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Adam Drewnowski, William J.


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WE live in an aging society. Not only is 1 in every 8 Americans older than 65 years, but a person aged 65 can expect to live an average of 18 more years 1. Continued good health of the elderly population is a major challenge to public health 3. Increased longevity is associated with an increase in multiple chronic conditions that sometimes translate into functional disability and need for assistance 2. The extra years can be marked by declining health, reduced mobility, depression, isolation, and loneliness 4.

Health and functioning of older adults are influenced by many factors other than biological senescence. Demographic, social, and environmental factors, including physical activity and dietary habits, play a major role. Fortunately, many of these societal factors are amenable to public health interventions and programs 5.

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More than any other age group, older adults are seeking health information and are willing to make behavioral changes to maintain their health and independence into advanced old age 1. Among the most important self-care behaviors are those that involve physical activity and diet. Their contribution to health and quality of life is the principal topic of this review. In many past studies the success of the efforts at health promotion has been measured in terms of lower mortality rates or reduced disease risk.

There is increasing concern that these classic medical endpoints mortality and morbidity may not adequately represent functional impairments and disabilities during the later years of life. Increasingly, health is viewed as not only the absence of infirmity and disease but also as a state of physical, mental, and social well-being 6 7.

Much progress has been made in establishing a broader conceptual framework of health status for older adults 8. Indexes of health-related quality of life HRQL , a relatively new concept, expand the morbidity- and mortality-based definition of health to include a personal sense of physical and mental health, social functioning, and emotional well-being.

Other and more global measures of quality of life are even more inclusive, taking overall life satisfaction and happiness into account 9 Quality-of-life measures permit researchers to compare the status of different groups over time and assess the effectiveness of public health interventions and programs 2 7. However, the effectiveness of diet and exercise programs continues to be measured in terms of biomedical endpoints. Many of the existing quality-of-life indexes do not directly address the contribution of either physical activity or diet. Very few studies have explored the interrelationships among dietary measures, physical activity variables, and quality-of-life indexes in older adults or the nature of the intervening variables.

As documented below, such factors as perceived mastery and control, enjoyment of the diet, or satisfaction with exercise programs may be as important to quality of life as is reduced plasma cholesterol or increased grip strength. This monograph summarizes what we know about age-associated changes in activity levels and eating habits and suggests how these factors may be related to quality of life. Healthy life means a full range of functional capacity at each life stage, from infancy to old age 1.

Some age-related changes involve a gradual decline in function that is due to biological senescence For example, aging is generally associated with more body fat and reduced muscle mass 12 Reduced muscle mass has been directly linked with lowered muscle strength, lowered maximal aerobic capacity, and decreased bone density in elderly adults However, not all age-associated changes are caused by age alone.

Some scientists believe that the age-associated decline in function is caused by cumulative exposure to risk factors rather than only by aging 2 For example, lower insulin sensitivity and increased risk of type 2 diabetes are also influenced by genetics, body composition, and sedentary lifestyles Very little, if any, of the age-associated change in glucose tolerance is caused by age alone Age-associated changes in metabolism or physiological function may be partly responsible for the observed decline in energy intakes as well as for shifts in dietary choices and eating habits Reduced muscle mass results in lower energy requirements.

As noted by Morley 16 , aging has been associated with altered sensations of thirst, hunger, and satiety and with incomplete adjustments for day-to-day variations in food intake. The observed deficits in taste and smell may lead to a reduced sensory enjoyment of foods by elderly adults 4. The lack of sensory-specific satiety a variety-seeking mechanism may explain why some elderly people restrict food choices and adopt a monotonous diet 4.

