The editor of Biblical Archaeology Review, Hershel Shanks, 84, told it straight while dining at the Cosmos Club in Washington, D.C. "There's not much written on diets for octogenarians," he commented casually as the waiter brought him a fruit bowl sans dessert. "I hope I'm doing the right thing." He was. But why can't someone as erudite and research-facile as Shanks find answers to his nutrition questions?
Shanks is unlikely to glean helpful advice from diet books. An analysis of 12 robust clinical studies across four popular diets (Atkins, Weight Watchers, South Beach, and Zone) didn't focus on dietary outcomes of particular relevance to elders, nor were the elderly represented in these studies.
Some people reason that it's unproductive for the elderly to diet. The rationale I've heard sounds like this, "Reaching one's 80s and living a vibrant life, that's success. You can't improve on that. Besides, who is going to change what they eat in their 80s?" Dr. Zeke Emanuel took this argument disturbingly further. His essay entitled "Why I Hope to Die at 75," published in The Atlantic last fall, implies that elder nutrition should not be supported by healthcare dollars. For Emanuel this was more than personal opinion because he helmed the nation's healthcare reform. Following the controversial essay, the American Medical Association Foundation reconsidered, but ultimately upheld, Emanuel as the 2013 recipient of the organization's prestigious Award for Leadership in Medical Ethics and Professionalism, leaving our nation with lingering questions.
But in practice, doctors are having success extending vibrant lives and changing the refueling habits of their elderly patients. "There's no upper age limit for obesity medicine," maintains Lawrence Cheskin, MD a gastroenterologist and Founding Director of the Johns Hopkins Weight Management Center for the past 24 years. He has treated several nonagenarians.
Doctors in various medical specialties are taking a renewed interest in the gastrointestinal tract of their elderly patients. Five interventions which are backed by strong evidence and clinical experience are presented here in order of their geographic appearance along the alimentary tract (gut). I call it the "nutrition takes guts" check-up:
- Screen for loss of taste and smell. Sense of smell and taste diminish at variable rates with advanced age, and their loss has recently been identified as a predictor of life expectancy. Loss of smell can be easily assessed with a physical exam, while patients may be more likely to notice and tell their doctor about a diminished sense of taste. Both are important for diet and recognizing thirst. While only some underlying causes such as sinusitis, colds and zinc deficiency can be treated, diagnosing loss of smell and taste are clinically useful even in the absence of treatment. Awareness can be life-saving when accompanied by practical precautions such as upgrading the kitchen smoke detector, looking at expiration dates of refrigerated foods rather than relying on the whiff test, drinking water on a schedule, and flavoring with spices instead of sweeteners. Spices are especially important because they aid digestion, are nutritious (in contrast to artificial sweeteners) and add flavor with fewer calories. Therefore, I recommend those who can't smell chipotle use it to season their food.
- Examine for dental issues. Imagine a meal prepared from a 3-D printer. Such food is quickly becoming available for several applications, including elderly people suffering from dysphagia (difficulty swallowing). 3-D foods look appetizingly like the real thing, but dissolve in the mouth as if they are puree. While most elderly patients with dental and swallowing issues don't need 3-D printed steak, they do need their doctor to examine them for dental problems, which impact overall health. Dental pain makes it harder for the elderly to meet protein requirements. Gum disease predicts vascular disease and heart attacks, although the association is not fully understood. And a red, swollen tongue is an often overlooked sign of vitamin B12 deficiency.
- Apply the stomach acid test. During a meal, the stomach's pH drops to 1, nearly the pH range of battery acid, in order to increase nutrient absorption and foodborne pathogen resistance. Physiologically expensive, stomach acid production wanes during aging and is thought to be why protein requirements increase for the elderly despite a slowing metabolism. Low vitamin B12, anemia, and characteristic nail bed changes point to a decline in stomach acid. Physicians can help patients evaluate the merits of antacids; learn to eat low-sodium fermented vegetables such as sauerkraut, kimchee, and pickled garlic; include vinegar, coffee, and bitters as digestive aids in their diet; and skip the raw bar.
- Alkalinize the small intestine through diet. Blood has a pH range of 7.34 to 7.45, which is precisely maintained by the kidneys and lungs. A diet high in refined carbohydrates, meat, and salt generates biologic acids that must be quickly neutralized by the body's metabolism so as to protect the pH of blood. As kidney and lung function decline with age, an acid-producing diet metabolism doesn't get balanced as well. The body taps bone calcium reserves and refrains from repairing proteins such as muscle to keep blood at the necessary pH. The loss of bone and muscle tends to be insidious until compounded by minor illness and bed rest because exercise is needed for strong bones. Boosting fruit and vegetable intake and a daily supplement of lime juice, which is biochemically alkalinizing even though it is acidic by pH, or citrate have been shown to protect muscle and bone.
- Restore the large intestine's microbiome through diet. The gut's microbial workforce, colonic bacteria, diminishes with age, with the elderly having fewer than half the microbes than people half their age. Ongoing research suggests that bulking up stool can help bulk up muscle. Clinical recommendations include hydration, prebiotics (dietary fiber), and probiotics from dietary sources such as cultured dairy. A diet rich in vitamin C and magnesium and magnesium sulfate baths (Epsom salts) may help regularity, especially for symptoms following antibiotic use.
In my experience patient interest is seldom a barrier to accessing nutritional medicine services. A more formidable challenge is reimbursement for both physician visits and the diagnostic tests they order. Dr. Cheskin says reimbursement hasn't gotten any easier; there is no single checkbox on billing forms. Instead a nutritional assessment requires many screening diagnostic billing codes.
At the D.C. luncheon lecture on health insurance and medical research where I met Mr. Shanks, he stopped me, punctuating the air with his dessert fork. "It's not about doctors, researchers and the government [health insurance]. Try writing for people. People need to know about this." And, ultimately, it is the people's choice.