Aging, Nutrition and Taste: Nutrition, Food Science and Culinary Perspectives for Aging Tastefully 012813528X, 9780128135280

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Aging, Nutrition and Taste: Nutrition, Food Science and Culinary Perspectives for Aging Tastefully
 012813528X, 9780128135280

Table of contents :
Content: Front Cover
Aging, Nutrition and Taste
Copyright Page
Contents
Acknowledgments
Overview-The Aging and Taste Revolution
Introduction
What Is Aging
What Is Taste?
Why Focus on Aging?
Why Focus on Taste?
Why Does Taste Change in Aging People?
What Are the Concerns of Taste Changes in the Aging?
What Can Resolve Taste Changes in the Aging?
Nutrition, Food Science and Culinary Perspectives for Aging Tastefully
Chapter Summaries That Address Nutrition, Food Science and Culinary Perspectives and Aging
Nutrition and Aging
Highlights of Chapters 1, 2, 8 and 12
Food Science and Aging Highlights of Chapters 3 to 7Culinary Perspectives and Aging
Highlights of Chapters 7, 9, 10 and 11
Chapter Summaries
Chapter 1: Global and US Aging
Chapter 2: Nutritional and Physical Concerns in Aging
Chapter 3: The Senses, Chemosensory Changes and Aging
Chapter 4: A Taste Primer
Chapter 5: A Smell Primer
Chapter 6: Flavor Enhancement Ingredients
Chapter 7: Flavor Enhancement Techniques
Chapter 8: Meeting Nutritional and Disease-Specific Needs of Aging
Chapter 9: Culinary Considerations for the Aging
Chapter 10, Menus and Recipes That Appeal to Aging Palates Chapter 11: Cooking Aids, Tableware Tips and Dining AdviceChapter 12: Prime Time Resources for Aging, Taste and Health
Other Elements
1 Global and US Aging
Summary
Introduction
Global Aging
Global Aging by the Numbers
World Population
Aging Populations Worldwide
Global Aging and Life Expectancy
Global Aging and Disease
Global Aging and Ethnic and Racial Disparities
Global Aging and Residence
Global Aging and Education
Global Aging and Employment
Global Aging, Health, and Health Care
Global Aging and Nutrition
Global Aging and Chemosensory Changes Global Aging Impacts on Nutrition, Food Science, and Culinary PerspectivesNutrition
Food Science
Culinary Arts
The Impact of Global Aging
Global Aging by the Numbers
Impact-Global Gerontology and Geriatrics
US Aging
US Aging by the Numbers
US Life Expectancy
US Aging and Disease
US Aging and Chronic Diseases
US Aging and Ethnic and Racial Disparities
US Aging and Residence
US Aging and Education
US Aging and Employment
US Aging and Socioeconomic Costs
US Aging, Health, and Health Care
US Aging and Nutrition
US Aging and Chemosensory Changes US Aging Impacts on Nutrition, Food Science, and Culinary PerspectivesNutrition
Food Science
Culinary Arts
Nutrition and Culinary Arts Partnerships for the Aging
Impact: Gerontology and Geriatrics in the United States
Digest
Manner of Speaking
References
2 Nutritional and Physical Concerns in Aging
Summary
Introduction
Nutrient Needs for Aging
Overview
Functional Decline and Aging
Dietary Decline and Aging
Physiological Changes During Aging That Affect Nutritional Status
Calories During Aging
Calories by Gender: Women and Men
Women
Men
Weight Loss
Anorexia
Weight Gain

Citation preview

AGING, NUTRITION AND TASTE

AGING, NUTRITION AND TASTE Nutrition, Food Science and Culinary Perspectives for Aging Tastefully

JACQUELINE B. MARCUS, MS, RDN, LDN, CNS, FADA, FAND Jacqueline B. Marcus and Associates, Highland Park, IL, United States

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2019 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN: 978-0-12-813527-3 For Information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

Publisher: Charlotte Cockle Acquisition Editor: Nancy Maragioglio Editorial Project Manager: Tasha Frank Production Project Manager: Mohanapriyan Rajendran Cover Designer: Miles Hitchen Cover Photographer: © 2019 Grace Natoli Sheldon. Reprinted with Permission. Typeset by MPS Limited, Chennai, India

Acknowledgments

This book represents 20 plus years of my involvement in the field of taste and aging and of translating chemosensory research into nutritional and practical ways of feeding the aging both healthfully and satisfactorily. There are many people and organizations that have been instrumental in this pursuit. These include Catherine Broihier, RD, MS, who helped support my countless national and international speaking engagements and writing projects; the Institute of Food Technology and the World of Food Ingredients that showcased my writing; and the Academy of Nutrition and Dietetics and the International Association of Culinary Professionals that both featured my speaking and writing. As with Culinary Nutrition: The Science and Practice of Healthy Cooking (Elsevier, 2014), I want to once again thank my intrepid editor Nancy Maragioglio who spearheaded this undertaking as well as this text, Aging, Nutrition and Taste: Nutrition, Food Science and Culinary Perspectives for Aging Tastefully. Chef Golda Ewalt, MS, RDN, LDN, CEC, was instrumental in expert recipe testing and preparing the finished dishes for photography. Photography/Stylist Grace Natoli Sheldon was indispensible once again for her exceptional photography, as in Culinary Nutrition: The Science and Practice of Healthy Cooking (Elsevier, 2014). Also, throughout the writing of this textbook, my family has been insurmountable in their backing of my drive and determination in nutrition, food science and the culinary arts. My husband, Harvey, and my children, Meredith, Morgan and Mason, have endlessly supported my ongoing quest to help the science behind food and nutrition come alive through healthful, memorable and tasteful beverages and foods. They have been my truest tests and the keenest results of the impact of taste and flavor enhancement throughout the lifecycle. Jacqueline B. Marcus Spring, 2019

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Overview—The Aging and Taste Revolution

Photo: Forks and Plates. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I don’t like to eat plain foods anymore—such as plain fish. I like very flavorful foods with accompaniments, like sauces. M.W.

INTRODUCTION The world is aging exponentially. People around the globe are living longer and in some instances, they are living healthier. While this aging phenomenon is considered as a “crowning achievement” of the last century, it is also sometimes considered as a “significant challenge.” This is because living longer may not ensure living better, it may not always be healthful, nor physiologically or psychologically “tasteful.” In fact, living longer may actually be “tasteless” for a significant portion of the aging population. The reasons are likely multifactorial, as one will learn throughout this text. Different countries are aging at different rates due to such factors as access to healthy beverages and foods, chronic disabilities, diseases, education, gender, healthcare costs, injuries, race, socioeconomic influences and many others. Loss or decline in the chemosensations of taste and smell may also be contributing factors, and in some instances, at the root of tastelessness in the aging.

WHAT IS AGING Simple speaking, aging is the process of becoming older. Rather than the notion that aging is 50 years or older, from the moments that humans enter this world, everyone ages.

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Though everyone ages, the aging process is genetically determined and environmentally regulated. While there are some exceptions to this norm, the rate at which the aging process occurs may be modulated by such factors as activity, diet, environmental considerations, health issues and other influencers.

WHAT IS TASTE? Taste is the perception that results from the stimulation of a gustatory nerve from the oral cavity to the gustatory cortex of the brain where it is established. Taste is also inextricably linked with the sense of smell that also declines with aging and might be at the heart of decreased taste perception. Humans are born with a certain number of taste cells at birth that generally decline over the years. In great part, taste determines food and beverages preferences throughout the lifecycle. This factor may be as important to those who are aging as it is to infants, since it is one of the cornerstones of health and well-being.

WHY FOCUS ON AGING? Declining taste and smell are major reasons why aging people lose their interest in foods and beverages. Declining taste and smell may translate into poor diets and contribute to chronic conditions and/or diseases. Decline in taste generally occurs in people over 50 years of age; however, taste and smell loss may occur even sooner. The phenomenon of global and US aging is exponentially increasing, as addressed in Chapter 1, Global and US Aging, and taste and smell disorders may be parallel in growth.

WHY FOCUS ON TASTE? By improving taste, people who are aging may show increased interest in foods and beverages, thus improving their dietary intakes and reducing their health risks. By ignoring taste, aging people may make poor food and beverages choices that may contribute to poor health and ill feeling. Quality of life may also suffer and healthcare costs may soar.

WHY DOES TASTE CHANGE IN AGING PEOPLE? Compared to the decreases in other body cells and systems, loss or decline in the cells that determine taste and smell is a normal occurrence in the aging process. People may not be aware of the subtle changes in taste and smell as opposed to other sensory changes, such as vision or hearing loss. The exception may be the start of a new medication with change-of-taste side effects, such as when a person detects a bitter taste that dissipates when medication is completed.

WHAT ARE THE CONCERNS OF TASTE CHANGES IN THE AGING? Since taste and smell changes may go unnoticed or overlooked, they are important to address with healthcare providers that may include nutrition professionals such as Registered Dietitians/Nutritionists. /. Changes in taste and/or smell may provoke higher fat, sodium or sugar intake to make foods and/or beverages “taste better,” that may contribute to conditions such as cardiovascular disease, hypertension, diabetes and others.

WHAT CAN RESOLVE TASTE CHANGES IN THE AGING? The purpose of this book is to inform and educate all parties who are involved with aging people and to provide tasteful solutions for chemosensory changes that are associated with aging. Some simple strategies in food selection, preparation and presentation may offer some surprising and welcome options and improve dietary

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intake and health status. Instead of viewing the aging process as a bleak ending to life, the ideas in this book are celebratory, caring and progressive and focus on the possibilities for eating enhancement, enjoyment and recovered energy.

NUTRITION, FOOD SCIENCE AND CULINARY PERSPECTIVES FOR AGING TASTEFULLY This book is similar to Culinary Nutrition: The Science and Practice of Healthy Cooking (Elsevier, 2014) in that is uses a three-prong approach to taste and aging: nutrition, food science and the culinary arts. This is because the food science behind nutrition also has culinary roots. The acts of eating and drinking have both science and art implications, so the three disciplines of nutrition, food science and the culinary arts should be viewed in an interdisciplinary manner. For example, if a person does not perceive a plated arrangement of food as appealing, he or she may not consume it. This is significant since food is not nutritious unless it is consumed, nor can it contribute to good health and well-being. Furthermore, this is why the recommendations provided in Chapter 9, Culinary Considerations for the Aging, are so critical for approachability and satisfaction.

CHAPTER SUMMARIES THAT ADDRESS NUTRITION, FOOD SCIENCE AND CULINARY PERSPECTIVES AND AGING NUTRITION AND AGING Nutrition and the aging process are covered in Chapter 1, Global and US Aging,Chapter 2, Nutritional and Physical Concerns in Aging,Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging and Chapter 12, Prime Time Resources for Aging, Taste and Health, with guidelines that are driven by the nutritional and physical needs of the aging.

Highlights of Chapters 1, 2, 8 and 12: • Comprise the 2015 US Dietary Guidelines with general and specific recommendations for the aging. • Feature solutions for eating issues with easy-to-incorporate foods/beverages that meet specific nutrient requirements and targets recommendations for nutrient-related conditions and disease states. • Focus on phytonutrients and incorporates nutraceuticals (if and where needed) and their roles in healthy diets for the aging.

FOOD SCIENCE AND AGING Food science awareness and roles that address chemosensory decline in the aging and parallel conditions and disease states are discussed in Chapter 3, The Senses, Chemosensory Changes and Aging, Chapter 4, A Taste Primer,Chapter 5, A Smell Primer, Chapter 6, Flavor Enhancement Ingredients and Chapter 7, Flavor Enhancement Techniques.

Highlights of Chapters 3 to 7 • Comprise practical research and applications on taste and smell: informs about the basic tastes of sweet, sour, salty and umami for aging diets, dietary fats as their own taste and texture and products that address acceptance or rejection of foods and beverages by the aging based on taste and smell. • Feature products that are designed for aging diets with their physiological functions, including those that are or contain substances with antioxidant-rich ingredients (for immunity); glucosamine and chondroitin (for joint/mobility); beta glucans (for heart/circulatory health); higher-fiber, higher protein (for muscle maintenance); lactose-free, nondairy calcium sources (for bone health); reduced-acidity, omega 3-fatty acids

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and B vitamins (for cognition); rich in vitamin A and lutein (for vision); and vitamin C (for immunity) and others. • Focus on brain gut connections and emotional and physical satiety that interact with chemosensations and food and beverage intakes.

CULINARY PERSPECTIVES AND AGING Culinary perspectives that include instructions and applications with recipes, menus, tips and techniques for healthful and sensory-appealing foods and beverages and are featured in Chapter 7, Flavor Enhancement Techniques, Chapter 9, Culinary Considerations for the Aging, Chapter 10, Menus and Recipes That Appeal to Aging Palates, and Chapter 11, Cooking Aids, Tableware Tips and Dining Advice.

Highlights of Chapters 7, 9, 10 and 11 • Comprise creative dining programs, menus and recipes that are designed for the aging in a variety of settings, including those who age at home. • Feature unique tips and techniques designed for compromised mobility and functionality, diminished eyesight, taste and smell and reduced functionality of the gastrointestinal and other organ systems. • Focus on chewing and swallowing issues, familiar foods and beverages, flavor enhancement, moist cooking techniques, smaller portions and other age-appropriate considerations.

CHAPTER SUMMARIES Chapter 1: Global and US Aging Summary: To imperatively stress the importance of the growing demographic of aging people in the United States in relation to other population groups and the need for individual and collective attention to their exponentially expanding needs

Chapter 2: Nutritional and Physical Concerns in Aging Summary: To specifically identify the uniqueness of nutritional and physical concerns during aging and the emotional, nutritional and physical stresses on individuals, their care providers, family and friends and healthcare

Chapter 3: The Senses, Chemosensory Changes and Aging Summary: To resourcefully explore the sensations of sight, smell, taste, sound and touch during the aging process, with particular attention to the chemosensory changes of taste and smell and their long-range implications

Chapter 4: A Taste Primer Summary: To expressly examine the sense of taste in the aging, how this sense interacts with the sense of smell and what may be done to compensate for decreased overall taste or specific taste losses in the aging

Chapter 5: A Smell Primer Summary: To explicitly investigate the sense of smell, how this sense interacts with the sense of taste and what can be done to compensate for decreased sense of smell or specific smell losses in the aging

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Chapter 6: Flavor Enhancement Ingredients Summary: To uniquely examine flavor enhancement ingredients specifically designed for the aging from common, everyday foods and beverages to novel manufactured products

Chapter 7: Flavor Enhancement Techniques Summary: To principally examine flavor enhancement techniques that are specifically designed for the aging that may be self-implemented or employed by food healthcare providers or food service personnel and determine their use for improving nutrition and well-being.

Chapter 8: Meeting Nutritional and Disease-Specific Needs of Aging Summary: To distinctively connect specific nutritional needs, conditions and disease states in the aging with foods, beverages, supplements and support systems that may meet nutrient deficiencies, dietary guidelines, drug interactions, ethnic preferences and other specialized requirements

Chapter 9: Culinary Considerations for the Aging Summary: To tangibly comprehend cooking and baking techniques that will be more desirable and palatable for aging palates, contribute to food and beverage appeal, ingestion and ongoing attraction and be easy to prepare, economical, memorable, recognizable and simplistic

Chapter 10, Menus and Recipes That Appeal to Aging Palates Summary: To creatively assist in Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging, and Chapter 9, Culinary Considerations for the Aging, relevant and useful for aging people, their care providers or food service operators. Recipes cover Starters, Soups, Salads, Entre´es, Sides, Desserts, Beverages, Breakfasts and Finishing Touches with information about leftovers and eating out. Each recipe contains tips such as basic tastes, featured ingredients, techniques, substitute ingredients, optional ingredients, recipe variations, nutritional analyses and nutrient modifications. Over 30 finished dishes are captured in color photographs. • • • • • • • • • • •

Starters: Little Appetizer Bites Soups: Light and Wholesome Salads: Fiber and Nutrient Rich Entre´es: Animal and Vegetable Options Sides: Simple Vegetables and Wholesome Grains Desserts: Healthy and Memorable Beverages: Practical and Filling Breakfasts: To Start the Day or Anytime Finishing Touches: Dressings, Marinades, Sauces and Relishes to Increase Palatability Leftovers: Practical, Economical and Tasteful Moving On: Eating Out/Carrying In

Chapter 11: Cooking Aids, Tableware Tips and Dining Advice Summary: To collectively provide special attention to address the ease and pleasure of eating and drinking for the aging, with unique tools, concepts and instructions designed for those who need dietary assistance due to behavioral or physical compromises, especially chewing and swallowing, decreased eyesight, reduced manual dexterity and/or other disabilities

Chapter 12: Prime Time Resources for Aging, Taste and Health Summary: To comprehensibly provide additional resources, from government agencies and educational institutions and other nonprofits to housewares and food and beverage manufacturers, for nourishing aging people enjoyably, healthfully and safely, attending to their healthcare and determining disability and end-of-life choices

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OTHER ELEMENTS Supportive materials accompany many chapters and include tables and figures, insightful sayings from aging people called “Pearl of Wisdom,” a word bank entitled “Manner of Speaking,” references after each chapter and an index that provides clarity of information and easy access. In addition to the photos that accompany Chapter 10, Menus and Recipes That Appeal to Aging Palates, characteristic photos serve to open each chapter.

C H A P T E R

1 Global and US Aging

PHOTO: Steamer Basket r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I like hot sauce on everything—salsa, srirache, Tobasco. Otherwise nothing has taste anymore. I even use it on salad! H.M.

O U T L I N E Summary

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Introduction

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Global Aging Global Aging by the Numbers World Population Aging Populations Worldwide Global Aging and Life Expectancy Global Aging and Disease Global Aging and Ethnic and Racial Disparities Global Aging and Residence Global Aging and Education Global Aging and Employment Global Aging, Health, and Health Care Global Aging and Nutrition Global Aging and Chemosensory Changes

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Aging, Nutrition and Taste. DOI: https://doi.org/10.1016/B978-0-12-813527-3.00001-6

Global Aging Impacts on Nutrition, Food Science, and Culinary Perspectives The Impact of Global Aging Global Aging by the Numbers Impact—Global Gerontology and Geriatrics US Aging US Aging by the Numbers US Life Expectancy US Aging and Disease US Aging and Chronic Diseases US Aging and Ethnic and Racial Disparities US Aging and Residence US Aging and Education US Aging and Employment US Aging and Socioeconomic Costs

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© 2019 Elsevier Inc. All rights reserved.

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1. GLOBAL AND US AGING

US Aging, Health, and Health Care US Aging and Nutrition US Aging and Chemosensory Changes US Aging Impacts on Nutrition, Food Science, and Culinary Perspectives Nutrition and Culinary Arts Partnerships for the Aging

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Impact: Gerontology and Geriatrics in the United States

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Digest

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Manner of Speaking

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References

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LEARNING OBJECTIVES 1. Examine US and global population trends for the aging. 2. Identify US and global aging impacts on nutrition, food science, and the culinary arts. 3. Speculate on future US and global requisites to meet growing aging needs. 4. Highlight food, nutrition and health collaborations that address growing aging needs in the United States and globally. 5. Present forthcoming opportunities that meet increasing nutrition and health needs of the aging in the United States and globally.

SUMMARY To imperatively stress the importance of the growing demographic of aging people in the United States in relation to other population groups and the need for individual and collective attention to their exponentially expanding needs.

INTRODUCTION This chapter provides an examination of aging throughout the United States and globally and attempts to identify the implications of chemosensory changes that are associated with aging on diet, nutrition, health and well-being. The importance of this growing demographic in relation to younger population groups is stressed, as well as the need for more attention to aging populations for improved health, longevity and quality of life. This chapter also provides the foundation for the chapters that follow and gives credence for this interdisciplinary approach of nutrition, food science and culinary arts perspectives. While the population figures and trends for the aging were the most current at the time of this writing, it is important to note that they are anticipated to grow both globally and within the United States, not decline in numbers. The imperative is to gather the information that is presented in the context of diverse aging environments and considerations and take action.

GLOBAL AGING Global Aging by the Numbers For the majority of human history, the aging demographic has represented 5% or less of worldwide populations. This was until the nineteenth century and the Industrial Revolution in the developed world when aging

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populations comprised about 15% of the world’s population. By the mid-21st century, this number is projected to increase threefold or more than in 2015. This increase in the aging demographic means that most developed countries will have both aging populations and declining or stagnant populations simultaneously [1].

World Population In July, 2015 the world population was 7.3 billion and was projected to reach 8.5 billion by 2030 (most current figures to date). From 2015 to 2050 half of the population growth around the world is expected to be concentrated in nine countries (listed according to their size of contribution to total world population growth): India, Nigeria, Pakistan, Democratic Republic of the Congo, Ethiopia, United Republic of Tanzania, the United States, Indonesia, and Uganda [2]. As of 2016, the number of people worldwide who were aged 65 years or older was 8.5% (around 617 million). This percentage is projected to double to almost 17% (around 1.6 billion) of the world’s population by 2050 and more than triple by 2100 [2].

Aging Populations Worldwide Growing aging populations around the world are an upward trend that impacts both developed and underdeveloped countries. As the world populations age, burdens are placed on both economic and social support systems. Throughout Europe, 34% of the population is projected to be over 60 years of age by 2050. In Italy and Germany the aging populations are expected to increase from about one-fifth to one-third of their respective populations by 2050. In Italy, 22% of the population that was 65 years or older in 2015 and this number is projected to increase to 35% in 2050. In 2015, 21% of the population in Germany was 65 years or older and this number is projected to increase to 32% by 2050 [3]. Rapid increases in populations have already impacted Japan where the number of aging people is projected to surpass that of the United States by 2050. Twenty-six percent of the population of Japan was aged 65 years or older in 2015. In comparison, this number is expected to increase to 35% in 2050 [3]. Other parts of Asia, including China and India, have also projected escalated aging populations. By 2050, South Korea will be competing with Germany, Italy and Japan for the country with the oldest country in the world. The biggest increase in aging people over 65 years of age is expected in China that is projected to have about 371 million people by 2050. As of 2015, this number is greater than the entire US population. This is particularly concerning since low fertility levels and rapid economic developments in China and other countries have caused the proportion of older persons to increase over time and reduce available care providers. In general, the US population is aging at a slower rate than in other developed countries. While 15% of the US population was aged 65 years or older in 2015, this segment is projected to increase to 22% in 2050. In comparison, in the Caribbean and Latin America the aging populations are projected to increase from 11% to 12% of people over the age of 60 years in 2015 to more than 25% by 2050. Only 8% of the population of Brazil was 65 years or older in 2015. This figure is estimated to increase to 23% in 2050 (more than in the United States). Mexico, with just 7% of the population aged 65 years and older in 2015, is anticipated to increase to 19% in 2050. As of 2015, Africa had the “youngest” aging population, but it is projected to age rapidly, from 5% in 2015 to 9% by 2050 [3].

Global Aging and Life Expectancy In recent years, global life expectancy has substantially increased in the least developed and poorest countries. Because people are living longer, this phenomenon increases the relative number of aging people. Postwar era, life expectancy in developed countries has increased about 10 years. Now, in most countries, people live until their late seventies or early eighties. For example, life expectancy in China is 76 years, which is higher than in 1950 when it was 41 years. In Mexico, life expectancy is 78 years, which is higher than in 1950 when it was 51 years. In South Korea, life expectancy is 83 years, which is higher than in 1950 when it was 48 years [3]. There was a 6-year gain in life expectancy among the poorest countries worldwide from 56 years during 20 05 to 62 years in 2015. This is about double the gain in life expectancy than in more developed countries around the world. This difference is expected to markedly decrease by 2050 [3].

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1. GLOBAL AND US AGING

Global Aging and Disease Noncommunicable diseases among the aging, including certain cancers, diabetes, heart disease, hypertension and lung disease are anticipated to rise globally. Other common conditions in the aging which include back and neck pain and osteoarthritis, cataracts and refractive errors, chronic obstructive pulmonary disease (COPD), dementia, depression and hearing loss are also expected to increase proportionally with aging. Global aging is also characterized and complicated by complex health states due to multiple underlying factors. These may include delirium, falls, frailty, pressure ulcers, and urinary incontinence among others. A large part of who is inflicted with what health state depends on environmental, physical and social factors as well as ethnicity, gender, genetic and healthcare inequalities worldwide. Changing gender norms, globalization, migration, technological innovations, and urbanization are also concerning and complicating factors in global aging.

Global Aging and Ethnic and Racial Disparities Certain cancers, cardiovascular disease, chronic respiratory disease and diabetes are considered the four main noncommunicable diseases. When at least two of these chronic health conditions occur in an individual, the state is referred to as multimorbidity. Multimorbidity may impact health and quality of life, require complex care management and increase health needs and services. Aging may increase the occurrence of noncommunicable diseases and multimorbidity, and there is a higher incidence of these conditions associated with lower income, low-level education and unemployment, concurrent with higher levels of depression, disability, and poorer quality of life. Physical activity is positively correlated with better health and longevity as well as education and income. It is negatively correlated with age, gender, nonwhite race and ethnicity, rural residency, and weight. Prior to the 20th century, sufficient research on minority populations was sparse. Subsequently, it was then postulated that cost-effective, culturally appropriate and responsive programs may be able to eliminate disparities and thus providing opportunities for better fitness, health, and longevity [4]. There may be more access to health care for intervention in urban environments to help to prevent/control noncommunicable diseases and multimorbidity. The past 50 years have seen massive demographic shifts from rural to urban living worldwide. The majority of the world’s population now lives in cities, although as in the United States there is increasing disparity. Older people with financial flexibility, desirable knowledge and skills might have better access to global health care and better equipped to control the ravages of the diseases of multimorbidity and the escalating healthcare costs than those with less means.

Global Aging and Residence An increasing number of aging people are residing in urban areas. As of 2007, about half of the world’s population was living in cities. Mega-cities, with 10 million inhabitants (such as Mexico City, Moscow, New Delhi, Rio de Janeiro, Shanghai, and Tokyo) or more increased 10-fold during the 20th century and accounted for 9% of the world’s urban population in 2005. This number is projected to rise, particularly in cities with fewer than 5 million inhabitants and that by 2030 three out of five people globally are projected to reside in cities [5]. Aging people who reside in cities in less developed regions of the world will then outnumber those who reside in developed regions of the world by about four times. This number is projected to increase from 56 million in 1998 to over 908 million in 2050. The aging will then comprise about one-fourth of the total urban population in less developed countries [5]. In general, people want to age in place where it is familiar as long as possible. This phenomenon is caringly referred to as “aging in place.” Place-based interventions are needed to help to accommodate this unending need. Creating more age-friendly cities worldwide my help to promote the health and well-being of their residents and the continuity of community life.

Global Aging and Education Differences in rural and urban education among countries worldwide may reflect distinct epidemiological and social histories and present unique disparities. These differences may also determine how people age across time and place and may reveal how education is related to life expectancy.

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Low levels of education vary globally. A low level of education may be considered as only a third-grade education in the United States; slightly higher than a third-grade education in Taiwan, through a middle school education in China and England; and a slightly higher education level than third grade in Mexico. This makes early education a difficult variable for comparison among countries and their aging populations. Additionally, low education in certain countries may be associated with underweight (such as in Indonesia), while in China, England and Mexico obesity is more common with low education. While being too under- or overweight is considered a health risk during aging, obesity is consistently a marker of greater health hazards and reduced life expectancies at other junctures of the lifecycle [6].

Global Aging and Employment There are clear differences in the labor force and labor force participation in those who are aging around the world. In general, countries with more substantive economic resources, higher income per capita and patterns of public spending that provide financial security for people who are aging tend to have lower rates of active labor force participants by the aging. For example, declining labor force participation by aging men in 2015 occurred in Greece, Japan, and Poland. In lower-income countries where residents may have to work until they are mentally or physically unable, early retirement may not be an option. For example, some aging African men and women had the highest rates of labor force participation than in the rest of Europe in 2015. More than 50% of African men and more than 30% of African women were employed at during 2015, versus less than 10% of European men and less than 5% of European women in the workforce. However, the impressive amount of aging people that were working at that time was contradicted by Algeria, South Africa, Egypt, and Tunisia where the aging labor force was below 15% in 2015. In Malawi, Mozambique, the Central African Republic, and Zimbabwe more than 70% of their aging were not working. Also at this time, countries with increasing labor force participation by both aging men and women were Australia, New Zealand, Sweden, and the United States. This was especially true in countries where the aging were employed in agriculture and mining. The global gender gap among people 65 years of age and older in the workforce has been held constant since the 1990s. While labor force participation rates for older men have increased more than older women in developing countries, the impact of economic activity by older women is on the rise. Aging female laborers are more prevalent in more developed societies, among women who accept less traditional roles and among women who have fewer children. Though European countries had the smallest gaps between men and women in the labor force, Guatemala and Pakistan had the largest gaps. Unless the retirement ages increase parallel to increased life expectancy, global societies may have to shoulder the extra costs that are incurred by longer periods of retirement. Part-time work provides an income stream for the aging and an outlet for social connections. It is more common among older women than in older men worldwide. In 2013, about 40% of older women were employed part-time worldwide compared to 33% employed fulltime. In comparison, under 20% of older men were employed part-time in countries that include Greece, Latvia, Russia and South America, and over 60% of older men were employed full-time in Belgium, Germany, Luxembourg, the Netherlands, and Sweden. Countries that had a higher interest in hiring aging employees were Germany, India, and Sweden and those with a lower interest in hiring aging employees were Greece, Japan, and Spain. Unemployment patterns tend to vary across different genders and over time. They are difficult to access due to business cycles, differences among countries and lack of data. During the Great Recession (2007 09) that originated in the United States, world markets experienced a general economic decline and nearly all European Union member countries were affected. China and India also experienced slow economic growth during this time period. The retirement plans and wealth of aging populations that were most affected by the Great Depression were also affected by declines in asset prices—especially in financial investments and housing. Concurrently, the Great Depression had major impacts on unemployment rates among the aging, but rising labor force participation in developed countries around the world continued (except in Ireland, Greece, and Portugal). Some aging people were motivated to postpone retirement while other aging people returned to the workforce (and still others retired). Financial circumstances and health problems complicated their decision-making.

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Aging workers in Canada and China were more optimistic about their lifestyle post- retirement, while those who were aging in France, Hungary, Poland, and Spain were less confident in 2013. In the United States, Baby Boomers were generally pessimistic about their future living standards postretirement that could have been attributed to difference in experiences and hope. Statutory requirement ages vary worldwide from 55 to 65 years of age. Some European countries and the United States are gradually increasing (or considering to increase) their statutory ages for pensions [7]. It is projected that global government budgets will be pressured by rising pensions and healthcare expenditures. Businesses will have fewer young workers and families will have frailer elders. Budget allocations for social security will need to increase. To date, the social security system in India only covers about 10% of its working population and the system operates at a deficit. India is expected to experience a 46% increase in its working-age population over the next 25 years, but with slow economic growth. India’s oldest old may be destined for economic ruin. China, Japan and Mexico are expected to experience a decline in their workforce from 2030 to 2050. In European countries, some nations have payroll tax rates that equal or exceed 20% of wages to fund social security. In the United States, it was projected that social security contributions may fall short of legislated benefits in 2017 and beyond. These changes might lead to an increase in the “age dependency ratio,” which is the ratio of working-aged individuals to older-aged individuals. In 1970, this age dependence ratio worldwide was 10 workers for each person who was 64 years of age or older. By 2050, the Age Dependency Ratio is anticipated to be four workers for each person who will be aged 64 years or older [8]. Economic growth is also predicted to slow as the rates of savings and investments are prone to fall as the aging workforce declines. However, pension and healthcare reform and support of healthier and longer work lives may help to ameliorate some of these declines in proactive countries worldwide.

Global Aging, Health, and Health Care The World Health Organization (WHO) estimated that by eliminating the major health risk factors (inadequate diet, lack of exercise and smoking) that are implicated with chronic disease, then cardiovascular disease, stroke, and type 2 diabetes would substantially be reduced as much as 80% [9]. To achieve the ultimate goal of achieving active and healthy aging, in 2006 the WHO developed a policy framework that focuses on the prevention and reduction of chronic diseases, disabilities and premature mortality; the reduction of risk factors that are associated with noncommunicable diseases and functional decline to protect health; the enactment of policies and strategies for a continuum of care for the aging with chronic diseases and/ or disabilities; the education and training of care providers; the dignity, protection safety; and aging of the aging and the enablement of the aging to contribute to their communities and their families and economic development. In 2015, the WHO released the first World Report on Ageing and Health that considers aging from a lifecycle perspective and focuses on the second part of life [10].

Global Aging and Nutrition According to the WHO, those people who are aging are especially positioned for malnutrition. In addition, there are practical problems for the provision of adequate nutrition to the aging. Though caloric needs are less than during younger years due to decrease in both lean body mass and basal metabolic rate, other nutrient needs may actually increase. In 2002, despite the increasing numbers of older people in developing countries, the nutritional requirements for the aging were not well defined. This created a need to review the current recommended daily nutrient requirements and WHO guidelines. Collaborative efforts with the WHO included the US Department of Agriculture Human Nutrition Research Center on Aging at Tufts University in Boston, Massachusetts to examine the epidemiological and social aspects of aging [11]. Factors that were taken into consideration were influences that affect dietary intake and nutrient absorption in the aging; nutritional requirements of aging people; nutrition for people who are aging in developing countries; nutrition and immune function in the aging; dietary guidelines for the aging; and community support and interventions among the aging [11].

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Recommendations for energy (calories), calcium, copper, chromium, fat, folate, iron, magnesium, protein, riboflavin, selenium, vitamins A, B12, C, D, E, K, and zinc were established, as well as food-based guidelines, phytochemicals, water, exercise, and physical activity need to maintain an optimal immune response and reduce the burden of disease. These nutrients and other considerations will be discussed in Chapter 2, Nutritional and Physical Concerns in Aging.

Global Aging and Chemosensory Changes With the considerable population changes that are anticipated globally, requisite changes in such areas as packaging, product design, private and public spaces, transportation and workplace features are looked-for to follow. This is especially important to meet the chemosensory changes that may parallel aging and their effects on cognition, sensory function and mobility. Chemosensory changes (or alterations in responses to chemical stimuli) include audition (hearing), gustation (taste), kinesthesis (body movements), olfaction (smell), textural and trigeminal senses (touch or pain), and vision (sight). From global food science and technology standpoints, while obvious solutions to these changing needs is to develop flavor systems with enhanced flavors to appeal to chemosensory decline, older consumers may not think that they need or want flavor-enhanced foods and beverages. Due to problems chewing and/or swallowing some aging people may also require more texture-modified foods. These realizations and acceptances may require more professional and public education about availability, benefits and costs, and other variables. It is also important to note that other age-associated factors that impact food intake, such as appetite and satiety, eating alone and healthy food and beverage access should be considered along with chemosensory changes in the aging for optimal nutrition, health, and well-being.

Global Aging Impacts on Nutrition, Food Science, and Culinary Perspectives The aforementioned population predictions indicate that the number of aging people worldwide are, and will be, significant yet wide-ranging. However, this makes it virtually impossible for blanket recommendations for all aging people. Still, nutrition, food science and the culinary arts may both independently and collectively address the profound changes that are, and will be occurring, throughout the United States and global aging. Many are addressed and outlined in the following chapters of this book. Nutrition In 2014, the World Health Assembly initiated a comprehensive global strategy and action plan for aging and health. In 2016 the 69th World Health Assembly produced the report, “Multi-sectorial action for a life course approach to healthy ageing: global strategy and plan of action on ageing and health.” This strategy was considered a significant step in the establishment of a framework for member states to move forward so that all people can live healthy and long lives [12]. The strategy had two goals: (1) 5 years of evidence-based actions to maximize functional ability that reaches every person and (2) by 2020, establish evidence and partnerships necessary to support a Decade of Healthy Aging from 2020 to 2030. The strategy also had five strategic objectives: (1) commitment to action on Healthy Ageing in every country; (2) developing age-friendly environments; (3) aligning health systems to the needs of older populations; (4) developing sustainable and equitable systems for providing long-term care (i.e., communities, home, and institutions); and (5) improving measurement, monitoring, and research on healthy aging. In this document, healthy ageing (aging) is defined as “the process of developing and maintaining the functional ability that enables well-being in older age.” Functional ability is determined by intrinsic capacity (a combination of physical and mental capacities) and environmental factors—nutrition, health, and long-term care vital components. Economic and resource issues, food insecurity, nutrient intake (both excessive and inadequate), nutrition screening, sarcopenic obesity, and weight loss were some of the independent and collective concerns considered essential to address during this Strategy’s timeframe [12].

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Food Science The global food industry has been addressing aging consumers’ needs for products to help them cope with chronic conditions and illnesses, combat some of the ravages of aging (such as diminished eyesight, hearing, and taste) and potentially help extend lifetime. Some of these strategies have included products with increased animal and vegetable proteins to boost metabolism and prevent fat gain and muscle loss; antioxidants such as vitamins A and C to strengthen immunity; Bvitamins and omega-3-fatty acids for cognition and to protect against dementia and Alzheimer’s disease; beta glucans and fibers for heart health and circulation; eye-enhancing nutrients such as lutein and vitamin A for better eyesight; supplements such as chondroitin and glucosamine for joint health and mobility; and vitamins A, D, and K and minerals such as calcium, phosphorus, and magnesium for bone health. Other food products on the global horizon may offer options for balancing blood sugar, boosting the immune system, decreasing the risk of prostate cancer, lowering blood pressure, and many more prospective benefits. Culinary Arts The aging might experience some difficulties cooking that may be caused by dysfunctional kitchen designs and products along with decreased functional capacities. The acts of bending down to retrieve items from lower shelves or storing items on higher shelves; cleaning the kitchen after cooking (particularly the stove and its accompanying equipment); using major and small appliances; and opening packaging continue to be some of the topmost concerns worldwide that prevent those who are aging from cooking. Aging eyesight may interfere with aging people from reading packaging and recipes correctly. Aging smell may preclude aging people from knowing when food is ripe or spoiled. Aging taste may contribute to too much fat, salt, or sugar used in cooking. Aging touch may cause hot foods and beverages to be too hot or too cold, interfere with food choices and perhaps the digestion process. These sensory changes may not be universal. Given anticipated societal changes with fewer younger family or eldercare providers, people who are aging may be alone to handle the challenging and cumbersome chores of cooking. Providing realistic, nutritious foods and beverages that require a minimum of shopping, preparation, cooking, and cleanup may be necessities of food preparation for this rapidly growing demographic. Smaller kitchens and age-friendly cooking and dining equipment are also anticipated to be in demand. See Chapter 11, Cooking Aids, Tableware Tips and Dining Advice, for more details. Also see below.

The Impact of Global Aging It may be difficult to fathom the enormity of global aging or the ramifications. As a country or society, it may be easier to address and manage current population needs than to anticipate or strategize for the future. The summary in Table 1.1 may help to condense the facts and illuminate the immediacies for calls to action.

Global Aging by the Numbers TABLE 1.1 Global Aging: Facts, Figures, and Future Needs • The 2015 world population was approximately 7.3 billion. • It is expected to reach 8.5 billion by 2030. • Brazil, China, Germany, Italy, Japan, and Mexico should be monitored to gauge how these rapidly growing countries address their aging population issues. Life expectancy • In most countries worldwide people live until their late 70s or early 80s. • Global life expectancy substantially increased in the least developed and poorest countries worldwide. Disease • Noncommunicable diseases (such as certain cancers, cardiovascular disease, diabetes, and stroke/hypertension) are anticipated to rise globally. • Other common maladies of aging (such as back and neck pain and osteoarthritis, cataracts and refractive errors, chronic obstructive pulmonary disease, dementia, depression, and hearing loss) are expected to increase globally. (Continued)

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TABLE 1.1

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(Continued)

Ethnic and racial disparities • Certain ethnic groups may have lower levels of quality-adjusted life expectancy and require specialized attention for lifestyle improvement and access to health care. • Racial disparities related to inequities in medical care, neighborhood environments, and socioeconomic circumstances reflect racial disparities in mortality over time. Residence • As of 2007, one-half of the world’s population was living in cities. • By 2030, three out of five people may reside in cities globally. Education • Low-level education varies by country. • The differences may reflect distinct epidemiological and social histories and present unique disparities. Employment • Clear variances exist in labor force participation and global aging. • While global labor force participation rates for older men increased more than older women, the impact of economic activity by aging women is on the rise. Socioeconomic costs • Rising pensions and healthcare expenditures are projected to affect global government budgets. • Global aging may increase “Age Dependency Ratio”: number of working aged-individuals compared to aging individuals. Health and health care • The WHO estimated that by eliminating major health risk factors (such as inadequate diet, lack of exercise, and smoking) that noncommunicative diseases (such as certain cancers, cardiovascular disease, diabetes, and stroke/hypertension) would substantially be reduced. • WHO developed a policy framework for disease prevention and reduction in 2006. Nutrition • According to the WHO, those who are aging globally are more prone to malnutrition. • Global nutritional requirements for those who are aging are not uniformly well defined; there is a need for collaboration to collect more information and establish recommendations. Chemosensory changes • Chemosensory changes may exacerbate the effects of aging on cognition, sensory function, and mobility. • Changes in packaging, product design, private and public spaces, transportation, and workplace features may be needed to globally meet the chemosensory changes that are instigated or elevated by aging. Nutrition, food science, and the culinary arts • A comprehensive global strategy and action plan for aging and health were initiated in 2014 by the WHO. • Antioxidants and phytonutrients, bone vitamins and minerals, brain health circulation, eyesight, heart health, immunity, joint health, mobility, and muscle loss are ripe for culinary, food science, and nutrition global innovations. • Aging mobility, agility, eyesight, and smell create unique yet universal problems for food preparation and cooking, with limited family and eldercare providers available to help.

IMPACT—GLOBAL GERONTOLOGY AND GERIATRICS Many global organizations are dedicated to gerontology and geriatrics, as in the United States. What follows is a sampling. See Chapter 12, Prime Time Resources for Aging, Taste and Health, for more ideas and sources. The mission of the International Association of Gerontology and Geriatrics (IAGG) is to promote gerontological research and training worldwide and to interact with other intergovernmental and nongovernmental organizations and international associations to help to enhance the quality of life and well-being of aging people at individual and societal levels. Members include key opinion leaders in health and social services, housing and income support, public policy and administration, research and education, and other disciplines that impact the aging worldwide.

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The IAGG for the European Region has four main purposes in addition to those of the IAGG: (1) To promote gerontological research in the behavioral, biological, medical, and social psychological fields; (2) to promote the training of highly qualified personnel in the aging field; (3) to promote the interests of the gerontological organizations in international matters; and (4) to promote and assist in the European and International Congresses [13]. The Global Coalition on Aging (GCOA) is a compilation of world leaders who represent different industries and geographies, from health and pharmaceutical companies to financial services and technology. The coalition is committed to fostering discussions about global aging and longevity. The GCOA aims to reshape how global leaders both approach and prepare for the world’s aging population growth. It serves to advance innovation solutions through advocacy, communication, public policy analysis and research for “fiscally sustainable economic growth, social value creation and wealth enhancement” [14]. The GCOA designates people who are aged 55 through 75 years as the “new middle age” and supports them for their productivity and potential wealth creation. Advocacy for policy adjustments and workplace programs that promote healthy living, saving, smarter learning and working along with reduced dependence on government programs are also supported, as well as optimism for the achievements that are attained with longevity. The International Federation on Ageing is an international, nongovernmental organization comprised of academics, governments, industry, NGOs and individuals worldwide. It consults with the United Nations and the WHO and has been involved with such key initiatives as the US Principles for Older Persons and the Sustainable Development Goals. It is particularly concerned with the maintenance of a strong voice in the protection of the rights of the aging around the world [15]. Other international organizations that are dedicated to gerontology and geriatrics include the regional suborganizations of the IAGG, the International Council on Active Aging, and the International Psychogeriatric Association among many other regional and local societies and groups. There is also cross-membership among the US organizations that are also committed to gerontology and geriatrics. It is anticipated that more analogous organizations will form and grow as the world ages. Also see the section Gerontology and Geriatrics in the United States that follows in this chapter.

US AGING As expressed in the overview of this textbook and introduction to this chapter, global aging is occurring in exponential numbers, and this includes aging throughout the United States. Shared concerns include life expectancy, disease, ethnic and racial disparities, residence, education, employment, sodium-economic costs, health and health care, nutrition, chemosensory changes, and other concerns. An eye-opening account of the numbers of aging people in the United States follows.

US Aging by the Numbers As of November, 2016, the number of Americans who were aged 65 years or older was over 50 million. This figure was more than the combined population of 25 US states and a new milestone, since was the first time in US history that so many Americans were recorded to be aging in record numbers. Additionally, this number has steadily increased since the 1960s. The number of Americans who are aged 65 years or older is projected to more than double to over 98 million by 2060. Their share of the total US population is projected to increase from 15% to about 24% during this time period. Moreover, the aging US population is transforming by more racial and ethnic diversity. From 2014 to 2060 the aging non-Hispanic white segment of the US population is projected to decrease from about 78% to about 54% [16].

US Life Expectancy A combination of the post-World War II baby boom and longer life expectancy has contributed to this aging population surge in every US state. This trend is projected to result in more US Medicare beneficiaries and higher US Medicare spending, with fewer contributions into the US Medicare system.

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This trend parallels the increase in US life expectancy from an average of 68 years of age in 1950 to 79 years of age in 2013. In 2017, US life expectancy was 76.5 years for US men and 81.2 years for US women. It was speculated that nearly 10,000 baby boomers will become 65 years of age each day for the subsequent 15 years. The growth in the aging segment of the US population is due, in part, to declines in fertility and immigration after the US Great Recession during 2007 09. This growth is considered as one of the most notable demographic trends in the United States [17]. The United States is on course for the lowest average life expectancy levels of all the richest countries worldwide. The average life expectancy predicted by 2030 is 79.5 years for men and 83.3 years for women, which is similar to the life expectancies forecasted for Mexico and Croatia. As of 2012, the United States ranked only 27th out of 34 countries in overall life expectancy, as determined by the Organization for Economic Cooperation and Development. This may be due to obesity and tobacco use in the United States [18]. Healthy Americans may expect to live disability-free until about 70 years of age. There is a trend for increased life expectancy while disability-free due to the prevention and treatment of certain chronic diseases, including eye disorders and heart disease. While US baby boomers are less likely to smoke cigarettes than their parent’s generation, they tend to have more diabetes, high blood pressure, and obesity than other generations that may require more disability benefits. The number of centenarians in the United States has increased since 1980, from about 32,000 Americans to more than 53,000 in 2010. This number is speculated to increase to more than 600,000 Americans that are 65 years of age or older by 2060. The aging US population is not uniform; rather, it is more concentrated in certain parts of the country more than in others. These include the Appalachian region, Florida, and parts of the upper Midwest and Northwest. About 77% of counties throughout the United States (particularly in rural regions) already have aging populations that are at or over the national average. Populations in Alaska and the western states tend to have smaller numbers of people who are aging. The largest cities in the United States are already experiencing an increase in aging. The top 25 cities with the highest percentage of aging include (in descending order): Seattle, Washington; Austin, Texas; San Jose, California; Charlotte, North Carolina; San Antonio, Texas; Dallas, Texas; Charlotte, North Carolina; Houston, Texas; Phoenix, Arizona; San Diego, Florida; Jacksonville, Florida; El Paso, Texas; Columbus, Ohio; Boston, Massachusetts; Denver, Colorado; Nashville, Tennessee; New York, New York; Los Angeles, California; San Francisco, California; Chicago, Illinois; Indianapolis, Indiana; Detroit, Michigan; Memphis, Tennessee; Philadelphia, Pennsylvania, and Baltimore, Maryland [19].

US Aging and Disease In the early 1900s, the main health hazards in the United States were infectious and parasitic diseases that mainly claimed infants and children. Today, noncommunicable diseases such as certain cancers, heart disease, diabetes and hypertension or stroke may affect those who are aging and pose even greater burdens on health and well-being, not to mention economic growth. Reducing the disabilities that result from these diseases may enhance health and reduce societal costs. People can choose to remain healthier and more independent into older ages than ever before. Approximately 11% of aging Americans were diagnosed with Alzheimer’s disease and dementia in 2015. Dementia and especially Alzheimer’s disease are potential consequences of longer life expectancies and many people with dementia and Alzheimer’s disease may require constant care. This type of care is projected to pose a weighty financial and social burden on the United States. Due to demographic and family changes there may be fewer care providers to provide for the nutritional and personal needs of those who are inflicted with Alzheimer’s disease or dementia. Dementia and Alzheimer’s disease may also exacerbate other conditions or diseases and further reduce health and quality of life.

US Aging and Chronic Diseases As of 2017, about 92% of those aging in the United States have at least one chronic disease, and about 72% have at least two chronic diseases. The noncommunicable diseases of some cancers, diabetes, heart disease and hypertension/stroke account for about two-thirds of all deaths in the United States annually.

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There is a disproportionate amount of money spent in the United States on health care for these chronic diseases compared to the amount of healthcare dollars that are spent on improved public health. As of 2009, 75% of health care is designated for chronic diseases in the United States, while only 1% of healthcare dollars are invested in public health improvements [20]. About 29% of aging Americans were treated in 2015 for ischemic heart disease (IHD), a condition caused by plaque that builds up in the coronary arteries. IHD decreases the amount of oxygen-rich blood that is delivered to the heart and may cause other complications such as angina, blood clots, or heart attacks. About 47% of aging Americans had high cholesterol, a precursor of heart disease and about 14% had heart failure. While diabetes affected 12.2 million Americans aged 60 years or older (about 23% of the US population), it was projected that lifestyle intervention may be able to reduce the risks of developing diabetes in this age group by about 71% [21]. Likewise, about 90% of aging Americans are at increased risk for developing hypertension. American women are more likely to develop hypertension than American men. It was estimated that about half of American women who are aged 60 years or older and 77% of American women who are aged 75 years or older have hypertension in comparison to 64% of aging American men [21]. Aside from Alzheimer’s disease and dementia, arthritis, chronic kidney disease, COPD, falls, fractures, depression and anxiety disorders, substance abuse, and suicide are other issues that may severely impact the aging during the final years of their lives. About 31% of aging Americans had arthritis in 2015. About 14% of people 65 years or older in the United States were diagnosed with clinical depression, 18% had chronic kidney disease and about 11% had COPD [21]. Each of these chronic conditions have lifestyle interventions that may help to prevent the onset of the conditions and/or mitigate the ongoing conditions. Many nutritional interventions will be discussed in Chapter 2, Nutritional and Physical Concerns in Aging [21].

US Aging and Ethnic and Racial Disparities The aging population in the United States is evolving to be more ethnically and racially diverse. In 2014, over three-fourths of Americans aged 65 and older were non-Hispanic white. Between 2030 and 2060 non-Hispanic white Americans who will be aged 65 years or older will drop by about 17% and aging Hispanic Americans will double in size, from about 11% to 22%. The proportion of the US population that is non-Hispanic white is projected to decrease from 78.3% (as determined in 2014) to 54.6% by 2060 [22]. Between 2014 and 2030 it was speculated that the aging Caucasian US population will increase by 46% compared to 110% for racial and ethnic minority populations that include Hispanic (137%), African American (90%), American Indian and Native Alaskan (93%) and Asian (104%) [22]. This diversity gap between aging Americans and those under 20 years of age may contribute to an “intergenerational conflict” over public resources. A mostly Caucasian older population that is eligible for Social Security and Medicare benefits may be in opposition to a younger and racially and ethnically diverse workforce, also vying for available US dollars.

US Aging and Residence Those who are aging in the United States are tending to “age in place,” staying where they live as opposed to younger Americans who are more mobile. This phenomenon is particularly true in the rural Midwestern states and may lead to difficulty accessing nutritional beverages and foods, increased health issues, isolation, and loneliness. About one-fourth of aging US men and women between the ages of 65 and 74 years lived alone in 2014. This number increased to 42% among the 75-to-84-year age group and to 56% among the 85 years or older age group [23]. In addition to higher divorce rates, fewer children among the aging also has contributed to this isolation. A “gray divorce revolution” has been noted in aging baby boomers over 50 years of age, along with an increase in cohabitation of unmarried baby boomers. If aging adults live alone, then they may lack the care that they may require if they are injured or ill. Divorced women, in particular, may have less income and/or live in poverty. These circumstances may increase the demand for community-based social services and/or home health care. Furthermore, there may be less money

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for food and more medical expenses including prescription drugs and costs for transportation to/from healthcare providers. In 2014, the majority of aging Americans lived in apartments and homes compared to group quarters, such as nursing homes or skilled-nursing facilities. The proportion of aging Americans who live in nursing homes tends to increase by age 80 and above. Due to the large number of US baby boomers it is expected that a substantial number of people will need nursing homes or skilled-nursing facilities by 2030. About 1.3 million people aged 65 years and older required nursing or skilled-nursing facilities in 2010, and this number is expected to increase to about 2.3 million by 2030 and almost 3 million by 2060. In 2016, about 8% of the gross domestic product (GDP) represented US Social Security and Medicare expenditures, which is projected to increase to about 12% by 2050 [23].

US Aging and Education The completion of education beyond high school is associated with a longer life expectancy and better health. Aging Americans are more educated today than they were in 1965 when only 5% had completed a bachelor’s degree at the minimum. This is in comparison to 2014 when 25% of Americans aged 65 years or older completed a bachelor’s degree at the least. More aging US men (31%) than aging US women (20%) attained a bachelor’s degree or greater in 2014. This is significant since lower levels of education in aging US women tend to affect their socioeconomic status, with lower income levels and higher poverty rates, and may lead to poorer nutrition status and health [24].

US Aging and Employment It is forecasted that by 2050 that the United States will still be growing in population and in its workforce. As of 2014, about 15% of US women and 23% of US men aged 65 years or older were still working. These figures are projected to increase to 20% of aging women still working and 27% of aging and working men by 2022 [25]. Since the 1990s, the rising labor force has benefitted by employee-funded defined contribution plans, such as 401(k)s; mandatory retirement ages have been eliminated or nearly so, and Americans are able to work past the ages of 60 or 65 years [25]. This is coupled with the ability of American workers to receive full Social Security benefits by age 66 or 67, with less tax penalty for earning income while receiving Social Security benefits. Since Americans are both in better health and living longer, they may benefit by these provisions; however, these provisions may change according to governmental priorities. In addition, since the 1990s, some aging Americans are returning to the workforce beyond retirement age on a consultant or part-time basis.

US Aging and Socioeconomic Costs Aging Americans are doing better economically than in the mid-1990s. The poverty rate in the US for people who are aging over 65 years of age has dramatically dropped since 1966 from 30% to 10% in 2014. This may be due, in part, to the expansion of Social Security expenditures that helped to keep poverty under control among the US aging for more than three decades. However, there are widespread economic disparities among US subgroups within the aging populations. Divorced aging women, aged 65 years and older, increased from 3% in 1980 to 13% in 2015. Divorced aging men, aged 65 years and older, increased from 4% to 11% also during this time period. Higher poverty among older US women may be linked to the gender gap in wage inequity compared to men, lower Social Security payments for women during retirement years, and higher out-of-pocket healthcare expenses over longer lifetimes [26]. In 2015, about one-fifth of aging US racial and ethnic minorities relied on Social Security for some of their income compared to about 13% of aging US Caucasians. Social Security benefits accounted for the income of 21% of higher-income households that were headed by the aging, while 43% of their income was derived from earnings. This was about four times that of lower-income households that were headed by the aging.

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Also, assets from investments, rental income and savings accounted for a higher share of income at 12% in higher-income households that were headed by the aging, compared to lower-income households that were headed by the aging at a 2% share of income.

US Aging, Health, and Health Care When compared to previous generations, the aging US population appears to be healthier; living longer with less disabilities and losses of mental or physical functions. But upon closer assessment, it may be seen that aging Americans are living longer but with at least one chronic condition. Some conditions are more complex and create a greater strain on healthcare dollars. During 2012 14 the most frequent occurring conditions among those who were aging were arthritis, heart disease, cancers, diabetes, and hypertension. These conditions put a burden on long-term care for mental and physical well-being. The obesity rates among aging Americans have been steadily increasing similarly to the rest of the US population. During 2009 12 about 40% of 65 74 year olds were classified as obese. Among aging US men aged 65 74 years, obesity rose from 24% to 36% over two decades since 1988. In aging US women, obesity rose from 27% to 44% during this same time period. Obesity is considered both a disease and as a risk factor for a variety of other chronic conditions and/or diseases that include arthritis, some cancers, diabetes, heart disease, hypertension, and others. A steep rise in the number of Americans who live with Alzheimer’s disease is projected as Americans age with a concurrent increase in needed elder care. About 5 million Americans were afflicted by this age-related condition in 2013, which is expected to triple to about 14 million Americans by 2050, and place increased burden on long-term care and medical costs. Progressively aging US Americans with disabilities may rely on assistive devices and technologies to aid their independence, such as scooters, walkers or wheelchairs. The 1990 Americans with Disabilities Act promoted the use of assistive technologies and public accommodations for Americans with cognitive or functional limitations. Unfortunately, Caucasians and aging Americans with higher education and income levels were/are more likely to employ these technologies and prevent disabilities from deteriorating further than lower-income Americans. Annual healthcare expenditure per person for aging people who were 85 years or older in 2015 was nearly five times higher than the national average of $7097.00. In addition, Medicare spending was then projected to increase to 3.8% of the GDP by 2026. The ratio of people that are of working age compared to the number of people that are of retirement age has been shifting. In 2000 there were slightly over five working persons for each retired person, but by 2030 this number is projected to drop to three working persons for each retired person, that is projected to cause more strain on US Medicare and Social Security [27].

US Aging and Nutrition As the US population ages, an increasing significant portion will be prone to “nutritional frailty,” a condition characterized by sudden and significant weight loss, loss of muscle mass and strength which makes a person vulnerable to disability. In turn, this condition may result in additional age-related diseases that may include cognitive decline, infectious disease, malnutrition, and/or sarcopenia, a degenerative loss of skeletal muscle mass, quality, and strength associated with aging. On the other hand, the prevalence of obesity is increasing in the United States as it is globally. Obesity is associated with noncommunicable diseases such as certain cancers, diabetes, heart disease and hypertension in the aging. Still, overweight and mild obesity have been associated with some of the lowest all-cause mortality in the aging in the United States. Aging people in the United States and globally may have less support in procuring nutrient-dense, ageappropriate diets. This is especially true if they live in remote or impoverished areas. They may also be prone to more age-related changes in appetite, chewing and dentition, mobility, and taste and smell. As a result, they may fall short in such nutrients as calcium, carotenoids (vitamin A precursors), dietary fiber, magnesium, omega-3 fatty acids, potassium, protein, and vitamins B6, B12, D, and E. Common medications that are taken by the aging may also affect nutrient requirements since they may interfere with proper absorption or metabolism of certain nutrients. Supplements may also be warranted but they may be subjected to absorption and metabolism issues.

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In general, people who are aging tend to have inadequate dietary intakes of fish, fruits, lean meats, low-fat dairy products, legumes, nus or seeds, poultry, vegetables, and whole grains, and more than ample intakes of added sugars, fatty meats, fried foods, processed meats, refined grain products, and solid fats—much like their younger counterparts. For older adults who live in remote areas or some communities such as senior centers, inadequate intake of nutrient-dense foods may be one of the main causes for under-nutrition due to inadequate detection or treatment [28].

US Aging and Chemosensory Changes Declines in the sensory systems involved in hearing, smell, taste, and vision have been detected in those who are aging in the United States. These declines may impact food acceptance, choices, decisions and enjoyment, and may further affect food intake, nutrient status, health, and well-being. Olfactory loss may decline in the late 60s to early 70s and then decline further thereafter, particularly in men more than women. This decline and lack of regeneration in the olfactory cells may be an early indicator of early onset or subsequent aging. Localized taste loss is common in the aging and somewhat analogous to phantom taste sensations that may occur after bacterial, medicine-related and/or viral conditions. Sensory disorders of the aging such as these may affect the quality of life by reducing food enjoyment, increasing food safety and personal hygiene concerns, and/or impacting employment performance. While taste disorders may impact the quality of life less than smell disorders, taste disorders may have a greater impact on food intake. Approximately 19% of people who are 40 years of age or older in the United States have reported problems that involve the ability to taste and about 23% have acknowledged problems with their ability to smell [29]. These numbers may not accurately capture the numbers of Americans with taste and/or smell disorders since they are difficult to recognize and may even be more difficult to admit and/or diagnose. In aging Americans who are 80 years or older, these figures increase to 27% of Americans who recognize decreased taste and 31% of Americans who recognize decreased smell. Once again, these figures are based on self-assessments and may not fairly represent the entire field of partakers.

US Aging Impacts on Nutrition, Food Science, and Culinary Perspectives What is quite profound about the trends in United States and global aging is that while aging is inevitable there are lags in keeping pace. Aside from the effects that aging has upon factors such as disease, education, employment, ethnic and racial disparities, health care, life expectancy, residence, and socioeconomic costs, aging has profound effects on the future of nutrition, food science, and the culinary arts and how these fields interrelate with the above-mentioned factors. Nutrition The United States Department of Agriculture (USDA) created a Healthy Eating Index (HEI) for 1994 96 that summarized the diet quality of Americans who were aged 65 years and older. HEI was used to assess the quality of food assistance menus, packaging and the US food supply; examine the relationships between diet and healthrelated outcomes, diet costs and quality and the effectiveness of nutrition interventions; and monitor the quality of American diets. This document was compared to the 1995 US Dietary Guidelines and some of the many conclusions included that 13% of those queried had poor diets, 67% needed improvement and diet quality slowly declined past 74 years of age [30]. In this summary, it was ascertained that one of the factors that influenced the dietary quality of aging Americans was income. People with higher incomes were able to purchase foods with more variety and conceivably more fruits and vegetables, thus increasing their HEI scores. Education also influenced the diet quality of the respondents who attained more education (4 years of college) and more nutrition information: they had improved diets. Age, area of residence, ethnicity, gender, and race were also influencers. Those adults who were 50 years or older generally had a better diet than younger adults and females had slightly better diets than males. Among racial groups, African Americans had poorer diet qualities than other racial groups and those respondents who resided in the southern US states and nonurban areas also reported poorer diets [31].

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1. GLOBAL AND US AGING

Fifteen years later, the USDA HEI for 2010 assessed the diet quality of Americans as specified by the 2010 US Dietary Guidelines. The overall diet quality of Americans who were aged 65 years and older did not significantly improve from the 1994 to 1996 values up to the 2001 to 2002 values when the HEI was recalculated. In the later assessment, older Americans who were aged 65 years or older met the US Dietary Guidelines for total protein, and those 75 or more years of age met the US Dietary Guidelines for whole fruits. It was determined that, in general, aging Americans needed to choose more nutrient-dense foods and increase their consumption of dark green and orange vegetables, legumes, milk, and whole grains, and lower their consumption of added sugars, saturated fats, solid fats, and sodium—much like younger Americans. Reduced overall caloric intake is known to help delay aging. Calorie restriction may be necessary to reduce obesity in the aging population, as obesity is equated with the noncommunicable diseases of aging: certain cancers, cardiovascular disease, diabetes, and hypertension/stroke. Individual nutrients may have some regulatory roles in the aging process by influencing longevity and/or health and maybe overlooked when calories are restricted. These issues and others will be explored in Chapter 2, Nutritional and Physical Concerns in Aging. Food Science Since sensory dysfunction is common throughout aging and since it may affect the perception and enjoyment of food, foods that look good and taste great are essential matters for the aging. If these determinants are not met, then food intake, nutrition, health, and wellness may be compromised. Eating and swallowing problems along with impaired appetite are also limiting factors for beverage and food selections, and may contribute to dehydration and/or malnutrition in the aging. Foods and beverages should supply concentrated energy (calories) with nutrient density in small, easy to manage and easily digestible portions. When creating foods and beverages for the aging, food manufacturers also need to consider the familiarity of foods and beverages along with nutritional components that meet United States and global dietary guidelines and any potential medical contraindications. Texture modification is a potentially successful strategy for decreased saliva and mouth dryness, but acceptability may be limiting. Specific food science-based strategies for obtaining nutrients and other potentially health-enhancing substances will be discussed in Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging [32]. Culinary Arts Continual access to nutritious foods and beverages that are designed for the aging is a goal for assisted living and community-based facilities and individualized living situations. Even the simplest tasks of cooking plus shopping, lifting grocery bags, maneuvering heavy cooking equipment and hours of standing may be overwhelming for the aging and dissuade cooking or assembling meals of any kind. In turn, this pervasive attitude may lead to compromised nutrition, health, and well-being. Similarly, chronic conditions so prevalent in the aging may be exacerbated by unhealthy diets that may be poorly cooked or prepared. Prepackaged and frozen meals may offer some solutions for decreased energy and mobility, and but they may also be filled with unneeded calories, fats, sodium, sugar, and/or preservatives. This may be a “golden” opportunity for more individualized meal and menu planning for the aging. Chefs may be able to team with registered dietitians/nutritionists, gerontologists and other health specialists to create foods and beverages that have both sensory appeal and are designed for behavioral, medical and/or physical limitations.

Nutrition and Culinary Arts Partnerships for the Aging Some examples of inspired, healthful and socially redeeming nutrition and culinary partnerships include the following: • Meals on Wheels, which began in 1954 in Philadelphia, Pennsylvania to provide the aging with foods and beverages and support their independence and health, provides meals to more than 2.4 million older and impoverished adults annually. Professional chefs and volunteers help to prepare meals with the best available ingredients designed by registered dietitian/nutritionists to meet a wide variety of medical and nutritional needs. Menus may be customized to meet an individual’s health status, including food aversions, food allergies, food safety, medication interactions, and other issues.

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US AGING

According to the Meals on Wheels program, about one in six aging people in the United States struggles with hunger [33]. In 2015, Meals on Wheels served 219.4 million meals besides providing companionship for homebound seniors to help decrease healthcare costs. In 2017, proposed budget cuts had the propensity to place Meals on Wheels in jeopardy (https://www.washingtonpost.com/news/wonk/wp/2017/03/16/trumpbudget-chief-says-meals-on-wheels-is-not-showing-any-results-hes-wrong/?noredirect 5 on&utm_term 5 . cd420d2f60fa). • Meal delivery services are rapidly changing in number and approach in the United States due to the Internet. They offer a wide range of products and services, such as equipment, recipes and ingredients for healthy homemade meals. Chefs, in collaboration with registered dietitians/nutritionists, may create many of the recipes and meals. Some are predelivered and can be customized to meet specific dietary needs. Care providers may be needed to complete the meals if the recipients are incapable of meal preparation. • Home care agencies in the United States may employ professional care providers who may be able to take charge of meal preparation responsibilities to support the independence of the recipients. However, this option may be expensive and may not be reimbursable by insurance. If eating problems are an issue, then a one-time visit by a chef/registered nutritionist may serve to establish a healthy eating program that professional care providers may then implement. Information on US aging and future needs is summarized in Table 1.2. TABLE 1.2

The Impact of US Aging

US aging by the numbers • There were 50 million people aged 65 years or older in 2016. • This figure is projected to more than double to over 98 million by 2060. Life expectancy • Life expectancy was 68 years of age in 1950. • This figure is expected to increase to 83.3 years of age for women and 79.5 years of age for men by 2030. Disease • Infectious and parasitic diseases were the main health hazards in 1900s. • Noncommunicable diseases (certain cancers, diabetes, heart disease, and stroke/hypertension) are greater burdens on health and wellbeing today. Ethnic and racial disparities • In 2014, 75% of aging Americans were non-Hispanic white. • This figure projected to decrease to 54.6% by 2060, while aging Hispanic population is projected to double. Residence • Aging Americans are tending to “age in place.” • Aging American women tend to live longer and alone than men with less income and/or in poverty. Education • Only 5% of aging Americans completed a bachelor’s degree at minimum in 1965. • One-fourth of aging Americans completed a bachelor’s degree at minimum in 2014. Employment • In 2014, about 15% of US women and 23% of US men were still working. • This figure is projected to increase to about 20% for women and 27% for men by 2022. Socioeconomic costs • The US poverty rate for aging Americans was 30% in 1966. • This figure dropped to 10% in 2014, but there are still widespread disparities. Health and health care • Aging Americans tend to live longer, but they have chronic conditions. • Obesity, dementia, and Alzheimer’s disease are on the rise. (Continued)

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TABLE 1.2 (Continued) Nutrition • Nutritional frailty, access to healthy beverages and foods and medication interactions are increasing concerns of aging Americans. • Inadequate nutritional and some intake issues in remote regions and/or inaccessible community centers are of concern. Chemosensory changes • Olfactory decline may occur in late 60s and early 70s; more so in men than in women. • About 19% 23% of Americans 40 years of age or older report difficulties with taste or smell. Nutrition, Food Science, and Culinary Arts • Healthy Eating Indexes for 1995 and 2010 were similar: aging Americans needed to choose more nutrient-dense foods and increase their consumption of dark green and orange vegetables, legumes, milk and whole grains, and lower their consumption of added sugars, saturated fats, solid fats, and sodium. • The act of eating, food familiarity, impaired appetites, nutrient density, and swallowing are important concerns in beverage and food development for the aging. • Meals on Wheels, meal delivery services, home care agencies and other outreach programs may need to increase in benefits, funding, and/or prominence to meet aging American nutrient needs for health and well-being.

IMPACT: GERONTOLOGY AND GERIATRICS IN THE UNITED STATES Gerontology is the study of the biological, cognitive, cultural, psychological, and social components of aging. The term gerontology was first created by zoologist and microbiologist E´lie Metchnikoff in the beginning of the twentieth century. In the 1940s, the field of gerontology was subcategorized by James Birren into primary aging, secondary aging and tertiary aging. Primary aging is defined as the natural physical deterioration of the human body over a period of time. Secondary aging is considered as the diseases and illnesses that speed the aging process. Tertiary aging is identified as increased cognitive and physical deterioration of the aging shortly before demise. Many specialists in gerontology are trained in policy, physiology, psychology, public health, social sciences, and more disciplines. As a whole, gerontologists study the processes associated with the bodily changes that occur with aging and societal changes among aging populations and apply this knowledge to policies and programs that affect groups and individuals. Gerontology differs from geriatrics that is a division of medicine that involves the treatment of existing diseases of aging. Both disciplines are involved in maximizing the functioning of the aging for a better quality of life. Social gerontology is a subfield of gerontology that addresses the social aspects of aging. Biogerontology is another subfield of gerontology that deals with the biological aspects of aging. The Gerontological Society of America (GSA), founded in 1945, is the oldest and largest interdisciplinary organization in America that is devoted to education, practice and research about the aging field. The membership in GSA also includes 50 countries. The principal mission of GSA is to advance the field of aging among the general public, decision makers and scientists. The GSA seeks to convene alliances and multi-stakeholder collaborations on aging. Its policy branch, the National Academy on an Aging Society (NAAS). oversees policy and provides advocacy information. The GSA Corporate Advisory Panel works with the NAAS to address issues that impact business models, education, practice enterprises and research that concern the aging [34]. The American Geriatrics Society (AGS) is a nonprofit organization of health professionals that is devoted to improving the health, independence, and quality of life for aging Americans. The AGS provides leadership for healthcare professionals, policy makers and the public through programs in patient care, professional and public education, public policy, and research. Its strategies include expansion of the geriatrics knowledge base, guidance of public policy, and the elevation of public awareness for improvements in quality care, promotion of the development of systems of care and practice, recruitment of physicians and other healthcare professionals, and support of geriatric education [35]. In the United States, geriatricians are generally primary-care physicians (DOs or MDs) who are board-certified in either family or internal medicine with additional training in geriatric medicine. This provides them with the expertise in the aging process itself and its impact on the different conditions and illnesses of aging, drug therapy, end-of-life issues, health maintenance concerns, and rehabilitation options. This may involve the inclusion of nurses, ophthalmologists, pharmacists, physical and psychological therapists, social workers, and other healthcare professionals.

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Other US organizations that are involved with and dedicated to gerontology and geriatrics include the US Administration on Aging, Alliance for Aging Research, Alzheimer’s Association, Alzheimer’s Foundation of America, American Federation for Aging Research, American Society on Aging, Association for Gerontology in Higher Education, National Association for Geriatric Education, National Council on Aging, and the National Institute on Aging. More information on these organizations and others may be found in Chapter 12, Prime Time Resources for Aging, Taste and Health. With both in-person and online gerontology and geriatrics programs expanding in upper education throughout the United States, gerontology is growing as an important topic and sought-after career option. This interest parallels the growth in the United States and global aging populations.

DIGEST While global and US aging have many similarities and unique considerations, the facts remain that both entities are increasing in prodigious proportions. This surge in aging populations has the potential of affecting food and beverage resources, finances, health care, living environments, medications, personalized care, supplements, and countless other areas. Nutrition, food science, and the culinary arts will be called upon for newer approaches, research and technologies to address these growing needs. Opportunities in the fields of geriatrics and gerontology will require the commitment of funding, people power and other support, coupled with a healthy mindset to address this natural winding-down and completion of the human lifecycle. Chapters 2 through 12 help to provide this foundation with an in-depth look at what’s ahead and the opportunities that await.

