Most older adults want to make healthy food choices to create healthy diets. About one-third of older adults rate the healthfulness of their diets as extremely to very good, according to findings from the 2012 International Food Information Council's (IFIC) Food & Health Survey. Fifteen percent of the 1,057 respondents were 65-80 years old. Fifty-five percent of seniors thought their eating pattern was somewhat good and 10% believed it not at all healthful.
Older adults joined the women and "consumers with a BMI over 30" groups, stating in the IFIC Survey that changes in the nutrition information they read and hear makes it very difficult for them to know what to choose to eat healthfully. Since the 2010 Dietary Guidelines for Americans (DGAs) Advisory Committee report, the spotlight has been on fiber and whole grains. Both are very important components of a healthy eating pattern. In fact, when the IFIC Survey asked respondents if they considered whole grains (WG) when choosing packaged food over the prior year; 67% of seniors responded yes and 62% thought about fiber, while 56% of all age groups report trying to obtain their daily fiber goal.
This is encouraging news because the DGAs earmarked grains as one food group to increase and recommended all individuals, including older adults 1) consume ten 1 oz. servings daily, 2) consume at least half of their grains as whole grains and 3) replace refined grain with WG products. Fiber is extremely beneficial for healthful eating. The Institute of Medicine (IOM) established an Adequate Intake (AI) for fiber at 14 g per 1,000 calories consumed, or 25 g/day for women 51 years and older and 38 g/day for older men. Most adults average only 15 g per day.
Achieving these recommendations is a basic step toward healthy eating. However, if it isn't hard enough to understand and to differentiate the terms grains, whole grains and fiber, then it is equally formidable to achieve the goals. (See Explanations & Examples below.) Dietary fiber improves laxation and reduces diverticular disease. Physicians recommend an increase in the consumption of foods containing fiber to reduce obesity, cardiovascular disease, type 2 diabetes, and some cancers.1
Christine Gerbstadt, MD, RD, a spokesperson for the Academy of Nutrition and Dietetics, said the key to achieving the daily recommendation for whole grains is to eat foods high in fiber. "Whole grains are powerful sources of B-vitamins, trace minerals and aid in the release of glucose. They also help to control LDL-cholesterol levels. This is very important since two-thirds of adults have Type 2 diabetes and one-third don't know they have diabetes," Gerbstadt explained. Diabetes may be more common in long-term care as residents are not living independently often because of their inability to manage an array of chronic diseases, including diabetes.
Why Is Fiber Important?
Fiber stimulates the transit of medications and foods in the bowels for absorption and the health of the intestines and colon. Fiber reduces impaction which is an expense in time and materials to the staff and a challenge to the patient. The general medical care rule for a healthy gastrointestinal tract is to increase fluid, increase fiber and increase exercise for the senior, according to the DGAs.
Most individuals achieve their recommended servings of 10 grains each day by eating rice, pasta, bread and oats. The bad news is that only 1 in 10 individuals in the general population achieve the fiber recommendation and less than 5% of the U.S. population achieves the WG recommendation, according to the DGAs.
No federal definition exists on foods for a "good" or "excellent" source of WG making it difficult to know if a food is acceptable as one of the five recommended whole grain servings each day. One guide would be to check the ingredient list and select foods with the words "whole grain" at the beginning of the list, which means the food has a substantial proportion of whole grains. But it is perplexing when knowing a food has whole grains but the WG content may not be the reason it is actually purchased and eaten.
For the 65-80 year-old IFIC respondents, fiber content is not the primary reason for selecting a food and beverage. Choices are influenced by taste first, as reported by 92% of the respondents; by healthfulness second at 74%; price third, stated 62%; fourth is convenience with 52%; and sustainability was fifth as reported by 44% of the older adults. Coincidentally, seniors reported a significantly higher influence of taste, healthfulness and sustainability on their purchases than younger ages reported these because price was most important for consumers younger than 50 years old.
