The University of North Carolina at Chapel Hill: SOCI 431

More than Frail Bones:

A deeper understanding of the increasing problem of malnutrition in the aging population

Caroline Bowden 11/16/2010

Introduction Nutrition, along with physical activity, is a critical component for a healthy lifestyle and active aging. Malnutrition in the elderly has been an ongoing matter that seriously affects quality of life. Under-nutrition can result from earlier social determinants of the life course or diet in current living arrangements and can consequently produce increasing diseases, disabilities, and earlier death (or further economic or physical burdens to their caregivers or health services). New measures to assess and eliminate inadequate nutritional care are being stressed in order to battle potential risks of hunger and decrease mortality. This paper will start from the beginning of the life course and work its way up to elderly age, showing what pertinent factors accumulate into a massive ball of nutritional shortcomings by which the elderly suffer. By drawing on scholarly research articles, journals, and experiential evidence for current nutritional habits, I will discuss factors for malnutrition. The paper will identify social differences throughout the life course and how they determine health status later in life due to dietary causes and deficits. Risks for inadequate food intake because of lack of attention, care, or improper functioning of the aged will support how current living conditions contribute to negative health. Finally, methods to improve dietary intake will be described, showing how malnutrition is presently trying to be inverted for the elderly to withstand additional disabilities or sicknesses. I will begin with an evaluation of trends in elderly nutrition and then argue how important good nutritional habits are throughout the life course, using past and current issues in the life course that contribute to poor nutrition. Because of poor dietary habits, the prevalence of malnutrition in elderly populations is increasing. In 2005, fifteen percent of those living in communities or homes, 62 percent of the hospitalized elderly, and up to 85 percent of those residing in nursing homes endured protein-

energy malnutrition in the United States according to The American Journal of Clinical Nutrition (Kagansky et al., 2005). In a study of geriatric hospitalized patients aged 75 or older in 2005, less than twenty percent were well-nourished. Only 73 of the 414 elderly patients studied were well-nourished, and those that were malnourished had longer hospital stays and higher long-term mortality. During acute hospitalizations patients need high energy, yet this deficit becomes more apparent during these times because of prior reduced food intake of the elderly patients (Kagansky et al., 2005). Unintentional weight loss is encountered in about twenty-seven percent of frail people over the age of 65 in clinical practice, which is associated with a poorer quality of life and a decline in physical function. Increased mortality can even range from nine percent to thirty-eight percent within one to two and a half years after weight loss has taken place (Alibhai, Greenwood, & Payette, 2005). These frightful statistics are good indicators that change in nutritional assessment, feeding, and health care must be made in an attempt to overcome poor diets in older adults. And elderly with malnutrition do not only have problems of underweight and lower skin fold thickness, as there is a growing problem with obesity as well. Some of the elderly populations with food insecurity have lower body weight while some have obesity problems, depending on what the daily consumed diet entails. Food insecurity, or when nutritionally adequate or safe foods are not available or acceptable, can be one reason for malnourishment in the elderly. Older people, despite food insecurity status, consume less than the recommended dietary allowance in many nutrients; and then the food-insufficient elderly consume only about two-thirds of the recommended dietary allowance for energy and calcium (Lee & Frongillo, Jr., 2001). Calcium, vitamin D, iron, zinc, protein, carbohydrates, energy, and B12 are all important nutrients that are especially low in the aged population. Calcium and vitamin D supplementations are needed to help deter weak bones,

frailty, and possible falls in the elderly. Iron is quintessential for production of blood and healthy blood flow, and zinc contributes to immune function and wound healing. Deficiencies of vitamins B1, B2 and C are correlated with cognitive dysfunction, and B12 deficiency can lead to abnormal sensory and motor functioning, such as tongue tingling, memory impairment, or numbness (Morley & Silver, 1995). One can understand why not having these vitamins and nutrients is detrimental to health and well-being, especially if the deficiency has been long-term. For example, a study by Lee and Grangillo proves: significantly lower skin fold thickness measures and inadequate eating habits suggests that they had lower and poorer nutrient intake for an extended time than did those who were food secure, which led to the existence of cumulative effects on their energy stores and nutritional risk status. In other words, persistent (or intermittent) food insecurity that existed in the past among elderly persons may have led them to consume lower nutrient intakes, and even change their body composition and eating habits. (2001). This leads me to further explanations of how past actions and habits contribute to ones overall health in increasing age. Social Determinants of Malnutrition While food insecurity is not dependent on physical or socioeconomic conditions, social determinants in the life course can all indirectly be risks for insufficient food intake. Race, class, gender, heredity, stress, education, marital status and other social conditions all factor into the health status of the aging and their dietary habits. Poor nutrition can be, but does not have to be, caused by prior eating tendencies due to state of poverty, living in rural or urban communities, access to proper education, or being male or female. Link and Phelan developed a model suggesting that social conditions are the fundamental causes of disease. It examines what in society places individuals (or groups) at risk. Social conditions cause lifestyle behaviors (such as diet, exercise, smoking, and alcohol use) and also determine health care utilization, depending on

