Micronutrient requirements in older women1–3

Ronni Chernoff

ABSTRACT increase in the proportion of total body fat), as well as physio-

The nutritional requirements of older women is an area of great logic challenges associated with chronic and acute medical con-
interest because the extended life expectancy leads to an increase in ditions. Compounding these changes, there may be environmen-
women living into their 80s, 90s, and longer. The recommended tal, social, financial, and functional barriers faced by older
dietary allowances (RDAs) and dietary reference intakes (DRIs) are women that may interfere with adequate dietary intake.
not specific for women living to advanced ages, and little research One of the most significant changes that is seen in old and very
has been conducted specifically on the micronutrient needs of el- old adults is a decrease in basal energy requirements; this can
derly women. Older adults are at greater risk for nutritional defi- generally be attributed to the decrease in lean body mass. A

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ciencies than are younger adults due to physiologic changes associ- reduction in energy expenditure is also associated with sedentary
ated with aging, acute and chronic illnesses, prescription and over- behavior and a loss of mobility related to systemic (eg, cardio-
the-counter medications, financial and social status, and functional vascular, pulmonary) or bone and joint disease. To avoid weight
decline. Among the significant age-associated changes in nutrient gain, which may compound already existing functional deficits
requirements, the need for energy decreases and the requirements for (4, 5), dietary intake may be decreased. A reduction in nutrient
protein increase with age. Among the micronutrients, the significant consumption will add to a decrease in overall dietary quality
ones that may be associated with deficiencies in elderly women because favorite foods are consumed and foods that are less
include vitamin B-12, vitamin A, vitamin C, vitamin D, calcium, well-liked (vegetables) are often the ones first eliminated.
iron, zinc, and other trace minerals. In old and very old women, these Nutrient-dense foods often fall into that category; favorite and
are micronutrients of interest but there is a great need for research to
“comfort” foods are frequently those that are high in fat and
determine appropriate recommendations. The importance of these
carbohydrate. Obtaining sufficient amounts of micronutrients
selected nutrients and the reasons for the likelihood of deficiency are
becomes a challenge within the complex nature of the human
discussed briefly. However, there is little specific information re-
aging process (6).
garding micronutrient requirements for elderly women. One reason
Risk for poor nutritional status is also related to a decreased
for this is the difficulty in conducting reliable and valid studies due
efficiency of the gastrointestinal tract that occurs in some elderly
to the heterogeneity of older adults and their unique rate of aging
people. Chewing, swallowing, digesting, and absorbing nutrients
associated with their health status, limited income, disability, and
may be impaired for a variety of reasons (7). Oral health status,
living situation. Am J Clin Nutr 2005;81(suppl):1240S–5S.
edentulousness, dentures that may not fit properly, or lesions in
KEY WORDS Micronutrient requirements, older women, en- the oral cavity will interfere with consumption of a well-balanced
ergy, protein, vitamins, trace minerals diet and sufficient intake to meet nutrient needs (8). Nutrients
may not be as proficiently digested and absorbed due to atrophic
gastritis, a decrease in hormone and enzyme production, senes-
INTRODUCTION cent changes in the cells of the bowel surface, and the interactions
The nutritional requirements of older women is an area of great among drugs and nutrients (7). Constipation is a chronic problem
interest, particularly because their life expectancy continues to in many older adults; this may be associated with a decrease in
increase due to better health care and earlier awareness of health peristaltic strength or in adequate dietary fluids and fiber to
promotion activities. Interestingly, though interest in the area of provide bulk.
nutritional requirements is increasing, there is a lack of research Compounding these changes is the effect of both chronic and
targeted to exploring the needs of the very elderly. The nutrition acute illness (6). Dietary modifications are frequently introduced
recommendations provided by the RDAs and the DRIs levels are
1
not helpful when it comes to providing advice to old and very old From the Associate Director for Education, Geriatric Research Educa-
women, although in the most recent publications there are sep- tion and Clinical Center, Central Arkansas Veterans Healthcare System and
Professor, Geriatrics, Professor, Health Behavior and Health Education, Di-
arate recommendations for individuals over age 70 (1–3); little
rector, Arkansas Geriatric Education Center, University of Arkansas for
research has been conducted specifically on the needs of elderly
Medical Sciences, Little Rock, AR.
women. 2
Presented at the conference “Women and Micronutrients: Addressing the
Older adults are generally at greater risk for nutritional defi- Gap Throughout the Life Cycle,” held in New York, NY, June 5, 2004.
ciencies than are younger adults. They experience the normal 3
Address reprint requests and correspondence to R Chernoff, GRECC
changes associated with aging (decrease in lean body mass, de- (182), CAVHS, 4300 West 7 Street, Little Rock, AR 72205. E-mail:
crease in total body water, decrease in bone density, and an [email protected].