MANNER OF SPEAKING African Americans Age Dependency Ratio Aging in Place Aging Alzheimer’s Disease American Geriatrics Society (AGS)

Arthritis

Baby Boomers Beta-glucan

Cancers Cardiovascular Disease Carotenoids

Cataracts

Americans of African and especially of black African descent ratio of dependents (people younger than 15 or older than 64) to the working-age population (those ages 15 64 years of age) term that describes a person living in the residence of their choice for as long as they are able to as they age the process of growing older progressive disease that destroys memory and other vital mental functions that leads to confusion and other disabilities nationwide nonprofit society of geriatrics healthcare professionals that is dedicated to improving the health, independence and quality of life of older Americans combination of conditions that may be identified by inflammation of one or more joints of the body that causes pain and stiffness and worsens with age demographic cohort that includes birth years from the early-to-mid 1940s and ranges until 1960 or 1964 sugars that are found in the cell walls of certain algae, bacteria, fungi, lichens, yeasts and plants such as barley and oats; sometimes used for medicine, as to lower cholesterol, protect against cancer and control diabetes group of diseases that involve abnormal cell growth that has the potential of invading or spreading to other areas of the body collection of conditions that involve blocked or narrowed blood vessels that may lead to chest pain (angina), a heart attack or stroke class of mainly orange, red or yellow fat-soluble pigments (that include carotene), which helps color plant parts such as carrots and brightly colored leaves clouding of the lens in the eye(s) that affects vision

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Caucasians Centenarians Chemosensory Changes Cholesterol Chronic Obstructive Pulmonary Disease (COPD)

Clinical Depression Delirium

Dementia Depression

Diabetes

Food Insecurity Functional Ability

Geriatrics Gerontological Society of America (GSA)

Gerontology Global Coalition on Aging (GCOA)

Gray Divorce Revolution Healthy Eating Index (HEI)

Hearing Loss

Hispanic Home Care Agencies

white-skinned people, often of European origin; from the Caucasus race people who are 100 years or older highly specialized sensory systems, such as taste and smell, that may change in their perception, often due to aging or physical alterations waxy, fat-like substance that is found in all body cells; responsible for bile, hormones and vitamin D production common lung disease that affects breathing of two types: chronic bronchitis involves a long-term cough with mucus and emphysema involves lung damage over time more severe form of depression than mild depression; also known as major depression or major depressive disorder acute disturbed state of mind that may occur with fever, intoxication and other disorders; characterized by illusions, incoherence and restlessness group of thinking and social symptoms that requires medical diagnosis; may interfere with daily functioning and last for years or a lifetime mental health disorder that is characterized by consistently depressed loss of interest in daily activities and mood; may lead to significant impairment in daily activities group of diseases that result in high blood glucose; a chronic condition that manifests in type 1 diabetes whereby the pancreas produces little or no insulin, or type 2 diabetes that affects the manner how the body processes blood glucose state of being without reliable access to a sufficient amount of affordable, nutritious foods and beverages ability to perform daily living activities such as cleansing, dressing and eating, as well as the independent living skills of driving, housework or shopping branch of medicine or social science that is devoted to managing the health and well-being of aging people multidisciplinary organization that is devoted to the education and research of gerontology, or the biological, medical, psychological and social aspects of aging scientific study of the biological, cognitive, cultural and psychological aspects of aging and the challenges of aging pioneering initiative that strives for innovative solutions and public policies that address global aging; focuses on developing and promoting innovative corporate strategies among governments and policy stakeholders expression that denotes the rate at baby-boomers are getting divorced past 50 years of age at a rate that has doubled over the last 30 years measure of diet quality that assesses the conformance to the US Dietary Guidelines for Americans; used to examine the relationships between diet and health outcomes and assess the quality of food assistance programs, menus and the US food supply significant or total loss of hearing; often the result of inner ear or nerve damage as a result of age-related wear and tear, certain medications, congenital defects, diseases and/or exposure to loud noises person of Latin American descent who may live in the United States and may speak Spanish; relating to Spanish-speaking countries or Spain public agencies or private organizations that provide skilled nursing services with other home health services

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MANNER OF SPEAKING

Hypertension

Immune Function

International Association of Gerontology and Geriatrics (IAGG) International Federation on Ageing (IFA)

Intergenerational Conflict Intrinsic Capacity Ischemic Heart Disease (IHD) also known as Coronary Artery Disease (CAD) Labor Force Life Expectancy

Localized Taste Loss

Lutein

Meal Delivery Services (MDS) Meals on Wheels

Medicare

Multimorbidity

National Academy on an Aging Society (NAAS) Noncommunicable Diseases Non-Hispanic Blacks Non-Hispanic Whites Nutritional Frailty

Nutrition Screening

21

condition in which the force of the blood against the arterial walls is too high (above 130/80 mm [millimeters of mercury]); may be chronic and lead to heart disease or stroke, but treatable how the body recognizes and defends itself against bacteria, substances that appear foreign and harmful and viruses; protected by a network of cells, organs, and tissues called the immune system nongovernmental organization that promotes gerontological research and training in the behavioral, biological, medical, and social aspects of aging international and nongovernmental organization that is comprised of academics, governments, industries, NGOs, and individuals to protect and respect the choices and rights of aging people and influence agerelated policies conflict situation between generations that may involve prejudices combination of a person’s mental and physical capacities; a strong predictor of health and well-being in an older person group of diseases that includes angina, unstable angina, myocardial infarction, and sudden cardiac death collective members of a particular organization or population who have the ability to work statistical measure of the average amount of time that an organism is intended to live based on such factors as current age, gender, and year of birth, among others taste loss in one area of the oral cavity as opposed to its entirety; may specifically alter the sensations of beverages and foods; may increase signals from unaffected systems naturally occurring carotenoid (phytonutrient) that is only synthesized by plants; found in higher quantities in green leafy vegetables such as kale, spinach and yellow carrots services that send customers fresh, prepared meals (that are usually preportioned and pre-packaged) that are delivered to their homes organization that provides critical fundraising, outreach, technical and volunteer assistance for home-based services, regular nourishment, and social connection for the aging, caregivers, and families federal health insurance program for people who are over 65 years of age that includes specific services for hospital and medical insurance and prescription drug coverage presence of two or more chronic medical conditions in individuals; may create care challenges from higher numbers of coexisting conditions and related multiple medications policy branch of GSA; oversees policy and provides advocacy information diseases of long duration and generally slow in progression; also called chronic diseases people that have origins in any of the black racial groups of Africa except those of Hispanic origin Americans who are racially white and are not of Hispanic or Latino origin/ethnicity condition characterized by decreased reserves and robustness (such as diminished endurance and strength) that causes extreme vulnerability to stressors; nutrition is a contributing factor first-line process of identifying patients who are already malnourished or at risk of becoming so and/or developing nutrition-related disorders

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22 Obese

Obesity

Omega-3 Fatty Acids

Organization for Economic Cooperation and Development (OECD) Osteoarthritis

Phantom Taste Sensations

Plaque

Pressure Ulcers

Primary Aging Secondary Aging Tertiary Aging Quality-Adjusted Life Expectancy (QUAL) Refractive Errors

Retirement Sarcopenia Sarcopenic Obesity

Social Gerontology

Social Security

Stroke

1. GLOBAL AND US AGING

disorder of excessive body fat (adipose tissue) that may increase the risk of serious health problems; may be chronic and require a combination of behavior modification, diet, exercise, medications, surgery and/or other approaches condition that occurs when a person’s body mass index is 30 or greater; may have a negative effect on health as obesity increases the likelihood of cardiovascular diseases, certain types of cancers, depression, obstructive sleep apnea and/or osteoarthritis essential fatty acids that must be obtained from foods and/or beverages; foods high in omega-3 fatty acids include fatty fish, flax seeds and flax seed oil, nuts (especially walnuts), leafy green vegetables, and vegetable oils intergovernmental economic organization to stimulate economic progress and world trade type of arthritis that occurs when the protective flexible tissues at the ends of bones (cartilage) gradually wears down and worsens over time; most common in the hands, hips, knees, neck, and lower back common taste disorder whereby there may be a lingering and often unpleasant taste (often bitter or metallic), though nothing is in the oral cavity; may also occur in the other senses substance that is composed of calcium, cholesterol, fat and other constituents that is found in the blood; may build up inside the arteries and contribute to atherosclerosis, a disease that is often referred to as “hardening of the arteries” injuries to the skin and underlying tissues that may result from prolonged pressure on the skin; people at most risk are those who are unable to change their positions; also referred to as bed or pressure sores natural physical deterioration of the human body over time diseases and illnesses that speed the aging process increased cognitive and physical deterioration of the aging before demise generic measure of disease burden, including quality and quantity of life lived vision problems that occur when the shape of the eyes do not bend light correctly and cause blurred images; main refractive errors are astigmatism, farsightedness (hyperopia), nearsightedness (myopia), and loss of near vision with age (presbyopia) conclusion and/or withdrawal from an active working life, occupation, or position degeneration of skeletal muscle mass, quality, and strength; a natural stage of the aging process medical condition that involved both sarcopenia and obesity; the presence of low muscle mass that is coupled with low muscular strength and/or low physical performance, accompanied by excessive body fat subfield of gerontology that focuses on the social aspects of aging; practitioners seek to improve interactions among the aging and society—especially family members, healthcare professionals, and peers social insurance program that consists of disability, retirement, and survivors’ benefits; provides monetary assistance for retired and disabled people medical emergency that happens when blood flow to the brain stops and brain cells shortly die; symptoms may include difficulty speaking, walking, and understanding and/or numbness of the face and temporary or permanent paralysis

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REFERENCES

United States Department of Agriculture (USDA)

Urinary Incontinence US Great Recession

World Health Organization (WHO)

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US federal executive department of the government that is responsible for the development and execution of federal laws that are elated to agriculture, farming, food, and forestry loss of bladder control; sometimes referred to as a “leaky bladder” term that represents the abrupt decline in the economic activity during December 2007 to June 2009; generally considered as the largest decline since the Great Depression of 1929 39 specialized agency of the United Nations concerned with international public health; specifically the resistance of infectious diseases such as HIV and influenza and noncommunicable diseases such as certain cancers and heart disease

References [1] Bloom and Luca. The global demography of aging: facts, explanations, future, working paper series, Program on the Global Demography of Aging at Harvard University, PGDA Working Paper No. 130, ,https://cdn1.sph.harvard.edu/wp-content/uploads/ sites/1288/2012/11/The-Global-Demography-of-Aging.-Facts-Explanations-Future.pdf.; 2018 [accessed 30.08.18]. [2] United Nations Department of Economic and Social Affairs. World population projected to reach 9.7 billion by 2050. ,http://www.un. org/en/development/desa/news/population/2015-report.html.; 2015 [accessed 30.08.18]. [3] United Nations Department of Economic and Social Affairs, Population Division. World Population Ageing 2015 (ST/ESA/SER.A/390), ,http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf. [accessed 30.08.18]. [4] National Research Council (US) Panel on a Research Agenda and New Data for an Aging World. Preparing for an aging world: the case for cross-national research. Washington, DC: National Academies Press; 2001. ,https://www.ncbi.nlm.nih.gov/books/NBK98373/. [accessed 30.08.18]. [5] United Nations Human Settlements Programme (UN-Habitat), ,https://unstats.un.org/sdgs/metadata/files/Metadata-11-01-01.pdf. [accessed 30.08.18]. [6] Bhurosy T, Jeewon R. Overweight and obesity epidemic in developing countries: a problem with diet, physical activity, or socioeconomic status? Sci World J 2014;2014. Available from: https://doi.org/10.1155/2014/964236 Article ID 964236, 7 pages. ,https://www.ncbi. nlm.nih.gov/pmc/articles/PMC4212551/. [accessed 30.08.18]. [7] National Institute on Aging, National Institutes of Health, Department of Health and Human Services, US Department of State. Why population aging matters: a global perspective; 2007. Publication No. 07-6134, ,https://www.nia.nih.gov/sites/default/files/2017-06/ WPAM.pdf. [accessed 30.08.18]. [8] Guarino A. An aging global population and its economic implications. ,https://globalriskinsights.com/2017/02/aging-global-population-economic-implications/.; 2017 [accessed 30.08.18]. [9] World Health Organization. Preventing chronic diseases: a vital investment [Internet]. Geneva, Switzerland: WHO; 2005 [cited 2016 Jun 24]. ,http://www.who.int/chp/chronic_disease_report/en/. [accessed 30.08.18]. [10] World Health Organization. World report on ageing and health, ,http://apps.who.int/iris/bitstream/handle/10665/186463/ 9789240694811_eng.pdf?sequence 5 1.; 2015 [accessed 30.08.18]. [11] World Health Organization. Keep fit for life: meeting the nutritional needs of older persons. Geneva: WHO; 2002. ISBN 92 4 156210 2 (NLM classification: WT 115), ,http://apps.who.int/iris/bitstream/handle/10665/42515/9241562102.pdf?sequence 5 1. [accessed 30.08.18]. [12] World Health Organization Department of Ageing and Life Course. Global strategy and action plan on ageing and health (2016 2020). Geneva: WHO; 2016. ,http://www.who.int/ageing/GSAP-Summary-EN.pdf?ua 5 1. [accessed 30.08.18]. [13] IAGG-ER. Mission of IAGG-ER, ,http://www.iagg-er.net/.; 2013 [accessed 30.08.18]. [14] Global Coalition on Aging. ,http://www.globalcoalitiononaging.com/index.php?id 5 about. [accessed 30.08.18]. [15] The International Federation on Ageing. About IFA, ,https://www.ifa-fiv.org/about/. [accessed 30.08.18]. [16] Mather M. Fact sheet: aging in the United States, ,http://www.prb.org/Publications/Media-Guides/2016/aging-unitedstates-fact-sheet. aspx. [accessed 30.08.18]. [17] Meredith S. US life expectancy is low and is now projected to be on par with Mexico by 2030, ,http://www.cnbc.com/2017/02/22/uslife-expectancy-is-low-and-is-now-projected-to-be-on-par-with-mexico-by-2030.html.; 2017 [accessed 30.08.18]. [18] Organisation for Economic Co-Operation and Development. Health at a glance 2017, ,http://www.oecd.org/health/health-systems/ health-at-a-glance-19991312.htm. [accessed 30.08.18]. [19] Kotkin J. America’s senior moment: the most rapidly ageing cities. ,https://www.forbes.com/sites/joelkotkin/2016/02/16/americassenior-moment-the-most-rapidly-aging-cities/#185a5cb453e5. [accessed 30.08.18]. [20] Department of Health and Human Services, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. The power of prevention: chronic disease. . . the public health challenge of the 21st century, ,https://www.cdc. gov/chronicdisease/pdf/2009-Power-of-Prevention.pdf.; 2009 [accessed 30.08.18]. [21] Healthy Aging Team, National Council on Aging. Top 10 chronic conditions in adults 65 1 and what you can do to prevent or manage them, ,https://www.ncoa.org/blog/10-common-chronic-diseases-prevention-tips/.; 2017 [accessed 30.08.18]. [22] U.S. Bureau of the Census. Current Population Reports, Special Studies, P23-190, 65 1 in the United States. Washington, DC: US Government Printing Office; 1996. ,https://www.census.gov/prod/1/pop/p23-190/p23-190.pdf. [accessed 30.08.18]. [23] Mather M. PRB fact sheet: aging in the United States, ,https://www.prb.org/aging-unitedstates-fact-sheet/.; 2016 [accessed 13.09.18].

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[24] Mather M, Jacobsen LA, Pollard KM. Aging in the United States, Population Bulletin, vol. 70 Issue 2, ,http://www.prb.org/pdf16/ aging-us-population-bulletin.pdf.; 2015 [accessed 30.08.18]. [25] Toosey M, Torpey E. Older workers: labor force trends and career options. Bureau of Labor Statistics Career Outlook, ,https://www. bls.gov/careeroutlook/2017/article/older-workers.htm.; 2017 [accessed 30.08.18]. [26] Economics and Statistics Administration, U.S. Department of Commerce. U.S. Census Bureau, Statistical Brief, Sixty-five plus in the United States, ,https://www.census.gov/population/socdemo/statbriefs/agebrief.html.; 1995 [accessed 30.08.18]. [27] Ortman J, Velkoff V, Hogan H. An aging nation: the older population in the United States, current population reports, ,https://www. census.gov/prod/2014pubs/p25-1140.pdf.; 2014 [accessed 30.08.18]. [28] Mangels AR. CE: Malnutrition in older adults. Am J Nurs 2018;118(3):34 41. ,https://www.nursingcenter.com/cearticle? an 5 00000446-201803000-00023&Journal_ID 5 54030&Issue_ID 5 4549311. [accessed 13.09.18]. [29] Boyce JM, Shone GR. Effects of ageing on smell and taste. Postgrad Med J 2006;82(966):239 41 ,https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2579627/. [accessed 13.09.18]. [30] Bowman SA, Lino M, Gerrior SA, Basiotis PP. The healthy eating index: 1994 96. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion; 1998. CNPP-5. ,https://www.cnpp.usda.gov/sites/default/files/healthy_eating_index/hei94-96report.PDF. [accessed 13.09.18]. [31] Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. 2. The healthcare environment and its relation to disparities. Washington, DC: National Academies Press (United States); 2003. ,https://www.ncbi.nlm. nih.gov/books/NBK220362/. [accessed 13.09.18]. [32] Yasmine. The ageing palate. J Inst Food Sci Technol 2015. ,http://www.fstjournal.org/features/29-4/the-ageing-palate. [accessed 30.08.18]. [33] ,https://www.mealsonwheelsamerica.org. [accessed 30.08.18]. [34] The Gerontological Society of America. ,https://www.geron.org/about-us. [accessed 30.08.18]. [35] American Geriatric Society. ,http://www.americangeriatrics.org/about_us/who_we_are/. [accessed 30.08.18].

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PHOTO: Yellow Measuring Tape. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I have a very acute sense of taste—sometimes even too much that it interferes with my meal enjoyment. So I eat carefully. J.M.

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Introduction Nutrient Needs for Aging Overview Functional Decline and Aging Dietary Decline and Aging Physiological Changes During Aging That Affect Nutritional Status Calories During Aging Calories by Gender: Women and Men Weight Loss Anorexia

26 27 27 27 27

Aging, Nutrition and Taste. DOI: https://doi.org/10.1016/B978-0-12-813527-3.00002-8

Weight Gain Obesity My Plate for Older Adults Nutrients Dietary Carbohydrates Chronic Disease and Carbohydrates Solid Fats and Added Sugars Solid Fats Added Sugars Dietary Fibers Soluble Fibers Insoluble Fibers

28 29 29 30 30

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Dietary Fats Omega-3 Fatty Acids Dietary Protein

35 35 36

Minerals for Aging Diets Calcium Iron Magnesium Phosphorus Potassium Selenium Sodium Zinc

37 37 38 39 40 40 41 42 43

Vitamins for Aging Diets 44 Folate (Folic Acid or Folacin) 44 Vitamin A (Retinol, Retinal and Retinyl Ester) 44 Vitamin C (Ascorbic Acid or Ascorbate) 45 Vitamin D [Ergocalciferol (Vitamin D2) and Cholecalciferol (Vitamin D3)] 46 Vitamin E [α (Alpha), β (Beta), γ (Gamma) and δ (Delta) forms; Most Common Is Gamma-Tocopherol (γ-Tocopherol)] 46 Vitamin K [Vitamin K1 (Phylloquinone) and Vitamin K2 (Menaquinone)] 47 B Vitamins: Vitamin B6 (Pyridoxine) and B12 (Cyanocobalamin or Methylcobalamin) 48

Vitamin B6 (Pyridoxine) Vitamin B12 (Cyanocobalamin or Methylcobalamin)

48 48

Summary: Vitamins and Minerals in Aging Diets

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Other Nutrient Requirements for Aging Diets Phytonutrients Water

49 49 50

Aging and Physical Activity Physical Activities Versus Exercise

51 51

Physical Activity Needs

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Exercise Programs for the Aging Active Choices Active Living Every Day EnhanceFitness Fit and Strong! Healthy Moves for Aging Well Walk With Ease

53 53 53 53 53 54 54

Digest

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Manner of Speaking

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LEARNING OBJECTIVES 1. Identify the nutritional needs for aging people. 2. Compare the nutritional requirements for the aging with representative food and beverage intakes. 3. Recognize the nutritional needs of the aging with regard to chronic diseases and health. 4. Distinguish ways to meet the nutrition needs of the aging via foods, beverages and supplements where warranted. 5. Characterize the physical activity needs of the aging and methods to meet their physical fitness requirements.

SUMMARY To specifically identify the uniqueness of nutritional and physical concerns during aging, and the emotional, nutritional, and physical stresses on individuals, their care providers, family and friends, and health care.

INTRODUCTION This chapter will identify the uniqueness of nutritional and physical concerns during aging and the burdens that they may place on individuals, care providers, families, health care and society. Both normal nutrition and nutrition

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for specific conditions and disease states will be addressed. The most current nutrition recommendations and guidelines for the aging will be provided, as well as tasteful ideas for improving nutrition through healthier food and beverage choices. (Note that nutrition recommendations that are based on dietary guidelines and other parameters tend to change over time. What follows in this chapter is the most current information to date.) The importance of ongoing physical activity will also be featured, along with age-appropriate simple exercises to help maintain flexibility, mobility and strength in the aging. The role of physical activity with regard to weight management in the aging cannot be understated—both to decrease obesity that is associated with aging and sedentary living and to increase appetite in the case of nutritional frailty that is described in Chapter 1, Global and US Aging.

Nutrient Needs for Aging The most optimal way for aging people to obtain the nutrients they need is from nutritious foods and beverages. While some vitamin and mineral and nutritional supplements are designed to augment a healthy diet, by and large they do not replace a well-balanced diet. The following section describes how aging people should eat and drink and how their health may reflect their attention (or lack thereof) to dietary issues.

Overview A well-balanced and nutritious diet, regular physical activities, relatively stress-less living, the abstinence of alcohol and drugs (including nicotine) and the maintenance of normal blood pressure, body weight and cholesterol are lifestyle factors that may increase life expectancy. These lifestyle factors may also increase health, life quality and well-being. Individual variations must also be considered. Improved preventive efforts and medical care have produced a major shift in the leading causes of death in the United States, from infectious diseases and acute illnesses to chronic and degenerative disease. Many of the leading causes of death relate directly or indirectly to high-quality nutrition and physical activity or their absence. To help to detect and control chronic and degenerative diseases those who are aging should improve many aspects of their diet and health. These include the cessation of smoking and alcohol consumption, increased activity, and loss and/or maintenance of weight if it is not “ideal.” The aging should also schedule regular health screenings. In turn, governments and health organizations should collaborate to help to decrease health disparities in the aging and lower health care costs to help make healthy aging more economically viable. Other potential health disparities, such as education, employment, place of residence and racial and ethnic differences (as discussed in Chapter 1: Global and US Aging) will also need to be addressed so that aging individuals have comparable opportunities for future benefits. To begin, healthy foods and beverages should be available for all individuals who are aging and ideally in appropriate amounts.

Functional Decline and Aging The human body, like other bodily systems, is only programed to last so long. Around age 35 years, there is a slow-down in every human body system, organ and cell. Vital functions such as bone mineralization, cardiac output, handgrip flexibility, kidney function, maximum heart rate, maximum oxygen uptake, metabolism, muscle mass, smell and taste and the vital capacity of the heart decrease may be compromised. The rate at which each of these vital functions decreases is dependent upon such factors as environment, genetics, lifestyle and many more.

Dietary Decline and Aging There are many reasons that are postulated why the diets of aging people decline. They can mainly be grouped into the following categories: environmental, physiological, psychological and socioeconomic. • Environmental factors that contribute to dietary decline in the aging include inadequate transportation to access and transport of healthy foods and beverages, inadequate care or support, institutional living, isolation, lack of kitchens or other food production facilities, limited food and beverage availability other than supermarkets, poor housing often without cooking or refrigerator areas and restricted services, among other factors.

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• Physiological factors that contribute to dietary decline in the aging include alcohol or drug use (including nicotine), chronic diseases, decreased hunger, loss or decline in taste, smell and other sensory functions, genetics, immobility, inactivity, oral health disorders, physical disabilities and poor dietary intake, among other factors. • Psychological factors that contribute to dietary decline in the aging include cognition disorders, companionship or lack of friendship, cultural values, dementia, depression, economics, emotional isolation, genetics, indifference, loneliness, loss of spouse or significant other and marital status, among other factors. • Socioeconomic factors include cultural values, economics, education, health care or lack of coverage, racial and/ or ethnic diversity, religion and societal expectations, among other factors. The relationship among these factors is complex, ongoing and variable throughout the aging process. For example, a change in a physiological factor such as a new illness may bring about a change in psychological factors, such as depression, which may be compounded by a change in socioeconomic factors, such as health care expenditures, which may lead to a change in environmental factors, such as inadequate care or support. Without interventions at any of these points, emotional, nutritional and/or physical conditions may deteriorate as the aging progress progresses.

Physiological Changes During Aging That Affect Nutritional Status Nutrition shoulders a very vital role in the quality of life of the aging, specifically their mental, physical and social health and well-being. Physiological changes may provoke risk factors that, in turn, may spur nutritional deficiencies that may influence major health concerns. These include the increased needs for • • • • • • • •

Antioxidants and other phytonutrients for immune system protection; B vitamins (particularly vitamin B12) for the nervous system and brain function; Bone nutrients to improve bone density; Fiber for healthy gastrointestinal tracts; Lutein and zeaxanthin for healthy eyes and eyesight; Omega-3 fatty acids for brain and heart health; Protein to combat frailty; Vitamins A and C and zinc for wound healing, . . . [1].

Body systems are basically groups of organs that function together to perform a variety of bodily tasks. A number of body systems are affected by the normal physiological changes that are evident throughout the aging process. The process of senescence is the decline in organ systems during the aging process that may increase the risks of certain diseases. Human body systems include the circulatory system, digestive system, endocrine system, excretory system, lymphatic (immune) system, integumentary system, musculoskeletal system, nervous system, reproductive system and respiratory system. The changes in these systems and the potential diseases that are associated with these changes due to aging are shown in Table 2.1. Individual nutrients that may be implicated with these changes are discussed in the following sections. TABLE 2.1 Changes in Body Systems and Associated Diseases of Aging Body system

Disease potential

CIRCULATORY SYSTEM Heart, blood and blood vessels

Atherosclerosis, decreased cardiac output and increased blood clotting

DIGESTIVE SYSTEM Salivary glands, esophagus, stomach, liver, gallbladder, pancreas, intestines, rectum and anus

Decreased gastric acid, intrinsic factor and saliva and increased constipation, heartburn, ulcers and other gastrointestinal disorders

ENDOCRINE SYSTEM Hypothalamus, pituitary gland, pineal gland, thyroid, parathyroids and adrenals

Decreased growth, reproductive and thyroid hormone production (Continued)

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(Continued)

Body system

Disease potential

EXCRETORY SYSTEM Integumentary, digestive, respiratory and urinary systems

Decreased bladder control, blood filtration rate and kidney function

LYMPHATIC (IMMUNE) SYSTEM Leukocytes, tonsils, adenoids, thymus and spleen

Decreased immune function increased risk of infections and cancer

INTEGUMENTARY SYSTEM Skin, hair, nails and sweat and oil glands

Decreased elasticity, pigmentation and thickness and increased bruising, hair thinning, hair loss and wrinkling

MUSCULOSKELETAL SYSTEM Muscles, bones, cartilage, ligaments

Decreased bone formation, muscle and tendons mass, strength and stamina and increased bone loss, fractures, joint stiffness and pain

NERVOUS SYSTEM Brain, spinal cord and peripheral nervous system

Decreased brain weight, nervous impulses, neurotransmitters, short-term memory and sensory functions

RESPIRATORY SYSTEM Pharynx, larynx, trachea, bronchi, lungs and diaphragm

Decreased lung capacity and increased susceptibility to infections

REPRODUCTIVE SYSTEM Ovaries, fallopian tubes, uterus, vagina, mammary glands, testes, vas deferens, seminal vesicles and prostate

Decreased fertility, male and female hormone production, eggs and sperm count

From Culinary Nutrition: The Science and Practice of Healthy Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 525.

Calories During Aging Caloric needs generally progressively decline throughout aging. This is due to the fact that lean body mass (LBM), or the total weight of the bones, muscles, organs, skin, tissues and body water, other than body fat, decreases with age. A reduction of LBM lowers the basal metabolic rate, or the minimum amount of energy that is needed to keep the body functioning (that includes breathing and heart beat), and subsequently reduces the need for calories. When calorie needs decrease it may be difficult to obtain the needed nutrients, especially when there is also a decreased sense of appetite. To help to balance this decline, by eliminating extra calories and adding a muscle-building program to weekly activities this may help to maintain some LBM and build some muscle (which then burns calories). The goal (as in younger years) is to ensure that calories “in” or consumed equal calories “out” or expended. By preserving LBM, an aging active person may be able to afford to consume a few more calories now and then compared to an aging sedentary person. In general, the daily recommendation for calorie consumption for aging Americans from 51 to 76 years of age and beyond is 1600 2400 calories, depending upon age, activity level and gender [2].

Calories by Gender: Women and Men Women According to the 2015 2020 Dietary Guidelines for Americans (DGAs), women over 50 years of age require about 1600 calories daily if they are sedentary. If they are moderately active, then aging women require about 1800 daily calories. If they regularly participate in physical activity that is the equivalent of walking more than three miles daily at a 3 4 mile-per-hour pace, then they may require about 2000 2200 calories daily over and beyond everyday activities [3].

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Men Men who are aging tend to need more calories than aging women. The 2015 2020 DGAs recommend that sedentary men consume about 2000 2200 daily calories. Moderately active men who walk more than 3 miles daily at a 3 4 mile-per-hour pace require about 2200 2400 daily calories. Also, according to the 2015 2020 DGAs, aging men who lead a very active lifestyle might need as much as 2400 2800 daily calories [3]. A fairly easy way to determine the correct number of calories per pound that are required by aging people is by using this formula: • Sedentary—13 calories 3 body weight (in pounds); • Moderately active—16 calories 3 body weight (in pounds); • Active lifestyle—18 calories 3 body weight (in pounds). For example, a sedentary woman who weighs about 160 pounds may require about 2080 daily calories (13 calories 3 160 pounds of body weight). An active man who weighs about 150 pounds may need about 2700 daily calories (18 calories 3 160 pounds of body weight). Diets that are under 1000 daily calories may not provide enough calories nor nutrients. A nutrition specialist such as a registered dietitian/nutritionist may be consulted to determine daily caloric needs.

Weight Loss For all people, weight loss should be achieved slowly, over time and by a sensible diet and activity plan. This is particularly important for aging people so that there are not dramatic changes in blood sugar, energy, fluids and other important nutrients. A reduction of calories by about 500 1000 calories daily is suggested by the Centers for Disease Control and Prevention. Since one pound equals about 3500 calories, to lose one pound about 3500 calories must be at a deficit—either by eating less, exercising more, or with a combination of the two modalities. Since most of the body systems decline with aging and require fewer calories, the exact number of calories that are necessary to lose weight during aging may be difficult to ascertain, reach and maintain.

Anorexia Anorexia is the lack of appetite for foods and beverages. Anorexia is sometimes considered to be the medical condition anorexia nervosa, which is characterized by an obsessive desire to lose weight by the rejection of food, excessive physical activities, or a combination of both. In contrast, the anorexia of aging is defined by decreased appetite and/or food intake in the aging. The anorexia of aging may lead to inadequate food and beverage intake and inability to meet essential energy and nutrient requirements. The anorexia of aging is a major factor in the undernutrition and poor health outcomes in aging populations and may independently predict morbidity and mortality. The anorexia of aging is not an unavoidable consequence of aging; rather it is the result of a convergence of factors that may include age-related changes in lifestyle, behavioral and social factors and disease conditions that may affect dietary behaviors, nutritional status, health and well-being. Appetite regulation may be an overriding concern in the anorexia of aging. Functional impairments and changes in gastrointestinal function, hormones, inflammation, medical conditions, medications and smell and taste may also interplay. Malnutrition, frailty and sarcopenia (decline in muscle mass and strength) and even mortality may be consequences of the anorexia of aging. The treatment of the anorexia of aging may include food manipulation to improve flavor, dietary variety, palatability and texture and environmental adaptations to improve social isolation, feeding assistance and the identification of potential medication interactions and possible medical causes. As of 2016, there were not any therapeutic agents that were clearly effective in the treatment of the anorexia of aging, nor medications to stimulate appetite control that were recommended during routine clinical practice. Rather, it was recommended that specific individualized care plans be implemented to address anorexia of aging that provide adequate amounts of foods and beverages and limit excessive weight loss [4].

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Weight Gain Changes in total body weight differ between men and women as they age. In general, men may gain body weight up until about 55 years of age and then begin to lose weight in the years that follow. This may be the result of a decrease in the male hormone testosterone. In comparison, women may gain body weight up until about 65 years of age and then begin to lose weight, like men. In both genders weight loss may occur because the lean body weight that comprises muscles and other nonfat bodily components is replaced by body fat over the years, and body fat weighs less than lean body weight or mass. The amount of body fat increases in the human body after the age of 30 years. People who are aging may have as much as one-third more body fat than they did when they were younger due to loss of lean body tissues and cellular decreases in the kidneys, liver, muscles and other organs. This type of muscle loss is referred to as atrophy. As the tissues atrophy, the amount of water in the body may decrease. As bones atrophy, they may lose some of their mineralization and become less dense. This condition is referred to as osteopenia when it is in the early phases, and osteoporosis when it is in the later phases. Aging Americans of all races and genders tend to decrease stature as they age that may be related to, and affect the bones, joints and muscles. It is reasonable to assume that when bones, joints and muscles lose their cells and tissues during aging that height may be compromised. Loss in height is typically one-half inch per every 10 years, commencing around age 40 years. Height loss accelerates past 70 years of age. It is not uncommon for those who are aging to experience a 1- to 3-inch loss of height during aging. This loss in height may be combatted by a nutritious diet with plenty of bone nutrients (calcium, protein, vitamins A, B6 and B12, C, D, K and the minerals magnesium and zinc), regular physical activity and the physical prevention and treatment of any bone or tooth loss [5]. One’s diet and activity level also come into consideration. A nutritious diet with ample fresh fruits and vegetables, healthy fats, lean proteins and whole grains, regular exercise and other physical activities, and limited-to-no alcohol use may be effective in slowing down the loss of lean body weight and the replacement by body fat [6].

Obesity Much like early-to-middle adulthood, too many calories over and beyond daily caloric needs may eventually lead to obesity in the aging—especially when previous activity levels and lifestyle decline. In turn, obesity may increase the risks for many health conditions and/or diseases as shown in Table 2.2. TABLE 2.2 Obesity Instigated Health Conditions, Diseases and Increased Risks • All causes of death (mortality) • Body pains • Cancers (breast, colon, prostate) • Cataracts • Coronary heart disease • Difficulties with physical functioning • Dyslipidemia (high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol and/or high triglycerides) • Gallbladder disease • Hypertension • Inflammatory-related diseases • Mental illnesses • Osteoarthritis • Pulmonary abnormalities • Sleep apnea and breathing difficulties • Social stigmatization and discrimination • Stroke • Type 2 diabetes • Urinary incontinence [7]

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The Centers for Disease Control and Prevention reported that during 2007 10 over one-third of those aging who were 65 years of age or older were categorized as obese. Overweight and obese aging people require only 10 calories for each pound of their desired body weight to reach their weight goal weight [8]. For example, an aging woman who wants to weigh 130 pounds should consume about 1300 daily calories: 130 pounds desired body weight 3 10 calories per pound 5 1300 daily calories. An aging man who wants to weigh no more than 155 pounds should consume about 1550 daily calories: 155 pounds desired body weight 3 10 calories per pound 5 1550 daily calories.

MY PLATE FOR OLDER ADULTS The nutritional needs of aging Americans are depicted in an icon within the framework of the 2015 to 2020 DGAs from the US Department of Health and Human Services (US-DHHS) and the US Department of Agriculture (USDA). It represents a shift toward healthier food and beverage choices by the aging that may help to improve the symptoms or decrease the risks of certain chronic diseases, such as heart disease, hypertension or type 2 diabetes. The icon for MyPlate for Older Americans is a plate that contains colorful food images and is intended to foster healthy eating. About 50% of the plate is illustrated to contain fruits and vegetables, about 25% of the plate is shown to contain grains of which 50% are to be whole grain in nature and about 25% of the plate is portrayed to contain protein-rich foods, such as beans, fat-free and low-fat dairy products (such as cheese, milk and yogurt), fish and shellfish, leans meats, nuts and seeds and lean poultry. Other accompanying images include good sources of fluids (particularly water), heart-healthy fats (including some vegetables oils) and herbs and spices to be used instead of some measure of salt to help to lower-sodium consumption. Activity is also depicted and encouraged [9]. Overall, nutritional advice for the aging is similar to the 2015 US Dietary Guidelines that include: • • • • •

Follow a healthy eating pattern across the lifespan. Focus on consuming a variety and amount of nutrient-dense foods. Reduce the intake of added sugars, saturated fats and sodium to allowed limits. Shift toward healthier food and beverage choices. Support healthy eating patterns for all.

Additionally, MyPlate for Older Americans emphasizes all types of foods, including canned, dried, fresh and frozen, so that its depiction is relevant for many personal preferences and takes into account differences in availability and cultural backgrounds [9].

Nutrients It is true that people consume food and beverages, not nutrients. Still, nutrients are the building blocks of foods and beverages that are needed by the human body for building, maintenance and repair. Nutrient needs change throughout the lifecycle: some are just as significant as in younger years, while others may decrease in importance or elevate. This is why an examination of the unique nutrient needs for the aging is fitting.

Dietary Carbohydrates Dietary carbohydrates are organic compounds that are comprised of carbon, hydrogen and oxygen. They function as energy sources in the ultimate form of glucose to fuel the brain and nervous system; along with dietary fiber for healthy gastrointestinal tracts, such as signaling molecules for interactions and transmittance, and as structural components, such as cellulose in plants. Glucose is a simple sugar that circulates in the blood as blood sugar and is essential for energy and to life. Dietary fiber, or roughage, is the indigestible portion of food derived from plants. It helps to promote regularity and protect the human body against some diseases, such as gastrointestinal and heart disease. Signaling

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molecules help create normal tissue homeostasis, assist the cells to perceive and correctly respond to their environments, provide immunity and repair tissues. And the carbohydrates in structural components help to provide the building blocks of life [10].

Chronic Disease and Carbohydrates Chronic metabolic diseases (such as diabetes, cardiovascular disease and obesity) have been associated with carbohydrate-rich diets that have high glycemic indices. High GI values of 70 or more are more quickly digested, absorbed and metabolized and have the potential to cause a higher and faster rise in blood glucose and, therefore and usually, insulin levels. Dietary carbohydrates may also directly influence an organism’s life span through different signaling pathways. An abundance of glucose may decrease the activity of AMP-activated protein kinase, an energy sensor that regulates the life span of organisms, while the restriction of glucose may increase longevity. The mechanisms by which these processes occur are not fully clarified to date, nor are the roles of dietary carbohydrates in this aspect of human aging. As with younger age groups, a lower-carbohydrate diet along with higher fat and adequate protein may reduce body weight after about three months, with decreased levels of serum leptin (a hormone that is mostly made by adipose [fat] cells that helps to regulate energy balance by the inhibition of hunger), insulin, fasting glucose and triglycerides—substances that have been implicated with aging and metabolic defects. A lowcarbohydrate diet is also associated with reduced obesity and body weight and the reduction of many risk factors for coronary heart disease. Conversely, a higher carbohydrate diet is correlated with age-related diseases such as coronary heart disease and diabetes. For these reasons, a lower-carbohydrate diet is thought to help delay human aging, prevent metabolic diseases and improve overall health [11]. Based upon the 2010 DGAs a healthy dietary pattern emerged for the aging that was not so dissimilar than what was recommended for younger-aged people. The most nutritious carbohydrate-containing foods for the aging were shown to be nutrient-packed dairy products, fruits, grains and vegetables. By choosing nutritious carbohydrates such as these, it was postulated that aging may help to protect their heart and immune system and reduce the risks of some chronic diseases. Still, aging people should choose carbohydrates all carbohydrate-containing beverages and foods intelligently. This is because sugars may be naturally present in foods in the form of fructose in fruit and lactose in milk. Sugars may also be added during food processing, such as in high-fructose corn syrup that may be added to baked products or beverages. The 2015 to 2020 DGAs suggests that people 50 years of age or older choose carbohydrate-containing daily from the following food groups that are shown in Table 2.3. TABLE 2.3 Recommended Daily Servings of Carbohydrates for the Aginga Dairy foods—3 cups of fat-free or low-fat milk or equivalents • Example: Serving size 5 1 cup of fat-free or low-fat milk or yogurt, or 11/2 to 2 ounces of fat-free or low-fat cheese Fruits—11/2 to 21/2 cups • Example: Serving size 5 1 fresh 2-inch piece of fresh fruit, 1/2 cup of cut fresh fruit or fruit juice, or 1/4 cup of dried fruit Grains—5 to 10 ounces • Example: Serving size 5 1 cup of flaked whole grain ready-to-eat cereal, 1/2 cup whole grain cooked cereal (1 whole grain serving), 1 slice of 100% whole grain bread (1 whole grain serving), or 1/2 cup of cooked whole grain pasta or rice (1 whole grain serving) • Make at least one-half of the daily servings whole grain (at least three ounce equivalents). Vegetables—2 to 31/2 cups • Example: Serving size 5 2 cups of uncooked leafy green vegetables such as arugula or kale, or 1/2 cup of cooked vegetables, such as broccoli or carrots a

Based on 1600 2000 daily calories.

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Solid Fats and Added Sugars According to the 2015 2020 DGAs, solid fats and added sugars should be only be used in limited amounts. Solid fats are fats are solid at room temperature. Added sugars have been added to foods and beverages—they are not natural components.

Solid Fats Solid fats mostly come from animal foods and some vegetable oil that are solidified or partially solidified by a process called hydrogenation. Some common solid fats include beef fat (suet, tallow), butter, chicken fat, coconut oil, cream, hydrogenated and partially hydrogenated oils, milk fat, palm and palm kernel oils, pork fat (lard), shortening and stick margarine. Many solid fats are economical, tasty and satisfying and this is why they are so easy for the aging to consume. Most solid fats are high in saturated fats and/or trans fats and have less monounsaturated or polyunsaturated fatty acids (PUFAs). Many also contain cholesterol. Solids fats and trans fats are inclined to raise “bad” lowdensity lipoprotein (LDL) cholesterol levels in the blood, and in turn increase the risk of heart disease.

Added Sugars Added sugars include sugars and syrups that are added to products such as cakes, cobblers and pies, candies, cereals, cookies, energy and sports drinks, fruit drinks, sodas and yogurts, and the sugars that are added by consumers, such as the sugar that is added to coffee or tea before drinking. Most added sugars come from beverages that are economical, generally desirable and easy for aging people to consume. Added sugars contribute calories, but they offer few essential nutrients other than sucrose that breaks down into glucose in the human body for energy. Some aging individuals cannot afford the extra calories or sugars due to blood sugar management. This is why it is advised that people who are aging cut down on added sugars in their diets. They may do so by looking for added sugars on the ingredients list of packaged foods and beverages and by making some healthier shifts in their food and beverage choices. This may be accomplished by: • • • • • •

Cutting back on various types of sugar that are added to cold and hot beverages. Exchanging sugary cereals for unsweetened cereals with fresh or dried fruits. Replacing sugary drinks with lower-fat milk or calorie-free water. Substituting sweet snacks with fresh, fresh frozen or canned fruit in its own juice or water. Swapping larger drinking vessels with smaller-sized glasses or cups for 100% fruit juice. Using sugar substitutes if warranted.

Dietary Fibers Dietary fibers (roughage) are the indigestible parts of foods from plants. There are two types of dietary fiber: soluble fiber and insoluble fiber. Soluble fiber dissolves in water, may delay gastric emptying and provide a feeling of fullness, and ferments in the colon. Soluble fibers may include prebiotics (substances that may induce the growth or activity of beneficial microorganisms in the gut microbiome). Insoluble fibers do not dissolve in water; rather, they provide bulkiness that may help digestion and defecation. Some insoluble fibers may also be prebiotic. In contrast, probiotics are microorganisms (live bacteria and yeasts) that may support a healthy digestive system. They are often considered as healthy because they tend to support gut health. Lactobacillus (in yogurt and other fermented foods and beverages), bifidobacterium (in some dairy products) and saccharomyces boulardii (in yeast) are some examples. The recommended Adequate Intake (AI) of fiber for aging Americans is 25 grams daily for women and 38 grams daily for men, which is about 14 grams per 1000 total daily calories from foods and beverages. In comparison, the average daily consumption of fiber by aging Americans in 2015 was 15 17 grams of fiber daily [12].

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The most abundant sources of fiber in the USDA Food Patterns are from vegetables and whole grains, with fruit following. At least one-half of all grains consumed daily should be from whole grains.

Soluble Fibers Soluble fibers, due to their water-binding capacities, create viscous or sticky solutions and tend to slow gastric emptying, digestion and absorption. As a result, dietary patterns that are rich in soluble fibers are associated with decreased risks of gastrointestinal and cardiovascular diseases. This is because soluble fibers may help to decrease blood pressure, lower serum cholesterol and reduce the biomarkers of inflammation. Plus, soluble fibers that are partially fermented by gut microflora may be beneficial to diabetics since the microflora may help to increase satiety and improve insulin sensitivity [13].

Insoluble Fibers In tandem with proper hydration, insoluble fibers may help to reduce constipation. In turn, this may help to keep the intestinal tract functional and to protect against certain gastrointestinal diseases [13]. By focusing on higher protein and fat diets to lose weight, insoluble fibers may be compromised and lead to gastrointestinal complications. While fiber supplements may be useful, a diet that is filled with fruits, vegetables and whole grains may be better served.

Dietary Fats There is not a Dietary Reference Intake (DRI) that is established for dietary fats for people who are aged 50 years of age or older. However, it is sensible for aging Americans to limit their dietary fat intake to about 20% 35% of total calories. This range represents the recommendations by the 2015 20 US Dietary Guidelines Advisory Committee that uses the Acceptable Macronutrient Distribution Range as established by the Institutes of Medicine [IoM—now called the National Academy of Medicine for adults that are 19 years of age and older [14]]. This amount may vary according to individuals and their unique physical requirements, such as activity level, certain physical conditions, disease states, gender, medications and other factors. Less saturated fats (to no less than 10% of total calories) is also recommended.

Omega-3 Fatty Acids Essential fatty acids cannot be produced in the body in needed amounts, so they must be consumed through the diet. They are classified as omega-3 and omega-6 fatty acids. Omega-3 fatty acids are correlated with reduced age-related macular degeneration (AMD) and vision, coronary heart disease and rheumatoid arthritis, and may also reduce the risk of Alzheimer’s disease, dementia and some depression and asthma due to its inflammation-lowering effects. Two critical omega-3 fatty acids are eicosapentaenoic acid and docosahexaenoic acid that are primarily found in certain cold water, oily fish, such as herring, mackerel, salmon and sardines and in fish oils. Alpha-linolenic acid (ALA) is found in canola oil, dried cloves and oregano, flaxseeds and mustard seeds, green-leafy plants, black and red currant seeds, soybeans, walnuts and wheat germ. Two weekly servings of any of these foods, especially cold water, oily fish are advised. Omega-3 fatty acids may have distinct health benefits. They may help to reduce inflammation in the body that is associated with a number of diseases, especially those that are chronic. This is because they help to regulate a wide variety of biological functions. Some omega-6 fatty acids may promote inflammatory diseases, such as inflammatory bowel disease (IBD) or nonalcoholic fatty liver disease. A balance of dietary omega-3 fatty acids and omega-6 fatty acids is recommended. Omega-3 supplements have not been thoroughly shown to be heart-protective. The AI levels for omega-3 fatty acids for people who are aged 51 years of age or older are 1.6 grams [as ALA] daily for men and 1.1 grams [as ALA] daily for women. Food sources and amounts of ALA are shown in Table 2.4.

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TABLE 2.4 Food Sources and Amounts of Alpha-linolenic Acid (ALA) Food sources

Amount of ALA (in grams per serving)

1 tablespoon flaxseed oil

7.26 grams per serving

1 tablespoon whole flaxseed

2.35

1 tablespoon canola oil

1.28

3 ounces canned pink salmon, drained

0.04

1 ounce black walnuts

0.76

1 tablespoon mayonnaise

0.74

3 ounces wild Eastern oysters, cooked

0.14 [15]

Dietary Protein The need for dietary protein declines during the aging process since the body’s LBM decreases. However, there still needs to be enough dietary protein to sustain body weight and everyday body functions, in addition to increased or extenuating bodily needs such as illness. If there is insufficient protein in the diet then this may contribute to compromised (suppressed) immune function, frailty and insufficient wound healing and increase the potential of certain diseases. Depending upon body size and gender, the DRI for protein is 10% 35% of total daily calories. About 46 56 grams (about 184 224 calories) of protein daily are recommended for American women over the age of 50 years, and about 56 grams of protein (about 224 calories) are recommended for American men who are also over the age of 50 years. While high-quality proteins may be easier to obtain and consume (those from dairy products, eggs, fish and seafood, lean meats and poultry), vegetable proteins from grains, legumes and vegetables may also be adequate. High-quality protein foods may also be expensive, difficult to cook properly and readily transport to maintain food safety, so vegetable-based protein foods may provide healthy, economical alternatives. It is possible to follow a well-planned vegetarian or vegan diet with sufficient protein. The help of a nutrition professional, such as a registered dietitian/nutritionist is recommended. Examples of animal and vegetable protein sources are shown in Table 2.5. TABLE 2.5 Sources of Animal and Vegetable Proteins and Recommended Serving Sizes Foods and beverages

Serving sizes

Protein (grams)

Beef round roast, cooked

3 ounces

25 grams (g)

Bread, white

1 slice

3

Broccoli, cooked

1

/2 cup

3

Cheddar cheese

2 ounces

14

Chicken, white meat, cooked

3 ounces

30

Cottage cheese

1

/2 cup

14

Egg, whole

1

6

Fish (as flounder, halibut), cooked

3 ounces

12

Hot dog, cooked

2 ounces

7

Legumes (as kidney, lima, garbanzo), cooked

1

/2 cup

8

Milk, 2%

1 cup

8

Mozzarella cheese

2 ounces

12

Lamb, cooked

3 ounces

21 (Continued)

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TABLE 2.5

(Continued)

Foods and beverages

Serving sizes

Protein (grams)

Pasta, cooked

1

/2 cup

3

Peanut butter

2 Tablespoons

8

Pork roast, cooked

3 ounces

21

Rice, brown, cooked

1

/2 cup

5

Sausage, cooked

1 patty

5

Shrimp, cooked

12 large

17

Soymilk

1 cup

6

Tofu

3 ounces

8

Tortilla, corn

1 (6-inch)

2

Tuna, canned

3 ounces

24

Turkey, white meat, cooked

3 ounces

28

Yogurt, low-fat

8 ounces

12

From Culinary Nutrition: The Science and Practice of Healthy Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 195.

MINERALS FOR AGING DIETS Minerals are substances that are in many foods and beverages that are necessary for the maintenance of health and life. There are two types of minerals: macrominerals and trace minerals. Macrominerals are found in quantities that are greater than five grams and are generally needed in larger amounts by the human body. They include calcium, chloride, magnesium, phosphorus, potassium, sodium and sulfur. Trace minerals are found in quantities that are less than five grams and are generally needed in smaller amounts by the human body in trace amounts and include chromium, cobalt, copper, fluoride, iodine, iron, manganese, molybdenum, selenium and zinc. Some of the unique mineral requirements for aging people are as follows.

Calcium Since bone density decreases during aging, sufficient calcium and vitamin D are needed to curtail the development of osteoporosis, a condition whereby the bones become brittle and fragile from the loss of tissue. Consuming an adequate calcium intake may be able to reduce the risks of fractures and osteoporosis in some populations. Moderate physical activity along with healthy weight may also reduce osteoporosis risks by contributing to muscle mass and strength. However, the inability to access a consistent amount of calcium and vitamin D-containing foods and beverages, such as in food insecurity, may make it difficult for the aging to meet their calcium and vitamin D needs. Also medications that may decrease dietary calcium absorption may also put the aging at risk of calcium insufficiency. Calcium is normally the most plentiful mineral in the human body; the majority of which is located in the bones and teeth. Only a small percentage of calcium is found in the blood and other tissues. Calcium has many vital roles in the human body. These include bone development and maintenance, body fluid balance, blood clotting, blood pressure, enzyme activation, muscle contraction and nerve transmission. A lifetime of inadequate calcium intake, lactose intolerance and decreased gastric acidity may impair calcium absorption and contribute to decreased bone mass. The human body is able to transfer calcium from some of its body stores to maintain normal serum calcium and prevent hypocalcemia, a condition when the blood has too little calcium. Symptoms of hypocalcemia may include confusion, muscle spasms, numbness, seizures or even cardiac arrest. Conversely, calcium toxicity may be caused by calcium oversupplementation, hormonal disorders, or conditions that prevent calcium excretion, such as kidney dysfunction that is common in the aging. Still, calcium intake and metabolism should not be discussed in a vacuum. Phosphorus, vitamin D and protein are also important nutrients that contribute to the mix for healthy bones and teeth.

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For example, dietary protein provides Insulin-Like Growth Factor-1 (IGF-1), a substance that has the capacity to transform vitamin D into an active form. A function of IGF-1 is to move calcium into the bloodstream as it is needed. Vitamin D along with adequate dietary calcium reduces the risk of hip fractures. Phosphorus contributes to bone mineralization in addition to calcium, both in the formation of new bones and repair of existing bones. Adequate dietary protein supplies the amino acids that are required for muscle protein synthesis. Since the muscles and the skeleton comprise about 50% of the human body protein stores, adequate dietary protein should not be understated. Dietary protein is, in part, thought to combat sarcopenia, the loss of muscle strength and mass that occurs in more than 50% of Americans who are aged 80 years or older, and is a leading cause of fall risks [16]. Good food and beverage sources of calcium include calcium-fortified beverages and foods, dairy products, dark leafy green vegetables, fish with small bones and soy products. Particularly notable for their calcium content are plain low-fat and nonfat yogurt, bok choy, broccoli and kale, sardines, shrimp and calcium-fortified orange juice, tofu and nut-based beverages. Oxalic acid, found in green leafy vegetables, may bind with calcium and interfere with calcium absorption, as well as some higher-fiber foods (such as legumes, nuts and/or wheat bran) that tend to speed up transport time in the small intestine. Humans may only absorb about 25% of the dietary calcium that they consume through foods and beverages, so this should be taken into account in diet planning for the aging. The dietary requirements for calcium and other bone minerals and vitamins may slightly vary worldwide. According to the US DRIs: Estimated Average Requirements (EARs): • Men who are 51 70 years of age require about 800 milligrams of calcium daily. • Men who are older than 70 years of age require about 1000 milligrams of calcium daily. Women who are 51 70 1 years of age require about 1000 milligrams of calcium daily. Some representative sources of calcium-containing foods and beverages are shown in Table 2.6.

TABLE 2.6 Selective Sources of Calcium in Foods and Beverages Sources of calcium

Amount (in milligrams)

1 cup plain low-fat yogurt

415 milligrams (mg)

6 ounces calcium-fortified orange juice

378a

3 ounces sardines, packed in oil

324

1 /2 ounces part-skim mozzarella cheese

253

1 /2 cup calcium-fortified tofu

138a

/2 cup spinach, cooked

123

1

1

1

a

Average fortification. From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 297.

Iron Iron is an essential mineral for the synthesis of red blood cells and adenosine triphosphate, the energy storage molecule of the body. Though iron deficiency is common in younger people and especially in younger women, people who are 65 years or older generally have sufficient iron stores. In women, this may be due to menopause and the cessation of blood loss. That stated, a low intake of dietary iron over time may contribute to iron deficiency anemia, a condition when there are too few healthy red blood cells in the body to transport oxygen and to maintain healthy cells, hair, nails and skin. Symptoms of iron deficiency anemia include coldness, decreased energy levels, dizziness, impaired immune function, shortness of breath, slowed mental functioning, tiredness and weakness. Factors that increase the risk of iron deficiency anemia include low intake of vitamin C-rich foods and beverages that include broccoli, cabbage, cauliflower, citrus fruits and juice, green peppers, and potatoes; low intake of heme iron-containing foods such as fish, poultry and meats; high intake of calcium; and certain chronic diseases such as certain cancers, infections, inflammatory diseases and/or kidney disease.

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During aging, blood loss in the intestines and stomach may lead to iron deficiency, as well as antiinflammatory drugs such as aspirin (sometimes prescribed for cardiovascular disease), cancer of the colon or stomach, diverticulosis, hemorrhoids, hiatal hernia and/or frequent blood drawings. Too much dietary iron may lead to hemochromatosis, or iron overload, which may lead to infections, tissue damage and/or liver toxicity. Men are particularly vulnerable. For this reason, vitamin and mineral supplements with iron and iron supplements should only be taken under the advice of a health care provider. According to the US DRIs EARs, men who are 51 70 1 years of age require about 6 milligrams of iron daily, and women who are 51 70 1 years of age require about 5 milligrams of iron daily. Food and beverage sources of iron include dark leafy green vegetables, dried fruits, eggs, fish, enriched and fortified cereals, legumes, poultry, red meat and shellfish. The following sources of iron that are shown in Table 2.7 provide ample amounts of iron, in consideration of the US DRIs.

TABLE 2.7 Iron Sources in Foods and Beverages Sources of iron

Amount (in milligrams)

3 ounces clams, steamed

23.80 milligrams (mg)

1

/4 cup enriched breakfast cereal

1.80 21.1

1 tablespoon blackstrap molasses

3.50

1

/2 cup spinach, cooked

3.20

3 ounces chuck roast, cooked

3.13

/4 cup prune juice

2.25 [17]

1

Data from Culinary Nutrition: The Science and Practice of Healthy Cooking, Jacqueline B. Marcus (Elsevier, 2014), p. 307.

Magnesium Like calcium and phosphorus, magnesium is a mineral that is vital for bones and teeth. It is also critical in the protein synthesis of the heart, liver muscles and soft tissue cells and in their metabolism. In particular, magnesium assists the muscles to contract and relax and the nerves to transmit impulses. In total, magnesium is involved in about 300 physiological processes. Only about 40% 60% of the magnesium that is consumed from foods and beverages is absorbed, unless there is a magnesium deficiency, and then more is absorbed to meet the increased needs. Plus, magnesium absorption decreases with age. Besides having a negative effect on energy production, a magnesium deficiency may reduce the antioxidant capacity in people who are aging and their resistance to oxygen-free radicals may lead to inflammation. In turn, inflammation is associated with a wide range of chronic diseases that may include asthma, IBD, multiple sclerosis and rheumatoid arthritis. A magnesium deficiency may be caused by alcoholism, inadequate magnesium intake from foods and beverages, protein malnutrition, severe diarrhea, or vomiting, many of which are concerns of the aging. A magnesium deficiency may consequently result in confusion, growth failure, muscle spasms and/or overall weakness. On the other hand, magnesium toxicity may create unusually low blood pressure, coordination disorders and/or fatality. This could be the result of excessive magnesium-based antacids, laxatives or supplements and some medication interactions, many of which are risky behaviors in some aging people. The best sources of magnesium include almonds, cashews fortified cereals, spinach, tofu and oysters. Good sources include chocolate, dark leafy green vegetables, legumes, nuts and seafood. The chlorophyll in green leafy vegetables contains magnesium. Refined grains are generally poor in magnesium, unless they are fortified because their nutrient-rich bran and germ are removed. People who live in areas where there is “hard” drinking water may benefit from the calcium and magnesium that are often found in this type of water. According to the US DRIs: EARs, men who are 51 70 1 years of age require about 350 milligrams of magnesium daily, and women who are 51 70 1 years of age require about 265 milligrams of magnesium daily. In Table 2.8, the sources and amounts of magnesium in common comestibles are shown.

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TABLE 2.8 Amounts of Magnesium in Foods and Beverages Sources of magnesium

Amount (in milligrams)

2 tablespoons almonds

90 milligrams (mg)

1

/2 cup spinach, cooked

75

2 tablespoons dry-roasted peanuts

50

1 medium potato, baked

50

1 cup brown rice, cooked

40

1 medium banana

30 [18]

Data from Barbagallo M, Dominguez L J. Magnesium and aging. Curr Pharm Des 2010;16(7):8329, https://www.ncbi. nlm.nih.gov/pubmed/. [accessed 30.08.18]; https://doi.org/10.2174/138161210790883679.

Phosphorus Next to calcium, phosphorus is the second most abundant mineral in the human body and like calcium, phosphorus is essential for bone mineralization. About 85% of phosphorus in the body is found in bones and teeth. Phosphorus is also essential for cellular growth and development since it is a component of DNA and RNA, the genetic codes of every cell. Phosphorus may help prevent muscular fatigue, improve heart regularity and support the transference of nerve impulses beyond normal growth and body repair [19]. For these reasons, phosphorus is abundant in animal proteins, specifically in dairy products, fish, meats and poultry. Phosphorus is also found in processed foods and in some carbonated beverages where it is in the form of phosphoric acid. Diets that are high in animal protein and carbonated beverages with phosphoric acid may cause calcium to be excreted by the body. Diets of this nature should be balanced by the intake of calcium-rich foods such as dairy products, green-leafy vegetables and/or small fish with bones that include canned salmon and sardines. According to the US DRIs: EARs, men and women who are 51 70 1 years of age require about 580 milligrams of phosphorus daily. The following foods and beverages that are shown in Table 2.9 provide a range of choices.

TABLE 2.9 Food and Beverage Sources of Phosphorus Sources of phosphorus

Amount (in milligrams)

1 cup plain nonfat yogurt

385 milligrams (mg)

3 ounces salmon, cooked

252

1 cup skim milk

247

3 ounces beef, cooked

173

1 large egg, cooked

104

1 slice whole wheat bread

57

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 299.

Potassium Potassium functions in the human body as an electrolyte and as an essential mineral that is needed by all cells, organs and tissues. Electrolytes conduct electrical impulses within the body, along with calcium, chloride, magnesium and sodium. Potassium is also essential for normal heart, muscle and nerve functions and metabolism, particularly those that control brain functions, cardiac rhythm, energy levels, the movements of nutrients and wastes, and pH balance. One of the normal physiological changes that is associated with aging is decreased kidney function. As a result, urine output increases and the reabsorption of nutrients declines, so more nutrients are excreted, such as potassium. Decreased potassium reabsorption in conjunction with gastrointestinal changes due to aging, diarrhea and/or vomiting; medical conditions such as Crohn’s or Cushing’s disease, leukemia, or magnesium deficiency; or a

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variety of medications that include antibiotics, bronchodilators, diuretics, insulin, laxatives, steroids and theophyllines may also affect potassium absorption. Hypokalemia, a low level of potassium in the blood stream, may result, with its symptoms of constipation, leg cramps, tiredness and/or weakness. Hypokalemia may increase the risk of an abnormal heart rhythm, such as bradycardia or cardiac arrest. According to the US DRIs, the AI level of potassium for men and women who are 50 years of age or older is about 4700 milligrams daily. This amount is associated with decreased risks of hypertension, kidney stones, osteoporosis and stroke. It does not apply to people who have been instructed to limit their potassium consumption for various reasons. Fruits and vegetables have the highest concentration of potassium per serving. Bananas, broccoli, citrus fruits, kiwi, melons, peas, potatoes, tomatoes and winter squash are sources of potassium. Consumption of fresh fruits and vegetables and whole grains may be inadequate in the aging. Poultry, meats and whole grains are other sources of potassium, but they may provide proportionally less potassium than fruits and vegetables. Potassium supplements are sometimes prescribed with blood pressure medication since they function as a diuretic. While the kidneys normally regulate potassium that passes through the gastrointestinal tract, if supplemental potassium ever bypasses the gastrointestinal tract or is too high in the bloodstream, it may cause heart failure or death. For this reason, a health care provider should supervise the use of supplemental potassium [20]. Table 2.10 shows some sources and amounts of potassium in familiar foods and beverages. TABLE 2.10

Common Sources of Potassium in Foods and Beverages

Sources of potassium

Amount (in milligrams)

1 medium potato, baked

926 milligrams (mg)

1 cup plain low-fat yogurt

573

1

/2 cup lima beans, cooked

485

1 medium banana

422

3 ounces pork chop, cooked

382

6 ounces orange juice

372

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 305.

Selenium Selenium is an essential trace mineral that is needed for growth and protein synthesis. It supports the effectiveness of vitamin E and it acts like an antioxidant to protect human body cells from free radicals in the environment. For this reason, selenium is often linked with age-related diseases. Though antioxidant supplements have been proposed as a preventive measure against dementia, selenium and vitamin E do not seem to be effective in the prevention of neurodegenerative disorders such as Alzheimer’s and Parkinson’s diseases [21]. Supplemental selenium may reduce the incidence of colorectal tumors and lung and prostate cancer. Selenium may also help to increase the levels of high-density lipoprotein (good) cholesterol and lower levels of low-density lipoprotein (LDL) (bad) cholesterol, and reduce the risk of heart disease and stroke by decreasing the stickiness of the blood and reducing the risk of blood clots. It does so by preserving tissue elasticity and by delaying the aging and hardening of tissues that are associated with oxidation. Three antioxidants, selenium, vitamin C and vitamin E have also shown effectiveness in reducing the effects of the sun on the skin and preventing additional damage [22]. Because selenium is a component of glutathione peroxidase, a substance that protects the tissues from the effects of PUFA oxidation, it may help to prevent some oxidative stress. However, selenium supplements in excess may cause selenosis, or selenium toxicity, which causes these symptoms: fatigue, hair loss, nausea, weak and brittle fingernails, unusual body odor and/or vomiting [23]. A selenium deficiency may occur in people who have digestive disorders that may interfere with normal absorption of selenium. If the selenium level is low, then this may depress immune function and/or lead to eye disorders, heart failure, reduced thyroid activity and/or weakened red blood cells.

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According to the US DRIs: EARs, men and women who are 51 70 1 years of age require about 45 micrograms of selenium daily. Selenium is found in brewer’s yeast, eggs, fish and seafood, garlic, meats, mushrooms, organ meats, vegetables, wheat germ and some whole grains. The sources of selenium and the amounts provided are listed in Table 2.11.

TABLE 2.11

Food Sources and Amounts of Selenium

Sources of selenium

Amount (in micrograms)

2 tablespoons Brazil nuts

544 micrograms (mcg)

3 ounces light tuna canned in oil

63

3 ounces light meat turkey, roasted

27

3 ounces beef chuck roast, cooked

23

1 cup enriched noodles, cooked

17

1 medium egg

14

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 309.

Sodium Like potassium and chloride, sodium is considered an electrolyte, a “charged” substance that when dissolved in a liquid it helps to conduct an electrical current. Electrolytes help to maintain the human body’s fluid balance both inside and outside of the cells. Along with chloride (Cl2), sodium (Na1) is the most abundant electrolyte outside of the cells, while potassium (K1) is the most abundant electrolyte inside of the cells. The human body is capable of diffusing or moving electrolytes both inside and outside of the cells to keep the electrolytes and fluids in balance. If electrolytes are too high or low in concentration, then this finely tuned system may abnormally function. For this reason as well as others, sodium is essential to many body processes. Sodium helps to maintain the acid-base balance in the human body and is important in muscular contraction and nerve transmission. Decreased sodium may lead to appetite loss, mental confusion, or muscle cramping and if extreme, heart failure or stroke. Excessive sodium may increase blood pressure and stress the brain, heart, kidneys, or other organs. The recommended AI of sodium for aging men and women who are 51 70 years of age is 1300 milligrams daily, and 1200 milligrams of sodium daily for aging men and women who are 70 1 years of age. This may be difficult to accomplish for many reasons. To begin, the physiological need for sodium in the human body is only 220 500 milligrams daily. A sodium deficiency is rare. The average daily consumption of sodium may be as much as 10 times this amount. Ordinary table salt (sodium chloride) contains about 2300 milligrams of sodium per teaspoon—or about 40% sodium and 60% chloride. Kosher salt and some sea salts that may be used in cooking may contain about 1320 milligrams of sodium per teaspoon. As the senses of taste and smell decline during aging, an inclination is to salt foods to help it to “taste better.” This may be ill advised due to many of the well-tuned balances that rely on the right amount of sodium and other substances for proper functioning. As a whole, people are aging should choose and prepare foods and beverages with as little salt as possible (this includes many processed foods), and consume potassium-rich foods, such as fruits and vegetables, to help to reduce the risks of hypertension and stroke. In fact, those aging who have diagnosed hypertension should also meet the DRI for potassium that is 4700 milligrams of potassium daily. Sodium is abundant in common table salt, cured foods such as anchovies and pork products like bacon and ham, brined foods such as olives and pickles, processed foods and mustard, soy sauce and other condiments. Animal foods tend to be higher in sodium than plant foods because sodium is generally found in animal tissues. Higher amounts of sodium may be found in some green leafy vegetables, root vegetables and tomatoes; these might be limited on lower-sodium diets. Some sources of foods with sodium are shown in Table 2.12.

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MINERALS FOR AGING DIETS

TABLE 2.12

Food Sources and Amounts of Sodium

Sources of sodium

Amount (in milligrams)

1

/2 cup canned kidney beans (nonrinsed)

435 milligrams (mg)

1 ounce pasteurized processed cheese

405

1 ounce cured ham

376

1

/2 cup stewed tomatoes

282

2 tablespoons salted dry-roasted peanuts

230

1 ounce salted potato chips

168

Compared to . . . 1 cup plain skim milk yogurt

174

1 ounce part-skim mozzarella cheese

132

1 whole egg

59

1 cup fresh-frozen broccoli, cooked

35

1 medium avocado

22

1 medium banana

2 [24]

Data from http://fcs.tamu.edu/files/2015/02/sodium-content-of-your-food-b1400.pdf.

Zinc Zinc is a trace mineral that is essential for DNA synthesis, growth and development, immunity and would healing. Perhaps the last two functions are the most applicable to the aging. Aging people may have higher zinc requirements when their immune system is compromised and when they are recovering from surgery or major illnesses. This may be due to the fact that adequate zinc is critical for the production of lymphocytes, which are specialized white cells in the immune system that protect the body against bacterial, fungal, parasitic and viral infections. Diets that are high in phytates (antioxidant compounds that are found in legumes, nuts and seeds and whole grains) and fiber; iron and copper-containing foods (such as some meats) and/or alcohol may contribute to zinc deficiency, as may some conditions such as chronic diarrhea or other digestive tract disorders. This is partially because copper, iron and zinc are intricately connected and compete for absorption in the gastrointestinal tract. According to the US DRIs: EARs, men who are 51 70 1 years of age require about 9.4 milligrams of zinc daily, and women who are 51 70 1 years of age require about 6.8 milligrams of zinc daily. The most common dietary sources of zinc include enriched and fortified breads and cereals, legumes, meats, poultry and whole grains. Baked beans, crabmeat, oysters and soybeans are particularly abundant in zinc. Table 2.13 shows some common food sources of zinc and their zinc content.

TABLE 2.13

Common Food Sources of Zinc

Sources of zinc

Amount (in milligrams)

3 ounces oysters, cooked

28.3 milligrams (mg)

3 ounces beef shanks, cooked

8.9

3 ounces pork tenderloin, cooked

2.5

1

/2 cup baked beans

1.7

1 cup low-fat yogurt with fruit

1.6

2 tablespoons dry-roasted almonds

1.0

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 308.

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VITAMINS FOR AGING DIETS Vitamins are organic compounds that are naturally found in many foods and beverages. They are needed in very small amounts by the human body for normal development, functioning, maintenance, repair and good health. There are nine water-soluble vitamins: vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B3 (niacin), vitamin B5 (pantothenic acid), vitamin B6 (pyridoxine), biotin (vitamin B7 or H), vitamin B9 (folic acid), vitamin B12 (cobalamin) and vitamin C (ascorbic acid). And there are four fat-soluble vitamins: vitamin A (retinoids), vitamin C (calciferol, 1,25-dihydroxy vitamin D), vitamin E (tocopherol) and vitamin K. The following section highlights some of the more salient features of vitamins for aging diets.

Folate (Folic Acid or Folacin) Folate (Folic Acid or Folacin) is a co-enzyme, like the B vitamins thiamin, riboflavin and niacin. Folate is essential for the synthesis of DNA and for red blood cell formation. A folate deficiency may lead to megaloblastic anemia (also referred to as pernicious anemia). In this type of anemia, red blood cells are malformed, which may affect their oxygen-carrying capacity, and fewer red blood cells are produced in the bone marrow. Symptoms that may ensue include appetite loss, fatigue, headache and/ or weakness. A folate deficiency in the aging may develop as a result of inadequate dietary folate. The human body stores only enough folate to last about 4 6 months. The symptoms of folate deficiency are very similar and somewhat indistinguishable from a vitamin B12 deficiency. Folate is abundant in leafy green vegetables such as kale and spinach, and in asparagus, broccoli, fortified breakfast cereals, legumes (such as black-eyed peas) and lentils, oatmeal, and orange juice. According to the US DRIs: EARs, men and women who are 51 70 1 years of age require about 320 micrograms of folate daily, which is available from the sources listed in Table 2.14.

TABLE 2.14

Amounts of Folate in Common Beverages and Foods

Sources of folate

Amount [in micrograms of Dietary Folate Equivalent

1 cup fortified breakfast cereal

200 400 micrograms or mcg DFEa

1

/2 cup lentils, cooked

179

1

/2 cup asparagus, cooked

134

1

/2 cup spinach, cooked

132

6 ounces orange juice

83

1/3 cup peanuts

71

2 tablespoons natural peanut butter

25

a

Average fortification. From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 308.

Vitamin A (Retinol, Retinal and Retinyl Ester) Antioxidant vitamins A and C may be lower in aging diets, particularly if fruits and vegetables are not consumed. Lower levels of these vitamins may lead to compromised eyesight, epithelial tissues and skin, decreased immune function and increased oxidative stress to body tissues. Vitamin A is known as the “eyesight” vitamin since it is related to vision. Vitamin A is actually a family of compounds that include retinol (preformed vitamin A), which is an active form of vitamin A that is only found in animal foods and carotenoids (vitamin A precursors or provitamins).

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Rhodopsin, an eye protein that contains a retinal compound, helps to change the light that enters the eye into nerve impulses. These nerve impulses are then sent to the brain to create visual images. Rhodopsin can only be synthesized if vitamin A is supped by the diet. If it is lacking, then vision may be impaired and a condition called night-blindness may occur, which involves an inability to see in dim light and a slow recovery to bright light at night. People who have celiac disease or Crohn’s disease or have had a gastric bypass might have difficulty absorbing vitamin A and other nutrients that may contribute to night vision issues. Other complicating factors may include cataracts (that affects the lens behind the pupil and distorts the light that enters the eye), insufficient zinc (see the discussion about dietary zinc), LASIK surgery (that reshapes the cornea and restores 20/20 vision) and sunlight exposure. Too little vitamin A may also lead to xerophthalmia, which is an abnormal dryness of the eyeball that is characterized by conjunctivitis, an inflammation or infection of the membrane that lines the eyelids. On the other extreme, too much vitamin A may lead to liver disorders, and too much beta-carotene (after it is converted to vitamin A) may build up in the fat tissues and cause the skin to discolor and appear golden yellow. The best sources of preformed vitamin A are beef liver, eggs, fortified dairy products and some margarines that are fortified with vitamin A. The best sources of carotenoids are found in dark leafy green and brightly colored orange, red and yellow fruits and vegetables. Those that are particularly rich in beta-carotene include broccoli, oranges, spinach, sweet bell peppers and tomatoes. According to the US DRIs: EARs, men who are 51 70 1 years of age require about 625 micrograms of vitamin A daily, and women of the same age require about 500 micrograms. Some sources and amounts of vitamin A in foods are shown in Table 2.15. TABLE 2.15

Source and Amounts of Vitamin A in Foods

Sources of vitamin A

Amount (micrograms)

1 medium sweet potato with skin, baked

1096 micrograms (mcg)

1

/2 cup carrots, cooked

709

1

/2 cup butternut squash, cooked

604

1

/2 cup spinach, cooked

498

1

/2 cup canned apricots

169

/2 cup fresh cantaloupe

143

1

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 283.

Vitamin C (Ascorbic Acid or Ascorbate) In contrast to other mammals, humans cannot make their own vitamin C, so it must be obtained by the diet. Vitamin C is important for the production and maintenance of collagen, a protein that is found in bones, connective tissues, skin, teeth and tendons. Like vitamin A, vitamin C functions as an antioxidant, which means that it helps to protect the human body from oxidative damage due to such factors as environmental pollutants, ozone, radiation and ultraviolet light. In this capacity along with vitamin E and selenium, vitamin C works to decrease the effects of the sun on the skin and prevent additional skin damage. Vitamin C is also critical for the immune process. It helps to protect the human body from infections and illnesses from the common cold to more complicated diseases, such as certain cancers and cardiovascular disease. Vitamin C may also help the human body to rebound from certain stresses, such as physical exertion or extreme differences in temperatures. For these reasons and others, vitamin C is essential for the diet of aging people. While vitamin C is touted as an antiaging supplement, it is still best for those who are aging to try to obtain enough vitamin C from their daily diet. According to the US DRIs: EARs men and women who are 51 70 1 years of age require about 60 milligrams of vitamin C daily. Vitamin C is particularly rich in broccoli, cantaloupe, grapefruit, kiwifruit, lemons, oranges, papaya and sweet bell peppers. Food and beverage sources of vitamin C are shown in Table 2.16.

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TABLE 2.16

Food and Beverages Sources and Amounts of Vitamin C

Sources of vitamin C

Amount (in milligrams)

1 cup whole strawberries

85 milligrams (mg)

1 medium orange

70

1

/2 cup sweet bell pepper, chopped

65

1/2 cup orange juice

62

1

/2 cup broccoli, cooked

51

1

/2 medium grapefruit

38

1 medium tomato

16 [25]

Adapted from https://www.dietitians.ca/Downloads/Factsheets/Food-Sources-of-Vitamin-A.aspx.

Vitamin D [Ergocalciferol (Vitamin D2) and Cholecalciferol (Vitamin D3)] Vitamin D is known as the “sunlight” vitamin. Aging people who spend most of their time indoors and/or out of sunlight may be deficient in vitamin D. The sunlight helps to convert a vitamin D-precursor on the skin into the active form of vitamin D in the human body. While this attribute makes vitamin D unusual in that it does not rely upon diet intake, it also makes vitamin D more challenging to obtain either out-of-doors or by diet. Vitamin D is essential for bone growth and maintenance. It helps to enable the minerals calcium and phosphorus to be available to the bones of the human body for absorption and improved bone density. A vitamin-D disorder may contribute to musculoskeletal disorders, such as osteomalacia (adult rickets) or bone softening. It is also characterized by the rounding of the spine. Too much vitamin D may be caused vitamin D supplementation in excess of the vitamin D requirement and may be toxic. This elevated level of vitamin D may build up and affect the soft tissues. Also, the gastrointestinal tract may absorb excess vitamin D from the bloodstream, which in turn may cause a release of calcium from the skeleton and potential cardiovascular and kidney damage. According to the US DRIs: EARs men and women who are 51 70 1 years of age require about 10 micrograms of vitamin D daily. Vitamin D-fortified breads and cereals and dairy products, and salmon and other fatty fish, such as mackerel and sardines, are good sources. Other sources of vitamin D I International Units and micrograms are shown in Table 2.17. TABLE 2.17

Sources of Vitamin D in Foods and Beverages

Sources of vitamin D

Amounts (international units)

Amounts (in micrograms)

3 ounces salmon, cooked

447 IU

11.2 micrograms (mcg)

3 ounces canned tuna in water

388

9.7 a

2.9 3.1

1 cup vitamin D-fortified dairy milk

115 124

1 tablespoon vitamin D-fortified margarine

60

1.5

2 canned sardines

46

1.2

1 large whole egg

41

1.0

a

Varies according to fat content. From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 285.

Vitamin E [α (Alpha), β (Beta), γ (Gamma) and δ (Delta) forms; Most Common Is Gamma-Tocopherol (γ-Tocopherol)] Vitamin E is often referred to as the “antiaging” vitamin since it has so many vital functions that are associated with cellular longevity, including cellular reproduction, healthy eyesight and skin. This is because vitamin E is one of the antioxidant vitamins along with vitamins A and C that serve to protect the cells from damage that is due to oxygen-free radicals in the environment.

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VITAMINS FOR AGING DIETS

Vitamin E and other nutrients, such as beta-carotene, vitamins C and E, and zinc may help some people who have moderate AMD, and along with lutein and zeaxanthin when vitamin E is its alpha-tocopherol form, may decrease the risk of cataracts. More definitive research is needed [26]. A deficiency in vitamin E may lead to the rupture of red blood cells and their dysfunction. It may also damage the nerve tissues and lead to eyesight and/or neuromuscular disorders, including impaired vision. Some of these symptoms of vitamin E deficiency may be observed as a result of prolonged low-fat dieting and may potentially result from the “anorexia of aging” (see the section Anorexia earlier in this chapter). When taken in supplement form, vitamin E may also decrease normal thyroid gland function, increase fatigue and muscle weakness, thin the blood and increase the risk of hemorrhagic stroke. Vitamin E toxicity may result from supplementation and interference with normal blood clotting, and increased bleeding may result. According to the US DRIs: EARs, men and women who are 51 70 1 years of age require about 12 milligrams of vitamin E daily. Good sources of vitamin E include dark leafy green vegetables, nuts, polyunsaturated fruit and vegetable oils, seeds, wheat germ and whole grains. The foods shown in Table 2.18 provide notable amounts compared to the DRI for vitamin E. TABLE 2.18

Food Sources of Vitamin E

Sources of vitamin E

Amount (in milligrams)

2 tablespoons sunflower seeds

8.5 milligrams (mg)

2 tablespoons dry-roasted peanuts

6.8

1 tablespoon safflower oil

6.0

2 tablespoons peanut butter

3.0

1 medium avocado

2.8

1 medium mango

2.4

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 286.

