December 1992: 484-487
How Food-Related Industries Can Respond to the Nutritional Needs of the Elderly: An European View Joseph G.A.J. Hautvast, M.D., Lisette C.P.G.M. de Groot, Ph.D., and Wija A. van Staveren, R.D., Ph.D.
Introduction
The ultimate goal of programs aiming to fulfill the nutritional needs of older people is to improve quality of life rather than to attain longevity. Therefore, nutritional needs of the elderly have to be described in terms of adequate energy and nutrient supply as well as in terms of enjoyable meals. It is not easy to describe an adequate energy and nutrient supply for people aged 65 and over because this age category is more heterogeneous than other age groups. Furthermore, little is known about specific nutrient requirements for elderly people. Published recommended dietary intakes for older people are mostly an extrapolation of results from research conducted in adults.'.' However, it is well known that the energy requirement decreases with age due to decreases in resting metabolic activity. In contrast, requirements for most minerals and vitamins do not decrease. Consequently, the nutrient density of the diet of older persons should increase. Recent research has shown that this nutrient-dense energy supply should be distributed over at least three meals per day and one or two snacks3 In addition, sufficient fluid, 1.5-2 L, distributed over the day is a nutritional need that should receive specific attention in older person^.^ Euronut-SENECA Study on Nutrition and the Elderly
To be able to respond to the nutritional needs of the elderly in Europe it is important to know their food consumption pattern. This is one of the reasons that in 1986 the Project Management Group of Euronut, the Concerted Action on Nutrition and Health Drs. Hautvast, de Groot, and van Staveren are at the Department of Human Nutrition, Wageningen Agricultural University, P.O. Box 8129, 6700 EV Wageningen, The Netherlands.
484
in the European Community, decided to embark on a study of nutrition in the elderly. This study, entitled SENECA (Survey in Europe on Nutrition and the Elderly, a Concerted Action) was conducted to explore dietary patterns in the elderly in relation to both the social and economic condition of these people and their health and performance. About 2600 elderly people 7&75 years of age, living in 19 towns in 12 European countries, participated. The data comprise demographic, social, diet, mobility, health, and performance aspects, which were all collected by questionnaire. An adjusted dietary history method was developed and validated to assess food consumption.' In addition, anthropometry and blood analyses were carried out to evaluate nutritional status. A mixed longitudinal study design was used to discriminate for effects of age, period, and cohort. The core protocol, carried out in 19 centers, called for a random sample, stratified by age and sex, of elderly born in 1913-1914. In Figure 1, a geographical map of Europe indicates all the sites studied. The mixed longitudinal design is valid only for nine centers, which also include a random sample of subjects born in 1915-1918. All methods were highly standardized, using a detailed manual of operations and central training of fieldwork coordinators. For the blood samples, all collected material was supplied by the coordinating center in Wageningen, The Netherlands, and all parameters were analyzed in central laboratories with the exception of hemoglobin and hematocrit, which were measured at the respective sampling sites."' Variability in Dietary Patterns The assessment of food consumption showed an enormous variability in energy and nutrient intake between survey sites.8 These data have not been related to parameters of nutritional status and health, and performance. Figure 2 shows that men had a significantly higher energy intake than women in all research towns. However, in almost all the Nutrition Reviews, Vol. 50, No. 12
town
Figure 2. Mean energy intake (MJ/day) by survey town. For abbreviations, see legend Figure 1. Food consumption data are missing for C/P.
