Part I of this series dealt with the physiological changes that normally occur in the aging process. This article will focus on individual dietary components and their effects on the geriatric patient. Dietary advice for geriatric patients can be traced back as far as recorded history, and many nutritional theories have been advanced concerning aging. One theory proposed that the gradual accumulation of toxins secreted by intestinal bacteria caused aging, and eating certain types of yogurt could prevent this accumulation. More recently, gradual oxidation of lipid membranes has been advanced as the primary villain, and antioxidants as the knight in shining armor. Clearly, both theories have some validity, but neither is the total answer. While the search for the fountain of youth continues, one fact is clear: Prevention of many of the health problems found in old age must begin much earlier in life. I believe today's chiropractor is in a unique position, because of philosophy and training, to detect early deviations from normal homeostasis, before exhaustion and degeneration of the normal compensating mechanisms begin. All it takes is a thorough understanding of normal homeostasis and how the body uses the autonomic nervous system to maintain the extracellular fluid. Next, identify the stimulus producing the deviation from normal and correct it. Very often, the problem is lack of a balanced diet combined with an inability to digest, assimilate, or eliminate that diet. Particular emphasis was placed in the previous article on the apparent inability of geriatric patients to con- c e n Hut c h y d r o c h 1 o r i c acid. This severely compromises protein digestion by the elderly and contributes greatly to the formation of circulating immune complexes (C.I.C.'s). C.l.C.'s are the leading cause of fibromyalgia.' something every chiropractor can readily palpate. These facts are the foundation tor the information contained in this article. The information available on the nutrient needs of people over 40-years-old is scarce and is based primarily on studies of the intake of healthy people, rather than on experimental balance studies designed to determine their needs. Some allowances are extrapolated from data on younger people, while others are based on estimates of necessary losses from the body. So far, we have little or no evidence that, except for calories and the nutrients involved in energy metabolism, the elderly have nutritional requirements differing significantly from those ol middle-aged adults. Therefore, it is suggested that the intakes proposed for most nutrients during early adulthood be maintained throughout life. Although it is reasonable to assume that some nutrient needs do change with age. there are few for which we can confidently propose a decreased intake after age 70. Immune status Many studies have confirmed an age-related decline in immune competence characterized by losses in T-lymphocyte activity. Some of these changes resemble those induced by malnutrition.2 Whether malnutrition is a significant cause of depressed immune function in large numbers of older patients is still being debated. While scientists study the merits of the case, clinicians should keep in mind the following facts: Protein-energy malnutrition in individuals of any age alters the proportion of T-cell types, depresses T-cell function, impairs delayed hypersensitivity reac tions, and impairs thymic factor activity.-1 Such changes have a strong correlation to increased susceptibility to infectious dis eases.4 The passage of inadequately digested food particles across the gut wall always invokes an increase of white blood cells.5 making demands on the immune system every time we eat. The resulting formation of circu lating immune complexes is the leading cause of fibromyalgia.6 It is clear that malnutrition is related to impaired immune function, and improved dietary intake can. at least, partially repair the damage. What is never discussed in the literature is how improved protein digestion could enhance immune capabilities, particularly in an age group with compromised hydrochloric acid-producing capabilities. Protein Studies consistently find that geriatric patients are unable to maintain a positive nitrogen balance while consuming the RDA for protein (0.8 g of protein/ky/day).s and. therefore, protein requirements for the elderly should be higher than the RDA.9 Other studies find that patients in nursing homes consume less protein than the RDA. women averaging 40 percent less than the RDA, and men 12 percent less.10 Confusion exists, because healthy older patients do not