Vitamin K [Vitamin K1 (Phylloquinone) and Vitamin K2 (Menaquinone)] Vitamin K is a fat-soluble vitamin that is notable for its role in blood coagulation or thickening, most commonly known as blood clotting. Vitamin K also has a role in bone proteins and assisting minerals to bind to these proteins that makes the bones stronger. In this manner, vitamin K may help to prevent osteoporosis by regulating calcium. Thanks to its blood clotting functions, vitamin K may also aid in certain cancers and stroke prevention, improve insulin sensitivity and protect against hardening of the arteries. It may also play an important role in Alzheimer’s disease prevention since it helps to regular calcium in the brain as well as in the bones. It has been hypothesized that genetic variation of apolipoprotein E may help modulate bone mineral density through its effects on lipoprotein and vitamin K transport. The APOE4 gene is also needed for the metabolism of fats, and especially in Alzheimer’s disease and cardiovascular disease. Research is ongoing [27]. According to the US DRIs the AI level of vitamin K for men who are 51 70 1 years of age is about 120 micrograms daily, and for women who are 51 70 1 years of age the AI level of vitamin K is 90 micrograms daily. Poor vitamin K intake, antibiotics, anticoagulant medication and fat malabsorption may affect vitamin K availability. Vitamin K supplementation and drug interactions may lead to vitamin K toxicity, which in turn may lead to anemia from hemorrhages in the red blood cells, brain damage, or jaundice from bilirubin, a yellow pigment that surfaces right under the skin. Dark leafy green vegetables, soy foods and vegetable oils are good sources of vitamin K. Some of the highest concentrations of vitamin K are found in fermented foods, such as natto (a fermented soy product) and fermented vegetables, such as sauerkraut, which may not be prevalent in western diets. Specific foods that are higher in vitamin K include broccoli, Brussels sprouts, cabbage, collard greens, eggs, fish, kale, meat, spinach, Swiss chard and turnip greens—often in their fresh states. Table 2.19 lists the sources and amounts of vitamin K in some commonly consumed foods.

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TABLE 2.19

Sources and Amounts of Vitamin K in Common Foods

Sources of vitamin K

Amount (micrograms)

1

/4 cup fresh parsley, chopped

246 micrograms (mcg)

1 cup broccoli, cooked

220

1 cup fresh spinach

145

1 cup fresh green leafy lettuce, shredded

62.5

1 tablespoon soybean oil

25

1 tablespoon canola oil

16.6 [28]

Data from http://www.alzheimers.net/2014-07-09/vitamin-k-alzheimers-prevention/.

B Vitamins: Vitamin B6 (Pyridoxine) and B12 (Cyanocobalamin or Methylcobalamin) If people who are aging consume less-to-no animal proteins, then their levels of vitamin B6 and B12 may be substandard. Consequently, this condition may precipitate an elevated level of homocysteine in the bloodstream and may increase the risk of cardiovascular disease.

Vitamin B6 (Pyridoxine) According to the US DRIs: EARs, men who are 51 70 1 years of age require about 1.4 milligrams of vitamin B6 daily, and women of the same age require about 1.3 daily milligrams. Some food sources of vitamin B6 are provided in Table 2.20.

TABLE 2.20

Common Foods and Vitamin B6 Content

Sources of vitamin B6

Amount (in milligrams)

1 medium white potato with skin, baked

0.70 milligrams (mg)

1 medium banana

0.68

3 ounces salmon, cooked

0.48

3 ounces skinless chicken breast, cooked

0.51

1 cup spinach, cooked

0.44

3 ounces lean pork, cooked

0.42

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 291.

Vitamin B12 (Cyanocobalamin or Methylcobalamin) Since a number of people who are aging are deficient in vitamin B12, it is important to highlight. Vitamin B12 requires an essential component called the intrinsic factor for its utilization. An autoimmune reaction in which the immune system mistakenly attacks the stomach cells that produces the intrinsic factor may cause it to be lacking. An absence of the intrinsic factor is the most common cause of pernicious anemia when the blood is low in normal red blood cell. Inadequate vitamin B12 may affect mental functions and other physiological changes, such as lightheadedness, heart palpitations, shortness of breath, tiredness, weakness and others. Foods that are fortified with vitamin B12 may be easier for the aging to absorb than vitamin B12 that is protein-bound. This may be due to factors such as poor food choices or chewing and swallowing difficulties if protein-rich foods such as fish, poultry, or beef are not consumed.

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49

A vitamin B12 deficiency may affect about 10% 15% of people over the age of 60 years and may lead to atrophic gastritis, which is chronic inflammation of the stomach mucosa. Atrophic gastritis affects the stomach’s secretion of hydrochloric acid, pepsin and intrinsic factor, all factors that are involved in vitamin B12 absorption. Aside from vitamin B12 deficiencies, atrophic gastritis may lead to digestive disorders and megaloblastic anemia (an anemia that is characterized by larger-than-normal red blood cells). Stomach acid is preferred for vitamin B12 absorption, but it is not required for the absorption of vitamin B12-fortified foods or vitamin B12 supplements. Vitamin B12 is found in foods of animal origin. Chicken liver, cottage cheese, ground beef, sardines and tuna are good choices. Foods that are fortified with vitamin B12 may include some meat analogs, nutritional yeast, ready-to-eat cereals and some plant- and soy-based “milks.” According to the US DRIs: EARs, men and women who are 51 70 1 years of age require about 2.0 micrograms of vitamin B12 daily. Common food sources of vitamin B12 per serving are shown in Table 2.21.

TABLE 2.21

Sources and Amounts of Vitamin B12 in Common Foods

Sources of vitamin B12

Amount (in micrograms)

3 ounces clams, steamed

84.0 micrograms (mcg)

3 /4 ounces canned sardines

8.22

3 ounces Chinook salmon, broiled

3.25

4 ounces beef tenderloin, broiled

2.92

1 cup plain nonfat yogurt

1.39

1 whole large egg

0.60

1

From Culinary Nutrition: The Science and Practice of Health Cooking, Jacqueline B. Marcus, Elsevier, 2014, p. 293.

SUMMARY: VITAMINS AND MINERALS IN AGING DIETS Aging is associated with increased risks for lower vitamin consumption than is recommended for this age group. This association corresponds with decreased total energy intake in the seventh decade of life (about 600 800 kilocalories per day in women and about 1000 1200 kilocalories per day in men). Concomitant declines in most nutrients may result, especially the B vitamins, calcium, iron, vitamin E and zinc, that may increase the risks of diet-related diseases. Aging people with exceptional risks include those who are alcohol-dependent, individuals with malabsorption and vegans. Vitamin and mineral needs may exceed those that have been described, and may vary among aging people. This is why a prudent approach is to recommend a daily intake of fruits and vegetables, with a secondary approach of vitamin and mineral supplementation as determined by a health care provider or a registered dietitian/nutritionist. The Recommended Dietary Intakes should help to guide supplemental vitamin and mineral use; supertherapeutic doses should probably be avoided because some serious adverse events may result [29].

OTHER NUTRIENT REQUIREMENTS FOR AGING DIETS Phytonutrients Phytonutrients are nutrients that are found in plants that possess specific biological attributes that support human health. Phytonutrients play specific pharmacological effects that may affect aging, allergies, antioxidants, blood pressure, bones, cancer, the central nervous system, diabetes, the gastrointestinal tract, immunity, inflammation, lipidemia, the liver, microbes, pain and much more. Some important bioactive phytonutrients include anthocyanins, carotenoids, flavonoids, glucosinolates, isoflavonoids, limonoids, phytoestrogens, phytosterols, polyphenols, probiotics, resveratrol, terpenoids and ω-3 fatty acids.

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2. NUTRITIONAL AND PHYSICAL CONCERNS IN AGING

Typical Phytonutrients: Sources and Functions

Phytonutrient

Sources

Functions

Anthocyanins

Blue, red, violet plant pigments such as blueberries, raspberries and cherries

Defends cells, protects against blood clotting

Carotenoids

Orange, red and yellow plant pigments such as carrots, tomatoes and sweet potatoes

Antioxidant, antiinflammatory and cardiovascular protection

Flavonoids

Most common polyphenolic compounds in human diet from plants such as blueberries onions, parsley and tea

Chemical messengers, physiological regulators and cell cycle inhibitors

Glucosinolates

Components of pungent plants such as cabbage, mustard and horseradish

Cancer prevention

Isoflavonoids

Legumes and soy products

Antioxidants, antiinflammatory and anticarcinogenic

Limonoids

Citrus fruits

Antioxidants and cancer prevention

Phytoestrogens

Plant-like sterols such as barley, flaxseeds, lentils, oats, soyfoods and yams

Adaptogens (mimic human estrogen)

Phytosterols

Plant-like sterols such as vegetable oils and wheat germ, bran and whole grains

Compete with cholesterol absorption

Polyphenols

Berries, coffee, legumes, red wine, tea and variety of other fruits/vegetables

Antioxidant and antiaging

Probiotics

Live bacteria, yeast such as yogurt, and other fermented foods and beverages

Replenishes good bacteria and balances bad bacteria

Resveratrol

Berries, red grapes and peanuts

Antioxidant; protection from cancer and heart disease

Terpenoids

Citral, camphor, menthol and salvinorin

Herbal remedies and scents

Omega or ω-3 fatty acids

Fish and fish oils, nuts and seeds

Reduce stiffness and joint pain and antiinflammatory

The sources and functions of phytonutrients are shown in Table 2.22. Due, in part, to these potential interactions, phytonutrients have become somewhat of a panacea during aging to help prevent disease and extend longevity. Yet, studies of antioxidants and disease prevention show little supportive evidence at this time, although individual results may vary. For example, beta-carotene, vitamin E and other antioxidants may not prevent heart disease or stroke, but vitamin E still may show some promise for lung function. Likewise, the relationship between antioxidant supplements and cancer remains inconclusive and variable among men and women. Age-related eye disease such as macular degeneration but not cataracts seems to benefit from a combination of vitamin C, vitamin E, beta-carotene and zinc. Polyphenol phytonutrients with antioxidant pigments such as the natural blue and purple pigments in berries may cross the blood brain barrier and help protect the brain from the two most common types of dementia that affect older Americans, Alzheimer’s disease and vascular dementia. However, a very well-balanced diet with plenty of fruits and vegetables is still considered to be one of the best foundations for healthy aging, and a high priority for its supply of phytonutrients—particularly antioxidants. Beware of phytonutrient supplements that may have their downsides, such as increases in the diseases they were designed to protect [30].

Water Like carbohydrates, proteins, fats, vitamins and minerals, water is its own essential substance for the body because it is essential for normal body functions and for good health. Unlike carbohydrates, proteins and fats, water does not contain calories as long as it is without caloric sweeteners or flavors. Water is a component of body fluids both inside and outside of the cells. It serves to absorb shock in the spinal cord, hydrate the hair, nails and skin, lubricate the joints, maintain a normal body temperature, moisten the

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mucous membranes, participate in numerous chemical reactions, transport nutrients to the cells and carry waste products for elimination. In general, there is a decline in the sense of thirst after age 50 years. When this decline is coupled with disease-related factors such as diabetes, fever, incontinence and/or certain medications, then the need for water may escalate. Water is also very important if fiber is increased in the diet, since fiber typically absorbs water. Also with aging, renal water conservation is reduced. This means that aged kidneys are less able to concentrate urine and retain water when they are deprived of it. They are also less able to sufficiently regulate sodium excretion. Dehydration may pose serious health risks to older people, particularly in extreme temperatures. With activity, the need for water may increase; a full glass may be needed before exercise or walking—especially in hotter climates. About three to five glasses of water are recommended daily for the aging. If it is difficult to consume a full glass of water at a time, then sips may be consumed throughout the day. Water that is consumed during meals may cause a person to fill up and not consume the amount of food or fluids that are needed. If a pill or pills are to be taken, then a full glass of water should be consumed and attention should be given to the medication protocol. The color of one’s urine is a marker by which one may measure hydration: pale yellow, rather than bright or dark yellow is preferred—otherwise more water may be necessary. It is important to check with a health care provider to ensure that this is the correct strategy to take. Sometimes water and other fluids may need to be restricted due to kidney or liver disease. A health care provider should determine the right amount of fluid to consume each day that is based upon individual issues and needs such as these.

AGING AND PHYSICAL ACTIVITY Physical activity should not terminate just because a person is aging. In fact, physical activities, including exercise, are life-enhancing for emotional and physical health, weight management and well-being. Physical activity and regular exercise may help to reduce the incidence of some chronic diseases that are associated with aging, such as arthritis, coronary heart disease, diabetes, obesity and some cancers, and may be prescribed as strategies for the treatments of some of these conditions. Physical activity and exercise may also help people who have balance problems, depression, high blood pressure or trouble walking. Activity and exercise prescriptions, observations and monitoring should be crafted and executed by qualified exercise and fitness professionals. Some people who are aging may be fearful of physical activity because it might be too difficult or painful to accomplish. Simple physical activities that add motion to a person’s life such as gardening, taking the stairs or walking the dog burn calories over and beyond normal expenditure. Exercises such as biking or jogging, sports such as golf or tennis and the use of exercise equipment at home or in a gym also burns calories, but generally at a higher rate. Care should be taken to consult with a trained exercise professional before starting any exercise or exercise program such as these. If needed, a care provider or trainer should be present to prevent any exercise exertion and/or injuries. As people age and their metabolism slows down compared to when they were younger, they actually require fewer calories (units of energy that supply the capacity to do work). Because many people become sedentary as they age, this state may decrease calorie requirements even further. (See Calories During Aging in this chapter for further discussion.) For these reasons, physical activities and exercises that expend calories higher than normal are decidedly recommended throughout aging, no matter how limited [31].

Physical Activities Versus Exercise Physical activities are bodily movements that are produced by the skeletal muscles that require energy expenditure in the form of calories. Physical exercise is considered as any bodily activity that enhances or maintains physical fitness and overall health and wellness. Exercise is generally categorized into the following classifications: balance, endurance, flexibility and strength.

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Balance Balance is the ability in which different parts of the body are in equilibrium or in the correct proportions in order to remain upright or steady. When a person is “in balance,” this state helps them to ascend and descend the stairs, improve their personal balance within space and prevent falls. Falls are a common malady of older people that may be due to dizziness, poor balance or vision, slower reflexes, sudden drops in blood pressure and/or weak muscles. Falls may escalate into a host of other physical problems, including at its worst a hip fracture that may manifest into blood clots, infections or even death. Simply alternating standing on one foot (and holding the wall for balance to start), walking heel-to-toe with arms extended for balance and/or doing yoga or tai chi (an internal Chinese martial art that is practiced for defense training and health benefits) may help to improve a person’s balance over time. Endurance Endurance is the ability to exert oneself and remain active over a period of time. Endurance activities are usually aerobic or depend upon oxygen, so they invigorate the cardiovascular and respiratory systems and increase breathing and heart rate. In turn, this helps to improve overall fitness and conditions a person to better handle everyday tasks that require endurance, such as brisk walking or continuous yard work. The types of physical activities that develop endurance include biking, climbing stairs or hills, dancing, jogging, playing basketball, hockey, racquetball, swimming, tennis, or walking. All adults, including the aging, may benefit from as little as 15 minutes of endurance activities daily. It is important for aging people to select an endurance activity that they enjoy and may choose to participate in for about 30 minutes per session (or three 10-minute workouts); ideally daily or nearly every other day, in addition to other daily activities. Moderate aerobic activity that totals about 150 minutes per week is a general goal for healthy aging people. This is in addition to yoga or other flexibility exercises and strength training with small weights or resistance bands at least twice weekly. (For specific recommendations for generally fit individuals, see the section Physical Activity Needs that follows. Aging people with restrictive conditions should follow the advice of their health care providers that may include physical therapists or other fitness professionals.) Flexibility It is common to feel tightness in muscles as one ages which may bring inflexibility and cause one to be more prone to muscular damage. The act of stretching helps to restore flexibility and agility that frees movements for endurance and strength-training activities. Shoulders, upper arms and wrists should be stretched to help to maintain upper body flexibility. Calf and hamstring muscles and ankles should also be flexed to keep the lower body fluid. Easy yoga may provide allover body stretches and if practiced daily, it may produce a relaxed and flexible body to better handle daily activities and increased exercise. Strength Strength is the ability to do work against a resistance. For example, to improve muscular strength, lifting weights—even small ones—resists gravity and may improve one’s overall strength. Even small increases in muscular strength may make a difference in one’s ability to do such activities as carrying groceries, climbing stairs or opening jars. These are simple, everyday tasks that may become increasing difficult as the years progress. Strength training or resistance training includes activities that improve strength over time. Weight lifting and/or resistance bands (stretchy, elastic bands that may be used in place of small weights), or small objects such as canned foods or bags of beans are relatively economical strength-building tools that may be employed. As with the other modes of physical exercise, endurance, flexibility and strength training should be under the supervision of qualified exercise professionals and especially those who are trained for the concerns, limitations and needs of the aging [32].

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PHYSICAL ACTIVITY NEEDS For those people who are age 65 years or older and who are generally fit without any limiting health conditions, the following guidelines have been recommended by the Centers for Disease Control and Prevention: • 2 1/2 hours (50 minutes) of moderate-intensity aerobic activities (such as brisk walking)* weekly AND; • 2 1 days of muscle-strengthening activities that use all major muscle groups (abdomen, arms, back, chest, hips, legs and shoulders) weekly OR; • 1 1/4 hours (75 minutes) of vigorous-intensity aerobic activities (such as jogging or running)** weekly AND; • 2 1 days of muscle-strengthening activities that use all major muscle groups (abdomen, arms, back, chest, hips, legs and shoulders) weekly OR; • An equal amount of moderate- and vigorous-intensity aerobic activities weekly AND; • 2 1 days of muscle-strengthening activities that use all major muscle groups (abdomen, arms, back, chest, hips, legs and shoulders) weekly [33]. *Physical activity that is done at 3.0 5.9 times the intensity of rest. **Physical activity that is done at 6.0 or more times the intensity of rest.

EXERCISE PROGRAMS FOR THE AGING Physical activity and exercise programs in aging communities are evolving that are specifically designed for aging individuals at all levels. However, anytime that a new or different physical activity or exercise is initiated it should first be discussed with a health care provider and exercise specialist and evaluated for its competence and suitability. • Go4Life is an exercise and physical activity campaign from the National Institute on Aging at the National Institutes of Health. It is designed to help people who are aging fit exercise and physical activity into everyday lives. Go4Life offers various exercises, free resources, healthy eating and motivational tips and safety information in both English and Spanish. Additionally, the National Council on Aging advocates evidence-based physical activity programs that have been proven to produce measurable health benefits for those who are aging. These include Active Choices, Active Living Every Day, EnhanceFitness, Fit and Strong!, Healthy Moves for Aging Well and Walk with Ease.

Active Choices Active Choices is a 6-month individualized physical activity program that helps participants to incorporate certain physical activities into their daily lives.

Active Living Every Day Active Living Every Day uses facilitated group-based problem-solving approaches to incorporate physical activities into daily living.

EnhanceFitness EnhanceFitness offers challenging and safe exercise programs for both active adults and unfit or near frail adults.

Fit and Strong! Fit and Strong! combines aerobic walking, flexibility and strength training with health education for sustained behavior change. This program focuses on the aging with lower extremity osteoarthritis.

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Healthy Moves for Aging Well Healthy Moves for Aging Well is a safe and simple physical activity intervention program that is designed to enhance the activity levels of frail, high-risk sedentary at-home individuals.

Walk With Ease Walk with Ease was developed by the Arthritis Foundation to help participants develop an individualized walking plan that is safe, motivational and provides pain management. As an offshoot, the Walk with Ease program has not only decreased pain, but it has also helped to decrease depression [34].

DIGEST Nutrition research and recommendations for people who are aging in the United States and around the world is ever changing. This is because people are living longer than ever before and many people are healthier and better fit than their ancestors. The challenges of staying informed and disseminating state-of-the-art nutrition and physical fitness information is ongoing and daunting. This is because nutrition and physical fitness can play important roles in helping aging people to stay healthy and enjoy wellness during their later years. The interest in healthy aging and nutrition can be seen in large research grants in the United States and globally on topics that include vitamins D and K in dementia, the effects of lutein and zeaxanthin carotenoids in age-related macular degeneration, protein intake (through food and supplements) and muscle function, mass and rehabilitation, and personalized nutrition projects that are designed to help aging people guide their diets and lifestyles. Moreover, strong national and global interests in probiotics, sustainability, Type II diabetes research and vegan and vegetarian foods and beverages are also manifest in nutritional research that have the potential of affecting aging dietary recommendations. The National Institutes of Health in the United States and the European Commission’s Community Research and Development Innovation Service are but two organizations that support national and international research of this nature and others. This is a golden time to monitor this relevant research in nutrition and physical fitness for the aging and apply it en masse, group or at individual levels. The nutrition and health of this often-forgotten age group is at stake [35].

MANNER OF SPEAKING Acceptable Macronutrient Distribution Range (ADMR)

Active Lifestyle

Added Sugars Adenosine Triphosphate (ATP) Adequate Intake (AI)

Age-Related Macular Degeneration (AMD)

Aerobic

range of intakes for a particular energy source associated with reduced risks of chronic disease; provides AIs of essential nutrients combination of physical and recreational activities aimed to encourage healthier lifestyles and mental, physical and social well-being sugars and syrups that are added to foods or beverages when processed or prepared complex organic chemical that is the primary carrier of energy in cells recommended average daily nutrient intake level assumed to be adequate, based on intake levels by a group of apparently healthy people disease that affects the macula of the eye and blurs sharp, central vision for “straight-ahead” activities such as driving, reading and sewing exercise that improves the efficiency of cardiovascular system in absorbing and transporting oxygen; examples are walking, running, or swimming

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MANNER OF SPEAKING

Alpha-Linolenic Acid (ALA)

Alpha-Tocopherol (Type of Tocopherol or Vitamin E)

AMP-Activated Protein Kinase (AMPK)

Anaerobic

Anorexia/Anorexia Nervosa

Anorexia of Aging APOE4 Gene

Anthocyanins

Antioxidants

Atrophic Gastritis

Atrophy Balance

Basal Metabolic Rate (BMR) Bifidobacterium Bilirubin

Blood Sugar (Blood Glucose) Body Systems Bone Mineralization Bradycardia Calories

Cardiac Arrest

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one of two EFAs (with linoleic acid), that is necessary for health, cannot be produced by the human body and must be obtained through the diet potent antioxidant that may balance normal coagulation, maintain endothelial cell integrity, protect cells from oxidative stress and regulate immune function energy sensor when activated in the right tissues decreases inflammation, improves insulin sensitivity and muscle performance and stimulates weight loss exercise that does not improve the efficiency of the body’s cardiovascular system in absorbing and transporting oxygen; examples are jumping, sprinting, or weight training eating disorder typified by fear of gaining weight, low body weight and a strong desire for thinness that results in food restriction decrease in appetite and/or food intake in aging; major contributing factor to undernutrition and adverse health outcomes gene that provides instructions for making apolipoprotein E protein that combines with lipids (fats) in the body to form lipoproteins water-soluble vacuolar pigments that may appear red, blue or purple depending on their pH; demonstrated ability to protect against many human diseases man-made or natural substances that may delay or prevent some types of cell damage; high in fruits and vegetables and fruits chronic inflammation in stomach mucosa; may cause gastric glandular cell loss and intestinal and fibrous tissue replacement wasting away or decrease in size of an organ or tissue in the human body state of equilibrium or equipoise with even distribution of weight; the ability to uphold the center of mass of the body over its base of support rate of energy expenditure per unit of time that is needed by the human body at rest category of bacteria that comprise the colon flora in mammals; used as probiotics orange-yellow pigment that is formed in the liver by the breakdown of hemoglobin (red blood cells); higher levels may indicate liver disorders; excreted in bile amount of glucose that is present in the blood of humans and other animals; body’s main source of energy group of body organs or structures that collectively perform one or more vital functions; necessary for life to be sustained process of laying down minerals on the matrix of the bones of the human body slow heart rate of less than 60 beats per minute (BPM) in adults unit of energy that is needed to raise the temperature of one gram of water by one degree Celsius at the pressure of one atmosphere; also known as a food calorie loss of heart function, with sudden and unexpected cessation of breathing and consciousness; differs from heart attack when blood flow to a portion of the heart is blocked

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Cardiac Output Cataracts Carotenoids (Vitamin A Precursors or Provitamins)

Chronic Metabolic Diseases Circulatory System

Collagen Conjunctivitis

Dehydration Dietary Carbohydrates

Dietary Fat

Dietary Fiber

Dietary Guidelines for Americans 2010 (DGA)

Dietary Minerals

Dietary Protein

Dietary Reference Intake (DRI) Dietary Vitamins

Digestive System

Docosahexaenoic Acid (DHA)

Eicosapentaenoic Acid (EPA)

amount of blood that is pumped by the heart per minute (in beats per minute or BPM) clouding of the normally clear lens of the eyes that may impair vision class of mainly orange, red or yellow fat-soluble pigments that provide color for plant components; important antioxidant functions ongoing diseases of metabolic disorders, such as diabetes, heart disease or hypertension system that circulates blood and lymph throughout the human body; consists of the blood, blood vessels, glands, lymph and lymphatic vessels main structural protein that is hard, fibrous and insoluble and found in connective tissues, including the skin inflammation of the outermost layer (or thin clear tissue) of the white part of the eye, and the inner surface of the eyelid; often called “pink eye” excessive loss or removal of body water that is greater than water taken into the body carbohydrates that are present in beverages and foods that include celluloses, gums, starches and sugars; serve as a major source of energy fat that is consumed in beverages and foods; provides a concentrated source of energy and fat-soluble vitamins among other substances roughage or indigestible portion of foods by the gastrointestinal tract; derived from plants (fruits, legumes, vegetables and whole grains) set of recommendations that emphasize the importance of creating a healthy eating pattern for health maintenance and disease prevention group of inorganic elements that are derived from the earth’s crust and extracted by plants; essential to humans and animals for normal body functioning substances in beverages and foods from both animals and plants that break down into amino acids; contribute to key body functions, such as blood clotting, cellular repair, enzyme and hormone production, fluid balance, vision and others set of reference values that are used to assess nutrient intakes of healthy people and plan diets/beverage and food intakes complex organic compounds that are supplied by beverages and foods; needed in small amounts by the body for normal growth and development group of organs that work together to convert beverages and foods into energy and other nutrients to fuel and sustain the human body polyunsaturated fatty acid (PUFA) that is found throughout the body; major structural fat in the eyes, brain and skin; body cannot make in sufficient amounts so needed in diet and/or supplements principal omega-3 fatty acid with antiinflammatory and potential; found in canola oil, flaxseed oil and walnuts; limited ability of the body to manufacture

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MANNER OF SPEAKING

Endocrine System

Endurance Electrolytes

Environmental Decline in Aging

Essential Fatty Acids (EFAs)

Excretory System

Flavonoids

Flexibility (Limberness)

Fructose Glucose (or Dextrose)

Glucosinolates

Glutathione Peroxidase Handgrip Flexibility Hemochromatosis

Hemorrhagic Stroke

High Glycemic Indices

Homocysteine

Hydrogenation

Hypocalcemia

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collection of glands that produce hormones that help to regulate growth and development, metabolism, mood, reproduction, sexual function, sleep, tissue function and other purposes ability to withstand a prolonged activity or effort; often requiring great physical stamina substances that dissociate into irons in solutions with the capabilities to conduct electricity; include chloride, magnesium, phosphate, potassium, sodium and others alterations in environmental factors that contribute to the decline in people who are aging; such as food “dessert” or inadequate transportation fatty acids that humans and other animals need to obtain from beverages and foods; cannot be synthesized by the body; required for health and well-being biological system that is responsible for the removal of body wastes; preserves internal chemical homeostasis and prevents bodily damage diverse group of phytonutrients that are found in most fruits and vegetables—particularly brightly colored; responsible for antioxidant effects and cellular signaling pathways ability to move within an unrestricted, pain-free range of motion in joints, series of joints and/or across joints; capacity to bend simple fruit sugar that is found in plants; bonds with glucose to form sucrose simple sugar that is a component of carbohydrates and an important energy source; called blood glucose or blood sugar when travels through bloodstream natural sulfur-containing components of pungent plants that include cabbage, horseradish and mustard; potential beneficial effects in antioxidant activities, inflammation and stress responses among others selenium-containing enzyme in cellular antioxidant defense systems that helps to detoxify peroxides and hydroperoxides elasticity with which an individual can squeeze to handles together between the palm and fingers condition whereby too much iron build up in the human body and creates iron overload where more iron is absorbed than needed; especially vulnerable are the heart, liver and pancreas brain aneurysm that bursts or a weakened blood vessel that leaks; results in blood spilling into or around the brain; may result in pressure, swelling, damaged cells and/or tissues beverages and foods that tend to release glucose rapidly and increase blood sugar such as potatoes, white bread and white rice common amino acid in the human body; high levels are linked to the early development of heart disease and low levels of folate, vitamins B6 and B12 chemical reaction between hydrogen and other compounds or elements; commonly used to “saturate” or fill organic compounds as in stick margarine low calcium levels in blood serum; potential of nervous system irritability, such as abdominal and muscle cramps and/or hand and feet spasms

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Insoluble Fiber

Institutes of Medicine (IOM)

Insulin-Like Growth Factor (IGF) Integumentary System

Intrinsic Factor

Iron Deficiency Anemia

Isoflavonoids

Jaundice

Kidney Function

Lactobacillus

Lactose LASIK Surgery Lean Body Mass (LBM)

Limonoids

Lutein

Lymphatic System

2. NUTRITIONAL AND PHYSICAL CONCERNS IN AGING

low potassium levels in blood serum; commonly due to excess losses from gastrointestinal tract or kidneys group of inflammatory conditions of the gastrointestinal tract; include Crohn’s disease and ulcerative colitis; may result in damage if prolonged fibrous plant materials found in some fruits, vegetables, wheat bran and whole grains; adds bulk to feces; helps food pass more quickly through stomach and intestines nonprofit organization and component of the US National Academy of Sciences; US-NAS; provides evidence-based research and recommendations for public health and science polity proteins with similar sequencing to insulin; capability to stimulate growth and decrease blood glucose organ system that consists of the exocrine glands, hair, nails and skin; protects the body from damage, provides structure and support, and regulates body temperature among other functions glycoprotein that is secreted by the stomach that enables the body to absorb vitamin B12; failure to produce may result in pernicious anemia condition in which the blood is inefficient in adequate healthy red blood cells that carry oxygen to body tissues; due to inadequate iron in beverages, foods and/or supplements class of flavonoid phenolic compounds; sometimes referred to as phytoestrogens; produced chiefly by plants of the legume family, especially soybeans medical condition manifest in yellowing of the skin or whites of the eyes; caused by excessive amounts of the pigment bilirubin from excessive breakdown of red blood cells, obstruction of the bile duct or liver disease two body organs that work to keep the composition of the blood and electrolytes stable, make hormones for body function and prevent the buildup of wastes and extra body fluid type of Gram-positive bacteria that are characterized by their ability to produce lactic acid as a by-product of glucose metabolism; common type of probiotic; may be found in fermented beverages and foods, yogurt and supplements double sugar that is present in milk and other dairy products; contains the simple sugars glucose and galactose surgical procedure that uses a laser to correct astigmatism, farsightedness and/or nearsightedness lean body weight; the difference in the mass of the human body (such as bones, muscles, organs, skin, water, etc.) without the body fat; a component of body composition phytochemical compounds that are found in citrus fruits, peel and seeds and other plants; may reduce blood cholesterol and certain cancers xanthophyll (or yellow pigment) and naturally-occurring carotenoid; synthesized only by plants such as carrots, kale and spinach; may be effective in the prevention of eye disease, particularly AMD, cataracts and retinitis pigmentosa network of vessels by which lymph drains from the tissues into the blood stream

AGING, NUTRITION AND TASTE

MANNER OF SPEAKING

Lymphocytes

Maximum Heart Rate (MHR) Maximum Oxygen Uptake (VO2 max)

Megaloblastic Anemia

Metabolism

Moderate Active Lifestyle

Muscle Mass

Musculoskeletal System

MyPlate for Older Americans Natto Nervous System

Night-Blindness (Nyctalopia) Nonalcoholic Fatty Liver Disease (NAFLD)

Obesity Omega-3 Fatty Acids (ω-3 Fatty Acids)

Omega-6 Fatty Acids (ω-6 Fatty Acids)

Osteomalacia

Osteopenia

Osteoporosis

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form of small white blood cells in the lymphatic system; part of the immune system that functions in cell-mediated immunity to fight infectious microorganisms and other foreign substances number that serves as a basis for determining a THRZ which is a guide for effective exercise; based on a person’s age maximum rate of oxygen consumption that is measured during exercise of increasing intensity; derived from “V” for volume and “O2” for oxygen anemia that manifests as abnormally large type of red blood cells (megaloblasts); produced in bone marrow when vitamin B12 or folic acid levels are low sum or all chemical processes that occur within living organisms to maintain life by which the human body converts beverages and foods into energy lifestyle that is filled with physical activities that are equivalent to walking about 15-3 miles daily at about 3-4 miles per hour plus light physical activities physical size of muscles; constituent of muscular strength, one of the components of total fitness along with endurance, flexibility, power and speed system of bones, cartilage, joints, ligaments, tendons and other connective tissues that creates and facilitates form, movement, stability and support for the human body icon that features healthy foods straight from the plate that corresponds with the US 2015 2020 DGAs traditional Japanese food made from soybeans that are fermented with Bacillus subtilis var. natto. complex network of nerve cells and fibers that transmit nerve impulses from the brain and spinal cord among the various body systems condition that creates difficulty seeing in relatively low light; symptom of other eye conditions and/or diseases condition in which excess fat is deposited (steatosis) or stored in the liver and cause “fatty liver” and inflammation; closely related to metabolic syndrome excess adipose (fat) tissue; significantly (20% or greater) above one’s ideal body weight PUFAs; mainly found in chia and flaxseeds and fatty cold water fish (such as salmon and sardines); precursors to substances involved in blood pressure regulation, inflammatory responses and other functions PUFAs; mainly found in nuts, seeds and their oils; prevalent in fast and processed foods; tend to increase blood clotting, cellular proliferation and inflammation softening of the bones due to impaired bone metabolism; most often through a calcium, phosphate or vitamin D deficiency bone density that is lower than normal, but not low enough to be categorized as osteoporosis (see below); often due to lack of calcium and vitamin D; mostly affects women medical condition whereby the bones become brittle and fragile; fragile from tissue loss; may be result of calcium or vitamin D deficiency and/or hormonal changes

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Pernicious Anemia

Physical Activities

Physical Exercise Physiological Decline in Aging

Phytates

Phytoestrogens

Phytonutrients Phytosterols

Polyphenols

Prebiotics Probiotics

Psychological Decline in Aging

Reproductive System Resistance Training

Respiratory System

Resveratrol

2. NUTRITIONAL AND PHYSICAL CONCERNS IN AGING

inorganic acid that is found in plants, mainly some cocoa, fruits, leafy greens, nuts and/or seeds; may bind to minerals in body in colon, kidney and/or urinary tract and increase risks of kidney stones and other health problems condition that occurs when the human body cannot absorb enough vitamin B12 for proper functioning; commonly due to insufficient vitamin B12, a weakened immune system and/or stomach lining movements of the human body that utilize energy; include brisk walking, climbing stairs, dancing, gardening, playing sports, or others of this nature body activities that initiate, augment, or maintain physical fitness and promote health and wellness decrease in bodily functions due to factors such as alcohol or drug use, loss or decline in taste and smell, inactivity and/or poor dietary intake among others antioxidant compounds that are found in legumes, nuts and seeds and whole grains; may bind with certain dietary minerals such as calcium, iron, manganese and zinc and slow their absorption plant-derived compounds in a variety of beverages and foods, mainly soy; considered as dietary estrogens; potential health benefits that include lowered risks of breast cancer, heart disease, menopause and osteoporosis plant nutrients that are found in certain plants that may help to prevent diseases and be beneficial to human health cholesterol-like compounds that are found in plants; the highest concentrations are naturally found in legumes, nuts and vegetable oils abundant dietary micronutrients; found in beverages and foods such as black and green tea chocolate, coffee, extra virgin olive oil, olives, red wine and some fruits and vegetables; act as antioxidants and may protect the human body against free radical damage natural, nondigestible food components; linked to the promotion of healthy gut flora (bacteria) microorganisms (particularly live bacteria and yeasts) in some fermented foods and yogurt with potential health benefits; includes the prevention or treatment of health problems such as certain allergic and/or digestive disorders decrease in emotional/mental functions with aging; may include cognition, dementia, depression, emotions, genetics, loneliness and other conditions and/or disorders genital system of sexual organs; responsible for human reproduction and the creation of live offspring form of physical training in which the human body works against some type of force that resists movement; includes body weight exercises, movement in water, running with weights and/or weight training series of organisms that are responsible for taking in oxygen and expelling carbon dioxide; include the airway, lungs, muscles of respiration and cellular exchange fat-soluble polyphenolic compound called a stilbene; found in red and white wine and skin of grapes; antioxidant functions might contribute to cancer protection and cardiovascular health

AGING, NUTRITION AND TASTE

MANNER OF SPEAKING

Retinol (Preformed Vitamin A)

Rhodopsin Sarcopenia

Sedentary Lifestyle

Selenosis

Senescence Signaling Molecules

Sociological Decline in Aging Solid Fats

Soluble Fiber

Strength Strength Training

Structural Components

Target Heart Rate Zone (THRZ) Terpenoids

Tai Chi

US Department of Agriculture (USDA)

US Department of Health and Human Service (US-DHHS)

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yellow compound that is found in egg yolk, fish liver oil and green and yellow vegetables; may treat vitamin A deficiency, especially a consequence of xerophthalmia biological pigment found in the rods of the retina that is sensitive to light; enables low-light vision decline or loss of skeletal muscle tissue with age; important factor in functional decline and loss of independence in the aging type of lifestyle that entails little to no physical activity; often blamed for obesity and/or certain conditions and/or chronic diseases potentially toxic condition of excess selenium in the human body; may be the result of pharmaceutical interactions and/or selenium supplements; may result in diarrhea, nausea, skin disorders and/or nerve damage biological aging; the condition or processes of gradual deterioration of body functions due to aging molecules that bind to other molecules as receptors; relayed through a chain of chemical messengers inside cells; often called ligands decline in such factors as culture, economics, education, racial and/or ethnic diversity and/or religion coupled with aging fats that are solid at room temperature, such as beef fat, butter and solid vegetable shortening; derived from animal foods and hydrogenated vegetable oils fiber that readily dissolves in water; found in barley, legumes, lentils, nuts, oat bran, peas, seeds and some fruits and vegetables (among others), as well as psyllium, a common fiber supplement; may help lower low-density lipoprotein—(bad) cholesterol and influence cardiovascular risks and provide satiety, or fullness inherent capacity to be strong, endure, manifest energy and/or resist type of physical exercise; centers on resistance to induce muscular contractions; has the capacity to build anaerobic endurance, strength and relative size of skeletal muscles musculoskeletal system that consists of the human skeleton; induces bones cartilage, ligaments and tendons; provides human body with ability for movement and structure range of heart rate percentages for which to aim when exercising; expressed as percentage of MHR class of organic compounds; found in the oils of plants that include basil, black pepper, cloves, hops, lemon, mango, pine, and others; responsible for aromas and tastes internal Chinese martial art and graceful form of exercise; practiced for defense training and health benefits including stress reduction Department of the US Government; responsible for the development and execution of federal laws that interrelate with agriculture, farming forestry, and food Department of the US Government; serves to protect the health of all Americans; provides essential human services, many for the least able

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US Dietary Guidelines for Americans

US Dietary Reference Intakes (DRIs): Estimated Average Requirements (EARs)

Vital Capacity (VC)

Vitamin A Precursors

Weight Gain Weight Loss

Yoga

Xerophthalmia

Zeaxanthin

compilation of recommendations published every five years by the USDA and the US Department of Health and Human Services (US-DHHS) that encourage Americans to eat healthfully, maintain a healthy weight, prevent disease, and promote health set of reference values that are used to assess and plan the nutrient intake of healthy people; the average daily nutrient intake levels estimated to meet the requirements of half of the healthy people in a group maximum amount of air that a person may be able to force out from the lungs after a maximum inhalation of air; closely related to circulatory functions and/or disorders inactive substances, such as carotenoids (abundant in carrots and green leafy vegetables); vitamin A precursors in the diet that help to synthesize vitamin A; the active form of vitamin A is retinol, a compound that is rarely found in foods increase in total body weight; due to parallel increases in excessive fluids, fat deposits, muscle mass and/or other factors reduction in total body mass; due to parallel decreases in total body mass; result of mean losses in body fluids, body fats or lean body mass and/or other factors group of mental, physical and spiritual disciplines and/or practices; originally based on Buddhism, Hinduism and/or Jainism practices and/or schools; a potentially complementary intervention for some mental and physical conditions abnormal dryness of the conjunctiva and cornea of the eye; symptoms may include inflammation and/or ridge formation; may be associated with vitamin A deficiency common carotenoid alcohol found in many green leafy plants and colorful fruits and vegetables; gives yellow to red pigments their characteristic pigments; important antioxidant functions in the human body, particularly eyesight

References [1] Feeding America, Senior Nutrition Guide, ,https://www.eatwellbewell.org/uploads/resources/Senior-Nutrition-Report.pdf. [accessed 30.08.18]. [2] 2015 2020 Dietary Guidelines. Appendix 2. Estimated calorie needs per day, by age, sex, and physical activity level. Source: Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington (DC): The National Academies Press; 2002. ,https://health.gov/dietaryguidelines/2015/guidelines/appendix-2/health.gov. [accessed 13.09.18]. [3] 2015–2020 Dietary guidelines, Appendix 2: Estimated calorie needs per day, by age, sex, and physical activity level ,https://health. gov/dietaryguidelines/2015/guidelines/appendix-2/. [accessed 05.09.18]. [4] Landi F, Calvani R, Tosato M, Martone AM, Ortolani E, Savera G, et al. Anorexia of aging: risk factors, consequences, and potential treatments. Nutrients 2016;8(2):69. Available from: https://doi.org/10.3390/nu8020069 ,https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4772033/. [accessed 30.08.18]. [5] International Osteoporosis Foundation. Nutrition, ,https://www.iofbonehealth.org/nutrition. [accessed 30.08.18]. [6] US National Library of Medicine. Aging changes in body shape. Medline Plus, ,https://medlineplus.gov/ency/article/003998.htm. [accessed 30.08.18]. [7] National Institutes of Health and National Heart, Lung and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report, NIH Publication No. 98-4083, September 1998. ,https://www.nhlbi. nih.gov/files/docs/guidelines/ob_gdlns.pdf. [accessed 30.08.18]. [8] Coleman, E. The best daily calorie intake for a senior citizen. Chron, Hearst Publications, 12 May 2018, ,http://livehealthy.chron.com/ daily-calorie-intake-senior-citizen-3211.html. [accessed 30.08.18]. [9] Tufts Now. Tufts University Nutrition Scientists Provide Updated MyPlate for Older Adults, 7 March 2016, ,http://now.tufts.edu/ news-releases/tufts-university-nutrition-scientists-provide-updated-myplate-older-adults. [accessed 30.08.18]. [10] Older Adult Health Facts, ,https://health.gov/dietaryguidelines/dga2005/toolkit/olderadults/OAcarbohydrates.htm. [accessed 30.08.18].

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[11] Rosedale R, Westman EC, Konhilas JP. Clinical experience of a diet designed to reduce aging. J Appl Res 2009;9:159 65 ,https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4326908/.. [12] McGill CR, Birkett A, Fulgonii III VL. Healthy Eating Index-2010 and food groups consumed by US adults who meet or exceed fiber intake recommendations NHANES 2001-2010. Food Nutr Res 2016;60:29977. Institute of Medicine. Dietary reference intakes for energy, carbohydrates, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington (DC): The National Academic Press; 2002. p. 339 421. [13] 2015 2020 Dietary Guidelines for Americans: Implications for Older Adults. In: Wong, QH, Grainger E, Clinton SK. Today’s geriatric medicine, vol. 9 no. 5, pp. 20. ,http://www.todaysgeriatricmedicine.com/archive/SO16p20.shtml. [accessed 30.08.18]. [14] ,http://nationalacademies.org/hmd/B/media/Files/Activity%20Files/Nutrition/DRI-Tables/8_Macronutrient%20Summary.pdf. [accessed 30.08.18]. [15] US Department of Health and Human Services, National Institutes of Health. Omega-3 fatty acids fact sheet for health professionals, ,https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/.; 2018 [accessed 30.08.18]. [16] Beto JA. The role of calcium in human aging. Clin Nutr Res 2015;4(1):1 8. Available from: https://doi.org/10.7762/cnr.2015.4.1.1 PMID: 25713787. ,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4337919/. [accessed 13.09.18]. [17] Feosol. Iron for seniors. ,http://feosol.com/who-needs-iron/iron-for-seniors/. [accessed 30.08.18]. [18] Barbagallo M, Dominguez LJ. Magnesium and aging. Curr Pharm Des 2010;16(7):832 9 ,https://www.ncbi.nlm.nih.gov/pubmed/ 20388094. [accessed 30.08.18]. [19] Freeman, B. Phosphorous, WorldHealth.net, 19 March 2008, ,http://www.worldhealth.net/news/phosphorus/. [accessed 30.08.18]. [20] Wickham, E. Potassium amount for the elderly. Healthy Eating|SF Gate, ,http://healthyeating.sfgate.com/potassium-amount-elderly7550.html. [accessed 30.08.18]. [21] Sandoui. Dementia not prevented with vitamin E, selenium, study finds. 20 March 2017, Stanford Center on Longevity, ,http://longevity.stanford.edu/blog/2017/03/20/dementia-not-prevented-with-vitamin-e-selenium-study-finds-medical-news-today/.; 2017 [accessed 30.08.18]. [22] WebMD Feature reviewed by Gary D. Vogin, 2002, myth vs. reality on anti-aging vitamins. ,http://www.webmd.com/beauty/features/myth-vs-reality-on-anti-aging-vitamins#1.; 2002 [accessed 30.08.18]. [23] Freeman, B. Selenium. WorldHealth.net, 30 December 2005, ,http://www.worldhealth.net/news/selenium/. [accessed 30.08.18]. [24] United States Department of Agriculture, Agricultural Research Service, USDA Food Composition Databases. Sodium, Na (mg), nutrient content, household measures. USDA National Nutrient Database for Standard Reference Legacy Release, April 2018. ,https://ndb.nal. usda.gov/ndb/. [accessed 13.09.18]. [25] Dieticians of Canada, Food Sources of Vitamin A, ,www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/cnf_aboutus-aproposdenous_fcen-eng.php. [accessed 27.03.12]; ,https://www.dietitians.ca/Downloads/Factsheets/Food-Sources-of-Vitamin-A.aspx. [accessed 30.08.18]. [26] Kozarsky A. WebMD medical reference, vitamin E and vision. ,http://www.webmd.com/eye-health/vitamin-e-vision.; 2018 [accessed 30.08.18]. [27] Peter I, Crosier MD, Yoshida M, Booth SL, Cupples LA, Dawson-Hughes B, et al. Associations of APOE gene polymorphisms with bone mineral density and fracture risk: a meta-analysis. Osteoporos Int 2011;22(4):1199 209. [28] Sauer A. How vitamin K is good for the brain and Alzheimer’s prevention, ,http://www.alzheimers.net/2014-07-09/vitamin-k-alzheimers-prevention/.; 2016 [accessed 30.08.18]. [29] Thomas DR. Vitamins in aging, health, and longevity. Clin Interv Aging 2006;1(1):81 91 PMID: 18047260. ,https://www.ncbi.nlm.nih. gov/pmc/articles/PMC2682456/. [accessed 30.08.18]. [30] Harvard, TH. The nutrition source: antioxidants beyond the hype. Chan School of Public Health, ,https://www.hsph.harvard.edu/ nutritionsource/antioxidants/. [accessed 30.08.18]; Gupta C, Prakash D. Phytonutrients as therapeutic agents. J Complement Integr Med 2014;11(3):151 69 ,https://www.ncbi.nlm.nih.gov/pubmed/25051278/. [accessed 30.08.18]. Esposito L. Eating for your brain as a senior. U.S. News and World Report/Wellness, ,http://health.usnews.com/health-news/health-wellness/articles/2016-01-05/eatingfor-your-brain-as-a-senior.; 2016 [accessed 30.08.18]. [31] National Institute on Aging, US Department of Health & Human Services. Exercise and physical activity, ,https://www.nia.nih.gov/ health/publication/exercise-physical-activity/introduction. [accessed 30.08.18]. [32] Joyce K. How often and how long should the elderly exercise. Livestrong.com, ,https://www.livestrong.com/article/522381-how-oftenhow-long-should-the-elderly-exercise/.; 2017 [accessed 30.08.18]. [33] Centers for Disease Control and Prevention. Physical Activity: How much physical activity do older adults need? Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, ,https://www.cdc.gov/physicalactivity/basics/older_adults/. [accessed 30.08.18]. [34] National Council on Aging. Exercise programs that promote senior fitness, ,https://www.ncoa.org/center-for-healthy-aging/physicalactivity/physical-activity-programs-for-older-adults/. [accessed 30.08.18]. [35] Bird J. The future of nutrition: Outlook 2018. Nutrifacts, ,http://www.nutri-facts.org/en_US/news/the-future-of-nutrition-outlook2018.html.; 2017 [accessed 30.08.18].

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PHOTO: Salt and Pepper. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I am a more aware and sensitive eater. I am particular about what I choose. Then I am happier.

E.B.

O U T L I N E Summary

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Introduction

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Aging, Disease, Health Care and Prevention

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Decline in Diet Quality During Aging

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Other Sensory Considerations (Balance, Kinesthetic, Pain and Temperature) 72 Balance 72 Aging and Balance 72 Kinesthetic 72 Aging and Kinesthesia 73 Pain 73 Aging and Pain 73 Temperature 73 Aging and Temperature 73

Decline in Behavioral, Environmental, Physical and Social Factors During Aging 68 The Senses Hearing Sight Smell Taste Touch Aging, Nutrition and Taste. DOI: https://doi.org/10.1016/B978-0-12-813527-3.00003-X

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Temperature Texture Touch Other Flavor Factors

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Gustation

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Taste Pathways

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Five Basic Tastes Bitter (Bitterness) Salty (Saltiness) Sour or Acidic (Sourness) Sweet (Sweetness) Umami (Umaminess or Savoriness)

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Other Debated Tastes: Fatty and Starchy Fatty (Oleogustus) Starchy

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Taste Perceptions Across the Lifecycle

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Oral Cavity

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Taste Buds and Stem Cells

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Supertasters

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Sensitive Tasters

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Taste Loss

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Taste Thresholds

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Medical Conditions Implicated With Smell and Taste Decline

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Medications Implicated With Decline in Taste and/or Smell

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Taste and Smell Interactions and Affects Olfaction Olfactory Pathways Olfactory Loss Versus Taste Loss Types of Taste Loss Types of Smell Loss

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Consequences of Chemosensory Decline

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How Olfactory Dysfunction Affects Nutrition Status

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How Adulthood Affects Nutritional Status Body Composition Reconfigurations Brain Function Variations Dehydration Irregularities Digestive System Changes Malnutrition Sensory Alterations

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Digest

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LEARNING OBJECTIVES 1. Differentiate among the basic human senses of vision (sight), audition (hearing), gustation (taste), olfaction (smell) and somatosensation (touch) and their relationship to food intake, satisfaction and wellbeing. 2. Distinguish among the chemosensory perceptions of taste, smell and flavor, in particular, and how they may change over the lifecycle. 3. Address the behavioral, environmental, medical, physiological and social declines that may be the result of chemosensory losses during aging. 4. Apply the concepts of chemosensory changes to normal and therapeutic food preparation and nutrition for aging populations. 5. Integrate practical and flavorful chemosensory tips and techniques into the dietary practices of aging populations in various settings.

SUMMARY To resourcefully explore the sensations of sight, smell, taste, sound and touch during the aging process, with particular attention to the chemosensory changes of taste and smell and their long-range implications. AGING, NUTRITION AND TASTE

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INTRODUCTION This chapter explores the sights, smells, tastes, sounds, touches and other sensations, predominantly as they affect the aging process. In particular, chemosensory changes that are related to the chemical substances that are found in beverages and foods and affect the senses of taste and smell may become more significant during aging. Subsequently, chemosensory changes may contribute to a host of other bodily changes and affect health and well-being. While it is important to note that the occurrence of chemosensory decline in the aging is debatable, as is the order of chemosensory loss, it is important to discuss this trend, the research that exists and the measures that may be taken for dietary and nutritional improvement and potential health enhancement.

AGING, DISEASE, HEALTH CARE AND PREVENTION According to the Centers for Disease Control and Prevention of the US Department of Health and Human Services about 80% of older Americans have at least one disease concern. Approximately 50% of older Americans have at least two disease concerns. These chronic and sometimes life-threatening condition and/or diseases may impose dramatic effects on health care costs. As a consequence, more efforts may be needed for their prevention [1]. Many of these conditions and/or diseases that may affect aging people are shown in Table 3.1. Those that are nutrition related are emboldened. Some are independent of diet, but they may be exacerbated by a person’s diet. Many of these conditions and diseases are interconnected. TABLE 3.1

Conditions, Diseases and Aging People

• Alzheimer’s disease • Arthritis • Bone fractures • Breathing problems • Cancer • Cataracts • Congestive heart failure • Coronary heart disease • Dementia • Depression • Diabetes • Frequent falls • Glaucoma • Hypertension • Impaired immune functions • Incontinence • Macular degeneration • Osteoporosis • Parkinson’s disease • Vascular disease Data from http://www.rd.com/health/wellness/sharpen-your-sense-ofsmell-and-taste/

Increased longevity may have major effects on age-related conditions and diseases that may influence food and nutrition choices and heighten taste and smell disorders. In turn, untreated taste and smell disorders may further intensify age-related conditions and diseases, and affect health and wellness. These cyclical effects may be ongoing unless interventions occur. Thus, by addressing chemosensory disorders early in the aging process this may help to improve dietary intakes and health status and prevent or manage certain conditions and/or diseases. For example, a 70-year-old person may have cardiovascular disease and diabetes, and due to medications, both taste and smell may be compromised. This person may choose foods and beverages that are higher in fat, sodium and/or sugar to compensate. These seemingly imprudent actions may further aggravate the diseases or other medical conditions, and lead to poorer nutritional status, health and well-being. If there are chemosensory interventions, then these may help to improve food intake and nutrition, stabilize the disease states, and potentially prevent further or more rapid decline. AGING, NUTRITION AND TASTE

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DECLINE IN DIET QUALITY DURING AGING There are many factors that might contribute to decline in diet and nutrition during aging. These include behavioral, environmental, physical and social factors, with the chemosensory changes in taste and smell often at the root of many of these factors.

DECLINE IN BEHAVIORAL, ENVIRONMENTAL, PHYSICAL AND SOCIAL FACTORS DURING AGING • Behavioral factors during aging that may affect a person’s diet may include agitation, aggressiveness, combativeness, critical and/or demanding personality, depression, hallucinations, indifference, mistrust, mood swings, overcontrolling personality, restlessness and/or wandering. • Environmental factors during aging that may affect an individual’s dietary intake may include environmental toxins such as asbestos (that may affect the lungs) and chemicals (that may affect the kidneys and liver); heavy metals such as lead and mercury (that may affect the brain); smog and particulates (that may affect the lungs); smoking (that may affect the lungs); and UV radiation (that may affect the skin). Financial changes, food availability and solitary living are also environmental considerations that may have dietary consequences. • Physical factors during aging that may affect an aging person’s dietary quality may include: changes in body composition, the brain and nervous systems, blood circulation and the heart, falls, immobility, metabolic diseases and sensory changes that may include decreased eyesight, hearing and touch, as well as chemosensory changes that may include decline in smell and taste. Chemosensory decline may the underlying problem in many of these physical factors. • Social factors during aging that may affect an aging person’s beverage and food consumption may include age, companionship, education, family/marital status, income/wealth, race/ethnicity, religious/spiritual beliefs, sexual orientation and work/employment/volunteerism.

THE SENSES The senses are a part of a system of sensory cells that respond to certain external and internal occurrences. They connect to specific regions of the brain where their sensations are interpreted. The interplay of the senses and how they influence food choices is depicted in Fig. 3.1. Interplay of the senses (touch, sound, sight, smell, taste) to influence food choices Touch

Sound

Sight

Smell

Taste

Perceptions of foods or beverages

Appetite (desirability, satiety, satisfaction)

Food preferences and behaviors

Food selections or rejections

Nutrition or malnutrition

Health and wellness or disease FIGURE 3.1 Interplay of the senses that influence food choices. Source: From Marcus JB. Culinary nutrition: the science and practice of health cooking. Elsevier, 2014, p. 58. AGING, NUTRITION AND TASTE

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The senses may be divided into two basic groups: the exteroceptive and the interoceptive senses. Exteroceptive senses help the human body to perceive motion, position and state. They include the traditional five senses of hearing, sight, smell, taste and touch, plus other sensations such as balance, direction, pain and temperature. Interoceptive senses are those that detect sensations within the internal organs [2].

Hearing Hearing (audition or auditory perception) is the body sense that involves the perception of sounds. Sounds are motions or vibrations that are propagated through different mediums, such as air, then turned into electrical impulses within the inner ear by a series of tiny bones and hair-like fibers. The ability to hear, particularly at higher frequencies, appears to decline with aging. This inability to hear is referred to as deafness or hearing impairment. The ears are responsible for hearing. The outer ear projects like a cup to capture sounds and direct them to the tympanic membrane. The tympanic membrane is a thin, cone-shaped casing that functions to transmit sounds from the air to the ossicles (three bones inside the middle ear), and then on to the oval window (a membranecovered opening that leads from the middle ear into the vestibule of the inner ear), which contains the fluidfilled cochlea (the spiral cavity of the inner ear). The cochlea is the portion of the inner ear that resembles a snail shell. It contains the Organ of Corti that produces nerve impulses in responses to sound vibrations. Sound information travels via the auditory nerve to the brainstem where signals are integrated from other parts of the brain and experienced in the primary auditory cortex. Within the middle ear there is also a vestibular system that provides information about the sense of balance and spatial orientation. It is formed by three semicircular canals that are responsible for the detection of rotational movements; the sense of balance and special orientation. Contained within these canals are chambers that are filled with a viscous fluid, and otoliths or small calcium carbonate particles. When these otoliths move across the small hair cells in the inner ear, then signals are sent to the brain that are translated into such sensations of movements such as accelerations and motions. Hearing and Aging Aging may affect all of the senses; however, hearing and vision may generally be the most affected. Presbycusis, or age-related hearing loss, is a common condition of aging people. Hearing loss may arise from changes in the middle ear or the nerve pathways that lead to the brain. According to the National Institute on Deafness and Other Communication Disorders, as of 2016 about one in three people between the ages of 65 and 74 years of age in the United States had hearing loss, and nearly onehalf had difficulty hearing. Hearing loss may involve more than physiological changes. It may affect the identification of sounds such as alarms, doorbells, phones and/or smoke detectors; the hearing and understanding of the advice of health care providers; and the socialization (or lack thereof) among family and friends. Sometimes hearing loss accompanies the loss of taste and smell. This is why the identification and individualization of (and compensation for) hearing losses may be needed to thwart impending dangers in the aging. Interviewing individuals with sensory decline (including hearing losses) and then adjusting for living environments that may be affected may be warranted [3].

Sight The eyes are responsible for vision. What a person sees is comprised of light reflected from objects around them. This light enters the eyes through the cornea, which is controlled by the pupil, which is surrounded by the colored section of the eye, or the iris. Because the front of the eye is curved, the light bends and creates an image on the retina that is upside down. The images are then transmitted to the brain through the optic nerve. The brain then combines the images from both of the eyes and depicts them right-side-up as three-dimensional figures. The sense of sight (or vision) enables the eyes to focus, detect images and to discriminate among various degrees of brightness, colors from reds to violets and hues. The visual cortex of the brain is responsible for discerning and interpreting objects and patterns based on previously acquired information from the eyes. This

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process is referred to as visual memory. The inability to see is referred to as blindness and may be caused by damage to the eyeball (including the optic nerve or retina), medications, poisons or a stroke. The human eye cannot detect ultraviolet light, but the skin might tingle by exposure to ultraviolet light, so it is felt. Infrared light also cannot be seen; it is sensed as heat. Sight and Aging As with hearing, the sense of sight commonly changes as people age. The following eye conditions may occur throughout aging. Many are treatable by attentive eye care. • Cataracts are an eye condition whereby the lens of the eyes becomes progressively opaque which makes vision blurry. Symptoms may also include problems with bright lights or night vision, faded colors and/or halos. Cataracts may be removed by surgery and replaced by an artificial lens. • Conjunctivitis is a condition when the tissues that cover the eyes become inflamed. It may contribute to burning, itching, redness or tearing. Conjunctivitis may be the result of allergies, exposure to chemicals or irritants, or infection. An eye specialist may be needed for treatment. • Dry eyes occur when the tear glands either make insufficient or lower-quality tears. Dry eyes may or may not be accompanied by itching that may also indicate allergies. • Floaters are small spots that seem to drift across the fields of vision. While normal, floaters may indicate more severe eye problems, such as a detached retina. • Glaucoma is an eye condition that may be the outcome of too much eye pressure inside of the eyes. It may be the result of a blockage of watery fluid between the cornea and the lens. Untreated, glaucoma may lead to vision loss and/or blindness. Regular eye care is recommended. The need for ongoing eye drops, oral medications and/or surgery may be necessary. • Presbyopia is a normal condition that occurs when nearby objects or small print is difficult to see. Reading glasses or contacts may provide adequate correction. • Retinal disorders may include a detached retina, diabetic retinopathy or macular degeneration. These eye disorders may affect the thin lining on the back of the eye that is responsible for the collection of visual images that are transmitted to the brain. Diagnosis and intervention may help to identify any of these disorders, treat them and preserve vision. • Tearing may be accompanied by light, temperature or wind changes in the environment, or be the sign of a blocked tear duct or an eye infection. Surgery may be necessary. Scratches or corneal abrasions may make the eyes more susceptible to bacteria or fungal infections. Eyesight Related to Taste and Smell Although sight is theoretically not needed for the sensations of taste or smell, the sense of sight may influence the perception of taste or smell. The senses of sight and smell unite to identify foods and beverages, not necessarily the sense of taste. Some foods may be identified by sight alone to help to stimulate or nullify the appetite, except when there is failing eyesight. For example, a very red tomato may register all five of its acidic, bitter, salty, sweet and umami tastes. If a person cannot visualize its redness or shape, the taste messages may be lost in translation. So the eyes may trigger the taste buds, along with the other senses of smell, taste and touch, and to an extent hearing (consider the sounds of boiling water, popping corn or sizzling foods). These factors should be taken into account if one of the senses appears to wane so that others may be employed to compensate [4].

Smell Smell, or olfaction, is a chemical sense, like taste. The nose and specifically the nasal cavities are responsible for the sense of smell. The nasal cavities are lined with mucous membranes that contain olfactory, or smell receptors that are aligned with the olfactory nerve. There are about 5 million olfactory receptors that are located in a small patch of tissue about the size of a postage stamp in the roof of each nasal cavity. Smells are detected in two ways: the orthonasal route through the nostrils and the retronasal route from the back of the throat and upward toward the nasal cavities. Odors are detected when scents that consist of vapors travel through the air into the nasal cavities, dissolve in the mucus, bind to the olfactory receptors and produce excitatory signals. These signals are then transmitted to the brain, specifically the olfactory bulb where they are

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processed, then on to the limbic system, or to the “emotional” brain where they are felt and then finally to the cerebral cortex there they are interpreted. The limbic system is a center for emotions and memory. This is why a person rarely has a neutral response to odors. The cerebral cortex plays a vital role in the attention, awareness, cognition, consciousness, language, perception and thought of odors and other senses. The cerebellum then receives the olfaction information from the sensory systems (including taste, or gustation), the spinal cord and other parts of the brain, and then it regulates motor movements—including the acceptance or rejection of future odors. The olfactory receptors are continually being renewed with a turnover time between 30 and 120 days. If a person has a cold or sinusitis, it is not uncommon to temporarily lose one’s sense of smell until it restores. Smell and Aging Beginning at approximately 60 years of age there may be some loss of smell. This may be due to many factors that include Alzheimer’s disease, cigarette smoking, dental issues, facial or head injuries, some medications (particularly angiotensin-converting enzyme [ACE] inhibitors and beta blockers), nasal and sinus problems (especially allergies, nasal polyps and sinusitis) and Parkinson’s disease. Decline in smell as well as taste may significantly impact a person’s life by decreasing appetite, which in turn may affect nutritive intake, health and well-being. See the discussion of Olfaction that follows for a comprehensive description of the sense of smell and aging.

Taste The oral cavity, rather than just the tongue or mouth, is responsible for sensing taste. Taste, or gustation, is the ability to detect beverages, certain minerals, foods, medicines, poisons and other substances. Taste is detected by the taste buds, which are sensory organs that reside throughout the entire oral cavity (the back of the throat, the pharynx, epiglottis, esophagus), and upper part of the stomach that transmit the taste messages to the brain where they are detected. There are five basic tastes: bitter, salty, sour, sweet and umami (discussion follows). Other tastes such as calcium and free fatty acids have not been fully acknowledged. At the base of each taste bud resides a nerve that transmits the taste sensations to the brain where the sense of taste coordinates with the sense of smell and interpretation interplays. Taste and Aging As with the other senses, the sense of taste often declines during aging, but at an individualized and variable rate. The number and size of the taste buds often decrease with aging, as well as their sensitivities to different tastes. Since the sense of smell also frequently decreases with aging, and since the senses of taste and smell play such a combined role in the detection and identification of foods and beverages, it is often difficult to discern which loss is greater or more significant. Combined with less saliva that leads to dry mouth, decreased mucous production and loss of nerve endings in the nose, alcohol, certain diseases such as Alzheimer’s disease, diabetes or even the common cold, exposure to harmful chemicals in the environment and smoking it is not surprising that the sense of taste becomes more challenging to differentiate with age. See the discussion of Gustation that follows for a comprehensive description of the transmittance of taste and aging.

Touch Touch, or somatosensory, tactition or mechanoreception, is the sensation that results from the activation of neural receptors that are typically in the hair follicles, mucosa, skin, throat and tongue. Variations of pressure are sensed by touch, as well as itching. The sensations of numbness, pricking and tingling are referred to as parethesia. They may be the result of nerve damage, but may be temporary [5].

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Touch and Aging During the aging process, the sensations that involve the sense of touch may be reduced. This may be due to the decrease in blood flow to the brain, nerve endings or the spinal cord. This is because the spinal cord is responsible for transmitting nerve signals from touch sensations, and the brain is responsible for their interpretation. The symptoms that contribute to changes in sensitivity may be underlying and particularized. For example, decreased sensitivity to touch, pressure and/or vibration may increase the risks of injuries because either a person does not recognize pain, or they may be better able to tolerate pain. Or, they may have a false sense of stability while they are in pain, which may increase their risks of falling and becoming injured. Expressing pain issues to health care practitioners and treating them immediately are paramount to rule out and avoid more serious medical issues. Attention to the skin and extremities is vital to maintain effective reactions to the sense of touch.

OTHER SENSORY CONSIDERATIONS (BALANCE, KINESTHETIC, PAIN AND TEMPERATURE) Balance, kinesthesia (muscle sense), pain and temperature are other sensory considerations that have the capacity to affect how people feel and think, and conversely how they perceive the other senses of hearing, smelling, tasting and touching.

Balance The sense of balance (also called equilibrioception or vestibular sense) is responsible for acceleration, body movement and direction for equilibrium and steadiness. The semicircular canals in the middle ear are part of a person’s balance system. Sensory receptors sense the motion of the fluid within the semicircular canals and then this information is transmitted by the vestibular nerve to the brain for analysis, decision-making and action, if needed.

Aging and Balance Dizziness, lightheadedness, spinning and unsteadiness are often apparent in the aging. These conditions may interfere with aging people bending over without falling, carrying out daily activities without support, climbing stairs without tripping, moving without assistance, rising from a chair or couch without tipping, walking without staggering and basically staying independent. Vertigo, the medical condition that may cause people to feel that they are moving, spinning or swaying, may be diagnosed, as identified by one of these disorders: • Labyrinthitis, an infection or inflammation of the inner ear that is often associated with upper respiratory infections. • Meniere’s disease, a balance disorder that may cause irregular hearing loss, a feeling of fullness in the ear, tinnitus (or ringing in the ear) or vertigo. • Benign paroxysmal positional vertigo (BPPV), a brief, intense feeling of vertigo often due to the displacement or disruption of calcium particles in the inner ear and the imbalance of sensors. BPPV may be the result of aging, head injuries or inner ear infections.

Kinesthetic Kinesthesia is muscle sense. It is the sense or awareness that helps a person to detect their body weight, position and the relationships among their body parts that include the joints, muscles and tendons and bodily movements. The kinesthetic sense provides regular sensory feedback of the muscles during motion and how the body is to make any needed adjustments.

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Aging and Kinesthesia The sense of upper extremity position as determined by hand- and joint-based parameters, often declines with age. This information helps to provide a basis for understanding various impairments in the position sense may be due to neurological disorders [6]. In addition, people who have suffered brain damage or who have undergone a stroke may have to look at their limbs to know what they are doing or what to do since they may have lost this kinesthetic sense and abilities.

Pain There are three types of pain receptors that are lodged in the body organs (visceral), joints and bones (somatic) and skin (cutaneous). When pain is felt, these sensory receptors send messages through nerve fibers to the brainstem and spinal cord. The chemical messages are then sent to the brain where they are identified as pain; then they are processed and the pain may be felt. The purpose of pain is to bring attention to danger and motivate a person to try to eliminate the source of the pain. Physiological pain may signify nerve or tissue damage, called nociception (or physiological pain). This type of pain was once considered to be an overload on the pressure receptors. It is now considered to be a distinct phenomenon that involves many of the other senses and incorporates the sense of touch.

Aging and Pain As one ages the ligaments and tendons that attach to joints often become leathery and stiffer. Osteoarthritis may contribute to deterioration in the cartilage in the joints. By keeping the body as active as possible with a reasonable amount of physical activity, this may help to forestall these conditions. However, some arthritis and degenerative disks may still develop, in particular in the lower back. Inflammation and muscle soreness result in other areas, such as the Achilles tendon. Stretching activities such as yoga that promote flexibility are vital, as is strengthening the trunk muscles to help alleviate lower back pain from the upper body weight on the pelvis. Core exercises that focus on the back, buttocks, stomach and thighs are indispensable for strengthening, but should be executed as prescribed.

Temperature The sensation of temperature is referred to as thermoception, or the sense of heat and heat flow and the absence of cold. Thermoreceptors are located in the dermis (skin), hypothalamus, skeletal muscles and the liver. Cold receptors on the chin, chest, fingers, nose and upper lip are important to the sense of smell since they are involved in the perception of wind direction that may carry aromatic molecules. Heat receptors on the fingertips, elbows and nose are responsive to infrared radiation. The thermoreceptors in the skin are unlike the thermoreceptors receptors in the brain and other inner body parts that detect internal body temperature.

Aging and Temperature The process of aging may decrease a person’s ability to sweat. Sweating decreases body heat so that the body does not overheat. Overheating may lead to heat stroke. If heat stroke is unaddressed, then it may lead to an urgent medical state and/or death. Conversely, a decrease in body fat right under the skin may contribute to poor insulation and make it more difficult to keep warm. This condition may be more common in people with eating disorders such as anorexia or bulimia or with the anorexia of aging (see Chapter 2: Nutritional and Physical Concerns in Aging). If people who are aging have infections, then they may have a more difficult time producing a high enough temperature to mark their illness. Other symptoms and vital signs may have to be checked by a health care practitioner to rule out more serious medical problems that may have been masked.

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TASTE VERSUS FLAVOR Taste is one of the basic sensations along with hearing, sight, smell and touch. It is often confused with the concept of flavor. Flavor is a combination of the basic sensations of smell and taste and has a number of components such as the five basic tastes of bitter, salty, sour, sweet and umami and trigeminal senses that detect irritants in the mouth and throat. Even such factors such as appearance, consistency and contrasting tastes may affect flavor perception.

Appearance and Flavor Perception Appearance is the physical look of foods and beverages, including their color, size, shape and texture. Visual cues provide the first type of sensory interaction with foods and beverages before their consumption. People select or reject foods and beverages based upon their reactions to their presentation. Merely the sight of a food or beverage in near proximity to the eater is sufficient to trigger meal initiation. It is especially important for aging people with fading eyesight to clearly and accurately perceive the foods and beverages that are presented to them. This is so they are better able to detect and identify what is presented to them for their potential consumption. Foods should appear and be brightly colored and full-flavored, fresh and at their peak for more exciting visual appeal. They should be attractively arranged and garnished with ethnically correct accompaniments, such as lime or cilantro for Hispanic dishes, or spring onions or mung beans for Asian-inspired recipes. The foods should be placed in set layouts on dishware with simple patterns and solid colors if possible so that each food may be individually discerned. Brightly colored plates and cups are fine unless the foods and beverages complete and may not be differentiated for what they are. If aging people need to lose weight, cutting some foods into smaller pieces and artfully positioning them on a plate may help to reduce food intake and preserve the emotions that certain foods evoke. For example, if chocolate cake conjures happiness, then a mini slice that is flanked by berries may total fewer calories than a big slice, and may still convey pleasant thoughts and/or memories. Also, adjusting the size of dishware to smaller sizes may help to decrease portion sizes and food intake [7].

Smell (Odor) Smell, or the ability to perceive odors or scents in the environment through the organs within the olfactory system, is an essential component of human flavor perception for the important sensory signals that it provides. The sense of smell even shapes the ways that its companion senses of taste and texture are experienced. Before a food or beverage is even visually identified, their smells signal its near presence. This is why tempting aromas entice consumption, especially when they are enhanced for declining aging tastes. People who are aging should be encouraged to take a deep whiff of a food, beverage or meal and pause to consider their aromas before eating. This is because their aromatic appeal (or lack thereof) may help to determine whether or not these foods or beverages will be consumed. The smell of certain beloved foods, such as chicken soup, roasted meats or chocolate chip cookies may help to evoke buried food memories, instigate consumption, promote appetite, stimulate salivation or even increase food intake in some individuals. This may also be dependent upon such factors as body mass index (BMI), level of dietary restraint and/or impulsivity and food or beverage sensitivities. The impact of the sense of smell does not seem to transfer from one meal to the next. For example, odoriferous mushrooms in one dish may not be recalled in a future dish—particularly if the mushrooms are prepared differently. This is also why the aroma of a particular food or beverage is critical within the entire flavor experience, and not a focus on its own. In the aforementioned example, the mushrooms should blend into a dish and not be the emphasis in order to be appreciated and enjoyed. Suggestions for how to enhance the aromatics of food and beverages are shown in Table 3.2.

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How to Enhance the Aromatics in Foods and Beverages for the Aging

• Add as many herbs and spices to foods and beverages as tolerated to help to increase scent perception. • Chew food slowly and thoroughly mix with saliva to help to release more odorants. • Consume foods with different textures, one bite at a time and rotate them throughout the oral cavity to help to prevent olfactory boredom. • Serve foods and beverages that may be easily identified by their appearance via the sense of sight. • Smell some stronger odors, if tolerated, for short periods of time to help to recall how foods and beverages are supposed to smell. • Try to avoid long-term exposure to negative smells, such as those from rotting garbage or dirty laundry. Also . . . • Avoid cigarette smoking and alcohol consumption. • Check for allergies; then address any allergies as warranted by a health care provider. • Check with a health care provider about which medications and/or supplements that may affect the sense of smell and/or taste. • Drink an 8-ounce glass of water frequently throughout the day to help balance medication and supplement use and help to prevent dehydration. • Ensure that air is humidified. During spring and summer the sense of smell may be stronger due to higher humidity. • Keep the nasal passages moist by exercising (the sense of smell is higher after exercise, and may be related to additional moisture). • Make sure that zinc intake is adequate (from beef, flax and pumpkin seeds, kidney beans, oysters, shrimp or spinach, for example) since a zinc deficiency may contribute to a loss of the sense of smell. • Open the nerve receptors in the nose by blowing it frequently and cleaning it with a saline spray (if this is first approved by a health care provider) [8].

Taste Taste is the sensation that is produced when substances in the oral cavity react with taste receptor cells that are located on the taste buds in the oral cavity. While the appearance and smell of foods and beverages are important to identify and rouse food and beverage experiences, the sense of taste is a proximal sense that requires taste stimuli throughout the entire oral cavity to convey gustatory information. When foods and beverages enter the oral cavity through the mouth, the sense of taste provides important information to the brain about such factors as acceptability, nutrient quality and satiation. By increasing taste intensity while maintaining palatability many people, including those who are aging, may be able to consume less, yet be more satisfied. The term “taste” is often confused with the term “flavor” because people often state that a food or beverage “tastes” good, when they really mean that the entire “flavor gestalt” or “whole” of the dining experience is flavorsome. The basic tastes of bitter, salty, sour, sweet and umami likely stimulate or halt the ingestion of certain foods and beverages. For example, sweet tastes generally signal carbohydrates and energy; particularly those that are found in sugar-containing forms. So their consumption may encourage survival. The salty tastes generally signify electrolytes, particularly sodium chloride, which is found in table salt and in many processed foods and beverages. Their consumption is intended to replace bodily fluids and to keep the body in balance. The savory tastes generally signify protein-rich foods and beverages, particularly those that are found in meats and legume- or nut-based drinks. The consumption of foods such as these is essential for capabilities and strength. The sour tastes typically signify foods and beverages that are not predominantly at their peak conditions, particularly sour fruits that have not sweetened. They signify that consumers should wait until their sugars develop and mellow. The bitter tastes largely signal that they may be harmful if ingested, particularly bitter molds on some cheese, nuts or root vegetables. Some people distain bitter tastes, but they may be masked by other basic tastes. This feature is fortunate since bitter tastes often accompany nutritious foods and beverages, such as some leafy green vegetables and teas. The majority of human food and beverage choices come from sweet- and salty-tasting foods and beverages. People with a strong preference for a certain taste tend to consume more foods and beverages that contain this taste. Such tends to be true concerning the sweet taste.

