SEASONAL CARE

Nutrition for older people: building

immunity over t he wi n t e r season
Vanessa van der Kramer
Vanessa van der Kramer Email: paiicssa.i'dk@mac.com
F
or the elderly in our community, winter is a
difficult time. Not only is it expensive to heat the
home, but rising food prices mean that many are
going without vital nutrients needed to help ward off
winter ills. While many people continue to live healthy
lives in their senior years, ill health can cause others to
suffer malnutrition and this in turn can increase the
chances of catching colds, fiu and viruses. 'Unnoticed,
unheard and unsupported' is how Katherine Murphy,
Chief Executive, of the Patients Association described
the plight of more than 3 million people in the UK that
are suffering malnutrition or the risk of malnutrition
(Murphy, 2011). Ninety-three percent of these people are
living in their own homes and have simply'fallen through
the cracks', according to Ms Murphy. With malnourished
patients requiring three days additional care in hospitals
the annual cost of treating malnutrition is in excess of
13 billion. The NHS is being asked to save ^20 billion
by 2014 so tackling nutritional issues could help not only
the patient, but also help with financial overburden.
Maintaining nutrition in advancing years is not just a
matter of serving nutritious meals; there are often other
factors affecting a person's ability to take in and absorb
these nutrients. Health factors such as strokes, neurological
problems, arthritis, digestive problems, poorly fitting
dentures and diminished senses can all contribute to
nutritional deficits. Many diseases of the elderly have a
nutritional consequence, such as osteoporosis, diabetes,
depression, arthritis, heart conditions, but a diet rich in
nutrition may help (Jackson, 2008).
For those caring for the elderly it is essential to look
at the individual's needs in working out a balanced meal
plan. Can they feed themselves, i.e. cutting food, chewing,
swallowing? Can they digest the meals given or are they
going to cause digestive problems that niay deter them
from eating? What are the individual's personal likes and
ABSTRACT
Maintaining adequate levels of nutrition is particularly important over the winter
months when older people can be particularly vulnerable. This article discusses
ways of encouraging healthy eating among elderly people and suggests tips for
a balanced and nutritious diet.
KEYWORDS
Nutrition Elderly care Diet Vitamin supplements
dislikes? I recently heard of an elderly hospital patient
who had not eaten a thing for a week since being
admitted. He was too ill to order his own meals so they
were ordered for him. No one asked the patient or his
family what he liked to eat so staff quickly ordered a salad
for him each day. The gentleman had not eaten salad at
any time during his lifetime. The meals were changed
to cooked vegetables, meat and soups and his plate was
cleared.
Ideally we would start with the basic requirements
a person needs in order to stay healthy, i.e. the basic
'five-a-day' of fruit and vegetables, along with proteins,
carbohydrates, dairy foods and drinks, and then adapt this
to a person's special needs. In order to build immunity it
is essential to be able to absorb the nutrients. A digestive
system that functions poorly will hamper the best efforts
to consume a healthy diet. Building good flora in the
gut is a necessary part of improving overall health and
nutrition. This can be achieved by eating probiotic foods
such as a probiotic yogurt, or by taking a probiotic
supplement each day (NHS Live Well, 2011). As dietitian
Patti Milligan has stated, 'immunity starts in the gut.'
Down t o basics
when serving meals to the elderly there are a number
of factors to take into consideration. It's not all about the
food. Many older people will be used to eating their meals
in a manner quite different to today's families, where a fast
meal eaten on the couch in front of the TV is the norm
for many. The majority of elderly people, have been used
to eating meals at a table served on normal crockery and
often prefer a cup and saucer to a mug. Use a breakfast
plate instead of a dinner plate and use small bowls instead
of large ones. These may sound like trite aspects to
nutrition; however, they can make a world of difference to
the whole food experience. Aged and Disability Carer, Mrs
Heather Seppings ofVictoria, Australia, comments:
'Elderly clients respond in a very positive way
at meals times when the table is set with place
mats, napkins and nice china. The use of a napkin
lessens the worry of spills and embarrassment.
Many are worried about eating when they have
difficulties such as arthritis, dentures that don't
fit properly or are recovering from illnesses such
as strokes.'
S22
Nutrition, November 2011
SEASONAL CARE
Meal size is also a major factor in enjoying a meal.
Large meals can be very ofi"-putting to someone with a
small appetite! whereas 5 or 6 small meals per day served
attractively can be a lot more tolerable. Mrs Seppings
notes:
'They prefer meals served on smaller plates as
the meal does not seem too dijfftctilt to manage
and the presentation is more attractive. Most
who can manage it like a cup and saucer rather
than a mug, as this is what they grew up with.