have protein deficiencies and, therefore, no prevailing opinion exists concerning increased protein intake for the elderly. Yet, lower serum albumin levels are reported among the elderly, and these levels cannot be raised with increasing dietary protein." In light of the facts presented in this and other papers.12 I believe increasing protein consumption is detrimental to the elderly, while improving protein digestion is beneficial. Calcium Inadequate mineralization in children is called rickets; in adults it is referred to as osteomalacia. In these conditions, the protein matrix is poorly mineralized, so that the bone is soft and rubbery. Rickets and osteomalacia are uncommon today, because of the widespread addition of vitamin D to foods such as milk and bread. In osteoporosis, there is a loss of bone-forming activity, with a subsequent gradual loss of bone substance. The remaining bone is thinner, but normal in composition. There are two types of primary osteoporosis. Type I, or postmenopausal-accelerated bone loss, is due to declining estrogen levels. Type II is the age-related inevitable bone loss that occurs in all older men and women. A secondary osteoporosis may develop at any age. as a consequence of metabolic endocrine or gastrointestinal disorders, as well as prolonged bed rest. Mineralization of bone and calcium utilization have long been problems in Western societies. Poor absorption, transportation and utilization of calcium continue to frustrate doctors attempting to correct musculoskeletal conditions. The following reasons have been found for chronic negative calcium balances: Inadequate dietary intake.13 Age-related changes in gastric acidity. Reduced efficiency of intestinal calcium absorption.14 There is a very long list of studies which have been done in the last fifteen years that indicate elderly men and women do not consume adequate amounts of calcium.15 One study sug- gests that happens because geriatrics are lactose-intolerant."' Another study suggests that the RDA for calcium of 800 mg/day may not be sufficient to maintain calcium balance in populations consuming Western-type diets.'7 Age-related changes in gastric acidity are also associated with poor fat digestion. Consider the following: Geriatric patients have dimin ished capacity for concentrating hydrochloric acid. Hydrochloric acid is required to initiate protein digestion. This, in turn, provides acidity to the patient, and cal cium is absorbed best in an acid medi um. The acidity entering the duode num stimulates the flow of bile. This emulsifies fat and improves the absorption of calcium. Otherwise, cal cium combines with the fat to form an insoluble soap. While 98 percent of our calcium is found in bone and teeth, the remaining 2 percent is present in blood, and one-half is bound directly to protein. The other half is free in its ionized form. It is this portion which prevents tetany. It increases with adequate acidity and decreases with excess alkalinity. Calcium absorption, normally, diminishes with age. beginning about age 60 for women and 70 for men. However, poor absorption or malab-sorption may also be caused by inadequate quantities of the active form of vitamin D.14 Calcium supplementation should be coupled with vitamin D supplementation in such cases. However, supplementation of vitamin D is usually not necessary, and may be dangerous in excessive amounts. Hypervita-minosis D may lead to hypercalcemia, and such complications as apathy, nausea, arrythmias. and kidney stones. Recent recommendations for calcium supplementation suggest 1 gm/day of calcium for men over 50. and 1.5 gm/day for postmenopaiisal women not taking estrogen to slow the progression of osteoporosis.15 If the woman is taking estrogen. 1.0 gm/day is adequate.15 Adequate estrogen supplementation is effective in slowing osteoporosis and reducing the number of hip fractures resulting indirectly from this process.15 Doses of calcium above 2.5 gm/day seem unwise, since it is believed they may lead to kidney stone formation! For patients predisposed to calcium stones, much lower supplementation levels are recommended, if supplementation is considered at all. It is the author's clinical opinion that, if protein digestion and assimilation are adequate, calcium will not precipitate and high dosages are unnecessary. It is a curious fact that those soci- eties encouraging calcium supplemen- tation also have the highest incidence of hip fractures in elderly patients. Older people, especially Caucasian women, have a higher rate of hip fractures than young people.IS The inci- dence of hip fracture is lowest where