Lesley Carter: nutrition over the life course

Our nutrition is our fuel for our body – we need vitamins and minerals to support every cell that makes us up from our bones to our teeth and everything between. Having nutritious and varied food is important for good health and well-being throughout life. As we age, ensuring our body gets the fuel and nutrition it needs can be even more important – it is thought that at least 1 in every 10 older adults is malnourished or at risk of malnutrition. Here we talk to Lesley Carter, Head of Health Influencing at Age UK and Clinical Lead. Project Lead of the Malnutrition Taskforce.

Firstly, could you tell us a bit about nutrition over the life course, particularly as we age and how that might differ from our younger years?

I think none of us really understand nutrition even though it's something that we do every day. It’s important as we age, to have eaten sensibly in our younger years so that we have a healthy body. Then when we start to move through the decades, from 50 onwards, we need to be thinking about what it is that our individual body needs. For many in their 50s and 60s that’s lots of exercise, lots of good food. But from 65 and older, we need to be thinking about how we can ensure we are getting enough nutritious food in the right way. This is because we can be at greater risk of malnutrition: when we’re not feeling well, low in mood, grieving or bereaved - we may lose our appetite completely. We may be tempted to think we can survive just fine on cheese and crackers or toast every day for every meal. But of course, we can’t. If we don't eat enough, our body will start to close down. We may feel dizzy making us at a risk of falls, we may not be getting enough fluids through food or drink making our kidneys not work properly, our skin will get dry and put us at risk of skin tears, our hair may fall out - and there may be other effects on the body that will contribute to illness. Our approach to food and drink, and how it impacts our body, should change as we get older.

So, broadly, the message is that when we're younger, it's about moderation and balanced diets, the rhetoric that we're very used to hearing of not too much sugar, salt, fat and keeping physically active. But as we get older, we need to ensure that we are getting enough food as a number one priority rather than focussing too much on the type of food.

To some extent, as we age, we will experience a series of losses, and losses are really important to recognise. This may be the loss of a pet, a friend, a walking partner, or perhaps even loss through an argument with your daughter that you can't fix. We may feel loss through being diagnosed with a long-term condition, finding it more difficult to walk and move about, or being in chronic pain.

But through all of these losses, we also need to pay attention to how they can contribute to another loss – that of our appetite or ability to eat a meal. So many life events may contribute to us feeling like we can't be bothered to shop and cook and maybe we don't really want to eat because we just haven't got the energy. But it’s really important that we find a way to prioritise food. It doesn't have to be 5 a day. It doesn't have to be plates of salad, but it does need to be something that is nutritious, and you actually enjoy. 

We really need to shift the messaging away from feeling guilty about sweet treats in moderation, or sacrificing food that we enjoy. There’s nothing wrong with having an occasional doughnut and a nice milky cup of coffee or hot chocolate. In fact, those things are really important for both our physical and mental health as we get older. Particularly if we are going through a hard time, having a little bit of what we fancy can really help us build up an appetite because otherwise, the less we eat, the less we want.

And so how common is it that we struggle to eat regularly?

Well we know that 1 in 10 older adults are either suffering from, or are at risk of, malnourishment and 45% of older people who are admitted into hospital are malnourished or at risk of it. So, malnourishment is really common as we get older, and once we start eating less it can easily become a bit of a habit. Many people may not notice it and it can be easy to normalise. It’s easy to get into a bit of a slippery slope and then our stomach shrinks, preventing us from being able to eat as much. What may start of as a small issue in response to a recent life change such as a bereavement or illness, can quickly become a bigger issue because we lose the energy to resume our previous eating habits, or it becomes more difficult.

Not wanting to eat is also very clearly linked to feeling depressed and many older people will be reluctant to go to the doctor because of how down they are feeling. They often think “oh, I need to pull myself together” and try to ignore the issue, which is why it can often escalate and become their new normal. This is why it’s so important to know that there are some really effective medications and treatments which can help alleviate depression in older people, which in turn will help them start to eat more normally and start to feel better again – allowing them to have the energy to do the things they used to do and enjoy life a bit more again.

How do we define regular eating?

Regular eating may not look the same for everyone. Some of us may feel that a big meal served up on a big dinner plate is just too overwhelming and put us off. Instead, it can be a really good idea to just have 6 smaller meals or snacks, or 3 smaller meals and 3 snacks. We might wake up and have a smaller breakfast, have a snack, have some lunch, have a snack, have an evening meal, and then a final snack before bed. This would be perfectly fine – even if the snack is something really quite small but just what we fancy. The important thing is making sure we prioritise food and hydration, whilst also enjoying it and looking forward to it. Changing the size of the portion or how it is presented can really help.

