Nutritional Problems in the Ag Dietary Aspects Wendy Alicia Tempro Boston, Massachusetts
Aging is a normal process that begins with conception and ends only with death. This occurs at different rates in different individuals depending upon several factors, among them nutrition. Death in the aged may be caused by two related but separate problems: (1) death from diseases of old agedegenerative diseases which nutrition can play a role in preventing; and (2) death from old age itself-which nutrition may or may not be able to retard.1
Nutrition in the Aged Since good nutrition and good health are inseparable, the effects of a faulty diet appear sooner or later. The nutritional status of an individual of any age is a reflection of his previous, as well as present, dietary habits. The stresses that affect aging may be subtle and insidious, but over a period of years, they become cumulative and detrimental. One factor believed to be responsible for delaying the onset of the senile process is a high but not excessive level of nutritive adequacy in the presenile years in the presence of adequate, but not excessive caloric intake.2 Nutritional requirements of the elderly are basically the same as those for younger adults, except for somewhat lower caloric needs, which are due to the lower basal metabolic requirements of smaller lean body mass, and in most cases, less physical activity.3 Presented at the Second Annual ITTContinental Baking Company Symposium on Nutrition at the Sixth Annual Meeting and Scientific Assembly of Region of the National Medical Association and the Empire State Medical Association at Kiamesha Lake, New York, May 27-30, 1977. Requests for reprints should be addressed to Ms. Wendy Alicia Tempro, 229 Decatur Street, Brooklyn, NY 11233.
Energy expenditure is diminished in the aged so that calorie requirement is lessened, even though micronutrient requirement is continued. The density of micronutrients in food for the elderly must be increased.4
When considering the nutritional status of the elderly, several factors need to be considered: physical condition, economic status, social aspects, and mental health of the individual. The nutritional problems of the elderly stem, not from an actual increase in the bodily requirements for nutritional essentials, but rather from impaired intake or uptake. This may result from adverse economic conditions, reduced physical activity, eccentricities of food intake, and degenerative diseases having nutritional side effects.5 Degenerative changes in aging affect digestion, absorption, and metabolism of food. Poor mastication of food, decreased saliva, diminished secretion of most digestive enzymes, slower movements of the gastrointestinal tract, impaired liver and kidney function, loss of ability to do extra work, and difficulty in excreting excessive waste products are factors affecting the digestion and absorption of food in the aged.6
The chief changes observed in dietary surveys and studies on the elderly are in the speed and completeness of digestion and absorption, glucose tolerance, utilization of protein, fat, calcium, thiamine, and decreased appetite.
Malnutrition in the Aged A number of factors may contribute to the development of malnutrition in the aged. These include low income, isolation, poor dietary habits, and
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
coexisting disease or chronic illness. Loneliness, particularly, is often associated with poor appetite and apathy toward food or selection of foodstuffs that provide inadequate nutrients. Malnutrition in the aged is a complex problem in which there is a mix of physical, social, and psychologic factors not excluding the problem of economics. Disorders of the oral cavity often have been considered a major factor in poor eating habits of some aged people. By age 60, 45 percent of people in the United States have lost all of their teeth.7 Many older persons do not eat adequately because: 1. they cannot afford to do so; 2. they lack the skills to select and prepare nourishing and well-balanced meals; 3. they have limited mobility, which may impair their capacity to shop and cook for themselves; and 4. they have feelings of rejection and loneliness which obliterate the incentive necessary to prepare and eat a meal alone. These and other physiological, psychological, social, and economic changes that occur with aging result in a pattern of living which causes malnutrition and further physical and mental deterioration.8 Since malnutrition is widespread among the aged and latent deficiency diseases are not immediately apparent, a thorough nutritional evaluation is necessary, including history, clinical evaluation, and appropriate laboratory studies which are highly relevant to the total evaluation of the aging person.7 Assisting older persons to provide an adequate diet for themselves often 281
presents many problems. Food habits are firmly established by this age, and if poor, they are difficult to replace with better ones. The elderly are often unaccepting of dietary counseling due to their firmly established misconceptions about food. The absence of a satisfactory method of chewing food leads to many modifications in eating patterns. Food that is inadequately chewed is difficult to swallow. Thus, a tendency develops to substitute foods requiring little chewing for those requiring more. When foods high in cellulose, such as fruits and vegetables, are eliminated from the diet, the bulk in the diet is reduced, with a resultant decrease in gastrointestinal motility and problems of elimination. An examination of the dietary intakes of older people reveals that vitamin A and ascorbic acid are the nutrients most likely to be lacking. The observation has been made that a decreased interest in food often develops with increase in age due to a diminished number and sensitivity of taste buds. It is, therefore, understandable that much of the pleasure of eating is removed. A zinc deficiency may be a compounding factor, since it too results in decreased taste sensitivity.6 The ability to maintain fine neuromuscular coordination declines with the aging process, frequently mainifesting itself as an inability to manipulate eating utensils. This may lead to marked dietary changes and often nutritional inadequacies. The discomfort that often accompanies ingestion of certain foods is more pronounced in older persons. Efforts to avoid offending foods may lead to elimination of nutritious foods from the diet.2 The necessity of living on a meager income forces many older people to choose the least expensive foods, which frequently means substituting relatively inexpensive carbohydrate foods, breads, and cereal products, which are low in protective nutrients, for the more expensive meat, milk, fresh fruits, and vegetables. These are normally dependable sources of protein, minerals, and most vitamins. The ease with which carbohydrates are obtained and stored enhances their appeal. A person who preserves his independence by living alone may find that this, in itself, leads to modification of 282
