marinate meats in fruit juices, salad dressing, or sweet-and-sour sauce for extra zest.
• Use colorful garnishes to make foods more appetizing.
• Add variety and color to meals.
Sources: (1) Desai M et al. Trends in Vision and Hearing among Older Americans. Aging Trends, March 2001. Centers for Disease
Control and Prevention. (2) Institute on Aging Learning Modules, University of North Carolina,
Massachusetts Department of Education Child and Adult Care Food Program IT'S MORE THA N A MEAL
• Provide easy-to-grasp glasses and utensils. Cognitive impairments in older adults can range
• Model the use of utensils to encourage others from minor memory loss to progressive dementia.
to mimic your behavior. Use verbal cues Causes may include stroke, Alzheimer's disease, ("place the fork in your hand") if necessary.
neurological disorders, nutritional deficiencies, or • Remove utensils if using them becomes the side effects of taking medicines. As a result, these adults may have a diminished attention • Put foods on small bowls or plates, span, an increased risk of choking, an inability to and serve them one at a time.
recognize thirst, an inability to recognize food, confusion about meal times, and confusion • Serve small portions of tasty foods that are about how to use utensils. spiced to their liking.
Tips for serving meals to adults
• Offer some finger foods unless there is a risk with cognitive impairments:
of choking. Examples are mini-sandwiches and bite-size chunks of fruits, vegetables, • Serve meals in small dining rooms with a • To minimize the risk of choking, avoid hard- • Provide meals and snacks at consistent times.
cooked eggs, chunks of meat, nuts, whole • Provide a consistent seating arrangement to grapes, orange halves, popcorn, and hard offer structure and cues to mealtimes.
candy. Remove any pits, peels, or bones • Seat people next to compatible tablemates to from foods. Serve raw carrots in long slices.
reduce agitation.
Dilute peanut butter with applesauce.
• Provide adequate lighting to help them • If they fail to recognize foods, encourage recognize foods.
them to touch or smell the foods first.
Feed them orally by hand if necessary.
• Minimize distractive noises such as televisions • Provide fluids on a routine basis (at least every 2 hours).
• Use square place mats to help define personal territory and reduce the chances for people If these tips prove unsuccessful in encouraging taking each other's silverware by mistake.
food intake, refer older adults' caregivers to their health care providers.
• Use plain tablecloths and place mats to minimize distractions.
Source: Bakker R. Sensory Loss, Dementia, and Environments.
Generations: Journal of the American Society on Aging.
• Provide a strong contrast in color (such as Spring 2003.
cream of wheat in a dark bowl).
Nutrition Resource Manual for Adult Day Health Programs



Bull. Hiroshima Inst. Tech. Research Vol.49(2015)27-33 Inhibitory effect of cadmium on competitive nodulation ability of Bradyrhizobium japonicum Takashi OZAWA* and Kenji IJIRI** (Received Oct. 23, 2014) Competitive nodulation abilities of Bradyrhizobium japonicum strains USDA110ET and A1017ET were significantly depressed by growing the strains in yeast extract-mannitol broth supplemented with 2 μM CdCl2. Soybean seedlings were co-inoculated with each test strain and its competitor strain 138NR, and the bacteria in nodules formed on 21 days old plant roots were identified by the antibiotic resistant markers. Cell surface hydrophobicity of each test strain increased by growing the strains with 2 μM CdCl2, though definite increase in bacterial attachment to plant root surface was hindered by excessive secretion of exopolysaccharides of the strains. Polyacrylamide gel electro-phoresis revealed that growing the test strains in the medium with 2 μM CdCl2 induced the produc-tion of lipopolysaccharides of small molecular sizes. The results in this study suggest that cadmium of low concentration causes the weakening of competitive nodulation ability of rhizobia through in-hibition of the lipopolysaccharide synthesis.


The Association Between Rural Residence and the Use, Type, and Quality of Depression Care John C. Fortney1,2,3 Jeffrey S. Harman4 1. South Central Mental Illness Education and Clinical Center (MIRECC) and Health Services Research and Development (HSR&D), Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR.