Journal of Nutrition For the Elderly

ISSN: 0163-9366 (Print) 1540-8566 (Online) Journal homepage: http://www.tandfonline.com/loi/wjne20

Helping Older Adults Meet Nutritional Challenges

Magdalena Krondl PhD, RD , Patricia Coleman MS & Daisy Lau PhD, RD

To cite this article: Magdalena Krondl PhD, RD , Patricia Coleman MS & Daisy Lau PhD, RD
(2008) Helping Older Adults Meet Nutritional Challenges, Journal of Nutrition For the Elderly,
27:3-4, 205-220, DOI: 10.1080/01639360802261755

To link to this article: http://dx.doi.org/10.1080/01639360802261755

Published online: 11 Oct 2008.

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 Helping Older Adults Meet Nutritional
Challenges
Magdalena Krondl, PhD, RD
Patricia Coleman, MS
Daisy Lau, PhD, RD
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ABSTRACT. Prevention of premature chronic diseases is an

important component of healthy aging. Nutrition education can help
to reduce the risk of premature chronic diseases in some older adults.
Home delivered meals and congregate dining services assist vulnerable
elderly persons by providing opportunities for nutritional and social
support. Screening and assessment tools identify factors affecting
nutritional health and can also provide specific directions for
planning, implementation, and evaluation of tailored interventions.
Dietitians and allied health professionals are well positioned to assist
a heterogeneous population of older adults in securing nutritional
adequacy.

KEYWORDS. Congregate dining, food and nutrition, healthy

aging, Meals on Wheels, screening

Magdalena Krondl (PhD, RD) is Professor Emeritus, Department of

Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto,
Ontario, Canada.
Patricia Coleman (MS) and Daisy Lau (PhD, RD) are research consul-
tants in private practice.
Address correspondence to Dr. M. Krondl, 9 Marilyn Crescent, Toronto,
Ontario M4B 3C5, Canada. E-mail: maria.krondl@utoronto.ca

Journal of Nutrition for the Elderly, Vol. 27(3=4) 2008

Available online at http://www.haworthpress.com
# 2008 by The Haworth Press. All rights reserved.
doi: 10.1080/01639360802261755 205
 206 CHANGING DYNAMICS OF FOOD & NUTRITION IN OLDER ADULTS

INTRODUCTION
Each generation of elderly persons is shaped by lifelong experi-
ences within a changing environment. Under the umbrella of older
adults, there are at least two distinct groups. The dividing period
was around World War (WW) II when living conditions changed
dramatically. There are still living centenarians who can reminisce
about earlier times both before and after WW I, with each year
marked by growing urbanization, a high birth rate, and extensive
industrialization, when the population on the North American con-
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tinent grew rapidly. Urbanization brought about socioeconomic and

health problems. Living conditions were associated with unsafe
water supplies, sewage, and waste disposal. Poverty, poor diet,
unsafe food, and milk supplies were among the causes of the omni-
present communicable diseases and early death. Public health ser-
vices were minimal. Food production and distribution were
essentially unregulated from the health point of view. Health care
services were rudimentary in range and sophistication. Specialists
were few in numbers. In the early 20th century in North America,
life expectancy averaged 47 years, and persons aged over 65 years
represented 4% of the total population.
The younger generation of older adults, who are referred to as
‘‘Baby Boomers,’’ were born into times of economic growth and
increasing prosperity after WW II between 1946 and 1964. The
healthy economy had a positive impact on public health issues.
Attention started to focus on important legislative, organizational,
and financial decisions affecting the provision of health services. With
the advent of antibiotics and the decline in communicable diseases,
the number of older adults increased (Hastings, 1999). Life expect-
ancy by the year 2000 was extended to 77 years, a large increase
within one century. By 2005, adults older than 65 years comprised
13% of the American population (Administration on Aging [AoA],
2006). Those persons 85 years and older were the fastest growing
age group in most industrialized countries, and the situation
continues.
The extension of life expectancy mostly paralleled the economic
status of societies. In rich countries, such as the United States and
Canada, life expectancy is among the highest in the world while life
expectancy in poor countries, such as those in Africa, has remained
low, as illustrated in Table 1 (The Economist, 2007).
 Krondl, Coleman, and Lau 207