Some of these phenomena may be mediated by an age-associated increase in the levels of the satiety hormone cholecystokinin. A decline in testosterone levels is reported to lead to increased levels of leptin and therefore reduced food intakes by older men. Studies of aging rodents further point to reduced activity of dynorphin kappa opioid and neuropeptide Y systems, both of which influence food intake. Mild inflammatory disorders that result in the release of cytokines may also lead to age-associated anorexia. Loss of appetite and anorexia are the key predictors of malnutrition in clinical settings Among independently living elderly adults, low nutrient density of the diet and inadequate intakes of protein, vitamins, and minerals are the chief areas of nutritional concern The aging process can also be viewed as the cumulative effect of chronic diseases—namely, hypertension, diabetes, hyperlipidemia, and atherosclerosis—on individual functioning.

Poor health, medications, and medically prescribed diets affect dietary choices, eating habits, and nutrient intakes 4 Impaired mobility, inability to feed oneself, or poor oral health may alter eating habits and further contribute to dietary inadequacies Other studies suggest that the observed drop in energy requirements is only partly due to physiological factors such as reduced muscle mass and lower metabolic rate.


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    4. Recent studies based on the doubly labeled water methodology and reported by Westerterp and Meijer in this volume 13 suggest that the primary reason for reduced energy needs is the sharp drop in physical activity that also occurs with advancing age. Our knowledge of how dietary patterns change with age is limited. Most dietary data are cross-sectional—people in one age group are compared with different people in another age group. Such studies do not permit the effects of age to be distinguished from those of a given cohort.

    Studies of the same cohort followed over time would provide better data on how food preferences and eating habits change with age. Unfortunately, as noted by Wakimoto and Block 19 , few large-scale longitudinal studies collected comprehensive dietary data over several decades and even fewer have been published.


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    Furthermore, the emphasis has generally been on health outcomes rather than on age-associated changes in eating habits. For the most part, data from cohort studies, such as the Baltimore Longitudinal Study of Aging, are consistent with data from cross-sectional studies, such as the National Health and Nutrition Examination Survey NHANES , leaving no doubt that there is a substantial decline in food intake with advancing age 19 Reduced energy intakes can lead to inadequate intakes of protein, vitamins, and minerals. NHANES III data show potentially important decreases with age in median protein and zinc intakes down by about one third in men as well as intakes of calcium, vitamin E, and other nutrients Risk for inadequate nutrient intakes was especially acute for older men.

    In contrast to the general decline in micronutrient intakes, estimated intakes of carotene, vitamin A, and vitamin C tended to increase with age, especially for women. Wakimoto and Block 19 also examined the nutrient density of diet i.

    Questions and Answers

    Although the absolute intake of a nutrient may decrease with age, the absolute intake of energy decreases even more, such that the observed proportion of the nutrient in the diet is higher than that for younger groups. One question was whether dietary guidelines for older adults should be formulated in terms of absolute intake or in terms of nutrient density. There is no consensus at this point as to how dietary requirements change as a function of age.

    However, some evidence suggests that because of declining metabolic efficiency and bioavailability, requirements for some micronutrients might actually be higher for older adults than for younger people. Although clinical studies revealed few overt nutrient deficiencies among elderly adults 17 , subclinical deficiencies can adversely affect health and physical functioning. Diet and exercise modulate the rate of functional decline with age and can be used to delay or postpone the onset of disability or dysfunction.

    For example, the prevalence of osteoporosis goes up with age, roughly doubling with each decade. The risk of osteoporosis—a major cause of fractures in postmenopausal women and elderly adults—is reduced by a combination of diet and exercise. Similarly, optimal diets have been associated with lower risk of chronic diseases, notably coronary heart disease, obesity, diabetes, and some forms of cancer.

    Sedentary lifestyles are becoming increasingly common at any age. Aging leads to lower activity levels and a further narrowing of physical activity options.

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    Recent cross-sectional data from the Aerobics Center Longitudinal Study showed that older adults expended significantly less energy on exercise than did younger adults Walking was the most common physical activity reported by adults Older adults in the United States were more likely to report lower-intensity activities such as walking, gardening, or golf, rather than running, aerobics, or team sports Although the time spent on bicycling and gardening showed a significant drop with age in the Zutphen cohort, the time spent on walking was not affected Significant disparities in activity levels by sex and ethnicity were also noted.