the access one has. These health behaviors influence health outcomes such as morbidity, mental illness, or mortality (Link & Phelan, 1995). For example, growing up in a rural area with an insufficient education system and uneducated parents may limit health and nutritional education, leading to bad eating habits and lack of attention to proper nutrients and calories. Rural areas also have limited shopping for cheap food since supermarkets are mainly in suburban areas. These behaviors could lead to obesity or malnutrition and encourage disease or a malfunctioning immune system in later life. Marital status can also be a forgotten factor in nutrition because both unmarried men and women are at higher risk for food insecurity. Yet unmarried men have an even higher risk for food insecurity, possibly because men do not cook and purchase healthier foods as readily (Quadagno, 2010). Poverty may be the biggest factor of unhealthy eating behaviors simply because fresh produce is expensive. Many people have to choose between quality foods or other necessities in life and proceed to put nutritious foods on the back burner. People in poor towns without education or access to healthcare do not realize the impact that foods have on the physical body, immune system, brain, and overall functioning to name a few. Physical activity must be paired with an appropriate diet for stable health and good quality of life, and many underprivileged in society are not aware of the consequences of bad health earlier in life. Stress from financial problems can also contribute to over-eating or smoking, which decreases appetite, both being common methods of relaxation. One example of this theory in action concerns weight loss in the aged. Even pressure throughout childhood of trying to be skinny or continually being on a diet can transfer into older years, creating the anorexia of aging. Weight loss may be more likely to occur in those who have practiced dietary restraint lifelong in order to prevent weight gain. For some this may mean a recurrence of anorexia nervosa in later life, or a restriction of caloric intake in hopes of living

longer. Others may obsessively attempt to lower their cholesterol to prevent heart disease and therefore decrease food intake. This condition of cholesterol phobia also increases risk of malnutrition (Morley, 2003). To summarize, Link and Phelans model is one perspective on how societal states in ones life can contribute to lifestyle behaviors and therefore be causes of health in later life. Another theory for social determinants of health in the aging is that of cumulative inequality. Ones earlier life experiences greatly impact the quality of life later on, and social systems generate inequality, according to Ferraro and Shippee. Those who begin with greater resources continue having opportunities (such as good education, good jobs, high salary, and early retirement) to gather even more resources and advantages. Health lifestyles are affected by patterns of behavior based on available options that different life situations and socioeconomic statuses offer; this leads to increased inequality with age. Different individuals and social groups are exposed to various risk factors early in the life course that compromise health. Even though health inevitably declines with age among everyone, those with higher levels of education are usually later to decline in health and develop diseases or disabilities from malnutrition. This creates an increasing gap in health status as people get older, so the theory of cumulative inequality shows how childhood conditions can explain adulthood functioning and overall health (Ferraro & Shippee, 2009). One can see that diverse backgrounds of the elderly can have significant effects on the knowledge about nutrition and practices of dietary intake. Social conditions can function as fundamental causes of malnutrition in the aging population, but current conditions may also pose huge risks for lack of a satisfactory diet.