his eating pattern. Inexpensive living quarters may lack adequate cooking and refrigeration facilities. The aged individual, living alone, all too often limits nutritional selection to easily prepared meals, primarily consisting of carbohydrates. Calorie requirements progressively decrease with age and unless this factor is realized, elderly persons may consume excess calories and become obese. Conditions of emotional stress or deprivation often lead to modifications in attitudes toward food and in food habits as well as changes in utilization of nutrients. Failure to consume adequate calories and with it adequate levels of other nutrients may account for the fatigue, lassitude, and lack of interest in life so often experienced by elderly people.2 Primary nutritional deficiency disease may occur solely due to inadequate dietary intake, but this is rare unless the faulty diet persists for a long period of time. More commonly, and particularly in the elderly, such factors as malabsorption, decreased utilization of nutrients, increased excretion and destruction of nutrients, and increased nutritional requirements related to genetic or metabolic factors must be considered.7
Vitamin Deficiencies When diagnosing the elderly, consider the possibilities of vitamin deficiencies. Decreased stomach acidity may be a contributing factor to iron deficiency anemia and decreased intrinsic factor. Decreased vitamin intake is a frequent result of the physiologic, social, and economic handicaps of the aged. Various diseases may reduce absorption of vitamins in the aged. "Partial deficiencies in the B vitamins often are responsible for the mental confusion observed in old people. Deficiencies in fat soluble vitamins (A, D, and E) in the aged are frequently due to consumption of a diet very low in fat, such as tea and toast, to the interference in absorption caused by habitual ingestion of mineral oil as a laxative, or to disease itself."' Dietary surveys indicate that the aged often have decreased intakes of vitamins and minerals, particularly iron, calcium, and possibly magnesium. Unsatisfactory levels of ascorbic acid and B vitamins (especially folic acid) also occur in a significant number.7 Low-normal levels of vitamin B12 without evidence of associated neuropathy or
anemia are sometimes found in elderly patients. The presence of achlorhydria or history of gastric resection is a good basis for advising an increased intake of vitamin B,.2 Permanent parenteral supplement of vitamin B12 has been associated with improvement in appetite, strength, and sense of wellbeing, but six months or more of treatment may be necessary before results are observed.9
Vitamins C and E may be involved in the slowing down of cell aging due to its effect on minimizing peroxidation of cellular lipids.7 The amounts of these vitamins necessary to achieve an effect on the aging process is not known. Sufficient roughage and water must be included in the diet to preserve bowel regularity. Recent evidence suggests that roughage may be useful in reducing risk of diverticulitis and cancer of the large bowel. Excess salt consumption should be avoided in the elderly in order to prevent excessive fluid retention and elevation of blood pressure. The only practical sodium-restricted diet is the "no added salt". Dietary compliance to this is manageable, but any lower sodium restricted diet is increasingly less palatable and dietary adherence decreases substantially. Because the elderly tend to eat less and to eat capriciously, a routine multi-vitamin with iron supplement is the best way to forestall nutritional deficiency and anemia.10 More than one fourth of all elderly Americans are below the poverty line. Lack of transportation, the mobility and capacity to shop, and a lack of companionship militate against the elderly receiving a nutritionally adequate diet.II
Intervention Programs Concern over the inadequacy of food among the elderly has led to the development of intervention programs to help alleviate problems of inadequate food intake. Among these are meals-on-wheels and congregate meals programs. In the former, a hot meal is delivered to the recipient's home three to seven days per week, depending on the funding and personnel of the program. In some cases, food to be refrigerated for the evening meal and possibly for breakfast is delivered at the same time. The congregate meals program is designed to meet social and nutritional needs of the participants. The elderly
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
are provided with transportation to a centrally located dining area where, in addition to receiving an appetizing and nutritionally adequate meal in the company of others, they are able to participate in a variety of recreational, social, and educational experiences. Both programs are designed to meet the needs of older people regardless of income.2 The overwhelming majority of elderly in our country have at least one chronic illness which usually requires specialized nutritional care for effective management. Too often, the patient with a chronic disease is discharged and quickly forgotten by the medical team. Patients often are readmitted to the hospital because of inadequate discharge planning and follow-up. In an attempt to deal with this situation, many hospitals have developed continuing care services.