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However, this partiality is highly individualized and may not extend beyond an initial eating experience. The exception is the taste of umami that appears to cue further consumption due to its “savory deliciousness.” For this reason, the umami taste may help to moderate the feelings of satiety, particularly in instances of the anorexia of aging. The sense of taste, like the sense of smell, tends to decline over a lifetime; thus enlisting the other senses that comprise flavor to compensate—unless they, too, are compromised. This is why the flavor-enhanced recipes that appear in Chapter 10, Menus and Recipes That Appeal to Aging Palates, may be helpful for sensorycompromised consumers. Since taste loss is highly individualized, it may be that some recipes are more fitting for some diets versus others. Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging, and Chapter 9, Culinary Considerations for the Aging, should be consulted for individualized directives for customized diets and meal plans.

Temperature Temperature is the degree or intensity of heat that is present in foods and beverages. A correlation sometimes exists between increased temperature and the more intense perceptions of bitterness and sweetness. Despite changes in temperature, the tastes of saltiness and sourness tend to remain the same. However, the effects of temperature do not appear to be uniform across all compounds. This is why it is important to consume foods and beverages that are intended to be hot or cold at their recommended temperatures to help maximize their natural tastes. The taste receptor TRPM5 (that recognizes bitter, sweet and umami tastes) has been reported to be highly temperature sensitive and heat activated and affects taste perception. With regard to flavor, warmed foods and beverages may serve to highlight more appealing tastes to the aging, especially when leading a meal, such as a warm appetizer or soup. Slightly warming deserts, such as ice cream or pie, may help to elevate their sweetness, which is especially important if there is less natural sweetness in the recipes. However, once ice cream fully melts, it may be perceived as very sweet. Ice cream that is reduced in sugar or other sweeteners sweetness may become more palatable if liquefied [9]. These perceptions may vary depending upon brands and ingredients.

Texture Texture is a sensory characteristic of foods and beverages that has multimodalities. Texture includes the appearance, consistency and/or feel of surfaces or substances. Precisely, texture incorporates the mechanical, structural and surface properties of foods and beverages that are detected by and through the other senses. The consistency of a food or beverage may affect its flavor. For example, two foods that are similar in their taste and smell that differ in texture may also differ in their perceived intensity. An example is heavy cream that may be liquid or whipped. Both forms are similar in taste and smell, yet the whipped cream with more air and volume may taste milder than the liquid version. Some of the attributes that are used to describe texture include creaminess, crunchiness, firmness, smoothness and thickness. Depending upon the degree of texture of foods or beverages, caloric intake may be moderated. It follows that chewy, hard or viscous foods may be consumed at a slower rate or in smaller quantities that softer or more liquid foods or beverages. Taking smaller bites and chewing longer also tends to reduce food intake. Texturized foods may help to produce more memorable food experiences, reduce boredom, and vary the meal experience. Each of these factors are important variables for improving the eating experiences for the aging. More information on achieving texture can be found in Chapter 6, Flavor Enhancement Ingredients, and Chapter 7, Flavor Enhancement Techniques. Information on texturized foods and beverages can be found in Chapter 12, Prime Time Resources for Aging, Taste and Health.

Touch In the context of eating, touch is the movement to be close to a food or beverage to alter, manipulate or “sense” it. Cells, genes and neural circuits that are all involved with the sense of touch are important for its identification and for creating a unique human experience.

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The sense of touch is complex; consequentially the understanding of its function and how the brain processes the sense of touch is limited. There are two distinct pathways that process the sense of touch: the first is a sensory pathway that provides the facts about touch, such as location, pressure, texture or vibration via the somatosensory cortex. The second pathway processes both emotional and social information about touch that relies upon different skin sensors. This pathway is responsible for brain activation in regions of the brain that are associated with pain, pleasure and social bonding. After 18 years of age, the sense of touch steadily deteriorates at a rate of about 1% annually. By the time that people are 60 years of age or older the sense of touch may have greatly declined, since the density of the nerve endings in the hands decreases and does? not appear to restore. Myelin, the insulating material that covers fast-conducting nerve fibers and helps them to respond quickly to the brain, also deteriorates with age, so the process of transmittance of touch messages to the brain may be slower. These changes in the sense of touch may also affect the feet and may be part of the reason why people who are aging fall down. Therapeutic massage is useful to maintain cognitive function, equilibrium and mobility and to reduce pain among those who are aging. It may be helpful for aging people to feel the textures and shapes of certain foods at the supermarket and/or those that are used in food preparation—especially nutritious fruits and vegetables. They may be better able to identify, appreciate and enjoy certain foods once they are prepared for consumption. Specific examples for augmenting the touch of certain foods can be found in Chapter 7, Flavor Enhancement Techniques. For instance, it may be helpful in dietary instructions to compare the weight and texture of wholegrain bread to refined white bread, and explain why wholegrain bread with fiber is better for a person with certain gastrointestinal diseases, diabetes or heart disease. Sometimes illustrated decision-making may help to overrule emotional food choices.

Other Flavor Factors In addition to the perceptions that result from the stimulation of the taste buds, olfactory organs and chemosensory receptors within the oral cavity, or the combined effect of aromatics and chemical feeling factors that are evoked by substances in the oral cavity, broader aspects of flavor may also interplay. These may incorporate the chemical feeling factors or trigeminal sensations such as oleogustus (Latin for “a taste for fat”), and pungency may also be valued as flavor components [10].

GUSTATION Gustation, or taste, is one of the five traditional senses and is a part of the gustatory system. The sensations of taste are created when substances in the oral cavity link with taste receptors located throughout the entire oral cavity, epiglottis and digestive tract and communicate with the gustatory cortex of the brain. The sensations of taste register as the five basic tastes of bitterness, saltiness, sourness, sweetness and umami. In comparison, the flavors of foods, beverages and other substances are an amalgamation of taste; smell (or olfaction as detected by the olfactory epithelium of the nose), and trigeminal nerve stimulation that identifies pain, temperature (as detected by thermoreceptors), chemical stimuli (as detected by chemesthesis), and texture (as detected by mechanoreceptors).

TASTE PATHWAYS Thousands of papillae (small bumps on the tongue) contain hundreds to thousands of taste buds. There are four main types of papillae on the tongue, circumvallate, filiform, foliate and fungiform, in different numbers, shapes and functions. Taste buds are also located along the sides of the mouth and the roof and the back of the mouth, each with about 50 to 100 taste receptor cells.

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These taste buds are able to differentiate tastes by interacting with diverse ions and molecules. For example, salty and sour tastes are detected when alkali metal or hydrogen ions enter the taste buds, while bitter, sweet and umami tastes are activated when molecules bind to G protein-coupled receptors on the cell membranes of taste buds. These basic tastes are categorized as appetitive taste (meaning that these tastes appeal to the appetite), or aversive taste (meaning that they repulse the appetite) for reasons that are explained throughout this chapter. Consider the appeal of the sweet taste and the distaste of the bitter taste, for example [11].

FIVE BASIC TASTES The five basic tastes of bitter, salty, acid, sweet and umami and their sensations of bitterness, saltiness, sourness, sweetness and savoriness are generally accepted for their existence and distinctiveness. Taste receptors have been identified for each of these five basic tastes that help to support their existence [12].

Bitter (Bitterness) The bitter taste is considered as disagreeable or unpleasant. It has long been viewed as possibly poisonous. The ability to detect the bitter taste may have originally provided innate protective functions (e.g., for a pregnant woman to protect her unborn child). Still, many favorite tastes today are bitter, such as those found in citrus peels, coffee, green leafy vegetables, hops, olives, quinine, tonic, unsweetened chocolate and wine. It may be that dietary changes and toxin aversions over time have permitted reduced sensory impacts to the bitter taste. In turn, this has afforded the enjoyment of some-to-many bitter tastes throughout the lifecycle. Bitterness and Aging This is fortuitous since some bitter-tasting compounds may have health advantages. Glucosinolates that are present broccoli, Brussels sprouts and other cruciferous vegetables may play roles in cancer prevention and other conditions and/or diseases of aging. In additional to the oral cavity, bitter taste receptors are also found in the brain, gut, lungs and nose, and may play various roles in keeping the aging body healthy.

Salty (Saltiness) The salty taste is primarily created by the presence of sodium ions. The taste receptor for the salty taste is sodium chloride, commonly found in table salt and processed foods. Dilute solutions of sodium chloride also may produce bitterness, sourness or sweetness under certain conditions. The mineral salts of magnesium and potassium may also create a sensation of saltiness. Exactly how sodium chloride stimulates the taste buds is not fully clear since the cellular and molecular mechanisms are not completely understood. It is known that cells within the taste buds interact and produce signals that are transmitted to the gustatory sensory fibers, likely through multiple transduction mechanisms and thus, the salty taste may ensue [13]. The taste for salt is learned. Our true physiological need is for sodium, not sodium chloride, at about 180 milligrams daily. In the United States, at the time of this writing, the average consumption of sodium is over 3400 milligrams daily, while the 2015 2020 Dietary Guidelines for Americans recommended that Americans consume less than 2300 milligrams of sodium daily. US adults over 50 years of age, African Americans and people who have chronic kidney disease, diabetes and/or high blood pressure are advised to limit their sodium intake to 1500 milligrams daily [14]. Saltiness and Aging Those who are aging may require a two- to three-fold higher concentration of salt to be able to detect it in such foods as soup. However, higher salt intake may aggravate existing diseases and/or medical conditions. Since salt is one of the most widely used additives in flavor enhancement—particularly in processed foods—its abundance in the diets of aging people should especially be taken into consideration.

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A major reason is because sodium is known to raise blood pressure. Sodium has also been linked to cellular aging, which means that eating too much salt may speed up the aging process and conditions such as chronic kidney disease, dementia, heart disease, some cancers, obesity and type-2 diabetes.

Sour or Acidic (Sourness) The sour or acidic taste detects acidity in foods and beverages. The sourness of these substances is rated relative to dilute hydrochloric acid with a sourness index of 1.0. Generally, the more acidic a food or beverage is this means that the more hydrogen ions (H1) are available to trigger sour taste receptors. Mostly acidic solutions such as lemon or lime juice or organic acids taste sour. The food group with a predominant sour taste is the fruit group that contains grapefruits, kumquats, lemons, limes, oranges, pineapple and tamarinds, among other acid-forward fruits. Other sour foods and beverages include fermented products (such as pickles, vinegar, sauerkraut and soy sauce) and sour milk products (such as some cheeses, kefir, sour cream and yogurt). Sourness may have originally indicated that foods and beverages were disintegrating, and that they were potentially dangerous to eat. Exactly why humans need a sour taste receptor is not fully determined. Today the sour taste is indeed a measure of produce readiness, but it is also desired on its own for the freshness that it often conveys. Consider a squirt of lemon or lime juice to finish a dish and bring out the flavor. The sour taste is detected by a small group of specialized cells on the tongue that theoretically relay this taste through a complex pattern of nerve signals to the brain. Receptors for the sour taste have also been discovered in neurons of the spinal cord that may help the human body to monitor acidity of the cerebrospinal fluid in the nervous system. Another reason for the sour taste in the mouth is gastroesophageal reflux disease (GERD). In this condition the lower esophageal sphincter inadvertently opens and permits stomach acid into the esophagus. Acidic foods, alcohol, certain medications, cigarettes and obesity may be triggers [15]. Sourness and Aging With aging, the digestive tract generally slows down like other body functions and may not work as efficiently or quickly as during younger years. The muscles of the digestive tract may become less efficient, stiffer and weaker; tissues may become damaged; and cells may not form as quickly as they did throughout youth and middle age. GERD may become more serious in nature. In general, the aging (as well as younger individuals) tend to confuse the salty and sour tastes much more than they confuse the sour and sweet tastes. These confusions may have implications when mixtures of different foods and beverages are presented to and perceived by the aging. In particular, the ability to discern the salty taste at different thresholds may affect the desire (or lack thereof) for salty foods and beverages when diseases, medications and/or physical conditions may be contra indicatory of certain levels of sodium consumption [16].

Sweet (Sweetness) The sweet taste is considered as one of the more elemental of tastes. It is generally judged as a pleasurable sensation. Sweetness is detected by the presence of sugars that are the foundation of many foods and beverages. Chemical compounds such as aldehydes, ketones and sugar alcohols also may also impart a sweet taste, as may some complex carbohydrates that are found in fruits, vegetables and grains that break down into simple sugars in the human body. Fruits contain the simple sugar fructose, and dairy products contain the double-sugar lactose. It is common for people to develop an intolerance to lactose as they age. This is because a deficiency in lactase, an enzyme that is essential for the breakdown of lactose into the simple sugars of glucose and galactose, may develop. As a result, aging people (and particularly those of African-American, Asian or those of Middle Eastern heritage) may avoid dairy products. However, lactose-reduced and lactose-free dairy products are widely available so that these groups of people may still ingest and benefit from the vital nutrients that accompany dairy products.

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Different gene variations were discovered in the 1990s that showed laboratory animals preferred sweet foods to various extents. A sweet receptor protein complex is said to be responsible. Taste cells for sweet, bitter and umami appear to share a similar intracellular signally pathway. Not only are there sweet receptors in the oral cavity, sweet taste receptors are also located in the enteroendocrine cells of the gut and pancreas that may play important roles in nutrient sensing and sugar absorption. These cells are needed for energy and to maintain the normal metabolism in the balance of glucose and insulin levels. Some research has supported the hypothesis that the number of taste buds may play a role in how the body handles sugar throughout the aging process. Further investigation is needed [17]. Since the taste of sweetness tends to indicate that a quick source of energy may follow, humans are genetically programmed to seek out sweet sources of foods and beverages. But individual variations tend to determine who craves what type of sweetness, when and how much. Newborns have demonstrated preference for the sweet taste. This may be due to the fact that both amniotic fluid and breast milk are sweet and very satisfying. The satisfying aspects of sweetness have also been used to muffle pain: medications are often encapsulated or accompanied by sugary applications. Because the sweet taste (and specifically sugar) has such functionality in food and beverage development, food preparation and cooking execution, sugar provides a versatile tool for paring with or suppressing other basic tastes, and in nourishing aging palates. Sweetness and Aging An elevated taste threshold (or reduced sensitivity) for the sweet taste may occur in healthy older individuals. While there is debate about which of the basic tastes declines before others and at what pace, sensitivity to bitter and salty tastes may decline before the ability to distinguish sweet tastes. Individual variations still account for sweet taste preferences. The chemical structures of the tastants (or the substances that are tasted), medical conditions and pharmacological regimens are some variables that should be taken into consideration [18]. For people with different degrees of dementia, a preference for sweet foods and beverages may be a recollection of childhood with fond memories of specific sweet eating experiences. Sweet smells may also provoke similar feelings and entice people to regain interest in formerly enjoyed foods and beverages. For example, to augment the sweet taste, a little simple syrup or honey may be added to beverages or even soups, flaked proteins such as fish or poultry may be mixed into slightly sweetened sauces, and/or sweet vegetables such as carrots or parsnips may be mixed into cream sauce and sprinkled with a little sweet spices, such as cinnamon or nutmeg [19]. More ideas and recipes can be found in Chapter 9, Culinary Considerations for the Aging, and Chapter 10, Menus and Recipes That Appeal to Aging Palates. According to animal data, the ability to detect the sweet taste regardless of how much is consumed may significantly increase the length of life of an organism and potentially have a profound effect on physiological status and healthy aging. Further studies are needed in order to accurately apply these findings to humans, and for the potential of tailor-made taste-sensitive diets [20].

Umami (Umaminess or Savoriness) Proclaimed as the fifth taste of “deliciousness,” the umami taste is also deemed a savory taste since it is produced by foods, beverages and other substances that are high in certain amino acids—particularly glutamate (the salt of glutamic acid). Not surprisingly, glutamic acid is prevalent in dairy products, eggs, fish, kombu (seaweed) and meats. The umami taste is also released by such culinary practices as aging, cooking (especially lengthy), curing, roasting and/or searing. Foods and beverages that are rich in the umami taste from glutamates include aged cheeses such as Parmesan and Roquefort, anchovies, dried tomatoes, fish sauce, grape juice, green tea, peas, tomato juice, shrimp and walnuts, and the flavor enhancers autolyzed yeast extract, hydrolyzed vegetable protein, soy sauce and monosodium glutamate. Glutamic acid is the predominant free amino acid in tomatoes, a very popular food and ingredient in US foods. As tomatoes ripen and when they are cooked, dried and/or heat processed, the umami content increases and the dishes that contain tomatoes become more savory and desirable. Think about ketchup, pasta sauce, salsa, tomato juice and tomato sauce and their deep, rich flavors that are so prevalent in such dishes as chili, pizza and spaghetti and meatballs, common US dietary choices.

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Foods, beverages and flavor enhancers with the umami taste are useful in “rounding out” food flavors and decreasing sodium, among other culinary applications as discussed in Chapter 9, Culinary Considerations for the Aging. In 2000, specific oral receptors that respond only to glutamate were identified. This is significant because this discovery singled out the umami taste as unique, much like the other four basic tastes of acidic, bitter, salty and sweet. These oral receptors were likened to turning a key into an ignition that starts an engine. This is because the umami taste seems to enhance the breadths and depths of other tastes, and may permeate the oral cavity with more flavor than the foods and/or beverages that accompany it [21]. Umami and Aging By adding umami-rich ingredients to foods and beverages, both taste preferences and the amounts of foods and beverages that are consumed may improve. This is especially important to the aging whose appetites may have waned, and who may benefit from increase calories and other nutrients due to a heightened interest in consumption thanks to the umami taste. Umami-rich ingredients also may improve the amount of saliva that helps moisten foods, move foods around the oral cavity, and transport foods through the digestive process. Increased saliva production may be attributed to the deliciousness of umami-rich foods and beverages, as well as thoughts about their deliciousness that have the capabilities of triggering the release of saliva. The umami taste is beneficial for aging people who need to monitor their sodium intake. This is because the umami taste helps to compensate for less total sodium and even bitterness in a product or recipe due to its savory note. For example, chicken soup, a favorite of many aging people that may conjure enjoyable food memories, may have too much sodium per serving for some individuals with hypertension or kidney problems. By adding umami-rich ingredients, such as green peas or mushrooms, to a low-sodium chicken stock, the final product may still taste delicious to some individuals without contributing too much sodium. Other than the five basic tastes, other taste experiences such as coolness, fattiness, numbness, pungency or spiciness, and starchiness have been proposed. These taste experiences are basically detected by the somatosensory system. The trigeminal nerve (cranial nerve or CN V) that is responsible for facial sensations and motor functions such as biting and chewing provides information about the general textures of foods and beverages and the taste-related sensations of spiciness. Some of the free nerve endings of the trigeminal nerve monitor temperature as thermoreceptors. Coldsensitive thermoreceptors help to generate sensations of coolness, cooling and/or freshness. The sensation of numbness is characterized as chemesthesis, the chemically stimulated sensation of pain and temperature.

OTHER DEBATED TASTES: FATTY AND STARCHY The feelings of fattiness and starchiness in foods and beverages may be more sensations than actual tastes. An examination of their attributes may be helpful for their understanding and discrimination.

Fatty (Oleogustus) While the fifth basic taste of umami, discovered in 2000, is considered a relatively new basic taste, attempts have subsequently been made to add other tastes and sensations to the five basic tastes. One of these is fat, previously thought to be a texture, not a taste, with distinctive properties of its own. In order to be accepted as a taste, a substance must meet certain criteria that include a distinctive class of stimuli. In the case of fat, this amounts to certain byproducts of the breakdown of fats and fatty acids. On their own, fatty acids in a high concentration may impart an unpleasant taste and be displeasing for consumption. There must also be receptors that translate the chemical code of the fat(s) to electrical signals; neurotransmitters that send the signals to the processing areas of the brain; physiological effects of this activation; and independence from other basic tastes. The proposed taste of fat may accompany aroma or chemesthesis (see above: the chemical sensitivity of the skin and mucous membranes that mediate pain, thermal perception and touch).

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Some research has indicated that fatty acids evoke a unique sensation, similar to what the five basic tastes induce. This unique sensation is referred to as oleogustus (“oleo” is a Latin root word for oily or fatty, and “gustus” may be interpreted as “to taste”). It is unlike the “feel” of fat, such as creamy, silky or smooth. This oleogustus “taste” may act like a warning system for the human body, much like the bitter taste, because too much of it may be distasteful. This concept may why some foods, such as butter or ice cream, are so appealing to some people, other than for their sources of sugar and calories. It may also reveal while other people may find this “sensation” too “fatty” or even repulsive [22].

Starchy Another proposed “taste” is starchy, which is found in complex carbohydrates (starches) with their chains of sugar molecules that provide important sources of energy. Enzymes in saliva help to break down starches into shorter chains and simple sugars that are tasted as sweet molecules. In the United States, this described taste might be described as “bread-like” or “pasta-like,” while in Asia this taste might be described as “rice like.” The described taste of starchy does not meet the criteria used to determine a basic taste including recognizable taste of its own, specific taste receptors and an activation of useful physiological responses. However, initial research that compared the starchy to the sweet taste (when the sweet taste was controlled) indicated that humans may be able to taste the starchy taste independently [23]. Other potential tastes that are in the process of investigation include the flavor of carbonated drinks, the metallic taste of blood, the taste of amino acids that are the building blocks of proteins and kokumi, a full-bodied, hearty mouthfeel that conveys fullness, richness and satisfaction. It does so through calcium channels that are closely related to the receptors that sense the sweet and umami tastes. Like umami, in combination kokumi also enhances the other tastes in foods. Since the thresholds for most of the basic tastes appear to decline during aging, it makes sense to focus on the thresholds that are the most vulnerable and enhance their presence in foods and beverages. By individualizing chemosensory losses and matching with compensatory measures, foods and beverages may be more enjoyable, consumed and used for their nutritive and healthful values. Fats, starches and other substances that have the capabilities of enhancing taste may also be useful tools on the horizon [23].

TASTE PERCEPTIONS ACROSS THE LIFECYCLE Taste buds begin to form during the first two months of pregnancy. Clusters of taste receptors eventually recognize the five basic tastes, and neurons from the brain will connect with these developing taste buds. By the fourth month of pregnancy, taste pores will have developed that allow food molecules to come into contact with the taste buds. Fetuses appear to detect saltiness and sweetness in amniotic fluid; however, these tastes seem not as distinct or strong as after birth [24]. Some chemical sensitivities appear to be functional at birth. Newborns first flavor experiences are sweet ones, such as breast milk or formula feeding. Typical responses to the sweet taste often are lip smacking, puckering, sucking, an occasional smile and open, sparkling eyes. In contrast, typical responses to the sour taste often include tightly closed eyes, a wrinkled nose, pursed lips, drooling saliva and occasional gaping. Typical responses to the bitter taste frequently involve closed eyes, depressed mouth corners, wide gaping, excessive drooling and occasional retching. The abilities to detect bitter, salty, sour and umami tastes seem to develop throughout the first months of life [25]. Children appear to be ultrasensitive to their senses—particularly to colors and textures. They tend to skew toward sugary beverages and foods for energy, and away from bitter beverages and foods that could be potential toxins. After rapid growth through puberty and young adulthood there may be losses of acuity in taste and smell; stabilization and then decrease in the regeneration of taste buds as the sense of smell also stabilizes, then begins to decline. Both the sense of smell and taste appear to decrease more rapidly over 50 years of age. Individualized chemical, emotional and physical changes often interact along the way. Some people will expand their taste preferences and become more adventurous eaters and drinkers as they age. Their cognitive behaviors and memories may affect their food and beverages choices more than their senses of taste and smell alone.

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Still, sensitive eaters may exist throughout the middle years, unless they become more familiar with and accustomed to new tastes and smells and learn to enjoy them. This may be particularly true with regard to the bitter taste. Culture, exposure to bitter-tasting foods and beverages, interest in new tastes, personal motivation and sensitivity to bitterness may all determine if adults will choose to consume bitter foods and beverages. As people age, some taste buds do not regenerate, and some flavors may tend to be sensed as blander than remembered. Instead of serving underseasoned foods for sensitive gastrointestinal tracts and/or other conditions, some people who are aging may need tastier foods that remind them of how good food tasted when they were younger. Individualized tolerances are paramount. Plus, declining tastes and smells differ among aging people and what appeals to some individuals may be distasteful to others. In some instances during aging, certain tastes and smells might become more pronounced, and others more obscure. Some selective tastes may develop more with age, and selected scents may be more differentiated, identifiable and/or enjoyed. For example, bitter tastes may dissipate and foods such as bitter greens may be first or once again appreciated—especially if they are in appealing recipes, presentations or combined with fusions of tasty ingredients. Other sensory sensitivities may be displayed during acute olfaction or hyperosmia, which may be caused by lower threshold(s) for odor(s), prompted by abnormally increased signal(s) between the olfactory receptors and the olfactory cortex. Some theories for these occurrences include environmental or genetic causes. Genetics plays a role in which senses decline, the degree of failing, which senses compensate and to what extent. From a chemosensory standpoint, genetics may provide a reasonable picture of what to anticipate as a person ages, and how to adjust for selective chemosensory changes. Of course, individual variations, environmental factors and other influencers also matter [26].

ORAL CAVITY The oral cavity includes the lips, cheeks, hard palate (the bony part) at the roof of the mouth, floor of the mouth (the lowest part) and the tongue inside of the mouth. The inner surface of the cheeks forms the sides of the oral cavity. The oral cavity is generally protected by a mucous membrane. The oral cavity also includes the gingiva (gums), retromolar trigone (the area behind the back molars in the lower jaw), the teeth, the mandible (lower jaw) and the maxilla (upper jaw). The oral cavity leads into the oropharynx that includes the soft palate, the back of the tongue and the tonsils. The oral cavity functions to initiate the process of digestion. It is normally the first receptacle for foods and beverages where it is responsible for chewing, mixing with saliva, and swallowing. The oral cavity also plays vital functions in breathing, drinking, facial expressions, social interactions, speech and taste.

TASTE BUDS AND STEM CELLS Some research has sought to identify the specific locations and certain genetic characteristics of taste bud stem cells on the tongue. Their functions in taste bud homeostasis are not fully understood at this time. There may be some regulatory factors that control taste cell differentiation and degeneration. Preliminary findings of this research suggest that disruption and/or alteration due to disease and/or aging in taste bud homeostasis may contribute to taste dysfunction. These findings may also facilitate techniques to grow and manipulate new functional taste cells for clinical and research purposes. For example, the ability to activate adult taste stem cells may benefit cancer patients who have experienced taste loss following radiation, and aging people with diminished taste [27].

SUPERTASTERS Supertasters are human beings who experience a taste or tastes with much greater intensity than other human beings who taste at a more “normal” or average level. The causes and any evolutionary advantages are unknown, but the capability of being a supertaster is probably programmed into human DNA. In particular, the ability to

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taste the specific bitter chemical 6-n-propylthiouracil indicates if a person carries the specific bitter taste gene TAS2R38 and if he or she is a “supertaster.” About 50% of the US population detects bitter tastes and about 25% of the US population does not. Nonbitter tasters tend to be more accepting of bitterness. Approximately 25% of the US population has the supertasting gene and about 67% of those are female. Hypersensitivity to bitter tastes tends to fade with age [28,29]. Heightened taste responses to bitterness may be an important advantage for avoiding potential toxic substances. However, hypersensitivity to the bitter taste may also limit the selection and consumption of bitter-tasting foods and beverages. This is unfortunate since many bitter-tasting foods and beverages are also storehouses of nutrients, such as bitter green vegetables like Brussels sprouts and kale, as well as cilantro, grapefruit and green tea. Hypersensitivity to bitter tastes appears to fade with age for many reasons. For one, as other basic tastes change with aging, the predominance of the bitter taste may dissipate. Another reason may be more a matter of mind over matter. Significant predictors of whether or not a person will accept or even enjoy a bitter food or beverage are their exposure, interest and motivation to do so. Culture and memory may play big roles, as may flexibility in entertaining new and different tastes—especially bitter ones as the years progress [30]. Therefore, there is a need to individualize dietary approaches because hypersensitivity to the bitter taste (and others) may be so varied.

SENSITIVE TASTERS Highly sensitive tasters may have more taste buds than average. As a whole, women tend to be more sensitive to some sweet and bitter tastes than men. This may have evolved due to reproductive needs to nourish and protect their unborn children. Conceivably, maternal taste sensitivity would encourage a better array of nutrients from foods and beverages. Maternal taste sensitivities tend to increase during the first trimester of pregnancy, which corresponds to the time when the fetus is highly sensitive to potentially harmful and toxic substances. There are many hypotheses about taste cravings and aversions during the second and third trimesters of pregnancy, which may be due to changes in the insular cortex of the brain, behavioral, cultural and/or hormonal factors, and may also be highly individualized and/or speculative [31].

TASTE LOSS Complete loss of taste is referred to as ageusia. Total taste loss appears to be rare. Partial loss of taste is called dysgeusia. Historically, taste and smell disorders have been challenging to diagnose and treat since they may be secondary to various disease states—or may precipitate disease states. The extent of taste loss among the basic tastes due to aging is still debated. What is generally agreed on is that taste loss is associated with elevated taste thresholds or sensitivities to chemosensory stimuli [32].

TASTE THRESHOLDS The basic tastes have different concentration levels or sensitivities at which they can be detected. These are called taste thresholds. A detection threshold is the lowest or minimum concentration when the presence of a tastant can be detected. These thresholds may vary according to the area of the tongue or mouth that is stimulated by a particular taste, the current or previous presence of other taste stimuli, the stimuli that are tested, how the stimuli are measured and the temperature and viscosity of the stimuli, among other factors. A recognition threshold is the lowest concentration when a taste can be identified by a defined quality. In research settings, the recognition threshold typically refers to the amount of stimuli that is added to distilled water which can be detected as bitter, salty, sour or sweet. Recognition thresholds are typically higher than detection thresholds since stronger concentrations are generally required for identification.

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The thresholds for sweeteners, salts, acids and bitters appear to increase with aging. This means that more of these substances or a greater intensity is required to detect and/or identify them. The highest thresholds (or the degree of taste loss) have been debated. There are countless odorants to detect and recognize. Much of these processes depends upon past experiences and broad exposures to an array of different scents. Both middle-aged and aging people may be less able to detect or recognize even common odors over time [33].

MEDICAL CONDITIONS IMPLICATED WITH SMELL AND TASTE DECLINE There are many reasons why people may lose their sense of smell and taste that include congenital, endocrinological, developmental, infectious, medication-related and/or metabolic reasons. Some medical conditions associated with smell and taste decline are shown in Table 3.3, followed by descriptions and symptoms. TABLE 3.3

Medical Conditions Implicated in Smell and Taste Decline

• Allergic Rhinitis (Hay Fever) The loss of smell may result from damage to the olfactory cleft or nerve, or a physical blockage of the nose. Blockage may be caused by a deviated septum, nasal allergies (as in allergic rhinitis), or swelling of the mucosa as a result of chronic rhinosinusitis, with or without nasal polyps. Symptoms may include asthma, chronic cough, ear and sinus infections, congestion, fatigue, headache, itching of the eyes, intermittent ear plugging, hoarseness, redness and watering of the eyes, runny nose, sneezing, sore throat and/or wheezing. • Alzheimer’s Disease A failing sense of smell might be indicative of impending Alzheimer’s disease, especially if there are preexisting memory problems. Since chronic respiratory tract conditions may also interfere with the sense of smell, screening by a health care provider may be able to credibly ascertain cause and effect. One theory for the association of declining sense of smell and Alzheimer’s disease is that as dementia begins and progresses, regions of the brain that serve to distinguish odors begin to deteriorate. A loss of the sense of smell may also indicate the onset of cognitive decline and mild cognitive impairment and be a marker for Lewy body and vascular dementia. The loss of the ability to identify odors has been associated with plaques and tangles in the olfactory bulb (features of Alzheimer’s disease), entorhinal cortex and the cornu ammonis regions of the hippocampus that involves the sense of smell and memory (specifically the ability to store and retrieve smell memories and correctly identify odors). The loss of the sense of smell occurs only in neurodegenerative conditions where there is olfactory pathology, as what occurs with Alzheimer’s disease and Parkinson’s disease. Odor identification tests may be useful for early detection in people who are at risk of cognitive consequences. • Bronchial Asthma Bronchitis, an inflammation of the bronchial tubes and asthma, a chronic condition that causes swelling and narrowing of the airways, may both interfere with normal taste and smell. Medications that control both of these conditions may also contribute to chemosensory changes. • Cancer The loss of smell may be the result of benign or malignant tumors in the nasal cavities. Occasionally these tumors may grow from the olfactory nerves. Sinonasal, or other head or neck cancers, may lead to lack of smell, as may a history of radiation treatment to these areas. Malnutrition is a common side effect of patients who undergo various cancer treatments. Difficulties maintaining food intake are often attributed to altered tastes and may result in conditions such as distress, indifference to foods and beverages, reduced appetite, nausea and/ or poor nutritional status. Assessments that cover malnutrition, poor oral intake, taste dysfunction in relation to food flavor (smell, taste, and texture in particular) and food hedonics (pleasurable or unpleasurable states of consciousness) are recommended. Counseling on the impact of chemosensory changes on appetite and oral intake and their relationships upon nutrition and health status is also suggested. • Central Nervous System Disorders Initial decline in smell and taste with subsequent taste and flavor disturbance may indicate underlying neurologic problems. Gustatory issues may result from damage to the neural gustatory pathway at any point, from the taste buds to the peripheral (facial, glossopharyngeal and vagal nerve) and central nervous system (brainstem and thalamus) to interpretation within the cerebral cortex. (Continued)

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TABLE 3.3 (Continued) Bell’s palsy, cerebrovascular disorders including tumors, dementia, epilepsy, head trauma and skull base fractures, major depression, multiple sclerosis (MS), and/or polyneuropathy may also interplay. • Chronic Renal Failure The loss of appetite and the sense of taste are some of the common symptoms of renal failure. As a result, bodily wastes are retained in the blood that may become toxic to other tissues, including those in the gastrointestinal tract. People who have renal failure may also develop anemia and nerve damage, which may also play a role in smell and taste disorders. • The Common Cold (Respiratory Infections) The common cold or respiratory infections may lead to inflammation in the nose, swelling, and obstruction that may impair olfaction. Loss of smell might be temporary, lasting only a few days to a few weeks. Some people may report a longer or more permanent loss of smell that might be caused by inflammation of the olfactory neurons, a virus, or direct injury. A virus may attack the nerve cells without creating substantial inflammation in the nasal cavity. • Congestion The flavor of foods and beverages may be affected by nasal congestion, because this condition may prevent the aromas from reaching the sensory cells that detect and convey these odors. Specifically, the olfactory nerve may be unable to detect smells if the pathways are blocked. Nasal congestion may be due to allergic or nonallergic rhinitis, the common cold, flu or sinusitis. Also, the nasal passages may become blocked by a deviated septum or displacement of the nasal septum, nasal polyps (which are or painless, soft and noncancerous growths on the lining of the nasal passages), tumors, foreign substances or other factors. • Cushing’s Syndrome Endocrine disorders, such as Cushing’s syndrome, may result in alterations of smell or taste. Cushing’s syndrome is a hormonal disorder in which there is an excess of the hormone cortisol in the human body that is normally produced by the adrenal glands and controlled by the hypothalamus and pituitary gland. This may be the result of a tumor, or from high doses of glucocorticoids over time. Diabetes, hypertension or other complications may also be involved. Uncontrolled, Cushing’s syndrome may become life-threatening. • Diabetes Mellitus Olfaction and taste in people who have diabetes mellitus may be impaired and may become more acute in complicated diabetics. Diabetics may have impaired abilities to sense sucrose or glucose, which may result in higher sugar intake and exacerbate postprandial hyperglycemia. Dental and oral disorders and/or medications may also interfere and heighten this condition. People who have diseases in addition to diabetes may discover an even greater loss in smell acuity [34]. • Epilepsy Epilepsy, a group of neurological disorders characterized by epileptic seizures as a result of infections, injuries, stroke or tumors, may display smell or taste disorders. This may be due to the fact that different areas of the brain control all five of the senses (hearing, sight, smell, taste and touch), and also that seizures may affect emotions, movements and/or sensations. Simple partial seizures, whereby electrical disturbances are limited to a specific area of one side of the brain or cerebral hemisphere and consciousness is retained, may cause unpleasant tastes and strange and/or unpleasant smells—not to mention unusual and often unpleasant skin sensations, sounds and sights. • Gum Inflammation (such as Gingivitis or Periodontal Disease) If the gums or mouth become inflamed, then taste may be compromised. An example of a condition that might lead to oral inflammation is anemia, which may cause the tongue to be inflamed and interfere with taste. Taste sensations may return to normal once the inflammation subsides. Gingivitis in its mild forms, and periodontal disease in its more extensive forms, may be more complicated and interfere with taste even further. Gingivitis is a common and mild form of periodontal disease that may be caused by irritation, redness, and/or swelling of the gums around the base of the teeth. Unless controlled, gingivitis may lead to periodontal disease and tooth loss. Periodontal disease is a bacterial infection of the gums and bones in the mouth. Common symptoms may include bleeding, puffy or reddened gums that may recede or shrink and make the teeth appear longer and contribute to foul odor or taste, or loose or shifting teeth. • Head Trauma Head trauma, as one may experience in a car accident or a fall, may lead to brain injury and/or loss of taste or smell. Traumatic brain injury may damage the nasal passages or the nerves in the nose and mouth. The brain itself may also be injured. The areas of the brain responsible for the senses of taste and smell lay over bony protrusions within the skull that may be damaged during head trauma. Head trauma may also affect the nerves that transmit olfaction and taste that may contribute to temporary or permanent loss. • Hypothyroidism Taste and smell disorders are common olfactory disorders and abnormalities in hypothyroidism, an underactive or low thyroid, and may contribute to lack of interest in eating and/or anorexia. (Continued)

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TABLE 3.3

(Continued)

Hypothyroidism may also cause a primary taste disorder with usually normal olfactory function. Hypothyroid symptoms of cold sensitivity, constipation, dry skin, fatigue and unexpected weight gain may materialize before thyroid tests become abnormal. • Liver Disease/Cirrhosis Cirrhosis of the liver is a late-stage scarring or fibrosis of the liver that may be caused by many forms of liver diseases and conditions, including chronic alcoholism and hepatitis. Cirrhosis may be accompanied by olfactory loss. Alcohol intoxication may contribute to a stronger deficit in central nervous system processing of olfactory information than to peripheral lesions in the olfactory system. Olfactory dysfunction of this kind may be a subclinical indicator of hepatic encephalopathy, a brain disorder that may accompany advanced liver disease, and may also affect behavior, mood, movement, sleep and/or speech [35]. • Medications (as related to Medical Conditions) Over 250 drugs have been implicated with taste and olfactory decline. These include lipid-lowering medications, antihistamines, antimicrobials, anti-inflammatories, bronchodilators, antihypertensives, cardiac medications, muscle relaxants, antidepressants, anticonvulsants, vasodilators and others. Some zinc-based nasal sprays have been implicated with sudden and/or permanent loss of smell. Since the average American aged 65 years and older (one in six people) takes three or more medications daily, this practice may have a profound effect on taste and olfactory decline [36]. For more information about the medications that are implicated with taste decline, see the section Medications Implicated with Taste Decline that follows. • Multiple Sclerosis MS is an unpredictable and sometimes disabling disease of the central nervous system that may interfere with signaling and information exchange between the brain and the body. MS correlates with physical changes in the brain and sensory measures. Environmental exposures such as pathogens or smoking may exacerbate or trigger the inflammatory processes that may lead to MS. Olfactory tissues may be sensitive markers to the changes that occur throughout the body due to MS. Shortly after the onset of MS symptoms, the brain may undergo inflammatory changes, such as demyelination in the olfactory bulb and tract. The effects of MS on taste may involve higher brain structures. People with MS may lose their ability to distinguish different tastes. This condition may be associated with MS related brain lesions. As a result, people with MS may suffer from malnutrition since their loss of taste and smell may impact eating, food enjoyment and nutrition [37]. • Nutritional Deficiencies In Chapter 2, Nutritional and Physical Concerns in Aging, attention was given to potential nutrient inadequacies that may result during the aging process. Special vitamins and minerals may directly or indirectly affect the senses and may exacerbate the chemosensory changes that are associated with aging. These include vitamin E, folic acid, niacin, thiamin, vitamin B12 and zinc. Vitamin E is an antioxidant vitamin that protects the central nervous system. A vitamin E deficiency may lead to nerve damage that might affect the senses of smell and taste, as well as eyesight and touch, and/or contribute to muscle weakness. Vitamin E is found in dark leafy green vegetables, nuts, polyunsaturated fruit and vegetables oils, seeds, wheat germ and whole grains. Folic acid (folacin or folate) is a vitamin that is essential for DNA synthesis. It also assists in the formation of new cells in the human body. A folic acid deficiency may present as a reddened, smoothened tongue and result in a loss of taste sensations. Folic acid is abundant in enriched breads and cereals, foliage (green leafy vegetables), legumes, melons and oranges. Niacin (Vitamin B-3) is a vitamin that is responsible for the release of energy from carbohydrates. A niacin deficiency may lead to pellagra, a disabling disease that is associated with symptoms characterized by the “Four Ds”: depression, diarrhea, delirium and dementia. There is limited evidence suggesting that niacin in combination with vitamin A may ameliorate dysgeusia (loss of taste/metallic taste). Additional clinical research is needed. Niacin is plentiful in chicken, cooked potatoes, cottage cheese, fortified bran cereal, oatmeal, pork and Portobello mushrooms. Thiamin (vitamin B1) is a vitamin found in nut, legumes, pork, poultry and whole grains. Thiamin functions as a coenzyme in the release of energy. It is also involved in nerve function and appetite regulation. Thiamin occupies a special site on nerve cells. A deficiency of thiamin may interfere with normal taste sensations. Vitamin B12 (cobalamin) is a vitamin responsible for the maintenance of a healthy nervous system. It is found almost exclusively in foods of animal origin (such as eggs, fish, meats, milk and dairy products and poultry). Vitamin B12 is closely related to folic acid for the production (Continued)

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TABLE 3.3 (Continued) of red blood cells that carry oxygen. A deficiency of either vitamin B12 or folic acid is often linked with each other and to anemia. A vitamin B12 deficiency may also affect the nerves that carry taste sensations to the brain. Zinc is a trace mineral that is essential in several human body processes that include DNA synthesis, growth and development, immunity and wound healing and taste perception. A deficiency of zinc may lead to changes in appetite and taste. Zinc is found in dairy products, fish, legumes, meats, nuts, poultry, shellfish and whole grains. • Obesity Obesity is a disorder that concerns excessive, unhealthy body fat. Obesity may lead to alterations in the brain and nerves that control the peripheral taste system. It may modify or reduce the taste cells in the oral cavity, decrease the response to sweet stimuli, drive changes in the perception of the sweet taste and play a role in appetite and hunger control. Additional research is warranted to determine the exact mechanisms of appetite and hunger control, and what these changes may mean to longer-term obesity, taste and health issues [38]. • Parkinson’s Disease Parkinson’s disease is a disorder of the central nervous system that affects movement and often includes tremors. The sense of smell may be impaired in Parkinson’s disease and may be symptomatic of the disease during the early stages. This is similar for other neurodegenerative diseases such as Alzheimer’s disease. Olfactory testing may sometimes predict the future development of cognitive and motor dysfunction. The neurotransmitter acetylcholine plays a significant role in attention and the facilitation of cortical plasticity including recovery from brain injury and memory. This neurotransmitter and its system of operation may also be principally responsible for the smell dysfunction that occurs in connection with neurodegenerative disease [39]. • Polyps Nasal polyps are small, noncancerous growths in the nose and sinuses that may block the nasal passages. Nasal polyps can cause anosmia, or the absence of smell. Other factors may include nasal congestion from allergies, colds, poor air quality and/or sinus infections. Steroid nasal sprays and/or surgery may offer some relief. Once the normal course for odor detection is improved, then problems with the identification and enjoyment of odors may diminish or disappear. • Salivary Gland Infections All of the salivary glands empty saliva into the mouth through ducts that open into various places. Salivary gland infections may be due to bacteria or viruses that affect the salivary glands and their ability to produce saliva. This may be caused by blockage, chronic illness, dehydration, poor oral hygiene or smoking. Symptoms of salivary gland infections may include abnormal and/or foul tastes, decreased ability to open the mouth, dry mouth, fever, facial or mouth pain, redness or swelling. • Sinus Infections or Sinusitis The sinuses are cavities behind the cheeks, eyes, forehead and nasal bones that help to filter, moisten and warm the air that is inhaled into the body. The sinuses also act to open up space in the head and/or reduce pressure. If the miniscule holes that connect the sinuses to the nasal passages become clogged, then they may not drain properly and mucus may accumulate, which may produce inflammation, pain and pressure on the nerves. This inflammation may also affect the sense of balance. When the membranes in the nose are swollen, odor molecules may be prevented from reaching the smell receptors in the nose, thus reducing the sense of smell. Since the sense of taste also depends on the acuteness of the sense of smell, a decrease in the ability to smell due to sinusitis may also affect a person’s ability to taste at different levels. • Sjogren’s Syndrome Sjogren’s syndrome is an autoimmune disease that may be identified by the common symptoms of dry mouth and dry eyes. The mucous membranes and moisture-secreting glands of the eyes and mouth may be first affected, which then may interfere with and decrease the production of saliva and tears. Sjogren’s syndrome may accompany other immune disorders, such as lupus and rheumatoid arthritis. • Throat Infections (such as Strep Throat or Streptococcal Pharyngitis) Strep throat is a bacterial infection in the back of the throat and tonsils that is caused by Streptococcus or Strep A bacteria. Strep throat may cause symptoms such as enlarged lymph nodes, reddened and sore tonsils and/or throat, and sometimes tiny red spots on the roof of the mouth and white patches on the throat. While considered to be a common condition, strep throat and its accompanying maladies may decrease appetite and impair the sense of taste—a generally temporary state. • Tumors Occasionally, the loss of smell or taste may be the result of a tumor behind the nose, in the nasal canal, or in the membranes that surround the brain. Anosmia (partial or total loss of the sense of smell) may be caused by obstruction by the tumor, since it may impede airflow to the olfactory receptors. • Viral Hepatitis Viral hepatitis is a condition whereby the liver is inflamed due to a viral infection. Viral hepatitis may distort the sense of smell and lead to dysosmia (or distorted smell) when innocuous odors may smell disagreeable. This may result in nausea that is triggered by otherwise inoffensive odors. (Continued)

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(Continued)

• Viral Infections Some of the most common causes for temporary losses of smell and taste are due to viral infections or colds. Viral particles in the parotid glands in the mouth and nasal glands in the nose secrete various proteins. These proteins include growth factors that stimulate the stem cells of the taste buds and olfactory epithelial cells to initiate the growth and maturation of the olfactory epithelial cells and taste buds. This process may inhibit the synthesis of these proteins or alter their production so that they are no longer considered as normal. In turn, this condition may lead to cellular atrophy or apoptosis (programmed cell death), and the inhibition of smell and taste functions [40]. • Wernicke Korsakoff Syndrome Wernicke Korsakoff syndrome is a neurodegenerative disorder that may lead to dementia. It may be due to or an offshoot of alcoholism, certain cancers, severe intestinal problems, malnutrition and/or a lack of thiamine (vitamin B1). Wernicke Korsakoff syndrome may lead to permanent brain damage or even death.

MEDICATIONS IMPLICATED WITH DECLINE IN TASTE AND/OR SMELL As noted, certain medications may be associated with taste and/or smell disorders. Medications that are implicated with taste decline include lipid-lowering drugs, antihistamines, antimicrobials, anti-inflammatories, bronchodilators, antihypertensives, cardiac medications, muscle relaxants, antidepressants, anticonvulsants, and vasodilators. Medications such as these may affect salivation, smell and/or taste, and prompt people to alter their patterns of fluid and/or food consumption. The more medications that a person takes, along with poor food and beverage intake, might trigger concerns about the under-consumption of nutrients, nutritional deficiencies, potential weight loss and/or frailty Other consequences of taste decline may include excessive use of added fat, salt or sugar to compensate; exacerbation of preexisting conditions or disease states; polyuria (abnormally large volumes of dilute urine often in conjunction with polydipsia or increased thirst); incontinence; and/or overall functional decline among other conditions.

TASTE AND SMELL INTERACTIONS AND AFFECTS The interactions between taste and smell have the potential to affect the perception and selection of foods and beverages and their satisfaction, preferences, repeat choices, and ultimately appetite, satiety, nutritional status, health and well-being. When one or both of the senses of taste and smell are altered, any of these behavioral scenarios may be affected, from transiently to lastingly. For this reason, the sense of olfaction (smell) should be examined with as much rigor as the sense of gustation (taste).

Olfaction The sense of olfaction or smell is one that enables the perception of odors or scents. It requires the stimulation of chemosensory receptors in the nose by chemicals that are transported by inhaled air. In humans, chemoreceptors are situated in the olfactory epithelium, a patch of tissue located high in the nasal cavity. The olfactory epithelium is comprised of olfactory sensory neurons, supporting cells, brush cells and basal cells that replace olfactory epithelial cells as needed. Olfaction is important to detect odors and to interact with the sense of taste for food and beverage enjoyment. Damage may be the result of the inhalation of toxic fumes, physical injury to the interior of the nose or possibly abuse of some nasal sprays.

Olfactory Pathways The olfactory pathways are complex and not fully comprehended. Different scents such as odorant molecules may enter the human body through the primary pathway via the nose (the orthonasal route), or through the

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secondary pathway via the mouth and pharynx (the space between the nasal cavity and the mouth), called the retronasal route. Once these scents arrive into the nasal cavity, then the odorant molecules move into the nasal mucosa (the entire apparatus includes the mucous lining and olfactory epithelium with neural and supporting cells). Olfactory receptor neurons are contained within olfactory mucosa. These are responsible for scent transduction in the olfactory receptors that are located on the cilia at the ends of the neurons. There are about 1000 different kinds of olfactory receptors for an infinite number of scents. When scent molecules attach to these receptors there is a series of chemical reactions that occur. Electrical signals are sent via the axons of the neurons to the glomeruli (a spherical structure where synapses form among olfactory nerves) on the olfactory bulb that protrude from the brain. The olfactory bulb discriminates among odors, enhances the sensitivity of odor identification, filters background odors in order to augment the transfer of certain odors and permits higher brain areas to alter the identification or discrimination among odors. The olfactory sensory pathway may be pathologically affected in Alzheimer’s disease. In Alzheimer’s disease, neurofibrillary tangles and cellular loss have been discovered in the anterior olfactory nucleus [41]. Scent information is then communicated from the olfactory bulb with glomeruli to the primary olfactory cortex, then to the thalamus (a large mass of grey matter that both processes sensory information and relays it), and on to the orbito-frontal cortex. This is where mindful smell perception transpires. There is also a pathway that connects the thalamus to the amygdala (a part of the limbic system where scents are “felt”), and then further on to the hypothalamus where certain metabolic processes and other activities of the autonomic nervous system are conducted. The hypothalamus controls hunger and thirst among other critical functions. There is rarely a nonemotional response to scents because many may provoke old experiences and memories. The limbic system with the amygdala, epithalamus, hippocampus, mammillary body, thalamus and other organs may be particularly relevant in memory and processing [42]. In general, the conscious perception of sensory stimuli requires neurons in the thalamus and the cerebral cortex. The cerebral cortex is the outer layer of neural tissue of the cerebrum of the brain. It plays a vital role in attention, awareness, consciousness, language, memory, perception and thought. Most sensory information is routed to the cerebral cortex by way of the thalamus; however, sensory information also passes through the olfactory bulb to the olfactory cortex for processing. The cerebellum functions in motor control and in some cognitive functions that involve attention, fear, language and/or pleasure. It receives input from the sensory systems of the brain and spine, and while it does not initiate movement, the cerebellum contributes to accuracy, coordination and precision. It evaluates sensory information for actions by motor coordinates, such as the section of foods and beverages and the acts of eating and drinking. The human cerebellum changes with age, but it shows less age-related alterations than in the cerebral cortex, which shows atrophy of grey matter and decline in serotonin. The lungs are innervated by a variety of sensory nerves, and nerves of the parasympathetic and sympathetic nervous systems. They are responsible for important defense reflexes that help to defend the human body from airborne particulates and chemical irritants, such as environmental toxins [43]. The stomach also plays a role in sensory communication. The afferent fibers of the vagus nerve transmit sensory impulses from the stomach wall to the brainstem. The efferent fibers send impulses from the brainstem to the stomach. The nerve endings in the epithelium lining of the stomach may be able to detect changes within the stomach and transmit impulses to the brainstem, enteric nervous system and/or spinal cord. If chemicals are present, or the stomach is irritated or stretched, then these sensory nerve endings may influence the enteric, parasympathetic or sympathetic nerves. Accidental chemical ingestion, excessive consumption or unusual acidity may be causative [44].

Olfactory Loss Versus Taste Loss Olfactory loss is potentially greater than taste loss for the following reasons. Olfaction depends on one nerve, while three nerves transmit taste sensations: the facial nerve (cranial nerve VII) that innervates the anterior

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two-thirds of the tongue; the glossopharyngeal nerve (cranial nerve IX) that innervates the posterior one-third of the tongue and another cranial nerve (vagus nerve X) that carries taste information from the back of the mouth [45]. Olfactory receptors are lodged in small sinus area, while taste receptors are located throughout the entire oral cavity and beyond. Olfactory receptors are directly exposed to toxins, while taste receptors are protective when the mouth is closed. Both olfactory and taste receptors are affected by dentures, poor chewing, saliva, swallowing and a host of other factors.

Types of Taste Loss While total taste loss is relatively uncommon, partial taste loss may be mistaken or overlooked since it may be a matter of olfactory decline. The categories of potential taste loss follow: • Ageusia is the complete loss of the ability to taste. It is very rare due to the surplus gustatory innervation of the tongue. • Dysgeusia is an impaired taste sensation, and is often bitter or metallic. • Hypergusia is enhanced gustatory sensitivity. • Hypogeusia is the partial loss of the ability to taste.

Types of Smell Loss The sense of smell that declines with age is referred to as presbyosmia. It is generally not preventable; however, it may also be an expression of overall health. It seems that people who have “aged well” without medications may have normal smell thresholds. As with taste, there are different degrees of potential loss of smell that include: • Anosmia is the lack of the ability to smell. • Dysomia is an impairment of the ability to smell that may be caused by alcoholism, changes in the nose, in the nerves that lead from the nose to the brain, or in the brain; craniocerebral trauma, depression, olfactory nerve diseases, poor oral hygiene, schizophrenia, smoking, viral respiratory tract infections, or other conditions. • Functional anosmia is the significantly reduced ability to smell. • Hyperosmia is the enhanced ability to smell. • Hyposmia is the reduced ability to smell. • Specific anosmia is the inability to smell a particular odor [46].

CONSEQUENCES OF CHEMOSENSORY DECLINE Since both taste and smell contribute to flavor, olfactory deficits may affect the flavor of foods and consequently food intake, the diet and overall nutrition and health status, particularly during aging. Combined with cognitive and motivational factors, the complex multisensory aspects of chemosensation and flavor perception are crucial for identifying and treating the loss of smell and taste. Such factors as diseases, early food and beverage experiences, individual genetic variations, infections, injuries, medications and current diet should be taken into account. Sensory-specific satiety is a decrease in the pleasantness of a food as it is consumed. It declines with aging and may contribute to limited food and beverage choices. If the sense of smell and taste decline with aging, and these impairments combine with alterations in the food intake regulatory mechanism, the risks for nutritional deficiencies may increase [47].

HOW OLFACTORY DYSFUNCTION AFFECTS NUTRITION STATUS The degree of taste or smell loss may affect nutritional status (e.g., body weight and immunity) and wellbeing. Chemosensory changes in taste and smell may modify the sensory attributes of food and alter food preferences. In turn, these changes may affect appetite and satiety and further influence food selection and nutritional status.

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In essence, chemosensory dysfunction may affect what a person thinks about a food or beverage; what a person chooses to do about a food or beverage; how a person feels about consuming or not consuming a food or beverage again; and how a person continues to think, choose and feel about a food or beverage in the future. Self-rating of olfactory dysfunctions may also interplay. If people think that their sense of smell and taste are intact, then they may display certain food preferences or behaviors. Conversely, if people think that their sense of smell or taste is compromised, then they may exhibit other behaviors [48].

HOW ADULTHOOD AFFECTS NUTRITIONAL STATUS Various physiological and unique changes and conditions of adulthood may be intensified by chemosensory dysfunction, and may affect nutritional status by altering eating habits and reducing nutrient availability and absorption. This may lead to nutritional deficiencies that may manifest into various health problems. Some of these may include body composition reconfigurations, brain function variations, dehydrations irregularities and/ or digestive system changes.

Body Composition Reconfigurations Loss of bone density may increase the risk of osteoporosis and falls. The loss of lean body mass, or sarcopenia, may lead to a gain in body fat and a reduction in total body water content. This may bring decreased endurance, functional decline and/or loss of strength. With declined taste and smell, there may be inadequate bone nutrients and protein from the diet and available for bodily functions.

Brain Function Variations The adult brain is less efficient to train and to retrain with new information. For this reason, adults may find it more difficult to welcome newer tastes. They may also be conditioned by their past “programming,” or how they perceived different foods and beverages when they were younger. There also may be change in the hypothalamus that relay fullness. The aging brain may communicate satiation much quicker. As a result, appetite dysregulation may occur. Consuming scheduled small meals and snacks that are a combination of complex carbohydrates, healthy fats and lean proteins may help to remind individuals when to eat and how much, and foster better appetite and satiety.

Dehydration Irregularities Dehydration is the depletion of body water content due to decreased fluid intake, fluid losses or a combination of both conditions. Aging people are easily dehydrated because there may be a change in the mechanism in the brain that relays what we need to drink. This disorder may result in reduced thirst sensation and decreased fluid consumption. This condition may be due to changes in hormones and neurotransmitters, particularly a depletion of dopamine (a neurotransmitter that is involved in thirst induction). Additionally, renal water conservation may be impaired in aging kidneys. This is because aging kidneys may be less able to concentrate urine and retain water during water deprivation. There may also be age-related lower responsiveness to the antidiuretic hormone by the kidneys and lower ability to regulate sodium excretion. Medications for blood pressure and cardiac conditions, ACE inhibitors, diuretics and laxatives may compound these effects. So may limitations in comprehension and communication disorders, reduced mobility and/or reduced swallowing capacities. Environmental factors such as warm temperatures, poor attention by care providers and medical procedures that require electrolyte depletion or fasting may also put the aging at higher risks of dehydration. These conditions may become life threatening and should be conducted under the watchfulness of medical specialists [49].

Digestive System Changes Various changes may occur throughout the digestive system during aging. To begin, older people tend to wear dentures that may affect the way that food is masticated and taste is perceived. Additionally, aging adults

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may have less saliva to cleanse the tongue, lubricate the oral cavity, facilitate swallowing and carry flavors. Saliva contains enzymes that are needed to commence the digestion of starches. Decreased saliva may lead to slower peristalsis and constipation that may affect appetite. Furthermore, there may be decreased gastric acid secretion that may limit the absorption of iron and vitamin B12. Both of these nutrients are abundant in animal protein. If people lose their interest in meats, in particular, due to chemosensory changes, then nutrients such as these may be compromised. Aging adults may also have fewer enzymes for digestion. Finally, there may be shrinkage of the number of nerves in the stomach, the number of pacemaker cells that produce coordinated muscle contractions during digestion and smooth muscle. This may result in decreased capacity of the stomach to relax if there is dietary restriction [50].

Malnutrition Malnutrition in the aging may lead to poor wound healing, muscle weakness that may lead to falls and fractures, and a weakened immune system that may increase the risk of infections. In addition, unattended malnutrition may contribute to further disinterest in eating and/or lack of appetite. The root of malnutrition in the aging may be chemosensory decline.

Sensory Alterations Sensory alterations may affect the appetite in many ways. Vision loss may make food procurement, preparation, eating and drinking more challenging. Diminished senses of taste and smell may likely make some foods and beverages less appealing. Hearing loss may diminish the sounds that some foods and beverages make, such as crackle, crunch, pop, fizzle, slurp or splinter. Tactile loss may steal away sensations of ranges such as astringency and pucker, cooling and warming, dryness and smoothness, and bite, burn, numbing, prickle and/or pain. However, maturity may also bring the appreciation of robust flavors, such as anchovies, game, pickled foods and/or sour cheeses. Perhaps this is due to dulled tastes from alcohol, medications or smoking, or to the fact that those who are aging may be more tolerant of pungency [51].

DIGEST It is well established that there is a decline in practically all body systems with aging, the sensory system included. Unless addressed by modifiable efforts, these reductions may compromise life quality, reduce longevity, affect personal economic stability and/or burden health care. Sensory factors, including how foods and beverages taste and smell, may affect nutritionally modifiable health disorders, and either improve or lessen food and beverage consumption, nutritional status and/or health. It may be cavalier to suggest that if aging people eat better by including the most sensorial foods and beverages, then they will ward off certain conditions and/or diseases, and their quality of life will improve. It may be more plausible to consider all of the implications of sensory changes with aging, and whether or not they truly have practical significance; if food choices and decreased diet quality are genuinely altered, and as a result, if aging people become more prone to certain chronic conditions and/or diseases. Some of these chemosensory changes from aging may be addressed one on one. In larger-scale care settings and/or community-based programs, the reality of individualized approaches may be slim. In order to ascertain the incidence and relevance of chemosensory changes with aging, it may be prudent to first ask the following questions before implementing some of the ingredients and techniques that are featured throughout the remaining chapters of this text. These include: 1. Does the aging process cause identifiable changes in chemosensory functions? 2. Do sensory changes that are aligned with aging people translate into modifiable food choices and dietary behaviors? 3. Do sensory changes from aging cause differences or increased nutritional and/or health risks? 4. Are there relationships among the aging, chemosensory functions and increased foodborne illnesses? (i.e., Does the inability to taste or smell miss potential pathogenic organisms?) [52]

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Once greater understanding and answers to these questions are achieved, it may then be appropriate to develop protocols and action steps to more sensorially feed this aging demographic.

MANNER OF SPEAKING Acetylcholine (ACh) Acidic (Sour) Taste Ageusia

Allergic Rhinitis (Hay Fever) Amygdala Alzheimer’s Disease Anosmia Antidiuretic Hormone Appearance Appetitive Taste Asthma A-Streptococcus (Strep A Bacteria)

Audition

Autonomic Nervous System (ANS)

Aversive Taste Balance (Equilibrioception or Vestibular Sense) Behavioral Factors of Aging Bell’s Palsy

Benign Paroxysmal Positional Vertigo (BPPV) Bitter Taste Blindness Bronchial Asthma

organic chemical that functions in the brain and body as a neurotransmitter to send signals to other cells one of the five basic tastes that is sensed via ion channels loss of taste functions of the tongue; may be due to inflammation, local damage, neurological changes and/or problems with the endocrine system allergic response that causes itchy, watery eyes and/or sneezing, similar to the common cold rough-shaped mass of gray matter inside each cerebral hemisphere; concerned with experiencing emotions irreversible, progressive disease that destroys ability to carry out simple tasks, memory and thinking skills loss of the sense of smell, either partial or total; may be caused by blockage of the nose, head injury or infection small peptide molecule that is released by the pituitary gland; helps the kidneys manage body water manner that someone or something looks; affects food and beverage preferences pertains to appetite; characterized by a natural desire to satisfy the need to drink or eat condition whereby airways become inflamed, narrowed and/or swollen, with extra mucous; presents difficulty breathing species of Gram-positive bacteria found on the skin and in the throat; causes range of infections including scarlet fever and strep throat power or sense of auditory perception through vibrations and changes in surrounding mediums across time, via organs such as ears part of nervous system responsible for control of body functions without consciousness, such as breathing, digestion and/or heartbeat strong disinterest in taste(s) due to poisonous substances, rotten or spoiled beverages or foods or toxic substances result of the vestibular system, visual system and proprioception working together in equilibrium modifiable risk factors that include alcohol use, BMI, diet, health practices, physical activity level and/or smoking status facial paralysis that results in inability to control facial muscles; symptoms may include inability to move certain parts of the face, muscle twitching and/or weakness common cause of vertigo; sudden sensation of spinning often triggered by changes in head position one of the five basic tastes; a distinctive taste that often signals harshness, such as from coffee and some cruciferous vegetables state of being totally sightless in both eyes condition in which airways become inflamed, narrow and swollen with extra mucous; increases breathing difficulties

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Bronchitis

Cataracts Cellular Atrophy (Apoptosis) Central Nervous System Cerebral Cortex

Cerebellum

Cerebrum

Chemesthesis Chemoreception Chronic Renal Failure (Chronic Kidney Disease)

Chronic Rhinosinusitis (CRS) Cirrhosis of the Liver (CL)

Cochlea

Congestion Common Cold (Respiratory Infection) Conjunctivitis (Pink Eye) Cornea Cornu Ammonis Cortisol Cushing’s Syndrome (Hypercortisolism) Deafness (Hearing Impairment) Dehydration

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inflammation of the lining of the bronchial tubes; causes chest tightness, cough that emits mucous, shortness of breath and/or wheezing clouding of the normally clear lens of the eye; common cause of vision loss in older people programmed cell death as a controlled and normal stage of an organism’s growth or development complex of nerve tissues that control the body’s activities; in humans, the brain and spinal cord largest region of the cerebrum in the human brain; plays key roles in attention, awareness, cognition, consciousness, language, memory, perception and thought area in back and bottom of the brain; involved in higher levels of action and thinking; coordinated sensory input with muscular responses most anterior part of the brain in from of the skull; responsible for integration of sensory and neural functions; coordinates voluntary activities chemical sensitivity of the mucous membranes and skin when chemical compounds activate particular receptors process by which organisms respond to chemical stimuli in their environments; primarily depends on senses of smell and taste condition characterized by a gradual loss of kidney function over time; often result of diabetes, high blood pressure, glomerulonephritis and/or polycystic kidney disease disease that involves long-term inflammation of the nasal and paranasal sinus mucosa complication of liver disease; involves loss of liver cells and irreversible scarring of the liver; common causes alcohol and viral hepatitis B and C spiral cavity of the inner ear; receives sounds in the forms of vibrations that are converted into vibrations, nerve impulses and interpreted by the brain blockage of nasal passages; often due to swelling of membranes that line the nose common illness often caused by viral infection of the upper respiratory tract; primarily affects the nose infection or inflammation of the thin clear tissue that covers the eyeball and/or the inner eyelid outermost transparent layer of the eye that covers the anterior chamber, iris and pupil; plays important role in focusing vision the hippocampus of the brain; part of the limbic system; plays roles in the consolidation of information and memory steroid hormone produced by adrenal glands; related to stress response; works to control fear, mood and motivation rare condition from exposure to high levels of cortisol over time; sometimes due to synthetic hormone medication total or significant loss of hearing condition when losses of body fluids exceed the amounts that are consumed; often with accompanying disruption of metabolic processes sideways displacement of the wall between the nostrils; makes one nasal passage smaller, may block airflow and cause breathing difficulty

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Detection Threshold Diabetes Mellitus

Dopamine Dysosmia Dysgeusia Dry Eye Entorhinal Cortex Enteroendocrine Cells

Environmental Factors of Aging

Epiglottis Epilepsy

Esophagus Exteroceptive Senses Five Basic Tastes Flavor Floaters Flavor Gestalt “Four D’s” (Depression, Diarrhea, Delirium and Dementia) Functional Anosmia G protein-Coupled Receptors (GPCRs) Galactose Gastroesophageal Reflux Disease (GERD)

Gingiva/Gingivitis Glaucoma Glomeruli Glucose

lowest concentration at which a compound may be detected; associated with the ability to smell or taste group of metabolic disorders when production or response to the hormone insulin is compromised; results in abnormal carbohydrate metabolism and elevated glucose levels in the blood and urine chemical messenger; functions as neurotransmitter in the brain distortion or qualitative alteration of the perception of the sense of smell distortion of the sense of taste; associated with ageusia (lack of taste) and/or hypogeusia (decrease in taste sensitivity) condition that occurs when tears are not able to provide sufficient moisture area of the brain located in the medial temporal lobe; functions in memory and navigation specialized cells found within the gastrointestinal tract, pancreas and stomach; release signaling molecules that activate nerve fibers factors that may accelerate the aging process that influence cellular damage or interfere with repair; include chronic infection, inflammation, metallic chemicals and/or ultraviolet light flap of cartilage at the root of the tongue; depressed during swallowing to cover the opening of the trachea or windpipe neurological disorder; marked by sudden, repeated incidents of sensory disturbances or seizures; may lead to loss of consciousness fibromuscular tube that connect the throat (pharynx) with the stomach senses that perceive the human body’s motion, position and state (the proprioceptive senses) bitter, salty, sour, sweet and umami (savory); along with taste receptor cells help to create taste sensations sensory impressions of beverages, foods and other substances; determined by smell, taste and other sensory input small flecks of collagen that condense in the vitreous fluid that fills the posterior of the eye entire sensory impressions of flavor; integrates smell, taste, texture, temperature and other factors conditions that may be characteristic of niacin (vitamin B3) deficiency inability to perceive odor as a result of functional debility proteins that mediate physiological responses to environmental stimulants hormones and neurotransmitters simple sugar; found in nature combined with other sugars as lactose (in milk); also in polysaccharides and glycolipids digestive disease in which the stomach acid or bile irritates the lining of the esophagus; may cause acid indigestion or heartburn inflammation of the gums or gingiva; commonly due to bacteria or film of plaque that accumulates on the teeth group of diseases that damage the eye’s optic nerve; may result in vision loss and blindness cluster of capillaries, nerve ending, or spores; one capillary network around end of kidney tubule where waste products filter simple sugar; also blood sugar; important energy source

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MANNER OF SPEAKING

Glucosinolates Glutamate (Glutamic Acid) Gum Inflammation (Gingivitis) Gustation (Taste)

Gustatory Cortex Gustatory System

Head Trauma Hearing (Audition or Auditory Perception) Heat Stroke (Sun Stroke) Hepatic Encephalopathy Hyperosmia (Acute Olfaction) Hippocampus Hypergusia Hypogeusia Hyperosmia Hyposmia Hypothalamus

Hypothyroidism Interoceptive Sense Iris

Kinesthesia

Kokumi Korsakoff’s Psychosis

Labyrinthitis Lactase Lactose Lewy Body (Vascular Dementia)

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natural sulfur-containing components of pungent plants such as cabbage, horseradish or mustard; potential antibiotic effects amino acid present in many protein foods; main excitatory neurotransmitter in the brain inflamed gum tissue characterized by redness, swelling and sometimes bleeding one of the five traditional senses detected by the human body; develops through the interaction of dissolved molecules with taste buds structure within the brain that is responsible for the perception of taste and flavor sensory system responsible for taste and flavor perception; comprised of taste cells in the mouth, cranial nerves and the gustatory cortex trauma to the brain, scalp or skull ability to perceive sounds by detecting vibrations and changes in the pressure of a surrounding medium through the ear condition of severe hyperthermia or overheating; body temperature of 104 F (40 C) or higher syndrome of cirrhosis; loss of brain function when a damaged liver does not remove toxins from the blood increased olfactory acuity (heightened sense of smell); may cause discomfort and/or illness, such as migraines region of brain primarily associated with memory; located under the cerebral cortex enhanced gustatory sensitivity reduced ability to taste increased olfactory acuity reduced ability to smell and detect odors region of forebrain below thalamus; coordinates the ANS and pituitary activity; controls body temperature hunger, thirst and other bodily functions condition in which the thyroid gland does not produce enough of the thyroid hormone; may result in slower metabolism sense of the physiological conditions of the human body; might provide foundation for emotions, feelings and/or self-awareness pigmented muscular circular structure in the eye; responsible for controlling the size of the pupil and amount of light that reaches the retina awareness of the position and movement of the parts of the body; mediated by sensory organs (proprioceptors) in the joints and muscles full-bodied flavor described as “hearty”; thought to make foods feel richer and more satisfying disorder caused by thiamine deficiency; may produce manifest as alcoholic Korsakoff syndrome, beriberi or Wernicke encephalopathy inner ear disorder; inflammation of the inner ear or nerves that connect the inner ear to the brain enzyme that catalyzes the hydrolysis of lactose to galactose and glucose a double sugar composed of galactose and glucose; present in milk and some other dairy products protein deposits that affect brain chemicals; result of a series of small strokes that deprive the brain of oxygen; third most common cause of dementia AGING, NUTRITION AND TASTE

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Limbic System

Lower Esophageal Sphincter Malnutrition

Mandible Maxilla Mechanoreceptors Meniere’s Disease Mild Cognitive Impairment (MCI)

Multiple Sclerosis (MS) Myelin

Nasal Glands Nasal Mucosa Nasal Polyps National Institute on Deafness and Other Communication Disorders (NIDCD) Neural Gustatory Pathway

Neurons Nociception (Physiological Pain) Obesity Oleogustus Olfaction (Smell or Odor) Olfactory Bulb Olfactory Cleft Olfactory Epithelium Olfactory Nerve Olfactory Receptor Neurons or Olfactory Sensory Neuron Optic Nerve

complex system of nerves and networks in the brain near the edge of the cortex; concerned with instinct and mood; controls basic emotions and drives bundle of muscles at the lower end of the esophagus; prevents acid and stomach contents from regurgitating condition that results from an inadequate diet with either too little or too much of some nutrients; may lead to a host of health problems jaw or jawbone in lower jaw jaw or jawbone in upper jaw sense organ or cell; responds to mechanical stimuli as sound or touch inner ear disorder; causes episodes of vertigo, fluctuating hearing loss, ringing in the ear (tinnitus) and/or pressure intermediate stage between expected cognitive decline of normal aging and more serious clines as in dementia; may involve judgment, language, memory and/or thinking changes disease that cause demyelination (disruption of myelin sheath) of spinal nerves and brain cells mixture of phospholipids and proteins; forms a whitish insulating sheath around nerve fibers; increases speed of impulse conduction seromucous glands within the respiratory region of the nasal mucous membrane mucous membrane; moist tissue that lines the nasal cavity; bathed by secretions from the nose soft, painless, noncancerous growths on lining of nasal passages or sinuses (see Chapter 12: Prime Time Resources for Aging, Taste and Health). route for sensory information about gustation (taste) to be transmitted from the nose, skin and/or tongue to the brain for perception and interpretation specialized cells that transmit nerve impulses normal neural processing of pain; occurs when free nerve endings are activated by inflammation or tissue damage condition or disorder that involves excess body fat; contributes to over-fatness and risks of health problems taste for certain types of fats, such as linoleic acid found in nuts and vegetable oils process of chemoreception; forms the sense of smell neural structure of the vertebrate forebrain; essential to olfaction narrow chamber that lies on each side of the nasal septum at the top of the nose where the olfactory membrane lies sheet of cells that line part of the nasal passages; contain the olfactory receptors first cranial nerve; transmits impulses to the brain from the smell receptors in the mucous membranes of the nose transduction cell in the olfactory system; bind to odor molecules and cause different activations that result in unique odor profiles cranial nerve II; transmits visual information from the retina (back of the eye) to the brain for interpretation

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Oral Cavity

Orbito-Frontal Cortex Organ of Corti (Spiral Organ) Orthonasal Route Oropharynx

Ossicles Otoliths Outer Ear (External Ear)

Oval Window

Overheating Pain Receptors (Cutaneous, Somatic and Visceral) Papillae (Circumvallate, Filiform, Foliate and Fungiform) Parasympathetic Nervous System

Parotid Glands Parethesia Parkinson’s Disease

Periodontal Disease Peripheral Nerve

Pharynx

Physical Factors of Aging

Postprandial Hyperglycemia Presbycusis Presbyopia

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areas of mouth that include the bony roof of mouth (hard palate), cheeks, floor of the mouth below the tongue, front twothirds of the tongue, gums, lining of the lips and teeth prefrontal cortex area located in the frontal lobes of the brain; responsible for cognition processing of decision-making sensitive basilar membrane in inner ear; supports transduction of auditory signals into nerve impulses through vibrations olfaction that is detected through the nose part of the pharynx at the back of the mouth behind the oral cavity; includes back third of the tongue, side and back walls of the throat, soft palate and tonsils very small bones in the middle ear; serve to transmit sounds from the air to the cochlea three small oval bodies in the inner ear; involved in sensing gravity and movement external portion of ear; consists of auricle (pinna) and ear canal; collects sound energy; directs it to the tympanic membrane (eardrum) connective tissue membrane; leads from the middle ear to the vestibule in the inner ear; involved in transmittance of sound vibrations to make or become over hot free nerve endings; warn of potentially harmful changes in the environment, such as excessive pressure or temperature small protuberances found on the inside of the cheeks, epiglottis, soft palate, upper esophagus and upper surface of the tongue one of three divisions of the ANS; sometimes called the rest and digest system; conserves energy, increases intestinal and glandular activities, relaxes sphincter muscles in the gastrointestinal tract and slows heart rate pair of large salivary glands in front of each ear abnormal sensation without apparent cause; such as numbness, pricking tickling or tingling disorder of the central nervous system that affects neurons in specific area of the brain; affects movements; often includes tremors gum infection that damages gums; caused by bacteria in dental plaque; may destroy jawbone used to describe the peripheral nervous system; network of motor and sensory nerves that connect the brain and the spinal cord (the central nervous system) to the human body the membrane lined cavity behind the mouth and nasal cavity and above the esophagus and larynx; passageway down to the stomach and lungs physical aspects of aging that may include changes in body composition, the brain and nervous systems, blood circulation and the heart, falls, immobility, metabolic diseases and/or sensory changes excessive glucose (blood sugar) in the bloodstream; associated with diabetes mellitus common sensorineural hearing loss; caused by natural aging of the auditory system farsightedness; caused by loss of elasticity of the lens of the eye; often occurs with age

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Primary Olfactory Cortex (Piriform Cortex) 6-n-propylthiouracil (PROP) Pupil Recognition Threshold Retina Retinal Disorders Retromolar Trigone Retronasal Route Salivary Gland Infections

Semicircular Canals

Senses

Sensitive Tasters Sensory Alterations Sensory-Specific Satiety

Sight (Vision) Simple Partial Seizures (Focal Aware Seizures) Simple Sugar Sinonasal Cancer (Sinonasal Undifferentiated Carcinoma [SNUC]) Sinuses/Sinusitis

Sjogren’s Syndrome

Smell (Odor or Olfaction)

Social Factors of Aging

Sodium (Na) Sodium Chloride (NaCl)

all brain regions that receive direct input from the olfactory bulb chemical compound; probe for genetic variation in the bitter taste opening in center of iris in the eye; permits light to strike the retina level whereby a stimulus is detected and recognized as certain tastes sensory membrane at rear of eyeball with light sensitive cells; senses light and sends signals to the brain for sight disorders that affect vision and may cause blindness; examples include diabetic eye disease and macular degeneration oral cavity subsite; the region behind the wisdom teeth; carcinoma of this region often invades the mandible olfaction from odors released in the oral cavity while consuming foods and/or beverages infections that occur when bacterial or viral infections affect the salivary glands or duct; may result from blockage, inflammation and/or reduced saliva flow three bony channels filled with fluid; located in the inner ear; produce information about orientation to the brain; helps maintain balance five natural powers (hearing, seeing, smelling, tasting and touching) that provide information about factors such as balance, body position, pain, smell, taste, temperature and others people who are more sensitive to certain or all tastes more than others; may have more taste buds alterations in the senses that may cause other senses to compensate; such as taste and smell sensory phenomenon; declining satisfaction that is produced by eating a certain type of food; renewed satisfaction from exposure to new food or flavor the ability or power of seeing; one of the five natural powers along with hearing, smelling tasting and touching brief seizure that starts in one area of the brain carbohydrates that are quickly absorbed by the body to produce energy; galactose, glucose and fructose rare cancer of the nasal cavity and/or paranasal sinuses cavity within a bone or tissue in the face or skull that is connected with the nasal cavities; when inflamed, the condition is called sinusitis (rhinosinusitis or sinus infection) condition whereby the mucous membranes and moisturesecreting glands of the eyes and mouth decrease in tears and saliva chemoreception that creates the sense of smell; follows when odorants bind to specific sites on olfactory receptors in the nasal cavity factors that include age, companionship, education, family/marital status, income/wealth, race/ethnicity, religious/spiritual beliefs, sexual orientation, and work/employment/ volunteerism. mineral that is essential to life; maintains body’s fluid balance essential compound for absorbing and transporting nutrients, maintaining blood pressure, maintaining fluid balance and others; table salt

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Somatosensory System

Sounds

Somatosensation Somatosensory Cortex Specific Anosmia Strep Throat (Pharyngitis) Supertaster Sweating (Perspiration) Sweet Taste

Sympathetic Nervous System (SNS) TAS2R38 Gene

Tastants Taste (Gustation) Taste Buds Taste Pores Taste Receptors

Taste Threshold Tearing

Temperature Texture Thalamus

Thermoreception Receptors Tinnitus Touch (Somatosensory, Tactition or Mechanoreception)

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part of the sensory system; involved with intentional perception of movement, pain, position, pressure, temperature, touch and vibration vibrations that travel through the air or other mediums; can be detected when they reach the ear and are transmitted for hearing process that conveys information about the body surface and its interaction with the environment area of the brain that is located in the parietal lobe; processes sensory input from the joints, muscles and skin the inability to perceive a specific odor while olfactory perception is otherwise intact bacterial infection of the back of the throat including the tonsils; precipitated by group A streptococcus individual who experiences tastes with more intensity than ordinary; may be very sensitive to bitter tastes production of fluids that are secreted by the sweat glands; helps to regulate body temperature basic taste; commonly perceived in sweet foods, such as desserts and some beverages; may be very satisfying since glucose (a simple sugar) is essential to life part of the ANS; activates the “fight or flight” responses a human gene that encodes a bitter taste receptor; regulates the bitterness perception and differentiation of ingested nutritional and poisonous substances taste-provoking chemical molecules; dissolved in ingested liquids or saliva a flavor and a feeling that is produced by beverages or foods in the oral cavity; a chemosensation as is smell (olfaction) small organs on the tongue that contain taste receptor cells; function in the perception of taste small openings in the tongue epithelium; where parts of food dissolve in saliva and come into contact with taste receptors type of receiver that helps to facilitate the sense of taste; tastant molecules interact with saliva and bind to these receptors in the oral cavity and other locations concentration of a solution that is needed to identify a defined quality of taste to tear; may be accompanied by light, temperature or wind changes in the environment, or be the sign of a blocked tear duct or an eye infection measure of coldness or hotness; expressed in terms of scales, such as Celsius (C) or Fahrenheit (F) the appearance (visual), consistency and/or feeling (tactile) characteristics of a substance or surface large mass of grey matter in dorsal part of the brain; relays sensory signals to cerebral cortex; regulated alertness, consciousness and sleep free nerve endings that are located in the hypothalamus, liver, skeletal muscles and skin perception of noise or ringing in the ears one of the five senses, along with hearing, seeing, smelling and tasting; allows humans to receive information about external and internal environments for sensory perception

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Trigeminal Nerve/senses (Fifth Cranial Nerve or CN V) TRPM5 Tympanic Membrane (Eardrum)

Umami Taste Vagus Nerve (Pneumogastric Nerve, Tenth Cranial Nerve or CN X) Vestibular System Vestibular Nerve

Viral Hepatitis Viral Infections Vision (Sight) Visual Memory Wernicke Korsakoff Syndrome (Wernicke’s Encephalopathy or WKS)

nerve that is responsible for pain-temperature-touch sensations in the face, and motor functions that include biting and chewing cation channel; essential for transduction of bitter, sweet and umami tastes thin, cone-shaped membrane, that vibrates in response to sound waves and transmits them to the auditory ossicles in the tympanic (middle-ear) cavity the fifth basic taste of savoriness; characteristic of protein foods such as meats and seafood nerve that runs from brain through face and thorax to the abdomen; mixed nerve with parasympathetic fibers sensory system that provides information about balance and spatial orientation eighth pair of cranial nerves; transmits sensory impulses from the organs involved in hearing and balance in the inner ear to the brain liver inflammation from a viral infection in acute or chronic forms viruses that case infectious diseases; include the common cold, flue and warts one of the five senses; ability to see the environment via visible light and interpret the perceptions form of memory that preserves the recollection of visual images; critical in reading and writing neurological disorder; caused by a thiamine (B-vitamin) deficiency; may manifest as changes to eyes and/or nose and confusion

References [1] National Prevention Health Promotion and Public Health Council. Healthy aging in action. Advancing the national prevention strategy. Washington (DC): US Department of Health and Human Services, Office of the Surgeon General; 2016. ,https://www.cdc.gov/aging/ pdf/healthy-aging-in-action508.pdf. [accessed 14.09.18]. [2] Fulkerson M. Rethinking the senses and their interactions: the case for sensory pluralism. Front Psychol 2014;5:1426. Available from: https://doi.org/10.3389/fpsyg.2014.01426 PMID: 25540630. ,http://udel.edu/Bbcarey/ART307/project1_4b/. [accessed 14.09.18]. [3] US Department of Health and Human Services, National Institutes of Health, National Institute on Deafness and Other Communication Disorders. Age related hearing loss, ,https://www.nidcd.nih.gov/health/age-related-hearing-loss.; 2018 [accessed 31.08.18]. [4] Menuism. Does the way we see food affect its taste? HuffPost, The Blog. ET Updated Dec 06, 2017. ,http://www.huffingtonpost.com/ Menuism/does-the-way-we-see-food-affect-taste_b_1872204.html.; 2012 [accessed 31.08.18]. [5] Scientific Psychic. Anatomy and structure of human sense organs, ,http://www.scientificpsychic.com/workbook/chapter2.htm. [accessed 31.08.18]. [6] Herter TM, Scott SH, Dukelow SP. Systematic changes in position sense accompany normal aging across adulthood. J Neuroeng Rehabil 2014;11:43. Available from: https://doi.org/10.1186/1743-0003-11-43 PMID: 24666888. ,https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3974196/. [accessed 14.09.18]. [7] Steenhuis I, Poelman M. Portion size: latest developments and interventions. Curr Obes Rep 2017;6(1):10 17. Available from: https:// doi.org/10.1007/s13679-017-0239-x Springer PMID: 28265869. [8] Reader’s Digest Editors. Sharpen your sense of smell and taste, Reader’s Digest, ,http://www.rd.com/health/wellness/sharpen-yoursense-of-smell-and-taste/. [accessed 31.08.18]. [9] L Heller. Food temperature affects taste, reveal scientists, ,https://www.beveragedaily.com/Article/2005/12/19/Food-temperatureaffects-taste-reveal-scientists.; 2005 [accessed 14.09.18]. [10] Society of Sensory Professionals. Flavor flavour, ,https://www.sensorysociety.org/knowledge/sspwiki/Pages/Flavor%20Flavour. aspx. [accessed 31.08.18]. [11] Schacter D. Psychology. 2nd ed. Worth Publishers; 2009978-1-4292-3719-2. p. 169. Boron WF, Boulpaep EL. Medical physiology. 1st ed. Elsevier Science USA; 2003. Kean S. The science of satisfaction. Distillations Magazine 2015;1(3):5. How does our sense of taste work? PubMed Health, ,http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072592/.; 2012 [accessed 05.04.16]. DE Silverthorn. Human physiology: an integrated approach. 5th ed. [chapter 10]. p. 354. [12] National Library of Medicine, National Institutes of Health, Informed Health Online. How does our sense of taste work? PubMed Health; 2012. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG) 2006. [13] Roper SD. The taste of table salt. Pflugers Arch 2015;467(3):457 63. Available from: https://doi.org/10.1007/s00424-014-1683-z PMID: 25559847. ,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4326615/. [accessed 31.08.18].