T Figure 1. Situation of survey towns (W birth-cohorts 1913-1914 enrolled, 0 birth-cohorts 1913-1918 enrolled) No. Country Survey town Abbreviation 1. Belgium Hamme H/B 2. Denmark Roskilde R/DK 3. France Chateau Renaultl Amboise CNF 4. France Hapuenau H/F France Romans R/F 5. Greece Markopoulou M/GR 6. 7. Greece AnogidArchanes MGR Monor M/H 8. Hungary Padua 9. P/I Italy Fara Sabina, 10. Italy Magliano Sabina, FMPD Poggio Mirteto C/NL 11. Netherlands Culemborg 12. E/N Norway Elverum Marki M/PL Poland 13. Coimbra C/P 14. Portugal Vila Franca 15. Portugal V/P de Xira B/E Betanzos Spain 16. Y/CH Switzerland Yverdon 17. Switzerland Burgdorf Bu/CH 18. Be/CH Switzerland Bellinzona 19. w
centers, the diets of women had a higher nutrient density than those of men, except for iron.’ The data available for nine survey towns show that afternoon and evening average energy intake represented less than 40% of total daily intake and
Nutrition Reviews, Vol. 50, No. 72
was as low as 27-31% in eastern European towns where cooked midday meals predominate compared to 50% at sites where bread meals are usually eaten for lunch (site in the Netherlands; see Figure 3). The large proportion of energy consumed at the midday meal is one of the most important characteristics of the southern and eastern European meal pattern. The frequency of meals also varied considerably between the survey towns. In eastern towns the majority of the elderly subjects ate three times a day or less, whereas in the Dutch and the Germanspeaking Swiss towns, more than 50% consumed foods on six or more occasions during the day. A striking finding of the SENECA study is the enormous variability in dietary nutrient intake between the different centers and also within most research towns. To identify “risk nutrients” in this group is difficult, since the standards used to assess dietary adequacy are very controversial. However, the observed failure to meet the lowest published Recommended Dietary Intakes (RDIs for Europe suggests that in some of the research towns a con-
Figure 3. Distribution of energy intake (percentage of total energy intake) over the day. For abbreviations, see legend Figure 1.
485
siderable percentage of the elderly might be at risk of vitamin or mineral deficiency. This was particularly evident for vitamin A in both sexes and for vitamins B, and B,, and iron in women.’ It has been pointed out that when energy intake is lower than 6.3 MJ/day (1500 kcal), it is difficult to meet the requirements for minerals and vitamins,” especially for nutrients whose intake is already marginal.” In the SENECA study, 9% of the men and 28% of the women had energy intakes below 6.3 MJ/day. Unfortunately, in this study vitamin and mineral supplements did not complement the low intakes, because, as it was noted in other studies, they were mostly used in those study centers where the elderly already had an adequate intake of these nutrients. Shopping and the Use of Home-ProducedFoods Reduced access to food shops might be a cause of inadequate dietary intake in the elderly’2 when the preferred place of eating is at home. In most SENECA towns, 90% of the elderly always eat at home. Shopping facilities in these sites were reported to be close to or within walking distance of the homes of more than 70% of the subjects. This probably reflects the “traditional town” concept of the study design. No significant difference in the distance to shops was observed between those subjects for whom shopping was a problem or inconvenient and other subjects for whom it posed no difficulties. Shopping was considered a real problem for participants with food-budgeting problems. Of those subjects with shopping problems, 59% also had foodbudgeting problems compared to 6% of subjects without shopping problems. Again related to the selection criteria of “traditional towns” was the observation that, in all but one of the sites, one-half or more of the elderly consumed home-produced foods, mainly vegetables and fruit but also eggs, meat, milk, and alcoholic drinks. The fact that convenience foods (ready-made meals for reheating) were widely used, while at the same time two-thirds of subjects consumed home-produced foods is an important sign for the food industry. It implies a multifaceted approach to nutrition in the elderly. The use of convenience foods also confirms a fact observed earlier that older adults introduce novel foods in their diet as often as younger adults do.13
How Can the Food Industry Respond? It is obvious that by producing easy-to-prepare, enjoyable foods, high in nutrient density and with high
486