What may be happening is that older adults strive for their 10 servings of grains, but fall short of making half of them whole grains. This may be due in part to the fact that taste rules choice. Refined grains may be preferred by older adults when trying to eat healthy, but their taste buds are trained to prefer refined breads and cereals. Changing a food from the soft texture of a refined grain to a more course texture of a whole grain is very difficult. Further, the dental health of seniors may require softer foods with less seeds and skins.
Grains that have been milled to remove the bran and germ from the grain gives them a finer texture and improves their shelf life, such is the case for white bread and white rice, but it eliminates the dietary fiber, iron and the B-vitamins of thiamin, riboflavin, niacin, folic acid and iron. Refined grain products can be enriched, which means the iron, thiamin, riboflavin and niacin are added back with a bonus fortification of folic acid. But enriched does not mean fiber has been added. That would be an additional process.
Making It Easy for Seniors
Kathy Wiemer, Fellow/Director, General Mills' Bell Institute of Health & Nutrition recommended, "The best way to communicate a clear message so individuals can fill the grain portion of their plate with healthy choices is to see the phrase, 'fiber-rich' on the label, which requires 5 g of dietary fiber per serving." If cereals have "fiber-rich" or "whole grains" on their label, then the message is more informative for the adult at the grocery shelf or for the foodservice manager and registered dietitian in long-term care.
It must be easy for seniors in LTC to achieve their fiber goals because their menus are planned by professionals to meet standards. Ann K. Tornyos, MPH, RD, LD, senior vice president and corporate RD, HPSI, who oversees menus for contracted facilities said, "We definitely look at the fiber content in foods on the menus in LTC, however, there are a few big problems."
Federal regulations require menus to be planned according to the RDAs not the DRI. Fiber is neither a required nutrient nor required on food labels. It is a dietary component with health benefits and basically up to the menu planners to include. Why is it a problem?
RDAs refer to the nutrients that are required by the body daily, like calcium and magnesium, protein, vitamins A, C, D and E, and the B-vitamins of thiamin, niacin and riboflavin. Menus are approved as adequate for the residents if surveyors determine the menus contain foods meeting all the nutrient needs of the residents daily defined by RDAs. Fiber content of meals is not part of the required standards used by surveyors.2 However, fiber is listed in both the DRIs and the DGAs.3-4 These are additional qualitative guidelines that surveyors use to evaluate LTC menus, but they are not requirements. Some states, like California, are trying to require a certain fiber content in menus, but this controversy is challenging for facilities and surveyors. The DRIs may need to be added to the menu planning standards for LTC, so they become requirements used by surveyors when evaluating LTC facility menus. Otherwise, the menus across LTC facilities may not be planned to contain the fiber recommendation of 25 g/day for women 51 years and older and 38 g/day for older men.
Even without a fiber standard used by surveyors, Tornyos considers the fiber content of foods when calculating menus. If the fiber content is not available on the product label or nutrient data base, then she plans menus adding good sources of fiber. Tornyos said, "We offer whole grain cereals three to four times a week, have 100% and high-fiber juices daily, and include several varieties of beans multiple times a week as a side (lima, butter, kidney, pinto, black) or serve lentils and quinoa in a salad or a lentils and beans as a soup. This increases menu costs by $0.14 to $0.24 a day but helps achieve 30 g of fiber."
Other simple and acceptable menu options are available. Gerbstadt noted, "It totally makes sense to have a whole grain cereal meal with milk because so many seniors are exhausted, winding down and prefer a lighter meal at the end of the day." She added, "Seniors enjoy a comfort food like cereal and milk." Even though other good choices of whole grains include WG tortillas and pitas, Gerbstadt feels many cultures are not as tolerant or accepting of whole grain foods on the market. She believes we are making good progress adding whole grains to menus for seniors with the caveat, "the ultimate goal is to reduce reliance on supplements for a healthy bowel program because foods are less expensive, dependable and more user-friendly for the senior."