1240S Am J Clin Nutr 2005;81(suppl):1240S–5S. Printed in USA. © 2005 American Society for Clinical Nutrition
 MICRONUTRIENT REQUIREMENTS IN OLDER WOMEN 1241S
to accommodate loss of functional capacity to feed oneself, ef-
fectively lower sodium intake, manage lipid profiles, control
blood glucose levels, lose weight, or manage other metabolic
conditions associated with disease. Demands for specific nutri-
ents may be increased because of increased needs associated with
healing, recovery, or rehabilitation (9). Dietary intake in elderly
women may decrease due to alterations in their health, functional
or cognitive status, disease-related anorexia, or changes in taste
sensitivity often associated with medication use.
Many very old women face challenges associated with their
environment, social and financial status, and their level of func- FIGURE 1. Mean intake of vitamin B-12 (␮g) in adults age 20 – 80ѿ,
tional ability. Many older women have been widowed, have had NHANES III, Ref 12
their children move to other geographical areas, are living on a
fixed income, and experience disability. Cooking for one may
not be an activity that motivates an elderly woman after years of (13). The production of gastric acid is necessary for the digestion
shopping and preparing food and meals for a family and spouse. of food rich in vitamin B-12. Animal protein, the primary source
There may be financial challenges associated with limited in- of vitamin B-12, is expensive, difficult to chew, and has been
come, living on pensions, or social security. Health care costs can associated with elevated blood lipids. Bacterial overgrowth in
be burdensome, even for someone in relatively good health; costs the gut may also be a factor in the reduction in the bioavailability
for someone who has multiple chronic conditions or acute illness of vitamin B-12; bacteria may bind the B-12, rendering it un-

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may be financially disastrous. Because older women have a available for absorption (14). This condition is easily treated with
greater life expectancy than elderly men, there is a greater like- antibiotics.
lihood that they will experience more disability in their later Vitamin B-12 requirements that are not met through diet can
years simply because they live longer. Disability may lead to be met with supplements that contain crystalline vitamin B-12;
elderly women becoming homebound or more dependent on however, there is still a limited bioavailability (15). For elderly
social services that will help them meet their basic needs. Obesity adults, the recommendation to meet vitamin B-12 needs is
is a risk factor for disability, and sedentary lifestyle is a risk factor through foods fortified with B-12 or B-12-containing supple-
for obesity; this is a difficult cycle to avoid but one that adds ments.
burden to nutritional intake and status (4 – 6).

Vitamin A
NUTRIENT NEEDS OF VERY OLD WOMEN
Vitamin A has many roles in the maintenance of health; it is
Although there is little research conducted on micronutrient important to maintain normal vision, for cell differentiation, ef-
requirements in elderly women, there are key nutrients that de- ficient immune function, and genetic expression (6, 16). Vitamin
mand attention. Though not a micronutrient, protein is an impor- A recommendations for older adults have been lowered from
tant nutrient for old and very old individuals. Protein needs ac- previous editions of the RDAs (2). Present suggested levels are
tually increase with age (10,11). Because lean body mass 700 ␮g retinol activity equivalents (RAEs) for women and 900
decreases with age, it would seem that protein requirements ␮g RAE for men. Some researchers have recommended that
would decline, but they increase to maintain nitrogen equilib- these recommendations be set at even lower levels because al-
rium; when demands increase to heal wounds, fight infection, though the vitamin A intake for many older adults is below
repair fractures, or restore muscle mass lost from immobility, current recommendations, their vitamin A levels remain nor-
dietary protein must be increased above maintenance require- mal (17). (Figure 2) It has been suggested that dietary vitamin
ments but frequently protein is overlooked as a target nutrient in A be obtained from an increased intake of carotenoids, in-
the very old patient. cluding ␤-carotene, lycopene, zeaxanthine, and lutein, among
Among the micronutrients, the significant ones that may be others (18).
associated with deficiencies in elderly women include vitamin It is not common to find vitamin A deficiency in elderly indi-
B-12, vitamin A, vitamin C, vitamin D, calcium, iron, zinc, and viduals in the United States, as vitamin A is easily obtained from
other trace minerals. In old and very old women, these are the food as well as dietary supplements. However, absorption in
micronutrients of interest and there is a need for a great deal more
research.