hygienic standards, the industry might better meet the nutritional needs of elderly people. A changing variety of small packs of nutritious instant and convenience foods, easy to open and store, at reasonable cost and attractive “at first sight,” with acceptable flavor, texture, and color will help the elderly in regularly eating healthy and tasty meals. Euronut-SENECA,14 but also o t h e r studies, showed many gaps in the food market for the elderly. However, one should realize that some of the requirements are for technical and logistic solutions that are more or less opposing, especially in the field of meal services. For example: 1) meals should have a high temperature-however, containers in which the food is kept should be easy to open for the elderly; 2) today service is given at high speedhowever, elderly people often need attention and extra help; 3) meals should be inexpensive, but still rich in nutrients, highly attractive, and with sufficient variety. Can all of the elderly afford this? 1. Munro HN, Suter PM, Russell RM. Nutritional requirements of the elderly. Annu Rev Nutr 1987;7: 23-49 2. Trichopoulou A, Vassilakou T. Recommended dietary intakes in the European community member states: an overview. Eur J Clin Nutr 1990;44(suppl 2)2:51-100 3. Jansen RW, Hoefnagels WH. Postprandial blood pressure reduction. Neth J Med 1990;37:80-8 4. Rolls BJ, Phillips PA. Aging and disturbances of thirst and fluid balance. Nutr Rev 1990;48:137-44 5. Nes M, Van Staveren WA, Zajkas G, lnelmen EM, Moreiras-Varela 0. Euronut SENECA study on nutrition and the elderly: validity of the dietary history in elderly subjects. Eur J Clin Nutr 1991;45 (SUPPI 3):97-104 6. De Groot CPGM, Van Staveren WA. Nutrition and the elderly. A European collaborative study in cooperation with the World Health Organization and the International Union of Nutritional Sciences (IUNS), Committee on Geriatric Nutrition. Manual of operations. Euronut report 11, Wageningen, the Netherlands, 1988 7. Van’t Hof MA, Hautvast JGAJ, Schroll M, Vlachonikolis IG. Euronut SENECA study on nutrition and the elderly: design, methods and participation. Eur J Clin Nutr 1991;45(suppl 3):5-23 8. Moreiras 0, van Staveren WA, Amorim Cruz JA, Nes M, Lund-Larssen K. Euronut SENECA study on nutrition and the elderly: intake of energy and macronutrients. Eur J Clin Nutr 45;(suppl 3):10519 9. De Groot CPGM, Sette S, Zajkas G, Carbajal A, Amorim Cruz JA. Euronut SENECA study on nutrition and the elderly: anthropometry. Eur J Clin Nutr 45;(suppl 3):121-38 10. Lowenstein FW. Nutritional status of the elderly in
Nutrition Reviews, Vol. 50, No. 72
the United States of America, 1971-1974. J Am Cot1 Nutr 1982;1:16577 1 1 . Mertz W. Minerals. In: Horwitz A, Macfayden DM, Munro H, et al. eds. Nutrition and the elderly. London: Oxford University Press, 1989 12. Coe RM, Miller DK. Sociological factors that influence nutritional status in the elderly. In: Ambrecht HJ, Prendergast JM, Coe RM, eds. Nutritional in-
Nutrition Reviews, Vol. 50, No. 12
tervention i n the aging process. New York: Springer-Verlag, 1984:3-12 13. Davies L. Three score years . . . and then? A study of the nutrition and well-being of elderly people at home. London: Heinemann, 1981 14. De Groot CPGM, Van Staveren WA, Hautvast JGAJ, eds. Euronut SENECA, nutrition and the elderly in Europe. Eur J Clin Nutr 1991 ;45(suppl 3):l-196
487
How Food-Related Industries Can Respond to the Nutritional Needs of the Elderly: An European View Joseph G.A.J. Hautvast, M.D., Lisette C.P.G.M. de Groot, Ph.D., and Wija A. van Staveren, R.D., Ph.D.
Introduction
The ultimate goal of programs aiming to fulfill the nutritional needs of older people is to improve quality of life rather than to attain longevity. Therefore, nutritional needs of the elderly have to be described in terms of adequate energy and nutrient supply as well as in terms of enjoyable meals. It is not easy to describe an adequate energy and nutrient supply for people aged 65 and over because this age category is more heterogeneous than other age groups. Furthermore, little is known about specific nutrient requirements for elderly people. Published recommended dietary intakes for older people are mostly an extrapolation of results from research conducted in adults.'.' However, it is well known that the energy requirement decreases with age due to decreases in resting metabolic activity. In contrast, requirements for most minerals and vitamins do not decrease. Consequently, the nutrient density of the diet of older persons should increase. Recent research has shown that this nutrient-dense energy supply should be distributed over at least three meals per day and one or two snacks3 In addition, sufficient fluid, 1.5-2 L, distributed over the day is a nutritional need that should receive specific attention in older person^.^ Euronut-SENECA Study on Nutrition and the Elderly
To be able to respond to the nutritional needs of the elderly in Europe it is important to know their food consumption pattern. This is one of the reasons that in 1986 the Project Management Group of Euronut, the Concerted Action on Nutrition and Health Drs. Hautvast, de Groot, and van Staveren are at the Department of Human Nutrition, Wageningen Agricultural University, P.O. Box 8129, 6700 EV Wageningen, The Netherlands.