    Reported levels of leisure-time physical activity were lowest for minority respondents and for older women. Data from the Coronary Artery Risk Development in Young Adults study showed that important ethnic differences in physical activity patterns remained even after adjustments were made for important demographic factors such as education or income Significantly, unfavorable perceptions of one's own health were associated with lower participation in a cardiac rehabilitation program In contrast, perceived enjoyment and satisfaction were positive predictors of physical activity in men and women of all ages These data suggest that psychosocial rather than biomedical variables may influence continued participation in exercise programs.

    The recommendation that every American accumulate at least 30 minutes of exercise on most—and preferably all—days 25 26 is based on evidence that even moderate physical activity is associated with a substantial drop in all-cause mortality Although there is evidence that current activity is more protective than past activity, cumulative lifetime activity pattern may be the most influential factor of all The question remains as to whether a sustained active lifestyle can delay the age-associated changes in body composition and decline in lean body mass.

    Studies of physical activity and aging, including some outlined in this volume, suggest that fat-free mass and body composition of active elderly subjects are not very different from those of inactive elderly subjects In contrast to younger subjects, the effect of exercise programs on total activity of elderly subjects was minimal because elderly subjects compensated for exercise training by reducing their spontaneous physical activity.

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    However, exercise training did have a positive effect on muscle function and may have contributed to the activities of daily living. Continuing to function without assistance may be the most salient outcome variable. Some 7 million Americans over age 65 depend on others for help with some basic task of daily living 2. The Activities of Daily Living score includes capacity for daily self-care as well as other functions related to cooking, eating, and access to food.

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    Such activities are essential for ensuring independent living and contribute importantly to overall quality of life. Physical activities that improve muscular strength, endurance, and flexibility also improve ability to perform the tasks of daily living. For example, strength training can result in substantial improvements in muscle size and strength in elderly men and women 28 and can also increase resting metabolic rate, resulting in increased energy requirements In addition, strength training improves balance and gait speed in very old and frail nursing home residents, improves bone health, and decreases many of the risk factors for an osteoporotic fracture Exercise programs for elderly adults can delay the age-induced impairment in personal mobility necessary for the performance of routine activities.

    The definition of health used to be based on life expectancy, mortality, and morbidity statistics. Quality of life provides a validated approach for expanding the definition of health to include other domains of physical, mental, and social well-being HRQL measures reflect a personal sense of physical and mental health and the capacity to react to diverse factors in the environment.

    Among measurement tools are years and days of healthy life and a self-rated index of overall health. HRQL indexes address broad aspects of physical, mental, and social functioning and their determinants at both individual and community levels 9 One important domain of quality of life is physical functioning, as assessed with the Activities of Daily Living score. Some researchers have argued that quality-of-life measures should go beyond biomedical and health outcomes and that global concepts such as life satisfaction and happiness also ought to be included 9.

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    In this view, quality of life is a multidimensional construct that addresses physical state, social functioning, and emotional well-being. Recent studies suggest that the key perceived dimensions of quality of life may be comparable across cultures and can be broadly grouped into health, psychological, social, and environmental domains 9.

    The item quality-of-life instrument developed by the World Health Organization lists physical health, psychological health, social relationships, and environmental issues as its four domains 9. As shown in Table 1 , neither the domains nor facets incorporated within domains directly assess food, eating habits, or physical activity issues. Much current research on quality of life has come from clinical studies. The usual focus has been on quality-of-life indexes after surgery or some major health trauma.

    Studies of quality of life of cancer patients have focused on physical functioning, psychological distress, pain and pain relief, fatigue and malaise, nausea and vomiting, symptoms, and toxic effects. Social support, economic disruption, and global quality of life were also measured.

    A number of disease-specific tools were outlined by Amarantos and colleagues One such instrument assessed HRQL specific to obesity and included general health, distress, depression, and self-esteem among its key domains The benefits of diverse medical treatments and interventions are often measured with regard to quality-of-life outcomes 9.