Current Factors of Malnutrition Current internal factors like functional, cognitive, and sensory impairment, wealth, and emotional state can greatly affect amount of nutrients consumed. Current external factors such as living arrangements and outside services also play a vast role in how the elderly are nourished. Here I will first explain how individuals internal factors contribute to eating habits, and then an explanation of external environmental factors will follow. Current Internal Factors Reduced functional capacity may be one determinant of food choices and meals in the elderly, causing inadequate food intake. Older people tend to consume a monotonous diet, excluding bulks of fruit and vegetables from their diet, because of functional difficulties preparing complicated meals (Bartali et al., 2003). This in turn limits the amount of vitamins and minerals consumed and puts the elderly at risk for infection, weaker bones, disabilities, vision problems, etc. Mobility impairment is also a crucial drawback to commuting to grocery stores for food shopping whenever necessary or carrying groceries home without help. Just as functional impairment is one current limiting factor for individuals, cognitive impairment also creates troubles for the elderly. A large number of elderly are institutionalized in nursing homes and hospitals because of cognitive impairment. This impairment causes an inadequate supply of protein and energy in diet because most patients cannot properly feed themselves. Dementia can bring about swallowing difficulties, and people with stroke disabilities may not be able cut meat, thus not being able to eat meat for protein. Others may have the tremors and spill much of their food transporting it from the plate into their mouths or are too weak to feed themselves in general

(Morley & Silver, 1995). Many times elders will not eat due to these difficulties, or eating takes so much effort that they may only eat one or two meals a day, a dangerous risk of malnourishment. Sensory impairment is yet another factor of minimal eating in the elderly. Being unable to enjoy the aroma and flavor of food is detrimental to having a desire to eat. As people grow older, the degeneration of taste buds results in loss of taste. Similarly, there is a loss in ability to detect odors and smell foods, so people may lose their appetite and risk malnourishment. To compensate for this loss of taste many older people add salt and seasoning to the majority of their foods, which can lead to higher blood pressure (Quadagno, 2010). Since most elderly have little or no exercise, metabolism is very low and appetite is decreased in that way too. More encouragement for physical activity could be emphasized, stimulating appetite and increasing food intake and muscle mass. Another less common internal reason for malnutrition can be the emotional state of the elderly. Even though depression is actually less common in the elderly than in middle aged adults and younger adults, problems dealing with depression from loss of a loved one or having to be institutionalized can hurt diet. The realization of not being able to clean, cook, dress, pay bills, and other activities of daily living or instrumental activities of daily living can be depressing for the aged. Clinical depression decreases appetite, food intake, and can cause weight loss. But food intake could have adverse affects with subclinical depressed feelings, since they would parallel with sadness. Having milder depressive symptoms create tendencies to invoke reward upon oneself, especially food. This is further supported by a positive correlation between feelings of dysphoria and carbohydrate consumption (Paquet et al., 2003). In brief,

general emotions can contribute to maladaptive eating behaviors, but individual experiences while eating can also play a role. Studies have found that everyday emotions, those experienced at nonclinical levels from events having personal significance, can likely affect food intake. This is because everyday emotions guide decisions and actions; and for elderly people in health care facilities or nursing homes, inherent emotions are created from their experiences living in institutionalized settings. Emotions can have direct behavioral impact and indirect impact on quality perceptions. Positive emotions from perceived quality of service and food had a favorable effect on intake of protein and energy, and anxiety or anger encouraged negative emotions, increasing pessimism about quality and service and decreasing nutritious food intake. But some foods can be difficult to cut or eat or requires more time to ingest, which generates frustration and an unwillingness to keep eating. The sensory quality of a meal and interpersonal relationships and encouragement by staff are important for patients of nursing homes to continue eating enough (Keller, Ostbye, & Goy, 2004). Both positive and negative emotions respond to physical environment cues such as odor, temperature, light, and music, while eating meals. Exposing the elderly to dinner music has been found to reinforce positive emotions, leading them to eat more and lessen their anxiousness or depressive symptoms (Paquet et al., 2003). Emotional experiences surrounding meals, especially in nursing homes, can truly affect health status and body weight in the elderly. Now that I have discussed several internal contributing factors to negative eating, I will move onto external situational factors that also may determine the nutritional intakes of the elderly. Current External Factors On top of internal risks like senses, disabilities, and emotions that affect dietary intake, there are quite a few external risks that contribute to eating habits of the aging. Financial status,

