The first article, in this series, dealt with the physiological changes that occur normally in the aging process. The second article focused on individual dietary components and their effects on the geriatric patient. This article will focus on the increased nutritional requirements during treatment for specific conditions. In the year 1900, Amen- cans expected to live 47 years. Today, we have a life expectancy of 75 years. In 1900, only four percent of the population was 65 years or older. Today, twelve percent of the population is at least 65. By the year 2030, it is expected that twenty-one percent of the population will reach that age. Statistics also indicate that, if you reach the age of 80 without a life-threatening health problem, you will probably make it to 100. Today, there are more than 50,000 Americans over the age of 100, and the number is growing. Much evidence suggests that a varied, well-balanced diet meets the mineral and vitamin needs of the elderly. We need to be aware, however, that megavitamin abuse can occur. Older patients are more vulnerable to vitamin overdose, and should be so advised. However, certain vitamin deficiencies do occur more often in this group. Pernicious anemia (from vitamin Bp mal-absorption) is not common in the elderly; however, deficient intake of both folate and vitamin Br may lead to confusion and psychiatric disorders.1 During periods of stress, wound healing, or serious illness, increased intake of vitamin C is necessary to maintain normal tissue levels. Decline in kidney and liver function can affect the activation of vitamin D, and alcoholism can cause multiple vitamin and mineral deficiencies.1'2 Nutrition is linked to many of the chronic diseases that afflict the elderly, including arteriosclerosis, dental disease, diabetes, cancer, hypertension, and stroke. Diet and specific nutritional interventions are becoming a vital component of the health care delivery system for the elderly. Constipation Problems with bowel movements become prevalent with aging. Chiropractic adjustments have long been recognized by doctors and patients, alike, as a stimulus for improving bowel habits. Inadequate exercise and water intake are common problems for the elderly. Very frequently, the clinician will find a compromised biliary system, and inadequate bile flow is involved. Correction of middle thoracic subluxation patterns should accompany low-fat diet recommendations. Constipation caused by a lack of bulk and fiber in the diet can be offset by increased intake of fiber, especially that from bran, fruit, and vegetables. Bran added to the diet is effective in increasing stool bulk and volume and decreasing transit time.2 Fiber has also been used to treat diverticular disease; but whether it may help to prevent it, if used early enough in life, is unproven.2 The RDA of fiber is 7 gm/day. Increased fluid intake, including the use of prune juice, should also be recommended. Dental disease Dental disease in the elderly almost certainly involves protein assimilation, calcium absorption, and bone mineralization. We have discussed these relationships to hydrochloric acid deficiencies in the elderly, and have written about the ineffectiveness of betaine HC1 supplementation.1 Diabetes Type II diabetes has long been a major concern of the elderly. A family history of the condition concerns many elderly patients. These patients are usually overweight. Dietary prevention of cancer Many vitamins and foods have been related, both directly and indirectly, to the cause or prevention of cancer. Enough evidence has been collected to warrant a discussion of lipids (fats and cholesterol), fiber, cruciferous vegetables (eg., cabbage), and alcohol. Vitamins A, C, and E and selenium were discussed in the Supplements section. (Volume 23, Issue 5). Strong evidence indicates that dietary fat is associated with an increased risk of cancer, especially of the breast, prostate, and large bowel.4-8 The Committee on Diet, Nutrition, and Cancer6 recommend decreasing fat intake to less than 30% of total calories. According to this committee, a cause-and-effect relationship between cholesterol and cancer has not been shown. Dietary fiber has been associated with a decreased risk of colon cancer, but the source of the protective effect is unclear.5-8'' Specific components within fiber may have anticarcinogenic effects, or the effects may be from increased stool bulk and shortened transit time, which lower the concentration of carcinogens that contact the gut wall. Fiber might also decrease bile acid concentration, another proposed promoter of colon cancer.6'7-8 A good recommendation is to increase consumption