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Clinical Nutrition 29 (2010) 170–174

Contents lists avai

Clinical Nutrition

journal homepage: http: / /www.elsevier .com/locate/c lnu

Review

Restrictive diets in the elderly: Never say never again?

Patrice Darmon a, Matthias J. Kaiser b, Jurgen M. Bauer b, Cornel C. Sieber b, Claude Pichard a,*

a Medecin Responsable, Nutrition Clinique, Hopitaux Universitaires de Geneve, 1211 Geneve 14, Switzerlandb Institute for Biomedicine of Aging, Friedrich-Alexander University Erlangen-Nuremberg, Heimerichstrasse 58, 90419 Nuremberg, Germany

a r t i c l e i n f o

Article history:Received 12 January 2009Accepted 4 November 2009

Keywords:DietDietary restrictionsElderlyFrailtyMalnutritionMorbidity

* Corresponding author. Tel.: þ41 22 372 9349; faxE-mail address: claude.pichard@medecine.unige.c

0261-5614/$ – see front matter � 2009 Elsevier Ltd adoi:10.1016/j.clnu.2009.11.002

s u m m a r y

Restrictive diets have long been an essential part of standard nutritional therapy for a wide range ofdiseases like obesity, diabetes, hyperlipidaemia, arterial hypertension and chronic renal failure. Althougha relevant number of studies have been published in this field, most of these have concentrated on adultsbelow age 65. Data on the effects of restrictive diets in older persons are still scarce. With increasing age,restrictive diets seem to be less effective with regard to relevant study endpoints like morbidity, qualityof life and mortality. This applies in particular to chronic indications which are in most cases associatedwith additional co-morbidities. Here the focus shifts towards providing adequate nutritional intake richin macro- and especially micronutrients and a diet that is also highly palatable as older individuals are atincreased risk of becoming malnourished and sarcopenic. In this context, nutritional prevention andtherapy are of utmost importance for maintaining quality of life. This review summarizes the presentevidence for the application of restrictive diets in older persons and balances it against potential risks.

� 2009 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Background

Life expectancy is increasing worldwide. In the period 2010–2050, the population of subjects aged 65 years or older is expectedto increase from 7.7% to 16.2% of the world’s population, and from15.9% to 26.1% in more developed countries; during the sameperiod, the population of individuals aged 80 years or older willincrease from 1.6% to 4.4% of the world’s population, and from 4.3%to 9.4% in more developed countries.1 Although the elderly pop-ulation is extremely heterogeneous, many of these older adultssuffer from chronic diseases or disabilities that can impact theirnutritional status and/or involve dietary management. Conse-quently, restrictive diets are commonly prescribed in the elderly,especially those with cardiovascular, kidney or metabolic diseases.Furthermore, one should not underestimate the prevalence of self-prescribed dietary restrictions that are not based on scientificevidence but on popular belief (‘‘older persons must eat less’’,‘‘certain foods are bad for health’’.), religious principles, culturaltraditions or self-suspected food intolerances or allergies. Long-term dietary restrictions expose older individuals to inadequateprotein–energy and micronutrient intake that may cause a wors-ening of nutritional status, even more since those people showa higher risk for nutritional deficits comparing to younger peopledue to physiological, psychological and socio-economic reasons.

: þ41 22 37 293 63.h (C. Pichard).

nd European Society for Clinical N

Anorexia is a common phenomenon among older persons which isrelated to multiple factors like age-associated changes of appetite,deterioration of taste and smell, chewing problems, depression orcognitive decline, but dietary restrictions may also contribute to theanorexia of aging,2 thereby increasing the risk of worsening ofnutritional status with its potentially serious complications.Moreover when dependence on external services increases,intentional and unintentional attempts to change life-long dietaryhabits may cause anxiety and mood disturbances which may inturn result in decreased food intake.3,4 In addition, a favourite dishthat has been banned from the menu may hardly be successfullyreplaced by another that brings the same nutrients. Under thesepremises, restrictive diets may contribute to the development ofsarcopenia, frailty and functional impairment which both willcause a deterioration of quality of life resulting in deprivation,frustration and social isolation.5–7 However, subtle adjustments ormodifications of diet may positively influence prognosis and overallquality of life,8 when co-morbidities and individual nutritionalneeds are meticulously taken into account. A thorough evaluationof the benefit/risk ratio of restrictive diets in older persons istherefore indicated. Before starting any dietary restriction in anolder individual, a careful nutritional evaluation is thus indicated,which should be completed by a comprehensive geriatric assess-ment in those showing signs of functional impairment. Whenconsidering a restrictive diet in an older person, the pros and conshave to be weighed against each other. Anticipated benefits withregard to prognosis and quality of life as well as potentialharm have to be taken into account, and a multidimensional

utrition and Metabolism. All rights reserved.