Team Approach At Peter Bent Brigham Hospital, a continuing care service was established in 1966. The service was designed to assist patients, especially elderly ones, in following medical therapy after discharge to an environment most conducive to their needs. The team approach to patient care was initiated. Team members included a physician, responsible for primary medical care, a dietitian, responsible for providing the patient with an individualized
diet, staff nurses, social workers, and physical therapists who are involved when appropriate. Weekly patient care rounds are held to discuss the patients' problems. The team approach results in improved patient care. Through sharing and cooperation, team members gain insight into all needs of the patient and are better equipped to formulate an optimum plan of care. These rounds provide a multidisciplinary approach to discharge planning by reviewing each patient's current status and projecting discharge planning needs. This approach sensitizes all disciplines to the problems being faced by the patient and provides an avenue for communication and coordination of care. There are also continuing care nurses, dietitians, and home-care coordinators who are responsible for follow-up of the patient once he returns home.'2 The aged must help to minimize the incidence of disease by following the same rules of hygiene that are recommended for younger people. This includes weight control, adequate sleep, and moderation in exercise and other endeavors. To be well adjusted, the aged person needs some interests and activity, both mental and physical, plus a feeling of usefulness and being wanted."
Conclusions An adequate diet and sound nutritional practices, therefore, remain key
factors, not only in the limitation of the aging process, but also in the maintenance of the quality of life for the aged. In addition, government agencies must provide the elderly either with assistance or finances to lead adequate lives. More intervention programs, such as meals-on-wheels and congregate meal sites, should be established to satisfy the needs of the elderly with adequate food, nutrition services, and readily accessible and safe socialization areas. Literature Cited 1. MayerJ: Aging and nutrition. Geriatrics 29:57-59, 1974 2. Guthrie H: Introductory Nutrition, ed 3. St. Louis, CV Mosby Co, 1975, pp 41, 421-431 3. Christakis G (ed): Nutritional Assessment of the Elderly. Am J Pub Health (suppl) 63:68-73, 1973 4. Mann G: Relationship of age to nutrient requirement. Am J Clin Nutr 26:1096-1097, 1973 5. Jukes B: Nutritional management of the anemic geriatric patient. Geriatrics 29:147-150, 1974 6. Krause M, Hunscher M: Food, Nutrition, and Diet Therapy, ed 5. Philadelphia, WB Saunders, 1972, pp 292-298 7. Krehl W: Influence of nutritional environment on aging. Geriatrics 29:65-76, 1974 8. US Department of Health, Education, and Welfare, Administration On Aging: National Nutrition Program for Older Americans. 1976 HEW Fact Sheet, DHEW Publication No. 76-20230, pp 1-4 9. Balacki J, Dobbins W: Maldigestion and malabsorption: Making up for lost nutrients. Geriatrics 29:157-166, 1974 10. Smith E: Nutritional needs of the elderly. In Nutritional Problems in a Changing World. London, Halsted Press, 1973 p 221 11. Peleovits J: Nutrition for Older Americans. J Am Diet Assoc 58:17-21, 1971 12. Baumgarten S, Collins M, Goodhue P: Continuing nutritional care for the discharged patient. Ross Timesaver 3:1, 1976, pp 1-4
John Maxwell Scholarship Fund of the Medical College of Wisconsin The Medical College of Wisconsin in Milwaukee has announced the establishment of the John Maxwell Scholarship Fund in honor and memory of Dr. John Maxwell, Sr. The fund will be in the amount of $100,000 to be used as loans to be repaid by students over a period of years so that the fund will be continuing. It will be used for economically disadvantaged students with a preference for minority students. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
283
Aging is a normal process that begins with conception and ends only with death. This occurs at different rates in different individuals depending upon several factors, among them nutrition. Death in the aged may be caused by two related but separate problems: (1) death from diseases of old agedegenerative diseases which nutrition can play a role in preventing; and (2) death from old age itself-which nutrition may or may not be able to retard.1
Nutrition in the Aged Since good nutrition and good health are inseparable, the effects of a faulty diet appear sooner or later. The nutritional status of an individual of any age is a reflection of his previous, as well as present, dietary habits. The stresses that affect aging may be subtle and insidious, but over a period of years, they become cumulative and detrimental. One factor believed to be responsible for delaying the onset of the senile process is a high but not excessive level of nutritive adequacy in the presenile years in the presence of adequate, but not excessive caloric intake.2 Nutritional requirements of the elderly are basically the same as those for younger adults, except for somewhat lower caloric needs, which are due to the lower basal metabolic requirements of smaller lean body mass, and in most cases, less physical activity.3 Presented at the Second Annual ITTContinental Baking Company Symposium on Nutrition at the Sixth Annual Meeting and Scientific Assembly of Region of the National Medical Association and the Empire State Medical Association at Kiamesha Lake, New York, May 27-30, 1977. Requests for reprints should be addressed to Ms. Wendy Alicia Tempro, 229 Decatur Street, Brooklyn, NY 11233.