484
in the European Community, decided to embark on a study of nutrition in the elderly. This study, entitled SENECA (Survey in Europe on Nutrition and the Elderly, a Concerted Action) was conducted to explore dietary patterns in the elderly in relation to both the social and economic condition of these people and their health and performance. About 2600 elderly people 7&75 years of age, living in 19 towns in 12 European countries, participated. The data comprise demographic, social, diet, mobility, health, and performance aspects, which were all collected by questionnaire. An adjusted dietary history method was developed and validated to assess food consumption.' In addition, anthropometry and blood analyses were carried out to evaluate nutritional status. A mixed longitudinal study design was used to discriminate for effects of age, period, and cohort. The core protocol, carried out in 19 centers, called for a random sample, stratified by age and sex, of elderly born in 1913-1914. In Figure 1, a geographical map of Europe indicates all the sites studied. The mixed longitudinal design is valid only for nine centers, which also include a random sample of subjects born in 1915-1918. All methods were highly standardized, using a detailed manual of operations and central training of fieldwork coordinators. For the blood samples, all collected material was supplied by the coordinating center in Wageningen, The Netherlands, and all parameters were analyzed in central laboratories with the exception of hemoglobin and hematocrit, which were measured at the respective sampling sites."' Variability in Dietary Patterns The assessment of food consumption showed an enormous variability in energy and nutrient intake between survey sites.8 These data have not been related to parameters of nutritional status and health, and performance. Figure 2 shows that men had a significantly higher energy intake than women in all research towns. However, in almost all the Nutrition Reviews, Vol. 50, No. 12
town
Figure 2. Mean energy intake (MJ/day) by survey town. For abbreviations, see legend Figure 1. Food consumption data are missing for C/P.
T Figure 1. Situation of survey towns (W birth-cohorts 1913-1914 enrolled, 0 birth-cohorts 1913-1918 enrolled) No. Country Survey town Abbreviation 1. Belgium Hamme H/B 2. Denmark Roskilde R/DK 3. France Chateau Renaultl Amboise CNF 4. France Hapuenau H/F France Romans R/F 5. Greece Markopoulou M/GR 6. 7. Greece AnogidArchanes MGR Monor M/H 8. Hungary Padua 9. P/I Italy Fara Sabina, 10. Italy Magliano Sabina, FMPD Poggio Mirteto C/NL 11. Netherlands Culemborg 12. E/N Norway Elverum Marki M/PL Poland 13. Coimbra C/P 14. Portugal Vila Franca 15. Portugal V/P de Xira B/E Betanzos Spain 16. Y/CH Switzerland Yverdon 17. Switzerland Burgdorf Bu/CH 18. Be/CH Switzerland Bellinzona 19. w
centers, the diets of women had a higher nutrient density than those of men, except for iron.’ The data available for nine survey towns show that afternoon and evening average energy intake represented less than 40% of total daily intake and
Nutrition Reviews, Vol. 50, No. 72
was as low as 27-31% in eastern European towns where cooked midday meals predominate compared to 50% at sites where bread meals are usually eaten for lunch (site in the Netherlands; see Figure 3). The large proportion of energy consumed at the midday meal is one of the most important characteristics of the southern and eastern European meal pattern. The frequency of meals also varied considerably between the survey towns. In eastern towns the majority of the elderly subjects ate three times a day or less, whereas in the Dutch and the Germanspeaking Swiss towns, more than 50% consumed foods on six or more occasions during the day. A striking finding of the SENECA study is the enormous variability in dietary nutrient intake between the different centers and also within most research towns. To identify “risk nutrients” in this group is difficult, since the standards used to assess dietary adequacy are very controversial. However, the observed failure to meet the lowest published Recommended Dietary Intakes (RDIs for Europe suggests that in some of the research towns a con-
Figure 3. Distribution of energy intake (percentage of total energy intake) over the day. For abbreviations, see legend Figure 1.