of foods that are high in fiber, such as fruits, vegetables, and whole cereals. The Committee on Diet, Nutrition, and Cancer6 and other researchers recommend consumption of cruciferous vegetables (i.e., cabbage, broccoli, cauliflower, and Brussels sprouts) to reduce the incidence of cancer. The dietary recommendation seems reasonable, although the actual reduction, if any, in the incidence of cancer seems difficult to predict. The use of alcohol associated with increased risk of cancer of the mouth, esophagus, pharynx, larynx, liver,colon, and rectum.46 Alcohol has also been shown to act synergistically with cigarette smoking to further increase the risk of cancer of the mouth, larynx, and respiratory tract.4-6 Obviously, physicians should encourage their patients to avoid both of these carcinogens. Evaluation for hypercholesterolemia The frequency of testing for hypercholesterolemia in adults should be individualized. Adults who have not been evaluated should be. A good time is in their early 20's, since the individual's norm tends to be established at that time. In cases of average or below average serum cholesterol levels, retesting may not be necessary for five years (perhaps nine or ten years, if the level is < 160 mg/dl), un- less substantial changes in weight or diet occur. If hypercholesterolemia is discovered, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol levels should be checked. The ratio between LDL cholesterol and HDL cholesterol levels may prove to be the best predictor of cardiovascular disease. Certain persons, such as athletes, may have high levels of total serum cholesterol and LDL cholesterol, yet be at reduced risk for cardiovascular disease because of correspondingly high levels of HDL cholesterol. However, persons with a high LDL cholesterol level accompanied by a low HDL cholesterol level need diet therapy. An LDL/HDL cholesterol ratio of 4:1 indicates that the person has a low-to-average risk of cardiovascular disease; whereas, a person with an 8:1 ratio has a threefold risk.10 For every 10 mg/dl that the HDL cholesterol level increases above baseline, the risk of coronary artery disease decreases by 50%.l0 Men with a level of about 30 mg/dl or less, and women with 40 mg/dl or less are below the tenth per-centile for this measure of cardiac risk. If HDL cholesterol deficiency syndromes can be ruled out, the HDL cholesterol level may identify persons at risk for cardiovascular disease.' In cases of abnormally high total cholesterol levels and high LDL/HDL cholesterol ratios, dietary modification (restriction of polysarurated fats, possibly coupled with a change in physical activity) should be the first course of action. Hypercholesterolemia can be described as mild, moderate, or severe.2 These distinctions are made because severe hypercholesterolemia, which occurs in about l-in-500 persons, cannot be treated with diet therapy alone. However, all three forms are associated with a substantial increase in heart disease and myocardial infarction. The term "mild" for a serum cholesterol level that is elevated, but less than 275 mg/dl, is misleading, especially in the patient under age 50. Such a level is not acceptable, and both the physician and patient must respect an elevated cholesterol level, since the top quartile is a conservative assessment of patients at increased risk. Thus, "mild" elevation may imply very significant risk. Moderate hypercholesterolemia (total serum cholesterol, 275-to-350 mg/dl; LDL cholesterol, 200-to-275 mg/dl) may be associated with a genetic defect or a disease continued, in which clearance of LDL cholesterol is reduced. Patients with cholesterol levels in this range are at high risk for coronary artery disease. An LDL cholesterol level above 170 mg/dl is associated with a definite, significant increase in morbidity, and is consistently associated with increased cardiovascular disease. Diet may contribute to the increased levels.2 For this reason, diet therapy should be the first course of action. Cholestyramine resin (guestran) was demonstrated to slow the progression of arteriosclerotic heart disease in a major recent study." However, the drug resins that bind bile acids may cause other nutritional disorders, such as malabsorption of fat-soluble vitamins, so use of a multi- vitamin would seem to be a wise adjunct to cho-lestyramine therapy. Also, some hypolipidemic agents cause gastrointestinal upset and are quite expensive. Severe hypercholesterolemia (>350 mg/dl) is usually familial. It is present at birth, most likely caused by defective genetic coding for LDL cholesterol receptors that results in inadequate clearance of LDL cholesterol