P. Darmon et al. / Clinical Nutrition 29 (2010) 170–174 171

consideration may be necessary. When eventually a restrictive diethas been prescribed, its indication has to be re-evaluated at regularintervals as physical condition may rapidly fluctuate in the elderly(Fig. 1). Nevertheless, scientific papers on this topic are scarce.Moreover, almost every paper has a different range to define the oldage. Existing guidelines are frequently imprecise in this regard andoften based on experts’ opinion alone.

The aim of this review is to specify the clinical situations espe-cially in the field of cardiovascular, kidney and metabolic diseases,in which cautious dietary restrictions for individuals aged 65 andolder are reasonably justified. The review will also consider theproblem in the oldest old (�80 years).

2. Potential indications for restrictive diets in the elderly

2.1. Obesity

The prevalence of obesity (i.e. Body Mass Index� 30 kg/m2) hasbeen rapidly growing over the past decades across all age groupsthroughout the world.9 However, it tends to remain lower beyond65 years than in younger adults certainly due to the prematuremortality related to excessive weight. In the United States, 37% ofthe population between age 40 and 59 and 31% above age 60 havebeen reported to be obese.10 The well-known relationship betweenobesity and risk of mortality weakens with age and the BMI that isassociated with the lowest mortality increases.11,12 After 70 years,a BMI of 29 kg/m2 in men and 32 kg/m2 in women would be themost protective for early mortality.12 Obesity, however, hasa negative impact on functionality in older persons and it is asso-ciated with disability. Obesity may contribute to the developmentof frailty which leads to loss of autonomy and impaired healthstatus.13 Sarcopenic obesity, defined by the coexistence of lowmuscle mass and/or strength and increased fat mass, is common inthe elderly and exposes to functional limitations and poor healthoutcomes.14 Several studies suggest that weight loss is associatedwith increased mortality, although none of these studies wererandomized controlled trials and most used self-reported weightchange and did not distinguish between weight loss in obese andlean subjects.15 Moreover, unintentional weight loss is a commoncomplication of many serious diseases which could confound theinterpretation of weight loss effects on mortality. Nevertheless,substantial weight loss (>5%), whether intended or not, has been

Potential risks Medical benefits

Chronic disease in the elderly

Diet

?

Life expectancy

Co-morbidities

Nutritional evaluation

Geriatric assessment

Associated treatments

Socio-economic context

Patient’s motivations

Conditions

to consider

Fig. 1. When and how to prescribe a restrictive diet in the elderly?

observed to be a negative prognostic factor with regard to mortalityin adults older than 65.16 In addition, weight loss may havepotentially harmful effects by promoting sarcopenia and loss ofbone density. Therefore, prescribing weight loss in the elderly,especially in those aged 75 years or older, remains debated. Alter-natively, a diet which aims at weight stability combined withregular physical activity – helping to stabilize the age-associatedloss of muscle mass – exerts beneficial metabolic effects.17 In thecontext of physical activity, the best results with regard to strengthand muscle mass were obtained when resistance training was partof the training protocol. Regular physical training, supported bya physiotherapist, may significantly decrease central obesity andimprove peripheral insulin sensitivity.18 In some cases, a moderatecaloric reduction (i.e. �500 to 750 kcal per day compared with theusual diet), along with the practice of a regular, adapted and carefulphysical activity which can be secured and supported by a physio-therapist, could be proposed.19 Indeed, some studies have demon-strated beneficial effects on cardiovascular risk factors mediated bymoderate weight loss, especially when accompanied by a reductionof visceral adipose tissue.20–22 However, evidence for a significantdecrease in the incidence of major cardiovascular events ormortality could not be shown in these studies. Additionally, painfulsymptoms related to osteoarthritis may be relieved.23 As a conclu-sion, dietary counselling of obese older persons should be indi-vidualized according to functional status, life expectancy and goalsto be reached (prevention/treatment of metabolic complications,reduction in osteoarthritis-related pains, improvement of func-tional performances and quality of life). Exercise training promo-tion should be preferred over dietary restrictions as preservation oflean body mass seems to be critical to health. In the oldest old (�80years) with absence of validated data, it seems reasonable to refrainfrom the prescription of hypocaloric diets.