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[34] Hilson R. Taste and smell in diabetes. Pract Diabetes 2014;31(7):269 270a. ,http://www.practicaldiabetes.com/wp-content/uploads/ sites/29/2016/03/Taste-and-smell-in-diabetes.pdf. [accessed 31.08.18] Naka A, Anton L. Clinical significance of smell and taste disorders in patients with diabetes mellitus Arch Otorhinolaryngol 2010;267(4):547 50 ,https://www.researchgate.net/publication/ 26892415_Clinical_significance_of_smell_and_taste_disorders_in_patients_with_diabetes_mellitus. [accessed 31.08.018]. [35] Temmel AF, Pabinger S, Quint C, Munda P, Ferenci P, Hummel T. Dysfunction of the liver affects the sense of smell. Wien Klin Wochenschr 2005;117(1 2):26 30. [36] Barrett LL. AARP knowledge management, prescription drug use among midlife and older Americans, Data collected by the Roper Public Affairs & Media group of NOP World, ,https://assets.aarp.org/rgcenter/health/rx_midlife_plus.pdf.; 2005 [accessed 31.08.18]. [37] Morton CC. Sniffing out demyelination, multiple sclerosis discovery forum—new findings, ,http://www.msdiscovery.org/news/new_findings/11556-sniffing-out-demyelination.; 2014 [accessed 31.08.18]. [38] Maliphol, AB, Garth, DJ, Medler, KF. Diet-induced obesity reduces the responsiveness of the peripheral taste, ,http://www.plosone. org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0079403. [accessed 27.03.14]. [39] Doty RL. Smell and the degenerating brain, The Scientist, ,http://www.the-scientist.com/?articles.view/articleNo/37603/title/Smelland-the-Degenerating-Brain/.; 2013 [accessed 31.08.18]. [40] Taste and Smell Clinic, Center for Molecular Nutrition and Sensory Disorders. How viruses inhibit taste and smell function and what can we do about it? ,http://www.tasteandsmell.com/jul06.htm.; 2006 [accessed 31.08.18]. [41] Esiri MM, Wilcock GK. The olfactory bulbs in Alzheimer’s disease. J Neurol Neurosurg Psychiatry 1984;47(1):56 60 ,https://www. ncbi.nlm.nih.gov/pubmed/6693914. [accessed 31.08.18]. [42] University of Calgary. Mod 8, the olfactory system, the olfactory pathways, ,http://www.ucalgary.ca/pip369/mod8/smell/pathways. [accessed 31.08.18]. [43] Lee L-Y, Yu J. Sensory nerves in lung and airways. Compr Physiol 2014;4(1):287 324. Available from: https://doi.org/10.1002/cphy. c130020 ,http://www.comprehensivephysiology.com/WileyCDA/CompPhysArticle/refId-c130020.html. [accessed 31.08.18]. [44] Dr. Chris. Stomach nerves—vagus nerve, celiac and enteric plexus, HealthHype.com, ,https://www.healthhype.com/stomach-nervesvagus-nerve-celiac-and-enteric-plexus.html. [accessed 31.08.18]. [45] Delicious, scrumptious, delectable, mouth-watering, yummy. That’s tasty. ,https://faculty.washington.edu/chudler/tasty.html. [46] Hummel T, Landis BN, Hu¨ttenbrink K-B. Smell and taste disorders. GMS Curr Top Otorhinolaryngol Head Neck Surg 2011;10:Doc04. Available from: https://doi.org/10.3205/cto000077 PMID: 22558054. ,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341581/. [accessed 31.08.18]. HealthOsphere. Dysomia: what exactly are “phantom smells”? Healthosphere.com, ,https://healthosphere.com/ dysomia-what-exactly-are-phantom-smells/.; 2015 [accessed 14.09.18]. [47] Rolls BJ. Do chemosensory changes influence food intake in the elderly? Physiol Behav 1999;66(2):193 7 ,https://www.researchgate. net/publication/12962885_Do_Chemosensory_Changes_Influence_Food_Intake_in_the_Elderly. [accessed 31.08.18]. [48] Duffy VB. Smell, taste and somatosensation in the elderly. In: Chernoff R, editor. Geriatric nutrition, the health professional’s handbook. 2nd ed. Gaithersburg (MD): Aspen Publishers, Inc.; 1999. p. 195. [49] h4h Initiative. Hydration in the aging risks, ,http://www.h4hinitiative.com/h4h-academy/hydration-lab/hydration-aging/risks. [accessed 31.08.18]. [50] Hoffman A. Does dieting actually make your stomach shrink? Smithsonian.com, ,https://www.smithsonianmag.com/science-nature/ does-dieting-actually-make-your-stomach-shrink-180955521/.; 2015 [accessed 31.08.18]. [51] The Guardian. Changing tastes: food and ageing, ,http://www.theguardian.com/lifeandstyle/wordofmouth/2013/jan/29/changingtastes-food-and-aging. [accessed 31.08.18]. [52] Mattes RD. The chemical senses and nutrition in aging: challenging old assumptions. J Am Diet Assoc 2002;102(2):192 6 ,https://jandonline.org/article/S0002-8223(02)90047-7/fulltext. [accessed 14.09.18].

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4 A Taste Primer

PHOTO: EVOO. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: My sense of smell has diminished, but I still have my sense of taste. I have lost my sense of sharpness, which is good and bad. L.C.

O U T L I N E Summary

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How Taste Is Produced and Perceived

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Introduction

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Synopsis of the Five Basic Tastes

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The Sense of Taste

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Highlights of the Five Basic Tastes

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Bitter (Bitterness)

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Taste Opposition/Antagonism

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Supertasters and the Bitter Taste

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Taste Juxtaposition

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The Bitter Taste in Depth Methods to Combat the Bitter Taste Methods to Add the Bitter Taste 6-n-Propylthiouracil

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Taste Augmentation

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How the Sense of Smell Affects the Sense of Taste

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Salt (Saltiness)

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Sour (Sourness)

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Sweet (Sweetness)

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How the Senses of Sight, Sound and Touch Affect the Sense of Taste Sight Sound Touch

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Umami

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Fat and Other Proposed Tastes Fat Calcium Carbonation Electrical Hydroxide Kokumi Lysine Minerals Polycose Protein Pyrophosphates Soapy Starchy

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Taste and Health

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Taste Decline and Loss

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Taste Thresholds

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Aging Tastes

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Oral Disease

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Use of Medications

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Behavioral Changes

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Improving the Sense of Taste

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Treatment of Taste and Smell Disorders

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Temperature and Touch

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Strategies for Addressing Chemosensory Changes

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Taste Enhancement Taste Combinations for Balance Other Taste Balances Ingredients That Activate Taste Balance

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Digest

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Manner of Speaking

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LEARNING OBJECTIVES 1. Describe the taste pathway and how it is affected by the physiological changes associated with aging. 2. Differentiate among the five basic tastes with regards to taste and flavor perception and how they change throughout the aging process. 3. Recognize which of the basic tastes complement and which compete for taste, flavor and enjoyment. 4. Relate how the senses of smell, sight, sound and touch affect the sense of taste and which changes are furthered affected by aging. 5. Associate taste decline with aging, disease and health and align promising age-appropriate improvements.

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SUMMARY To purposely examine the sense of taste in the aging, how this sense interacts with the sense of smell and what may be done to compensate for decreased overall taste or specific taste losses in the aging.

INTRODUCTION The sense of taste is mutually physiological and psychological, scientific and gastronomic, intense and mild, pleasing and distasteful, essential to health and the enjoyment of foods and beverages and a possible indicator of aging, disease, injury, and/or various conditions that may affect well-being or woe. Compared to the complexities of the sense of smell, the sense of taste, at the offset, is fairly straightforward. Chemical substances in the mouth come into contact with nerve cells that are activated by alterations of specific proteins in the walls of the sensory cells. The sensory cells then transmit messenger substances that activate nerve cells. Then the nerve cells transmit information for specific flavor perceptions on to the brain where they are interpreted and even felt [1]. When the sense of smell interplays with the sense of taste, and the other senses of sight, sound and touch interact, then the sense of taste amplifies into the impression of flavor. And it is this impression of flavor that dictates the acceptance or rejection of foods and beverages that ultimately determines health and well-being. Certain tastes combine sensibly and tastefully; other taste combinations contrast and conflict, while still other taste amalgamations seem to please, but are dependent upon individual preferences. This chapter covers the basics of taste combinations with particular attention to aging tastes, and offers suggestions for waning tastes when foods and beverages lose appeal. It also addresses the introduction of new tastes and the emotionality involved in taste loss, rejected tastes and acceptance. Examples of changes in taste and taste enhancements are explored, along with recommendations and applications for home-based and institution care settings.

THE SENSE OF TASTE The sense of taste, or gustation, is one of the five basic senses of sight, sound, smell, taste and touch. Taste is what one commonly confuses with flavor, which is a combination of all of the basic sensations and more features that will be revealed later in this chapter and throughout this text. As currently recognized, the sense of taste dates back to prehistory when sensory cells were essential to detect safe and/or toxic environment environmental substances—not dissimilar from chemosensory functions today. Through natural selection, receptor proteins evolved to respond to various chemicals and other stimuli. As life continued to evolve and humans were fashioned with mouths, noses, digestive organs and brains, the sense of taste became even more paramount for survival. Our human predecessors chose or avoided foods and beverages for hunger, and to some degree satisfaction. As human brains evolved and humans were able to process what they consumed, they were better able to discern tastes, smells and a variety of sensations. Still, the neural pathways that are followed to detect taste and smell are linked with the most primitive areas of the brain. Thanks to the evolution of the human body; the culture in which humans evolved, the changes in human diets, the use of tools in the preparation of foods and beverages, taste, smell and flavor considerations became dominant issues in food selection, preparation, nutrition, health and survival. Evolution depended upon the survival of the fittest, and the fittest depended on their sense of taste to drive their food choices. As the brain further developed, it was able to recollect associations, emotions, memories and thoughts to propel future choices—nutritious or otherwise. The five basic tastes of acidic (sour), bitter, salty, sweet and umami (savory), and their interactions interplay to help make food and beverage selections tasteful or distasteful to each of us [2].

HOW TASTE IS PRODUCED AND PERCEIVED Taste is created when a substance inside of the oral cavity reacts chemically with receptors within taste buds, called gustatory calyculi, which are concentrated on the tongue, but are also located on the sides, roof and back of the mouth, the epiglottis, esophagus, nasal cavity and even within the upper digestive tract. AGING, NUTRITION AND TASTE

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The human tongue is covered with papillae with sensory cells. Papillae are small bumps on the mucous membrane of the tongue that contain hundreds to thousands of taste buds, the organs by which the sense of taste is transduced. This is where taste is transformed into nerve signals. In the middle of each of the taste papillae is a small indentation filled with fluid. Chemical substances involved in nerve transmission enter this space before foods and beverages continue the digestion process. There are three main types of taste papillae: circumvallate papillae, foliate papillae and fungiform papillae. Circumvallate papillae are located at the back of the tongue by the throat. There are only 7 12 circumvallate papillae, yet each of them may contain several thousand taste buds. When the mouth is opened, the circumvallate papillae appear to be arranged in a “V” formation that is surrounded by glands that move the chemical substance into the sensory cells. Foliate papillae are located in the back and along the edges of the tongue and appear as closely aligned folds. Each of the 20 foliate papillae contains many hundred taste buds. Fungiform papillae are the most common of the three types of papillae. There are about 200 400 fungiform papillae, each with about 3 5 taste buds throughout the tongue’s surface, mostly at the tip of the tongue and at the edges. These papillae detect taste and also may sense temperature and touch. Younger adults have a total of about 2000 4000 taste buds throughout the papillae. The sensory cells that are contained within these taste buds may be renewed after a few weeks. This is particularly notable if a person “burns” the roof of his mouth on hot soup or pizza, then regains his sense of taste sometime later. With aging, this process may not be as rapid. Taste receptors may decline or decease at variable and individualized rates as will be discussed later in this chapter. Many cranial nerves serve to transfer the sensations of taste to an area in the lower section of the brainstem called the medulla oblongata. Then some fibers transmit taste signals and other sensory signals such as pain, temperature and touch to help enable their perception. Other fibers transmit taste signals to areas of the brain that register sensory perception, which is necessary for survival. This is where taste or gustatory signals combine with smell or olfaction signals, and why these combined senses are inextricably linked to human health and well-being. The sense of taste is very vulnerable to nutritional status, particularly malnutrition, which may affect the turnover of taste bud cells and the integrity of taste receptors. Generally speaking, the overall health of an individual influences taste and may affect future consumption experiences. Ultimately, the sense of taste combines with the sense of smell (olfaction) and trigeminal nerve stimulation (which registers pain, temperature and texture) and collectively help to determine flavors: the comprehensive sensory impressions of foods, beverages and other substances [1].

SYNOPSIS OF THE FIVE BASIC TASTES The five basic tastes (bitter, salty, sour, sweet and umami) have been recognized through the identification of taste receptors for each of these tastes. Controversy exists as to if other human tastes exist, and/or if these experiences are more textural in nature. The reason the taste buds have the ability to differentiate among the five basic tastes is because they interact with different molecules or ions, and are particularly sensitized to these interactions. The bitter, sweet and umami tastes are activated by connecting molecules to G protein-coupled receptors located on the cellular membranes of the taste buds. The salty and sour tastes are identified when alkali metal or hydrogen ions enter the taste buds. Controversy exists as to whether individual neurons respond to a single tastant and to only one taste quality, or to more than one taste. This may be because the neurological response to one tastant may be stronger than one or more other stimuli. However, some studies show that both central gustatory and peripheral neurons typically respond to more than one type of stimulus. The responses to different-tasting stimuli that generate unique patterns of activity over a spectrum of neurons may be revealing [3].

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HIGHLIGHTS OF THE FIVE BASIC TASTES Each of the five basic tastes will be highlighted, along with their identification, description and function; where they are present in foods, beverages and ingredients; and what happens to each of these five basic tastes with aging. A summary of the five basic tastes is shown in Table 4.1. TABLE 4.1 Basic Tastes and Food Sources Basic tastes

Food sources

Sweet

Bananas, carrots, corn, grapes and onions

Salty

Bacon, cheese, ham, oysters and soy sauce

Bitter

Beer, coffee, deep leafy greens, rosemary, walnuts and wine

Sour

Buttermilk, citrus fruits, rhubarb, sour cream and yogurt

Umami

Aged cheese, mushrooms, peas, seafood and soy sauce

From Marcus JB. Culinary nutrition: the science and practice of healthy cooking. Elsevier; 2014. p. 55.

BITTER (BITTERNESS) Perhaps the most sensitive of the basic tastes is the bitter taste, or bitterness, which some find as disagreeable, sharp or unpleasant. Sensitivity to the bitter taste is an inherited trait (see discussion of 6-n-propylthiouracil (PROP) that follows). To many other people, the bitter taste is bearable when it is weak, and it offers multidimensionality to beverages, foods, ingredients and recipes. Bitterness also warns the human body that some substances, such as toxins, may be dangerous to consume. Women vary in their ability to taste bitter. They tend to be heightened responders to the bitter taste during pregnancy—likely to protect the fetus. This sensitivity may continue throughout menopause, then wane throughout the remaining lifetime. Plant-derived alkaloids and glycosides tend to be bitter. Consider the bitterness of caffeine and nicotine that may be toxic in higher quantities, and particularly strychnine, a poison that was once prescribed as a heart remedy. However, there are many taste receptors for the bitter taste so that humans may be broadly and quickly aware of potential toxins. Unfortunately, the bitter taste is also what prevents some individuals from consuming very nutritious bitter foods, such as broccoli, cranberries, grapefruits or kale. While cranberries are not a vital food or beverage in the human diet, they do offer many nutritional benefits. For example, cranberries are so naturally astringent, bitter and tannic that they are usually blended with some type of sweetener to offset these sensations. Yet, the phytonutrients in cranberries offer antioxidant and anti-inflammatory benefits and might be helpful for avoiding urinary tract infections. Plus, astringency and tannic qualities tend to be feelings, not tastes. Thus, suppressing the bitter taste of cranberries may be beneficial to some people.

SUPERTASTERS AND THE BITTER TASTE Individuals with the genotypes of hTAS2R38 PAV/PAV, PAV/AVI and AVI/AVI are considered as “supertasters”: people with extreme sensitivity to bitter tastes in foods and to manufactured compounds such as phenylthiocarbamide (PTC) and PROP, which is mostly used in research. People who have inherited PAV from one parent and AVI from another parent are considered as “medium tasters,” and people who are AVI/AVI in genotypes are considered as “nontasters” who are insensitive to bitter tastes. Having the supertaster genotype may influence food choices, but it does not mean that bitter foods and beverages will always be rejected. If supertasters are repeatedly exposed to the bitter taste, especially within the context of complementary ingredients, such as a little fat or salt, and at the most optimal temperatures, then they may be educated to consume some nutrient-rich bitter foods and/or beverages.

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Supertasters may have a higher density of papillae on the tongue than nontasters. This may render their tasting mechanisms more sensitive than individuals with less papillae tongue density. For this reason, some supertasters may also “taste” fat, salty, spicy and sweet sensations to a greater extent that those with fewer papillae. Similarly, supertasters tend to avoid high-fat and very-sweet foods and tend to consume less food overall. Caucasians appear to be more prominently bitter tasters than Asians and West Africans, where nontasters appear to be more dominant. Taste “blindness” is prevalent in India, where about one-half of the residents are unable to detect as bitter such chemicals as PTC. When it comes to the bitter taste, the threshold for what is acceptable to what is not acceptable may vary from person to person, since there is such a wide range of individual taste variances. This may be due to age, behavioral, cultural, educational, environmental, gender, inherited taste factors and a host of other reasons. There may not be one bitter taste profile that fits every individual, but a range that is aided by functional foods and beverages that contain phytonutrients with a broad spectrum of chemopreventive benefits [4]. Since supersensitive taste may influence what certain people choose to consume, it befits people who are responsible for food selection and preparation to provide a wide range of food and beverage options. In particular, supertasters tend to eschew strongly flavored foods and beverages such as beer, coffee and bold red wines, and oral irritants such as black pepper, chili pepper and ginger. They also do not tend to crave fats or sugars, which partially explains why some supertasters may be on the slimmer side. Thus, milder and simpler tasting foods and beverages may be better appreciated. From a health standpoint, supertasters tend to have better cholesterol profiles than average, and reduced risk of coronary heart disease. But they may not consume enough bitter-tasting vegetables with phytonutrients that are thought to be cancer-protective.

THE BITTER TASTE IN DEPTH Multiple receptor and transduction mechanisms have been proposed to elucidate the bitter taste in humans. These include the tongue and extra-oral tissues that include some internal organs such as the airways, brain, gut and even the testis. Other than the functions of the bitter taste in the oral cavity, it may function in such areas as appetite control, the control of airway innate immunity, the regulation of gastrointestinal motility and the treatment of asthma [5]. Bitter compounds include amino acids (proteins, such as fish, meats or poultry); esters (fruit, such as banana, pineapple or strawberry); flavonoids (phytonutrients, such as berries, red wine or tea), glucosinolates (cruciferous vegetables, such as broccoli or Brussels sprouts); lactones (dairy products, such as milk or butter); methylxanthines (alkaloids, such as caffeine or tea); peptides (short amino acid chains, such as eggs, milk or soybeans); phenols (chemical compounds found in fruits, such as apples, berries or citrus fruits); polyphenols (plant-based compounds, such as cocoa, legumes or nuts); salts (minerals such as sodium or potassium or their derivatives); sulfimides (sulfur-containing chemical compounds, such as saccharine); and terpenes (fragrant oils, such as menthol).

Methods to Combat the Bitter Taste Some people may be bitter-taste aversive and not necessarily supertasters (see following discussion on 6-npropylthiouracil (PROP)). A way to combat the bitter taste is to add counterpart tastes. For example, the bitter taste may be alleviated by any of the measures shown in Table 4.2. TABLE 4.2 Ingredients to Help Suppress the Bitter Taste • Bitter—such as a piece of lemon or orange peel in coffee or chocolate, or citrus zest on cooked green vegetables (e.g., mustard greens or kale) • Fat—such as butter on cruciferous vegetables (e.g., broccoli or Brussels sprouts), or cream in coffee or tea • Salt—such as salted water for blanching bitter greens (e.g., cabbage or collards), or a coarse-grained finishing salt after cooking • Sour—such as a squirt of lemon on vegetables in the Brassicaceae family (e.g., cauliflower or kohlrabi), or a lemon wedge with tea • Sugar—such as a sprinkle of agave, fruit juice, honey or maple sugar on bitter salad greens (e.g., arugula or radicchio)

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The reasons why some of these taste combinations work to help camouflage bitterness is that acidity tends to soften tannic bitterness, fat tends to round the sharp edges of bitter tastes, and salt tend to suppress the bitterness in green leafy vegetables.

Methods to Add the Bitter Taste Adding a little bitter taste to sweetness tends to soften the flavor (consider bittersweet chocolate). Or caramelizing a bitter ingredient in a little oil or butter (consider saute´ed broccoli or Brussels sprouts) may help bring out its sweetness and round out its flavor. Even slightly cooking a bitter food by boiling, grilling, roasting or steaming may help to offset bitterness or heighten its flavor—in a pleasurable manner (consider grilled eggplant or squash). As the sulfurous smell is released, the bitterness tends to dissipate. To add the bitter taste to foods, beverages and other substances, consider the addition of items that feature acridity (bitingness, pungency or sharpness): alcohol, ale, beer, bitter gourd, bitter orange, angostura bitters, broccoli, Brussels sprouts and other plants in the Brassicaceae family, coffee, dark chocolate, escarole, extra-virgin olive oil, grapefruit, herbs, hops, mate, citrus peel, collards, dandelion and other bitter greens, lager, olives, quinine, red wine, smoke, sulfur, tea, unsweetened cocoa, watercress, wild chicory and others. To add bitter notes in food preparation, consider bitter garnishes (such as the herbs basil or parsley); caramelized sugar; bittersweet-sour fruit jellies (such as crabapple, cranberry, elderberry or plum); capers or olives; cocoa, horseradish, lemon, lime or orange zest; or spices (such as a dusting of cinnamon or nutmeg).

6-n-Propylthiouracil PROP, used as a thyroid medication that tastes like quinine, is also a bitter marker compound of supertasters. The genetically determined ability to taste PROP has been linked with decreased acceptance of some bitter foods and beverages that may last a lifetime. People who are identified as PROP tasters tend to perceive PROP and PTC as moderately to intensively bitter, whereas nontasters tend to perceive these compounds as relatively tasteless or weak. Higher responders to PROP are associated with greater bitterness perception of caffeine and naringin (from grapefruit); greater oral sensation from ethanol; and more intensity of pungent spices such as capsaicin (chili pepper) and zingerone (ginger) [6]. Personality factors may also play a strong role in food preferences among PROP sensitive tasters. Food neophobia (fear of trying novel foods) may be associated with lower preferences for alcoholic beverages and certain assertive ingredients, such as chili peppers, ginger or horseradish It is speculated that PROP tasters who are more food “adventurous” may learn to appreciate bitter fruits and vegetables, hot and pungent condiments and strong alcoholic beverages over the years more so than less adventurous PROP tasters. In fact, food adventurous PROP tasters may be able to behave more like nontasters in their appreciation of a wide variety of foods and beverages that may continue with aging. This suggests that there may be many personal attributes and varying individual preferences that should be taken into account when designing or preparing foods and beverages for taste-sensitive individuals, and when tailoring their diets and meal plans. Contrariwise, food adventurousness, as defined by culture and family in childhood, may dissipate during adulthood. Nevertheless, some approval for phytochemical-rich fruit and vegetables may emerge with acceptability, age, exposure, open-mindedness and/or renewed venturesome attitudes. In reality, as adults age into their later years, often the opposite happens: they become more set in their ways and unadventurous consumers. For this reason, techniques such as the ones discussed in Chapter 9, Culinary Considerations for the Aging, and Chapter 10, Menus and Recipes That Appeal to Aging Palates, may help to persuade even the most challenging older consumers that bitter-tasting foods and beverages are healthful, tasteful and useful dietary components [6].

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SALT (SALTINESS) The taste of salt or saltiness is essential to life. On its own, salt may taste biting, briny or puckery. In combination, salt may enhance other tastes, mask “off” tastes and round out flavor, while it improves flavor intensity. There are few naturally salty foods. Most salty foods and beverages are manufactured and many were probably first created for food preservation. Salt may trigger both appetitive and aversive behavior responses. Appetitive behavior responses tend to increase the appetite for sweet and umami-rich foods, such as naturally sugary fruits and savory meats. Aversive behavior responses tend to protect humans from consuming potentially poisonous animals and plants, so often associated with the bitter and/or sour tastes. This is why the salty taste is both useful on its own and for its interaction with other tastes [7]. Generally speaking, the less salt that is used, the more salt that is tasted. It may take sometime to disassociate from a higher salt diet to a lower one—and to then enjoy its subtleties. Oversalting foods may dull our perceptions of the other four basic tastes. Very salty foods, such as salt pork or salted fish as in Portuguese bacalao (codfish), usually require blanching, dilution or soaking to remove much of the saltiness. Sweetness appears to help lessen the perception of saltiness (and vice versa), while bitterness and umami tend to increase the awareness of saltiness. A small amount of sourness may emphasize saltiness. For example, a squirt of lemon or lime on seafood may bring out the saltiness of the water from which the seafood was procured. The taste of salt or saltiness is primarily created by the passage of sodium (Na1) ions through sensitive channels. Other ions of alkali metals [lithium (Li1), potassium (K1), rubidium (Rb1), cesium (Cs1) and francium (Fr1)] may also have a salty taste, but generally less so than sodium ions. The saltiness of substances is typically compared to sodium chloride (Na1Cl2), which equates to “1.” Potassium chloride (K1Cl 2) is commonly used in salt substitutes. Common foods with salty tastes include anchovies, bacon, canned soups, cold cuts and cured meats, olives, Parmesan cheese, pickles, salted nuts and other snacks, sausages, sea salt, seaweed, soy sauce, tomatoes and tomato products. Salty notes in cooking may be provided by a variety of sea salts (with and without herbs and spices); capers, gherkins or olives; matured Blue cheese such as Roquefort or Stilton; meat, poultry or vegetable stock; Parmesan cheese; preserved artichoke hearts; soy or teriyaki sauce; smoked fish such as haddock or salmon (lox); and/or tomato products. With aging, the perception of saltiness may decrease, which may translate into the desirability for saltier foods and/or beverages. This practice may have ramifications with regard to blood pressure and hypertension, with greater strain on the arteries, brain, heart and kidneys and a propensity toward dementia, heart attacks, kidney disease and/or stroke. Preparing and enjoying foods and beverages with less salt while preserving flavor is essential. Table 4.3 provides some examples. Other ideas will be given later in this chapter. TABLE 4.3 Ingredients That Help Balance the Salty Taste Salty taste pairings

Ingredient combinations

Bitter 1 salt (and fat)

Green leafy vegetables, grapefruit, tomatoes, watermelon 1 cheese (e.g., feta or Parmesan)

Sour 1 salt

Sourdough bread Sour salt (citric acid)

Sweet 1 salt

Honey-roasted nuts Chocolate-dipped pretzels Prosciutto-wrapped melon

Umami 1 salt

Chicken or miso soup Bacon or ham

Umami 1 sweet 1 sour 1 salt

Barbeque sauce Teriyaki sauce

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SOUR (SOURNESS) The sour taste or sourness is the taste responsible for detecting acidity. In fact, the terms sourness and acidity are often used interchangeably. Sour has the capability of creating a “mouthwatering sensation” because when a sour food enters the mouth with more acidity than saliva, saliva tends to flood the mouth to help to dilute the acidity. The sour taste also communicates that foods such as fruits and vegetables are not at their peak, and that they need more time for their natural sweetness to develop. While babies may be able to detect sour, they are typically sour adverse, and may prefer sweeter tastes. This may be a measure of natural selection whereby babies seek to protect their developing teeth from acid erosion, and their immature gastrointestinal tracts from too much acidity. Organic and inorganic acids are perceived as sour, likely due at the molecular level to acid-sensing ions and proton-selective ions. Sourness is scored in relation to dilute hydrochloric acid, which equates to “1.” Other acids in comparison to hydrochloric acid are carbonic acid with a sourness index of 0.06, citric acid with a sourness index of 0.46 and tartaric acid with a sourness index of 0.7. The sour taste is detected by a small subset of taste buds through the expression of the protein PKD2L1. The protons that are found in sour substances may directly enter the sour taste cells on the tongue, and may trigger electrical responses in the brain. Weak acids, such as acetic acids, are capable of activating this response. Hydrogen ions that are released by acids directly enter the taste cells on the tongue and trigger electrical signals to the brain. The pH of a substance, or the concentration of weak acids, plays an important role in how sour a beverage, food or ingredient tastes. In the food industry, the acidity level of foods and beverages is measured on a scale from zero to fourteen, using seven as a midpoint. This is the pH scale that indicates the concentration of hydrogen ions. A pH lower than seven is considered to be acidic. A pH higher than seven is considered to be alkaline. A pH of seven is considered to be neutral. The lower the pH, then the higher the acidity and the converse is also true: the higher the pH, then the lower the acidity. Since water has a pH of seven, it may be used to “cleanse” the mouth and return it to neutral if it has been bathed in a very acidic or alkaline substance. Examples of acidic foods and beverages include black coffee, citrus juices (such as lemon, lime, orange and/or tomato), milk and tea. Examples of alkaline substance include ammonia, baking soda, blood and milk of magnesia. Common sour tastes include citrus fruits such as lemon and lime, rhubarb, sorrel, tamarind, vinegar, yogurt and wine. Sour notes in cooking include citrus juice, fruit preserves such as lemon or orange marmalade, salsa, sour cream or sour dipping sauces such as sweet and sour sauce or “cocktail” sauce. The use of acidity in cooking helps to make foods taste “brighter” or fresher. Sometimes a squirt of lemon or lime is all that is needed to bring out the food flavors in meats or vegetables; or a simple vinaigrette dressing to enliven yet soften bitter salad greens, or a tomato-based sauce to accompany protein foods, such as beef or poultry. Some combinations of ingredients that intermingle the sour tastes with other basic tastes and ingredients are shown in Table 4.4. TABLE 4.4 Sour Taste Combinations and Ingredients in Common Food Preparations • Sour 1 fat—such as in vinaigrette salad dressing (e.g., Greek or Italian dressings) • Sour 1 herbs 1 spices—such as in marinades (e.g., lemon or vinegar with garlic, fragrant herbs and pepper) • Sour 1 hot 1 salt—such as in hot sauce (e.g., salsa or sriracha sauces) • Sour 1 salt—such as in pickled vegetables (e.g., pickles or sauerkraut) • Sour 1 sweet—such as in Asian cuisine [e.g., sweet and sour sauce, coconut-lime soup, pad Thai with sweet vegetables, sweet jasmine rice with kimchi (fermented cabbage)]; or yogurt sauce [e.g., raita with Indian curries or tzatziki sauce with falafel (chickpea patties)]

In reading a recipe or menu, descriptor words, such as cultured, fermented or pickled and ingredients that include grapefruit, lemon, lime, orange, rhubarb, vinegar, tamarind, or yuzu usually mean that a dish, food or ingredient contains or is prominent in the acid taste.

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Too much acidity may also be a warning sign of food spoilage. Consider a wine that has become too acidic or vinegary, or dairy products that age beyond their “use date.” Food spoilage is usually caused by microbes and by their ability to multiply. A range of factors that include oxygen, pH, temperature and water are all considerations. Every microbe has a minimum and optimum pH range for growth. Usually foods with a pH level less than 4.5 (and thus are more acidic) are less susceptible to bacteria spoilage.

SWEET (SWEETNESS) The taste of sweet, or sweetness, is primarily a pleasurable sensation (except in excess), and is largely derived from foods and beverages that contain some type of sugar. The sensory appeal of sweetness is innate commonly universal. The foods and beverages that activate the sweet taste are typically simple carbohydrates or sugars in the forms of glucose, fructose and sucrose to be metabolized for energy, and complex carbohydrates in the form of starches for energy or storage. The sweet taste is also often produced by the presence of D-amino acids, coumarins, dihydrochalcones, glycosides and modified sugars, peptides, proteins, selected salts, substituted aromatic substances, ureas and other nitrogenous compounds. The sweet taste that results may be the product of an exchange of hydrogen ions. The sensation of sweetness is frequently connected to aldehydes and ketones with a carbonyl group. It is identified by a range of G protein-coupled receptors that are joined to the G protein gustducin on the taste buds. Two different variants of sweet receptors or more must be activated for the brain to identify the sweet taste. Mostly all of the sensations of the sweet taste are the result of the bonding to two different receptors: T1R2 1 3 (heterodimer) and T1R3 (homodimer). The taste thresholds for the sweet taste are scored in relation to sucrose, which equates to “1” [8]. Tastes, ingredients and cooking techniques that serve to counterbalance sweetness to combat its occasional cloyingness are shown in Table 4.5. TABLE 4.5 Ingredients and Cooking Techniques That Counterbalance Sweetness • Bitterness or spiciness—use cinnamon, cocoa, nutmeg or vanilla for their bittersweet tastes with some spicy notes • Browning—use the Maillard reaction or Maillard browning (sugars that are heated in the presence of amino acids in protein foods) for sweetness plus nuttiness and some roasted notes • Caramelization—use the transformation of granular white sugar into golden brown syrup for sugary-bitter notes • Fattiness—use fragrant oils, such as avocado, olive or walnut for their fullness and some bitter notes • Sourness—use semiripe fruit, such as apples, nectarines or pears, for their sweet and sour tastes and fresh notes; or use citrus juices, vinegars, yogurt or wine for their sweet and sourness and tangy notes

Classic combinations of sweet and sour (such as Asian sweet and sour sauce); sweet and fat (such as some rich and sweet bakery items); and sweet and bitter (such as some bittersweet chocolate varieties) are common examples of how the blends of sweetness and other basic tastes can be employed by chefs, home cooks and food manufacturers for flavor enjoyment. Common sweet tastes may be found in the following foods and substances: bananas, berries, breadstuffs, butter, cake and pastries, caramel, cinnamon, cream, dates, honey, maple syrup, milk chocolate, nutmeg, peas, parsnips, ripe apples, scallops, vanilla extract and the many guises of sugar. Sweet notes may be achieved in cooking and baking by adding pureed sweet root vegetables such as beets, carrots, celeriac (celery root), parsnips and/or sweet potatoes; sweet fruits such as bananas, dates, pears or prunes; agave, honey or maple syrup; sweet butter and other dairy products; or sweet wine to recipes. Like most cooking and baking techniques, prudence matters: while a little bit of sugar may help the “medicine go down,” too much sweetness in a recipe or meal may be distasteful. More ideas follow later in this chapter and in Chapter 10, Menus and Recipes That Appeal to Aging Palates.

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UMAMI The fifth taste of umami is described as appetitive, brothy, delicious(ness), meaty, savory or sometimes “yummy.” The umami taste is central to Asian cuisine where it has been recognized for hundreds of years. This may be because the umami taste helps to make foods, beverages and ingredients taste fuller and rounder—even with little-to-no animal products. Asian cuisine is filled with vegetables and rice, where beef, fish and poultry are used more as accents, so the umami taste helps to enhance the ingredients both individually and collectively. Umami was the most recent of the five basic tastes to be identified in 2000 by Dr. Stephen Roper and colleagues at the University of Miami. The umami taste is thought to be produced by the taste receptors TAS1R1 and TAS1R3, which are activated by a broad range of amino acids and display a strong potentiated response to the presence of nucleotides, the building blocks of nucleic acids, such as DNA. The human TAS1R1/TAS1R3 is more sensitive to glutamate in humans than to other amino acids, and it often signifies the presence of protein in foods and beverages [9]. Common foods and beverages with the umami taste may be found in aged cheese such as Parmesan or Romano, anchovies, cured foods such as bacon or ham, fermented foods such as fish sauce, miso or sauerkraut, mushrooms (especially shiitake), seafood, seaweed, soy sauce, peas, tomatoes, wine and in flavor enhancers such as monosodium and monopotassium glutamate. Pairing umami foods and beverages with each other serves to magnify the umami taste, such as in Italianinspired recipes with tomatoes and Parmesan cheese, omelets with ham and mushrooms and/or the classic American hamburger with aged cheese, such as cheddar. Umami notes may also be achieved by the use of broth (beef, chicken, mushroom or savory vegetable); beef and other meats; brewed beverages; chocolate; roasted poultry; and onions and other root vegetables, such as carrots, celery or potatoes. The concept of long and slow cooking as in roasts and braises, with tomatoes and often wine as the cooking liquid, along with hearty vegetables conjures up an umami-rich meal. A little acid, such as lemon juice or vinegar, may balance the umami taste if it becomes too assertive. For example, if a sauce reduces and concentrates, sometimes the “meatiness” of it may be too overwhelming and may benefit by acidity. Just the opposite may also be the case: if a tomato-based sauce is too acidic, then it may benefit by umami-rich ingredients, such as mushrooms or the rind of Parmesan cheese. Even a little soy sauce in a pasta-type sauce has been known to temper acidity. More examples are provided in Table 4.6.

TABLE 4.6 Simple Techniques for Balancing the Umami Taste in Cooking If the umami taste is too prominent, add ingredients that add the . . . • Bitter taste—use saute´ed broccoli, escarole, green beans or spinach with reduced umami-rich sauces (such as tomato or wine) and aged beef • Salty taste—use vegetable-based broths and stocks instead of beef or chicken that may be higher in glutamates (beets, carrots, celery, chard and spinach tend to be higher in sodium, but may also add some umami taste) • Sour taste—use acidic ingredients, such as a squeeze of citrus juice, dash of vinegar or wine, dollop of cre`me fraiche, spoonful of ricotta cheese, sour cream or yogurt or pickled vegetables, such as dill pickles or ginger • Sweet taste—use a higher proportion of sweetness to umami, such as fruit pie with sliced aged cheddar cheese, milk chocolate instead of bittersweet chocolate and sweet dried fruit with roasted nut mixes If the umami taste is missing, add ingredients that add the . . . • Bitter taste—use almonds, green tea, mushrooms (particularly Portabella or shiitake) and walnuts • Salty taste—use anchovies, bacon, blue-veined cheese, fish sauce, marmite, miso soup, olives, Parmesan cheese, sea vegetables and tomatoes • Sour taste—use fermented vegetables, such as kimchi and sauerkraut • Sweet taste—use carrots, corn, legumes, peas, potatoes, red peppers, soybeans, tomato and tomato products and winter squash

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FAT AND OTHER PROPOSED TASTES Fat Fat is more than a taste. Fat is also considered a mouthfeel. This is because fat provides a concentrated source of sustained energy that may also be satiating. Fat provides foods and beverages with appearance, aroma, palatability, taste and texture. The first sensation of fat is its appearance; then its aroma of volatile flavor molecules. The next sensations of fat are oral perception and texture. Taste preferences for fat depend on such matters as body fat and gender. Generally, people with more body fat prefer foods and beverages that are higher in fat, and this penchant may be both biologically and behaviorally facilitated. In the 1500s, French physician and philosopher Jean Fernell (who coined the term physiology) proposed the idea that humans could taste fat, but that there was not a mechanism to detect fat. Then in 2010, researchers at Deakin University in Australia discovered that people were able to detect the taste of fatty acids. In 2012, researchers at the Center for Human Nutrition at Washington University School of Medicine in St. Louis proposed that some people may be more sensitive to the presence of fat in foods than others. These studies provided indication of a fat-taste component, but exactly how it influenced human behavior and fat intake was still not fully comprehended. Subsequently in 2015, Richard Mattes, professor of foods and nutrition and Purdue University, reported that there may be a chemosensory component to fat perception, specifically taste, and that it may cause a rise in blood fat levels. As of this writing, fat has not been deemed the sixth basic taste. However, the human body’s ability to taste fat may hold evolutionary advantages in the ability to absorb essential fatty acids from food [10]. The third sensory system, referred to as chemesthesis, is based on touch and is perceived by the trigeminal nerve. Fat is also perceived through the trigeminal nerve that sends signals to the brain that the oral cavity experiences. Branches of the trigeminal nerve travel to the eyes, nose, teeth and tongue where they are responsible in sensing irritation, pain and temperature. The question of where fat is tasted or felt is still obscure because it remains difficult to distinguish taste from texture. For a tastant to be tasted it needs to come into contact with the oral cavity and dissolve in saliva. Like the taste of salt, fat tends to help some foods and beverages taste better. For texture to be appreciated, it must be identified. This is also why the texture of fat may be so difficult to imitate. As a mouthfeel, fat helps to make foods richer, smoother, softer and longer lasting. While free fatty acids in fats do not seem to stimulate or correlate with the other basic tastes, there seems to be taste receptors that are dedicated to unique fatty acid stimuli. And if the taste nerve is severed, animals may no longer be able to respond to fat. Therefore, though some indications show that fat might be the sixth basic taste, the answer is somewhat elusive for now, much like the slipperiness of fat itself [11]. Fat descriptors allude to its texture: chewy, creamy, fatty, greasy, juicy, luscious, luxurious, oily, smooth, soft, unctuous, viscous and others. These descriptors are also illustrative of its sights and smells. This aligns with how the presence of fat affects the appearance, aromas and textures of certain foods and beverages. Its specific sensations depend upon the foods or beverages in which it is contained. For example, the invisible emulsified globules in dairy products help to create a visible creaminess or smoothness. Also, the fact that fat binds water helps to produce desirable juiciness and tenderness in steaks and moistness in baked items. And when exposed to high heat transfer, the fats in foods also help to create brittleness, crispness and crunchiness. The use of fat for its taste and texture, even in the smallest amounts, may be an effective ingredient in diets for the aging. More information and practical applications can be found in Chapter 6, Flavor Enhancement Ingredients.

Calcium Humans may be able to detect the mineral calcium in foods. The sweet and umami taste receptors may be involved, though the “taste” of calcium is neither sweet nor savory, but bitter and sometimes sour. Calcium channels exist on the tongue that target compounds with the calcium taste. The taste for calcium is sensed by the taste receptor, T1R3 that is found in the fungiform papillae at the tip and edges of the tongue, and in the palate taste receptor cells in the roof of the mouth. This is a component of the “sweet-taste” receptor.

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Also, a calcium-sensing receptor called CaSR, a Class C G-protein coupled receptor that senses extracellular levels of the calcium ion, is found in abundance in the parathyroid glands and kidney cells, and also in the brain and gastrointestinal tract [12]. People who have increased needs for calcium in their diet (such as growing children or pregnant women) may find the calcium taste tolerable. Other people may dislike the calcium taste that is mainly associated with dairy products and deep leafy green vegetables. Generally, the fat and protein in dairy products combine to buffer the calcium taste. The calcium taste could be perceived as metallic in deep leafy greens unless they are dressed with butter, dressing or oil. By discovering how calcium is detected in the oral cavity, food manufacturers may be able to reduce its perceived distaste and improve its palatability. Chocolate milk serves this purpose as does a creamy Caesar or Ranch dressing for arugula or kale [13].

Carbonation In humans, carbonation, the chemical reaction between carbon dioxide gas (CO2), carbonic acid (H2CO3) and liquid(s) that causes small bubbles to form and yield effervescence, may prompt both chemosensory and somatosensory responses, including the activation of taste neurons. Carbonation may have its own taste and human taste buds may be able to sense CO2 in effervescence. Taste buds that sense sour may also respond to carbonated beverages that are demonstratively referred to as bubbly water, club soda, fizzy water, soda water, seltzer, seltzer water and sparkling water. The carbonation converts into chemical components, one being a proton that is sour acid. A single gene encodes an enzyme that breaks down CO2 and water into bicarbonate and protons that are mainly acidic. The protons are what sour-sensitive cells sense. There may also be a tactile sensation when the bubbles burst, tickle and tingle the oral cavity. Carbonation may have developed throughout evolution to help humans avoid foods and beverages that have become soured or spoiled. The slight acid tingle of CO2 today is mostly manufactured and considered to be safe. Carbonated waters may be of particular appreciation by people who wish to reduce or eliminate the added sugars in some carbonated beverages. Carbonation is also preferred in fermented beverages, such as beer and champagne [14].

Electrical The “electrical taste” has been recognized for about 250 years as an offshoot of the invention of the battery. When two different, interconnected metals were touched by the tongue (lead silver), an electrical taste was induced. Each of these metals by itself was tasteless, but when they were in contact, a vibration occurred that affected the nerves on the tongue. While this type of electrical taste may not have created any true taste on its own, it may have served to stimulate the tastes buds of the five basic tastes of acidity, bitterness, saltiness, sweetness and umami. The oral cavity, like the rest of the human nervous system, is designed to facilitate electrical impulses that are transferred along nerve pathways, and chemical reactions inside and among the cells. Electrical energy requires a cellular liquid environment that is filled with dissolved electrolytes (minerals in solutions that assist the conduction of electrical currents) and enzymes (naturally occurring reusable proteins that speed up biological reactions). Electrolytes and enzymes work together to create and help identify the tastes and sensations of many substances. The salt solutions in human blood, cellular fluid and saliva may react to allergies, dental filling materials, medical problems, medications, toxins, viruses and a host of other conditions and/or diseases. In addition, a compromised immune system as experienced in aging may contribute to greater taste sensitivity to metallic tastes. The notion of adding electricity to certain foods and/or beverages may be stimulating to some, yet skeptical to others. Adding electricity to foods in augmented gustation (an increase in the number of perceptible tastes) may help to transfer electric charges to beverages through straws, or through eating utensils, such as chopsticks or forks. Information may then be able to be conveyed to the human body that may not be perceptible via the tongue.

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For example, a revolutionary fork of this kind may be able to render certain recipes salty, and thus help to reduce the amount of salt that is used in some foods and beverage preparations. Further research and applications may be illuminating [15].

Hydroxide The taste of hydroxide may resemble limewater, a diluted solution of calcium hydroxide (Ca[OH]2). Pure limewater is clear and colorless with a slightly earthy smell and an alkaline bitter taste. Limewater is commonly used to reduce water hardness and as a neutralizing agent in water treatment. In food manufacturing, limewater may be used in the preparation of maize for corn tortillas in a process known as nixtamalization. Caustic soda (lye or sodium hydroxide) may be used in the preparation of Bavarian-type chewy and soft pretzels to help create a crisp crust. Sodium hydroxide may be used to cure foods such as olives, remove the skin from fruits and vegetables such as potatoes or tomatoes for canning and also as a preservative to help prevent bacteria and mold. While highly corrosive and used in industry for cleaning, dissolving and pulping, under the right conditions sodium hydroxide may achieve baking qualities that are difficult to attain by home bakers and cooking qualities in food production. People with taste changes may find any remnants of the hydroxide taste disagreeable [16].

Kokumi Kokumi, a food sensation that has been identified by the Japanese as “rich” and “taste,” has also been described as “heartiness,” “mouthfulness” or “thickness.” These descriptors are very similar to those used to describe the fifth taste of umami. Garlic, onions and scallops are said to contain kokumi in abundance. Gamma-glutamyl peptides appear to be responsible for the kokumi-like taste. Gamma-glutamyl peptides are chains of three linked amino acids with the amino acid glutamate at one end. Glutamate is also responsible for the umami taste. Kokumi may amplify the umami taste. To date, no gamma-glutamyl peptide receptor cells have been detected on the human tongue. Also like umami, kokumi may enhance other tastes with which it combines without a detectable taste of its own, such as calcium; protamine (in milk or fish sperm); the amino acid L-histidine; and glutathione (in yeast extract). The calcium channels on the tongue may be targets for kokumi compounds. These channels may sense and regulate the levels of calcium in the body. They are also closely related to the sweet and umami (savory) receptors. Glutathione is also known to interact with calcium channels. It has been suggested that the addition of kokumi to foods may help to reduce fat intake and make low-fat foods more palatable, instead of the practice of adding sugar. Kokumi has been marketed as yeast extract and may be able to replace the food enhancer monosodium glutamate (MSG) in some applications. While not a definable basic taste, kokumi may be a sensation to observe [17].

Lysine Lysine (Lys) is an essential amino acid produced by the fermentation of carbohydrates. It has a slight bitter taste. It is used as a compound for amino acid preparation and as a component for livestock feed. Lysine may be a limiting amino acid in predominately cereal-based diets. Presently lysine is not considered as a direct precursor of any neurotransmitter in the brain. Lysine fortification has been shown to enhance growth, fight infections and strengthen bones. Lysine is used in body-building communities to “load” muscles and in the cosmetic industry to enhance the skin. Huitlacoche, a corn fungus or “corn smut” that attacks corn, forces metabolic processes within the corn to modify and generate healthier nutrients. While corn does not contain lysine, huitlacoche has a fair share, as well as beta-glucans, soluble fiber with cholesterol-lowering capabilities. Lysine is known to improve the sensory qualities in some foods, along with aspartic acid, glutamic acid, glycine and methionine. With its high taste activity level, lycine has the potential for strong taste impact on some foods, such as fish.

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At a concentration of 1% lysine, the sensory defects that are created by replacing sodium chloride with potassium chloride may be reduced. This action may allow for a decrease of sodium in food manufacturing of about 50%. When salty flavors are decreased in the preparation of some processed foods, astringency, bitterness and metallic tastes may arise. The addition of lysine alone may serve to eliminate some, but not all sensory defects. When in combination with other substances, such as disodium guanylate, or disodium inosinate, the aroma, taste and overall acceptance may improve. If people select to follow plant-based diets, then the presence of lysine in the food supply may provide beneficial health and taste results [18].

Minerals Certain minerals may create a metallic taste. These include copper, iron, manganese and zinc. A metallic taste may be prevalent for the following reasons: a compromised sense of smell; hormonal changes; medications; pregnancy; underlying medical conditions (such as diabetes, Crohn’s disease, pernicious anemia or Sjo¨gren’s syndrome); zinc deficiency; or upper respiratory infections [19]. Different types of water may contain a range of metallic tastes. Well water may taste like minerals or “chalklike” due to layers of limestone or other inorganic substances through which the water has passed. Beach water may taste like sulfur from sulfur-producing microbes in the groundwater. Lake or river water may taste earthy or organic, and mountain spring water may taste like the minerals in the surrounding environment. These tastes may be pleasant or disagreeable depending upon individual tastes, medical conditions, medications and/or other factors. The taste of calcium in water may seem milky and/or smooth, magnesium may taste bitter and sodium may taste salty. If there is too much magnesium or sodium in water, the water may taste like too many minerals are in it. This is sometimes referred to as “hard water.” If hard water is used for cooking fruits and vegetables, then it may toughen their natural pectin and interfere with softening, but a little salt may help to alleviate the situation. When water is too soft it may have less calcium and interfere with baking, since the gluten molecules in the dough might not have enough structure. The use of disinfectants in water may also produce a mineral taste. Think about the use of chlorine in swimming pools and the resultant taste. If chlorine combines with other compounds in the water and forms disinfectant by-products, then this may also influence the taste. Other metals in water may also affect taste, such as iron or lead from unclad iron pipes, and may also become health risks, especially to the brain. Symptoms of lead poisoning may include abdominal pain, constipation, headaches, irritability, memory disorders and/or tingling in the extremities. Lead poisoning may be subtler than zinc poisoning. Zinc in the form of zinc acetate and gluconate in lozenges has been used to treat the common cold. Zinc supplements may suppress copper and iron absorption, two minerals that are necessary for normal blood functions. If filters are used to reduce the impurities in water, then they may have a taste of their own, which may also affect the taste quality of water. Water filters have become more common in areas with environmental concerns that may include contaminants such as hexavalent chromium, lead and others It should be noted that they may also affect the taste of drinking and cooking water.

Polycose Polycose (also referred to as glucose polymers or maltooligosaccharides) may have the ability to condition flavor preferences. Yet, the taste of polycose itself is considered as a bland taste. Different taste receptors may help to mediate the sweet taste and the Polycose taste in genetically modified lab animals who may be absent of sweet taste receptors. In humans, unlike the sweet taste Polycose does not easily support flavor preference conditioning. Sucrose and Polycose may differentially activate the brain’s dopamine and serotonin receptor systems that are involved in flavor preference learning—particularly for strong flavor preferences. Additionally, Polycose may have potential “reward” effects in the gut that may condition strong and lasting flavor preferences. So the taste of Polycose may be twofold: initially distinctive and conditioning. Polycose may be especially useful for people who suffer from, or are prone to, malnutrition, or for those individuals who may require the introduction of calories and nutrients through dietary supplements [20].

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Protein The taste of protein is the taste of amino acids, the building blocks of proteins. The basic taste of umami, with its sensitivity to the amino acid glutamate and its meaty, savory taste, epitomizes the protein taste. MSG also captures the taste of umami and savory protein foods. This is one of the reasons why this flavor enhancer is used in plant-based cuisines: to bring out the savory taste in essentially plant-based recipes. In laboratory animals, the taste of umami is not always enjoyable, but may eventually be preferred. This suggests that laboratory animal may learn to enjoy protein as evidenced by their neural activity—especially in the parts of the brain that are responsible for representing “viscerosensory cues” and in their digestive tracts. Whether or not these observations may be applied to human taste preferences for protein is arguable. Humans need protein, since the amino acids that are the building blocks of proteins are the constituents of every cell. Amino acids have a myriad of vital bodily functions that include the building and repairing of blood, bones, cartilage, enzymes, hormones, muscles, tissues and more. The human body produces over 40 grams of the amino acid glutamate daily that prompts continual replenishment. Whether humans crave the protein taste, the umami taste or the glutamate taste may be a moot debate because they may all be inextricably linked. At the beginning of their lifecycle, humans seek protein in breast milk to survive; breast milk contains 10 times more glutamate than cow’s milk. Toward the end of the lifecycle, when chewing and swallowing may become issues, humans may rely upon protein supplements that deliver digestible amino acids, such as glutamate. While the taste of protein may not be one of the basic tastes, it is the taste of life [21].

Pyrophosphates Pyrophosphates are salts or esters of pyrophosphoric acids. They are used as acidity regulators, emulsifiers, raising agents, sequestrants, stabilizers and water retention agents in food processing. Pyrophosphates act as buffering and chelating agents in canned and processed seafood and as scald agents in products that are made from potatoes and sugar syrups. They also improve the shelf life or quality of foods, maintain color and shorten (or lengthen) the fermentation time in baked goods. Pyrophosphates are commonly found in commercially prepared cake, muffin, pancake and pudding mixes. Sodium acid pyrophosphate may be added to canned fish, cured meats, flavored milk and potato products. Laboratory animals may demonstrate preference to phosphates and pyrophosphates before water. Gustatory receptors T1R2 and T1R3 are implicated as pyrophosphate detectors. When trisodium pyrophosphate is combined with a flavor and taste enhancer, there may be applications for increasing and enhancing the tastes in domestic animal foods. In particular, cats have demonstrated preference for a blend of pyrophosphate and yeast extract [22]. Phosphate additives including sodium acid pyrophosphate may pose some safety concerns if a number of prepared mixes are used. One reason is because phosphate additives add to the amount of phosphorus from dairy products and meats in the human diet. The phosphorus-to-calcium ratio in the human diet should not exceed 1 to 1. Beyond this amount, excessive phosphorus might lead to the inability to fully absorb dietary calcium and a loss of bone mineral density [23].

Soapy The common causes for a soapy taste may be due to carrots or cilantro. Carrots contain compounds that are called terpenoids that may contribute to this taste sensation. The cause for the soapy taste of cilantro may be genetic. Other causes may be poor oral hygiene that may lead to the tongue turning white and coated with plaque. The plaque may be responsible for the soapy taste. A soapy taste might be at the root of sodium fluoride poisoning that may also taste salty. Sodium fluoride poisoning may be accompanied by numbness of the mouth, dilated pupils, diarrhea, vomiting, pallor or shock. It may be the result from too much fluoride in drinking water, use by dentists or contamination in baking powder, cake mixes, dry milk and/or flour.

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Smoking may contribute to a soapy taste from the contaminants used in cigarette production. A soapy taste may be prevalent in the first trimester of pregnancy, perhaps from hormonal changes. A sour taste such a lemon juice and drinking water are sometimes used to combat the soapiness. Food contamination may also contribute to a soapy taste. So may the taste of soap used to clean dishes and glassware [24].

Starchy Food cravings should not be confused with food tastes. The craving for carbohydrates is different that the taste of sugar that has its own taste receptors. Some research has indicated that humans were able to detect a starchy taste in solutions that contained either long or shorter carbohydrate chains that ultimately break down by enzymes in saliva into shorter chains and simple sugars. When compounds blocked the tongue receptors that detect sweet tastes, a rice-like or floury taste was still detected by study subjects. This suggests that this starchy flavor may be the result of shorter chain carbohydrates and not just the sugar molecules themselves [25].

TEMPERATURE AND TOUCH For people who are more sensitive to tastes in general, temperature alone may elicit taste sensations. Cold or hot temperatures that are placed on the right part of the tongue may evoke a clear, strong taste in some individuals, according to some taste research. At the tip of the tongue is an area that may be more sensitive to thermal changes and detect sweetness. Cooling this spot may induce sourness and saltiness. It may be that temperature sensitivity may have to be endured by people with high sensitivity to taste. This may be the reason why very cold ice cream may taste salty to some people, while it may taste sweet to others, and why astringency and bitterness may seem stronger in their respective tastes when foods and beverages are warmer rather than when they are colder [26].

TASTE ENHANCEMENT The enhancement of tastes may be used to augment, balance or juxtapose tastes. The augmentation of various taste intensities may help if salt and sugar are reduced in products, foods and beverages to improve flavor, maintain highly desired taste quality and ensure microbiological safety. Taste enhancement may also successfully be used when calories are decreased in foods, beverages and other products to help compensate for reduced or eliminated flavorful and textural ingredients; for example, added sugars and fats. Taste enhancement may hold particular interest for food and beverages developers and manufacturers who are responsible for new products and ingredients for the aging diets as their sense of taste diminishes. Some aging people are natural tasters and savor new taste experiences, while others need to learn the art of tasting. A trained palate may be the result of exposure to different tastes and combinations over a lifetime, in addition to an openness for new experiences. Learning how certain tastes combine or clash may help in food selection, preparation and overall dining experiences. Some of these taste associations follow.

Taste Combinations for Balance When tastes combine they often form a different or new taste that may be superior to the original tastes. Chili powder and curry powder are examples of a myriad of tastes that unite to form distinctive tastes. Most foods and beverages have a dominant taste that may be transformed by the addition or deletion of other tastes. The secondary taste may not be as noticeable, and it may or may not add its own distinctive taste, but may bring out other tastes instead. In general, consider this maxim: “Use salt to enhance tastes, fat to carry tastes and acid to balance tastes.” Consider each of these three elements singularly and in harmony. Add each element at the right time in cooking or baking so that the dish is flavored or seasoned both from within the dish and without. For example, in

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select cases salt should be added early to cooking water, then fat should added during cooking and acid should be added to finish a dish. Meats should be seasoned for browning, then braising; then finished with an acid to add brightness and complete the flavor profile. Examples of ingredients that effectively balance the basic tastes are shown in Table 4.7. TABLE 4.7 Use of Ingredients to Achieve Taste Balancing Taste Balance: Sweet 1 Sour If there is a sweet taste and a little sourness is added, then the sweet taste may taste sweeter. Example: Honey-flavored (sweet) syrup 1 lemon (sour) tea Other options: 1 Additional Sourness As additional sourness is added, then the sweet taste might dissipate altogether and become more sweet-sour. Example: Sugary (sweet) marmalade 1 tart (sour) lemon rind 1 Neutral Taste To make both the sweet and sour tastes subtler, a neutral-tasting fluid such as water could be added. Water may dilute the sweetness and the sourness. Example: Sugar (sweet) syrup 1 lemon (sour) juice 1 water and ice (neutral) 5 lemonade 1 Sourness, Saltiness, Bitterness or Sweetness Sourness, saltiness or bitterness may decrease the perception of sweetness and the opposite may also be true: sweetness may lessen the perception of sourness, saltiness or bitterness, especially if it is diluted. Example: The lemonade may taste delete hyphenless sweet as more lemon juice is added to the mixture. Also . . . A little honey in bitter tea may soften its bitterness. 1 Additional Taste(s) Sometimes just a small amount of one taste may enhance the perception of another taste(s). A little saltiness or sourness may bring out the bitterness in foods and beverages and the opposite may also be true: A little saltiness or bitterness may bring out the sourness in a recipe or ingredient. Example: A little salt (saltiness) and fresh lemon juice (sourness), squirted on saute´ed escarole or other bitter greens, with some olive oil (fattiness) to smooth. Also . . . A little salt (saltiness) and lime juice (sourness), added to a tropical beverage such as tequila (some bitterness), sometimes with coconut “milk” to smooth. 1 Sourness, Saltiness and Bitterness Sourness, saltiness and bitterness or umami may enhance sweetness and add more complexity. Example: Salted (saltiness) caramel (bitterness) ice cream (sweetness), with some fattiness to smooth. 1 Bitterness, Umami and Sourness A little bitterness or umami and sourness may highlight saltiness. Example: A squirt of lemon (sourness) added to anchovies or sardines (umami and saltiness), with some olive oil to smooth. A small amount of bitterness or umami and sourness may enhance both sweetness and saltiness and lessen bitterness in ingredients that contain some sweetness. Example: A serving of smoked salmon (umami and saltiness) accompanied by sour cream or cre`me fraıˆche (sourness and sweetness), with some fattiness to smooth. Also . . . A serving of fresh Belgium endive (bitterness) with Balsamic vinegar (sourness), and extra-virgin olive oil (bitterness) and some fattiness to smooth, plus salt (saltiness).

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Other Taste Balances In other taste balances, some ingredients may act as catalysts to both combine with a basic taste or tastes and trigger a change in it. For example, garlic has a prominent pungent taste of its own. When garlic combines with lemon, it subdues the tartness of the lemon and adds another dimensionality to its taste. The garlicky-lemon taste can then be used successfully in a number of applications whereby the use of garlic and lemon independently may fail. This may also be true for onions (fresh or cooked), lemon, vinegar, wine or salt. Each of these ingredients may brighten and enhance tastes that were incapable of achieving strikingly on their own. Acidic ingredients and salt may act as catalysts to add substance to dishes and prevent the primary tastes from disappearing. Acidic white wine is often meshed with bitter herbs in umami-rich fish sauces; vinegar is often added to robust soups and stews to temper their meatiness, and is often served with French fries to combat the fattiness. Citrus juice is often added to raw fish such as ceviche to help to marry the tastes and break down the protein. Salt may act as the ultimate flavor saver. It is generally best to add a taste balancer or catalyst judiciously at first and then adjust as needed. It is more difficult to add too much and then try to compensate to save the dish. If too much salt is inadvertently used early on, it may be corrected by diluting the dish to increase the total volume; dividing and correcting the dish in batches so as not to overcorrect it at first; balancing the dish with still another ingredient—generally a little acid or fat; changing the dish’s cooking water or sauce; or salvaging some of the ingredients in a dish, then adding fresh unseasoned cooking liquid and sweeter vegetables, such as carrots or onions. A rich or starchy accompaniment may also help to foil heavy-handedness in certain taste while it lends another dimension of texture. But too much fat or starch may be too rich or heavy for the desired final product. The starch may be able to be rinsed, such as in pasta. More ingredients or liquid may be added to increase the total volume of a recipe, or an acid (such as citrus or tomato juice or vinegar) may be added in a small amount. Or, the dish may be dabbed when warm to remove some of the visible fat or oil, or chilled for the fat to congeal and be removed. If a food, ingredient or recipe is too sweet or acidic, by using either sugary or acidic ingredients this step should help to moderate the other taste. This is also true for both savory and sweet preparations. In savory dishes, browning the ingredients first before adding acid may help to caramelize the ingredients to help bring out their sugars. Very-sweet fruits, for example, may be moderated by a little acid in their preparation. For example, fruit pies may become just a little oversweet unless they are paired with an acidic ingredient, such as in strawberry rhubarb or blackberry peach pie. Likewise, stewed prunes may be mitigated in their sweet taste by some lemon zest.

Ingredients That Activate Taste Balance Before discussing the ingredients that may activate taste balance, the most optimal temperatures to transmit these tastes need to be mentioned. In general, bitter, sweet and umami tastes may taste more intense and transmit stronger signals to the brain when the foods and beverages that contain them are warmer. But excessive heat may interfere with the true taste of a dish or beverage. Preparing and serving warm or room temperature foods and beverages may be most palatable. Plus, aromatic molecules may be liberated, sensed and experienced. If fat accompanies a dish, either layered throughout a recipe or as an emulsion (such as a salad dressing or topping), it too may be fuller reaching if it is not too chilled. The ingredients that comprise the basic tastes of bitterness, saltiness, sourness, sweetness and umami are tools for taste balancing. Basic taste sensations and examples of ingredients that produce these sensations are featured in Table 4.8. Table 4.9 details condiments, foods, herbs and spices that naturally achieve various basic taste sensations.

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TABLE 4.8 Basic Taste Sensations Produced by Food and Ingredient Sources Bitterness (used within a recipe, or as the recipe is served) • Beer • Bitter herbs, such as basil, parsley or sorrel • Bittersweet fruit preserves, such as chutney or cranberry • Caramelized sugar • Cocoa, coffee and tea • Collard or mustard greens, escarole, spinach or watercress • Freshly grated horseradish, or ginger • Grapefruit, lemon, lime or orange zest • Mayonnaise (bittersweet) • Olives Saltiness (used within a recipe, layered as a recipe is prepared, and/or as it is served) • Anchovies • Blue cheese • Sea salt, often flavored with herbs, spices • Meat, poultry or vegetable stock • Parmesan cheese • Preserved artichoke hearts, capers, olives or pickled gherkins • Seaweed • Smoked fish • Soy or teriyaki sauce • Tomato paste or tomato sauce Sourness (layered during a recipe’s execution, and/or at the finale to enhance) • Buttermilk, cre`me fraıˆche, sour cream or yogurt • Grapefruit, lemon, lime, or orange juice or rind • Lemon butter • Molasses • Salsa with lime • Sour sugar syrup or preserves, such as bitter orange • Sour dipping sauce, such as sweet-sour chili sauce • Tart fruit curd, such as lemon or lime • Vinegar • Wine Sweetness (used during a recipe’s execution, plus more to finish) • Agave • Baby vegetables (such as beets, carrots or peas, with a higher sugar content) • Bananas • Dried fruits (such as apricots, dates, figs or raisins) • Egg custard • Honey • Maple syrup • Root vegetables (such as carrots, celeriac, onions, parsnips, sweet potatoes, yams; baked, mashed or pureed to bring out sweetness) • Sweet liquor or dessert wine (such as Cre`me de Cassis or Cointreau) • Unsalted butter Umami (integrated during a recipe’s preparation, or at the finish) • Anchovies • Dashi and miso with kelp (large seaweed) • Fish sauce • Green tea • Marmite • Oysters • Parmesan cheese • Shiitake, other mushrooms and truffles • Soy sauce • Tomatoes

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Taste combinations/sensations

Foods, condiments, herbs, and spices

Hot

Cayenne pepper, chili pepper, curry powder, hot paprika and wasabi (paste, powder or raw)

Hot and bitter

Cinnamon sticks, chicory, cloves and watercress

Pungent

Allspice, cumin, ginger, mustard and turmeric

Salty and sour

Pickled fish and vegetables, sorrel and tamarind

Salty, bitter and umami

Caviar, clams, nuts, olives, sardines and Worcestershire sauce

Sweet and bitter

Bitter chocolate, caramel, caramelized sugar and cranberries

Sweet and sour

Apples, berries, kiwi, oranges and pomegranates

From Marcus JB. Culinary nutrition: the science and practice of healthy cooking. Elsevier, 2014; p. 57.

