The Health and Nutrition Examination Survey (HANES) states, “16% of community dwelling Americans older than 65 consume fewer than 1,000 calories in a day which is considered under nutrition”. Most of the educational focus in America remains on obesity and “over nutrition” since it is the prevalent problem. There are no shortages of diets, pills and drinks to help you lose weight. There are multiple health initiatives trying to educate Americans about obesity found in community centers and YMCA centers. Most physicians are encouraging their patients to lose weight to lower their chances of chronic diseases including diabetes. What we rarely discuss is malnutrition and diabetes.
There is an explosion of TV and internet commercials addressing quick weight loss diets, fitness counting bracelets and watches to track your calorie intake, App’s focused on weight loss, Nutrisystem, Jenny Craig and other boxed and delivered food programs for weight loss plans as well as the old standby, Weight Watchers. There are clinics that advertise body sculpting, freezing fat and rolling machines that instantly burn fat. There are multiple prescription diet pills and supplements as well as over-the-counter pills for quick weight loss. The demand for surgeries targeting those who can’t achieve their weight loss goals such as gastric bypass and gastric sleeves are reaching all-time highs.
What is not commonly addressed is malnutrition and how it affects the senior population in this country. Yes, the aging population has recently become more vibrant, active and fit but there remains many other elderly people who are frail, dependent, have chronic diseases and who are under nourished. This adds to the medical costs that our society faces as well as frustration for those who are actually under fed.
“Weight loss and poor nutritional status in older patients is associated with an increase in morbidity and mortality”. When older adults become malnourished it increases the risk for hospitalization, limited daily functioning, poor healing and decreased surgical outcomes. When diabetes is added with malnutrition then healing becomes almost impossible. According to Michi Yakawa MD, MPH, Professor of Medicine, and Division of Geriatrics at The University of California- San Francisco “Poor nutrition and involuntary weight loss can lead to the development of cognitive decline”. The Academy of Nutrition and Dietetics and American Society for Parental and Enteral Nutrition states “malnutrition or under nutrition occurs in older adults due to many things including a result of impaired nutrient utilization, transport or absorption of nutrients”.
Although malnutrition is limited in this country, in the aged population, it is estimated to be between 5 – 30%. Healthful and well balanced nutrition is important to all age groups including the elderly whether they have diabetes or not.
What Indicates Malnutrition to the Physician?
- Insufficient calorie intake
- Loss of weight, loss of muscle mass, loss of fat
- Decreased hand grip strength
- Malnutrition due to acute problems such as burns or trauma
- Malnutrition due to chronic problems such as cancer, chronic renal disease or heart failure
How Does the Physician Assess Malnutrition?
There is a Mini-Nutritional Assessment (MNA) which you could ask about for yourself or for a loved one. It consists of 18 questions including the body mass index-BMI, self-assessment of health and abilities, dietary habits and a general assessment. It is graded from 0-30 with less than 17 being considered malnutrition.
Screening for under nutrition and malnutrition should become part of the exam in the elderly at each 3 month visit. Weight loss that is involuntary may be from uncontrolled diabetes, so blood A1C levels must be evaluated. Weight loss can occur when blood sugars extremely are high since the body can literally waste away. A1C control in seniors is generally not as tight as those in the younger population but an A1C of 8.0%or higher is generally considered unacceptable in any age group.
Early and routine screening for “eating disorders” should be assessed for everyone. A prescription to a registered dietitian should be written for anyone who has questions or concerns. This will be covered by Medicare and similar plans.
The senses of seniors decline and all senses should be evaluated at the same time. Taste, smell, vision, hearing, balance as well as cognition should be addressed.
What Causes Malnutrition in Aged People?
Overly restrictive diets. Some people with diabetes are so afraid to eat or do not know what to eat that they actually lose too much weight. They completely give up carbohydrates to lower blood sugars and the weight falls off. This is even more apparent in the elderly. They eliminate entire food groups, generally carbohydrates, and reduce protein intake. They end up with infections which do not heal since they have no reserve of fat or muscle mass. They experience severe hypoglycemia (low blood sugar) which could lead to unnecessary hospitalizations. They should be educated in a proper and complete meal plan for optimum health and proper weight.
Taste buds and sense of smell. As we age our sense of taste and smell changes and decreases. It could be due to fewer taste buds as well as their acuity which also influences our sense of smell. According to Post Graduate Medical Journal, written by Hickson, “elderly people need 11 times as much salt and 3 times as much sugar to detect tastes in food compared to younger people”. Other things that affect taste are multiple medications including antibiotics, lipid lowering drugs, and asthma drugs such as bronchodilators, blood pressure medications, antidepressants and anti-inflammatories. Diabetes medications are not known to change sense of taste but each person may experience things differently. Even drug interactions could be an issue for loss of taste.
Dysphagia or difficulty to swallow. Many aging people suffer from gastric reflux or hiatal hernias and may encounter problems swallowing due to a narrowing of the esophagus. They are afraid they may choke or regurgitate and neglect eating. This could lead to calorie deficiency.