Vitamin B-12
Vitamin B-12 is a nutrient of interest in the old and very old
woman primarily because the consumption of foods rich in this
nutrient decreases with age (12). (Figure 1) The bioavailability
of protein-bound vitamin B-12 decreases as people age. The
mechanism that is most affected by age is the ability to cleave the
vitamin from its protein carrier; the prevalence of atrophic gas-
tritis, reported to be 40%–50% of individuals over age 80, is a FIGURE 2. Mean intake of vitamin A (IU) in adults age 20 – 80ѿ,
severe impediment to the transport and release of vitamin B-12 NHANES III, Ref 12
1242S CHERNOFF

elderly adults increases, therefore making the possibility of tox- not get out at all if they live where it is cold (6). For those who live
icity greater if supplements with high levels of vitamin A are in warmer areas, fear of skin cancer from too much sun exposure
included in the diet daily. Compromised hepatic function may is also an impediment to the activation of vitamin D precursors.
contribute to an increased risk of toxicity, particularly in those Additionally, the vitamin D precursor found in skin decreases
who are using supplements or eating fortified foods. In old adults with age. The ability of the kidney and liver to hydroxylate
who may have asymptomatic hepatic dysfunction, the risk for vitamin D precursors is affected by age, thereby suggesting that
vitamin A toxicity increases. Levels of retinyl esters rise when the vitamin D requirements might be higher than have been
liver damage or vitamin A toxicity occurs (19). recommended (24).
One consequence of high vitamin A intake is its association
with a higher risk for fractures. Vitamin A is a vitamin D and
calcium antagonist and a high intake of vitamin A over long Calcium
periods of time may create serious bone health problems (20). Calcium is an essential nutrient that many older women con-
Obtaining supplemental vitamin A in its precursor form, sume in inadequate amounts. (Figure 3) Despite this, the endo-
␤-carotene, appears to be considerably safer, more effective, and crine system serves to maintain serum calcium within a fairly
has not been associated with adverse or unanticipated side ef- narrow range by managing absorption, bone mineral balance,
fects. Consuming a diet rich in fruits and vegetables is a reason- and calcium excretion in urine (25). For older women, the dy-
able way to meet vitamin A needs in older adults as well as namics of calcium requirements change. Presently the DRI for
providing a good source of dietary fiber. calcium for adult women is 1200 mg calcium/d but there have
been suggestions that a daily intake of 1500 mg/d for postmeno-
pausal or over 65-year-old women would be appropriate (26).