TABLE 1. Life Expectancy and Gross Domestic Product (GDP) per head
of Selected Countries (Adapted from The Economist, 2007)

Country Life Expectancy in Gross Domestic Product (GDP)

years Projected 2005–2010 per head in US dollars in 2004

Swaziland 29.1 (World’s lowest) 5,640

Malawi 41.1 650
Nigeria 44.2 1,150
Tanzania 46.6 670
United States 77.9 39,680
Canada 80.7 31,260
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Japan 82.8 29,250

Andorra 83.5 (World’s highest) 26,290

DIVERSITY AMONG OLDER ADULTS

The majority of older adults in Western society today live indepen-
dently in their chosen communities. Nevertheless, they may be placed
at nutritional risk at some stage of the aging process if food-related
activities are disrupted. This may include factors such as living situ-
ation, socioeconomic status, and access to food-related support ser-
vices. Independent elderly couples are the least at risk. Living alone
increases the chance of not eating regularly, particularly among men,
unless opportunities to socialize and share meals are available.
A recent prospective cohort study (Willcox et al., 2006) has ident-
ified certain midlife risk factors that decrease the probability of
healthy aging among men. The greater the number or risk factors that
could be avoided or modified in middle age the greater the prob-
ability of better health at older ages. Exceptional survival to 85 years
occurred when participants maintained greater physical fitness, as
evident by greater grip strength; avoided overweight, hyperglycemia,
hypertension, smoking, and excess alcohol consumption; and were
better educated. Men who had a marital partner in midlife survived
longer but did not appear to be healthier in very old age. It was
not possible to address nutritional issues in this long-term study of
55 years, but with dietary components associated with the risk of
major chronic diseases, a relationship between disease prevention
and healthful food choices would be anticipated.
Recent widowers rather than women living alone appear to be
at greater nutritional risk with subsequent impact on their health.
 208 CHANGING DYNAMICS OF FOOD & NUTRITION IN OLDER ADULTS

However, at highest risk are housebound elderly persons who are

lacking family support. In a study of independently living older
adults aged 60 to 94 years (Payette & Shatenstein, 2005) it was
reported that when living situation produced social isolation and
perceived loneliness, dietary adequacy was negatively related to
degree of loneliness. It is important to differentiate between
‘‘aloneness’’ and ‘‘loneliness’’ since the quality of relationship may
be more important than the number of social contacts. Social
isolation may be a major contributor to emotional depression; this
can result in deterioration of health, accelerated by decreased inter-
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est in food, which eventually results in loss of ability to manage

self-care.
Research related to social factors and nutritional risks identified
two poles. At one pole are widowed individuals in good health,
irrespective of gender, in good health and without financial
constraints, who continue to drive and remain independent in their
dietary self-management. At the other pole are those in poor health
with no adequate services or assistance, who experience difficulties
obtaining appropriate home or health-care support, have little social
contact, and are at great nutritional risk, since their food preparation
abilities and dietary intakes could become limited.

Caregivers
Informal care giving remains the most prevalent source of care for
the elderly in the community. Research on long-term care for the eld-
erly indicated that two in five care recipients receive all care infor-
mally, and two in three receive some informal care. About 30% of
persons caring for elderly long-term care users were themselves aged
65 years and older (Agency for Healthcare Research and Quality,
2001). By 2050, the number of individuals using paid long-term care
services in any setting will likely double (Family Caregiver Alliance,
2007). Care giving for prolonged periods can be a burden and can
cause depression in the caregivers when relief is not provided. When
living at home is no longer possible, the option is institutionalization.
In 2004, about 1.6 million nursing home residents were 65 years and
older (National Centre for Health Statistics, 2006). The number
increases drastically with advancing age (Table 2). Over half of the
older residents of nursing homes were among the oldest old (He
et al., 2005).
 Krondl, Coleman, and Lau 209