calcium supplementation is low. This seems to indicate that calcium supplementation is not effective in preventing demineralization. Iron Iron was one of the first substances identified as essential in the human diet. It is contained in the hemoglobin molecule of red blood cells. Hemoglobin is essential lor delivering oxygen from the lungs to the body's tissues. The tissues use oxygen in the ATP cycle to produce energy. The symptoms of oxygen deficit in the tissues are: Fatigue and reduced work capac ity Impaired brain function Inability to maintain body temper ature. More than iron is needed for adequate red blood cell production. The synthesis of blood cells requires many cellular and metabolic steps, and nutritional anemia can occur because of dietary deficiencies of any of the following: Vitamins A, E. C. B,,. B(->. riboflavin. and folate Protein Iron. zinc, and copper There are three main causes of low red blood cell levels: Loss of blood from circulation Hemolysis. or increased destruc tion, of red blood cells Reduced production of red blood cells and hemoglobin. Iron Deficiency Anemia Iron deficiency anemia occurs when the pigment hemoglobin in red blood cells falls below normal. Symptoms of fatigue, anxiety, lack of energy, and sleeplessness are a common result of inadequate iron. Iron inadequacy can be caused by: • Low dietary intake, impaired absorption (possibly resulting from lack of heme iron or vitamin C or blood loss) Inherited or acquired inability to utilize nutrients required for hemoglo bin production Chronic inflammatory or infec tious diseases Lead poisoning. Treatment may involve using iron supplements together with a diet providing iron sources of high bioavail-ability and vitamin C to enhance absorption. However, be aware that a comparison of older subjects who took iron supplements with those who did not showed no clinically significant differences in the biochemical measures of iron status.1'' I could not find studies comparing improved digestion to supplement use. Scientific studies on iron status in older patients are confusing and often misleading. This is because iron stores, or reserves, increase with age. Therefore, studies that measure only iron intake must be interpreted cautiously. Also, little data on the iron status of older persons in the United States is available. Most studies report conclusions based on hemoglobin and hematocrit values. These studies suggest that the standard for low hemoglobin in men (I4g/dl) is too high. A high prevalence of low hemoglobin and hematocrit is consistently reported when using adult reference values, especially in black elderly. Remember that anemia is not uncommon in adults, but iron deficiency is not always the cause. If the mean corpuscular volume is greater than 95 gm. indicating macrocytic anemia, serum folate and vitamin Bi: levels should be checked. If microcytic anemia is discovered (mean corpuscular volume <8()«m3). the possibility of gastrointestinal blood loss from a neo- plasm should be evaluated before prescribing iron supplementation. Indeed, iron supplementation is potentially dangerous, if it is not necessary. Iron supplementation can conceal anemia thai is caused by gastrointestinal bleeding from a gastric or colonic neoplasm. Pernicious anemia was first described by Addison in 1849. and so-named because no cure could be found. It was found to be a deficiency of Vitamin Br in 1926. when liver was used to correct the condition. Liver also corrected macrocytic anemia, which is a deficiency of folic acid or folacin. Megaloblastic anemia, as a result of Iblatc deficiency, often occurs simultaneously with iron-deficiency anemia. Zinc Zinc has been found to enhance wound healing, tissue repair, and taste acuity in the elderly. Although absorption decreases with age. zinc is available from many foods. Thus, zinc deficiency is probably not common in the well-nourished elderly. High-risk groups for zinc deficiency are those with diminishing immunity and cancer. Magnesium Magnesium requirements are also adequately met by diet, although deficiency may occur secondary to dehydration, malabsorption. diuretic use. liver disease, and alcoholism. If any of these risk factors exist, periodic magnesium determination is warranted. While much attention has been paid lo magnesium in recent years, the clinician should remember that much of that research was gathered in emergency rooms, while the patient was in acute myocardial distress. Magnesium is a primary ingredient in most antacids, because it has an alkalizing effect. Hydrochloric acid production is usually compromised in the elderly, and