Wiemer at the General Mills' Bell Institute added, "Fiber is not the best marker of whole grain, but 48 g of whole grains are needed each day for a beneficial effect. As of January 2013 all GM cereals have 10 g or more of whole grain per serving. All products available in retail will be available for purchase in bulk size for the LTC market."
Bethany Thayer, MS, RD, director, Center for Health Promotion and Disease Prevention at Henry Ford Health System in Detroit noted, "Each patient and LTC resident is on their own journey to wellness and may vary how they optimize their wellness. A healthy diet is important for everyone and this includes attention to whole grain and fiber intake." One reason she gave was that whole grains and fiber not only provide nutrients, but provide them in a nutrient-dense way. This simply means that each calorie of a high fiber food, like whole grain bread, has more nutrients than a calorie of plain white bread.
LTC facility menus are evaluated by surveyors who use the RDAs. If fiber is to be an official part of healthy menu planning for seniors, then surveyors should check for actually grams of fiber. Currently because fiber does not have an RDA, it does not fall under the official requirement. Instead it is reviewed more as a qualitative evaluation of the menu. Even then, states may be inconsistent in whether they evaluate fiber content of menus. It is smarter for both the consultant RD who plans menus in LTC and for the older adult who seeks a healthy diet to do the following:
- know which foods are good sources of fiber and WGs,
- prepare and eat a variety of whole grains,
- moderate amounts of whole grains to control calories, and
- search for labels that say, "fiber-rich" and "'whole grain"
Since all General Mills cereals have a 10 g of whole grain per serving requirement, making cereal an evening meal or bedtime snack, seems practical for seniors.
Explanations & Examples
Fiber: Carbohydrate and lignin in plants that are not digested in the small intestine because humans do not produce the enzymes to hydrolyze them. As they enter the colon intact, bacteria ferment them.
Soluble fiber: Found in oatmeal, bran, nuts (almonds, walnuts, peanuts) and seeds, most fruits (strawberries, blueberries, pears, and apples), and dry beans (pinto, kidney and black), peas (split and crowder), and lentils.
Insoluble fiber: Found in whole wheat bread, barley, brown rice, couscous, bulgur or whole grain cereals, wheat bran, seeds, most vegetables, and fruits.
Whole grains (WG): Foods that are a good source of fiber and nutrients, have all of the parts of the grain seed or kernel (bran, germ and endosperm). Examples of whole grains are brown rice, buckwheat, bulgur (cracked wheat), millet, wild rice, popcorn, quinoa, triticale, whole-grain barley, whole-grain corn, whole oats/oatmeal, whole rye and whole wheat. Whole grains are added as ingredients to cereals, breads, or crackers.
Bulgur: A Middle Eastern WG staple made of kernels that have to be steamed, dried and crushed resulting in a tender and chewy texture.
Millet: A WG staple from Africa and Asia having several varieties with a bland flavor.
Quinoa: A South American WG with a texture similar to couscous.
Triticale: A blend of WG wheat and rye in several varieties including whole berry, flakes, and flour.
For more information see "10 Tips to Get Your Daily Fiber"
1. Turner, ND et al. Dietary fiber. Adv Nutr. 2011; 2: 151-152.
2. California Department of Social Services Regulations. Residential Care Facilities for the Elderly 87508. Title 22, Division 6, Chapter 8, Article 9. MANUAL LETTER NO. CCL-08-01; 2008.
3. Code of Federal Regulations. Department of Health & Human Services. (2012). Title 42-Public Health. Requirements for States and Long Term Care Facilities. Section 483.35/Dietary Services.
4. Institute of Medicine, National Academy of Sciences. (2001). Dietary reference intakes: proposed definition of dietary fiber. Washington, DC: National Academy Press.
Gail C. Frank is a freelance writer, professor and nutritional epidemiologist at California State University Long Beach, Long Beach, Calif.