Energy expenditure is diminished in the aged so that calorie requirement is lessened, even though micronutrient requirement is continued. The density of micronutrients in food for the elderly must be increased.4
When considering the nutritional status of the elderly, several factors need to be considered: physical condition, economic status, social aspects, and mental health of the individual. The nutritional problems of the elderly stem, not from an actual increase in the bodily requirements for nutritional essentials, but rather from impaired intake or uptake. This may result from adverse economic conditions, reduced physical activity, eccentricities of food intake, and degenerative diseases having nutritional side effects.5 Degenerative changes in aging affect digestion, absorption, and metabolism of food. Poor mastication of food, decreased saliva, diminished secretion of most digestive enzymes, slower movements of the gastrointestinal tract, impaired liver and kidney function, loss of ability to do extra work, and difficulty in excreting excessive waste products are factors affecting the digestion and absorption of food in the aged.6
The chief changes observed in dietary surveys and studies on the elderly are in the speed and completeness of digestion and absorption, glucose tolerance, utilization of protein, fat, calcium, thiamine, and decreased appetite.
Malnutrition in the Aged A number of factors may contribute to the development of malnutrition in the aged. These include low income, isolation, poor dietary habits, and
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
coexisting disease or chronic illness. Loneliness, particularly, is often associated with poor appetite and apathy toward food or selection of foodstuffs that provide inadequate nutrients. Malnutrition in the aged is a complex problem in which there is a mix of physical, social, and psychologic factors not excluding the problem of economics. Disorders of the oral cavity often have been considered a major factor in poor eating habits of some aged people. By age 60, 45 percent of people in the United States have lost all of their teeth.7 Many older persons do not eat adequately because: 1. they cannot afford to do so; 2. they lack the skills to select and prepare nourishing and well-balanced meals; 3. they have limited mobility, which may impair their capacity to shop and cook for themselves; and 4. they have feelings of rejection and loneliness which obliterate the incentive necessary to prepare and eat a meal alone. These and other physiological, psychological, social, and economic changes that occur with aging result in a pattern of living which causes malnutrition and further physical and mental deterioration.8 Since malnutrition is widespread among the aged and latent deficiency diseases are not immediately apparent, a thorough nutritional evaluation is necessary, including history, clinical evaluation, and appropriate laboratory studies which are highly relevant to the total evaluation of the aging person.7 Assisting older persons to provide an adequate diet for themselves often 281
presents many problems. Food habits are firmly established by this age, and if poor, they are difficult to replace with better ones. The elderly are often unaccepting of dietary counseling due to their firmly established misconceptions about food. The absence of a satisfactory method of chewing food leads to many modifications in eating patterns. Food that is inadequately chewed is difficult to swallow. Thus, a tendency develops to substitute foods requiring little chewing for those requiring more. When foods high in cellulose, such as fruits and vegetables, are eliminated from the diet, the bulk in the diet is reduced, with a resultant decrease in gastrointestinal motility and problems of elimination. An examination of the dietary intakes of older people reveals that vitamin A and ascorbic acid are the nutrients most likely to be lacking. The observation has been made that a decreased interest in food often develops with increase in age due to a diminished number and sensitivity of taste buds. It is, therefore, understandable that much of the pleasure of eating is removed. A zinc deficiency may be a compounding factor, since it too results in decreased taste sensitivity.6 The ability to maintain fine neuromuscular coordination declines with the aging process, frequently mainifesting itself as an inability to manipulate eating utensils. This may lead to marked dietary changes and often nutritional inadequacies. The discomfort that often accompanies ingestion of certain foods is more pronounced in older persons. Efforts to avoid offending foods may lead to elimination of nutritious foods from the diet.2 The necessity of living on a meager income forces many older people to choose the least expensive foods, which frequently means substituting relatively inexpensive carbohydrate foods, breads, and cereal products, which are low in protective nutrients, for the more expensive meat, milk, fresh fruits, and vegetables. These are normally dependable sources of protein, minerals, and most vitamins. The ease with which carbohydrates are obtained and stored enhances their appeal. A person who preserves his independence by living alone may find that this, in itself, leads to modification of 282