TASTE OPPOSITION/ANTAGONISM Taste opposition or taste antagonism may fight other tastes for prominence and may interfere with harmonious tastes and flavors. Some people may say that a recipe or formulation doesn’t taste good, but they may not necessary know why. This may occur when one taste or aroma dominates another taste or tastes. This is fairly easy to detect when a food or beverage is too bitter, salty or sour because it might be offensive to the palate. An overly sweet taste might be preferred because the palate may skew toward the sweet taste. However, an overly savory taste might be difficult to detect because savory, like sweet, is a preferred taste by many people because it is often recognized as the taste of protein. For people whose taste skew to lighter tastes, this savory taste might be perceived as too earthy or dirty. For example, a hearty beef stew in an aged wine sauce may be perceived as too robust for milder palates. Taste antagonists are different than taste opposites. Opposite tastes may highlight or cancel the other tastes where they are exposed. Taste opposites include such combinations as salty and sour, salty and tart, sweet and salty, sweet and hot and sweet and sour. The classic sweet and sour taste may be achieved through a sweet ingredient, such as honey and a sour ingredient, such as vinegar or citrus as in a sweet and sour sauce. When sweet and fatty ice cream is topped with salted nuts, both the sweet and salty tastes may be amplified. But when the salty and sugary tastes are close to balanced, they may cancel each other out entirely. The use of sweet pickle relish on a salty hot dog, or in salty canned tuna fish are good examples. The resultant tastes maybe uniformly delicious to many. Others may find the combinations cloying. Or consider Asian cuisine where sugar may be used to balance the saltiness of soy sauce. Neither taste may be prominent, yet the resultant whole may still be unifying and satisfying. While opposite tastes may balance each other so that no single taste dominates, when acidity is added, the combined tastes may become apparent within the whole. For example, smoked fish is salty and fatty, so much so that it is hard to tell which of these tastes rules. When smoked fish is served with a slice of lemon to release its acidity, the complete flavor is not salty, fatty or sour, but pleasing. To calm salty tastes and over-salted food, try a squirt of lemon, lime or orange slice, depending on the other ingredients of the dish. Chocolate, by nature is bitter, and this is why it often is accompanied by sugar and fat. The sweetness muffles the bitterness and the butterfat adds mouthfeel. Spicy tastes are often balanced by sweet or fruity tastes, such as in mango salsa, hot sauce spooned over tropical fruits or black pepper sprinkled over strawberries. When ingredients are astringent, such as some apples, cucumbers, grapes or mint, then their tastes might have the capacities to “cut through” other tastes. For example, both apples and grapes are often served with cheese because they may provide both the tastes and textures to offset the fattiness of cheese. When cucumbers are used in a mustard sauce with fatty fish, such as salmon of trout, a similar equalizer may occur. And fresh mint and lamb, a proverbial springtime pairing, serves to cut, then elevate the gaminess of the lamb.

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TASTE JUXTAPOSITION Juxtaposed tastes are two tastes that may meet and contrast. Sometimes tastes are juxtaposed in layers, which means that a person may detect them at different times during the eating experience. This is what makes foods and beverages so interesting and why dining experiences may be so memorable with initial, then lingering tastes. For example, a seafood sauce may immediately taste spicy and tomatoey, then sharp from the horseradish, then smooth once the sweet taste of the seafood is revealed. When a squirt of lemon juice is added, then all of the tastes should unify and the flavor of the seafood sauce endure. On the other hand, juxtaposed tastes may be effective in reducing a taste from an ingredient without negating it altogether. For example, when garlic merges with bitter basil in a classic pesto sauce, it tastes more herbaceous and less medicinal than when on its own. Sometimes red wine reduction sauces are too musky unless a little bit of spice, such as allspice or cloves is added. Similarly, spice cakes with allspice or cloves might be too overwhelming with their aromatics unless some sweet and sour orange juice or zest is added to the recipe for moderating. And apple cider with its recognizable cinnamon stick provides just the right balance of sweetness, bitterness and earthiness. Once removed, these features may dissipate.

TASTE AUGMENTATION It is possible to amplify or expand taste with fats by employing a process called taste augmentation. Fats have a potentially powerful impact upon taste and flavor. Sometimes more than one fat or oil in a dish may be transformational. For example, if some butter or oil is used to prepare a dish, then a similar fat or oil should be used for finishing the dish. Or multiple types of fats or oils may be used in the same recipe for both texture and taste. For example, if fish is fried, then an emulsion-based tartar sauce may act as a compatible accompaniment. If a recipe turns out to contain too much fat, then there are at least four options. To begin, the recipe may be doubled in size, with the amount of fat or oil remaining the same. Second, if the recipe dictates, liquid may be added to dilute the fat or oil and extend it in the recipe. Third, a dense or starchy ingredient (such as potatoes or rice) may be added to soak up some of the fat. And fourth, the dish could be refrigerated so that some of the fat or congeals and may be removed. On the other extreme, if food is too dry, then it might not carry taste molecules in the manner that is intended. A little avocado, butter, cre`me fraıˆche, egg yolk, goat cheese, olive oil, mayonnaise, soft spreadable cheese, sour cream or vinaigrette might improve both taste and texture. To summarize, before discarding foods or beverages because they do not taste right, employ any or all of these techniques: taste balance, taste opposition, taste juxtaposition or taste augmentation to equalize, counter, contrast or enhance singular tastes and all-over flavor. The final product or recipe may be improved, better sensed, more accepted and enjoyed.

HOW THE SENSE OF SMELL AFFECTS THE SENSE OF TASTE The sense of smell has a profound effect on the sense of taste—so much so that the sense of smell is often referred to as the companion sense to the sense of taste. If a person has a cold or sinusitis, her sense of taste might also decline. In younger individuals, the sense of taste may then restore soon after the infection or inflammation has subsided. In older people, a chronic condition or illness might affect their sense of taste for a longer term and affect their nutrition and health over time. An examination of how the sense of smell affects the sense of taste helps to elucidate this process. The nose can sometimes detect an upcoming taste—even before the eyes see a certain food or beverage. This is because aromas travel via vapor molecules outside of the line of sight. And since there are thousands of odors, there may be infinite possibilities to imagine what a food or beverage may actually be. Additionally, each nostril may smell differently and switch roles several times daily, so it is possible that a food or beverage may seem to smell differently at various times of the day and affect the perception of tastes dissimilarly. While aromas appear to come from the mouth, there are not cells in the oral cavity for actually detecting aromas. For instance, while berries might look fresh and fragrant, the cells that detect the berry aroma at the end

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of the nasal passage must first be activated for detection. Then information about the berry aroma may be accumulated and communicated to the mouth through the process of olfactory referral. Also, as described in Chapter 3, The Senses, Chemosensory Changes and Aging, and Chapter 5, A Smell Primer, aromas may also be detected through retronasal olfaction from the back of the mouth. So information about a food or beverage’s smell and ultimately flavor may be influenced by both of these methods. Certain aromas may cause a food or beverage to taste bigger or better, such as the sweet fragrance of vanilla. Vanilla does not typically have a true taste since it is a smell. The pleasant sensation of vanilla may come from the nose, not the mouth, through retronasal olfaction from the back of the mouth and the back of the nose. The odor and taste components of vanilla and sugar are considered congruent—this is why they may often be found in similar foods and beverages, such as cookies and ice cream. They may be perceived as one sensation that appears to come from the mouth—the sweet taste. But this impression may be the result of the taste and smell centers in the brain and the orbital frontal cortex, where smell and taste sensations are integrated into the perception of a singular flavor message that is conveyed back to the oral cavity. This message relays the impression of flavor(s) in the mouth, such as oatmeal cookies or vanilla ice cream. Once the aroma of vanilla is experienced in conjunction with the taste, then the two senses may become inextricably linked in one’s flavor memory. The flavor combination of oatmeal cookies and vanilla ice cream may become a profound flavor memory that may last a lifetime.

HOW THE SENSES OF SIGHT, SOUND AND TOUCH AFFECT THE SENSE OF TASTE Sight The eyes have been conditioned to see foods and beverages based upon memory. A previous experience plus emotions may “color” a person’s attitude, and just the sight of a food or beverage may be appalling—whether or not the item actually may be vile. Additionally, the appearance of a dish or drink may affect its desirability. Appealing foods and beverages may often look and are nutritious, such as brightly colored fruits and vegetables, pure-white dairy products, ruby-red meats, yellow-tinged fats and/or earthy-colored grains, nuts and seeds. A balanced diet often resembles a rainbow of colors. Some foods and beverages may be detected by sight alone. Think about the image of a strawberry. It is unique and our brain registers the image of the strawberry, then it transmits this information so that the taster may anticipate what to expect. Color may predominately determine how a food or beverages tastes. If the strawberry is colored blue or purple, then this may distort the image and confuse the taster. Another example is white wine that has been tinted pink or rose with a few drops of red wine. The taster might think that the wine is sweeter due to the rosy color (and may be surprised about the taste). These color changes might affect future food and beverage preferences. This color phenomenon has profoundly affected how food is packaged and marketed, and may be particularly important when fading eyesight in the aging may become an issue. In contrast, dangerous foods and beverages may look burnt, moldy, undercooked or rotten. The sense of smell often (but not always) may confirm this occurrence, as may the sense of taste. If either the sense of smell or taste is compromised by aging, a toxic substance could potentially be consumed [27].

Sound The loud volume of music and voices and auditory background noise may affect the perception of the gustatory properties of foods and beverages; in particular, they may suppress how people perceive the saltiness and sweetness of foods. In one study, the reported saltiness and sweetness were significantly lower when tasters were exposed to loud versus quiet conditions [28]. Under the right conditions, loudness may enhance certain flavors. A 2015 study revealed that loud airplane noise might drive interest in the fifth taste of umami. It was postulated that auditory conditions including noise and cabin pressure that are common in air travel may serve to boost the appetitive and sought-after taste quality of umami. The chorda tympani nerve that transmits directly across the tympanic membrane of the middle ear may be partially responsible for this effect [29].

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The effect of music and food and beverage consumption has also been investigated and it was determined that the reactions to various wines tended to mirror the sound of the background music. Furthermore, it was established that the symbolic functions of auditory stimuli, such as music, may influence the perception in other sensual modalities, such as gustation. Strategically employed, this might be mean that different sounds may be used to emphasize or focus attention to certain flavors or conversely, ignore other flavors. Care providers, cooks and food marketers may benefit from exploring music, sounds (or lack thereof) during food and beverage presentation for maximum impact upon dining behaviors. Although the mechanism for understanding how sounds affect consumption is not fully understood, there has been recognition of “tasting sound” with regards to synesthesia. Synesthesia is a rare neurological phenomenon by which stimulation of one sensory pathway may cause an involuntary experience in another pathway. There has also been speculation that sound parameters such as loudness, pitch and timbre are naturally congruent with specific taste or flavor attributes, and that some may be culturally, experientially or physiologically driven. While research about the possible association between the auditory and olfactory senses holds promise, as the aging lose their senses of hearing and taste these reductions may add more challenges. Sounds may need to be higher pitched to uplift sweetness and deeper toned to emphasize bitterness or umami. The nutritional impacts and health values may be provocative but have yet to be determined [30].

Touch There are two distinct but parallel brain pathways for processing the sense of touch. One is a sensory pathway that provides information such as location of the touch, pressure, texture and vibration. The sensory pathway is a brain region known as the primary somatosensory cortex, which serves to analyze information through a series of sequential processing stages to create tactile images and construct object recognition. The second pathway functions to process emotional and social information of personal or interpersonal touch by way of skin sensors. Activated brain regions are associated with pain and pleasure centers and social bonding. Since these two pathways are separated, if there are brain disorders, then the two types of touch identification may also be disconnected, so that the actual physical sensation of a touch may be disassociated from the emotional impact of the touch. This may have profound effects with regards to taste—especially for those individuals where the emotional sensations of touch preclude the real physical sensations, so much so that foods and/or beverages may be rejected before consumption. During the aging process, the sense of touch may decline as with the other senses. It may decrease at a rate of about 1% per year after 18 years of age, and may affect both tactile acuity and sensitivity. This is partially due to a decrease in the density of nerve endings in the extremities and a breakdown of myelin, the insulating material that coats the fast-conducting nerve fibers that causes them to project slower than in younger years. As a result, information about touch may arrive to the brain slower than during earlier stages in the lifecycle. Not everyone has the same sensitivity to touch. Haptic perception is the human ability to experience and interpret the environment based upon touch and movement, such as diagnosis, safety, tactile information and quality. People may be strong autotelics and internally driven, and may like to touch products before they purchase or use them. Or they may be low autotelics, and may not need to see or touch products before purchase or use. They may be more externally driven by such motivating factors as comfort, fame, money or power. Individuals who like to touch tend to receive more pleasure from the experience and may be more conscious of haptic clues about their judgments. They may also be better able to adjust their judgments when they are nondiagnostic in nature. If the sense of touch wanes with aging, then this information may help to establish who selects which beverages, foods or products and why, or why not. This knowledge may be useful for creating diets and products with better chances of selection, use and enjoyment that may ultimately lead to improved nutrition and health [31]. A summary of how the sense interplay to influence food and beverage choices is displayed in Fig. 4.1.

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Touch

Sound

Sight

Smell

Taste

Perceptions of foods or beverages

Appetite (desirability, satiety, satisfaction)

Food preferences and behaviors

Food selections or rejections

Nutrition or malnutrition

Health and wellness or disease FIGURE 4.1

Interplay of the senses (touch, sound, sight, smell, taste) to influence food choices. Source: Marcus JB. From culinary nutrition: the science and practice of healthy cooking. Elsevier; 2014, p. 58.

TASTE AND HEALTH The sense of taste may normally be taken for granted. This may be partially the reason some people are unaware when their sense of taste wanes or may attribute it to their loss of ability to smell. Problems in the detection of taste may be caused by anything that interferes with the transmittance of taste sensations to the brain or by conditions that affect how the brain interprets these and other sensations (such as those from the sense of smell). Both smell and taste disorders may be diagnosed by an otolaryngologist, or an ear, nose and throat (ENT) specialist through assessment of oral hygiene, dental examination, physical examination, review of health history and/or smell and taste tests. Olfactory dysfunction may affect the perception of foods and beverages, which may in turn affect appetite and satiety, food behaviors, preferences and selection, nutritional status (such as body weight and/or immune response) and wellness, or lack thereof. This is to say that the lack of taste may affect what a person thinks about a food or beverage; what a person chooses to do about that food or beverage; how a person feels about consuming or not consuming that food or beverage again; and how a person continues to think, choose and feel about that food or beverage in the future [32]. If the loss of taste is due to medication usage, then changing or stopping the medication (as first determined by a healthcare provider) might help to remedy the problem. Likewise, if the problem is due to allergies or to respiratory infections, then once these conditions are alleviated, the loss of taste might be rectified. Dental hygiene may be improved, which may include better brushing, flossing and rinsing. Proper mastication (chewing), moistening (via water or other liquids if lack of saliva is of issue) and swallowing are vital concerns. Partial or complete well-fitting dentures may often be to blame, and while costly, may help to improve chewing and heighten taste. A loss of the sense of taste might be a risk factor in certain conditions, such as cancer, diabetes, heart disease, malnutrition or stroke, especially if specific medications or foods and beverages are needed and/or precise diet protocol must be followed. Impaired taste may be very unsatisfying and cause a person to eat too much or too little, which might result in weight gain or weight loss. This may lead to additional physical or psychological disorders including depression or social isolation and may require the intervention of a behavioral or mental specialist [33]. When the sense of taste is compromised, it can become a serious risk factor in the detection of spoiled foods, liquids or poisonous substances. While most people may take this internal protection system for granted, it can jeopardize health or safety if it remains unnoticed.

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TASTE DECLINE AND LOSS Ageusia, or the absence of taste, at any point in the lifecycle is rare. Changes in taste may include cacogeusia (an unpleasant sense of taste), dysgeusia (a distorted sense of taste such as a metallic taste) or hypogeusia (a partial loss of taste). There are many reasons for a decline in the sense of taste other than the aging process itself. These may include changes in the manner that the nervous system processes the sense of taste, changes in the tongue, cigarette smoking or smokeless tobacco, decline in the density of taste buds, decreased saliva or increased stickiness of the saliva, dental problems, diseases (see the following), elevated cholesterol, injury to the mouth, medications, minor infections such as the common cold or influenza, neurological conditions, nutritional deficiencies (particularly vitamin B12 or zinc), oral cancer, surgery, thyroid conditions and/or xerostomia (or dry mouth). Certain cancers may change or intensify some taste perceptions and may provoke abnormal taste sensations. Some diabetics may be less able to perceive certain tastes. Other medical conditions besides cancer and diabetes that are implicated with olfactory decline include acute and chronic liver disease/cirrhosis, allergic rhinitis, Alzheimer’s disease, Bell’s palsy, bronchial asthma, chronic obstructive pulmonary disease, chronic renal failure, Cushing’s syndrome, epilepsy, head trauma, hepatitis, hyper- or hypothyroidism, hypertension, irritable bowel syndrome, mild cognitive impairment, multiple sclerosis, niacin (B-3) deficiency, obesity, Parkinson’s disease, postinfluenza conditions, sinusitis, Sjo¨gren’s syndrome, tumors and/or viral hepatitis. Obesity is considered its own disease and may also contribute to other diseases. Obesity may drive changes in the perception of the sweet taste. It may lead to alterations in the brain and specifically in the nerves that control the peripheral taste system. Obesity may also modify and/or reduce the taste cells on the tongue that may decrease a person’s response to sweet stimuli. And obesity may play a role in appetite and hunger control due to the condition of being overfat [34]. Some medications may nullify certain tastes and elevate others. Over 250 drugs are implicated in taste/ olfactory decline. These include many anticonvulsants, antidepressants, antihistamines, antihypertensives, antiinflammatories, antimicrobials, bronchodilators, cardiac medications, muscle relaxants, lipid-lowering medications, vasodilators and others. Genetic patterns and environmental factors may also interplay and affect different people at different times in their lifetimes, which in turn may have implications for taste and/or smell. While a sour taste may tend to stimulate the flow of saliva, dehydration, medications and/or radiation treatments may lessen it. Since saliva serves to moisten foods and also carry taste molecules, a reduction in saliva may be indicative of impending taste impairment—even without aging. “Dry mouth” may be due more to illnesses and medications than to aging, per se. Medications for diabetes, incontinence and psychiatric problems may also contribute to dry mouth sensations [35].

TASTE THRESHOLDS The degree of taste loss that a person incurs may be highly individualized. It may be ascertained by a measure that is referred to as a taste threshold. A detection threshold is the lowest concentration of a taste when it may be detected. A recognition threshold is the lowest concentration of a taste when it may be identified. For example, people may detect a taste as sweet and think that it is sugar, and then recognize the taste as honey as they consume more of it. Or they may initially detect the tastes of acidic, bitter, deliciousness, salty and sweet all at once, and not recognize that the combined tastes are actually tomatoey because tomatoes contain all of the basic tastes. In other words, detection generally precedes recognition—but not always the case. In particular, it is speculated that the taste thresholds for acids, bitters, salts and sweeteners may become elevated as people age, and so people may require more of these basic tastes in order for them to both detect and identify the foods, beverages, ingredients and products that contain these tastes [36].

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AGING TASTES A person is born with about 10,000 taste buds and this number may decline with aging. Young adults have about 250 taste buds per papillae throughout the entire oral cavity. Taste buds are reasonably able to regenerate. If an illness temporarily affects the taste buds, then they may “turnover” in an average of 10.5 days. Older taste buds appear to be less able to regenerate after disease or injury. Between the ages of 40 and 50 years the number of taste buds may begin to decrease. But they may decrease sooner due to a variety of circumstances that include conditions, illnesses and injuries. A higher incidence of hypogeusia may emerge among older women of all races compared with older men. This may be due to a greater usage of long-term prescription drugs [37]. A more noticeable decline in taste bud number may commence between the ages of 60 70 years of age. By the time a person is in their mid-70s, he may have as few as 100 taste buds per papillae or less. The consequences of this decrease in the number of taste buds are that a person may begin to lose their ability to distinguish the tastes of bitter, salty, sour and/or sweet foods and beverages. A person’s health may also affect these taste abilities. The most common causes are oral and/or systemic diseases, as well as the use of medications and zinc deficiency. The taste threshold levels for each of the basic taste qualities may increase with aging. The degree of loss of each of these basic tastes continues to be controversial. In contrast, the sense of smell does not seem to fade until after 70 years of age, which may intensify the loss of taste at this age and afterward. The combined effects of taste and smell losses may be even more significant during this time period when a host of other conditions and diseases may be on the upsurge. A common concern as people age, especially in care facilities, is the lack of taste, appeal and interest of foods and beverages. This is why the nutritional status of individuals who are diagnosed with chemosensory decline is fundamental to investigate and address [38]. As people age they may undergo physiological changes that may affect their taste for foods and beverages and their appetite, satiety, nutrition and health. These physiological changes may include the fact that the adult brain may be less efficient to train and to retain information. Moreover, there may be changes in the hypothalamus with regards to its function of relaying fullness. Aging adults may also easily become dehydrated that may decrease the amount of saliva to carry tastes, cleanse the tongue, lubricate the oral cavity and provide fluids that are necessary for healthy digestion. Fewer enzymes may also be available for normal digestion and there may be some stomach muscle shrinkage. People who are aging may have a decreased ability to detect foods and beverages that are sweet and thus may want sugary foods and beverages and/or add sweeteners to their foods and beverages. This may be fine for aging people who are not diabetic or overfat, but it may not suffice for people who are on carefully monitored diabetic diets or weight loss protocols. Another condition of aging may be “burning mouth syndrome (BMS)” whereby one’s tongue may tingle or burn and interfere with eating and/or drinking. The factors that contribute to BMS may include allergies, diabetes, gastrointestinal disorders that cause reflux, local trauma, renal disease, salivary dysfunction and/or vitamin B deficiencies. Furthermore, renal disease may contribute to a phantom taste that may be either bitter or metallic and cause unpleasantness. This may be secondary to the accumulation of uremic toxins, but may improve after dialysis treatment [39]. For some people who describe a decreased ability to perceive food flavor or who experience unpleasant tastes in foods or beverages, the sense of taste may be intact, but they may suffer from olfactory dysfunction. This may necessitate the intervention of medical specialists.

ORAL DISEASE Dentition, oral health and oral disease may affect food intake and gustatory function. Both proper dentition and oral health may decline during aging. The common complaint that foods and/or beverages taste bitter might be the result of poor oral health, including dental caries, gingivitis and periodontal diseases, oral

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candidiasis, stomatitis (or inflammation of the mouth and lips that may provoke the noxious bacterial products of dental-alveolar infections and tumors), tooth loss and/or xerostomia (or dry mouth). Adequate rinsing of the mouth, diligent brushing and/or massaging of the gums and tongue may be helpful. These conditions may lead to further mastication and swallowing problems, increase the risk of mucosal infections and interfere with the consumption of a wide variety of foods for both oral and general health and well-being [40].

USE OF MEDICATIONS Aging people who take a number of daily medications may have higher taste thresholds for sodium and sugar. Additionally, several drugs with sulfhydryl groups (such as captopril, methimazole, penicillamine and propylthiouracil), which are associated with angiotensin-converting enzyme (ACE) inhibitors, may induce hypogeusia, or bitter or metallic dysgeusia. Anticoagulants (such as clopidogrel), antiarrhythmic agents (such as metoprolol), antidepressants (such as tricyclic antidepressant compounds), anti-inflammatories [such as nonsteroidal anti-inflammatory drugs (NSAIDS like ibuprofen)], metabolic agents (such as biguanide and thiamazole), and/or diuretics may also affect the sense of taste in various means. Tobacco and tobacco products may alter chemosensation via a number of mechanisms. Individuals who smoke may have altered tastes of foods and beverages with high-fat content, such as chocolate, which may ultimately affect their food intake, weight and health [41].

BEHAVIORAL CHANGES Behavioral changes that may accompany aging may also interfere with normal taste sensations. Older adults may have a difficult time welcoming newer tastes due to past “programming,” or how they perceived certain tastes when they were younger. While taste may be dulled as people become older, this may also be beneficial since the aging may then become more tolerant of pungency. Consequentially, the process of aging may bring the appreciation of robust flavors, such as anchovies, game, pickled foods and/or sour cheeses. This is why repeated introduction of these foods may be warranted for approval.

IMPROVING THE SENSE OF TASTE Taste buds go through a lifecycle of growth from basal cells, development into taste cells and then their demise and removal. The normal taste bud lifecycle is about 10 days to 2 weeks. Taste dysfunction may result from an alteration of the renewal capacity of taste buds, due to physical or psychological stress, malnutrition or all of these factors. Alterations in taste may be observed in oncological patients who undergo chemotherapy and/or radiation usually due to direct radionecrosis of the salivary glands. Findings indicated a positive culture of Candida spp. and noted a close relationship between candidiasis and taste disturbances. Aging people who undergo middle ear surgery or tonsillectomy may also report taste ramifications [42]. What may be particularly concerning about taste loss for the articulated reasons is the condition of anhedonia, the inability to experience pleasure in the eating experience. To many, the act of eating is joyful and the loss of this pleasure may lead to decreased calorie, fluid and/or nutrient intake and further a loss in body weight. Malnutrition may provoke serious nutritional and medical consequences, either from under- or overnutrition. To help to uplift their mood as well as elevate their taste thresholds, aging people may be prompted to consume more sugar and salt and fewer foods and beverages with acidic or bitter tastes. Ironically, sweet and salty foods and beverages should be limited during the aging years due to their potential influence upon diabetes, hypertension and obesity, while nutrient-rich fruits and vegetables (sources of acidic and bitter tastes) should be encouraged for their disease-fighting potentials.

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TREATMENT OF TASTE AND SMELL DISORDERS To begin, accurate assessment of taste and smell disorders should be made to successfully identify, understand and treat any chemosensory disorders. Healthcare providers should inquire about any potential chemosensory losses very early in treating a patient. They should assess whether taste loss is a natural process of aging, or if some drugs (such as ACE inhibitors or DHP calcium channel antagonists) may lead to its manifestation. Serum ferrum and zinc are two microelements known for addressing taste disorders, so an evaluation of their status may also be warranted. Taste tests can be used for aging people to help to determine the lowest concentration of a substance that they may detect (detection threshold) or recognize (identification threshold). As the concentrations of substances increase and the intensities change, this information might be useful for assessing which of the basic tastes has declined the most or the least. Then dietary changes may be made to support or negate these changes. Other taste tests serve to measure different concentrations of substances that people may detect by “sipping, spitting and rinsing,” or by applying various strengths of substances directly on the tongue with an eyedropper. If a healthcare provider suspects that there may be head or neck issues that are involved in taste disorders, then an X-ray or CAT scan may be suggested [43].

STRATEGIES FOR ADDRESSING CHEMOSENSORY CHANGES It is important to understand that changes in taste do not always accompany aging; nor will every person who is aging experience many or all of the aforementioned chemosensory changes. In addition to care providers and otolaryngologist physicians who specialize in the ENT, registered dietitian/ nutritionists may be able to provide insights about any disinterest in foods and beverages, food enrichment, food supplements, poor appetite and satiety, vitamin and mineral supplementation and weight loss or weight gain. Speech and language therapists may offer some advice and guidance about swallowing difficulties. If any type of dietary adjustments is needed, they should work closely with registered dietitian/nutritionists and other healthcare providers. Occupational therapists may offer advice on adaptive eating tools that may include cutlery and tableware that support independent living. More information about these tools can be found in Chapter 11, Cooking Aids, Tableware Tips and Dining Advice, and in Chapter 12, Prime Time Resources for Aging, Taste and Health. Dentists may help aging people maintain oral health, assuming that aging people seek proactive dental care. Psychologists and psychiatrists may provide the support that some aging people may need to ward off depression, maintain a positive outlook on food and life and/or deal with the potentially debilitating problems that stem from dysphagia. The use of food and beverage enhancement may help to improve dietary intake. So may simple dietary techniques, such as varied meals and socialization. Despite taste decline, people tend to engage more in eating when there is interest in a food or a meal and when in a communal situation. These scenarios are discussed further in Chapter 6, Flavor Enhancement Ingredients, and Chapter 7, Flavor Enhancement Techniques.

DIGEST While research on chemosensory losses with aging is ongoing, there is a general consensus about the decline in taste and smell with aging. This reduction may be concurrent with overall declines in other bodily systems and functions as people approach the end of their lives. However, the recognition, identification and/or treatment of chemosensory disorders in the aging may not be as advanced as changes in eyesight or hearing and their corrective measures. This is unfortunate since taste and smell are such requisites for nutritious eating and drinking, the prevention of diseases, health and wellness. Regular medical consults are needed to help to identical any behavioral, mental or physical changes that might indicate taste or smell decline. Proactive interventions by registered dietitian/nutritionists may help to identify troublesome tastes or smells and resolve many nutritional gaps. Specific taste and/or smell tests may be warranted to further disclose the roots of taste or smell disorders and necessary steps to consider.

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As global and US aging continue to grow exponentially, it behooves care providers, family members and friends of people who are aging, healthcare practitioners and the aging themselves to raise their awareness about the effects of chemosensory changes and to take appropriate and reasonable actions, such as those found in Chapter 6 through Chapter 12 of this text.

MANNER OF SPEAKING ACE Inhibitors Acidic Taste (Acidity or Sourness) Acridity Ageusia Alkaloids Amino Acids Angiogensin-converting Enzyme (ACE) Inhibitors Anhedonia Appetitive Behavior Responses Augmented Gustation Aversive Behavior Responses Beta-glucans Bitter Taste (Bitterness) Brassicaceae (or Cruciferae) Family

Burning Mouth Syndrome (BMS) Cacogeusia Calcium Channel Blockers Calcium-Sensing Receptor (CaSR) Candida spp. Capsaicin Carbonation Caustic Soda Chemesthesis Circumvallate Papillae Chorda Tympani Coumarins D-amino Acids

pharmaceutical drugs; primarily used to treat congestive heart failure and hypertension one of the five basic tastes; triggered by acids with hydrogen ions (H 1 ) biting or sharp to the taste or smell; irritating to the eyes, nose or mouth the loss of taste functions of the tongue; inability to taste the five basic tastes naturally occurring chemical compounds primarily found in plants; include ephedrine, morphine, nicotine and strychnine organic compounds that contain amine and carboxyl functional groups along with a specialized side chain; the building blocks of life drugs primarily used to treat congestive heart failure and hypertension inability to feel pleasure actions that increase the likelihood of satisfying particular needs improved action or faculty of tasting learned negative or undesirable reactions to unpleasant event(s) sugars found in cell walls of algae, bacteria, fungi, lichens, yeasts and some plants, such as barley or oats one of the five basic tastes; often described as disagreeable, pungent or sharp a family of flowering plants commonly known as the mustard family; contains arugula, broccoli, Brussels sprouts, cabbage, kale, mustard greens, rutabaga and turnips, among others a painful burning sensation on the tongue or in the mouth; may include dry mouth, loss of taste or bitter, metallic taste a bad taste; not due to drugs, food or other ingested substances several medications that have the capacity to disrupt the movement of calcium through calcium channels a protein-coupled receptor that senses the extracellular levels of calcium ions (Ca21) a genus of yeasts; the most common cause of fungal infections an active ingredient in chili peppers; an irritant that may produce a sensation of burning reaction of carbon dioxide (CO2) and carbonic acid (H2CO3) and liquid (s); adds “bite,” fizz or a slight burning sensation a common name for sodium hydroxide (NaOH); also known as lye; produces heat when dissolved in water the chemical sensibility of the mucous membranes and the skin large specialized taste buds (papillae) located toward the very back of the tongue, near the tonsils; help the identification of unpalatable tastes a branch of the facial nerve; originates from the taste buds in the front of the tongue; transmits taste messages to the brain vanilla-scented compounds found in many plants; used for flavoring foods and/or beverages chiral forms of L-amino acids; function in nonribosomal Physiology; some found in cell wall bacteria

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Detection Threshold Dihydrochalcones Disinfectant By-products

Disodium Guanylate

Disodium Inosinate Dysgeusia Ear, Nose and Throat Specialists (ENTs)

Electric Taste Electrolytes Enzymes Esters Five Basic Tastes Flavor

Flavonoids Foliate Papillae

Food Adventurousness Food Neophobia Fungiform Papillae G Protein Gustducin G Protein-Coupled Receptors (GPCRs) Gamma-Glutamyl Peptides Genotypes (such as hTAS2R38 PAV/PAV, PAV/AVI and AVI/AVI) Glycosides Glucose Polymers Glucosinolates

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lowest concentration (or weakest stimulus) of a certain substance that can be detected or is perceivable chemical compounds related to chalcone (an aromatic ketone); basis of many biologically active compounds also known as trihalomethanes; formed when chlorides and bromine interact with natural organic materials in water; include chlorinated drinking water a natural disodium salt of the flavor enhancer guanosine monophosphate (GNP); food additive often used in conjunction with glutamic acid a natural disodium salt of inosinic acid; food additive used in combination with MSG to provide the umami taste a distortion of the sense of taste; may be altered, persistent and/or unpleasant also known as otolaryngologists; physicians who are trained in the medical and surgical management and treatment of diseases of the ear, nose and/or throat a sensation that is elicited when certain parts of the tongue are stimulated substances (minerals) that produce electrical charges when dissolved in solutions such as water; capable of conducting electricity substances produced by living organisms; act as catalysts for specific biochemical reactions chemical compounds; made by replacing the hydroxyl of an acid with an alkyl group; components of essential oils and naturally occurring fats acidic (sourness), bitter (bitterness), salty (saltiness), sweet (sweetness) and umami (savoriness) the sensory impressions of beverages, foods and other substances as mainly determined by the senses of smell, taste; also by appearance, sound, texture and other components a diverse group of phytonutrients; found in most all fruits and vegetables; responsible for vivid colors along with carotenoids short, vertical folds on each side of the tongue with embedded taste buds which can distinguish the five basic tastes; are innervated by the facial nerve characteristic of food risk-taking, as defined by culture and family, especially in childhood reluctance to eat; avoidance of new foods club-shaped projections on tip and sides of tongue; embedded with taste buds; respond mainly to sour and sweet tastes a protein that is found in some taste receptor cells; associated with the gustatory system and taste a protein family of receptors; detect mediate physiological responses to environmental stimulants, hormones and neurotransmitters types of enzymes that catalyze reactions; key contributors to the kokumi taste of edible beans genetic constituents of organisms; involved with bitter taste sensitivities a compound formed by a combination between a saccharide (sugar) and another functional chemical group, such as a hydroxyl compound densely branched glycogen; known as “animal starch” and cellulose biologically active sulfur-containing compounds; natural components of many pungent aroma and bitter-tasting plants

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136 Glutathione (GSH) Gustation Gustatory Calyculi Haptic Perception Hard Water Huitlacoche Hydroxide

Hypogeusia Kokumi L-histidine

Lactones Limiting Amino Acids Low Autoletics Lysine

Maillard Reaction or Maillard Browning

Maltooligosaccharides Mastication Medium Tasters Medulla Oblongata Methylxanthines

Minerals

Modified Sugars

Monosodium Glutamate (MSG) Myelin Naringin

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antioxidant in animals, some bacteria and archaea, fungi and plants; detoxifies and prevents cellular damage the action or capacity of tasting taste buds found on the tongue and adjacent parts; certain modified epithelial cells arranged in flask-like shapes the human ability to feel and interpret objects based on touch water with a high mineral content; principally salts of calcium and magnesium as bicarbonates, chlorides and sulfates a smut plant disease on maize and teosinte; caused by a pathogenic fungus; earthy; and smoky in flavor a chemical compound that contains a hydroxyl group; an important constituent of water; performs many biological functions, including as a catalyst in reactions a diminished sense of taste a Japanese taste concept; a certain type of mouthfeel that the body detects through calcium channels on the tongue a conditionally essential α-amino acid; used in the biosynthesis of proteins; benefits digestive, nervous and reproductive system, fat loss and muscle growth organic compounds with ester (OCO) group; many occur in essential oils and more complex molecules with low volatility amino acids not found in food; may limit protein synthesis; include lysine, methionine threonine and tryptophan a low degree of having a purpose in an activity or creative work and not apart from this venture an essential α-amino acid that is used in the biosynthesis of proteins; used to make medicine and prevent and treat cold sores (herpes simplex labialis) a chemical reaction between amino acids and reducing sugars; yields browning and complex, distinct flavors, such as charred, malty and/or toasty derived from glucose monomers; linked as in maltose; produced from the hydrolysis of starch to masticate or chew; the process by which food is crushed and/or ground by the teeth into smaller components people who have inherited PAV genotypes from one parent and AVI from another parent; a “medium” responsiveness to the bitter taste the lowest section of the brainstem; contains the control centers for the heart and lungs a unique class of drugs derived from the purine base xanthine; produced naturally by animals and plants; includes caffeine, theobromine and theophylline naturally occurring solid inorganic substances distinguished by chemical and physical properties; include essential (such as calcium and potassium) and trace (such as iron and zinc) changed sugars, generally by replacing one of more hydroxyl ( OH) groups with other functional groups; include caramel, golden syrup and high fructose corn syrup the sodium salt of glutamic acid, an abundant and naturally occurring nonessential amino acid; broad use as a flavor enhancer a fatty white substance that is a mixture of phospholipids and proteins; forms an insulating sheath around nerve fibers a flavonoid glycoside abundant in the skins of grapefruit and orange; provides the bitter taste and other diverse biologic activities

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MANNER OF SPEAKING

Nixtamalization Nontasters Nucleic Acids Nucleotides Oral Disease Otolaryngologist Papillae Peptides pH/pH Scale Phantom Taste Phenols/polyphenols

Phenylthiocarbamide (PTC) Polycose Polyphenols Primary Somatosensory Cortex PROP (6-n-propylthiouracil) Protamine Protein PKD2L1 PTC (Phenylthiocarbamide)

Pyrophosphates Radionecrosis Recognition Threshold Salty Taste (Salt, Salts or Saltiness)

Soapy Taste Sodium Hydroxide

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process for chemically preparing maize or other grains; increases bioavailability of niacin and protein and reduces toxins people who are AVI/AVI in genotypes are insensitive to bitter tastes complex organic substances in living cells; essential to life as DNA or RNA compounds that consist of nucleosides linked to phosphate groups; form basic structural components of nucleic acids, including DNA a host of oral diseases, from dental cavities to cancer that affect oral health physician trained in medical and surgical management and treatment of people with ear, nose and/or throat (ENT) diseases and disorders a small, rounded protuberance or projection that contain taste buds; involved in taste short amino acid monomer chains linked by peptide bonds; play key roles in regulating the activities of other molecules potential of hydrogen; a numerical scale that is used to specify the acidity or basicity of aqueous solutions a common taste disorder; the perception of a lingering and often unpleasant taste though nothing fills the oral cavity a class of organic chemical compounds with a hydroxyl group ( OH) bonded to an aromatic hydrocarbon group; some antioxidants considered cancer chemopreventives an organosulfur thiourea; a chemical that either tastes very bitter or tasteless depending upon genetic determinants a glucose polymer module; a readily digestible carbohydrate for increased energy needs compounds largely found in plants that include flavonoids and phenolic acids; many act as antioxidants with potential health-enhancing benefits area of brain located in the parietal lobe; part of the somatosensory system that processes auditory, pain, skin and visual stimuli a bitter marker compound that identifies supertasters; used as a thyroid medication that tastes like quinine a positively charged protein molecule; rich in the amino acid arginine; function in DNA stabilization a gene that encodes a member of the polycystin protein family; the encoded protein may be involved in cell-cell/matrix interactions a chemical substance with an organosulfur thiourea with a phenyl ring; either tastes bitter or tasteless depending upon the taster; resembles alkaloids in some poisonous plants metabolic by-products of many intracellular reactions; major source appears to be extracellular ATP a major complication or tissue death; may follow the use of radiotherapy in the treatment of malignant tumors the level at which a stimulus (such as taste) may be both detected and identified one of the five basic tastes; primarily produced by the presence of sodium ions; sensed by taste receptors that mostly respond to sodium chloride (NaCl) or table salt a sensation in the mouth; usually a symptom of overexposure to sodium fluoride in oral products or fluoridated water, carrots or cilantro a white, crystalline odorless solid; known as caustic soda and lye; when dissolved in water or neutralized with acid, it liberates heat

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Starchy Taste Stomatitis Strong autotelics Strychnine Sulfimides Substituted Aromatic Substances Sulfhydryl groups Supertasters Sweet Taste (Sweet or Sweetness) Synesthesia T1R2 1 3 (Heterodimer) and T1R3 (Homodimer) TAS1R1 and TAS1R3 Taste Antagonists (Taste Antagonism) Taste Augmentation Taste Blindness Taste Buds Taste Enhancement Taste Juxtaposition (Juxtaposed Tastes) Taste Opposition Taste Threshold Temperature Terpenes Touch

Trigeminal Nerve Umami Taste (Savoriness or Meatiness) Urea Viscerosensor-Sensory Cues

a sensation of complex carbohydrates, such as starch; described as bread, flour or pasta-like inflammatory process that affects the mucous membranes of the mouth and lips a strong persistence to absorb oneself to the point of subconscious flow and mastery a bitter, colorless, highly poisonous alkaloid; used in nonketotic hyperglycinemia and sleep apnea chemical compounds that contains a sulfur to nitrogen double bond; stabilize collagen strands aromatic substances (usually ring-shaped) that replace other chemical compounds in a chemical reaction families of organic compounds that contain an R group bound to a sulfur and a hydrogen atom; common in enzyme activation and proteins individuals who experience certain taste sensations with more intensity than others; especially high sensitivity to the bitter taste one of the five basic tastes; flavor of fructose, glucose, maltose, lactose and sucrose; essential to life the production of a sense impression that relates one sense or body part to another through stimulation two different taste receptors that bond and help to create the sensations of the sweet taste taste receptors that serve to produce the umami taste; activated by a broad range of amino acids inhibition or interference of taste as opposed to taste opposition; often due to the action of one substance by another the ability to augment or increase the sense of taste and/or flavor an inability to detect certain substances as bitter, such as PTC; likely due to an autosomal recessive trait clusters of bulbous nerve endings; located on the tongue and within the lining of the mouth; help to provide the sense of taste the ability to enhance the sense of taste; often to bring out flavor without adding a distinct flavor on its own tastes that neither fight with each or marry together, but are side by side for comparison tastes that may highlight or cancel the other tastes where they are exposed as opposed to taste antagonism the minimum concentration at which taste sensitivity to a certain food or substance may be detected or identified the degree or intensity of heat that is present as measured in a comparative scale; may affect the perception of smell and/or taste a group of volatile hydrocarbons; found in fragrant plant essential oils one of the five senses; a sensory modality that allows people to sense and identify what they come into contact with and/or are close to their proximities related to or mediated by the sensory innervation of the viscera (internal organs in main cavities of the human body) one of the five basic tastes; characteristic of substance with the amino acid glutamate, such as aged cheese, canned seafood and cured meats an organic compound; serves an important role in the metabolism of nitrogen-containing compounds by animals related to the sensory innervation of the internal organs

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REFERENCES

Zinc Acetate Zingerone

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a salt of zinc; often used to help treat a zinc deficiency; found in lozenges for treating the common cold a crystalline solid also called vanillylacetone; considered a key component of the pungency and sweetness of ginger

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redirectedFrom 5 PDF. [accessed 03.09.18]. Google Patents, Appetizing factor and taste enhancer, ,https://www.google.com/patents/ US20040247741.; Palatability of cat food with sodium pyrophosphate and yeast extract, ,http://www.scielo.br/scielo.php? script 5 sci_arttext&pid 5 S0103-84782016001202202. [accessed 03.09.18]. [23] Clarke, N. Is sodium acid pyrophosphate dangerous? Livestrong.com, ,http://www.livestrong.com/article/549169-is-there-any-dangerin-using-sodium-acid-pyrophosphate-in-food-mixes/.; 2017 [accessed 03.09.18]. [24] MDDK, Soap taste in mouth, ,http://mddk.com/soapy-taste-in-mouth.html. [accessed 03.09.18]. [25] Hamzelou, J. There is now a sixth taste—and it explains why we love carbs. New Scientist/Daily News, 2 Speptember 2016, ,https:// www.newscientist.com/article/2104244-there-is-now-a-sixth-taste-and-it-explains-why-we-love-carbs/.; 2016 [accessed 03.09.18]. [26] To get the full flavor, you need the right temperature. New York/Heidelberg: Springer Select; 2012. 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Geriatric nutrition, the health professional’s handbook. 2nd ed. Gaithersburg, MD: Aspen Publishers, Inc.; 1999. p. 195. [33] U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Deafness and Other Communication Disorders. Taste Disorders, ,https://www.nidcd.nih.gov/health/taste-disorders. [accessed 03.09.18]. [34] Maliphol AB, Garth DJ, Medler KF. Diet-induced obesity reduces the responsiveness of the peripheral taste, ,http://www.plosone.org/ article/info%3Adoi%2F10.1371%2Fjournal.pone.0079403. [accessed 27.03.14]. [35] WebMDs. Oral care, reference, why might my sense of taste change? ,http://www.webmd.com/oral-health/tc/taste-changes-topicoverview. [accessed 03.09.18]. [36] Stevens JC, Cain WS. Changes in taste and flavor in aging. Crit Rev Food Sci Nutr. 1993;33(1):27 37 ,https://www.ncbi.nlm.nih.gov/ pubmed/8424851. [accessed 03.09.18]. Fukunaga A, Uematsu H, Sugimoto K. 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[40] Ship JA. The influence of aging on oral health and consequences for taste and smell. Physiol Behav 1999;66:209 15. Bozena BW, Leopold DA. Clinical assessment of patients with smell and taste disorders. Otolaryngol Clin N Am 2004;37:1127 42. [41] Ackerman BH, Kasbekar N. Disturbances of taste and smell induced by drugs. Pharmacotherapy 1997;17:482 96. Schiffman SS, Gatlin CA. Clinical physiology of taste and smell. Annu Rev Nutr 1993;13:405 36. [42] Alt-Epping B, Nejad RK, Jung K, Gross U, Nauck F. Symptoms of the oral cavity and their association with local microbiological and clinical findings—a prospective survey in palliative care. Support Care Cancer 2012;20:531 7. [43] Sasano T, Satoh-Kuriwada S, Shoji N, Sekine-Hayakawa YS, Kawai M, Uneyama H. Application of umami taste stimulation to remedy hypogeusia based on reflex salivation. Biol Pharm Bull 2010;33:1791 5.

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5 A Smell Primer

PHOTO: Lemon Zest. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: My sense of taste is fine, but I am just over 60 years of age. I enjoy what I eat and drink.

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Introduction

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The Sense of Smell (Olfaction) The Olfactory System Emotion Memory Habituation Motivation

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Aging, Nutrition and Taste. DOI: https://doi.org/10.1016/B978-0-12-813527-3.00005-3

Cognition (Conscious Thoughts) How Smells Are Perceived Expectations Interpretations Evolutions Genes Infants Pregnancy Adulthood

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146 146 147 147 147 147 148 148 148

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Types of Aromas Aroma Categorizations Multidimensional Aroma Classifications

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Aromas and Aging

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Smell and Behavior

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Pheromones

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Smell and Health

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Smell and Obesity

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Smell and Weight Loss

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Smell Disorders: Mechanical and Metabolic Types of Smell Disorders Diagnosis of Smell Impairment Smell Tests to Detect Olfactory Function Treatments for Smell Disorders Smell Fatigue

157 158 158 159 160 160

Smell Adaptations Improving the Sense of Smell Utilizing Smell Memory for Improving Smell Sensations

160 161 161

Interactions of the Sense of Smell with Other Senses Sight Sound Taste Touch

162 163 163 163 164

Challenging Assumptions About Chemosensory Changes with Aging

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Digest

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Manner of Speaking

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References

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LEARNING OBJECTIVES 1. Describe the sense of smell and its passageways, and how the sense of smell may be affected by the physiological changes that are associated with aging. 2. Differentiate the sense of smell from the sense of taste and its interaction with flavor, and indicate how each of these senses transforms independently and collectively throughout the aging process. 3. Recognize the vital significance of smell disorders, and note their potential effects upon health and disease, in addition to taste, flavor and enjoyment. 4. Indicate how the sense of smell interacts with the senses of sight, sound and touch to affect the sense of taste, and identify these impacts on aging. 5. Associate smell decline with aging, disease and health, and align age-appropriate improvements.

SUMMARY To fully examine the sense of smell, how the sense of smell interacts with the sense of taste, and what may be done to compensate for the probable loss of smell in the aging.

INTRODUCTION The sense of smell is referred to as the chemoreception olfaction. Olfaction is one of the oldest senses and one of the most important senses for interacting with the environment. Olfaction is critical for health and well-being; specifically for the capacity to identify aromas that are hazardous, nourishing, sexually satisfying and/or memorable. In humans, the sense of smell has important interconnections with language and neuro-vegetative areas (necessary to maintain life), and plays an important role in the identification of objects and in the modulation of behavior and interpersonal relationships. The sense of smell is able to accomplish these many functions because there are thousands of different smells and smell variations [1].

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Olfaction may be a person’s first response to stimuli, such as environmental poisons, fire or rotted food. Long before a person sees a food or beverage or tastes their nuances they may be able to detect their odors. As few as one molecule in a million may be perceived by the nose, but it may take a minimum of one part per thousand to stimulate the taste cells. The human nose may be able to discern an almost infinite number of smells. In contrast, humans are able to distinguish several million different colors, over 300,000 audio tones and five basic tastes. Once they are sensed, then odors are transmitted to the brain where they are interpreted, identified and often acted upon rapidly. The only other bodily system that utilizes chemicals in a similar manner is the immune system that identifies, gives significance to, and memorizes new molecules. Along with hunger, the sense of smell drives humans to eat and drink, and this drive is mainly for carbohydratecontaining foods and beverages, which are the body’s main energy source. Since the body’s most sensitive receptors are for smell, people do smell and seek out carbohydrates for energy. They are driven to the sweet smell of baked goods or sweetened beverages, for example, because they generally signify a sign of calories to come. While the sense of smell is so easily stimulated, it is also very fragile and may easily deteriorate or fatigue. Some adaptations may be short term; other modifications may take more time, or they may not return fully. Identification of smell losses with mechanisms for changes is key to olfactory recovery [2]. Due to beliefs, cultures, genes, past experiences and a host of other reasons the same scent might be perceived differently from one individual to another. Disease processes that cause or are associated with smell disorders may be fleeting (as in a cold), metabolic (as in vitamin or mineral deficiencies) or permanent (as in head trauma or tumors). With aging, there appears to be a decline in the sense of smell, although many individuals may not be aware of this debility until food tastes poorly or there is undetected chemical exposure. While there are tests that measure the loss of smell, regular examinations and evaluations by healthcare professionals may identify olfactory losses before they become critical. Discovering about the process of olfaction and how it affects taste, flavor and environmental toxin identification is an important step in this direction [3].

THE SENSE OF SMELL (OLFACTION) The sense of smell, or olfaction, allegedly was detected in ancient times. Lucretius, an Epicurean and atomistic Roman philosopher during the 1st century BCE, speculated that different odors are attributed to different shapes and sizes of odor molecules that stimulate the “olfactory organ.” Hundreds of years later in 2004, olfactory researchers Linda B. Buck and Richard Axel were awarded the Nobel Prize for the cloning of olfactory receptor proteins and subsequent pairing of odor molecules to specific receptor proteins. This discovery confirmed that like taste and taste receptors, odor molecules are detected by odor receptors [4]. So like gustation or taste, the sense of smell or olfaction is a type of chemoreception: a physiological process whereby organisms respond to chemical stimuli. Humans and other “higher animals” have two primary types of chemoreceptors: taste or gustatory, and smell or olfactory. Similar to gustation, the olfactory sensory system relies on molecular chemical compounds within substances to distinguish environmental data. While gustation depends on the main sensory structures involved with taste, olfaction depends on the nasal cavities with their olfactory receptors and the transduction of odors from the environment into neural impulses. Olfaction is closely tied to gustation, as well as to the other senses of sight (vision), sound (audition) and touch (somatosensation). Olfaction is also the sense that is closely connection with memory, due to its close neural networks to the parts of the brain that are responsible for emotion and place memory [5]. When olfaction works in conjunction with gustation to perceive complex flavors, this interaction is referred to as chemoreceptive sensory interaction. If the olfactory or gustatory systems are compromised (as they may be with differing conditions and/or with aging), then foods and beverages may smell, taste or smell and taste differently. This is one of the reasons why olfaction is so essential to life—in fact, about 5% of human DNA is devoted to this basic sense. Early in the lifecycle, the sense of smell may elicit orientation and movement toward maternal odors in newborn babies. Later in the lifecycle, the sense of smell may trigger some humans to follow a scent trail. With training, it is thought that humans might be capable of doing tasks that were considered to be the exclusive domain of nonhuman animals. For example, as people age and their eyesight diminishes, their sense of smell might be able to help them maneuver their environment, much like some animals use this sense to master their surroundings [6]. AGING, NUTRITION AND TASTE

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The Olfactory System Odorants, or odor molecules, are chemicals that are vaporized and travel via the air to the nostrils. Typically odorants encounter the cilia of the sensory neurons that are immersed in a layer of mucous on the roof of each nostril where they dissolve. Specifically, sensory receptors, also called chemoreceptors, are enmeshed within the olfactory epithelium, a patch of tissue similar in size to a postage stamp that is highly situated in the nasal cavity. The olfactory epithelium is composed of sensory neurons with each containing a primary cilium, supporting cells and basal cell that replenish the sensory neurons that perish. The olfactory epithelium is where the neurons detect different odors; in fact, they are capable of detecting literally thousands of various odors so their integrity is of upmost importance. Once the odorant molecules dissolve in the mucus lining they bind to the receptors on the cilia. These are referred to as transmembrane proteins. This process then activates a G protein that is coupled to the receptors, and then adenylyl cyclase (AC), an enzyme that is rooted within the cilia’s plasma membrane. AC catalyzes the conversion of adenosine triphosphate energy to cyclic adenosine monophosphate (cAMP). In turn, cAMP opens sodium channels that diffuse sodium into the cells, that generates an action potential when a threshold is reached. This action is conducted along the olfactory nerve to the olfactory bulb at the back of the nose, where sensory input interacts to identify the smell(s), and to evoke smell memory(s) and emotion(s) [7]. The sensory receptors within the olfactory bulb accomplish this action by sending messages to the most primitive parts of the brain (the limbic system structures where emotions and memories are influenced). The limbic system is composed of connected structures within the middle of the brain, and is linked with the central nervous system (CNS). These structures work collectively to affect many behaviors that include emotions, memory and motivation, and are more automatic or instinctive versus intentional in nature. The limbic system is also responsible for the translation of sensory information from the neo-cortex into motivational forces that promote certain behaviors. Messages that are sent to the neo-cortex, or higher center of the brain, may modify a person’s conscious thoughts. When the primitive and the higher-brain centers combine efforts, they are capable of perceiving smells, accessing smell memories and evoking emotions in reaction to a wide range of smells. The human sense of smell is more sensitive than other senses, so smell recognition may be fairly instantaneous. In comparison, the senses of taste and touch need to communicate through neurons throughout the human body and the spinal cord before they reach the brain. This system provides direct exposure from the environment to a person’s CNS, and is one reason why toxic smells may potentially be dangerous [8].

Emotion More than any other sense, olfaction successfully activates emotions and memory. This may be because the olfactory bulb directly connects to two brain areas with significant implications for emotion and memory: the amygdala and hippocampus. The amygdala is one of two almond-shaped groups of nuclei that is located deeply and medially within the temporal lobes of the human brain, and is considered to be part of the limbic system. It has a primary role in decision-making, emotional reactions and memory. Older adults tend to show less amygdala activity than younger adults; however, less amygdala response to negative stimuli is not necessarily an indication of poor function. The hippocampus is also located in the medial temporal lobe of the human brain and is also a part of the limbic system. It performs vital functions in the consolidation of short and long-term memory and in spatial memory that facilitates navigation. In Alzheimer’s disease, the hippocampus is one of the first regions of the brain to deteriorate. Auditory, tactile and visual information are not processed within these brain areas. While the perfume industry has developed state-of-the art creative packaging for visual appeal, fragrances are developed for their emotional responses: desire, earthiness, power, relaxation, sweetness and vitality and the nuances of other esoteric responses. The sense of smell is also very important from an emotional perspective with regard to the social/sexual attraction between people. Human body odor, produced by genes that make up the immune system, assist in partner selection. Sniffing, smelling and tasting (through kissing) either confirm or negate a match.

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Emotional responses to smells are generally ruled by connections: individual perceptions of the same smell(s) may be experienced differently. This may be the case with perfumes that appeal to a wide range of consumers, but may be repugnant to others. Very offensive smells, such as rotten food, smoke or toxic chemicals, may elicit universal emotional responses [9].

Memory People who have full olfactory function may be able to recollect specific smells that evoke distinct memories. The experience may occur instantly as when one walks into a bakery and smells a particular style of fresh bread or pastry. Due to the olfactory bulb’s positioning within the limbic system, or emotional brain, smells rarely have a neutral reaction if the olfactory system is intact. Even an unborn child that is exposed to certain environmental substances (such as cigarette smoke) or tastes (such as odorous garlic or onions) may demonstrate a preference or dislike for them after birth. Explicit memory is a term that describes the memories that are recalled by conscious thoughts. With regard to olfaction, explicit memory attributes associative meaning to odors and to nonodor stimuli. It includes information to process and compare confronted odors. Odor recognition and identification are common tests for explicit odor memory. Implicit memory is a term that describes the memories that do not require conscious recollection of the initial encounter of an odor. For odors to form in the brain, deliberate recollections of odor experiences are not essential. Common tests for implicit memory include those that measure previous exposure to similar stimuli: classical conditioning, habituation, perceptual learning and/or sensitization. These types of tests may be especially useful in evaluation of brain injuries. Measures to utilize smell memory for invoking pleasant thoughts about beverages, foods and dining experiences may be found within the upcoming section on Improving the Sense of Smell.

Habituation The concept of habituation refers to decreased responsiveness to odors due to prolonged exposure. It involves decreased attention and sensitivity to stimuli that may no longer appear to be novel. This is may be due to the adaptation of receptor neurons in the olfactory system in reaction to certain odors. During habituation, fewer neurotransmitters may be released at the synapse. Yet, in sensitization there are more presynaptic transmitters. Also, the neuron itself tends to be more excitable. The neurotransmitter norepinephrine is thought to have effects on olfactory functioning with regard to habituation [10].

Motivation Motivation is closely related to emotions in the brain where smell information projects into the medial temporal lobe near the midline of the cerebrum. The limbic system’s network of connected structures that are linked within the CNS work together and affect a wide range of behaviors. Motivation is also concerned with translating sensory information from the neo-cortex, or the “thinking” area of the brain, into motivation or incentive that translate into behaviors. This anatomically interconnected network of nuclei and cortical structures is critical to the survival of individuals and species that includes the identification of predators, the location of food and the recognition of individuals for procreation or social hierarchy. Complex behaviors may be modulated by odors and prompted by motivations to produce adaptive responses. Humans who are compromised in their senses of vision and/or hearing may rely on their other senses, namely smell and taste to compensate. They may be motivated or inspired to perform or undergo certain activities that are based on environmental factors, such as pleasing aromas. For example, the wafting smell of freshly baked cookies may arouse a person’s hunger even if she cannot see the cookies. Or chemosensory compromised older individuals may be motivated to taste a very aromatic soup if they take a deep whiff—despite not being able to adequately see its contents.

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Cognition (Conscious Thoughts) Cognition, or conscious thoughts, may significantly influence the perception of smell. Humans possess unique abilities to detect and discriminate odors. They tend to have less ability to identify certain odors. This may be due to lack of language skills to describe particular odors that tend to be more sensory than cognitive in nature. Olfactory cognition has some features in common with auditory and visual cognition, but it is also unique. Of concern is that mild cognitive impairment and Alzheimer’s disease have been demonstrated in olfactory dysfunction. While age is associated with decline in many cognitive functions, some cognitive changes might also indicate a disease process that may culminate in dementia. A noticeable loss of smell has been correlated with neurodegenerative diseases such as Alzheimer’s or Parkinson’s disease and other forms of dementia. Demographic and genetic factors may also interplay. The olfactory receptor neurons (ORN) also known as olfactory sensory neurons (OSN) have two notable properties: the first is that they are nerve cells that are closely related to nerve cells in the brain, and the second is that they continually regenerate throughout the lifetime, unlike brain nerve cells. A decline in olfactory performance may be indicative of changes in the functional or regenerative abilities of the ORN. This condition may also signal neuronal deterioration. If any changes are questionable, smell identification tests may be warranted [11]. The University of Pennsylvania Smell Identification Test (UPSIT) can be used to test the functionality of an individual’s olfactory system. It measures a person’s ability to detect odors at a suprathreshold level. The UPSIT has application in the diagnosis of conditions and diseases that are classified as degenerative neuropsychiatric disorders. These include acquired immunodeficiency syndrome, Alzheimer’s disease, brain tumors, congenital anosmia, head trauma, Huntington’s disease, Korsakoff’s psychosis, multiple sclerosis, Parkinson’s disease and/or schizophrenia. More information about these conditions and/or diseases can be found in Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging. As people age, they may undergo several stages of olfactory dysfunction. Individuals with the most dysfunction also tend to be the ones with the most pathology, such as Alzheimer’s or Parkinson’s disease.

HOW SMELLS ARE PERCEIVED As with the sense of taste, olfactory sensation depends on a finely wired messaging system. This is dependent upon olfactory receptor cells in the nose and electrical messages via the olfactory nerve to the olfactory bulb, where the brain’s first processing of these sensations occurs. Each receptor is reportedly unique and ascribed to just one type of olfactory receptor. As nerve axons travel to the olfactory bulb, they coalesce to form hundreds of glomeruli, or tiny spheres. Each of the glomerulus obtains axons from the nose cells with a similar type of olfactory receptor. This is where the finely wired messaging system really interplays. The glomeruli are activated by many different receptors and the pattern is unique depending on the smell(s). This unique configuration is processed by the olfactory bulb, then dispersed to other areas of the brain. This distribution includes the limbic system where emotion and memory come into play, the olfactory cortex where conscious awareness is added and the orbitofrontal cortex where feedback from other sensory systems is obtained [12]. Rarely does a person have neutral reactions to smells. Rather, many reactions are based on pure emotional associations. By the time olfactory cognition correctly identifies and names a smell, the smell has probably activated the limbic system and triggered a deeply rooted emotional response. Take the scent of vanilla, for example. While the scent of vanilla is commonly thought to be a sweet and pleasant smell that influences mood and the sense of well-being (consider the strong scent of vanilla in body care products), it may actually be the expectations of the vanilla aroma that affect disposition and health benefits. This is why the use of the word vanilla in foods and beverages may evoke a happy feeling even before they are consumed. This may also be one of the reasons why vanilla ice cream is the most popular flavor of ice cream in the United States. The use of pleasant fragrances continues to have positive effects on mood, despite the projected decline of olfactory sensitivity as people age. Perceived differences in the stimulation of right and left nostrils with pleasant fragrances (such as vanilla) indicate differences in olfactory cortical neuron activity in the right and left hemispheres of the brain. The left hemisphere has shown predominant processing of positive emotions, while the right hemisphere has shown

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predominant processing of negative emotions, which may be produced by the perception of unpleasant fragrances [13]. By enhancing or altering smells, it may be possible to modify how smells are processed and the emotions that are evoked. For example, in the example of the cookies described in the previous section on “Motivation,” the amount of vanilla in the cookie recipe could be doubled to boost the vanilla aroma. This may be particularly helpful for people with dementia if they have forgotten the smell and/or taste of cookies altogether. Conversely, if ground nuts (with a bitter taste) are used in the cookie recipe, then the enhanced vanilla flavor may not only boost the sweet taste, but may also serve to camouflage any bitterness [14].

Expectations Not only do smell and taste expectations influence a person’s taste ratings of foods and beverages, but they also may influence the consumption of accompanying foods. In other words, if people expect a delicious food or beverage, then they may consider the rest of the meal equally delicious. This concept is called “expectation assimilation.” It may also work in the opposite manner: if one anticipates that a food, beverage or meal will smell or taste poorly, then it just might happen. Additionally, brain imaging research demonstrates that as people consume what they consider to be an expensive beverage, areas of the brain that are linked with pleasure are more activated than if they think that the beverage in inexpensive [15]. Scent signals may also be affected by the milieu in which one encounters them; by how they are “packaged” (as in bottles, cans, cartons, etc.); and when and where they are sensed. Visual cues should also connect with expected scents, such as peaceful or stimulating images in conjunction with soft or rousing aromas (e.g., the smell of cotton candy and summer at the beach, versus blackened marshmallows and a fireplace hearth) [16].

Interpretations The manner in which scents are interpreted involves the areas of the brain that process the electrical signals that travel from the sensory neurons to the olfactory bulb. One of these areas is called the piriform cortex, a collection of neurons located just behind the olfactory bulb that function for smell identification. Other smell information travels to the thalamus, which functions as a “relay station,” or transmitter for sensory information that travels into the brain. Some smell information is transmitted from the thalamus to the orbitofrontal cortex where it is integrated with taste information. If any of these brain areas are compromised by age, disease or impairment, smell identification might be compromised. In the limbic system the smell(s) are interpreted in relation to past experiences. Then the smell(s) are processed and transmitted through a pathway to the CNS that manages cognition, emotions and behaviors. Reactions may be, “I like that smell since it reminds me of my grandma’s chicken soup, and I’d like to have some right now,” versus “I do not like that smell because it reminds me of my uncle’s cigar smoke that infiltrated our bread, so I don’t want to eat it!” [16].

Evolutions Global studies of genes have helped to provide insights into how the taste for different foods and beverages may have been influenced by variations in the ability to smell. In turn, the sense of smell, as it is linked to foods and beverages, has played decisive roles in human societies. Likewise has the identification of pleasant and unpleasant substances, edible and nonedible.

Genes The smell receptor OR7D4 enables humans to detect androstenone, a very specific odor that is produced by pigs and found in boar meat. If people have different DNA sequencing in the gene that produces the OR7D4 receptor, then they may respond different to this odor.

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Populations that have different gene sequences tend to respond differently in their ability to detect this substance. Humans evolved from African roots where populations were able to detect this odor, as opposed to populations in the northern hemisphere. This is just one example of how gene sequencing is so diverse and has evolved to affect odor acceptance or rejection. For most mammals, the sense of smell is dominant. Humans have fewer olfactory receptors than dogs or mice. But the gene family is still large. The human genome contains around 900 genes and pseudogenes (genes that have either lost their ability to produce proteins, or fail to produce them within a particular type of cell) that are associated with smell perception; this provides some idea about how difficult it is to gain access to individualized smell perception and assess its decline. In humans (as compared to other species) the number of human olfactory receptor genes may be more pseudogenes than genes. Emotional stress, the act of eating, the immune system, reproduction and social communication may be individually or mutually involved [17].

Infants The human fetus may detect smells even before childbirth. Amniotic fluid is sweet and so is human breast milk. Right after childbirth, an infant may be able to detect early breast milk and seek its first breastfeeding. After the first trimester of pregnancy, the fetus may be able to smell the foods and beverages that the mother is consuming. Smell is the predominant sense because it can cross the amniotic fluid. The senses of smell and taste are considered to be the most powerful at birth, while the sense of hearing fully matures about 1 month after birth, and the sense of sight develops progressively throughout the first year of life. After the end of the first week of an infant’s life, its nose is so finely adapted that the infant may be able to discriminate among different types of breast milk, if necessary. By 1 month of age, an infant might find strong aromas to be overwhelming. These strong scents might interfere with its sense of taste, so it is advisable to avoid fragranced skin care products and/or very odorous perfumes. By 3 months of age an infant may be able to discriminate among the people in their life by their aromas. By 6 months of age when many US babies are weaned to solid foods, the aromas and tastes may begin to dictate preferences or rejections. Then by 10 months to 1 year of age, an infant’s sense of smell and taste may make feeding more challenging, as food and beverages predilections really begin to occur. Flavor complexity depends on food odor. While food odor permits a person to discriminate among the subtle differences amid foods and beverages (such as members of the “stone” family with its apricots, peaches and plums), it may also be overwhelming (such as the odorous Brassicaceae family that includes broccoli Brussels sprouts, cabbage and cauliflower). Food odor familiarity may be essential to help foster healthy feeding experiences.

Pregnancy Anecdotal reports of increased olfactory sensitivity and hormonal changes before and during pregnancy are common, although the scientific literature may not unconditionally support these reports. Olfactory sensitivity during pregnancy may function as an evolutionary mechanism to protect the developing embryo from environmental substances or ingested toxins. This heightened sensitivity may trigger nausea and/or vomiting during pregnancy. It is known that there is a complex interaction among hormones that underlie olfactory perception during pregnancy, estrogen being one such hormone. Human chorionic gonadotropin (hCG), a hormone that is produced by the placenta after impregnation, may stimulate the hormone estrogen. Estrogen levels tend to rise during pregnancy and reach their peak right before childbirth. Incidents of nausea and vomiting may also be correlated with hCG levels during pregnancy [18].

Adulthood While a decline in the sense of smell and taste may happen anytime during the lifecycle, due to such factors as the common cold or influenza, head trauma, nasal and/or sinus blockages and others, there may be more dramatic changes in both olfaction and gustation with aging.

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Individual ORN in healthy aging people may be less selective in their responses to odors. While they may respond to a wider range of odorous substances, they also may provide less discrimination among odors [19]. An acute sense of smell may last until age 50 or 60; then older adults may experience a subtle or radical decline, with more major chemosensory changes in the 70s and 80s, according to the 2015 2016 National Health and Nutrition Examination Survey. Definitive comparisons of chronological age and decline in cognition and olfaction characteristically require individualized examination and prognosis. Age-related anatomical and structural losses in the CNS may affect both cognition and olfaction in older adults. These may include plaques and tangles in the anterior olfactory nucleus, hippocampus and parahippocampal gyrus of older adults aged 54 89 years who may not exhibit any signs of dementia. These neuropathological changes have not commonly been reported in younger adults, yet are thought to underlie olfactory dysfunction in this older age group, and are hypothesized to affect the cognitive performance of certain tasks during adulthood and advancing years. It has been conjectured that olfactory modality is a valid marker of CNS function, especially in older adulthood, and may be further suggested as a potential measure of brain integrity. Other reputed factors for olfactory decline after early adulthood include pathological changes at both the peripheral and central levels. Many of these changes are listed in Table 5.1. TABLE 5.1 Pathological Changes That Hasten Olfactory Decline • Alterations in the regulation of intracellular calcium levels • Atrophy of the olfactory bulb and in the olfactory tract • Changes: neuropathological in the mesial temporal lobe and the orbital frontal cortex • Decreased glomeruli and mitral cell numbers • Dementia • Diseases: nasal and/or sinus • Head trauma • Increases in the amplitude and prolonger excitation of calcium potentials • Leakages of synaptic transmitters • Longer latency and smaller amplitudes in cognitive and sensory components • Medications • Ongoing smoking • Shifts from more activity in central and parietal electrode sites to the frontal sites [20]

Individuals who lose their sense of smell as they age may be at greater risk of neurological disorders, particularly Alzheimer’s and Parkinson’s disease. They may also be at greater risk of dying shortly after their loss in olfactory function is determined, since the loss of smell may be a factor in overall bodily decline. Treatments to maintain or protect future olfactory decline appear to be limited. Smell training, an approach whereby individuals may train their nose to detect strong smells such as cloves, eucalyptus or lemon through daily whiffs, may produce some beneficial results. Implanted devices to help the brain process odors as distinctly as during younger years may be forthcoming [21].

TYPES OF AROMAS Contrary to the five basic tastes of acidity, bitter, salty, sweet and umami, attempts to quantify and quality aromas may seem unwieldy. By examining the essence of aromas, their impressions and reactions, some clarity may be established for baseline interpretations and potential applications.

Aroma Categorizations An aroma is a distinctive and noticeable smell or scent. It generally connotes a pleasant quality. In contrast, a repulsive smell or scent is generally referred to as an odor. But the words aroma, odor, scent and smell are often used interchangeably.

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At the beginning of the 20th century, German psychologist Hans Henning (1885 1946) postulated that there were only six categories of smells and combinations of smells that characterized all of the detectable aromas and odors. These included burned (such as burnt toast or tar oil); ethereal (such as cleaning fluid or ether); flowery/fragrant/fruity (such as lavender or rose); putrid (such as decaying fish or rotten eggs); resinous (such as resin or turpentine); and spicy (such as cinnamon or nutmeg). Some thought was that flowery, fragrant or fruity was one of the six primary odors. Henning arranged these classifications into an odor or smell “prism”; an olfactory model with the primary odors located at the corners and the complex odors shown on the edges, face and sides of the prism. Many criticized this arrangement as too impromptu and restrictive [22]. Contrary to the senses of hearing or vision that are connect to measurable physical phenomena, the sense of smell is much more difficult to quantify as a systematic interpretation of which smells are perceived and how they compare to physical phenomena. Part of this conundrum may be that an individual’s perception of an aroma is highly personalized, and furthermore, it may be difficult to extrapolate into an objective label. Pleasantness and/or unpleasantness, learning, context and memory may all interplay. This puzzle has applications in both the food and cosmetics industries. In the world of perfume, aromas have been classified as camphoraceous, citrus, earthy, floral, herbaceous, resinous, spicy or woody and others to help attract and/or match individual preferences. In the realm of food (as opposed to the five basic tastes) another aroma schematic suggests that there may be 10 basic categories of aromas that are based upon a classification that utilizes odor character profiles—once again, taking individualized nuances into account. This helps to demonstrate that while individuals may not necessarily like or dislike an aroma, each aroma may play an important role and interplay in everyday life, from luxurious enjoyment to the assurance of human survival [23].

Multidimensional Aroma Classifications Still another method for describing odors involves their multidimensional characters. According to this approach, the spaces that odors occupy are not homogenous. Rather, it is proposed that they exist in a discrete and intrinsically clustered manner. Also according to this process, aroma clusters include such impressions as chemical, decayed, fragrant, fruity (noncitrus), lemon, minty/peppermint, popcorn, pungent, sweet and woody/resinous. • Chemical aromas include those from bleach, gasoline, household cleaning supplies, markers, nail polish and nail polish remover and paint. A food or beverage may smell of chemicals depending on the degree of enrichment (such as protein, vitamins and/or minerals) or fortification. • Decayed aromas incorporate those from burnt rubber, household gas, sewage or sulfuric acid. They are usually putrid and sickening in nature. Decayed aromas may be nature’s sign that a food or beverage is too repugnant to consume and may lead to illness if ingested. • Fragrant aromas are described as those from cologne or perfume: floral, flowery, grassy, intoxicating, herbal, light, natural or rosy. When a food or beverage is deemed fragrant, it often means that that it has a hibiscus, jasmine, lavender, orange blossom, rose, vanilla or other similar aromas. • Fruity (Noncitrus) aromas are described as fresh and light aromas that are connected with such foods as bananas, peaches, strawberries or vanilla and fragrances with similar ingredients or scent profiles. As opposed to citrusy aromas, fruity aromas tend to smell fruitier, silkier or smoother, compared to the acidity from citrus fruits, such as grapefruit, lemon, lime or orange. • Lemon is a very popular aroma in both the food and beverage and fragrance domains. It has a connotation of freshness and suggests that lemon-scented cleaning supplies not only cleanse but revive. When used in cooking and baking, lemon has the capability of brightening foods and beverages when they may taste or smell flat, or when the ingredients in a dish need to be unified before consumption. • Minty/peppermint, like the aroma of lemon, suggests cleanliness and freshness, and is one of the main reasons while this aroma is used in oral hygiene products. The minty/peppermint aroma is also described as cool, exhilarating and spicy. It contributes an adult-like smell and taste to foods and beverages, such as mint jelly that is often served with lamb chops or minted tea. Minty/peppermint may also provide some gastrointestinal comfort, and for this reason they are frequently used in medications.

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• Popcorn is a distinctive aroma that usually implies pleasant memories, often from childhood. Other distinctive aromas that are grouped in this category include caramel and peanut butter, with their burnt, heavy, nutty and warm aromas and tastes. However, because the aroma of popcorn is so distinctive, it may overpower a food when it is used as an ingredient, so it may have limited applications. • Pungent aromas are often deemed as sharp and for good reason: they are usually easily discernible at their first whiff. Pungent aromas include repulsive substances such as sour or spoiled milk or other dairy products or fecal matter or sweat. However, pungent aromas may also include garlic and onion aromas if they are overwhelming to some individuals. In some countries, pungent/sharp ingredients are valued for their culinary touches such as very pungent cheeses or fermented foods and beverages that may also have gastrointestinal health advantages. • Sweet aromas include almond, chocolate, malty and vanilla scents. Sweet aromas also capture the sweetness in very ripe and fragrant fruits, especially bananas, berries, melons and pineapples. Sweetness is also used to describe the aromas in aromatic baked goods, including breads, cakes, cookies and pastries, and from the caramelization of sugars in the baking process. • Woody/resinous aromas bespeak the outdoors. They are often referred to as the scent of nature, and include reference to burnt, earthy, exotic, green, heavy, tobacco, moldy, musky, musty, Oriental, smoky and woody smells and others. Some think that woody/resinous aromas are more masculine in nature. For this reason, many aromas of this kind are used in men’s fragrances and body care products, and they may have universal appeal—particularly for active individuals [23].