TABLE 2. Nursing Home Residents among People

Aged 65 and by Age and Sex: 1999 (Adapted from
He et al., 2005)

Age in years Men Women

65–74 10.3 11.2

75–84 30.8 51.2
85 and older 116.5 210.5
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Living Location
Location is another issue of concern. Elderly persons residing in
rural areas could be at greater nutritional risk, versus those in urban
areas, because of isolation. Obtaining food requires transportation.
Widowed women must be able to drive or have access to public
transportation. Both of these conditions are not often met. Approxi-
mately 25% of adults aged 65 years and older in the United States
live in rural areas; thus, the proportion of the population affected
is large (McLaughlin & Jensen, 1998). However, it has been reported
that rural elderly persons receive more support from family members
and the community than do their urban counterparts. Opportunity to
socialize and share meals can rekindle interest in eating and lead to
greater variety in food use. Meal programs such as congregate dining
and home-delivered meals are much needed for the older adults living
in rural areas.

Socioeconomic Status
An individual’s purchasing power is constrained by socioeconomic
status. Older adults who are on fixed incomes may have to reduce the
allocation of money for nutritious food. The relationship of income
to food intake is complex. The use of cheaper brands and concern
with food waste may precede limiting the amount of food. Compared
with the average single living individual or childless married couples,
the elderly tend to spend less money on food. Females spend less
money than males. Of the total food expenditure, the elderly allocate
less money to eating out than other lifecycle groups. This had been
attributed to decreased mobility, reduced income, and fewer opportu-
nities to purchase foods away from home (Krondl & Coleman, 1987).
 210 CHANGING DYNAMICS OF FOOD & NUTRITION IN OLDER ADULTS

Ethnicity
A fairly large proportion of older adults in the United States (US)
and Canada are made up of immigrants. These older individuals of
minority cultures are often at greater risk of poor health, isolation,
and poverty (Garcia & Johnson, 2003; Johnson & Garcia, 2003;
Jones, 2005). In the US, minority elders comprise over 16% of all
older Americans aged 65 years and older in 2005; these numbers
are expected to rise dramatically. The older minority population is
projected to increase by 217% between 1999 and 2030, compared
with only 81% for the older white population (AoA, 2006). The
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special needs of this growing minority population must be recog-

nized. Interventions such as nutrition education and meal programs
should include racially and culturally appropriate components to
meet the requirements of this diverse population of older adults.

HEALTH AND NUTRITIONAL STATUS OF THE

OLDER ADULTS

Chronic Diseases
Health status of older adults decreases with age. While 43% of
Americans aged 65 years and older are in very good health, 33%
of those between 75 and 84 years, and 28% older than 85 years sub-
jectively considered themselves to be healthy (AoA, 2006). Some of
the elderly are burdened with chronic diseases, including being over-
weight and obese. Obesity is one of the most common nutritional dis-
orders in older adults. Nutritional factors are especially pronounced
in increasing obesity among seniors 65 years and older from 12% in
1990 to 19% in 2002 (Lucas, Schiller, & Benson, 2004); undernutri-
tion continues to be a pervasive problem in older adults with
inadequate income and hunger.
The metabolic syndrome (MetS) is related to diet and lifestyle.
MetS is a clustering of chronic disease risk factors, including abdomi-
nal obesity, dyslipidemia (elevated triglycerides and=or low levels of
high-density lipoprotein cholesterol), elevated blood pressure, and
elevated fasting glucose. Individuals with MetS are at high risk of
developing type 2 diabetes and cardiovascular disease, and have
greater mortality rates than those without the syndrome (Brien &
 Krondl, Coleman, and Lau 211