his eating pattern. Inexpensive living quarters may lack adequate cooking and refrigeration facilities. The aged individual, living alone, all too often limits nutritional selection to easily prepared meals, primarily consisting of carbohydrates. Calorie requirements progressively decrease with age and unless this factor is realized, elderly persons may consume excess calories and become obese. Conditions of emotional stress or deprivation often lead to modifications in attitudes toward food and in food habits as well as changes in utilization of nutrients. Failure to consume adequate calories and with it adequate levels of other nutrients may account for the fatigue, lassitude, and lack of interest in life so often experienced by elderly people.2 Primary nutritional deficiency disease may occur solely due to inadequate dietary intake, but this is rare unless the faulty diet persists for a long period of time. More commonly, and particularly in the elderly, such factors as malabsorption, decreased utilization of nutrients, increased excretion and destruction of nutrients, and increased nutritional requirements related to genetic or metabolic factors must be considered.7
Vitamin Deficiencies When diagnosing the elderly, consider the possibilities of vitamin deficiencies. Decreased stomach acidity may be a contributing factor to iron deficiency anemia and decreased intrinsic factor. Decreased vitamin intake is a frequent result of the physiologic, social, and economic handicaps of the aged. Various diseases may reduce absorption of vitamins in the aged. "Partial deficiencies in the B vitamins often are responsible for the mental confusion observed in old people. Deficiencies in fat soluble vitamins (A, D, and E) in the aged are frequently due to consumption of a diet very low in fat, such as tea and toast, to the interference in absorption caused by habitual ingestion of mineral oil as a laxative, or to disease itself."' Dietary surveys indicate that the aged often have decreased intakes of vitamins and minerals, particularly iron, calcium, and possibly magnesium. Unsatisfactory levels of ascorbic acid and B vitamins (especially folic acid) also occur in a significant number.7 Low-normal levels of vitamin B12 without evidence of associated neuropathy or
anemia are sometimes found in elderly patients. The presence of achlorhydria or history of gastric resection is a good basis for advising an increased intake of vitamin B,.2 Permanent parenteral supplement of vitamin B12 has been associated with improvement in appetite, strength, and sense of wellbeing, but six months or more of treatment may be necessary before results are observed.9
Vitamins C and E may be involved in the slowing down of cell aging due to its effect on minimizing peroxidation of cellular lipids.7 The amounts of these vitamins necessary to achieve an effect on the aging process is not known. Sufficient roughage and water must be included in the diet to preserve bowel regularity. Recent evidence suggests that roughage may be useful in reducing risk of diverticulitis and cancer of the large bowel. Excess salt consumption should be avoided in the elderly in order to prevent excessive fluid retention and elevation of blood pressure. The only practical sodium-restricted diet is the "no added salt". Dietary compliance to this is manageable, but any lower sodium restricted diet is increasingly less palatable and dietary adherence decreases substantially. Because the elderly tend to eat less and to eat capriciously, a routine multi-vitamin with iron supplement is the best way to forestall nutritional deficiency and anemia.10 More than one fourth of all elderly Americans are below the poverty line. Lack of transportation, the mobility and capacity to shop, and a lack of companionship militate against the elderly receiving a nutritionally adequate diet.II
Intervention Programs Concern over the inadequacy of food among the elderly has led to the development of intervention programs to help alleviate problems of inadequate food intake. Among these are meals-on-wheels and congregate meals programs. In the former, a hot meal is delivered to the recipient's home three to seven days per week, depending on the funding and personnel of the program. In some cases, food to be refrigerated for the evening meal and possibly for breakfast is delivered at the same time. The congregate meals program is designed to meet social and nutritional needs of the participants. The elderly
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
are provided with transportation to a centrally located dining area where, in addition to receiving an appetizing and nutritionally adequate meal in the company of others, they are able to participate in a variety of recreational, social, and educational experiences. Both programs are designed to meet the needs of older people regardless of income.2 The overwhelming majority of elderly in our country have at least one chronic illness which usually requires specialized nutritional care for effective management. Too often, the patient with a chronic disease is discharged and quickly forgotten by the medical team. Patients often are readmitted to the hospital because of inadequate discharge planning and follow-up. In an attempt to deal with this situation, many hospitals have developed continuing care services.