2.2. Type 2 diabetes mellitus

The prevalence of type 2 diabetes mellitus in industrializedcountries is rising which is mostly related to the increasing prev-alence of obesity, but also to the trends in life expectancy in thesepopulations. In many countries, type 2 diabetes mellitus is presentin 10–20% of the population above age 65.24 In older patients withdiabetes, the target range for glycaemic control and glycated hae-moglobin (HbA1c) should be individually adapted according to theindividual’s overall health status, duration of diabetes mellitus, pre-existing vascular complications, co-morbidities and life expec-tancy.25 One of the primary goals is to prevent hypoglycaemicevents in patients on insulin, sulfonylureas or glinides, as suchepisodes may cause falls and fractures. Severe hypoglycaemias arealso associated with an increased risk of myocardial infarction orstroke, and probably, in the long run, deterioration of cognitivefunction. Low-carbohydrate diets based on extensive reduction ofsimple carbohydrates and starches have indeed to be regarded as‘‘historical’’ and should be avoided. Such diets were commonlyrecommended two or three decades ago, but are still followed bysome over-conscientious patients. Dietary assessments carried outin older diabetics following these recommendations revealedinsufficient caloric and carbohydrate intake. A study conducted ina long-term care centre found that switching from diabetic tostandard diet did not deteriorate the mean HbA1c-level.26 Sweet-ened products can be consumed at the end of a meal without anyinfluence on HbA1c, if they are part of a reasonable daily carbo-hydrate load.27 Data are still equivocal with regard to the signifi-cance of the ‘‘glycaemic index’’ for older persons.28,29

In summary, a balanced diet of about 30 kcal/kg body weight/d providing 50–55% of the total energy contribution by carbohy-drates, rich in fibres (25–30 g/d) and which favours mono- and

P. Darmon et al. / Clinical Nutrition 29 (2010) 170–174172

polyunsaturated fatty acids should be proposed in elderly diabeticpatients. The intake of such a diet should by spread over three fullmeals per day. In obese patients, a moderate caloric restriction of500–750 kcal/d might be useful if coupled with physical exerciseto minimize loss of muscle mass and if closely monitored.19

Several studies have suggested that nutritional teaching incombination with regular physical training improves glycaemiccontrol.30 Regular physical activity might therefore be a worth-while alternative to food restrictions since it also decreases insulinresistance, favourably impacts cardiovascular risk profile andincreases muscle mass and autonomy as well as quality of life.Physical exercise, though, must be adapted to the patients’ abili-ties (cardiovascular state, etc.) and the risk of hypoglycaemia hasto be considered.31

2.3. Hypertension

Hypertension is a major contributing factor to cardiovascularrisk. Depending on the characteristics of the population studied, itsprevalence in older persons ranges from 50% to 80%.32 Lowering ofblood pressure in hypertensive individuals decreases the incidenceof major cardiovascular events, even beyond the age of 80.33

Excessive sodium consumption may be involved in the pathogen-esis of essential hypertension in a relevant percentage. Severalstudies have revealed that a decrease in daily sodium intakesignificantly reduces blood pressure. This effect was morepronounced in hypertensive than in normotensive subjects.34

Therefore, a daily sodium intake of 100–120 mmol is widely rec-ommended in hypertensive individuals.35 Some studies haveshown that the antihypertensive efficacy of sodium restrictionincreases with age which may be due to two mechanisms. First, asarterial compliance decreases with age, any diminution of intra-vascular volume due to sodium restriction will result in a greaterreduction of blood pressure compared to younger individuals.Second, because of the progressive decline in kidney function, olderadults may retain sodium to a greater extent than youngerpersons.21 Moreover, older patients may ingest more sodium tocompensate their loss of taste. In addition, they may depend tohigher degree on processed, pre-packaged food preparations whichare richer in sodium than fresh foods. The TONE study (Trial of NonPharmacologic Interventions in Elderly) illustrated the impact ofsodium restriction in hypertensive elderly.36 In 681 patients withmoderate hypertension, a reduction of dietary sodium intake of40 mmol per day significantly reduced systolic and diastolic bloodpressure. Additionally, the incidence of major cardiovascular eventsdecreased when compared to controls. However, there was nosignificant risk reduction in the subgroup of study participants aged70 years or older. It has to be mentioned that the reduction of dailysodium intake in the intervention group was accompanied bya significant decrease in energy and in calcium intake, which has tobe regarded as harmful in most older individuals. Due to theabsence of an official recommendation with regard to sodiumintake in hypertensive elderly, the authors propose that a reductionof daily sodium intake to 100 and 120 mmol per day may beconsidered, if there is no indication of impending malnutrition.Nevertheless, it has to be kept in mind that sodium depleted dietslack taste and thereby frequently induce loss of appetite.37 The riskof malnutrition should therefore be re-evaluated several weeksafter a low sodium diet has been started, not the least as thereduced palatability of these diets may also hamper the long-termacceptance of their recommendation. In ‘‘real life’’, it may seemintricate and annoying to register and control the daily sodiumintake which is true for both, the young and the old people. So,sodium restriction should preferably be limited to those whosehypertension is either sensitive to salt, i.e. in particular black