Katzmarzyk, 2006). The chronic diseases diagnosed in the majority of

older adults are included in the MetS cluster.
There may be a genetic predisposition to the metabolic aberrations
in chronic diseases such as hyperlipidemia and diabetes. Technologi-
cal advances in genomic research and nutrigenomics (Afman &
Muller, 2006; Ordovas, 2006) will enable the development of custo-
mized designer foods based on an individual’s genetic profile, with
products to treat or prevent diseases earlier and better (Coulston et
al., 2003; University of Toronto, 2006).
Nutritional genomics (nutrigenomics) is described as a com-
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bination of molecular nutrition and genomics. It is a relatively new

area of study, but has far-reaching potential in the field of dietetics.
Genetic information about individuals could lead to more specific
dietary recommendations, and may further the prevention of diet-
related disease (Debusk et al., 2005). An individual’s personal genetic
profile on a compact disc can be purchased for around half a million
dollars (Elias, 2002). This information will allow personalized
approaches to disease treatment and prevention (Coulston et al.,
2003). Considerable research will be required to better understand
complex diseases and to further identify the molecular pathways that
are influenced by individual nutrients. Eventually, nutrigenomics will
have practical applications that change generalized nutrition rec-
ommendation to targeted interventions to help consumers optimize
their health potential (Debusk, et al., 2005).

PREVENTION: NUTRITION EDUCATION, HEALTHY

EATING, AND MEAL PROGRAMS

Nutrition Education
Reducing the risk of premature chronic disease in some older
adults may be helped by the promulgation of accurate information
through education programs and individual counseling, translating
nutritional guidelines into manageable food use. Knowledge may
not be reflected in actual practices without attention to the past
experiences and perceptions of the target audience. The subgroup
of ‘‘younger’’ older adults may be more receptive to knowledge-based
intervention (DeWolfe & Millan, 2003). The future generation of the
elderly is likely to be more health conscious and better educated;
 212 CHANGING DYNAMICS OF FOOD & NUTRITION IN OLDER ADULTS

innovative approaches to nutrition education will be needed to keep

pace with these changes (Krondl & Coleman, 1987). The message
must be tailored to the target audience, and skill in selling the
message is required (Gordon, 1983).

Healthy Eating
North Americans are confronted by an ever-increasing variety of
food such as imported products, frozen meals, genetically modified
foods, irradiated foods with prolonged shelf life, and organic foods.
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Fresh fruits and vegetables that were once considered exotic are
available throughout the year. This food abundance did not seem to sig-
nificantly effect the caloric consumption of elderly men and women in
Canada, as shown from a comparison of two surveys by Health Canada
(Garriguet, 2004) between 1970–1972 and 2004. In contrast, the caloric
consumption of elderly persons aged 51 to 71 years in the US has
increased over this same period. Despite easy and available access to
fruit and vegetables, consumption of this food group by the elderly is
below the recommended number of servings; the situation is worse
for the 71 years and older-aged subgroup. Efforts must be made to
improve the consumption patterns of older adults, in particular the
intake of fruits and vegetables. The Transtheoretical or Stage of Change
Model has been found useful in planning strategies to change the dietary
behaviors of older adults (Greaney et al., 2004; Green et al., 2004).
The protective role of omega-3 fatty acids in reducing the risk of
cardiovascular disease may be familiar but not incorporated into eat-
ing patterns. Preliminary evidence linking omega-3 fatty acids to
reduction in risk of dementia and Alzheimer disease has been found
but must be repeated in other studies before confirmation (Schaefer
et al., 2006). A protective effect for more than one health condition
would be advantageous.

Meal Programs: Meals on Wheels and Congregate Dining

Nutrition is recognized as one of the major determinants of suc-
cessful aging, defined as the ability to maintain three key behaviors:
low risk of disease and disease-related disability, high mental and
physical function, and active engagement of life (Rowe & Kahn,
1998). As a primary prevention strategy, nutrition helps to promote
health and functionality; millions of older Americans would benefit
 Krondl, Coleman, and Lau 213

from nutritional services if they were broadly available (American

Dietetic Association, 2005).
Meal programs for the elderly have a long history. The first
organized meal delivery service to the elderly who had been displaced
by the Blitz was established in Great Britain during WW II by the
Women’s Volunteer Services. The benefits of this delivery service
gained recognition and continued as a peacetime effort. Later, the
idea was carried across the Atlantic. The first Meals on Wheels pro-
gram in the United States began in 1954 on a volunteer basis. The
program was initiated by Margaret Toy, a social worker at the Light-
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house, a settlement house in northern Philadelphia (Lloyd, 1997). In