They like the homely, familiar feel.'
Bread cut irito small pieces is easier to handle and seems
a lot less daunting than a large sandwich, as handhng
foods with hands that no longer do what they used
to do is often too much trouble. Soup served in a cup
with a saucer!is easier to manage than soup on a spoon.
Providing a serviette or table napkin gives a security
feeling against being embarrassed by spills and messy
hands. It's the little things that make all the difference.
How mubh is enough?
Exactly how much of each food type is enough? The
answer will vary according to a range of factors, including
the individual's weight and level of activity. The figures
given in Table 1 may be used as a rule of thumb for the
calorie needs of people aged over 55 and performing
minimal daily I physical tasks.
Foods to include for optimum
health
Some foods are known to have particularly high
nutritional ori vitamin value, and can play an important
part in a nutritious diet. These include:
Fruit: In particular those high in vitamin C, like
blackberries. strawberries, raspberries, blackcurrants.
citrus fruit, kiwi fruit, peaches, mango, cantaloupe melon,
apples
Vegetables: In particular vegetables high in vitamin
A (beta-carotene) and vitamin C, such as carrots, squash,
sweet potato, tomatoes, spinach, kale, spring greens,
broccoli, cabbage, Brussels sprouts, onions, leeks, avocado
Oily fish: Rich in omega-3 essential fatty acids
and high in yitamin E, like salmon, mackerel, sardines,
herring, tuna and trout. White meat used in place of red
meat is more j easily digested, while providing a low-fat
form of protein and B12.
N uts and seeds: Rich in omega-3 essential fatty
acids and high in vitamin E. Unsalted nuts, like walnuts,
cashews, brazil nuts and almonds, and seeds like poppy
seeds, sunflower, flax seeds and pumpkin seeds
Protein: Eggs, white fish, milk, cheese, yogurt, lean
meat, chicken! beans, lentils
Pulses andi grains: High in fibre, these include lentils,
chick peas, brown rice, whole grain bread, wheat germ,
whole grain cereals, whole grain crackers.
Table 1. Daily Calorie requirement for men and
women aged over 55
45kg-7st1lb
50kg-7st12lbs
55 kg - 8st 9lbs
60 kg - 9st 6lbs
65kg-10st3lbs
70 kg- l i st
75 kg- l i st nibs
80kg-12st81bs
85kg-13st5lbs
90kg-14st2lbs
1430
1500
1550
1600
1630
1660
1720
1900
2000
2100
2200
2300
2400
2600
Bright and bold
Including brightly coloured fruits and vegetables in
diets may increase the immunity factor by boosting
antioxidants (Cable, 2007). Many foods can be substituted
for a healthier option. By substituting sweet potatoes
for white potatoes the level of antioxidants in the meal
increases; sweet potatoes have a lower GI level than
white potatoes and are an excellent source of vitamin
C (Reader's Digest, 2011). Blueberries can be added
to yogurt to make a delicious dessert, a slice or two
of tomato can be added to a sandwich rather than just
adding protein, and adding a banana to porridge to
increase fibre and nutrition is a good source of potassium
which helps to protect against hypertension, heart
disease, kidney disease, metabolic syndrome and strokes
(Organicfacts.net, 2011).
The role of vitamin D
During the winter months in the UK, vitamin D, found
naturally in sunshine, is in short supply. Vitamin D is a
fat-soluble vitamin that is naturally present in only a few
foods such as shitake and button mushrooms, salmon,
tuna, herrings, sardines and eggs, and is added to others,
or available as a dietary supplement. It is also produced
endogenously when ultraviolet rays from sunlight strike
the skin and trigger vitamin D synthesis. Vitamin D
obtained from sun exposure, food, and supplements is
biologically inert and must undergo two hydroxylations
in the body for activation.The first occurs in the liver and
the second in the kidneys.
Vitamin D promotes calcium absorption in the gut
and maintains adequate serum calcium and phosphate
concentrations to enable normal mineralization of bone
and to prevent hypocalcmie tetany. It is also needed for
bone growth and bone remodelling. Without sufficient
vitamin D, bones can become thin, brittle, or misshapen.
Vitamin D sufliciency helps protect older adults from
osteoporosis (Office of Dietary Supplements, 2011).