I found that link to depression very interesting because I associate food with pleasure, enjoyment and actually socialising. Could you talk a bit about the strategies to make meals more positive for older people, particularly if they're not fancying it?

First of all, you've got to eat what you fancy. Don't try to make yourself eat something that you really don't want or like. It is far better to have an ‘unhealthy’ meal that you really enjoy and eat all of it, than to make a stereotypically nutritious meal that you end up throwing in the bin. Secondly, you need to eat in a way that helps you to eat. The environment that we have our meals in can be very important. So for example, if you feel lonely because perhaps you've lost a partner or you live on your own, maybe have your meal watching your favourite television program. Because then it feels like you're eating in a comfortable place and the meal will be more appealing. And chose foods that are comfortable to eat; there is no point in trying to chew a piece of steak if your teeth are not working well or sore. If you're in that position, then you need to eat softer food until you can sort out your dentition, because otherwise it's so painful and then you don't want the next meal because your mouth is still sore.

And so thinking about younger people that might be interested in taking part in take five, is there different advice to younger people who may be in their 50s or early 60s and for instance are wanting to avoid diabetes or any of the other things that we keep hearing about that are linked to diet?

I think it's important in those younger years, 50s and 60s, to set the tone for how it's going to be as you start to age and to build up some positive routines that may be easier to follow as we get older. But we need to recognise that everyone is different; some people at 50 are really fit and healthy and feel very comfortable with their nutrition and hydration. But there are other people, perhaps who have been poorly or have one or more long term conditions, and actually they feel quite unable to match up to other 50 year olds in terms of energy or the types of meals they are able to prepare or have. I think that you should eat for now, so you should eat well for how you feel now. So if you're very fit and able at 50, then you need to go and do all the things that we stereotypically hear about for good nutrition. But if you're not so well at the moment, I think that you need to be kind to yourself: try to eat regularly, little and often, and don't beat yourself up thinking, “oh, I should do better because I'm only 55”. There is not a one-size-fits-all when it comes to eating and drinking, and we shouldn’t put pressure on ourselves otherwise this can lead to some really unhealthy eating habits and relationships with food.

It sounds like really there's no one-size-fits-all with this; everyone is utterly different, things can happen over the life course where we may have changes in our appetite and changes in our ability to eat, but also on an individual level, you may have been told you're pre diabetic and therefore you've got a particular diet that you need to follow.

Yes, all of that. Obviously, you should always take into consideration any health and medical advice relating to diet and any diagnosed conditions.

So for people taking part in Take Five, what would be your advice for them on eat?

I think that you need to know you. You need to take stock. You need to think about what you are doing; “How healthy am I? What are my difficulties? What do I want to do?” And take it from there. If the action you try doesn’t work for you, try and read something to help you do it or seek advice. There are many voluntary sector organisations offering help so don’t be afraid to seek support.

Do you have any tips for people struggling with eating?

In can be helpful to fortify foods to improve nutritional content – for instance you can fortify milk by whisking in skim milk powder and you can't really taste the difference. You can also add egg to mashed potato; put 1/2 an egg in and whip it up and it just makes it creamy. You could also try adding a little bit of protein to meals; so if you're having beans on toast, have some grated cheese on the top.

And what about for people that are not necessarily identified as being malnourished – people that might be overweight or obese?

That’s a very interesting point, because most people do not realise that you can actually be overweight and still malnourished. People may even make some really unhealthy assumptions that if somebody is overweight, they shouldn’t eat so they can lose weight. This is really poor advice, and you should never lose weight by stopping eating. It is not often spoken about enough, but it is very important that even people who appear overweight should still eat well. Food is important for everybody and it should never be discouraged, particularly with older adults. Sadly, I have seen many instances where older ladies, for example, have been so used to dieting and cutting back for most of their life that when they need to have something like full fat milk – this is met with resistance.

As you get older, having a bit of extra padding around areas such as your hips and bum is actually really important in protecting you in case you fall over, making it less likely that you will get a hip fracture and need to go to hospital. I’m not a dietician so I can’t overtly say that all older people would benefit from having a little bit extra weight – but what I can say, from my experience, is that those with a little bit extra weight that they can afford to lose are in a much better position when it comes to falls or dealing with an illness. Of course, there is a limit to what is a healthy amount of extra weight – but the point is that our priorities really shift as we get older, and we need to protect our bones and body in a different way. This is why the traditional way of thinking about healthy diets and losing weight, really shifts and is no longer the best advice for when we get older.

Finally, why are you supporting Take Five, why is it a good idea?

I think that we need to raise awareness of how important it is to eat and drink well in later life.

THANK YOU FOR READING

Thanks to The Centre for Ageing Better for the images in this article.