AROMAS AND AGING The ability of humans to detect certain aromas is disputable. This is because smell sensitivities may vary widely from person to person according to factors that include cognition, genetics, perception and physiology— and specifically his or her amount of olfactory receptors. Unless they are identical twins, no two individuals will probably possess the identical genetic make-up for olfactory receptors. One explanation is that genes have mutated throughout evolution. This may be why smell has gradually become less important for survival than color vision, for example, in the identification of rotten food or toxic substances. Another explanation is that proteins may be the biological determinants of smell detection. Proteins ensure that the signals that are produced by the olfactory receptors are effectively transmitted to the higher processing areas of the brain. Proteins may hold the answer to why some people have higher than average smell sensitivities, while other people are more sensitive overall to some smells versus others, and why still other people may seem to have no sense of smell at all [24]. It is suspected that there may be at least one odorant that a person cannot detect at all. This is referred to as a specific anosmia, or as an olfactory blind spot that is likely inherited. For example, some wine drinkers may be “smell blind” to specific chemicals, such as TCA (2,4,6-trichloroanisole, a chemical substance known as “cork taint” that is common to “corky” wines), while others may seem to tolerate it. Specific anosmias may be related to the molecular weight of an odor, and they may become more common as the molecular weight of an odorant increases. A heavier, more complicated odor molecule might have a more difficult time binding with one specific smell receptor and become undetectable—particularly if the smell receptor’s gene becomes a pseudogene. Once damaging mutations occur in certain genes, then these genes may stop producing working receptors and become pseudogenes. As previously mentioned, these pseudogenes may vary among individuals and form different combinations of olfactory sensitivities. Genetic variability in olfactory sensitivities may also be reflected in behavioral variability. While people may not be conscious of smelling anything, they may still display physiological responses to odorants, both conscious and otherwise. For example, a spicy odor may not register at all, or as strongly liked or disliked odor, but it may still provoke increased skin conductance, from slight perspiration and/or warming at the thought of consuming spicy foods or beverages. Sensory perception and sensory loss with aging, like in the younger years, is dependent on intact olfactory sensory neurons. To better understand the crucial roles that they play in olfaction throughout the lifetime and particularly throughout aging, it is logical to examine their response(s) to various stimuli during the aging process.

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Olfactory sensory neurons respond to many diverse odorants if they share common features. For example, olfactory sensory neurons may not selectively respond to chocolate or vanilla flavors, but they may respond to the chemical groups that are found within these flavors (such as alcohols or aldehydes). In the brain, the olfactory bulb and olfactory cortex collectively serve to (1) examine the combinations of sensory neurons that are activated at any given time, (2) translate these patterns in the context of previously experienced patterns and (3) interpret the smell or smells. These olfactory sensory neurons simply do not live forever; in fact, they expire and are usually replaced throughout life. This may be in contrast to aging when they may perish and may not be replaced. Fortunately, all of the sensory neurons do not die simultaneously. A small subset of sensory neurons may fail, and the resultant patterns of activities that the olfactory processing regions of the brain receive may be somewhat affected. However, and in general, there is remarkable stability throughout a lifetime. For the most part, new neuron axons connect to the same group of olfactory bulb neurons as existed before their death. This “rewiring” process generally continues until the close of the lifecycle. Then the sensory neurons may die and may not be replaced [25]. Several studies have demonstrated age-related changes in olfaction in humans that may involve sensory neuron dysfunction or demise. These include decreased odor discrimination, decreased odor memory, decreased smell identification and/or increased odor detection thresholds. Additionally, those who are aging appear to be more prone to olfactory adaptation, and slower to recover threshold sensitivity than younger adults. For example, when older people are exposed to a suprathreshold level of an odorant, such as garlic or onions, they may recover slower than younger people who have progressed to new odorants [26]. Retronasal smell, or the ability to smell through the back of the mouth to the rear of the nose, also tends to decrease with aging. There may be many issues for this decrease in occurrence. These include the multitude of mental and physical changes that occur during aging, prolonged use of medication and the use of dentures that may affect the perception of both odors and tastes. Insensitivity to food odors that are produced retronasally may not be recognized during actual food consumption, since most food odors are identified nasally. Individual differences in odor responsiveness that are generated retronasally may become even greater with age. The ability to sense salty and sweet tastes may decreased sooner than the ability to sense bitter or sour tastes because the anterior taste buds (which are responsible for the salt and sweet tastes) seem to be affected first by aging. The posterior taste buds for bitter and sour seem to be affected later, but both of these conditions may be highly individualized and variable. Since aromas are so closely associated with taste, suprathreshold losses in the perception of the sweet and salty qualities of foods and beverages may have health consequences in the aging. For one, decrease in suprathreshold sweet taste perception may increase the possibility that people with diabetes consume excess sugar. Likewise, decrease in the suprathreshold salty taste perception may make it more difficult for hypertensive patients to comply with strict salt (NaCl) restrictions [27]. Specific odors that signify a certain deleterious food or designate danger may alter an animal’s potential lifespan and physiological profile. These odors may accomplish this through the activation of many highly specialized sensory neurons. Carbon dioxide (CO2) is the first well-defined odorant that is able to modify physiology and influence aging in laboratory specimens. Carbon dioxide may stimulate the trigeminal nerve responsible for facial sensation and motor functions [28]. Insect studies have demonstrated that that the incapability to smell CO2 is associated with longer lifespan, more resistance to stress and increased body fat. CO2 is said to be an ecologically important odor cue that is indicative of animal blood, distress (it is implicated as a stress pheromone) and/or rotting food. It has been postulated that similar effects may be evident in humans but that more research is warranted [29]. The human ability to discriminate odors in a mixture may be limited. So it makes sense that simple foods with distinct aromas are created and presented to those who are aging. This way aging people are better able to discriminate individual smells and assign their likes and dislikes. When a recipe is mixed with multiple ingredients and is accompanied by other recipes with a variety of dressings, herbs, sauces and/or spices it is not surprising that aging people are confused and reject mixed dishes, much like some children and their insistence for singular tastes. For individuals who reportedly have lost some or more of their sense of smell, chemosensory enhancement by the use of certain ingredients and techniques may be useful. These strategies may help aging people to remember how certain aromas or odors used to smell when they were younger so that they may regain their approval. Examples are provided in Chapter 6, Flavor Enhancement Ingredients, and in Chapter 7, Flavor Enhancement Techniques.

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SMELL AND BEHAVIOR The sense of smell is inextricably linked with behavior and has been throughout human evolution since it has been aligned with survival. Olfaction drives behavior both at the instinctive and subconscious levels. For instance, a negative smell such as rotting meat may instigate an impulse to take heed while a positive smell such as cinnamon with its sweet-spiciness may conjure up pleasant, safe and secure life experiences. The idiosyncrasies of olfactory perception may be formed by cultural and geographic variations and by personal history. In the United States, the aroma of citrus is characterized as bright (consider the array of household and personal care products with this scent); the aroma of peppermint is considered as arousing; and the aroma of lavender is regarded as calming—also as evidenced by products with these fragrances. On the contrary, in the Far East, a soothing aroma is thought to be jasmine, while orange or rose water is considered to be energizing. To those who are aging, lavender and rose may be scents that are reminiscent of yesteryear, lemon or orange may connote a younger or more vibrant aroma and jasmine may designate a more exotic fragrance. Scents such as these may be important in settings where the aging have lost some of their sense of smell. Prosocial behavior has been shown to be significantly greater when people are exposed to sweet fragrances, such as the aromas from baked cookies or warm chocolate. These aromas may also help aging people with dementia remember these enjoyable scents and the pleasant associations from the past that they evoked [30]. Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, may occur in differing degrees in people with dementia. They may vary according to the degree of cognitive and functional impairment. These symptoms may include aberrant motor behavior, agitation, anxiety, apathy, appetite changes, delusions, depression, disinhibitions, elation, hallucinations, irritability and/or sleep changes due to genetic, neurochemical and/or neuropathological factors. Aromatherapy is a nonpharmacological intervention that has been used to treat the symptoms of BPSD, and is generally recommended as first-line treatment followed by the least harmful medication for the shortest possible period of time. Evidence about the efficacy of various psychotherapies has been insufficient, but if and when they are individualized, then some psycho-educational interventions may be longer lasting. Sensory interventions such as aromatherapy, environmental modifications and music therapy have been shown to be useful to reduce agitation in some people with dementia [31]. Aromatherapy is based on the use of therapeutic oils that are extracted from barks, bushes, flowers, leaves, peels, shrubs, stems and trees to help support equilibrium, health and well-being. These essential oils are based on naturally forming chemicals, many of which have antifungal and antiviral properties that have been used in traditional medicine by ancient civilizations for thousands of years. They are typically colorless mixtures of alcohol, aldehydes, esters, ethers, ketones, oxides, phenols and/or terpenes that may produce characteristic odors. Essential oils help to provide their beneficial effects through absorption and inhalation. A summary of the plant parts that are used in the preparation of essential oils is provided in Table 5.2. TABLE 5.2 Parts of Plants That Produce Essential Oils Parts of plants

Essential oils

Bark

Cinnamon

Flowers

Jasmine, orange blossom, rose and ylang ylang

Leaves

Citronella, lemongrass, palmarosa, patchouli and petitgrain

Peels

Bergamot, grapefruit, lemon, lime, orange and tangerine

Roots

Ginger and vetiver

Whole plants

Geranium, lavender, rosemary and rose

When absorbed into the skin via baths and/or local application by massage, essential oils may pass through the epidermis and into the blood stream. If essential oils are inhaled, they may deliver aromatic molecules that are sensed by receptor cells in the nose, and then transmitted to the limbic system and the hypothalamus via the olfactory bulb. These signals then may cause the brain to release neuromessengers, such as endorphins and serotonin, which link the nervous and other body systems into desirable actions or changes that may include the feeling of relief. Thus, the essential oil connection with relaxation is suggested. AGING, NUTRITION AND TASTE

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For example, essential oils may serve as springboards for neurochemicals that are released by the brain on their own, or with the assistance of hormones that are released by the body, to help to regular blood pressure, slow the heart rate and stimulate the immune system, among other functions. Their stimulating properties may be the result of their structures that have been said to resemble some hormones. When the essential oils are within the body, then they may remodulate and focus on certain targeted areas. As a result, behavior, mood and productivity may be affected. In particular, serotonin is said to be released by calming essential oils, endorphins by euphoric essential oils and noradrenaline (NA) by stimulating essential oils. It is important to note that some of these associations may be speculative [32]. Different types of essential oils are often used in aromatherapy as shown in Table 5.3. Their outcomes may be both variable and conjectural. Often considered as alternative therapies or “home remedies,” some have migrated into mainstream usages. It is important to first check their usage with health care professionals to ensure their safety.

TABLE 5.3 Applications of Essential Oils in Aromatherapy Essential oils

Applications

Almond, jojoba or grape seed

Healing

Angelica

Fatigue

Basil

Exhaustion

Bergamot

Agitation, anxiety or stress

Chamomile

Hay fever, inflammation, gastrointestinal disorders and rheumatic pain management

Citronella

Fatigue

Eucalyptus

Headache, neuralgia, joint and muscle pain and immunity

Everlasting

Exhaustion

Frankincense

End-of-life

Germanium

Anxiety, emotions and stress and skin disorders

Ginger

Fatigue

Juniper berry

Insomnia

Lavender

Agitation, anxiety or stress, circulation, digestion, end-of-life, immune system, joints and muscles, respiration and skin care

Lemon

Antiseptic, astringent and detoxifying properties

Lemon balm

Insomnia

Myrtle

Insomnia

Patchouli

Agitation, anxiety or stress

Peppermint

Exhaustion, reduced arthritic pain and spasms and memory loss

Pine

Pain management

Rosemary

Blood pressure regulation, colitis relief, constipation and indigestion symptoms and exhaustion

Sage

Muscle cramps and tension Sandalwood End-of-life

Spearmint

Fatigue

Sweet marjoram

Pain management

Tea tree

Acne, blisters, burns, cold sores, dandruff, insect bites and oily skin

Valerian

Agitation, anxiety or stress

Ylang ylang

Insomnia, antidepressive and aphrodisiac properties [32]

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Essential oils are considered to be generally safe with minimal reported side effects. Some essential oils are considered as “approved food additives” by the US Food and Drug Administration and appear on the Generally Recognized as Safe list. Adverse side effects of essential oils may include irritation of the eyes, mucous membranes and skin, and sensitization to essential oils that contain aldehydes and/or phenols. Cross-sensitization to other essential oils, foods and beverages, seasonal sensitivities and allergic reactions may also become present and require treatment. Individualized considerations should always be taken into account. Once again, healthcare professional should be first consulted before essential oils are used, especially if there is any history of reactivities to these substances.

PHEROMONES Pheromones are chemical substances that are created and emitted by organisms as odorants—often as oils or sweat—into the environment that may influence the behavior or physiology of other members of their species. This is particularly the case for mammals or insects. Pheromones may be immediate acting, slower acting or signalers. They include pheromones that are designated aggregation, alarm, epideictic, food, primal, releaser, sex, signal, territorial, trails and others (such as calming and necromones). In mammals, primer and releaser pheromones may predominate. • Aggregation Pheromones are involved in defense, mate selection and overcoming host resistance. They are generally used for pest suppression and may be ecologically selective, effective and nontoxic. • Alarm Pheromones may be released when predators attack, and they may trigger aggression or flight in animals and insects. In plants, alarm pheromones may result in tannin production by surrounding plants that decreases palatability if these plants are consumed. • Epideictic Pheromones largely mark the spots where female insects lay their eggs. • Food Pheromones tend to be linked to trail pheromones; they are connected to organisms that use volatile hydrocarbons that guide their activities toward nesting for survival. • Primal Pheromones help to trigger changes in developmental events. They tend to differ from other pheromones that primarily trigger behavioral changes. • Releaser Pheromones principally cause rapid responses in recipient behavior that are promptly reduced as opposed to primer pheromones. • Sex Pheromones signify when females are approachable for breeding, or they serve to indicate the species and genotype of males. Females produce most sex pheromones. Sex pheromones may also be involved in aggregation pheromone activities. Male-producing sex attractants may also be referred to as aggregation pheromones. • Signal Pheromones serve to create brief changes, including neurotransmitter release. • Territorial Pheromones basically mark boundaries and territorial identities. These pheromones include those that are in the urine of cats and dogs. • Trail Pheromones (see Food Pheromones). • Other Pheromones such as calming pheromones for appeasement and necromones that are indication of decomposition or death [33]. There have been some demonstrable reports in humans that exposure to body odors may elicit responses by other humans, but with few consistent and strong behavioral responses. Rather, chemical messengers may function as modulating pheromones that may affect mood or mental states. A person’s “odorprint” may also be responsible for attraction, such as between a nursing human infant and its mother. This type of odorprint may be affected by such factors as diet, the environment, genetics and/or health [34]. How do pheromones fit into the aging profile, if at all? Research has demonstrated that aging affects sexual appeal. Pheromones produced at different ages appear to change with age and affect sexual attractiveness differently. Certain hydrocarbon production may indicate fertility and health, which may wane with age. Throughout reproductive years, genes are transmitted that ensure continuity among generations. Pheromones attract desired members of species for this purpose; however, these chemicals appear to fade with age [35]. This may be one of the reasons why some people who are aging rely on perfumes with marketed pheromone effects—particularly at a period of time when their sense of smell may be decreasing. It may also be an effort to

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mask “old people smell,” the characteristic odor of elderly people that might be linked to the way that animals recognize who is young or old, or who is sick or dying. With age there is a change in human body odor, as determined by various skin gland activities, and how substances that are emitted from these glands intermingle with bacteria. When sebaceous glands secrete sebum, a waxy substance to lubricate and waterproof the skin, apocrine sweat glands discharge perspiration and eccrine sweat glands emit a clear, odorless but salty-tasting liquid. These substances along with their lipids and steroids combine and create body odor. This “old people smell” may not as intensive or offensive as the smell of younger or middle-aged men when sweating may be at its peak in relation to musculature, but it still may be distinctive to this age group. Some postulation is that it is the result of a higher level of 2-nonenal in the sweat and on the skin of older people, but this compound has also been connected with the scents of aged beer and cucumbers—two familiar and often appreciated smells. Staying clean and well hydrated, with diets devoid of alcohol, cigarettes and spicy foods may also be preventive [36].

SMELL AND HEALTH When humans become infected or sick their odors may switch from agreeable to offensive, as detected through breath, blood, skin and/or urine. The reason may be due to changes in immune activities to fight infections. In particular, the smell of urine may be affected by inflammation, and this odor may be used to distinguish between healthy and unhealthy individuals. Age, gender and health may all contribute to this unique odor, which is referred to as an “odorprint.” In turn, these subtle changes may signal the need for protection from additional infections. Or this ability might instigate an immune response in preparation for potential bacterial or viral intruders. Odorprints have been correlated with some disease states. These include baked bread and typhoid fever, raw meat and yellow fever, and stale beer and glandular disease. Cancer cells may release compounds that are unlike than those that are found in healthy cells; particularly during the earlier stages of development, but this level may be quite subtle and hardly noticeable [37]. To some people, phantosmia, the smell of something that is not present, or parosmia, a smell that is no longer appealing, may be indicative of changes in health. More common are hyposmia, or diminished smell, or anosmia, or smell loss, both described in the section on Smell Decline and Loss that follows. Changes in smell and associative diseases include differences in smell between the left and right nostrils that have been associated with early-stage-Alzheimer’s disease; diminished sense of saltiness that may be indicative of a respiratory infection or sinusitis; overall decline in a person’s sense of smell or “olfactory hallucinations” (unusually unpleasant and/or highly individualized smells such as the smell of fish when fish are not present) that may be signs of a forthcoming seizure or stroke; or unpleasant, hallucinated smells (such as burning or decomposing) that may signify premigraine sensations [38]. For these and other conditions, it is best to communicate their occurrence with a healthcare professional at their earliest signs of development.

SMELL AND OBESITY Obesity may be linked to a gene that affects appetite and a person’s sense of smell. The gene FTO on chromosome 16 is the first widespread genetic flaw to be linked to obesity. It may have a major influence on obesity and diabetes and influence appetite by influencing the brain, or altering the messages from the fat stores and other tissues [39]. There may also be differences in how thin and overweight people access food smells, particularly if they have just eaten. Overweight people with a higher inclination for food odors may have greater appetites than thinner individuals after they were fed. An explanation for this phenomenon may be that the human body has the capacity to detect and reject foods that are no longer needed to maintain the correct energy balance, but that a keener sense of smell in overweight individuals might overrule this balance [40].

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Acute loss of smell may also impact metabolic health and obesity, according to some animal studies. Laboratory animals with an inability to smell had less body fat weight than laboratory animals with intact sensory receptors. Laboratory animals without a sense of smell appeared to be protected from some consequences of higher-fat diets such as inflammation in fat tissues and insulin resistance that might ordinarily contribute to diabetes [41]. Research has demonstrated that when some humans are hungry the body releases hormones and other signals that activate the sense of smell to search out food for satiation. In some laboratory animals, it was noted that chain reactions of hormones, nerves and physiological functions that were initiated by certain food smells altered their metabolism and triggered the animals to stockpile foods for energy [42]. Also in some laboratory animals, selected food smells increased thermogenesis in their brown and inguinal fat deposits for energy. This observation indicated that some smell signals were sent to the hypothalamus in the brain where metabolism is regulated, which activated the sympathetic nervous system to burn more energy and fat. In particular, NA, a hormone and neurotransmitter, was summoned to help mobilize the brains and bodies of laboratory animals for actions that were necessary for survival. It has been speculated that the pathway between smelling food and gaining weight may be through a cranial nerve known as the vagus nerve. However, this connection is uncertain in humans and may only apply to laboratory animals in the prevention of severe weight gain and/or the facilitation of weight loss. Eventually, laboratory studies of olfaction and obesity may shed light upon issues of binge eating and food additions in humans, and provide options to invasive weight-loss surgeries. At the present, interfering with olfaction is not considered as a viable obesity treatment [43].

SMELL AND WEIGHT LOSS Smell and taste dysfunction have been implicated in unintended weight loss as well as loss of appetite that may lead to malnutrition and decreased quality of life. It has been theorized that if the sensory system is saturated by sensory overload, then decreased hunger with subsequent weight loss may ensue. The abundance of sights, smells and tastes of foods and beverages might result in the release of insulin and an increase in metabolism in the short run, but not over the long run as there may be sensory adaptations. While it may be alluring to apply laboratory animal research to humans and manipulate the sense of smell for weight-loss purposes, real concerns about olfaction-related weight-loss stem from decreased interest in foods and beverages. This disinterest may trigger such conditions as anorexia, gastrointestinal disorders such as diarrhea, nausea or stomachache, inflammation, muscle wasting and/or weakness and other circumstances. Aging people may be at higher risks due to calorie protein nutrient malnutrition. A well-balanced diet with age-appropriate servings of foods and beverages and age-designed activities continues to be a more prudent approach to weight management than sensory manipulation. The services of a geriatric-trained registered dietitian/nutritionist may be especially beneficial. Food manipulation to enhance food texture, flavor improvement and palatability, provision of dietary variety and feeding assistance where necessary may collectively be beneficial. So may environmental adaptations to help prevent social isolation and support conviviality; the evaluation of pharmacological therapies to help to identify medications that may decrease appetite and/or affect weight loss or weight gain; and medical diagnoses to evaluate and address such issues as cardiovascular diseases, dyspepsia, endocrine disorders, malabsorption syndromes, neurological causes, psychiatric disorders, respiratory diseases and/or swallowing disorders that may individually or collectively affect weight issues [44]. For more discussion on olfactory decline and weight see the following section, Smell Decline and Loss.

SMELL DISORDERS: MECHANICAL AND METABOLIC A number of factors may contribute to smell disorders that are considered to be mechanical or metabolic. Mechanical factors may include changes in the nose, changes in the nerves that lead from the nose to the brain and/or changes in the brain itself. Metabolic factors may include those that directly or indirectly affect metabolism, such as chronic alcoholism or medical treatments.

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Sections of the olfactory area or its connections to the brain may be destroyed due to head injuries in young adults and Alzheimer’s disease in older adults. With head injuries, the fibers of the olfactory nerves that connect the smell receptors to the brain may be damaged, or a fracture of the cribriform plate bone that separates the brain from the nasal cavity may occur. In Alzheimer’s disease and other degenerative brain disorders such as multiple sclerosis, the olfactory nerve may be affected or destroyed. An additional mechanical cause of smell disorders may be the common cold that may contribute to conductive olfactory loss. A cold may clog the nasal passages and prevent odors from reaching the smell receptors lodged in the mucous membrane lining of the nose. Still another temporary condition of smell loss may be the result of the influenza virus, which may interfere with or damage the olfactory epithelium; however, in most cases the sense of smell and taste may return. Allergic rhinitis, which is activated by animal hair, dust and/or pollen; chronic rhinosinusitis with inflamed nasal passages, a deviated septum; or a foreign body that obstructs airflow may also be contributing factors of conductive olfactory loss [45]. Metabolic, environmental or situational causes for smell loss may include chronic alcoholism as previously mentioned, diabetes, drug use, epilepsy, exposure to toxins, latrogenic (caused by medications or treatments), pernicious anemia (as provoked by vitamin B12 deficiency), poor kidney function, radiation, stroke, tumors, vitamin A deficiency and/or zinc deficiency.

Types of Smell Disorders Smell disorders may be evidenced as decreases in the ability to smell, changes in the manner that odors are perceived or combinations of these manifestations. Anosmia, dysosmia, hyposmia, parosmia and phantosmia are recognized smell disorders. Anosmia, a complete loss of the sense of smell, is uncommon. Some people are born without a sense of smell, a rare condition referred to as congenital anosmia. • Congenital anosmia may be an aspect of Kallmann syndrome, a condition that is characterized by delayed or absent puberty, due to a lack of hormone production by the pituitary gland from a defect in the hypothalamus. • Idiopathic anosmia may occur in people who display no apparent cause for the loss of the sense of smell after extensive testing. Hyposmia, a partial loss of the sense of smell, is more prevalent than anosmia. People who have hyposmia may be able to recognize acidic, bitter, salty and sweet substances but may not be able to discriminate among specific flavors since this ability depends on the sense of smell. Both conditions of anosmia and hyposmia may affect the enjoyment of foods and beverages, nutrient intake and health and well-being. Dysosmia, a distortion of the sense of smell, may cause some odors to smell displeasing or even offensive. Dysosmia may be due to brain infections from the herpes virus, depression, mouth infections, partial damage to the olfactory nerves, poor dental hygiene, seizures, sinus infections or viral hepatitis that may provoke nausea. Parosmia, a qualitative alteration of the normal sense of smell, may occur when familiar odors are perceived but their smells are distorted (as in unpleasant smells). Phantosmia denotes phantom smells, the capacity to smell odors when they are not necessarily present [46].

Diagnosis of Smell Impairment If a person thinks that his sense of smell may be compromised, he should contact his healthcare professional and inform them of any sensory changes and/or symptoms before taking over-the-counter medications. Some of the questions that should be asked and addressed include those given in Table 5.4. The healthcare provider should review the patient’s dietary, medical and sensory history if it is available. A physical examination of the nose and oral cavity may disclose if there are any blockages. A more thorough examination of these areas may include a computed tomography scan, a magnetic resonance scan and X-ray and/or a nasal endoscopy that uses a smell camera encased in a thin tube to better examine the nasal passages. These tests may help provide a clearer examination of the structures inside of the nose. Imaging tests may show a polyp or abnormal growth that might impede the nasal passages. They may also show if there is an abnormal growth or brain tumor responsible for altered smell. A biopsy may be warranted for additional examination and determinations.

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TABLE 5.4

159

Questions About Chemosensory Identification, Impairment and Improvement

1. Why do you think that you taste or smell differently? 2. Can you taste or smell some foods and beverages better than others, and if so, which ones? 3. Do you have seasonal allergies, a cold or the flu, or are you recovering from any of these conditions? 4. Do you take any medications and if so, which one? 5. Do you have any long-term conditions or disease states, such as cardiovascular disease, diabetes, hypertension or kidney disease? 6. Have you been diagnosed with depression, the early stages of dementia or Alzheimer’s or Parkinson’s disease? 7. Have you been experiencing any falls, or have you had any head injuries? 8. Do you have any known vitamin and/or mineral deficiencies? Do you take supplements, and if so, which ones? 9. Have you sensed any strange smells, particularly when none are present? 10. Have you experienced a strange taste in your mouth, had dental or gum issues or acid reflux? Data from https://www.dartmouth.edu/Bdons/part_1/chapter_3.html.

Smell Tests to Detect Olfactory Function A specialized healthcare provider may test for olfaction using a number of methods. To begin, he may ask a patient to close her eyes and smell a comparatively familiar odor from a vile, and then repeat the procedure with alternate nostrils. A familiar substance may be coffee grounds because they are so easily identifiable and cause little trigeminal stimulation. Both acetic acid and ammonia should not be used because they are so strong and may cause strong trigeminal stimulation. Anosmic individuals may still be able to sense these very assertive smells. A specialized healthcare provider may then be able to tell if a person cannot smell at all, or can smell somewhat and whether or not she may be able to identify what she can smell. If he cannot identify an odorant, he may be able to identify which nostril is most operative, or recognize the asymmetry of their sensitivity [3]. The UPSIT is a commercially available test for smell identification that tests a person’s olfactory system. Dr. Richard Doty, a world-renowned researcher in the field of olfactory functioning and dysfunction, invented the UPSIT test in 1983. The UPSIT test has been widely used as a self-examination tool to help diagnose diseases that include Alzheimer’s and Parkinson’s disease. The UPSIT test measures a person’s ability to detect odors at the suprathreshold level with “scratch and sniff” smell strips and a short multiple question test. In Alzheimer’s disease, odor detection and identification may both be affected. People who have Alzheimer’s disease may have trouble with this test when they perform higher olfactory tasks with specific cognitive processes. Both olfactory dysfunction and decreased cognition are Alzheimer disease correlates. A very high percentage of cases of Parkinson’s disease involve smell dysfunction that may be diagnosed by the UPSIT test. The UPSIT test may also be able to differentiate among essential tremors, progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome) and/or Parkinson’s disease that may be induced by MPDP [(1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), a prodrug to the neurotoxin MPP 1 , which may lead to permanent symptoms of Parkinson’s disease]. The UPSIT test may also be able to detect if other family members besides the individual who was diagnosed with Parkinson’s disease might be at risk of developing Parkinson’s disease [47]. National Geographic Smell Survey In 1986, the National Geographic magazine circulated approximately 11 million copies that included a scratch and sniff panel to test the detection and identification of the smells of androstenone (a chemical in sweat), banana, cloves, mercaptans (chemical compounds that are added to natural gas to make it easier to detect because it then smells poorly, such as garlic or rotten eggs), musk and rose. The participants were also asked to rate the intensity of the odors, pleasantness (or lack of pleasurable appeal) and other attributes. General health, handedness, olfactory problems and the use of cologne or perfume were also taken into consideration [48]. It was detected that women were more likely to have a good sense of smell before men, but that this ability may declines with age (as it does for men). Factory workers were rated above average for odor identification, while people who worked outdoors were rated below average, but they were classified more sensitive to faint odors than indoor factory workers. Office workers were graded the best among the groups that were studied for identifying odors.

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Smell perceptions differed among people in different countries. People with allergies performed better than they anticipated. A significant percentage had suffered a previous loss of smell and a slight percentage reported that they could not smell at all. Smokers were more sensitive to banana and musk odors and less sensitive to the odors of cloves, androstenone and mercaptans. Pregnant women were not as acute at smelling than nonpregnant women. As people aged they were less likely to consider the smell of escaping gas as unpleasant. Sensory scientists from the Monell Chemical Senses Center in Philadelphia conducted the research. They discovered that strong odorants have a greater likelihood to evoke vivid memories, and that the most stirring recollections were created by extremely pleasant and/or extremely unpleasant odors [49]. Since sensory scientists believe that the sense of smell is intimately connected to areas of the brain most associated with emotions and memory, the notion that strong odorants have these capabilities provides compelling options for heathcare providers and flavor manufacturers. For more discussion on this topic and speculative opportunities, see Chapter 6, Flavor Enhancement Ingredients, and Chapter 7, Flavor Enhancement Techniques.

Treatments for Smell Disorders There does not appear to be specific treatments for smell disorders. Nasal surgery may be needed to remove any obstructions. Chronic rhinosinusitis may be treatable with medical care. People with this condition may be able to regain some of their sense of smell after oral steroid treatment or steroid sprays to reduce some inflammation. Oral corticosteriods may be another option. Mild exercise, steam and/or nasal rinses may be less invasive choices to help clear the nasal passages blocked by simple colds. Smoking may damage the sense of smell, particularly if it is long-term. By quitting smoking, some sense of smell may demonstrate some improvement. Distorted smells may be treated with small dosages of antiepileptic medications since the brain may misinterpret signals at the root of these distortions. On the other hand, sometimes the reduction or elimination of medications (as warranted by a healthcare provider) may also offer some relief. The improvement of any illnesses or disease states may also provide some reinstatement of smells.

Smell Fatigue Though the human sense of smell is so easily stimulated in comparison to other basic senses, it is quite fragile. This state is referred to as “smell fatigue” and is a normal condition for people of all ages, those who are aging included. However, with aging and decreased smell, the ability to sense the origin of a smell and to continue to detect and identify it over time might be exacerbated. Smell fatigue is a component of sensory adaptation whereby individuals may adjust to a constant level of stimulus in their environment that makes them able to retain sensitivity to changes in their surroundings. Smell fatigue may be likened to the sensory adaptation of the sense of sight that allows one to adjust to a pitch-black country road or darkened theater. Smell fatigue may also be compared to the sensory adaptation of the sense of sound that helps a person adapt to the noisiness of a busy city or a bustling restaurant. Generally in healthy, younger individuals sensory adaptation is fairly short term. Adaptation, recovery and return to “normal” sensory functioning may require a few short moments. Continuous exposure to environmental odors may literally necessitate days or weeks for adaptation, recovery and return to ordinary smell sensitivity, despite removal of the problematic odor source. The aging sense of smell might also impair the speed of recovery to normalcy [50].

Smell Adaptations Since smell loss or decline has been associated with decreased food enjoyment and possible depression, the identification of chemosensory decline is of primary importance for the health and well-being of aging people. So too is the issue of domestic safety: the employment of gas detectors is critical for the protection and peace of mind of aging people and their care providers, families and friends. Improving the personal hygiene of aging people with particular attention to dentition may help to correct disagreeable smells and ensure unobstructed flow of smell molecules.

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Taking precautions to check the safety of foods and beverages in home settings may help to ensure food safety when the sense of smell wanes. This measure includes the inspection of “sell by” and “use by” dates and the practice of discarding older canned and packaged goods, condiments, seasonings and older leftovers. Frugality and food safety do not go hand-in-hand: When in doubt, even aroma-free foods and beverages should be discarded if there are any questions about their safety [51].

IMPROVING THE SENSE OF SMELL While the restoration of the sense of smell is not yet a reality, chemosensory scientists are involved with ongoing research about such topics as the associations among food preferences, dietary changes and chronic diseases in the aging; the effects of the environment on chemosensation; new diagnostic tests for chemosensory disorders, and the potential regeneration of sensory nerve cells. This research may have the capacity to assist aging people who have undergone chemosensory changes or may be doing so in the future, and to provide guidance for healthcare professionals and care providers [52]. While the restoration of the sense of smell might be considered implausible to date, steps can be taken to try to sustain the senses of smell and taste. These include those shown in Table 5.5. TABLE 5.5 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Steps to Sustain the Sense of Smell (and Taste)

Address any known or suspected allergies. Adjust to less salt (and less sodium) and sugar, and allow the true tastes and smells of foods and beverages to surface. Attempt to remember the delights of significant foods and beverages. Avoid highly offensive odors to help prevent desensitization. Be hydrated—especially if taking medications. Chew foods slowly and thoroughly. Dine with others as much as possible to enhance eating experiences. Eat “around the plate” instead of one food at a time. Expose the olfactory receptors to a wide range of tastes and/or smells. Ensure that vitamin and mineral status is adequate. Humidify inside air to add moisture to dry environments. Investigate any pharmaceutical interactions. Keep the nasal areas clean and clear as much as possible. Meet hunger needs (instead of random eating), when the senses of taste and smell might be at their strongest. Moderate or eliminate alcohol consumption. Quit smoking to preserve olfactory receptors and nerves. Reduce the consumption of very hot or very cold foods and beverages; rather, appreciate foods and beverages at their ideal temperatures. Remain active, since the sense of smell may be heightened after activities. Serve recognizable foods and beverages so that the brain correctly registers their appearances. Stay free of head injuries by trying to prevent accidents and falls. Take a positive approach to newer smelling/tasting foods and beverages. Try “sniff” therapy to emphasize desirable smells [53].

Data from http://www.rd.com/health/wellness/sharpen-your-sense-of-smell-and-taste/.

Utilizing Smell Memory for Improving Smell Sensations Since odors play important roles in learning and memory with regard to events and places, some smells may provide cues for recalling emotional episodes. It also follows that by utilizing smell memory in positive ways, evoking happier food-centered times, these measures may encourage eating and drinking—particularly in aging people who have forgotten the “pleasures of the plate.” This is because certain smells may have been ingrained as emotional memories and may be retrieved as emotional responses in contrast to the conscious mind. This phenomenon may be most pertinent to people with forms of dementia, such as Alzheimer’s disease. One of the symptoms associated with dementia is identity loss. Certain smells may be able to trigger specific memories and their accompanying emotions, which may help to define the environments of dementia-affected individuals and their roles within them. AGING, NUTRITION AND TASTE

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The apolipoprotein E gene has been identified as a risk factor for late-onset dementia of the Alzheimer’s type. Swedish researchers have explored its association with smell and memory loss and speculated that this gene may be responsible for loss of both smell and memory. It may be possible to address the suppression of this gene or develop mechanisms to counterbalance its effects [54]. In the meantime, some of these measures might be taken: • Smell the aromas of comfort foods . . . Foods and beverages that are thought to be “comfort foods” tend to be very personal and likely vary among aging individuals with dementia. In general, comfort foods gravitate toward dishes that grandmothers or mothers prepared, such as buttered noodles, chicken soup, chocolate chip cookies or cake, mashed potatoes, oatmeal, puddings and/or other foods. Eating histories from family members or care providers may provide useful information for preparing comfort foods such as these, and for generating their reminiscent aromas. Allow time for these redolent aromas to permeate the dining environments. • Smell the aromas of “dining out” foods . . . A favorite neighborhood pancake diner, pasta restaurant or steak house might conjure memorable moments with friends or family. Preparing these foods at home or in institutional settings may help to fill the air with aromas that recall more celebratory and/or prosperous times. Do take ethic preferences into account. Aromas that are generated in Asian, Central American, Italian and other ethnic restaurants may be more profound and evocative for individuals from diverse cultures. • Smell the aromas of “childhood” foods . . . Perhaps there are favorite foods and/or beverages that are reminiscent of childhood days, such as hot dogs, grilled cheese sandwiches, macaroni and cheese, milkshakes, peanut butter and jelly sandwiches or tomato soup. Some of these items are clearly more fragrant than others—or they may be prepared with certain cooking techniques that especially bring out their aromas. Either eating histories or trial-and-error may indicate which aromas are appealing and have the potential to perk dull appetites. Many may be enhanced with other ingredients to add nutrients, others may be trimmed of calories, fats or sugars, but make sure that their aromatic qualities still remain or are elevated in the process. • Smell the aromas of “holiday” foods . . . Little compares to memorable holiday meals, such as those that might have been prepared for the Fourth of July, New Year’s Eve, Thanksgiving, religious holidays or others. A barbecue cookout, mulled wine and roasted nuts and a flavorful roast and gravy may conjure happy events with family and/or friends, along with a profusion of other filling foods and beverages. Even feelings of being “over-stuffed” may have evoked better times. By celebrating birthdays and other holidays such as these on a regular basis, and by incorporating some of the scents of these holiday-related foods and beverages, aging people with dementia may find some dining comfort. • Smell the aromas of “reward” foods . . . Less labor-intensive foods and/or beverages, such as candy, chips, chocolate, ice cream, popcorn and/or soft drinks that are often associated with good spirits and rewards, may have been common “go-to” foods and beverages during the younger years. While some of these items may be less nutritious than other choices, caloric intake may still matter. By preparing especially fragrant options that are higher in nutrients (such as freshly popped corn or warmed hot chocolate), some evocative smell memories may be aroused and calories consumed.

INTERACTIONS OF THE SENSE OF SMELL WITH OTHER SENSES The five basic senses of hearing, sight, smell, taste and touch are independent in some regard and highly collaborative in others. While each of these senses portrays the environment in which it functions from slightly different perspectives, in their entirety, they interact to provide a uniquely individualistic worldview. For example, an intact sense of sight provides visual cues, such as the advance of a car or animal. An intact sense of hearing provides “sensory crosstalk” communicating that the impending danger may be near. If either of these senses are compromised by aging, either an injury may occur, or other mechanisms may compensate.

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For example, a person may see the object nearing her before hearing it, or vice versa. Sensory compromised individuals may find that one or more of their senses plays “double duty” and counterbalances another, such as a blind person who can hear sharply, a deaf person who has keen vision or a blind and deaf individual who has a honed sense of touch. In some cases, this ability to “take on” other senses may seem to impact or stimulate any of the other senses into a sensory overload. This is called synesthesia, which is a union of the senses. In synesthesia, the cognitive pathways lead to automatic and involuntary experiences in one or multiple cognitive pathways. There is little explanation for the development of synesthesia. Nor is there strong scientific evaluation. Synesthesia may develop in childhood when children are first bombarded with a seemingly multitude of abstract concepts. This may explain why the most common forms of synesthesia have to do with color, number form and sequence. Less common forms of synesthesia include smell color, flavor color, month flavor, sound flavor and phoneme color. These perceptions may vary among individuals. Some synesthetes do not know how they perceive their environment until it becomes problematic [55]. Other than synesthesia, humans rarely experience isolated sensations. In fact, artists, musicians and poets tend to view their “worlds” simultaneously. The following senses of sight, sound, taste and touch interact with smell in a variety of respects.

Sight The normal sense of sight may be quicker than the sense of smell. The human ability to detect something visually may be less complex than that of smell, which often requires a number of sensory clues. For instance, when a person sees a common beverage such as orange juice, she may immediately know that it is bright orange, pulpy and thick, and that this usually indicates freshness. The nose requires a whiff and maybe a taste to discern if it is fresh orange juice, or if it is reconstituted or spoiled. Another example of how the sense of sight may impact the sense of smell involves the sight of an orange grove, which is replete with hundreds of brightly colored orange-filled trees. The eyes tell the viewer that the oranges are ripe for picking. This vision does not change once the oranges are picked and gathered for eating or processing. Unlike the sense of sight, the sense of smell may not identify the freshness of the oranges until they are in closer proximity, so in this instance the sense of sight is quicker, both for longer and shorter distances.

Sound The sense of sound may be captured digitally or electronically as compared to the sense of smell, which is usually captured in volatile molecules. Some research suggests that the information that is received through the nose may be transformed by noise. This implies that there might be a smell-sound sense. It seems that the olfactory tubercle at the base of the brain associated with odor detection may respond to some sounds in selected laboratory animals. When a mixture of tones and odors were sent into the tubercle cells of laboratory animals they became either enhanced or suppressed [56]. In fact, perceptual interplay between smells and sounds have been reported since the mid-1800s when French perfumerist G. W. Septimus Piesse cataloged odors that were based on analogous auditory pitches. Daniel Wesson and Donald Wilson discovered the first neural evidence for this occurrence in 2010 at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, New York. However, because sensory activity may not always equate with perceived changes, more research is needed to determine what these laboratory animals actually smelled and heard. The Wesson Wilson discovery of olfactory-auditory integration supported the notion that there may be intimate connections among sensory systems. Their work helped to clarify the “defective processing” that is related to the disorder of synesthesia: when the senses are overloaded colors may be tasted, flavors may be visualized and other often-bizarre sensory combinations may be experienced (see Interactions of Smell With Other Senses) [57].

Taste Smell and taste are known as the chemical senses since they depend on chemical transduction. Chemoreceptors respond to chemical stimuli from smell odorants and tastants, such as those from vanilla and

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sugar. When the odor and taste components of vanilla and sugar are congruent, they may be perceived as one sensation that seems to come from the oral cavity. In truth, vanilla is really tasteless. The smell of vanilla comes from the nose through the passageway between back of the nose and the back of the mouth. Incongruent tastes and smells also exist, such as vanilla and salt. People might think that they are sensing this ingredient combination in the nose, but they may actually taste this ingredient combination in the mouth. The phenomenon of sensory fatigue and adaptation with regard to smell is also operative for taste. And since the sense of taste is so intricately involved with the sense of smell, some of the fatigue and adaptation principles may overlap. For example, both astringency and bitterness may necessitate up to 90 seconds of recovery time so as not to influence the taste of wine. Sugar may also take some time to fade. Chocolate with its astringency, bitterness and sweetness tends to have a longer aftertaste and may fool the palate when tasting wine, as does some cheese [58]. Since olfaction engages a duel sensory process for perceiving odors orthonasally (via the nostrils) and retronasally (by means of the mouth), what interferes with either of these sensory processes may affect the detection and identification of odors. The issue of nasal congestion has already been discussed. Insufficient mucous production, poor chewing and/ or poorly fitted dentures or other oral conditions may hinder both gustation and orthonasal olfactory perception. Additionally, dentures that cover the palate may decrease retronasal flavor sensitivity and impede the transport of odors from the mouth to the olfactory receptors [59].

Touch Many aromas have a tactile component. In a manner of speaking, a person may be able to “feel” an aroma, such as cinnamon (spicy), spearmint (minty) or vinegar (acidy). While hot peppers, salsa and garlic are quite pungent, if a person has lost his ability to smell these foods and ingredients, he may be able to detect their bite, burn, numbing, pain, prickle or tingle. The same may be true for citrus slices with their astringency and pucker; ice cream, coffee and tea with their respective cooling and warming capabilities; butter and cream with their fullness and slipperiness; and crackers and popcorn with their crackling and jagged characteristics. These sensations and others fall into the classification of somesthesis, which is considered as the faculty of bodily perception. Somesthesis is responsible for the sense of touch (coldness and warmness, itchiness, pain and pressure), along with movement and positioning. One is graphically able to feel these sensations and to smell the foods and beverages that they simultaneously evoke. This is why the senses of touch and smell are so interwoven [60]. The skin is also known to have olfactory receptors that are postulated to have nonolfactory, ancestral function in epithelial biology. Likewise, olfactory sensors are also found in the blood, heart, lungs and sperm to help to locate eggs [61].

CHALLENGING ASSUMPTIONS ABOUT CHEMOSENSORY CHANGES WITH AGING While much has been speculated about chemosensory decline with aging, there is no consensus and challenges still remain. Some of these challenges may include the following considerations : • Do some taste(s) decline earlier than others, and if so, in what order and does this order matter? • How are changes in olfaction verified when there are so many smells and odors to detect and to identify? • Are aging people at heightened nutritional risks due to their reported chemosensory decline, or are medical conditions, diseases, medications and the aging process collectively responsible? • Can nutrition guidelines be accurately formulated when aging people demonstrate great variability in the many factors that comprise the aging process—chemosensory changes being just one facet? While an independent effect of aging on the chemical senses has been established, chemosensory changes due to aging appear to be decidedly variable among individuals and across diverse stimuli [62]. Additional discussion can be found in Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging.

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DIGEST Human beings may be less dependent upon their sense of smell as bears, elephants, kiwi birds, moths, sharks or snakes. When the brain’s olfactory lobes are measured and smell receptors are counted in these species they highly rate in number, and much more so than in some humans. The scent receptors in black bears may be highly activated for distant food. Grizzlies and polar bears may be able to smell through ice—not only for food, but also for sexual attraction. African and Asian elephants are known to have a superior sense of remote smell, particularly in the water for drinking and bathing. New Zealand kiwi birds are said to have a superior sense of smell since they are flightless and must scavenge for food on the ground. The male silkmoth relies upon its ultra-sense of smell for mating. Some sensory scientists are studying the silkmoth as a model for scent-detecting robots. The great white shark reportedly has the largest olfactory bulb of fellow sharks, but it may not foster a better smelling potential. Rather, it may contribute to the great white shark’s water movement and electromagnetics. Snakes do not use their noses to smell. Instead, they “taste the air” to capture scent particles, and they use a specialized organ in their mouths that is referred to as Jacobson’s organ for sensing food and/or danger [63]. These remarkable creatures are capable of an acuteness and diversity in their sense of smell that exceeds that of humans, and yet their milieu is so much different. They need to travel miles to seek and find their food sources, and all that humans need to do is travel to the nearest cupboard, refrigerator, market or restaurant. If and when the sense of smell changes in humans, they may be able to discover compensatory measures to help improve their conditions. By understanding the sense of smell as described in this chapter, aging people and their care providers, families and friends may be better equipped to address some olfactory changes that develop as the years progress. Unlike bears, elephants, kiwi birds, moths, sharks or snakes and other animals with their smell acuity, humans may be better able to improve their olfactory situations, procurement of sensory-satisfying food sources, nutritive intake, health and well-being—and for a potentially longer lifespan!

MANNER OF SPEAKING Acetylcholine Adenosine Triphosphate (ATP) Energy Adenylyl Cyclase (AC)

Aggregation Pheromones

Alarm Pheromones Amygdala

Androstenone

Anosmia Apocrine Sweat Glands

Aroma

compound that functions as a neurotransmitter throughout the CNS primary carrier of energy in cells; able to store and transport chemical energy within cells enzyme that synthesizes cAMP (or cyclic AMP) from adenosine triphosphate (or ATP) to help regulate a wide variety of cellular processes semiochemicals that play key roles in insects for defense against predators, mate selection, overcoming host resistance and other social behaviors chemical signals that are produced by insects and some animals in response to danger unevenly almond-shaped mass of gray matter in the interior of each cerebral hemisphere; involved with experiencing emotions steroidal pheromone found in boar’s saliva, celery cytoplasm and truffle fungus; produced by fresh male sweat that might be attractive to females partial or total loss of the sense of smell; caused by blockage of the nose, head injury, infection or other causes glands that are associated with the presence of hair in human beings; secrete a concentrated fatty sweat into the gland tube; stimulated by emotional stress distinct, typically pleasant smell as opposed to odor

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Aromatherapy

Behavioral and Psychological Symptoms of Dementia (BPSD) (also known as Neuropsychiatric Symptoms) Calming Pheromones cAMP

Central Nervous System (CNS)

Chemical Aromas Chemoreceptive Sensory Interaction Chemoreceptors Cilia

Computed Tomography (CT) Scan

Congenital Anosmia

Cognition Conductive Olfactory Loss

Cork Taint Decayed Aromas Degenerative Neuropsychiatric Disorders

Dysosmia Eccrine Sweat Glands Epideictic Pheromones Expectation Assimilation

Explicit Memory (also known as declarative memory) Fragrant Aromas Fruity (Noncitrus) Aromas

FTO on Chromosome 16

alternative medical practice that uses aromatic plant oils and plant materials to balance, harmonize and promote body, mind and spirit individual symptoms in dementia patients; include agitation, apathy, anxiety, depression and/or irritability chemical signals that help to reduce excitable behaviors cAMP; a chemical messenger that is vital to many biological processes that include hormones, ion channels and proteins integral part of the nervous system of the body that consists of the brain and spinal cord; integrates information and coordinates and influences body activities generally odorous synthetic aromas; often used as fragrances specialized sensory interaction that responds to chemical substance(s) and generates biological signal(s) sensory cells or organs that react to chemical stimuli short, hair like, numerous filaments; found in lining of the trachea (windpipe) that help remove mucus and dirt from various tissues and other movements scan composed of many X-ray measurements taken from different angles; produces cross-sectional images of blood vessels, bones and/or soft tissues condition whereby people are born with a lifelong inability to smell; may be an isolated abnormality or due to a specific genetic disorder mental action or process of obtaining knowledge and comprehending through experiences, senses and thought loss that causes sufficient airway obstruction in the nose; prevents odorant molecules from contacting the olfactory epithelium fault in wine due to undesirable smells or tastes; spoilage detected after aging, bottling and opening putrid or sickening aromas or smells; include those from burnt rubber, household gas, sewage and/or sulfuric acid mental disorders with a marked decline in cognitive ability; typically attributed to CNS disorders such as Alzheimer’s, dementia and/or Parkinson’s disease smell disorder; related to distortion or qualitative alteration of smell perception major sweat glands of the human body found in skin; highest density in the palms of the hands and the soles of the feet substances that are typically used by insects to mark territories notion that taste perceptions are biased by the imagination, and if a food is expected to taste good, then it will; expectation assimilation also works in the opposite direction a major subdivision of long-term memory; requires conscious thought aromas described for cologne or perfume: floral, flowery, grassy, intoxicating, herbal, light, natural or rosy fresh and light aromas; connected with bananas, peaches, strawberries or vanilla, and fragrances with similar ingredients or scent profiles enzyme that is encoded by the FTO gene (fat mass and obesity-associated)

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MANNER OF SPEAKING

Glomeruli G protein Habituation

Hippocampus Human Chorionic Gonadotropin (hCG)

Hyposmia Hypothalamus

Idiopathic Anosmia Implicit Memory (also called unconscious memory) Kallmann Syndrome

Latrogenic Lemon Aroma Mercaptans (also known as methanethiol) Minty/peppermint Aroma Motivation

Necromones Limbic System

Magnetic Resonance (MRI) Scan

MPDP ((1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) Nasal Endoscopy

Neo-Cortex

Neuro-Vegetative Areas Norepinephrine (NE) (also known as noradrenaline [NA]) Odor

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cluster of nerve endings, small blood vessels or spores proteins that bind to the guanine nucleotides GDP and GTP; important signal transducing molecules in cells type of learning whereby organisms decrease or cease stimuli responses to stimuli after repeated or prolonged appearances region of the brain that plays a vital role in short and longterm and special memory, responsible for navigation glycoprotein hormone that is secreted by the placenta after an egg is implanted; maintains corpus luteum function and stimulate placental progesterone impaired ability to smell and/or detect odors area of the forebrain that is below the thalamus; coordinate the automatic nervous system and pituitary gland activities (body temperature, hunger, thirst and other functions) loss of smell with no apparent origin one of two major types of long-term memory; may affect thoughts and/or behaviors condition that is characterized by delayed or absent puberty; due to a lack of hormone production by the pituitary gland from a defect in the hypothalamus effect on person due to medical care, medications or treatments popular aroma in both the food and beverage and fragrance domains; connotes freshness harmless and pungent smelling gas; smells like rotting food or smelly clothes aroma described as cool, exhilarating and/or spicy; connotes cleanliness and freshness rationale for particular behavior; involved in the translation of sensory information from the neo-cortex into incentives that translate into behaviors pheromones given off by a deceased and/or decomposing organism; consists of linoleic and oleic acids multifaceted system of brain structures that include nerves and networks located on both sides of the thalamus; involved with behavior, emotion, long-term memory, motivation and other functions noninvasive medical exam that utilizes electric field gradients, radio waves and strong magnetic fields to produce images of body organs prodrug to the neurotoxin MPP 1 ; causes permanent symptoms of Parkinson’s disease procedure that uses a thin, rigid tube with fiberoptic cables for light to diagnose nasal mucosa, nasal pathology and/or sinonasal anatomy section of the brain that is involved with higher-brain functioning; involved with cognition, language, motor commands, sensory perception and/or special reasoning areas of innervation of the internal organs by the autonomic nervous system; necessary to maintain life organic chemical that functions as a hormone and neurotransmitter in the brain and body distinct and often unpleasant smell; may cause lingering feelings, impressions and/or qualities

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Odorants Odorprint Olfaction Olfactory Adaptation (also known as odor or olfactory fatigue) Olfactory Blind Spot Olfactory Cognition Olfactory Epithelium Olfactory Hallucinations (also known as phantosmia) Olfactory Receptor Neurons (ORN) (also known as olfactory sensory neurons [OSN]) Orthonasal Smell or Olfaction Orthonasally Parosmia Phantosmia Pheromones Piriform Cortex (also known as pyriform cortex) Popcorn Aroma Primal Pheromones Primary Cilium Progressive Supranuclear Palsy (also known as Steele-Richardson-Olszewski Syndrome) Pseudogenes Pungent Aromas Releaser Pheromones Retronasal Smell Retronasally Rhinosinusitis (also known as sinusitis)

Scent Sebum

Sensory Neurons Sensory Receptors

substances that evoke distinctive smells body odors that proposedly provide a consistent imprint, such as a fingerprint or DNA sample sense of smell; the action or ability of the sense of smelling the temporary inability to differentiate a particular odor after lengthy exposure denotes an odorant that cannot be detected; a specific anosmia that is likely inherited cognitive processing (acquired knowledge and understanding) of the sense of smell specialized epithelial tissue inside that is located inside of the nasal cavity; involved in the sense of smell the detection of smells by one or both nostrils that are not present a transduction cell in the olfactory system; serve the conversion of odorant information perception of odors that occurs during sniffing act of smelling by sniffing odorants olfactory dysfunction; typified by an inability of the brain to correctly identify the natural smell of an odor phantom smell or olfactory hallucination; an odor that is not truly present chemical substances that are produced and released by animals; affect behavior, especially of other species region of brain in the cerebrum that is connected to the sense of smell distinctive aroma described as the scent of popcorn; usually implies pleasant memories, often from childhood chemical substances that trigger changes in developmental events as opposed to behavioral changes solitary and apparently nonfunctional cilia of cellular surfaces uncommon brain disorder that manifests in balance, eye movement and walking disorders segments of chromosomes that are imperfect reproductions of functional genes smell with a sharp or strong aroma or sensation that is often unpleasant chemical substances that evoke modifications in the behavior of recipients smell or olfaction through the mouth; emanates from the oral cavity during eating and drinking posterior from the oral cavity to the back of the nose a condition whereby the mucous membranes of the nose and sinuses become inflamed; may be caused by allergies or infections distinctive smell; usually connotes pleasantness oily, waxy secretion by the sebaceous glands; composed of metabolites of fat-producing cells, squalene, triglycerides, wax esters and other substances nerve cells in the CNS; responsible for translating external stimuli into internal electrical impulses specialized dendrites of sensory neurons; detect specific types of stimuli such as chemicals, light, mechanical forces, temperature and others

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REFERENCES

Sex Pheromones

Signal Pheromones Smell Fatigue (also known as olfactory fatigue or odor fatigue) Smell Receptor OR7D4

Smell Training

Somesthesis

Specific Anosmia Suprathreshold Level Sweet Aromas

Synesthesia

TCA (2,4,6-trichloroanisole) Territorial Pheromones Thalamus

Trail Pheromones Transmembrane Proteins (TP) University of Pennsylvania Smell Identification Test (UPSIT) Vagus Nerve Woody/Resinous Aromas

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chemical substances that are released by organisms to attract the opposite sex, for mating, or actions related to sexual reproduction chemical substances that trigger social responses in members of the same species a temporary and normal incapability to distinguish a certain odor protein that is encoded by the OR7D4 gene; intermingles with odor molecules in the nose; originates a neuronal response that initiates smell perception instruction or reinstruction of smells; generally for people who are recovering from upper respiratory tract infections; may be useful for brain injuries and/or other forms of smell impairment faculty of bodily perception; involves various sensory systems such as the skin and internal organs; responsible for sensations such as itch, pain, touch-pressure, warmthcoldness and movement-positioning inability to perceive a specific odor while olfactory perception is otherwise whole stimulus that is significant enough in scale to provoke an action potential in excitable cells aromas that include almond, chocolate, malty and vanilla scents; also capture the sweetness in very ripe and fragrant fruits production of a sense impression by one part of the body, or sensory or cognitive pathway through the stimulation of another part of the body chemical substance known as “cork taint” that is common to “corky” wines chemical substances that denote the boundaries and identities of the territories of organisms for survival either of the two masses of gray matter that lies between the cerebral hemispheres; relays sensory information and pain perception semiochemicals secreted by organisms that affect the behaviors of other organisms; commonly used by insects entirety of membranes; function to allow the transference of certain substances across membranes smell identification test that examines the functionality of the olfactory system tenth cranial nerve or CN X; mixes with the parasympathetic control of the digestive tract, heart and lungs aromas that are reminiscent of the scent of nature; include burnt, earthy, exotic, green, heavy, tobacco, moldy, musky, musty, Oriental, smoky and woody smells and others.

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[4] Axel R, Buck LB. Odorant receptors and the organization of the olfactory system. The Nobel Prize in Physiology or Medicine, ,https:// www.nobelprize.org/prizes/medicine/2004/press-release/.; 2004 [accessed 17.09.18]. [5] Mouly A-M, Sullivan R. Memory and plasticity in the olfactory system: from infancy to adulthood. In: Menini A, editor. The neurobiology of olfaction. Boca Raton (FL): CRC Press/Taylor & Francis; 2010 [chapter 15].,https://www.ncbi.nlm.nih.gov/books/NBK55967/. [accessed 17.09.18]. [6] BBC News. Sense of smell “underestimated,” ,http://news.bbc.co.uk/2/hi/health/6183379.stm.; 2006 [accessed 04.09.18]. [7] The sense of smell, ,http://www.biology-pages.info/O/Olfaction.html.; 2015 [accessed 04.09.18]. Smell: the nose knows, neuroscience for kids, ,https://faculty.washington.edu/chudler/nosek.html. [accessed 04.09.18]. [8] Rodriguez-Gil G. The sense of smell: a powerful sense. 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C H A P T E R

6 Flavor Enhancement Ingredients

PHOTO: Peppers and Knife. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: The smells of onions that are cooking and gas bother me. I try to avoid both of these.  C.L.

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Flavor Enhancement of the Basic Tastes The Use of Acid in Flavor Enhancement How to Reduce or Mask Acidity How to Compliment Acidity How to Heighten Acidity Acidic Aromas The Use of the Bitter Taste in Flavor Enhancement How to Reduce or Mask Bitterness

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The Use of Fat in Flavor Enhancement Types of Fatty Flavor Enhancers

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Butter Nuts and Seeds and Nut and Seed Oils Lard and Suet Olive Oils and Other Plant Oils

Fatty Aromas The Use of Salt/Sodium in Flavor Enhancement How to Reduce or Mask Saltiness How to Compliment Saltiness How to Heighten Saltiness Salty Aromas The Use of Sugar in Flavor Enhancement How to Achieve the Sweet Taste How to Reduce or Mask Sweetness How to Compliment Sweetness

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Umami-rich Ingredients with L-glutamate Umami-rich Ingredients with disodium guanylate Umami-rich Ingredients with disodium inosinate Umami-rich Combinations with L-glutamate, disodium guanylate and disodium inosinate

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Umami and Salt Reduction How to Heighten Umami Umami Aromas

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LEARNING OBJECTIVES 1. Distinguish among the many types of flavor enhancement ingredients, especially those that are natural versus manufactured. 2. Examine flavor enhancement ingredients in relation to healthy individuals versus those with disease states, and explore their pharmaceutical interactions. 3. Identify which of the flavor enhancement ingredients are particularly suitable for changes in chemosensory perception due to aging. 4. Formulate group and individualized approaches for flavor enhancement that meet changes in aging olfaction and gustation. 5. Assess targeted flavor enhancement practices with regard to food, beverage and meal enjoyment, nutritional intake, health and wellness.

SUMMARY To uniquely examine flavor enhancement ingredients specifically designed for the aging from common, everyday foods and beverages to novel manufactured products.

INTRODUCTION The concept of flavor, already discussed in Chapter 4, A Taste Primer, encompasses the sensations of olfaction (smell), gustation (taste), touch and chemesthesis (chemical irritation), and depending on interpretations, a host of other perceptions. In addition to the concept of flavor, a few working definitions are needed as a framework for this chapter: • A flavorant is a substance that provides flavor to another substance or substances that may alter the original characteristics of these substances.

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• Flavor enhancement is a technique that boosts the original flavor of a substance, balances it or nullifies it. Flavor enhancement is part art, part intuition, part methodology and part science. It is the signature of food scientists and chefs. In food science, flavorants and flavor enhancement distinguish ordinary chemical compositions from extraordinary amalgamations. Flavor enhancement is especially evident in complex cuisines by innovative chefs, yet has applications in the most fundamental cooking skills. When flavor enhancement is practiced to its fullest potential it has the capacity to transform ordinary foods and beverages into spectacular, flavorful comestibles, and convert commonplace meals into unforgettable experiences. The reason flavor enhancement is so important to taste and aging is that flavor-enhanced foods and beverages have been shown to be more appealing as chemosensory changes emerge. As discussed in both Chapter 4, A Taste Primer, and Chapter 5, A Smell Primer, chemosensory decline is neither uniform across the senses or among all aging people. This is one of the reasons both a broader and more individualistic approach should be taken in their understanding, use and future applications. When used in the diets of people who are aging, flavorful ingredients may help to improve their dietary intake and nutritional status, reverse the effects of anorexia and sometimes modify disease states and health outcomes. An array of natural and manufactured food and beverage enhancers is in ongoing development for use by care providers, chefs, food manufacturers, food scientists and home cooks. Many are addressed in this chapter. Along with Chapter 7, Flavor Enhancement Techniques, these two chapters are designed to assist individuals who work with aging people with the wherewithal for improving the eating experiences. There is an adage that reads, “No food is nutritious unless it is consumed,” which means that a discussion about nutrition is fruitless unless food is eaten. Another adage is also operative: “No food is consumed unless it tastes good.” This means that in order for food to move off of the plate and into the mouth it has to have great taste (or precisely great flavor). Flavor enhancement is sometimes the missing link between which foods and beverages are purchased, prepared and served; which items are consumed or remain; which comestibles equate with health and wellbeing; and which substances advance poor nourishment and/or malaise. Flavor enhancement provides a challenging, exciting and prospective examination into advancing or reducing each of these endeavors.

OVERVIEW OF FLAVOR ENHANCEMENT INGREDIENTS The decline in both smell and taste that normally occurs with aging and in other conditions and disease states may be irreversible. These declines may contribute to inadequate food and beverage intake, poor nutritional status and/or ill health and well-being. This is because chemosensory decline may alter food choices and exacerbate medical conditions and disease states that lead to weight loss and other nutrient-deficient disorders [1]. The addition of flavor-enhanced ingredients may be able to augment acceptance of certain foods and/or beverages, compensate for some perceptual losses, improve food palatability, increase salivary flow and reduce some depression associated with disinterest in foods—especially among those who are frail [2]. As discussed in Chapter 5, A Smell Primer, and Chapter 6, Flavor Enhancement Ingredients, chemosensory dysfunction may present itself as ageusia (the absence of taste), hypogeusia (the diminished sensitivity of taste), dysgeusia (the distortion of normal taste), anosmia (the absence of smell), hyposmia (the diminished sensitivity of smell or dysomia (the distortion of normal smell). Research has demonstrated that people with hypogeusia may require a higher concentration of a tastant to both detect and to recognize it other than normal. People who have hypogeusia may also distinguish suprathreshold concentrations of a tastant as less intense, and people with dysgeusia may report taste distortions that may include bitter or metallic tastes when none of these tastes are actually present. These inabilities or distortions in taste may also manifest themselves in changes in olfaction. The use of flavors and flavor enhancement to help intensify the smells and tastes of foods and beverages may be helpful to compensate for losses in age-related perceptions. Flavors are mixtures of odorous molecules that may be extracted directly from foods in their natural state or synthesized in a laboratory. Flavors may also contain nonvolatile compounds such as include amino acids or salts that may be responsible for taste induction and/or somatosensory stimulation.

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When flavors enhance foods and beverages at optimized levels, the aging may consume needed or additional calories at their meals, more fully enjoy their eating experiences, and develop or support positive relationships with food and beverage consumption. While the process of adding fat, salt or sugar to a food or beverage is in actuality flavor enhancement, flavor enhancement is also somewhat different and distinct from these measures. Flavor enhancement has the propensity to intensify the chemosensory properties of foods and/or beverages, rather than just add a different taste or flavor. Flavor enhancement may also stimulate, not merely irritate the mouth or stomach, as some individualized ingredients might generate. Some flavor enhancement may even improve the functional status, immunity and/or life qualities in humans. Other flavor enhancement may actually increase the number of molecules that interact with flavor receptors, and help to compensate for chemosensory losses from aging, certain conditions and/or diseases. In this chapter the specific flavors, flavor enhancers and ingredients that create them will be featured, along with their modes of action, impacts on the diet, effects on aging and longer-term effects on health and longevity [3].

FOOD INGREDIENTS THAT ENHANCE FLAVOR The food ingredients that have the capability to enhance flavor include both natural and manufactured substances. They have been used for centuries in cultures around the world to help impart acidic, bitter, fatty, salty and sugary tastes, among others. Today, some flavor enhancers are also used improve, preserve and thicken among their primary flavoring roles. Natural flavor enhancers encompass ingredients such as fats, sodium/salts and sugars and those that create bitter and umami tastes. Manufactured flavor enhancers incorporate such ingredients as artificial sweeteners (also known as nonnutritive or alternative sweeteners), autolyzed yeast extracts, guanylic acid, high fructose and fructose corn syrup (HFCS and FCS, respectively), hydrolyzed proteins (some that result in the formation of free glutamate that may join with free potassium or sodium to form monopotassium glutamate (MPG) and monosodium glutamate (MSG)), and maltodextrin, among others. The pros and cons of each of these flavor enhancers in foods and beverages for the aging will be discussed in this chapter.

FLAVOR ENHANCER REGULATIONS Food enhancers are substances that are added to foods. In the broadest sense, food enhancers are food additives, since they may not originate within a food or beverage, but are “added.” According to the US Food and Drug Administration (FDA), food additives are “any substance the intended use of which results or may reasonably be expected to result—directly or indirectly—in its becoming a component or otherwise affecting the characteristics of any food”. This definition excludes ingredients whose use is Generally Recognized as Safe (GRAS) or those ingredients that were “approved for use by the US FDA prior to the food additives provisions of law, and color additives and pesticides where other legal premarket approval requirements apply.” GRAS substances include such items as MSG, salt, spices, sugar and some vitamins. While flavor enhancers such as fat, salt and sugar contribute tastes and/or flavors of their own, other flavor enhancers may function by supporting these primary flavor enhancers. Direct food additives are those that are added to a food for a specific purpose, such as flavor enhancement. By definition, when flavor enhancers are used, they are directly added to the existing flavor of a food or foods. In contrast, indirect food additives become parts of foods in trace amounts because of packaging, storing or other handling issues [4].

ALLERGIES Flavor enhancers, food colorings and preservatives are some of the food additives that may prompt allergic reactions in people who are prone to food allergies. Some of these substances include benzoates, butylated

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hydroxyanisole (BHA) and butylated hydroxy toluene (BHT), MSG, nitrates and/or nitrites, potassium bromate, red or yellow food dyes and sulfites. Allergic reactions to food additives may provoke diarrhea or other gastrointestinal issues, hives, respiratory difficulties such as asthma, or multiple responses in predisposed individuals. In general, there are eight food additives that may produce adverse reactions. These are aspartame (Nutrasweet), sulfites, parabens, tartrazine, MSG, nitrates and nitrites, BHA and BHT and benzoates. • Aspartame (Nutrasweet) is a calorie-free sweetener that is widely used in the food and beverage industries. Individuals who have difficulty metabolizing the essential amino acid phenylalanine should avoid consuming aspartame. • Phenylketonuria is an inherited disorder that results in an error in the metabolism of phenylalanine, due to a deficiency in a key enzyme. A medical evaluation is warranted. • Benzoates function as preservatives in some candies, cakes, cereals, dry yeast, margarines and oils. Adverse reactions to benzoates are rare. • BHA and BHT are preservatives that may be used in breakfast cereals and other grain products to protect changes in color, flavor and/or odor. Adverse reactions to BHA or BHT may include hives and/or other skin disorders. • MSG is the sodium salt of the amino acid glutamate. Glutamic acid is a nonessential amino acid produced by the human body from other substances, and is responsible for the transmission of nerve impulses and the umami taste. MSG may be used in a wide array of foods that include canned soups and/or packaged meats. Adverse reactions may cause sensitive individuals to experience some burning sensations, chest tightness, diarrhea, nausea and asthmatic symptoms. • Nitrates and nitrites are used as flavor enhancers, food colors and preservatives in such foods as processed fish and meats. Rare reactionary symptoms may include headaches or hives in susceptible people. • Parabens are used to preserve foods and medications, and as an ingredient in shampoos and sunscreens. Reactions to parabens may include allergic contact dermatitis. • Sulfites are used to prevent foods from turning brown when they are exposed to air. Responses to sulfites may include respiratory and gastrointestinal difficulties that may be mild to life threatening. • Tartrazine is a yellow food dye that may be used in candies, canned vegetables, cheese, condiments, desserts, hot dogs and/or ice cream. Adverse reactions to tartrazine may include asthmatic symptoms, hives and/or swelling. The only assured manner to prevent a known adverse reaction to one of these food additives is to totally avoid the additive. However, some people avoid suspected food additives when they do not necessarily display negative consequences [5].

DIETARY RESTRICTIONS Various conditions and diseases of the aging may restrict some dietary components, such as cardiovascular disease and dietary fats and oils, hypertension and dietary sodium, diabetes and dietary sugars and obesity and dietary calories. Prudent use flavor enhancers will be provided for each of these dietary components: fats and oils, sodium, sugar and calories. Extreme dietary restrictions of fats and oils, sodium and sugars may blunt the appetite and food and beverage intake—especially for those who are aging who have diagnosed chemosensory disorders. Unnecessary or excessive restriction of dietary calories may also affect appetite, food and beverage consumption and/or satiation. By working with a registered dietitian/nutritionist to identify and address dietary restrictions, individual food and/or beverage desires, nutritional well-being and life quality may be realized. Flavor enhancers may bring increased satisfaction to calorie, fat, sodium, sugar and calorie-controlled and texture-compromised diets for the aging, and foster additional interest in newer, flavorsome options. While results may vary, due in part to the inconsistencies in the heterogeneity of chemosensory alternations among the aging, flavor enhancement may prove beneficial to improve food intake, weight and nutrient status. Additional attention should be provided to any individual with suspected or diagnosed food additive allergens or sensitivities as previously discussed [6].

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FLAVOR ENHANCEMENT OF THE BASIC TASTES Some flavor enhancement may be achieved by combining the basic tastes and/or textures (as in fat). This may be achieved through the processes of complimenting, heightening, masking and/or reducing. Aromas may be heightened or concealed depending on the procedures. Tips that are especially designed for the aging are provided.

The Use of Acid in Flavor Enhancement Many foods are acidic with a pH between 2 and 7. Acidity often means that a fruit or vegetable is immature and not at its peak and that its sugars need to develop. For example, a tomato with the five basic tastes might taste quite sour if green, while it sweet lusciousness may develop more as it reddens. Thus, this is one of the reasons fruits and vegetables should be picked and used at their utmost ripeness. That stated, the acid taste also has its desirability. The sour taste of acidity, also a basic taste like bitter, salt, sugar and umami, is a very handy taste and ingredient in beverage and food development and culinary applications. Some people may think of sourness as the opposite of sweetness, but sourness has its own unique characteristics. As one example, citrus foods and juices and vinegars tend to lend brightness to beverages and in cooking that helps to bring out freshness, heighten the perceptions of the other basic tastes and stimulate the palate. In particular, a few squirts of lime juice on melons or tropical fruits, such as mangoes or papayas, may enhance their sweetness. Lemon, orange or pineapple juice may help to bring out the natural sugariness of other fruits such as bananas or berries, fish and/or vegetables. Both citric acid and ascorbic acid naturally occur in citrus fruits. Citrus acid may be added to make some foods and beverages tarter in taste. Ascorbic acid (vitamin C) may help to prevent browning in some fruits and/or vegetables. This is because ascorbic acid reacts with oxygen before oxygen has a chance to interact with polyphenol oxidase, an enzyme released from some fruits, such as apples or pears, which may contribute to browning. Other acidity enhancers include a sprinkling of malt vinegar on fried foods, such as French fries or fried fish that may cut through the fat, and balsamic vinegar sprinkled on tomatoes to emphasize their sweetness and saltiness. With regard to another aspect of the taste spectrum, the sourness of lemons may help to negate any bloody tastes in fowl and meats. Many acidulants occur naturally in foods and beverages. Other than citric acid in citrus fruits, there is malic acid in apples and acetic acid in vinegars. Figs contain all three of these acids. Tartaric acid in apples, apricots, avocadoes, bananas and tamarinds, and phosphoric acid in baking soda, dairy products, processed foods and soft drinks are still other acidulants that are commonly used in the US food supply. Besides flavor enhancement, these acidulants may also be used to improve the gelling properties and textures in foods. The experience of the sour and salty tastes depends upon the detection of hydrogen and sodium ions respectively. Acidity, as with saltiness, promotes increased salivation that helps taste, flavor and food enjoyment. The constituents of saliva are bacteriostats, bicarbonate, electrolytes, enzymes, mucus and water in varying concentrations that may affect ion movement. Acidity may also alter a food’s texture, as when it is used in ceviche to “cook” raw fish, to tenderize meat and to soften the cell walls of tough vegetables. The citric acid within citrus fruits and juices assists in the breakdown of other foods and beverages into their components. It also assists in the preservation of foods and beverages since it tends to lower the pH level and inhibit microbial spoilage. Citrus fruits also contain oil within their zest that lends both taste and texture to foods and beverages. When paired with foods and beverages with bitterness, piquancy, sweetness or umami, the lemony acidity of citrus fruits helps to bring out these diverse tastes. Another acidic taste, that of vinegar, brings other tasteful nuances in some foods and beverages. The range of vinegars is extensive and includes, balsamic vinegar with its richness and sweetness, apple cider or raspberry vinegar with their boldness and fruitiness, and champagne vinegar with its delicateness. Black vinegar, distilled white vinegar, malt vinegar, red or white wine vinegar, rice vinegar and sherry vinegar are other tasteful and versatile options [7]. Other acidic tastes may be found in beer, citrus fruits and juices, dairy products (especially tangy buttermilk, cre`me fraiche, kefir, sour cream and/or yogurt), fresh berries, kimchi, kombucha tea, rhubarb, salsa, sauerkraut,

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sorrel, sweet-sour sauces, such as chutney or duck sauce, tamarind, tomatoes, vinegar, yogurt, wine and other foods and ingredients. Vegetables that tend to be more acidic in nature include escarole, pimentos and those that are processed with vinegar, such as some canned beets, cauliflower and pickles [8]. Methods to reduce or mask, compliment or heighten the acidity in foods and beverages include the following. How to Reduce or Mask Acidity • • • • •

Add fat, such as butter or cream sauce, over astringent green leafy vegetables (such as sorrel or spinach). Counter acidity with a touch of salt, such as the salty rim of a margarita, or finishing salt on grilled tomatoes. Dilute acidity with neutral ingredients, such as water or mild vegetable stock. Increase sweetness to negate some sourness, such as sweet carrots mixed into a marinara sauce. Intensify savoriness, such as soy sauce in some acidic stir-fry vegetables, or catsup in some sweet and sour recipes. Tomato products, such as tomato catsup, contain all of the basic tastes and are savory/umami flavor enhancers (see Umami). In the process, they may appear to reduce acidity.