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living arrangements and conditions, and social support can all factor into poor nutrition as well. Just as poverty greatly affects health status throughout the life course leading to old age, it also is a critical factor for nutritional wellbeing after retirement. Because of expensive healthcare or prescription medications, poor health contributes to financial difficulties. The elderly have a lot of expenses with no current income, so many times they will first pay their bills and buy medicines and then use whatever money is left over for food. Those who cannot afford nursing homes but have no transportation to and from grocery stores or restaurants are trapped in food insecurity. Elders may have enough money to buy food at the beginning of the month, but can quickly run out of funds towards the end of the month, creating a monthly cycle of food insecurity (Frongillo & Horan, 2004). Living arrangements are one of the biggest issues in varying nutritional intakes of the elderly. Whether the elderly are living at home in rural or urban communities, in a nursing home, in a hospital, alone or with a spouse, diets should be consistent. But many studies have proven many elderly living in these environments are underfed or have food insecurity in some way. Different places of living have distinct effects on eating habits. One study found that elders living in inner-city areas were twice as likely to have food insecurity than elders living in other urban areas, and elders living in the South were more likely to be food-insecure than other parts of the United States. Rural areas have limited formal assistance programs for the elderly (due to long distances and lack of public transportation) and have a limited shopping selection with high prices. On the contrary, urban areas have more available supermarkets and transportation for the elderly, but family is not as closely-knit and may live farther away from their elderly counterparts than in rural communities (Frongillo & Horan, 2004). Elderly people

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living in urban areas also are less likely to be married than in rural areas, which poses risk for malnourishment. Married couples are the most secure group for proper food intake. On a nutritional risk assessment for rural older adults older women were more likely to live alone, possibly due to women have longer life expectancies than men. Women living alone also were associated with higher BMI values, or body mass index. They also reported having lower nutrient intakes and lower energy intakes than males living alone or women living with other people (Ledikwe et al. 2003). Living with a spouse may help dietary intake by having to cook for someone else or take care of someone else, therefore being certain to eat more nutritious foods. Also, having someone to eat meals with helps maintain specific eating schedules and elongates length of eating time. This is also reason for why having a good social support system is pertinent for avoiding malnutrition. Many elderly people have informal arrangements with friends and family to eat together and prepare or obtain food. In some environments, such as nursing homes, groups of friends or neighbors eat together daily for sake of having a fixed schedule that is reliable. Social support is also significant for encouraging elders to eat enough meals and food. Especially in the elderly when time does not ever need to be rushed, eating is a social activity that promotes motivation to eat in a relaxing setting (Frongillo & Horan, 2004). If elders socially isolated they may not have that motivation to cook or eat, thereby increasing the chances of not eating sufficient meals. Many older people choose to continue living at home for as long as they can before health problems limit their abilities to function on their own, and they have to move into assisted living or nursing homes. During this time when their desires or abilities to cook nutritious meals are becoming more restricted they may choose to have meals delivered. Disabilities or illnesses

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may also force elderly people to be homebound and rely on some outside source of food, especially common for older women. A 2003 study evaluating the risk of nutrient deficiency from home delivered meals for elderly womens primary food source indicated that three important musculoskeletal nutrient levels were low in those eating delivered meals, among many other nutrients. Vitamin D, calcium, and magnesium levels were even lower on weekend days when meal service was not available. Many women also reported not eating breakfast regularly, which independently reduced the intake in nine to twelve nutrients. Thirty-two percent of the study participants were still at risk of food insufficiency despite having these delivered meals, and ten percent were considered food insufficient because of not having any food in the house or not having enough money to buy any food. Reliance on these daily delivered meals as ones main source of food intake is dangerous and raises risk of food insufficiency in homebound older women. This study again reflects a limited supply of financial resources in the elderly and shows how even food services for those not in assisted living is definitely not enough to seek food security and nourishment. Regardless of food sufficiency status, all recipients of homedelivered meals had lower intakes of nutrients, especially on weekends when they did not receive a meal (Sharkey, 2003). Another European study in 2008 suggested that little is known about how well delivered meals abilities are to meet the nutritional needs of the elderly in many countries. Several problems exist in this scenario, including lack of control over portion sizes and how much of it is actually consumed by the recipient, lack of flexibility or individuality based on diet, and lack of nutritional screening or lack of advice for the customers. Especially with regard to specific cultural or religious food guidelines that cannot be met by the larger scale food industry service, those with no other choice for food must eat what they can get delivered. An additional point is