further supplementation around mealtime should be considered very carefully. Selenium Selenium has been shown to prevent numerous types of cancers and tumors in animals. The Committee on Diet, Nutrition, and Cancer concluded that selenium might offer protection against cancer for humans. The committee also stated that intake of vitamins and minerals above the level published as the RDA has not been shown to be more anticarcinogenic. Although no RDA for selenium has been established, studies with animals suggest that levels above 200 mg/day may be toxic for adults. Chromium Body stores of chromium decline with aging, but a relationship to reduced glucose tolerance has not been established.2" There is very little other information concerning changes in other trace mineral element requirements that may take place during aging. Vitamin A Vitamin A deficiency does not seem to be a problem during old age. The National Health and Nutritional Evaluation Surveys (NHANES) of the 1970 s and I98()"s found less than I percent of the older population had low vitamin A blood levels. Yet, the same surveys indicated that about 50 percent of those tested had vitamin A intakes of less than two-thirds of the RDA. Other studies have also indicated blood levels can be maintained, despite low intake levels.-1 These apparent discrepancies are, possibly, due to large hepatic stores of the vitamin. Beta-carotene, melaboli/ed in the body to produce an active form of vitamin A. is an antioxidant that has been shown to fight cancer in animals. The Committee on Diet. Nutrition, and Cancer concluded that ingestion of foods high in beta-carotene or vitamin A is associated with a reduced risk of cancer. However, this does not mean that these foods prevent cancer. Overdosing on vitamin A from supplementation is relatively easy to do, and dangerous; so, recommending vitamin A supplementation may not be wise. Some signs of chronic hypervita-minosis A in an adult patient are pruri-lis. dry scaly skin, and fissures of the lips. I do not recommend vitamin A supplementation beyond what is contained in a typical multivitamin, but, rather, encourage intake of vegetables Continued on Pu^e 42 ...from Page 12 that contain carotene and vitamin A. This way, vitamin A overdose is very unlikely. ! Vitamins K and C Both vitamins E and C are antioxi-danls; they inhibit the formation of N-nitroso compounds that produce tumors. Empirical data about whether vitamin E or vitamin C inhibits cancer in humans arc inconclusive at this time.7* Toxic reactions to high levels of both these vitamins are rarely reported: however. long-term ingestion of high levels has not been studied. Since vitamin E is fat-soluble and stored in the body, it may be wise to avoid megadoses (ten or more times the recommended dietary allowance), until controlled studies show it to be less at these doses. Similarly, vitamin C in the normal healthy person has not been shown to be toxic at high doses; however, it has been shown that large doses become very concentrated in the urine. Scurvy has been reported in infants born to mothers taking high doses of vitamin C. and also in people abruptly withdrawn from high doses of vitamin C. Thus, an upper limit of 350 mg/day of vitamin C seems prudent for patients who desire its possible antitu-morigenic effects (RDA 60 nig). Millions of Americans follow a self-directed program of megavitamin therapy. A recent summary of this literature concluded that intake of megavita-mins may be dangerous. Although fat-soluble vitamins A and D are more likely to cause bodily harm, even the water-soluble vitamins can cause serious adverse effects. Vitamin B Vitamin B deficiencies may result from decreased dietary intake, absorption defects, and decreased storage and conversion to active metabolic forms. Unfortunately, very few studies have been done on the individual vitamins. The ones that have been done tend to indicate older adults do not have adequate dietary intakes. But such deficiencies are not always confirmed by biochemical or clinical results.:: And, analysis shows little statistical difference in mean dietary intake for those individuals taking a specific supple- ment. compared to those who did not take the supplement.2' Suboptimal levels ol' vitamin B,, are reported in the elderly, and il is worth noting that many cases of carpal tunnel syndrome are responsive to B() supple mentation in the elderly. j The elderly appear capable of maintaining normal I'olale nutriture. despite low intakes. It has been suggested that perhaps I'olate malabsorplion. as seen in atrophic gastritis, is compensated for by bacterial