485
siderable percentage of the elderly might be at risk of vitamin or mineral deficiency. This was particularly evident for vitamin A in both sexes and for vitamins B, and B,, and iron in women.’ It has been pointed out that when energy intake is lower than 6.3 MJ/day (1500 kcal), it is difficult to meet the requirements for minerals and vitamins,” especially for nutrients whose intake is already marginal.” In the SENECA study, 9% of the men and 28% of the women had energy intakes below 6.3 MJ/day. Unfortunately, in this study vitamin and mineral supplements did not complement the low intakes, because, as it was noted in other studies, they were mostly used in those study centers where the elderly already had an adequate intake of these nutrients. Shopping and the Use of Home-ProducedFoods Reduced access to food shops might be a cause of inadequate dietary intake in the elderly’2 when the preferred place of eating is at home. In most SENECA towns, 90% of the elderly always eat at home. Shopping facilities in these sites were reported to be close to or within walking distance of the homes of more than 70% of the subjects. This probably reflects the “traditional town” concept of the study design. No significant difference in the distance to shops was observed between those subjects for whom shopping was a problem or inconvenient and other subjects for whom it posed no difficulties. Shopping was considered a real problem for participants with food-budgeting problems. Of those subjects with shopping problems, 59% also had foodbudgeting problems compared to 6% of subjects without shopping problems. Again related to the selection criteria of “traditional towns” was the observation that, in all but one of the sites, one-half or more of the elderly consumed home-produced foods, mainly vegetables and fruit but also eggs, meat, milk, and alcoholic drinks. The fact that convenience foods (ready-made meals for reheating) were widely used, while at the same time two-thirds of subjects consumed home-produced foods is an important sign for the food industry. It implies a multifaceted approach to nutrition in the elderly. The use of convenience foods also confirms a fact observed earlier that older adults introduce novel foods in their diet as often as younger adults do.13
How Can the Food Industry Respond? It is obvious that by producing easy-to-prepare, enjoyable foods, high in nutrient density and with high
486
hygienic standards, the industry might better meet the nutritional needs of elderly people. A changing variety of small packs of nutritious instant and convenience foods, easy to open and store, at reasonable cost and attractive “at first sight,” with acceptable flavor, texture, and color will help the elderly in regularly eating healthy and tasty meals. Euronut-SENECA,14 but also o t h e r studies, showed many gaps in the food market for the elderly. However, one should realize that some of the requirements are for technical and logistic solutions that are more or less opposing, especially in the field of meal services. For example: 1) meals should have a high temperature-however, containers in which the food is kept should be easy to open for the elderly; 2) today service is given at high speedhowever, elderly people often need attention and extra help; 3) meals should be inexpensive, but still rich in nutrients, highly attractive, and with sufficient variety. Can all of the elderly afford this? 1. Munro HN, Suter PM, Russell RM. Nutritional requirements of the elderly. Annu Rev Nutr 1987;7: 23-49 2. Trichopoulou A, Vassilakou T. Recommended dietary intakes in the European community member states: an overview. Eur J Clin Nutr 1990;44(suppl 2)2:51-100 3. Jansen RW, Hoefnagels WH. Postprandial blood pressure reduction. Neth J Med 1990;37:80-8 4. Rolls BJ, Phillips PA. Aging and disturbances of thirst and fluid balance. Nutr Rev 1990;48:137-44 5. Nes M, Van Staveren WA, Zajkas G, lnelmen EM, Moreiras-Varela 0. Euronut SENECA study on nutrition and the elderly: validity of the dietary history in elderly subjects. Eur J Clin Nutr 1991;45 (SUPPI 3):97-104 6. De Groot CPGM, Van Staveren WA. Nutrition and the elderly. A European collaborative study in cooperation with the World Health Organization and the International Union of Nutritional Sciences (IUNS), Committee on Geriatric Nutrition. Manual of operations. Euronut report 11, Wageningen, the Netherlands, 1988 7. Van’t Hof MA, Hautvast JGAJ, Schroll M, Vlachonikolis IG. Euronut SENECA study on nutrition and the elderly: design, methods and participation. Eur J Clin Nutr 1991;45(suppl 3):5-23 8. Moreiras 0, van Staveren WA, Amorim Cruz JA, Nes M, Lund-Larssen K. Euronut SENECA study on nutrition and the elderly: intake of energy and macronutrients. Eur J Clin Nutr 45;(suppl 3):10519 9. De Groot CPGM, Sette S, Zajkas G, Carbajal A, Amorim Cruz JA. Euronut SENECA study on nutrition and the elderly: anthropometry. Eur J Clin Nutr 45;(suppl 3):121-38 10. Lowenstein FW. Nutritional status of the elderly in
Nutrition Reviews, Vol. 50, No. 72
the United States of America, 1971-1974. J Am Cot1 Nutr 1982;1:16577 1 1 . Mertz W. Minerals. In: Horwitz A, Macfayden DM, Munro H, et al. eds. Nutrition and the elderly. London: Oxford University Press, 1989 12. Coe RM, Miller DK. Sociological factors that influence nutritional status in the elderly. In: Ambrecht HJ, Prendergast JM, Coe RM, eds. Nutritional in-
Nutrition Reviews, Vol. 50, No. 12
tervention i n the aging process. New York: Springer-Verlag, 1984:3-12 13. Davies L. Three score years . . . and then? A study of the nutrition and well-being of elderly people at home. London: Heinemann, 1981 14. De Groot CPGM, Van Staveren WA, Hautvast JGAJ, eds. Euronut SENECA, nutrition and the elderly in Europe. Eur J Clin Nutr 1991 ;45(suppl 3):l-196
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