Nutrition, November 2011
S23
SEASONAL CARE
Sample menu
Breakfast
Cup of tea with semi-skimmed milk
1 cup of cooked porridge made with semi-skimmed milk, honey and one
small banana sliced on top
Mid morning
Cup of tea with semi-skimmed milk
1 healthy biscuit such as oatmeal, whole grain
Lunch
Glass of milk or juice
1 cup of vegetable soup
1 slice wholemeal bread spread with a healthy margarine spread and top
with a slice of cheddar or unprocessed meat such as turkey breast and
tomato
Mid afternoon
Cup of tea with semi-skimmed milk
Slice of fruit cake or similar
Dinner
Vi grilled chicken breast without skin
Vi cup cauliflower cheese
1 small sweet potato mashed
Vu cup peas
Dessert
1 small tub probiotic yogurt
y^ cup blueberries
Evening
Cup of tea or glass of milk
Drink ample water throughout the day. Vi -1 litre In addition to listed beven
ages.
Supplements
To ensure a minimal intake of nutrients on a regular basis and to improve
immunity, a daily multi-vitamin is a good Idea.
Vitamin D has other roles in the body, including
modulation of cell growth, neuromuscular and immune
function, and reduction of infiammation. Many genes
encoding proteins that regulate cell proliferation,
differentiation, and apoptosis are modulated in part by
vitamin D.
LEARNING POINTS
Keep meals offered as 'normal' as possible according to patients'
capabilities and expectations, to ensure they are eaten
Improving the digestive system will increase the body's ability to absorb
nutrition: 'immunity starts in the gut'
Including foods rich in vitamin D can increase the body's immune function
New studies into vitamin B12 indicate advantages in maintaining mental
function
Improving nutrition and building immunity begins with addressing the
basics of dietary essentials
Vitamin B12 for a healthy mind
Vitamin Bl 2 is important for maintaining mental function
Recent studies by Oxford University, into the benefit of
B12 suggest that it could be useful in helping maintain
mental function in the early stages of Alzheimer's
(Campbell, 2010).Vitamin B12 is found naturally in lean
red meat, chicken and skim milk. Folate and vitamins
B6 and B12 are required for homocysteine metabolism
(important in protecting against Alzheimer's and diabetes)
and have been shown t:o reduce heart disease if taken in
appropriate concentrations.These antioxidants potentially
reduce the incidence of several chronic illnesses affecting
the elderly. The bottom line is that vitamins are important
in maintaining our health.
Conclusion
Five to six small meals per day are usually less daunting
and better tolerated by the majority of patients than
three main meals. In addition, serving meals in a familiar
manner by using regular tableware such as cups and
saucers, placemats, napkins etc is, for most people, more
inviting and gives a feeling of normality. Whilst it is not
always easy to determine a patients like and dislikes, by
either asking the patient where possible or close family,
this could make all the difference to whether a patient
refuses meals or eats them. With a little imagination,
by making small but simple additions to meals offered,
the overall nutritional value of a meal can be greatly
enhanced, increasing the immunity value of a meal.
Although it may seem like stating the obvious, it is easy
to overlook some ofthe simplest reasons for someone not
eating well, such as ill-fitting dentures, poor swallowing
reflex, and difficulty managing with arthritic hands. In
many cases malnutrition and poor immunity can be
avoided by looking to the grassroots solutions. BJCN
Cable S (2007) Brightly coloured fruits could hold the key to fighting can-
cer. Daily Mail, 21 August 2007. http://www.dailymail.co.uk/health/
article-476366/Brightly-coloured-fruits-hold-key-fighting-cancer.html
.(Accessed 26 October 2011)
Campbell D (2010) Vitamin B supplements could delay onset of Alzheimer's,
says study. Tlie Guardian, 8th September 2010. http://www.guardian.co.uk/
lifeandstyle/2010/sep/08/vitaniin-b-could-delays-alzheimers (Accessed 26
October 2011)
Jackson F (2008) Nutrition in older adults. http://gicare.coni/Diets/nutrition-
for-older-adults.aspx (Accessed 26 October 2011)
Murphy K (2011) Millions of malnourished 'go unnoticed', http://www.bbc.
co.iik/news/health-14761421 (Accessed 26 October 2011)
NHS Live Well (2011) http://www.nhs.uk/LiveWell/Pages/Livewellhub.aspx
OfFice of Dietary Supplements (2011) Dietary Supplement Fact Sheet: Vitamin
D. http://ods.od.nih.gov/factsheets/vitamind (Accessed 26 October 2011)
Organicfacts.net (2011) Health Benefits of Potassium. http://www.organicfacts.
net/health-benefits/minerals/health-benefits-of-potassiuni.htnil (Accessed
26 October 2011)
Positivehealthsteps.com (2011) Daily calorie requirements, http://www.posi-
tivehealthsteps.coni/calories/daily-required.shtml (Accessed 26 October
2011)
Reader's Digest (2011) The Health Properties of Sweet Potatoes, http://
www.rd.com/health/the-health-properties-of-sweet-potatoes/ (Accessed 26
October 2011)
S24 Nutrition, November 2011
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