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the recipients of these meals have no knowledge about the larger food production technologies or quality control in order to prevent microbial growth and unfavorable serving temperatures (Arvanitakis et al., 2008). All in all, because of the lack of sufficient nutrients and lack of knowledge of its source, there may be more disadvantages to having meals delivered to the elderly. But this eliminates another option in preventing food insecurity in the elderly, especially if they cannot afford nursing homes to meet daily nutritional needs. Even though nursing homes seem to be a preferred living environment in later age when maintaining a house gets too difficult, they do have their flaws in fulfilling adequate dietary needs of the elderly. First off, if Medicaid is the primary funder for a nursing home then there are limitations on food spending. This means that meals and diets may become repetitive and boring, and the facility may not be able to meet individual dietary preferences. Using supplements to prevent malnutrition in the residents is also discouraged because of Medicaids lack of reimbursement (Morley & Silver, 1995). Even though sometimes physicians cannot stop weight loss in patients due to the cause being cancer, most causes can be treated and a potential cause should be found and prevented in nursing homes. The causes are rarely identified in residents by workers because they may not be obvious or the elderly do not notice the changes. Also, there are usually not enough nursing home workers to individually assist the residents with eating and consuming proper nutrients at meals if they have functional impairments; in addition dieticians do not usually play a central role in this area of nursing homes to decide appropriate meals as they should. Then kitchen staff and care home management can modify activities to promote nutrition and awareness among nursing homes. Institutionalized elderly people have also been found to have low blood levels of numerous vitamins, including vitamin D deficiency because they often get little sunlight. This

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low intake of vitamin D can lead to poor calcium absorption and ultimately be a cause of getting osteomalacia, or bone softening. Osteomalacia can easily cause falls of the elderly and hip fractures from frail bones. Vitamin deficiencies are usually from low caloric intake and may contribute to skin changes noticed in most nursing home residents including hemorrhage, skin dryness, and cheilosis, or dry scaling of the lips and mouth (Morley & Silver, 1995). It is uncertain whether all of these weight loss problems and deficiencies in nutrients are strictly from poor location or environment of institutionalization, poor staff, or poor health from prior backgrounds and lifestyles. Malnutrition of the elderly could very well be a mix of all of these social factors and not purely the fault of nursing homes or food delivery services. In sum, numerous current internal and external factors make an expansive field from which harmful behaviors develop or are enhanced. Malnutrition seems to be an ongoing circular pattern of poor health and increasing morbidity and mortality among the aged. Because of poor eating habits due to social determinants of the life course, older adults may have functional impairments or emotional problems as they age. These functional impairments lead to bad eating habits such as spilling, not being able to swallow, or being unable to cook, along with having no appetite because of distress or depressed symptoms. Caloric and nutrient intake is decreased because of the impairments, leading to more extreme malnutrition and possible entrance into a hospital or nursing home. Because of all of the risks of living in an institution explained above, there may be a greater risk of poor diet and more cause of morbidity or functional and cognitive impairments. The cycle then starts over with worse eating habits, malnutrition, vitamin deficiency, and overall health. This eventually leads to multi-morbidity or death. Because of so many risks associated with undernourishment in the elderly, especially those who have lived with poor habits for so many decades, it is hard to conquer the root of the

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problems of poor eating. Mini-nutritional assessments are being done with more elderly people to get an accurate account for the most problematic causes currently. There are also many small efforts by institutions that are being done in hopes to help this cause, but sometimes it is too risky and unhealthy to assess very old hospitalized patients or health care is too expensive for government programs to assist. Preventative Measures and Methods Due to the many contributing factors of the total life course, it is difficult to prevent malnutrition in full, but many efforts are being made to decrease risks and increase awareness. Because risk factors from earlier life habits cannot be reversed, I will show how present negative habits can at least be avoided and methods be implemented to let the elderly attain their best possible quality of life. The first step in preventing malnutrition in the elderly is implementing nutritional risk screenings and assessments of dietary intake in order to more accurately manage negative causes. In the United States, leaders from the medical and academic communities joined together and formed the Council for Nutritional Clinical Strategies in Long-Term Care in order to formulate clinical guidelines for professionals to diagnose and treat involuntary weight loss in the elderly. The guidelines, which are supported by the American Dietetic Association and the Gerontological Society of America, consist of three trigger conditions: having a BMI of less than 21 kg/m2, involuntary five percent weight loss within 30 days, or leaving 25 percent or more at two-thirds of meals over a weeks span (Arvanitakis et al., 2008). This information will trigger a careful analysis of an elderly person by a physician, dietician, or nursing home worker to find potential causes underlying possible lack of appetite or unintentional weight loss. No matter if an elderly person looks frail or not, general nutritional assessments should be implemented routinely. If malnutrition risks are caught earlier on, this would ultimately save