Emphysema, Parkinson’s, thyroid issues, cancer, infections, malabsorption problems. There are many medical conditions which cause lack of appetite and makes it more difficult to treat diabetes. With these problems it is important to work with a dietitian to make sure you are addressing the needs of all medical problems.
Chewing. Older adults may not have well-functioning teeth and end up with difficulty chewing due to ill-fitting dentures or lack of dentures. This happens as they lose weight and the denture actually “knock around in their mouth”. Routine dental check-ups and follow-up care is necessary to make sure chewing is functional for the patient.
Isolation, limited access and confusion. Many seniors do not drive and may be unable to lift or carry packages. They may be mentally confused and disoriented and just forget to eat. They may have marginal funds and spend their money on rent and medications instead of groceries. Studies have shown that those who live alone generally eat less than those who live with others.
What Can Be Done After Screening for Malnutrition?
Consider vitamin B12 supplements since poor absorption occurs as we age and stomach acid decreases. Try to find liquid vitamin B12 which can be placed under the tongue and is absorbed better than capsules or tablets. Foods to consider which are rich in vitamin B12 are animal based including: grass fed beef, dairy foods, fortified cereals, sardines, tuna and eggs.
Consider vitamin D and calcium supplementation. Again, always check with your physician before starting a supplement since it may interfere with other medications you are already taking. Try to choose foods like low-fat dairy including cheese, yogurt and milk for calcium. Vitamin D can be derived from 15 minutes in the sun with no sunscreen or vitamin D supplements. Some people may require prescription strength vitamin D, so check with your provider.
Protein rich diet. According to The Hebrew Senior Life Institute for Aging Research “seniors who consume higher levels of dietary protein are less likely to suffer hip fractures”. Muscle strength declines 3% annually from age 60, onward. Muscles need to be maintained as we age especially when we have diabetes, emphysema, COPD and heart failure. This will increase daily functioning and the ability to lower hospitalization. Sarcopenia which is “low muscle mass combined with muscle weakness causing limits in movement, activity, mobility and more fractures”. This condition is very common in seniors. Protein amounts should be calculated by a registered dietitian since seniors often have reduced kidney function that requires a proper balance of protein and other nutrients. Eating high quality lean protein such as eggs, skinless chicken, turkey, grass fed beef and fish should be the main focus since it repairs and builds muscle. Work with a dietitian if you are a vegetarian or vegan for other high quality sources of protein.
Use resistance and balance exercises. Weights, machines and bands can all help build muscle mass. Being active helps you remain agile as you age. Consider downloading ‘The National Institute of Aging Exercise and Physical Activity Guide’. This works on physical endurance, strength, balance and flexibility for seniors. Look into Silver Sneakers, an organized fitness program offered by most Medicare Advantage plans. Join the YMCA or a senior community center for various activity. Older adults should be able to:
- Climb at least 10 steps up and down.
- Balance independently on each leg for 10- 20 seconds.
- Lift and carry 10 pounds in both arms.
- Get up from a chair without holding on.
- Walk across a room without assistance.
Weigh yourself weekly. Keep a chart to make sure you are not losing or gaining too much weight which could indicate fluid build–up. There are ways to add calories to your diet without raising blood sugars. Think about healthful fats including nuts, avocados, olives and olive oil to add weight without influencing blood sugars. Add whole grains and plenty of fiber since constipation is frequently a problem in aging adults. Drink plenty of zero calorie fluids to stay hydrated. Look for frozen vegetables and no-syrup frozen fruits which have a long shelf life. Try to buy low-sodium/low-sugar/high protein prepared meals to simplify your life and time standing in the kitchen.
Aging does not have to lead to malnutrition or nutritional deficiencies with or without diabetes. Understand what your own situation is by getting evaluated by your physician. Although our country is dealing with an increase in obesity, we are also seeing a higher incidence of malnutrition in our seniors. Don’t be one of them!
Have a question or comment? Post below or email me at RKleinman@adwdiabetes.com if you would like to share them with ADW diabetes.
NOTE: Consult your Doctor first to make sure my recommendations fit your special health needs.
She is a member of the American Diabetes Association as well as the South Florida Association of Diabetes Educators. She worked with the education department of NBMC to help educate the hospital's in-patient nurses about diabetes. She practices a healthy lifestyle and has worked as a personal fitness trainer in the past.
She was one of the initiators of the North Broward Diabetes Center (NBMC) which started in 1990 and was one of the first American Diabetes Association (ADA) certified programs in Broward County, Florida for nearly two decades. Robbie has educated patients to care for themselves and has counseled them on healthy eating, heart disease, high lipids, use of glucometers, insulin and many other aspects of diabetes care. The NBMC Diabetes Center received the Valor Award from the American Diabetes Center for excellent care to their patients. Robbie has volunteered over the years as leader of many diabetes support groups.
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