Canada, the first Meals on Wheels program was introduced in 1963
by the Independent Order Daughters of the Empire (IODE) and
the Red Cross in Brantford, Ontario. Many of the early programs
in Ontario were sponsored and organized under the auspices of the
Red Cross and IODE. In subsequent years, as the benefits of
the program gained recognition, sponsorship extended to include
the Victorian Order of Nurses, service clubs, churches, centers for eld-
erly persons, hospitals, homes for the aged, and nursing homes with
partial financial support from the provincial Ministries of Community
and Social Services and Health (Meals on Wheels of Ontario, 1992).
Meal programs—both home-delivered meals and congregate
dining—have been evaluated to be effective and efficient in delivering
nutrient-dense meals, and demonstrated better food intake and
improved nutritional risk in their participants; congregate meal pro-
grams also provided opportunity for socializing among high-risk
older persons (Mathematica Policy Research, 1996; Millen et al.,
2002; Wellman, Rosenzweig, & Lloyd, 2002; Kretser et al., 2003;
Gollub & Weddle, 2004; Roy & Payette, 2006; Keller, 2006). Future
efforts should focus on exploring additional funding sources from
federal, state, or local agencies to increase program availability so
that those elderly persons who are at low or moderate nutritional risk
can also benefit from this preventive nutrition service.

FUTURE CHALLENGES

Screening and Assessment

Nutritional risk screening and health assessment for the general
older adult population should be in place to identify the needs of
 214 CHANGING DYNAMICS OF FOOD & NUTRITION IN OLDER ADULTS

the different elderly subgroups. Results from screening and assess-

ment will enable the planning and implementation of tailored and
appropriate programs such as meal service, congregate dining or
home-delivered meals, group nutrition education or individual coun-
seling, and special dietary prescriptions or nutrient supplements to
meet the requirements of the individual. The necessity for nutritional
risk screening and its usefulness in program planning and implemen-
tation is well documented (Sharkey, 2002, 2004; Weatherspoon et al.,
2004; Lee, Frongillo, & Olson, 2005a, 2005b). Besides identifying
needs, nutrition risk screening can raise awareness in the elderly
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regarding health issues, and can target limited resources (Rush,

1997; Chernoff, 2001). Several health and nutrition indices that are
specific to older adults in the community have been developed. The
most commonly used screening tool in the US is the Nutrition
Screening Initiative Checklist, or the DETERMINE checklist
(White et al., 1992). In Canada, two screening indices have been
developed: The Elderly Nutrition Screen (ENS#) is designed for
use with older adults who require home support (Payette, 2005),
and the SCREENTM is for use with older adults in the general popu-
lation (Keller et al., 2000; Keller et al., 2001). Different screening
instruments may be required for different segments of the older
adult population because they may range from well and successfully
aging to chronically ill and disabled (DeWolfe & Millan, 2003).
Further research would be required in developing appropriate
screening tools for a culturally and racially diverse population of
older adults. At present, most nutrition and health prevention
efforts have targeted those elderly persons that are at high health risk
(Wellman et al., 2002); however, healthier and ‘‘younger’’ older
adults should also be targeted for prevention of early onset of disease
and declines in function (Drewnowski & Evans, 2001; Sahyoun,
2002).