people, older persons with systolic hypertension and those withabdominal obesity,36 or in the rare cases of partial resistance tomulti-pharmacotherapy. As has been pointed out before, in all olderindividuals the impact of sodium restriction on daily calorie andprotein intake has to be regularly evaluated.

2.4. Congestive heart failure

Congestive heart failure (CHF) is highly prevalent in olderpersons38 and may be associated with a number of nutritionalproblems. Cardiac cachexia is an independent marker of poorclinical outcome.39 While advanced cardiac cachexia is in mostcases resistant to traditional nutritional intervention, adequateenergy and protein intake has to be regarded as a basic measurebefore new therapeutic options are considered. In older patientswith chronic heart failure, one should aim at stabilizing ‘‘dry’’weight and not at reducing it. This principle holds true even in theobese.40 A sodium-reduced diet, i.e. <50 mmol per day, is oftenprescribed in CHF to counter fluid retention and to preventepisodes of acute worsening. As pointed out above, dietary sodiumrestriction may promote anorexia.37 Therefore, strict dieteticmeasures should be used cautiously as they may promote thedisadvantageous reduction of oral intake in this population. Amoderate reduction of sodium intake of 100–120 mmol per daymay be considered in individual patients with CHF.41

2.5. Hypercholesterolemia

In a large cross-sectional study, serum total cholesterol levelsgradually increase up to the age of 50, then they plateau beforeslightly decreasing after the age of 70.42 The relationship betweentotal cholesterol and all-cause mortality in older persons is stillunder debate, although the hypothesis of a J or U-curve is widelyreported. High cholesterol levels are still an independent riskfactor for cardiovascular mortality after the age of 65, but thiscorrelation weakens with further advancing age.43 Several studiesdid not find a positive association between total cholesterol andcardiovascular mortality after age 70.44 In addition an increasedrisk of mortality was shown for older persons with explicitly lowcholesterol levels.45 A low serum cholesterol level may beregarded as an indicator of latent disease or deteriorating healthstatus. After the age of 85, normal or slightly elevated levels ofcholesterol are associated with a reduction of mortality risk bycancer and infection.46 In this context, it seems doubtful whetherthe prescription of low-cholesterol diets should be widely rec-ommended in older individuals. In fact, there is at present nosound scientific basis for such a proposition. However, even inthose beyond age 80, a ‘‘phobia’’ of hypercholesterolemia may befound. Older persons should be informed about the actualscientific evidence of potential benefits and potential risks ofa diet low in cholesterol in their age group. Conversely, patientsolder than 65 years on secondary prevention must benefit of theprescription of a statin. Favourable effects of statins on cardio-vascular morbidity and mortality are now well demonstrated inthese patients, whatever the plasma LDL cholesterol level,47,48

especially as the protection brought by statins is significantwithin a very short time (6 months to 2 years). In contrast, inprimary prevention, the debate is still opened: prescription ofa statin will be decided according to the co-morbidities and lifeexpectancy.

2.6. Chronic kidney disease

In animal models of chronic kidney disease (CKD), a low-proteindiet was shown to slow down the development of histological

Table 1Main long-term restrictive diets in the elderly.

Unwarranted and/or ‘‘historical’’ diets without benefit for the patient- Salt-free diet for hypertension or congestive heart failure- Low-carbohydrate diet, without simple carbohydrates, for type

2 diabetes mellitus- Low-fat diet for hypercholesterolemia- Very low-protein diet for chronic kidney disease

Restrictive diets sometimes justified but to be regularly evaluated- Moderate caloric restriction (�500 to 750 kcal/d compared with the

usual diet) coupled with regular physical activity for complicatedobesity (especially with type 2 diabetes)

- Moderate reduction of sodium intake (100–120 mmol/d) for resistanthypertension or congestive heart failure

- Moderate protein restriction (0.8–1.0 g/kg body weight/d) for chronickidney disease (before dialysis)