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nursing homes and hospitals money, so regular testing is cost effective for preventing major consequences. The Mini-Nutritional Assessment (MNA) is currently the first validated choice in screening tools for malnutrition or risk of malnutrition in geriatric patients age 65 and older. This is a quick and easy way to identify those at risk for malnutrition in any setting so that optimal intervention can be started right away (Nestle Nutrition Institute, 2009). Once proper assessment has been employed and malnutrition is discovered, medical or nutritional professionals can then identify and treat underlying causes in the endangered elderly. Some dieticians may try to reverse weight loss with high-energy drinks or nutritional supplements, but more importantly patients should be encouraged to consume supplements in addition to their usual food intake, preferably in between meals. This can minimize appetite suppression and increase dietary intake. A physiotherapist could be used to increase amount of exercise, which in turn will stimulate appetite a bit (Alibhai et al., 2005). Adding flavor enhancers to cooked meals in nursing homes and hospitals might also improve food intake and increased appetite. It has been suggested that using flavor enhancers can compensate for the loss of chemosensory functioning and restore the original attitude towards food intake by the elderly population. One intervention study showed that repeated consumption of flavor-enhanced meals over three weeks led to a stable dietary intake, weight gain, and increased feelings of hunger (Mathey, 2001). This method can also target the group of elderly at risk for anorexia of aging by loosening the control of appetite. Broad-spectrum vitamin and mineral supplements should also be considered for those at risk for malnutrition to make up for deficiencies (Alibhai et al., 2005). Management in care homes should also acknowledge their responsibility in monitoring food intake and improving ways to encourage eating. Many times workers are not trained

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enough and are ignorant to the nutritional needs of the elderly. There should be continuing education programs on general nutrition, malnutrition, and nutritional support for all staff members who are involved with meals and feeding. The staff of hospitals and nursing homes should pay special attention also to eating environments since many elderly people have functional and cognitive impairments, and therefore have problems eating and give negative attributions to meal times. There should be enough workers on duty to help with feeding and appropriate quantities of food for each meal, and a dietician should always maintain a central role in nursing home food services and assessments (Arvanitakis, 2009). Nutritional support should carry on, and reassessments must be made in order to ensure weight gain is not just shortterm. With the proper training, even care home workers can monitor residents body weight and estimate the amount of food intake weekly to make sure that the methods used are suitable for each individual (Arvanitakis et al., 2008). For those elderly people living at home, family members or care workers are needed to assist during meals. Family or social support is especially needed to those who have mild depression or other emotional issues due to functional impairments and other restrictions from their age. On top of delivered meals or Meals on Wheels, a great resource of free food for low income elderly people, groceries could be delivered or provided by the government to ensure enough food is in the house so that a normal diet can be consumed by those with financial constraints (Arvanitakis, 2009). Having access to a normal diet on a daily basis is one of the most important preventative methods of malnutrition. Finally, the most noteworthy method of preventing malnutrition in old age is evaluating personal nutritional habits throughout the whole life course. From birth to death, diet can play a crucial role in determining disease risk, life longevity, and functional abilities. Presently there

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are growing efforts to promote awareness of malnutrition problems, one of them being major health care costs to the community (Arvanitakis, 2009). If more public policies were made or more nutrition-based educational programs were offered throughout communities, people would hopefully begin to review their own habits, diets, and actions to ensure a better quality of life even into old age. It is unfortunate that the generations of elderly people now a day were not informed of the risks of malnutrition during childhood and young adulthood because the concerns were absent from clinical research. Conclusion On the whole, this paper was written with the hopes to create awareness for what roles everyday nutritional habits take in future health and quality of life. I began with factual evidence concerning the increasing issue of malnutrition in the elderly and then stressed the implications of various contributing factors throughout peoples total life course. Past and present living arrangements, social conditions, functional capacities, and dietary knowledge and practices were all shown to feed into how one develops eating practices. Some risks build up to poor health while others are newer with adulthood, but all are hard to reverse in elderly people. The aging population is sensitive to change and a lack of adequate nutrients and food intake. The pathway towards sound health is more complicated than most people believe, especially when ones body is disabled or deteriorating from malnutrition and fighting against their will to live longer. All in all, nutritional needs of the elderly may oftentimes be an overlooked topic among the sociology of aging. Perhaps my arguments and explanations in this paper can broaden the awareness of malnutrition so that it can be better assessed and prevented earlier in life.

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