Team Approach At Peter Bent Brigham Hospital, a continuing care service was established in 1966. The service was designed to assist patients, especially elderly ones, in following medical therapy after discharge to an environment most conducive to their needs. The team approach to patient care was initiated. Team members included a physician, responsible for primary medical care, a dietitian, responsible for providing the patient with an individualized
diet, staff nurses, social workers, and physical therapists who are involved when appropriate. Weekly patient care rounds are held to discuss the patients' problems. The team approach results in improved patient care. Through sharing and cooperation, team members gain insight into all needs of the patient and are better equipped to formulate an optimum plan of care. These rounds provide a multidisciplinary approach to discharge planning by reviewing each patient's current status and projecting discharge planning needs. This approach sensitizes all disciplines to the problems being faced by the patient and provides an avenue for communication and coordination of care. There are also continuing care nurses, dietitians, and home-care coordinators who are responsible for follow-up of the patient once he returns home.'2 The aged must help to minimize the incidence of disease by following the same rules of hygiene that are recommended for younger people. This includes weight control, adequate sleep, and moderation in exercise and other endeavors. To be well adjusted, the aged person needs some interests and activity, both mental and physical, plus a feeling of usefulness and being wanted."
Conclusions An adequate diet and sound nutritional practices, therefore, remain key
factors, not only in the limitation of the aging process, but also in the maintenance of the quality of life for the aged. In addition, government agencies must provide the elderly either with assistance or finances to lead adequate lives. More intervention programs, such as meals-on-wheels and congregate meal sites, should be established to satisfy the needs of the elderly with adequate food, nutrition services, and readily accessible and safe socialization areas. Literature Cited 1. MayerJ: Aging and nutrition. Geriatrics 29:57-59, 1974 2. Guthrie H: Introductory Nutrition, ed 3. St. Louis, CV Mosby Co, 1975, pp 41, 421-431 3. Christakis G (ed): Nutritional Assessment of the Elderly. Am J Pub Health (suppl) 63:68-73, 1973 4. Mann G: Relationship of age to nutrient requirement. Am J Clin Nutr 26:1096-1097, 1973 5. Jukes B: Nutritional management of the anemic geriatric patient. Geriatrics 29:147-150, 1974 6. Krause M, Hunscher M: Food, Nutrition, and Diet Therapy, ed 5. Philadelphia, WB Saunders, 1972, pp 292-298 7. Krehl W: Influence of nutritional environment on aging. Geriatrics 29:65-76, 1974 8. US Department of Health, Education, and Welfare, Administration On Aging: National Nutrition Program for Older Americans. 1976 HEW Fact Sheet, DHEW Publication No. 76-20230, pp 1-4 9. Balacki J, Dobbins W: Maldigestion and malabsorption: Making up for lost nutrients. Geriatrics 29:157-166, 1974 10. Smith E: Nutritional needs of the elderly. In Nutritional Problems in a Changing World. London, Halsted Press, 1973 p 221 11. Peleovits J: Nutrition for Older Americans. J Am Diet Assoc 58:17-21, 1971 12. Baumgarten S, Collins M, Goodhue P: Continuing nutritional care for the discharged patient. Ross Timesaver 3:1, 1976, pp 1-4
John Maxwell Scholarship Fund of the Medical College of Wisconsin The Medical College of Wisconsin in Milwaukee has announced the establishment of the John Maxwell Scholarship Fund in honor and memory of Dr. John Maxwell, Sr. The fund will be in the amount of $100,000 to be used as loans to be repaid by students over a period of years so that the fund will be continuing. It will be used for economically disadvantaged students with a preference for minority students. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 4, 1978
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