P. Darmon et al. / Clinical Nutrition 29 (2010) 170–174 173

lesions and the loss of nephrons. This effect was largely attributedto a reduction of intra-glomerular pressure. In humans, the benefitsof protein restriction (0.6–0.8 g/kg body weight/d) remain contro-versial. While earlier meta-analyses pointed towards a minor butsignificant effect of dietary protein restriction on the progressiontowards end-stage renal disease (ESRD),49,50 this was notconfirmed by a recent one focusing on patients with diabeticnephropathy.51 Considering both the absence of studies in olderpersons and the potential risks of such a diet in the long term, itseems reasonable to apply the actual recommendations foryounger subjects also to older individuals. This means recom-mending 0.8–1.0 g/kg body weight/d, favouring proteins of highbiological value and maintaining sufficient caloric intake accom-panied by nutritional monitoring.52,53 Such a diet can also reducethe phosphorus supply, which could contribute to slow down theprogression of the CKD. However, many CKD patients reveal signsof malnutrition which imply an increased risk of morbidity andmortality. Hence, it is crucial to evaluate the risks of a low-proteindiet in the oldest ones. It is excluded to recommend protein intakeslower than 1.0 g/kg/d in malnourished patients and/or in patientsolder than 80 years. In this age group, the risk of developing overtmalnutrition is probably higher than the chance to benefit fromprotein restriction.

In ESRD, anorexia and malnutrition are observed in about 50% ofthe patients older than 65 years54 – and are probably even morefrequent in diabetics.55 The recommendation of a low-protein dietin these patients might constitute an unnecessary additional riskfor becoming malnourished. However, a recent study56 showedthat a diet providing 0.3 g protein/kg body weight/d complementedby essential amino-acids, keto-analogues and vitamins was able todelay of the start of dialysis for nearly one year in ESRD-patientsolder than 75 years without increasing the risk of mortality.Although promising, such results have obviously to be confirmed.After the start of dialysis a protein intake between 1.0 and 1.2 g/kgbody weight/d is needed.57

Like in younger subjects, a reduction of the phosphorus intakes(800–1000 mg/d) can be considered in case of rebellious hyper-phosphoremia. It is proposed to reduce the consumption of dairyproducts and of potassium rich food (e.g. chocolate, dried fruits).57

Finally, as in CHF and hypertension, it might be useful to cut downsodium consumption.

3. And in the oldest old?

There are only few studies evaluating the effects of restrictivediets in subjects older than 80 years. Dietary restriction issometimes essential over a short period during an acute episode(e.g. salt-free diet during decompensated CHF). On the long term,the benefit/risk ratio of the restrictive diets is generally unfav-ourable considering the high risk of malnutrition and the highprevalence of co-morbidities. Some specific situations can makeexception: as an example, a diet bringing 100–120 mmol ofsodium per day may reasonably be proposed in case of severeCHF or of hypertension sensitive to sodium and/or resistant to thetreatments; in ESRD, the consumption of food rich in potassiumor phosphorus should be avoided. Outwards these rare excep-tions, a balanced diet covering the individual needs and inte-grating the concept of pleasure must be favoured. In thesesubjects, the promotion of the physical activity, when it ispossible, seems to better fulfil the goals of prevention that dietarymeasures. In this view, the current recommendations of theAmerican Dietetic Association are in favour of a liberalization ofthe diet in old patients living in institution, assuming the fact thata liberalized diet may enhance the quality of life and the nutri-tional status.58

4. Conclusions

Even in older persons dietary restrictions may be valuable overa limited period of time during an acute disease. In the long run, thebenefit/risk ratio of restrictive diets is usually unfavourable. Effortsto improve health status via dietary restrictions may translate intodeficiencies thus producing a major additional risk for malnutritionand frailty, with a subsequently increased risk of morbidity andmortality. In general, a balanced diet covering an individual’snutritional needs and integrating the concept of pleasure must befavoured. In older persons, the promotion of physical activity tomaintain muscle mass complies more effectively with the goals ofprevention than dietetic restrictions do. However, certain well-defined clinical situations may justify subtle adjustments ormodifications of the diet of an older individual, considering hisspecific needs and co-morbidities (Table 1). In any case, restrictivediets must be always handled with care in the elderly. Suchprescriptions have to be carefully weighed and repeatedly evalu-ated. Long-term randomized controlled clinical trials need to beconducted in older individuals in order to evaluate the benefit/riskratio of restrictive diets and to define on an evidence-basis thespecific circumstances in which cautious dietary restrictions forolder adults are reasonably justified.

Conflict of Interest

The authors confirm that there was no financial conflict of interest.

Acknowledgments

Patrice Darmon was supported by a grant by NovoNordiskFrance and by the public Foundation Nutrition2000Plus.

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