Maintenance of Independence
A common goal for all older persons is to maintain independent
living, especially for the Baby Boomers who have a goal of wellness.
They want the health care system to keep them healthy and have no
desire to go into nursing homes. The expected and most acceptable
option is home care (Gendreau, 1997). In order to meet the needs
of this heterogeneous group of older adults, expanded full-service
 Krondl, Coleman, and Lau 215

community programs, including meal service, transportation,

shopping assistance, wellness and exercise programs, medical and
case management, respite care, and caregiver support, would have
to be provided (Wellman et al., 2002). Community-based and cost-
effective services, nutrition screening, and early intervention may
enable the elderly to live independently and enjoy old age; inter-
vention strategies have to take into account both physical and
psychological well being and functional independence (Weatherspoon
et al., 2004).
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Increased Need for Geriatric Care

Since the eradication of infectious diseases as major causes of
death in the general population, public health professionals have
turned their attention to the diseases that affect middle and older
age groups such as cardiovascular disease, stroke, type 2 diabetes,
and cancer. Epidemiological studies led to education about pre-
ventive lifestyle practices, especially diet and exercise. Increased
attention was turned toward the elderly as having special needs.
The range of professionals and experts was broadened to include
clinical dietitians, community nutritionists, and, later, gerontological
nutritionists.
The older adults are the largest consumers of health care resources.
Medication use by seniors accounts for 34% of prescription drugs.
The adverse effects of some drugs may include dizziness, numbness,
dehydration, loss of appetite, nausea, or diarrhea. Elderly persons
taking multiple medications may be prone to falls, depression, con-
fusion, hallucination, and malnutrition. The patient may be at risk
of inappropriate drug dosage.
Unfortunately, specialization in geriatrics is not selected by many
graduates in medicine; in Canada, with approximately four-million
people older than 65 years, the number of geriatricians is 200. The
same situation prevails in the US. A recent article (Gawande, 2007)
describes the new demography and the difficulties that older adults
will have in accessing appropriate health care to maintain well being
in later years. Between 1988 and 2004, the number of certified geria-
tricians in the US decreased by a third, and few graduates in medicine
opted for specialization programs in this area. In 2007, 300 doctors
will complete geriatrics training in the US, while more than this num-
ber of persons will retire. A solution involves providing courses in
 216 CHANGING DYNAMICS OF FOOD & NUTRITION IN OLDER ADULTS

geriatrics for primary care doctors. Another alternative is being stud-

ied in the Baltimore and Washington, DC area, where local nurses
are being recruited for a highly compressed three-week course in
how to recognize specific problems in the elderly and then determine
appropriate solutions. It implies that registered dietitians could be the
best qualified professionals to provide nutrition services to older
adults in the community and be proactive in health promotion and
risk reduction (Wellman, 2007).
Preventing disease and functional disability is a significant chal-
lenge for the public health system (Drewnowski & Evans, 2001).
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Improving the nutritional status of all elderly persons should be the

ultimate goal of health prevention incentives and programs. How-
ever, most nutrition support for the elderly in the United States is tar-
geted toward the high-risk elderly subgroups because of budget
constraints (Millen et al., 2002; Wellman & Kamp, 2004) and there
are no legislated meal programs for the elderly in Canada. Health
prevention there is mostly targeted toward the adults and youths
(National Research Council Committee on Diet and Health and
Food and Nutrition Board Commission on Life Sciences, 1989).
Additional research to develop better screening instruments and
support from government to institute mandatory nutritional
screening is required. The next challenge is to expand available
resources, monetary and personnel, and coordinate operations
between federal, state, or provincial and local community agencies
for the provision of tailored interventions that are economical, easily
accessible, and ethnically and culturally acceptable to meet the needs
of the heterogeneous elderly population in maintaining health,
independence, and quality of life.

SUMMARY
. Heterogeneity in the elderly population necessitates customized
treatment and prevention measures.
. Prevention approaches have to be multifaceted, including nutrition
education on healthy eating and provision of nourishment via
food-based programs.
. Nutrition risk screening and health assessment should be in
place to identify specific needs of the heterogeneous elderly
subgroups.
 Krondl, Coleman, and Lau 217

. Registered dietitians can serve as expert consultants in coordinating

nutrition services to older adults in the community and can be
proactive in health promotion and risk reduction.

Received: June 1, 2007

Revised: June 10, 2007
Accepted: June 13, 2007

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