folate synthesis. There is a decreased hepatic affinity for folate. as in Laennec's cirrhosis. Declines in vitamin B,2 levels are seen, however, to be due to poor absorption in cases of atrophic gastritis. There is insufficient data to determine whether requirements for vitamins K. niacin. biotin. and pantothenic acid are altered in the elderly. Vitamin D Vitamin D was discussed briefly above. Suffice it to add. here, that the elderly are less able to absorb vitamin D through the gastrointestinal tract and to synthesize vitamin D in the skin following exposure to sunlight. Furthermore, these patients are less able to hydroxylate vitamin D. in the liver and kidney, to its metabolically active form. Increased sun exposure and low dose supplementation only, for housebound elderly, has been suggested. SUMMARY I have, previously, pointed out the importance of fresh fruits and vegetables, along with improved digestion, as the key to maintaining health in the elderly. In Part 3. we will conclude our discussion of Geriatric Nutrition by looking at common disorders found in the elderly and their relationship to diet and digestion. Howard F. Loomis, Jr., DC, president of Enzyme Formulations, Inc., has mi extensive background in enzymes and enzyme formulations. As president of 21s' Century Nutrition, Inc., for fifteen years, he has forged a remarkable career as an educator, having conducted over 400 seminars to date, in the United States, Canada, Germany, and Australia, on the diagnosis and treatment of enzyme deficiency syndromes. Call 21s' Century Nutrition at I-H00- 662-2630 for more information. REFERENCES I:ihromyalgia. Chronic Pain, and the Leaky Gut Syndrome. 1994. Thompson. Robbins and Cooper. "Nutrition and immune function in the geriatric population." Clinks in Geriatric Medicine. 1987: Vol. 3. pp. 309-17. Bciscl. "Single nutrients and immunity." Ameri can Journal of Clinical Nutrition. 1982; Vol. 35. pp. 417-68. Mullen. Gertner, Buzby. Goodhart. and Rosalo. "Implications of malnutrition in the surgical p-Micnl." Archives of Siirtun. 1979; Vol. I 14. pp. 121-25. Rudolf Virchow. Cellular Pathologx. special ed.. reprinted b\ Gryphon Kdilions. Birmingham. Alabama. 1978. Fibromyalgia. Chronic Pain, and the Leaky Gut Syndrome. 1994. Loomis. "Key Issues in Geriatric Nutrition." ICA Review. July/August I TO. Ciersovii/.. Motil. Munro. Scrimshaw and Young. "Human protein requirements." American Journal of Clinical Nutrition. 1982; Vol. 35. pp. 6-14. Munro. "Protein nutritive and requirement in elderly people." Bihliotheca Nutrilin Et Dieta. 1982: Vol. 33. pp. 61-74. Jansen and Harrill. "Intakes ami serum levels of protein and iron for 71) elderly women." Amen can Journal of Clinical Nutrition. 1977: Vol. 30. pp. 1414-22. Halpern. Clinical Nutrition. 2nd ed.. J.B. Lippin-cotl. 1987. Jordan. "Protein status of the elderly as measured by dietary intake, hair, tissue and serum albumin." American Journal of Clinical Nutrition. 1976: Vol. 29. pp. 522-28. Heaney. Recker. and Saville. "Calcium balance and calcium requirements in middle-aged women." American Journal of Clinical Nutrition. 1977: Vol. 30. pp. 1603-11. Avioli. McDonald and Lee. "The influence of age on the absorption of 47Ca in women and its relation to 47Ca absorption in poslmenopausal osteoporosis." Journal of Clinical Investigation. 1965; Vol. 44. pp. 1960-67. The Surgeon General's Report on Nutrition and Health. I'rima Publishing and Communications. 1988. Goodwin. Hunt. Hooper and Gary. "Relationship between zinc intake, physical activity and blood levels of high density lipoprolein cholesterol in a healthy elderly population." Metabolism, 1985: Vol. 34. pp. 519-23. Recker and Heaney. "The effect of milk supplements on calcium metabolism, and calcium balance," American Journal of Internal Medicine. 1985: Vol. 87. pp. 649-55. Sceman and Riggs. "Dietary prevention of bone loss in the elderly." Geriatrics. 1981: Vol. 36. pp. 71-79. Goodwin. Garry and Hunt. "Iron status and anemia in the elderly: New findings and a review of previous studies." Journal of American Geriatrics Society. 1983: Vol. 31. pp. 389-99. Halpern. Clinical Nutrition. 2n^ ed.. J.P. I.ippin-cotl. 1987. Yearick. Wang and Pisias. "Nutritional status of the elderly: Dietary and biochemical findings." Journal of Gerontolngw Vol. 5. pp. 663-71. Hutchinson and Munro. "Biochemical assessment of vitamin status in the elderly: Effects of dietary and supplemental intakes." Nutrition ami Aging. 1986: Vol.5. "Nutritional status in a healthy elderly population: Dietary and supplemental intakes," American Journal of Cltniiul Nutrition. Vol. 36. pp. 319-31.0