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Vitamin C The challenge is that when the RDA was 1000 mg/d there were
Vitamin C status is generally related to dietary intake; pres- a significant number of women who consumed diets with inad-
ently, requirements for older adults are higher than the 1989 equate levels of calcium; changing the requirement does not
RDAs. Newer data set the recommendations for vitamin C at 90 necessarily alter eating patterns and it is apparent that supple-
mg/d for males and 75 mg/d for females over age 50 (21). Re- mental calcium is needed from nondietary sources.
ductions in vitamin C intake are associated with illness, hospi- Calcium has been linked to the prevention or lowered risk for
talization, and institutionalization. Lowered intake often is asso- many chronic conditions such as osteoporosis (27, 28), colon
ciated with chronic disease including atherosclerosis, cancer, cancer (29), and hypertension (30).
senile cataracts, lung diseases, cognitive decline, and organ de-
generative diseases (21).
Iron
Vitamin C is relatively easy to replenish by consuming fruits,
fruit juice, and vegetables, or through vitamin supplementation. Requirements for iron for women change after menopause; the
Elderly individuals who smoke may require double the recom- need for iron to replace menstrual losses ceases, and tissue stores
mended intake just to maintain tissue levels. As a key nutrient, it are generally adequate if dietary intake is at acceptable levels.
is important to consume adequate amounts, particularly in old Needs for iron in older women revert to the same levels as those
adults. The role of vitamin C is that of an antioxidant; as a for adult males: 10 mg/d. Dietary iron bioavailability may be
metabolic reducing agent; as a catalyst needed for hydroxylation affected by the consumption of heme iron, supplemental iron,
for proline and lysine, needed for collagen production essential to dietary ascorbic acid, and alcohol (31, 32).
make new tissue and heal wounds; and, for the maintenance of If there is an inadequate consumption of dietary iron, iron
vascular integrity. deficiency anemia may occur. In older adults, this would indicate
Tissue saturation of vitamin C is achieved easily (22); excess a significant deficiency over a long time. However, there is little
dietary vitamin C will be excreted in the urine. Chronic large evidence that iron deficiency is prevalent in either an American
doses may contribute to diarrhea or renal calculi formation and or European population of older adults (33). Iron deficiency
should be discouraged among elderly persons. anemia is most often encountered in older adults who have co-
morbidities, particularly chronic inflammatory diseases. Iron de-
ficiency anemia can be diagnosed using serum ferritin measures,
Vitamin D plasma transferrin receptors, and erythrocyte sedimentation
It is well recognized that older women are at risk for inade- rates. There is an inverse relation between tissue iron stores and
quate vitamin D consumption. Vitamin D has significant roles in serum ferritin levels.
bone health by regulating bone mass, but it also is an essential
nutrient in immune function (9, 23). There are 2 primary sources
of vitamin D: diet and skin. Dietary sources of vitamin D are fatty
fishes and fortified dairy products. Consumption of fortified
dairy products is very variable among older women, especially
because lactose intolerance is more prevalent in older adults.
There has been some speculation that even in people who are
including fortified foods in their diet, the foods are underfor-
tified (6).
Skin as a source for vitamin D precursor may be helpful for
those who live in temperate climates where they can get outside FIGURE 3. Mean intake of calcium (mg) in adults age 20 – 80ѿ,
daily, however, during the winter months many elderly people do NHANES III, Ref 12.
 MICRONUTRIENT REQUIREMENTS IN OLDER WOMEN 1243S
Although iron deficiency may not be the most common type of adults to age 70 have been established at 700 ␮g/d (2). The RDA
anemia seen in older adults, it is seen among hospitalized, insti- is 900 ␮g/d.
tutionalized, or chronically ill older adults. Usually, anemia as-
sociated with age is due to chronic bleeding in the gastrointestinal
tract. Iron deficiency anemia may be manifested as “restless legs OTHER TRACE NUTRIENTS
syndrome” (34); this condition is easily treated by providing iron
supplementation. To enhance absorption, iron should be taken in
divided doses and with meals, which will decrease the gastroin- Chromium
testinal side effects. If oral supplementation is not tolerated, Chromium status in adults is most usually related to dietary
parenteral iron may be given as a short-term intervention. intake. Impaired chromium absorption is generally associated
with high intake of nutrients that impact on bioavailability or that
increase excretion; these food components include high levels of
Zinc fiber or simple sugars that increase urinary excretion. In in-
Zinc has been recognized as an essential trace nutrient since dividuals who have low levels of chromium, symptoms of
the 1930s. It is a metal that has a role in many enzymes, in gene hyperglycemia or abnormal lipid levels may be corrected by
expression, and in immune function, among other physiologic providing supplementation designed to normalize chromium
functions (35). Marginal intake of dietary zinc will lead to a lower status (39, 40).
physiologic zinc levels, but the real challenge may be factors that
inhibit or interfere with zinc absorption. Divalent positively
charged ions, such as iron, can interfere with zinc bioavailability. Selenium