and, thus, chroni- cally high levels. These elevated levels lead to childhood atherosclerosis and associated illnesses.2 When severe hyper-cholesterolemia is present, both drug treatment and dietary modification are required, although most of these patients have a very poor prognosis. Advice to patients should focus on control of weight, lipid levels, diabetes, hypertension, cigarette smoking and increase in exercise. Weight reduction not only lowers blood pressure but, also, helps control hyperglycemia and improve the LDL cholesterol/HDL cholesterol ratio. The amount of fat in the diet should not be greater than 20%, with one-third from polyunsaturated, one-third from monounsaturated, and one-third from saturated fats. If more calories are needed, unrefined carbohydrates, such as fruits, vegetables, and whole grains, are excellent sources. Cholesterol consumption can be decreased by exchanging high-fat dairy products and egg yolks for low-fat milk and egg substitutes. Over twenty years' experience treating patients has taught me that great improvement in cholesterol levels can be obtained by: Increasing the patient's awareness of food content; Improving dietary choices to reduce di etary fat intake; and Improving protein digestion. In 1984, the National Institutes of Health convened a consensus conference to assist physicians in using the recent plethora of recommendations about cholesterol. The conference recommendations included: (1) dietary treatment of hypercholesterolemia; (2) the later addition of drug therapy, if the level remains high; (3) dietary changes for all Americans, to reduce dietary fat intake; and (4) increased public awareness of food content and the importance of serum cholesterol. Specific food suggestions may be useful for individual patients. A local dietary association and the US Department of Agriculture are excellent sources of patient education literature. The following clinical considerations are useful to keep in mind: (1) cholesterol comes only from foods of animal origin; (2) animal fats tend to be polysaturated and vegetable fats tend to be polyunsaturated, with some overlap; (3) increasing the ratio of polyunsaturated fats to the polysaturated fats may be beneficial; and (4) saltwater fish, trout, and salmon have predominantly polyunsaturated fats. A good textbook on nutrition that can be used in advising your patients on specific issues should be available in your office library. Summary While hardly exhausting the subject, I hope this series of three articles has helped focus more attention on the spe- cific needs of older adults and will be useful to the reader in increasing the quality of care to these patients. Howard F. Loomis.Jr, DC, president of Enzyme Formulations, Inc., has an extensive background in enzymes and enzyme formulations. As president of 21" Cen-tury Nutrition, Inc., for fifteen years, he has forged a remarkable career as an educator, having conducted over 400 seminars to date, in the United States, Canada, Germany, and Australia, on the diagnosis and treatment of enzyme deficiency syndromes. Call 21" Century Nutrition at 1-800-662-2630 for more information. References I. Rifkind and Segal. "Lipid Research Clinics Program reference values for hyperlipidemia and hypolipidemia." Journal of the American Medical Association, 1983; Vol. 250, No. 14, pp. 1869-72. 2.Schneider, Anderson, and Coursin. Nutritional Support of Medical Practice, 2nd cd.. Harper & Row, New York, 1983. 3.Loomis. "Betaine HC1," Journal of the World Chiropractic Alliance, August 1996. 4.Ames. "Dietary carcinogens and anticarcinogens: Oxygen radicals and degenerative diseases," Science, 1983; Vol. 221, No. 4617, pp. 1256-64. 5.Willett and MacMahon. "Diet and cancer An overview," New England Journal of Medicine, 1984; Vol. 310, No. 10, pp. 633-8; Vol. 310. No. 11. pp. 697-703. Committee on Diet, Nutrition and Cancer, National Research Council. "Diet, nutrition and cancer: Directions for research," National Academy Press, Washington, DC, 1962. "Toxic effects of vitamin overdosage," Med Lett Drugs Tlter, 1984; Vol. 26, pp. 73-4. Wynder and Reddy. "Dietary fat and fiber and colon cancer," Seniin Oncol, 1983; Vol. 10, No. 3, pp. 264-72. Kay. "Dietary fiber." Journal of'Lipid Re search. 1982: Vol. 23, No. 2. pp. 221-42. Kennel, Doyle, Oatfield et al. "Optimal resources for primary prevention of athero sclerotic diseases, atherosclerosis study group," Circulation, 1984; Vol. 70, No. 1, pp. 155-205. Lipid Research Clinics Program. "The Lipid Research Clinics Coronary Primary Preven tion Trial Results: Reduction in incidence of coronary heart disease," JAMA, 1984; Vol. 251, No. 3, pp. 351-64.