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Phytates, from grains, cereals, rice and legumes, may interfere
with the absorption of zinc; the zinc found in vegetable foods may Selenium has been identified as an essential nutrient; however,
be less bioavailable than zinc from animal sources (35). it is rare to see selenium deficiency in the United States (21).
Malabsorption, physiologic stress, trauma, and muscle However, selenium deficiencies have been reported among in-
wasting will all contribute to inadequate zinc status, as will stitutionalized elderly, particularly those who have multiple pa-
both prescription and over-the-counter medications. For older thologies (41), but, once identified, this is easily corrected with
women, these circumstances may occur too frequently. Con- supplementation. Selenium does function as an antioxidant and
sequences of poor zinc status may include reduced immune individuals may take supplements to enhance immune function
function, dermatitis, loss of taste acuity, and impaired wound or increase antioxidant activity. There is an upper limit of 400 ␮g
healing (35). of selenium/d, which, if exceeded, may lead to toxicity. Symp-
In zinc deficient elderly individuals, T lymphocyte impair- toms of toxicity may include nausea, vomiting, hair loss, irrita-
ment and cellular immunity are compromised (36, 37). Zinc bility, peripheral neuropathy, and fatigue.
replacement will improve immune status. Inadequate zinc status
will affect the efficiency of wound healing, and zinc supplemen-
tation will contribute to more efficient healing; however, zinc Aluminum
supplementation in individuals with adequate zinc nutriture will Although aluminum has not been identified as an essential
not produce any benefit. nutrient, it is worthy of mention due to its past association with
Dermatitis is a commonly seen manifestation of zinc defi- the development of Alzheimer’s disease (42, 43). Elderly women
ciency, as is a decreased sense of taste. Zinc supplementation may have exposure to aluminum through excessive use of ant-
may contribute to a reversal of symptoms in individuals who are acids, buffered analgesics, some antiulcer compounds, and other
zinc deficient. In individuals who have adequate zinc status, medications (37). Although absorption of exogenous aluminum
supplementation will not improve their conditions. In fact, too may increase with genetic predisposition, advancing age or mu-
much zinc may lead to suboptimal absorption of other trace cosal damage, aluminum is absorbed in relatively small amounts.
minerals (38). Since Alzheimer’s disease was first described in 1907, the asso-
ciation between dietary aluminum, use of over-the-counter med-
Copper ications, use of aluminum cookware, or dialysis fluids that con-
tain high amounts of aluminum is extremely unlikely.
Copper is a positively charged divalent ion that is an essential
nutrient. Large doses of zinc will interfere with the absorption of
copper. Copper deficiency is difficult to diagnose and is not often
thought about. Symptoms are vague and can easily be associated Magnesium
with other nutritional or medical problems. In humans, copper Recommendations for intake of magnesium is 350 mg/d for
deficiency may manifest as hypochromic anemia, osteoporosis, men and 280 mg/d for women, and there is no indication that
arterial disease, myocardial symptoms, and decreased metabolic elderly adults have needs different from younger adults (25).
activity of copper-containing enzymes. Copper deficiency has Intakes of magnesium in elderly people may be marginal but,
been linked with hypercholesterolemia, glucose intolerance, and even in individuals with atrophic gastritis, there does not appear
hypertension, all of which are not unusual to see in elderly adults to be any interference with magnesium absorption. However,
(2, 39). hypomagnesemia should be considered as a possible factor in
Copper is widely distributed in a variety of foods and is rela- depressed immune function, muscle atrophy, osteoporosis, hy-
tively accessible if a diet with variety is consumed in adequate perglycemia, hyperlipidemia, and other neuromuscular, cardio-
amounts. Estimated average requirements (EAR) for copper for vascular, or renal dysfunction (25).
1244S CHERNOFF

Boron 11. Rand WM, Pellett PL, Young VR. Meta-analysis of nitrogen balance
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SUMMARY A and vitamin E intake on fasting plasma retinol, retinol binding protein,
retinyl esters, carotene, alpha-tocopherol, and cholesterol among elderly
There is little specific information regarding micronutrient

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