How to Compliment Acidity • Fat “rounds out” the acidity of vinegar in vinaigrettes. • Salt balances tartness and suppresses bitterness when it is added to sour vegetables, such as pickled beets, cabbage (as in sauerkraut) and/or cucumber pickles. • Sweetness in protein foods, such as coq co vin or beef bourguignon, is heightened by acidity. Sweetness brings out the natural sugars in meats, and sourness freshens up these dishes, especially if they are fried, as in scaloppine. Sugars also soften acidic flavors, such as in marinara or other tomato-based sauces. A small amount of white sugar or grated carrots or onions may help to neutralize the acidity and produce a sauce that is tasteful and easy on the gastrointestinal tract. How to Heighten Acidity • Add a hint of bitterness or saltiness, such as vinaigrette or wine, to bring up the acidity when finishing a dish. Usually a few drops will suffice. • Deepen acidity by adding bitter ingredients, such as cucumber, eggplant or mushrooms, either raw or lightly cooked to dishes. • Combine citrus fruit or juice with other sour ingredients, such as lemon or lime juice, along with acidic berries or oranges and tart arugula or spinach salad. • Cook acidic foods, such as onions or tomatoes, with other acidic ingredients, such as lemon juice, vinegar and/or wine. But longer cooking may overly concentrate the flavors, make them bitter and/or discolor neighboring foods or ingredients (Note: When foods are simmered for longer periods of times, such as in soups and stews, their natural acids may be reduced, volatiles may escape and flavors may dull. Some cooked acidic liquids such as citrus or tomato juice may actually become stronger and more acidic once they are reduced. This is one of the reasons a squirt or dribble of an acidic ingredient, such as lemon juice or vinegar, is used to replace some of the dissipated acids and brighten finished recipes.). If acidic ingredients are added the last minute, then adjoining ingredients might brighten in color, such as when green vegetables are dressed with lemon butter that intensifies their vividness. • Use hot sauce, such as Tabasco or sriracha (that are preserved with acidity) and salt to boost spicy flavors and yet balance the heat of other assertive sauces. Acidic Aromas • Acidic aromas are associated with the following aromas and others: • Citrus fruits and juices with citric acid—such as grapefruit, lemon, lime and/or orange • Fermented cheese products—such as some cheese like Bleu or Roquefort, “cultured” kefir, sour cream or yogurt • Fermented or “pickled” vegetables with ascetic acid—such as gherkins or Kosher pickles, rhubarb, tamarind or sauerkraut • Vinegars with ascetic acid—such as apple cider, Balsamic or red or white wine vinegar • Wine: Volatile acidity is a measure of a wine’s gaseous acids that contribute to the smell and taste of vinegar in wine. • Even if acidic tastes are modified, acidic aromas may remain.

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ACIDIC TIP: Especially for the aging—With aging, there may be changes in the acidity of the gastrointestinal tract. Also, gastroesophageal reflux disease is a common upper gastrointestinal disorder in aging people, when stomach acid refluxes into the esophagus and contributes to heartburn and other symptoms. Certain medications may contribute to heartburn, such as blood pressure medications, and obesity may also be causative. These conditions may be counterindicative of increasing acidity in one’s diet.

The Use of the Bitter Taste in Flavor Enhancement Detested by some people, treasured by others, the bitter taste stands boldly alone or greatly benefits from flavor enhancement ingredients such as those that follow. Bitter is one of the five basic tastes that also include acidic, salty, sweet and umami. Bitter is the basic taste that is so widely reactionary: it may run the gamut from distasteful to bearable, onto intriguing. The concept of supertasters, as discussed in Chapter 4, A Taste Primer, and the subsequent aversion to bitter tastes are central to its many reactions. It is not surprising that the word “bitter” is derived from the IndoEuropean root “bheid,” which is translated “to split,” the same root as the word “bite” [9]. Bitter tastes include those that are inherent in artichokes, asparagus, beer, bitter melon, bitter oranges, bitters, cabbage, caramelized sugar, chayote, chocolate, citrus zest, coffee, cucumbers, extra-virgin olive oil, green leafy vegetables, horseradish, melons, mushrooms, pickles, pumpkin, olives, rhubarb, tea, thistles, tomatoes, tonic water with quinine, wine, zucchini and others. The phenolic compounds found in bitter foods and beverages are partially responsible for their bitterness. These are the same phenolic compounds that act as natural pesticides and provide plants with their resistance to parasites, pathogens and predators. The key to incorporating bitter foods and beverages into healthy diets for the aging is to learn how to moderate their bitterness and to incorporate these substances into diets for their range of applications and enjoyment. Bitterness is considered a sophisticated taste that those who are aging may grow to enjoy even if they did not appreciate it when they were younger. Since the bitter taste is often present in very nutritious green leafy vegetables with their wide array of vitamins and minerals, it is considered an important taste to learn to enjoy. Paradoxically, the bitter taste also warns the consumer that the food or beverage carrier might be dangerous in small or significant amounts, such as the bitter substances caffeine, nicotine or strychnine. Memorably speaking, the bitter taste may conjure negative thoughts, such as when one was forced to eat their spinach or broccoli when they were younger. Overcoming these powerful images during aging typically requires trial and effort through repeated exposures, and a range of bitter enhancement strategies. Bitterness may taste good or even better when it is combined with other tastes. For instance, broccoli and other mustard-family members have an affinity to fats and oils, such as butter or olive oil. Leafy greens, such as collards or kale, often benefit by green extra-virgin olive oil or pork fat. English breakfast tea often calls for cream to buffer its bitterness, and sugar or honey to sweeten its sharpness. And wine and cheese pairings often match very bitter wines that have high levels of alcohol, oak or tannin with substantial harder cheeses, such as Aged Cheddar or Gouda, Asiago, Gruyere, Manchego, Parmigiano Reggiano or Pecorino, or very fruity or sweet wines that are low in alcohol, oak and tannin with cheeses that have a slight “undertaste” of bitterness, such as Gorgonzola, Roquefort or Stilton. Flavor enhancement of the basic bitter taste may be accomplished by these mechanisms: (1) reducing/masking, (2) complementing and (3) heightening. For example, people who do not enjoy a coffee taste may gravitate to tea or mask the coffee taste with cream and/or sugar (reducing/masking). Others may offset the bitterness of coffee with a slice of lemon peel, pinch of salt or an egg shell (complementing). Still others may appreciate the bitterness of coffee when it is pronounced in a mole sauce with chocolate (heightening)—another bitter ingredient that creates a flavor that is more than the sum of its parts. Methods to reduce or mask, compliment or heighten the bitterness in foods and beverages are as follows. How to Reduce or Mask Bitterness • Acid—Acidity lessens the perception of bitterness and adds freshness, such as tea with lemon. The acidity of the lemon may soften the tannins, as may pickle or sauerkraut juice, pomegranate molasses, tamarind juice, vinegar or whey (in other dishes).

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• Blanch—Blanching dilutes peppery-tasting glucosinolates, the natural components of pungent plants such as mustard, cabbage, and horseradish. Their bite is due to mustard oils. • Cook—Cooking also lessens the mustard-like bitterness of the members of Brassica family (such as arugula, mustard and/or watercress). • Dilute—Dilution disperses bitterness with water or by some other liquids. • Fat—The addition of fat decreases the sharpness of bitterness, such as chocolate served with whipped cream. • Remove—By removing the source of bitterness, such as the outer, older leaves of deep leafy green vegetables or the skin from the pith of citrus fruits, some of the bitterness may be discarded. • Salt—Salting extracts bitter “juices,” such as in salted cucumbers or eggplant. • Stir-fry—Stir-frying softens bitterness when the stir-fry oil is nonbitter, such as sunflower oil. • Umami—The addition of umami-rich ingredients enhances the inherent sweetness in bitter ingredients, such as anchovies in Caesar salad dressing that is served on bitter salad greens such as arugula, kale or Romaine lettuce. How to Compliment Bitterness • Add—Add or increase sweet extracts, such as banana, maple or vanilla. Use banana extract in banana/walnut cake or muffins; maple extract or syrup over bitter-skinned sweet potatoes, or vanilla extract within bittersweet chocolate recipes. • Balance—Offset greener (unripe) olives and olive oil with grassier, peppery flavors. An older, fuller, more developed oil may present less bitterness when in salads, vegetables and other dishes. • Fat—Combine celery leaves, Belgian endive or radicchio with creamy salad dressing to smooth their sharpness. • Salt—Sprinkle sea salt on grilled, steamed or stir-fried green vegetables, such as broccoli, Brussels sprouts, dandelion or collard greens or kale to soften their bitterness. • Sugar—Roll chocolate truffles in powdered sugar, or coat bananas or dried fruits with chocolate to highlight their sweetness. How to Heighten Bitterness • Condense—Reduce the amount of bitter ingredients to concentrate bitterness, such as fresh spinach that cooks “down” and reduces in volume. • Deep Fry—Submerge bitter ingredients in oil such as tempura vegetables or herb sprigs to capture their bitterness and moistness (that carries taste). • Oven Dry—Dehydrate bitter ingredients such as citrus zests or herb sprigs to intensify their bitterness. Bitter Aromas • Bitter aromas are associated with the following foods and ingredients and others: • Acrid (pungent) aromas—such as those found in beer, chocolate, citrus, coffee, green vegetables, herbs, hops, metallic, olive oil, saffron, smoke, soy, sulfur, tea, turmeric and wine. • Aromatic bitters—such as those found in anise, cardamom, cinnamon, clove, ginger and others for use in liqueurs and spirits. • Bitter essential oils—such as those that are pungent, sharp and/or strong as found in bergamot, frankincense, tangerine and ylang-ylang. • Even if bitter tastes are modified, bitter aromas may remain. • Unite with reducing/masking or complementing aromas to counterbalance. BITTER TIP: Especially for the Aging—Sweet aromas may remind some aging people of sweet memories. By combining the bitterness of chocolate with the sweetness of sugar such as in chocolate chip cookies or brownies, the bitterness may be nullified. Likewise, by using a sweet salad dressing over peppery salad greens, this measure may evoke a pleasant memory of bottled salad dressings that were so characteristic of childhood.

The Use of Fat in Flavor Enhancement Fat is a concentrated energy source with nine calories per gram (9 cal/g). To many people, fat has a creamyto-oily texture with a luxurious taste and aroma. Fat provides mouthfeel and mediates food preferences. Fat is also linked to fullness. In fact, people who do not “taste” fat may overeat. This suspicion has led to the belief that

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the taste of fat might be a contributing factor in obesity. More information about this supposition can be found in Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging. Depending on the source, the “taste” of fat is considered more as a textural component or “mouthfeel” rather than as a bona fide taste. In order to be categorized as a basic taste, taste receptors need to be identified and associated with a tastant. In fact, humans have orally detected fatty acid receptors of varying chain lengths and saturation. These are located on taste bud cells CD36 and the G-protein-coupled receptor 120. Once these taste bud cell receptors are activated by fatty acids, a series of transduction events occur that cause the release of neurotransmitters toward afferent fibers in the brain [10]. Whether these perceptions are independent of other tastes is debatable. Also of debate is whether these perceptions are at the detection threshold only, and/or if other perceptions are due to aroma or chemesthesis. Not only does there seem to be a coordinated bodily response to fatty acids in the alimentary canal, there also appears to be a coordinated bodily response to fatty acids in the gastrointestinal tract. These locations and coordinated responses may be some of the factors that contribute to the overconsumption of fatty foods and beverages and subsequent obesity. Since worldwide obesity is growing in surging numbers, the questioning of fat as the sixth basic taste and its implications are of significant growing interest. The beauty of using fat in food products and recipe development is that fat enhances bitter-tasting ingredients (especially vegetables), and it helps to promote the absorption of fat-soluble vitamins and phytochemicals. For example, beet, mustard and turnip greens and cruciferous vegetables such as broccoli, Brussels sprouts, cabbage, cauliflower and kale may be enhanced by fatty ingredients such as avocado, bacon bits, cheese sauce, creamy dressings, flavored oils and/or sweet butter. These fatty ingredients serve to moderate the bitter taste and make the resultant food product or recipe more unified and sumptuous tasting. Both an asset and a liability of dietary fats are that they have unique abilities to absorb and preserve flavors. Also, some dietary fats contain certain compounds with specific flavors. With regard to digestion, dietary fats may coat the oral cavity, allow tastes to remain longer than normal and contribute new flavors that may affect the total flavor experience. Types of Fatty Flavor Enhancers Butter Butter is about 80% fat, 15% water and 4% milk solids that may cause frothing upon heating. When the water evaporates, the milk solids may brown and become nutty in flavor. Browned butter may be used in moderation over protein foods, vegetables and whole grains to enhance flavor. Similarly, nuts with their higher fat content may be used in a comparable manner. • When butterfat is devoid of water and milk solids, as in clarified butter or ghee, it may be able to withstand higher heat without burning or creating controversial trans fats. Ghee is often cultured or flavored and primarily used in Indian cooking. • Clarified butter is useful for frying and searing meats and vegetables at higher temperatures for shorter periods of time, and for storage without the development of any off flavors. The aroma of clarified butter may also appeal to those people who are prompted by the smell of butter to eat. This may be a useful factor for aging people with dementia who have lost their interest in food and eating. Nuts and Seeds and Nut and Seed Oils Many cultures around the world use nuts and seeds and their oils as flavor enhancers. Neutral-tasting oils that include expeller-pressed canola, grapeseed oil and peanut oil have high smoke points. This means that they can withstand high heat and still retain their neutral taste. • Coconut oil (that is solid at room temperature) adds a tropical fatty flavor to beverages and foods. The saturated fat content of coconut oil continues to be controversial; however, the monounsaturated fatty acids in coconut oil have demonstrated some favorable applications for brain and heart health and other bodily functions. • Specialty nut and seed oils, such as avocado, hazelnut, sesame and walnut, have the capacity to add taste dimensionality without many calories. This is as long as they are used judiciously, such as if they are drizzled over cooked grains, salads or vegetables, or if they are mixed with other neutral-tasting oils with higher smoke points for rapid frying.

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Lard and Suet Solid beef fat is called suet and liquid beef fat is called tallow. Suet lends beefy flavor and moisture to common meats such as hamburgers and/or hot dogs. Tallow is used in frying and for popovers. Unlike suet, tallow may be stored for extended periods of time. • Suet is mostly comprised of saturated fatty acids. Tallow is mostly comprised of monounsaturated fatty acids that are considered to be more heart healthy. A little of either of these fats goes a long way to achieve better taste in beef products. Solid pork fat is called pork fat and liquid pork fat is called lard. Pork fat provides flavor and richness in sausages and terrines. Lard has a high smoke point so it is versatile in various doughs, frying and spreading, but doughs that are made with lard may take on a porky taste and/or aroma. Pork fat is mostly comprised of monounsaturated fatty acids, as is lard. Like the fats in beef, the fats in pork should be used sparingly and sensibly for taste enhancement. Olive Oils and Other Plant Oils Olive oils and other plant oils that are predominately monounsaturated fatty acids have wide applications in food product and recipe development, depending on the type of oil and the taste. There are olive oils and other plant oils for general cooking and baking; “finishing” olive oils and other plant oils that emphasize flavor; and textured and flavored olive oils and other plant oils that add extracts, herbs, spices and other ingredients to existing ingredients and/or recipes. Rancidity may affect the color, taste and texture of olive oils and other plant oils about 12 months after pressing or sooner, especially if they are not carefully preserved away from the heat and light. Many olive oils and other plant oils are naturally higher in monounsaturated fatty acids than saturated fatty acids, but check the nutrition labels to ensure that these oils are not mixed with oils that are higher in saturated fatty acids. Fatty Aromas The aromas of fats are caused by components that are dissolved within the fats and the ingredients that may be cooked alongside them, some of which may be lean and/or nonfat portions and ingredients. It may be that amino acids, sugars and other water-soluble components in foods and beverages may be involved in aroma formation, along with fatty substances. By decreasing the fat content of foods, the release of aromas and the viscosity of the foods may change, as well as a decrease in flavor perception. This suggests that if fat is reduced in a recipe or formulation that care should be taken for flavor compensation [11]. FATTY TIP: Especially for the aging—Aging people may have matured during a period of time when dietary fats were scorned for their relationship to coronary heart disease. So the use of dietary fats as flavor enhancers may be surprising, and especially if dietary cholesterol is an issue, they may be a deterrent for inclusion. If total calorie and fat intake are not concerns, then diet instructions could include the prudent use of dietary fats and/or oils as flavor boosters.

The Use of Salt/Sodium in Flavor Enhancement Saltiness, like bitterness, sourness, sweetness and umami, is one of the five basic tastes, and like sweetness, saltiness is paramount to body functions and survival. Pure table salt is about 40% sodium and 60% chlorine, and some versions contain iodine to help prevent iodine deficiencies that include thyroid disorders such as goiter. The salty taste may be found in foods and beverages such as bottled salad dressings; breaded poultry and fish; canned beans; canned fish (such as anchovies and caviar); canned and packaged soups; canned and packaged tomato products (such as tomato paste and tomato sauce); canned entrees (such as chili, ravioli and spam); cured foods (such as bacon, corned beef or smoked salmon); dairy products; eggs; meats; natural salts; processed meats (such as cold cuts, frankfurters and sausages); salted nuts, salted snack foods; seafood; sea vegetables; and many others. In cooking and baking, salt has the capacity to make foods tastier by bringing out other tastes, balancing other tastes and preserving foods. When used in low concentrations, salt may suppress the bitter taste (from

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compounds such as caffeine, magnesium sulfate, potassium chloride and quinine hydrochloride), and balance both the sour and sweet tastes (think vinaigrette and ice cream). At higher concentrations, salt may suppress sweetness (such as salted caramel) and enhance umami (such as soy or teriyaki sauce). When used in excess, too much salt may cause recipes to be distasteful or inedible. Another reason salt may affect food flavors has to do with the influence of salt on water activity. Specifically, salt may decrease water activity, which may lead to increased flavor concentration, improved volatility of flavor components and enhanced food aromas. By drawing out the moisture from food, salt also acts as a preservative but also disturbs the moisture that supports disease-causing microbes to flourish [12]. In addition to taste and flavor intensity, the use of salt in food formulation may also help to improve the perception of product fullness, thickness and overall balance and mask chemical or metallic off-notes. It also may be that salt activates the somatosensory (touch) neural systems as well as its interaction with salt taste receptors. As a texture enhancer, salt affects the rate of yeast fermentation and gluten formation that affect the final texture of yeast breads. Salt also affects the gelatinization of proteins in cheese production and in processed meats. By retaining moisture in processed meat products, sometimes less saturated fat is required. When salt is in its larger crystalized form it provides a crunchy texture on baked goods, or over meats and vegetables [12]. As a color enhancer, salt helps to maintain the color of processed meats from graying or mudding, as opposed to their anticipated pinkish-to-reddish colors. The taste intensity of salt both increases and decreases rapidly. Adding salt to dishes increases its palatability to a point, but too much salt may decrease its dimension of pleasurableness. This appears to be quite individualistic in scope, and likely due to any previous experiences with the taste and ingredient. This wide variation in salty perception helps to support why salt and/or sodium may be easy to decrease for some people’s taste, but quite harder for other taste preferences. When salt is sprinkled over some foods it may cause the fluids within these foods to be extracted. This is because the fluids flow through the cell walls of foods to greater concentrations of dissolved particles, pigments and proteins. This is the premise of the role of salt in food preservation. Once the fluids are extracted, then circulating air helps to evaporate these fluids and dry out foods that contain proteins, such as beef jerky or cured sausage. When the microorganisms that are normally found within the moisture content of cured meats is removed, then the storage time generally increases. Brining is another method whereby salt may be used in preservation. In brining the opposite of salting occurs: the brining liquid may be more dilute with fewer dissolved substances than the ingredients that are brined, and so it may move into the cells of some protein foods, bind, and result in juicier meats, poultry and/or fish. This may help to reduce the moisture loss of these protein-rich foods and result in more flavorful preparations. However, the structures of these proteins may be altered, which may in turn affect the cooking time and final texture. Plus, the total sodium content of these recipes may be affected—sometimes in a less desirable manner. Common cooking practices that employ the use of salt as a flavor enhancer are shown in Table 6.1. A caveat: They should only be used in diets that are not salt or sodium-restrictive. TABLE 6.1 Common Uses of Salt in Cooking Use SALT prudently in the following cooking applications: • Cooking liquid of vegetables to help break down the hemicellulose within vegetable fibers and minimize their nutrient losses. • Cooking water of pasta, potatoes, rice and other grains so that salt may infuse into these ingredients and enhance their taste. • Dried legumes to reduce cooking time (the magnesium in their cell walls is somewhat replaced with sodium for easier softening). • Raw vegetables before cooking or adding into salads to help prevent dressings and sauces from becoming diluted. • Salty/spicy mixtures over meats to create flavorful crusts and retain moisture. • Starch to limit gelatinization and reduce its stickiness (such as in cooked grains), and to improve the tastiness of starch-thickened sauces (such as those with cornstarch or flour) that tend to be bland. • Water to help to balance its neutrality. Data from http://www.finecooking.com/article/the-science-of-salt.

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After cooking, the use of larger-grain salt particles (such as sea salt or Kosher salt) helps to communicate the presence of salt to the diner, even if the total amount of sodium in a recipe is reduced. This is because the larger salt crystals display the taste of salt immediately to the diner. The palate might think that the rest of the dish is saltier than it actually is. Plus, the larger salt crystals tend to dissolve over time for a larger and longer flavor impression. However, it is easy to oversalt with larger salt crystals before serving, particularly if whomever prepares the recipes has any compromised sense of taste [13]. To find the balance between the use of salt for flavor enhancement and judicious sodium consumption, it is advisable to salt in increments until the desired taste of salt or flavor of a dish is realized. Some recipes do not state this instruction; rather, some recipes may read “salt to taste” at the finish. While it is true that the sodium content of a recipe may increase with each salting, the incremental practice of adding salt during cooking might actually guard against oversalting when the recipes are completed, or before individuals consume their food. Methods to reduce or mask, compliment or heighten the saltiness in foods and beverages include the following. How to Reduce or Mask Saltiness • A basic way to help to reduce the sodium in recipes is to dilute or disperse the recipe—assuming that it contains the ingredients to accomplish this. Either more liquid or solid ingredients can be added to redistribute the amount of salt per serving. • An unpeeled potato could be added to a dish to help to absorb some of the salt, and then this potato may be discarded before the dish is consumed. Rice may also be used in this manner, except it is more difficult to discard and may need to be integrated into the final dish. • A small amount of brown sugar, lemon juice, sour cream, vinegar, yogurt or wine may be used to add some acidity and/or sweetness to help balance the salt in a recipe, as long as the recipe is not distorted too much. This action will not reduce the total amount of sodium in the recipe, but it may serve to balance an oversalty taste. • In general, sweetness may balance the saltiness in a tomato-based dish, such as marinara sauce, while acidity may balance the oversaltiness in a meat-based dish, such as in sauerbraten. How to Compliment Saltiness • The pairing of the taste of salt and the taste of bitter may equal a complimentary union. Salt may help to suppress the bitter taste so that any sourness or sweetness may surface. For example, watermelon may be salted to tame its greenness and to uplift its sweetness and sometimes tanginess. Likewise, citrus fruits, such as grapefruit, may be treated in this manner. Only a little finishing salt may be needed to achieve this balance of tastes. • Blending the salty and sugary tastes may also be a successful coupling. For instance, when the saltiness of pretzels or salted nuts is mixed with a chocolate or honey glaze, then the combined tastes may be mutually inviting and satisfying. Granola bars often are formulated with these tastes in mind. How to Heighten Saltiness • By adding umami-rich ingredients to a salty dish, then both tastes may be highlighted. Imagine chicken soup with its characteristic umami-rich ingredients (chicken and a mirepoix with equal amounts of diced root vegetables: carrot, celery and onion) plus salt. The salt enhances the umami-rich ingredients, and the umamirich ingredients round out the salt—so much so, that in the right proportions, less salt may be needed. • Another method to heighten saltiness is to also boost the other four basic tastes: acidity, bitterness, sweetness and umami. This is evident in the very popular barbecue sauces that are frequently used atop umami-rich protein foods, such as fish, meats and poultry. In the United States, this taste combination is also achieved through the use of vinegar for acidity, honey or molasses for sweetness and tomatoes with their five basic tastes. Teriyaki sauce, common and popular in some Asian cuisines, relies on acidity from fruit juice or vinegar, sweetness from fruit juice or sugar, saltiness from salt or soy sauce and umami from soy sauce and/or other savory ingredients. Salty Aromas • Salty aromas are associated with the following aromas: beef, celery, cheese, cured meats, fish, pork, seafood, smoke and others.

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• Even if salty tastes are modified, salty aromas may remain. • Adding salt to foods helps to release aromas by driving aromatic compounds from food cells to volatize. • Salt may help to unravel or denature protein. In turn, this may make the flavors and aromas of protein-rich foods tastier and more aromatic. SALTY TIP: Especially for the aging—The taste for salt/sodium is partially instinctive and partially learned. The physiological need for sodium is only about 165230 milligrams per day. The average daily consumption of sodium in the United States is estimated to be more than 3400 milligrams, while the 20152020 Dietary Guidelines for Americans recommend that Americans consume less than 2300 milligrams of sodium daily [14]. A “taste for salt” may be acquired over the years from using too much salt throughout one’s life. It may take a few weeks or months to learn how to use less salt/sodium in one’s diet. It may also take some time to learn about and appreciated the use of thoughtful amounts of salt/sodium for flavor enjoyment—if health warrants this practice.

The Use of Sugar in Flavor Enhancement Sweetness is also one of the five basic tastes, like acidity, bitterness, saltiness and umami. Even a modicum of sweetness is detectable and preferable before and after birth, as observed in amniotic fluid and mother’s breast milk. After a lifetime of sweet exposure, the enhancement of the sweet taste in foods and beverages usually brings approval, unless the enhancement is cloyingly sweet. Fruits, dairy products, grains, proteins (that include fish, meats and poultry), nuts and seeds and vegetables with carbohydrates are all repositories of the sweet taste, but in varying degrees. Fruit at its ripest contains about 10%15% sugar by weight, while most vegetables contain just moderate amounts of sugar and acids that are used by the plant cells just after harvesting. This is why vegetables should be used and consumed at their peak to taste their best. Humans have different perceptions of sweetness; however, in general, when sweeter foods and beverages are regularly consumed, this tends to somewhat nullify the sweet taste. Additional sweetness may be needed to truly register the sweet taste. Research is ongoing [15]. If only a few sugars bind to the surface of sweet taste receptors, a weaker sweet signal to the gustatory cortex of the brain (the perceptual taste center) may be transmitted. If more sugars bind to sweet taste receptors, a stronger sweet signal may be communicated. Taste enhancer molecules may not prompt a signal of their own, but they may strengthen the likelihood that sugar molecules and sweet taste receptors bind, and this may result in the intensification of the sweet sensation [16]. Additionally, within the gustatory cortex of the brain, two spatially distinctive subregions appear to obtain, encrypt and denote either bitter or sweet stimuli. By selectively activating either of these subregions of the brain it may be possible to manipulate (1) taste perception, (2) associated behavioral actions and (3) perception of tastants [17]. Other sensory connections among sweetness and sound, texture and appearance also exist. For example, highfrequency sounds may enhance the sweetness in foods, while low frequency sounds may bring out the bitterness. Also the soft texture of foods may increase the flavor intensity, so as sugary foods become gooier in texture this may increase their sweet perception. Sweetness may also be correlated with plate size and color. According to some research, white, circular plates are better for communicated sweetness than black rectangular tableware [18]. How to Achieve the Sweet Taste The sweet taste may be achieved with common sugars, such as sucrose, galactose, glucose, fructose, lactose or sucrose. It may also be attained from artificial sweeteners such as aspartame (Equal or NutraSweet), sucralose (Splenda), sweet spices such as cinnamon or nutmeg or from unrelated sweet tastes such as chloroform. Many acidic, bitter, salty and/or umami-tasting foods and beverages contain some form of sweetness to help to make these substances more appealing. Consider sweet and tart orange juice, bitter-sweet chocolate, salted caramel or sweet black tea. A little bit of salt may emphasize sweetness and move a dish from brackish to pleasing. This phenomenon may be due to sugar receptors on oral sweet taste cells that were previously thought to exist only in the gut. These sugar receptors are called glucose transporters (GLUTs) and reportedly interact with sodium-glucose cotransporters (SGLT1). The presence of SGLT1 receptors on oral sweet taste cells function to transport sugars

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into cells only when sodium is present. This helps to explain why a little salt (or sodium chloride) has the capacity to enhance sweet perceptions [19]. As an example, try spreading whole grain toast with salted butter, then top the butter with marmalade. The composition should taste pleasantly sweet. Similarly, the sweetness of stir-fried shrimp saute´ed with salty soy sauce and peanut oil is tastier than if the shrimp were saute´ed in peanut oil alone. Sourness reduces sweetness and tends to cause a food or beverage to taste lighter and more refreshing. As an example, try swirling Greek yogurt with its acidity into fresh pea soup with its sweetness. The Greek yogurt may “cut” the heaviness of the legume-based soup. A little bitterness may also help to reduce sweetness, such as a squirt of lemon or lime over saute´ed bananas or very ripe melon. Sweetness may also enhance sweetness—especially if a food or beverage is not too sweet or under ripe. For instance, a little sugar sprinkled on grapefruit or berries may help to bring out their sugars, as may acorn squash with sweet butter and crystalized brown sugar. Sweet ingredients that are particularly helpful for enhancing the sweet tastes in some dishes include (but are not limited to) agave; apples; apple cider and balsamic vinegars; bananas; caramelized fruits and vegetables (such as apples, pears, garlic, and onions); corn; cream; dates; desert wine; honey; fennel; fresh peas; jams and jellies; ketchup; maple syrup and molasses; roasted carob, chicory or ginger; root vegetables (such as baby root vegetables that include beets, carrots, celeriac [celery root], parsnips, and sweet potatoes); scallops; squash; sugar snap peas; stevia (naturally derived from the herb); sugars (such as confectioner’s sugar, granulated, and light or dark brown sugar); sweet spices (such as cardamom, cinnamon, cloves, and nutmeg); sweet extracts (such as almond and vanilla), and unsalted butter. The following ingredients might be particularly helpful for attaining the sweet taste: • Ripe bananas are replete with natural sugars that constitute about 20% of their composition. Starchy bananas may best be used in savory dishes where their texture, not necessarily their sweetness, is important. When sweet bananas are paired with some acid, such as citrus juice or tangy yogurt, their sweetness may be enhanced. Coconut milk may also intensify the sweetness of bananas. If bananas are paired with bitter and/or salty ingredients, such as sea salt or dark chocolate—a consummate favorite combination—their sweetness may be imbued with salty umami-ness. • While berries are intrinsically sweet and sour depending on their degree of ripeness, by adding a sweet crumble of flour, nuts, oats and/or seeds, along with sweet spices such as cinnamon or nutmeg, this mixture may add sweet, bitter and umami tastes—especially if some of the ingredients are first toasted. When baked, the overall flavor is complex, with the rest of the tastes complimenting the sweetness. See the recipe for Blueberry and Fig Crumble in Chapter 10, Menus and Recipes That Appeal to Aging Palates. • Sweet butter has a delicious sweetness and adds an unmistaken taste and texture to grains, proteins and vegetables. Once sweet butter is flavored with herbs, juice, spices or zest, the sweet butter enhances the sweetness of what carries it. Plus, the sweet butter expands the overall flavor due to the element of texture that it contributes. Highly processed and/or salted butter may not achieve the same flavorful effects. • The use of cream in recipes may add different degrees of sweetness in both sweet and savory dishes, depending on the type of cream that is incorporated (Devonshire, heavy whipping, light, light whipping or table cream, for example). Due to its fluidity, cream is an especially versatile sweet flavor-enhancing ingredient. • Whipped cream with its natural milk sugar can add another layer of sweetness, as can dessert wine, such as Madeira, Port of Sherry, with their full-bodied sweetness, which have the ability to boost sweetness even further. • Dates and other dried fruits are concentrated sources of sugar. If they are macerated with water or a sweet liquid, then their sweetness may dissipate throughout a solution, and their flavor may integrate throughout an entire dish. • Honey may add a different complexity of sweetness than white sugar in recipes due to its double sugar sweetening potential (the simple sugars glucose plus fructose, as compared to the double sugar sucrose in white sugar). Honey fairly easily caramelizes and lends an umami savory note to glazes and marinades. The sweetness of honey also pairs well with soy sauce, vinegar and walnut oil. Citrus juice with honey slightly cuts its acidity and tends to brighten finished products. • Vegetables in the pea family, such as green beans, lima beans and sweet peas, may have both predominantly sweet and umami tastes. On their own, lightly poached beets, carrots, peas or squash add a pleasant sweetness to the bitterness of salad greens. When mixed with other sweet vegetables, such as onions or sweet bell peppers, then the sweet taste may magnify.

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• A little salt may further emphasize their sweetness and additionally enhance their savoriness. • An acidic/salty ingredient, such as sour cream or yogurt, or a bitter ingredient, such as arugula, cucumbers or deeply colored lettuce may also function to accentuate their sweetness. • Umami-rich ingredients, such as Parmesan cheese, seafood or stock, may further augment their sweetness. Root vegetables such as parsnips or rutabagas, may be intensified in flavor by frying or roasting—plus, their inherent sugars may caramelize and once lightly salted, their intriguing bitterness may peak. When sourness is added, such as a tangy vinaigrette salad dressing, or when umami is activated via a meat or mushroom sauce, then their sweetness may be somewhat subdued. If pureed, root vegetables such as beets, carrots, celeriac, parsnips, potatoes or sweet potatoes will both sweeten and thicken sauces that will then provide a flavorful adjunct to savory proteins, such as meats or poultry. If these root vegetables are first roasted before pureeing, their umami/savory tastes may be amplified even more. The addition of some seafood, such as scallops or shrimps to dishes, may add a sweet and briny taste to some recipes in addition to the umami taste. When seared, they caramelize that adds a slightly bitter note. The addition of bacon, citrus juice, corn and/or peas with scallops, shrimp or other seafood may also augment their sweetness. Sugars offer a wide range of sweetening opportunities that depend upon their degree of refinement; beginning with confectioner’s sugar that is one of the more refined sugars through granulated sugar, golden unrefined sugar, demerara sugar, light brown and dark brown sugar, and then one of the least refined sugars, molassesbased sugar.

For example, superfine sugar has the capacity to imbue discrete to significant sweetness in beverages, baking and cooking depending on the amount used. Superfine sugar, with only 15 calories per teaspoon, can lightly dust cut-up fruit in fruit salads to highlight their sweetness, coat apples, berries, citrus fruit or pineapple and slightly brown the exteriors of fruits, cakes and pastries into a caramelized bitter-sweet topping. Methods to reduce or mask, compliment or heighten the sweet taste in foods and beverages are as follows. How to Reduce or Mask Sweetness • Sweetness and bitterness is a classic combination whereby both tastes tend to offset each other. A wellrecognized example of this amalgamation is a chocolate bar with different degrees of sweetness that balances or emphasizes the bitterness in different percentages of cacao. • The use of caramel and coffee along with some sweetness may achieve similar effects because caramel and coffee, like cacao in chocolate, contain acidic, bitter and umami tastes. • If a little salt is added to the acidic, bitter, sweet and umami mix, then the final product will likely contain all of the basic tastes and probably activate many taste receptors. Sweetness will be just one taste within the mix. Such may be true with a salted caramel or chocolate sauce that may be used over ice cream or cake, each with their compositions of the basic tastes for unification. How to Compliment Sweetness • Sweetness and sourness tend to complement each other as practiced in Asian recipes with sweet and sour sauce and in sweet and sour candies. • The cloying degree of sweetness in some sauces and candies may be curtailed by some acidity, such as citrus fruit, juice or zest; by some vinegars (especially the sweeter ones, such as apple cider or sherry vinegars); and/or by some yogurt in sauces and for finishing dishes. How to Heighten Sweetness • Layering different sweeteners and sweet aromas may serve to amplify sweetness to a point, but then the resultant sweet taste or sweet aroma may become too overwhelming—a sensory overload to some people. Consider the sensory bombardment of the sweet taste that one may encounter inside of a bakery or ice cream shop. • Layering sweetness with fattiness, such as sweet and rich cakes, cookies, pastries and pies allows the fats to carry the sweetness throughout the oral cavity and intensify the experience.

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• Serving foods and/or beverages warm or at room temperature (when appropriate) may help to better diffuse the sweet taste. • Browning or roasting foods (as fitting in some recipes) may also help to elevate and transmit the sweet taste, along with other basic tastes. Sweet Aromas • Sweet aromas are associated with the following foods and ingredients and others: • Apples, bananas, berries, freshly baked bread, brown sugar, cakes, caramel, chocolate, cinnamon, coconut, cookies, doughnuts, frosting, fudge, honey, ice cream, jams and jellies, maple syrup, molasses, nutmeg, pies, puddings, sugars, syrups, tomatoes, vanilla and sweetened yogurts. • Even if sweet tastes are modified, sweet-smelling aromas may remain. SWEET TIP: Especially for the aging—According to the saying “a spoonful of sugar makes the medicine go down,” the sweet taste make help to make nonflavorful substances more palatable. This may be why some lozenges, medications, mouthwash, toothpaste and children’s beverages and foods have a mild-to-pronounced sweetness. A mere teaspoon of sugar at 16 calories may help to transform some fruits and vegetables to a more desirable taste threshold, improve palatability and encourage desirability. This assumes that both caloric intake and diabetic considerations are favorable for this measure.

The Use of Umami in Flavor Enhancement One of the most intriguing and newest of the five basic tastes is umami, which is characterized as an earthy, meaty or savory taste. The umami taste is both complex and synergistic in that the umami taste is difficult to pinpoint, and yet its interactive qualities influence palatability. Chapter 4, A Taste Primer, describes this taste sensation in detail. This chapter will cover the flavor enhancement applications of the umami taste, since umamirich ingredients have displayed both beneficial nutritive and health effects. The umami taste is far from new. Fermented fish sauces and meat and vegetable extracts with the umami taste have been valued for over 2000 years. Nonetheless, the discovery of umami taste receptors, which are taste receptors for L-glutamate, is a fairly recent highpoint of taste research. In 2000, a modified glutamate receptor of the brain was discovered, the tastemGluR4, which is a G-protein-coupled (metabotropic) receptor [20]. L-glutamate is a nonessential amino acid that naturally occurs in the L-form. L-glutamate is a salt of glutamic acid. Glutamic acid is the most common excitatory neurotransmitter in the central nervous system (CNS). Glutamic acid is strongly sour, yet the sodium in MSG contributes a salty taste so the resultant taste is a component taste and not necessarily pure. L-glutamate is an abundant amino acid in animal and plant proteins, and it is also available in “free form” (such as L-glutamate in aged cheese, mushrooms, peas, sardines and tomatoes). It functions as a building block for proteins and as a source of energy in the intestine that can be converted into glucose. L-glutamate may stimulate gastric secretion. It is a major neurotransmitter that is produced in the brain for the CNS. Mother’s breast milk is high in L-glutamate; however, the intestine metabolizes most dietary L-glutamate as soon as it is absorbed, and the blood-brain-barrier is not permeable to L-glutamate, so L-glutamate metabolism is regulated. For these reasons and others, the addition of L-glutamate to the diet under normal conditions should not be a concern. Rather, it may, in fact, improve the organoleptic properties of foods and beverages that are sensorial in experience, and lend beneficial health effects [21]. The umami taste may be found in substances that are naturally high in L-glutamate: anchovies; cabbage; dashi; dried tomatoes; dry-cured ham (such as prosciutto); fish sauce; fresh fish and seafood; grape juice; miso; mushrooms (especially shiitake); Parmesan/Roquefort cheese; peas; potatoes; tomatoes; Sake and Shochu; seaweed; soy beans; and walnuts. The umami taste may also be present in flavor enhancers that include autolyzed yeast extract; hydrolyzed vegetable protein; ibotenic, tricholomic, succinic and gallic acids; L-amino acids (such as glutamate and aspartate); MSG; purine 50 -ribonucleotides [such as monophosphates of inosine (IMP), guanosine (GMP), and adenosine (AMP)]; soy sauce; theogallin and theanine. Umami is useful in “rounding out” food flavors and decreasing sodium. This may be because there are specific oral receptors that respond only to L-glutamate.

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Umami as a Flavor Enhancer Within these umami tastes there are interactions between L-glutamate and purine ribonucleotides. How this synergism functions may not always be fully comprehended. Umami compounds may help to change the perception of nearby food ingredients by suppressing unpleasant flavors, they may increase the sensations of mouthfullness that include continuity and/or thickness and umami compounds may affect the palatability of L-glutamate itself [22]. Some common synergistic interactions that produce an amalgamation of the umami taste include the following umami-rich ingredients that contain the amino acid L-glutamate, or the 5v-nucleotides disodium inosinate and disodium guanylate that strongly contribute to the umami taste. Examples of common-to-distinctive umami-rich combinations of L-glutamate, GMP and IMP follow: Umami-rich Ingredients with L-glutamate • Asparagus, beets, blue cheese, broccoli, carrots, fish sauce, green tea, miso, onions, Parmesan cheese, pork, sardines, seaweed, shrimp, soy sauce, squid, sweet potatoes, tomatoes and white potatoes Umami-rich Ingredients with disodium guanylate • Black mushrooms and truffles, chicken, dried enokitake, hatsutake, matsutake, oyster and shiitake mushrooms, pork and white truffles Umami-rich Ingredients with disodium inosinate • Beef, chicken, cod, dried bonito flakes, dried ham, eggs, fish (such as sea bass and tuna) mackerel, pork, sardines and stockfish Umami-rich Combinations with L-glutamate, disodium guanylate and disodium inosinate • • • • • • • • • •

Anchovy paste in Caesar salad dressing Asian fish sauce in dressings, marinades, sauces and/or soups Balsamic vinegar in dipping sauces, salad dressings and marinades for fruits, proteins and vegetables Dried mushrooms (particularly shiitake and portabella) reconstituted in sauces, soups, grains, pastas, potatoes and other side dishes and roasted over pasta and other grains and proteins Miso paste soup with dashi broth, kelp and shiitake mushrooms Parmigano-Reggiano cheese in cooked vegetables, pasta and potatoes and salads Roasted garlic, onions and other root vegetables (such as beets or carrots) to a point of caramelization of natural sugars Soy or teriyaki sauce in tomato-based barbecue sauce, dipping sauces, marinades and/or salad dressings Tomato products in grain and vegetable side dishes, protein-based entrees and tomato-based sauces Worcestershire sauce in beef dishes, Caesar salad, chili, deviled eggs, oysters and Welsh rarebit Methods to reduce or mask, compliment or heighten umami in foods and beverages are as follows.

How to Reduce or Mask Umami • MSG, the flavor enhancer, considered as GRAS in the US food supply, has the capacity to contribute an umami taste to substances when it is incorporated. • The palatability of the amino acid L-glutamate depends on its form. While humans typically dislike or are indifferent to MSG solutions in water, they may appreciate it when MSG is present in a complex medium, such as broth or soup. • Therefore, to appreciate the umami taste, it may be necessary to be perceived in the context of other sensory stimuli. • It follows then to reduce or mask the umami taste other sensory stimuli need be stronger or compensatory. For example, in a broth or soup this may mean that the sweet tastes of some vegetables may be more pronounced than the savory taste of the same or different vegetables. How to Compliment Umami • Umami-rich foods and beverages may be supported by acidity since the sourness may cut the heaviness of the umami. While the flavor of meat is filled with the umami taste and is often valued (since it generally means that protein is forthcoming), too much meat with its umami fullness may be over-satiating.

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• By using some form of acid, such as vinegary sauces like barbecue sauce, catsup or mustard, or picked ingredients such as ginger, pickles or sauerkraut, the umami taste may be somewhat subdued in meat dishes, and the finished products may have more integrated flavors. • Beef and dairy aromas also tend to compliment, such as when aged cheese tops grilled hamburgers or blue cheese garnishes grilled steaks. The melded aromas are enticing to many meat and cheese consumers. • Many umami-rich ingredients are also salty in taste (such as anchovies, olives and soy sauce). This may occur because of the interaction of L-glutamate with sodium compounds in such substances as GMP, IMP and MSG. By using an ingredient with an umami-salt taste one may be able to use less of it, or fewer sodiumcontaining ingredients; thus, decreasing total sodium while preserving the taste and flavor of the finished product. • An example of this reaction is the use of soy sauce with its umami-saltiness. A lower-sodium soy sauce may still be able to achieve a roundness of flavor with decreased sodium. More possibilities follow. Umami and Salt Reduction One of the more salient uses of umami is its ability to reduce the amount of salt that is in a beverage or food, formulation, recipe or meal. Many umami-rich ingredients, such as cured meats and aged cheeses such as Parmesan or Romano, are also salty, and other umami-full ingredients naturally occur in foods, such as cheese, seafood and tomatoes. Although the umami taste is characterized by its savoriness and the salty taste by its saltiness, they tend to enhance one another. In fact, it has been estimated that the use of umami-rich ingredients may contribute up to a 50% reduction of sodium in some formulations and/or recipes [23]. How to Heighten Umami • By adding umami-rich ingredients to each other, then the combined effect may become bigger than its parts. For example, a sprinkling of aged Parmesan cheese over a tomato- and wine-based marinara sauce has the capability of producing a symphony of synergistic flavor. Or a traditional Caesar salad, with its combination of anchovies, aged Parmesan cheese and toasted croutons, has the ability of achieving an umami-rich starter or achieve entre´e prominence. • Other methods for boosting the umami taste include aging, curing, drying, fermenting and ripening. Examples include: • Aging: Aging concentrates and saturates natural flavor and tenderizes meat texture. • Beef that is aged 7 days contains more glutamate [21.1 milligrams of free glutamic acid (FGA) per 100 grams] compared to fresh beef (10 milligrams of FGA per 100 grams). • Curing: Salt-curing proteins, such as dry-cured ham, may increase amino acids, nucleotides and the umami taste. • Fresh pork contains about 2.29 milligrams of FGA per 100 grams compared to 337 milligrams of FGA per 100 grams in dry-cured ham. • Drying: Drying foods and ingredients may substantially increase their FGA. • Compare 150 milligrams of FGA per 100 grams in dried shiitake mushrooms, versus 71 milligrams of FGA per 100 grams in fresh mushrooms. • Fermenting: Fermenting imparts Asian fish sauce, beer, soy sauce and wine with increased umami. • For example, Asian fish sauce contains 6211383 milligrams of FGA per 100 grams and soy sauce contains 4121264 milligrams of FGA per 100 grams. • Ripening: Free glutamate levels may reach a pinnacle when the umami taste is optimal. • Ripe tomatoes (260 milligrams of FGA per 100 grams) contain more FGA than unripe tomatoes (140246 milligrams of FGA per 100 grams) depending upon ripeness [24]. Umami Aromas • Umami aromas are associated with the following aromas and others: Aged cheese (such as Parmesan or Romano); anchovies; beef (especially aged); brewed ingredients; browned ingredients; broth; chocolate; coffee; dashi; fermented ingredients; earthy ingredients; game; green tea; mushrooms; nutritional yeast; root vegetables (such as carrots, onions and potatoes, especially if they are roasted); other roasted ingredients; sardines, seafood and sea vegetables; stock; soy sauce; tea, tomatoes; wine; and yeast extracts (such as Marmite and Vegemite).

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• Even if acidic tastes are modified, umami aromas may remain. UMAMI TIP: Especially for the aging—Umami might be a strange taste to some aging individuals since it has a foreign-sounding name. On the contrary: umami is the familiar taste that so many aging people grew up appreciating, found in cured and fresh meats, tomato sauce and Parmesan cheese, as examples. Some of the more modern innovations and applications of the umami taste may be potentially concerning, such as the use of umami in flavor enhancers that include AMP, GMP, IMP or MSG that are prevalent in the US food supply. Many aging people may already consume these substances in their favorite products and recipes. An individualized approach to their usage is fitting.

OTHER FLAVOR-ENHANCING INGREDIENTS Natural Flavor Derivatives Mother Nature’s bounty (with some manmade interventions) is filled with ingredients with flavor enhancement potentials. These include the following substances for discussion: • • • • • • • • • • • • • • • • • •

Chilies and Other Peppers Citrus Coconut/Coconut Products Concentrated Fruit Purees, Jams, Jellies and Sauces Dairy Products Dry Rubs Extracts and Flavorings Garlic and Onions Herbs and Spices Horseradish Mint Mustards Nuts and Seeds Teas Turmeric Vegetable Purees Vinegars Wine

Chilies and Other Peppers The use of assertive ingredients such as chilies and other peppers [including, Anaheim, aji rojo, banana, cayenne, cherry, habanero, pimento, pimiento de Padro´, piquillo, poblano (Ancho), serrano, shishito, sweet bell peppers, Thai and others] may help to increase salivary flow and improve the palatability in foods for the aging as their sense of taste begins to diminish. Pungent qualities (as those that are found in chili peppers due to their capsaicin content) in the oral cavity are transmitted by the fifth cranial nerve, as well as the nerve endings of the seventh, ninth and tenth nerves. These cranial nerves transmit taste signals from taste receptor cells to the medulla in the brain stem, and then back to the gastrointestinal organs. These signals may affect ingestive and digestive activities by inducing gastric, insulin and pancreatic secretions. So while oral pungency is not a taste, it may contribute to the complete taste experience [25]. Citrus Citrus fruit and citrus juice impart acid to formulations and recipes that helps to add brightness and heighten the perception of other basic tastes. In particular, there are three main components to citrus fruits: the juice, pith and zest. The juice runs the gamut from grapefruit, lemon, lime and orange with their variations that are sweet-tart and freshly flavorful. Citrus juice helps to balance flavor, highlight natural flavors, preserve color and prevent oxidation.

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The pith, or the soft and spongy tissue under the zest, is bitter and is typically avoided for its harshness. The zest, or the outer skin is rich in oils with the most complex flavors and aromas. In general, the zest of citrus fruits is more tolerant to heat than citrus juice. This is one reason the zest is used in baking, since it may retain its complexity and flavor in various recipes after they are baked. Citrus juice may be used to add freshness to fresh and cooked fruits and vegetables; balance pan sauces, pasta sauces, salad dressings, soups and stews; and enhance the earthiness and nuttiness in rice, pasta and whole grains. It is an alternative to vinegar or wine in some acid-based dressings and/or sauces. Citrus juices blends well with some oils, such as canola or olive oil in salad dressings; acts as a replacement for wine in some pan sauces; heightens the umami taste and brings out the natural sugars in roasted fruits and vegetables; enhances the protein and sweetness in fish, seafood and poultry; cuts the starchiness in cooked grains, pasta and rice; softens the harshness of garlic and onions; and sours milk. One of the best assets of citrus juice and citrus zest is that it allows for sodium reduction without sacrificing flavor. Since lower-sodium diets may taste ordinary, a squeeze of lemon before eating or drinking may raise the taste of bland foods and seasonings in some sodium-restricted diets [26]. Coconuts/Coconut Products Coconuts and coconut oil may provide a mellow flavor and creamy texture to some formulations and recipes. Virgin coconut oil has a deep coconut flavor that may persist after cooking or baking. Refined coconut oil that has been processed to increase the smoke point may not be as intense in flavor, and it may be useful in deep fat frying and in stir-frying. Coconut oil may also be useful for saute´ing aromatics (combinations of herbs, vegetables and sometimes meats that are heated in a fat or oil in the beginning of a dish, such as butter, oil) or coconut milk and vegetables In turn, the aromatics may serve to absorb some of the sweetness of the coconut and imbue the entire dish with its fragrance. Consider using coconut oil to impart blander-tasting vegetables with more tropical notes, such as green beans or other legumes, or zucchini and other squashes. Not only will coconut oil help root vegetables caramelize, it will lend its essence to ordinary white or yellow potatoes, or bring sweet potatoes to a new pinnacle of taste. If sparingly applied to cooked grains or even popped corn, a little coconut oil should add a creamy, nutty sweetness without the need for excess fat or salt. Canned coconut milk (light and nonlight, with and without added emulsifiers) may be the basis of some savory sauces, especially those that are Asian-based. Coconut cream is coconut “milk” with more fat, less water and generally a greater coconut taste. Coconut “milk” is produced when the “meat” of a coconut is cooked, and then the meat is strained. Coconut water is the “juice” that flows from a newly cracked coconut. Coconut “meat” is the interior of the coconut that is often shredded and sweetened; however, unsweetened varieties may be available. Coconut powder (dried coconut milk) and coconut extract may also help to boost the coconut flavor in some recipes. The use of these coconut products also adds some texture to some formulations and recipes due to the fat in the coconuts, and to the dried, shredded consistency of the coconut meat. So for taste, texture and interest, a small amount of coconut and/or its products may be helpful additions. Concentrated Fruit Purees, Jams, Jellies and Sauces Concentrated fruit purees, jams, jellies and sauces, such as apple, apricot, banana, berry, cranberry, peach or pineapple, may serve to moisten and sweeten foods that are drier and not as tasteful to those who are aging. Catsup is considered as a concentrated fruit sauce since tomatoes are botanically deemed as fruits. Dried fruits and fruit pastes, such as tomato paste that can be squeezed from a tube or spooned from a can, may also serve to concentrate and enhance their deep fruit flavors. Dried fruits, such as apricots, dates, figs and/or raisins may be reconstituted in some fruit juice or water, and used as fruit sauces in some recipes when fresh fruits are not available. Dried fruits are high in beta-carotene, calcium, fiber, iron, niacin, magnesium, potassium and vitamin E, among other nutrients, so they may make nutritious contributions to the diet. Since dried fruits are also higher in fruit sugars, they may also add additional calories when they are needed, or if calories are of concern, then dried fruits and their sauces may be used in moderation. Concentrated fruit purees, jams, jellies and sauces may be particularly helpful for people who have chewing problems, and for those people who produce less saliva—a common occurrence in aging people. They may also

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be helpful in dietary planning for chemotherapy patients because apigenin, a natural compound found in fruits and vegetables, appears to make cancer cells more sensitive to chemotherapy. The uppermost fruit sources of apigenin include apples, cherries and grapes, and the top vegetable sources of apigenin include artichokes, basil, celery, nuts, parsley and some teas. Dysphagia (or difficulty swallowing) is both a symptom and a condition that may lead to choking on small amounts of foods or beverages. As age increases and there is more wear and tear on the esophagus, the risks of dysphagia may also mount—especially when it is connected with certain conditions or diseases, such as Parkinson’s disease. Risks of dysphagia tend to multiply in assisted living facilities if there is little close attention to residents. Concentrated fruit sauces may be used with alternate bites of foods to present different tastes and textures within the same meal. By permitting time between bites and tastes, this practice may help to better facilitate better swallowing. Drinking small amounts of water between bites and tastes may help to keep the oral cavity moist and permit foods to move around the mouth for greater taste activation. Some examples of concentrated fruit purees, jams, jellies and sauces that are paired with protein foods include the following: • • • • •

Applesauce mixed into barbecue sauce for fish, chicken or meats Blueberry jam or preserves atop low-fat cottage cheese or yogurt Cranberry sauce alongside chicken or turkey Mango salsa mixed with fish or seafood Red pepper jelly over low-fat cream cheese

Dairy Products Dairy products such as dairy butter, cheese, cream and half-and-half, milk and yogurt may lend their natural sweetness and tanginess (depending on the product) as well as their creamy mouthfeel to many foods and/or beverages. Butter • Butter has a dominant, signature volatile compound: diacetyl, a yellow or green liquid with a characteristic, intensely buttery flavor. • Diacetyl has commonly been added to margarines and other oil-based products, along with beta-carotene for aroma, taste and yellow color to replicate butter. Cheese (Soft and Hard) and Cottage Cheese (Cheese Curds) • The flavor of cheese depends on the flavor of the milk that was used in its preparation. And the flavor of the milk depends on the animal and its food source (e.g., cow vs goat, and grass vs grains). • In the United States, cheese is produced from pasteurized milk. Upon heating, the volatile top notes of the flavors may dissipate, unlike some European cheeses. • Aged cheeses, such as Asiago, aged Gouda, Grana Padano, Piave or Parmesan, with their sweet, salty umaminess, provide more pungency in flavor enhancement. • Cottage cheese is fresh cheese curd with a mild flavor. Cream, Half-and-Half (Also See Dairy Milk) and Sour Cream • Cream is composed of a high butterfat layer that is skimmed from the top of milk before it is homogenized. When skimmed from milk it is generally referred to as “sweet cream.” When cream skimmed from whey, it may taste more cheesy, salty and/or tangy. • Cream, milk and half-and-half have a pH between 6.0 and 8.0. This pH range is more alkaline than acidic. When any of these ingredients are combined with more acidic ingredients, such as coffee or tea, the resultant beverage may range from 5.0 to 6.0 in pH, or somewhere between acidity and alkalinity. • A similar concept may be operative in creamy pasta sauces, cream of tomato soup and cream that is added to some alcoholic beverages.

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• Half-and-half is a blend of equal parts of whole milk and light cream, with an average fat content of about 10%12%. • Sour cream is produced by the fermentation of regular cream with certain types of lactic acid bacteria. This process tends to sour and thicken the cream.

Dairy Milk and Cultured Buttermilk • Dairy milk that contains lactose that adds sweetness to recipes. • Depending on the fat content (whole milk, 2% or skim), a varying degree of texture may be added to recipes as well. • Dairy milk is generally neutral in acidity. However, spoiled milk may taste sour, and cultured buttermilk is intentionally sour: it is usually made from pasteurized milk with cultures such as lactic acid bacteria. Yogurt, Greek Yogurt and Kefir • Yogurt is produced by the bacterial fermentation of the milk sugar lactose that produces lactic acid. Lactic acid acts on milk protein to impart the characteristic acidic taste and creamy texture of yogurt. • Different types of milk that may be used to create yogurt include buffalo, camel, ewe, goat, mare or yak— some with less allergic sensitivities. • Greek yogurt has been strained to remove most of its liquid whey, so it tends to be thicker and sometimes more acidic, with less sugar and more protein, but less calcium than standard yogurt. • Kefir is a fermented and acidic beverage that is made with kefir "grains,” a yeast/bacterial fermentation starter. Unflavored, kefir is similar in taste to yogurt. Dry Rubs Dry rubs are mixtures of dried herbs and spices that are combined into a variety of flavors, and then rubbed onto the surfaces of fish, meats, poultry and some vegetables to create a seal and lock in flavor. Commonly included ingredients in rubs include sugar to assist in browning and crust formation and to enhance flavor; savory elements such as amino acids (especially glutamates); garlic and green herbs; paprika for color and flavor; pepper (black pepper, cayenne or chipotle), ginger; horseradish; and/or mustard for hot sensations and/or spicy flavors. Since salt tends to penetrate food, it is often eliminated or used sparingly. Extracts and Flavorings Liquid or dry extracts (such as savory: beef, poultry or vegetable bouillon, or sweet: almond, maple or vanilla), and formulated flavorings (such as essences or flavors) may be added to beverages or foods to enhance their tastes and aromas. They may help to compensate for flavor losses, impart targeted flavor attributes or aromatics to formulated products that lack flavor, and/or mask off flavors. Liquid or dry extracts may also help to stimulate aging taste buds and olfactory nerve endings, and serve to amplify desired tastes and aromas. Commercial extracts and flavorings may contain either natural or artificial (chemically synthesized) aroma compounds, or both types of these substances. Savory flavors, such as spice extracts. may contain both aroma and taste-active compounds. In general, choose extracts and flavors that complement the base food, such as savory extracts with savory dishes and sweet extracts with sweet dishes. Precisely, use beef extract to heighten the flavor of beef stew, and almond extract to heighten the flavor of almond cake. That stated, some of the most exciting taste combinations may be achieved when savory extracts are integrated into sweet dishes and vice versa. Specifically, chocolate extract has been used in mole sauce, and poultry extract has been used in sweet cornbread stuffing. Some examples of natural and artificially flavored extracts include almond, anise, butter, coconut, coffee, hazelnut, lemon, lime, maple, mint, peppermint, pumpkin pie, raspberry, root beer, rum, strawberry, vanilla, vanilla butter and nut. Some examples of the use of savory and sweet extracts for flavor enhancement are shown in Table 6.2. Table 6.3 shows how culinary herbs, herb blends and spices may be incorporated into cooking and baking for flavor enhancement.

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TABLE 6.2 Combinations of Savory and Sweet Extracts for Flavor Enhancement Type of extract

Combinations

Uses

As suggested in Recipes

Butter cream, or chocolate, coffee, lemon or strawberry-flavored cake; simple syrup for rum or vodka

SAVORY EXTRACTS Basil Beef

Broth for soups or stews and other liquid-based recipes

Cheese (cream)

Add to cream, dips and/or sauces

Garlic

Add to oils; refrigerate; use in oil-based recipes (also see Onion)

Hickory smoke

Flavor dips, marinades and sauces

Lemongrass

Used for baking, beverages (including beer and wine) and ice cream

Malt

Used for brewing

Onion

Adds allium flavor to Asian cuisine, baked goods, cereals and snacks, beverages, dairy products, dressings, sauces and soups, fats, margarines and oils, meat, poultry and seafood, noodles, pickles and seasoning blends

Pork

Noodles, pork products, sauces, seasonings, snacks and soups

Poultry

Similar to pork and beef; also, hot drinks

SWEET EXTRACTS Almond

1

/4 teaspoon 1 1 tablespoon sugar

Almond paste, custards, fruit, salad dressings, ice cream and sauces

Chocolate

1 tablespoon 1 1 teaspoon sugar

Chili peppers, legumes, tomatoes and vanilla

Coffee

1 teaspoon 1 /4 cup water

Baked goods, cocoa, frozen desserts, gravies, salsas, soups and stews

Lemon

1

/2 teaspoon 5 1 tablespoon lemon juice

Beverages, cakes, cookies, gelatin, frozen desserts, jams, jellies, frostings, pies Also: fish, pork, poultry, rice and vegetables

Orange

1

/2 teaspoon 5 2 tablespoons juice

Cakes, cookies, custards, fruit pies, gelatin, ice cream, jams, marmalades Also: fish, chicken, rice and salad dressings

Peppermint

Few drops

Bark, candy and cookies

Rose

Few drops

Chocolate, cookies, cream, glazes, mild cheese, milk, pastries, rice pudding, strawberries and tea

Vanilla

1 teaspoon 5 1 (2-inch) vanilla bean

Brownies, cakes, cookies, fruit salads, glazes, ice cream, marinades, muffins, sauces and vinaigrettes

1

TABLE 6.3 Culinary Uses of Herbs, Herb Blends and Spices Garlic and onions In the botanical world, both garlic (Allium sativum L) and onions (Allium cepa L) are considered vegetables. However, in culinary spheres, these vegetables are also considered convenient sources of pungent and savory aromas, tastes and flavors and very useful for flavor enhancement. Garlic Aged garlic extract (AGE) contains a wide array of antioxidants that may help to protect cells from oxidative damage and lower the risks of Alzheimer’s disease, cancer, heart disease, radiation and/or stroke. These health benefits may be partially the result of the high content of stable and highly bioavailable water-soluble organosulfur compounds in AGE [27]. When garlic is physically disrupted through chewing, crushing or slicing, allicin (an alliin metabolite) is released. Sequentially, allicin changes into a range of fat and water-soluble sulfur-containing compounds that emit hydrogen sulfide. This compound is responsible for the unmistakable smell and taste of garlic. Garlic relaxes the blood vessels and provides a variety of health benefits that may be initiated by this hydrogen sulfide signaling system. Other than health benefits, the pungency of garlic is valuable for amplifying flavors with less salt or sodium. Therefore, it is not surprising that garlic is present in a variety of states in almost every world cuisine. (Continued)

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TABLE 6.3

(Continued)

Raw garlic may be strong from the onset and may be used “as is,” or marinated in oil. As an aromatic ingredient, garlic is commonly cooked before use. It is often added early in a savory recipe along with a mirepoix, or mixture of carrots, celery and onions. Garlic may become sweeter once saute´ed, yet still maintain its garlicky taste. In some cuisines, garlic may dominate the recipes as in some Asian, Italian and Middle Eastern cooking. Onions Like garlic and chives, onions are members of the allium family and offer distinct flavors as a flavor enhancer, from strong to subtle depending upon their variety. Onion varieties run the range from cippolini onions, leeks, pearl onions, ramps, red ions, scallions, shallots, spring onions, vidalias, yellow onions to white onions and others. Organosulfur compounds also may influence the onion flavor. These compounds are released once the onion’s tissues are disrupted. Various thiosulfinates give onions their characteristic flavors. The flavor intensity of onions may also be governed by genetic factors and environmental conditions [28]. Horseradish The US Food and Drug Administration has approved the brassica Armoracia lapathifolia Gilib (horseradish) as a flavor enhancer, seasoning and spice. Horseradish purportedly has antiinflammatory, antioxidant, carminative, diuretic, expectorant and rubefacient properties. It may be a helpful flavor enhancer for people who are on long-sodium diets. Horseradish is utilized in more than 30 varieties worldwide that include Big Top Western, Bohemian type, common or Maliner Kren, Variegata and Wasabi. The most common form of horseradish is Armoracia rusticana that originated in Northern Europe. The intact horseradish root has very little aroma that is released when it is cut or grated. When enzymes break down the horseradish root, sinigrin (a gucosinolate) degrades to produce allyl isothiocynate or mustard oil. Mustard oil is responsible for the pungency of horseradish and mustard. It may also irritate the mucous membranes of the eyes and sinus regions. After horseradish is exposed to air it may become bitter, darken in color and/or lose its pungency. Mint Mint (menthe) and members of the mint family (lamiaceae) help to produce the familiar minty flavor that is used in mouthwash, toothpaste and other household products. The intense flavor of mint may mask bad breath and relieve some gastrointestinal symptoms. Coolness is a characteristic of menthol with its mint flavor that is often compared to cleanliness. Various types of mint, such as apple, orange, peppermint and spearmint, are often used in cakes, candies, garnishes, ice creams and tabbouleh (a Middle Eastern grain-based salad). Mint is easy to grow in a window garden or grows prolifically outdoors. Mint adds eye-appeal when its leaves are used for garnish, or when they are chopped in fruit salads or green salads. Mint generally pairs very well with desserts, eggplant, lamb, poultry, salads and teas, and is common in Mediterranean and Middle Eastern cuisines. Mustards Mustard, one of the world’s oldest condiments, may help to boost flavor, whether it is in liquid or powdered forms (from ground mustard seeds). The pungency of mustard and its heat are derived from enzymes that convert to mustard oil after the seeds are broken. The degree of heat of mustard is related to the type of seed that is used in its production. Yellow mustard seeds are the mildest, and brown and black mustard seeds have more pungency. The liquid that moistens and binds the mustard seeds may also affect its strength. Less acidic ingredients, such as water, may create extremely pungent mustards when freshly prepared; then they may rapidly lose their strength. Mustards with more acidic ingredients, such as vinegar, may present slow and steady causticness. Nuts and seeds Nuts and seeds are frequently added to dairy products for earthy and nutty tastes and texture, such as butter pecan ice cream, pistachio pudding, Swiss almond cheese spread, and most recently, in nut and seed “milks” (that are not made with dairy milk). The oils of the nuts and seeds contribute fat for browning (when nuts and seeds are roasted or toasted) and consistency. Nut and see oils are commonly used to flavor cold foods, or they are delicately added to hot dishes as a finish or garnish. Nut and seed oils such as Asian sesame, cold-pressed peanut, hazelnut, pine seed, pumpkin seed, sesame seed and/or walnut create flavorful marinades, salad dressing and vegetable sauces. A neutral oil, such as safflower or sunflower, may help to tame their assertive flavors when they are blended together. When nut and seed oils are used to replace butter or margarine, they have the capacity to create entirely new flavorful dimensions in cooked foods, especially vegetables. To help to reinforce the taste of nut and seed oils, roasted or toasted nuts and seeds that coordinate with the oils may be added to a dish for appearance, texture and/or additional taste. (Continued)

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TABLE 6.3 (Continued) Teas Teas are the dried and crushed leaves of Camellia sinensis tea plants that are infused to make cold or hot beverages. Tea leaves may also be used in cooking and baking. As the second most consumed beverage in the world behind water, tea is appreciated for its astringent, bitter and sometimes cooling properties, as well as for its floral, grassy, nutty and sweet notes. Teas are classified according to their processing techniques that may also affect their flavor. Flower buds, extracts, oils, petals and/or other plant leaves may be used to create different tea blends, flavors and scents. They are normally added to the tea leaves during the end of the tea manufacturing process. Some types of teas that are useful in cooking and baking include Earl Grey, roasted oolong, green tea, jasmine and matcha. Earl Grey is flavored with the essential oil of bergamot, an orange-like Mediterranean fruit, which can be used in sauces and rubs for meats and poultry and in sweet dishes such as fruits and salads. Roasted oolong can be finely ground into a power and incorporated into cookie dough. Green tea (such as matcha) is known for its antioxidant properties. It is also a common addition to ice cream and smoothies. Jasmine tea is flavored with jasmine blossoms to create its delicate, flowery and sweet aroma and taste that is often found in Asian-inspired desserts and baked goods. Turmeric Turmeric or curcuma longa (Latin, based on the Sanskrit word for “yellow”) is a member of the ginger family. Turmeric originates from the rhizomes or underground stems of the plant. Curcumin is the most active constituent of turmeric with powerful antioxidant and antiinflammatory properties. Turmeric is slightly bitter and woodsy in taste. It functions as a colorant and flavor enhancer, as well as an additive in cosmetics, dyes, perfumes and textiles. Turmeric blends well with legumes, poultry and vegetables as in Eastern Indian cooking. If turmeric is saute´ed in oil before it is added to other ingredients, it will release its flavor in a process called “blooming.” Vegetable purees Pureed is a culinary term that refers to foods (typically cooked fruits and vegetables) that are blended, mashed or processed into thickened consistencies. Pureed foods are generally given to infants when they are first learning to eat and especially before their teeth develop, aging people who may have difficulty chewing and swallowing and people who have recently undergone medical or surgical procedures who require pureed diets. The word “pureed” means purified or refined in French, where pureed foods used to add sophisticated touches to dishes. Common vegetable purees include mashed sweet and white potatoes and pea and squash purees, such as butternut. Vegetable purees such as these may supply concentrated flavor enhancement, decoration, smooth texture and thickening to dishes. Vegetable purees may add a concentrated mixture of tastes to dishes, depending upon whether they are cooked or fresh, and especially if they are grilled or roasted to further develop their umami taste. Vegetable purees may be added into sauces that taste “flat” or have poor texture to more fully develop their flavor and consistency. Vinegars Vinegar is a sour-tasting liquid that contains acetic acid. It is made by the fermentation of dilute alcoholic liquids, such as beer, apple cider, champagne, rice wine or white wine. Vinegars are mainly used as condiments or for pickling. Like citrus, vinegar has the potential of transforming recipes from bland tasting to brilliant in complexity by brightening dishes. In addition, ingredients with acids, such as vinegar, help to break down the fiber networks of foods and alter their chemical bonds. Milder foods, such as fish and shellfish, white-meat poultry and vegetables tend to pair with apple cider, champagne, rice and white wine vinegars; whereas heartier foods, such as beef, dark-meat poultry, fatty fish and pork tend to pair with red wine vinegars. Balsamic vinegar with its bold flavor, smoothness, sweetness and thickness pairs with grilled foods, some fruits and salads. Flavored vinegars may be infused with herbs, spices, fruit and/or vegetables. They include such varieties as berry, cinnamon, citrus, garlic, jalapeno, lemon, mint, mustard, peppercorn and others. Wine Wine is both a beverage and an ingredient. In both examples, wine is an amalgam of tastes and may either compliment or combat recipes and meals. The aromas, flavors and texture of wines may need to be taken into consideration since these chemostations may interact with each other and with other beverages and foods. When some wines are consumed with meals they may enhance the dining experience. They may also induce the appetite that may be beneficial for some aging people who have lost some of their sense of taste. Much has been researched and reported on the correctness of certain wines and specific foods. In general, it is prudent to combine lighter wines with lighter, flavorful foods, such as a white Sauvignon Blanc with its high level of acidity and citrus, with goat cheese, poultry, white fish or seafood, asparagus, light cream sauces and chives or tarragon. A full-bodied red Cabernet Sauvignon, with its bold tannins and full body, pairs better gorgonzola cheese, rib eye steak, grilled ahi tuna, tomatoes and tomato sauce and rosemary. Ingredients in wines such as calcium carbonate, enzymes, flavors, grape juice concentrated, potassium metabisulfite, potassium sorbate, sulfur dioxide, sugar, tannins, water and yeast may all affect the taste of some wines and how they react in recipes or meals [29]. From Marcus JB. Culinary nutrition: the science and practice of healthy cooking. Elsevier; 2014. p. 114116 [Table 3-4: Culinary uses of herbs, herb blends and spices].

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Other Sensory Agents A number of other sensory agents have been used by the food industry for flavor enhancement. These include the following substances: • • • • • •

Autolyzed Yeast Extracts Guanylic Acid Hydrolyzed Proteins Maltodextrin MPG MSG

While some controversies may exist about their applications, they have distinct applications in the food supply and merit review. Autolyzed Yeast Extracts Autolyzed yeast extracts are natural flavor-enhancing ingredients. They are substances that result when yeast is broken down by its own enzymes into its components to yield a partially nonsoluble flavor enhancer. Autolyzed yeast extracts contain the amino acid free glutamic acid, or the flavor enhancer MSG. They are often incorporated into formulations or foods as a less expensive alternative to MSG. Autolyzed yeast extracts are often used in baked goods and meats.to attain a grilled, roasted or toasted taste. If a person is allergic to yeast, then they may want to think about avoiding or limiting their consumption of foods that contain autolyzed yeast extracts. Guanylic Acid Guanylic acid is the nucleotide guanosine monophosphate that is formed during protein synthesis. It is the primary component for many natural chemical processes. These include deaminating to xanthine, hydrolyzing further to guanine and oxidizing to uric acid. Guanylic acid is generally broken down into the gastrointestinal tract and excreted in the urine. Guanylic acid is biosynthesized as a flavor enhancer—primarily to enhance the umami taste. Since it is an expensive ingredient, guanylic acid is usually combined with glutamic acid or MSG. On the negative side, guanylic acid may affect asthma and depress respiratory function, aggravate food intolerances and digestion and alter the pH levels in the body [30]. Hydrolyzed Proteins Hydrolyzed vegetable proteins (HVP) and hydrolyzed plant proteins (HPP) are added to foods to enhance flavor and to make the protein in these foods bioavailable. Bioavailability is the amount of drugs, nutrients or other substances that are absorbed by the body and used for bodily functions to derive active effects. HPP are often used in protein supplements as emulsion stabilizers and in personal care products as foaming aids. Hydrolyzation breaks down proteins into their amino acid building blocks that may be more absorbable after digestion (athletes seem to particularly benefit by this feature). For MSGsensitive individuals, this process may be bothersome. During digestion when the body breaks down HPP and HVP, glutamates may form that may combine with free sodium to create MSG. While MSG is generally considered to be safe, this may be of concern to MSGsensitive individuals [31]. Maltodextrin Maltodextrin is a polysaccharide used as a food additive and flavor enhancer. It is produced from starches in a process called partial hydrolysis, which is the breakdown of starch into smaller units called polymers. Maltodextrin has many functions that include its use as a filler ingredient, to extend shelf life, improve powdery appearance, mitigate sweetness, prevent melting, avert or retard granulation and reduce nutrient losses. Maltodextrin has a high glycemic index value of 185105, so it should be used sparingly by diabetic and/or hypoglycemic individuals, and under the advice of a healthcare practitioner.

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Monopotassium Glutamate MPG is the potassium acid salt of glutamic acid. It is used as a flavor enhancer and as a nonsodium MSG alternative in meat products and other foods, most usually to attain the umami taste. MPG is commercially prepared by the bacterial fermentation of molasses. MPG may also be prepared from vegetable proteins that include gluten or soy protein. Common products that use MPG as a flavor enhancer include canned tuna, canned vegetables, potato chips, stock “cubes” and some frozen foods. When MPG is added to processed foods their natural tastes may be more pronounced with a fuller flavor profile and augmented mouthfeel. However, a caveat is that some asthmatic people may demonstrate some sensitivity to MPG. Monosodium Glutamate MSG, originally isolated from seaweed, is the sodium salt of the amino acid glutamic acid. Glutamic acid and its salts may also be present in other food additives including autolyzed yeast, hydrolyzed yeast, HVP, sodium caseinate, soy extracts and yeast extracts. MSG appears on the US FDA GRAS list, and has been used for over 100 years as a flavor enhancer. Under normal conditions, humans may be able to metabolize large quantities of glutamate since it is also produced in the gut during protein hydrolysis and is a component of breast milk. Nonetheless, some individuals may display different degrees of sensitivity that may include asthmatic symptoms, headaches and Chinese Restaurant Syndrome, a pattern characterized by chest pain, facial pressure, flushing, numbness, sweating and/or other symptoms. One of the reasons for this occurrence may be that the glutamate in MSG is chemically similar to a natural neurotransmitter. MSG is naturally found in some cheeses and tomatoes, and it may also be present in gelatin, malted barley and rice syrup and other foods. In the food industry, MSG is used as a flavor enhancer for its widespread contribution of the umami taste. MSG is used to intensify the meatiness and savory aroma and taste of some processed meats, soups, stews and many other foods. The use of MSG in sodium reduction may be effective since MSG contains about 12% sodium (42 milligrams of sodium per teaspoon), as compared to one teaspoon of table salt (sodium chloride), which contains about 40% sodium (or 2300 milligrams of sodium per teaspoon). When MSG is combined with a little bit of sodium chloride or table salt, it may enhance flavor and decrease the need for salt to flavor foods. This may potentially decrease sodium intake in a manufactured food item, recipe and/or meal, thanks in part to the umami taste. Subsequently, the use of MSG has been found to be effective to help improve taste in aging people [32]. However, a healthcare provider should be consulted with to ensure that the use of MSG for these reasons is warranted, and that it does not negatively interact with other conditions, diseases, medications or other considerations [33]. Various taste sensitivities may be impacted by black pepper, too. Piperine is a component of black pepper that creates its pungency. Capsaicin in hot peppers along with piperine may cause mild irritation and inflammation that may contribute to the sensitivity of taste receptors or inhibit the normal taste receptors in large amounts. A small degree of sensitivity may enhance certain tastes, including saltiness [34]. This may be the reason why peppers are generally used in such small quantities in cooking. Other pungent ingredients and/or sensations such as carbonation, cinnamon and ginger may also produce mild irritating effects that may affect sensations, taste and overall flavor.

DIGEST The concept of flavor enhancement is generations old. The basic tastes of acidity, bitterness, saltiness, sweetness and umami all had their survival purposes: acidity meant that a food was not at its peak and that its sugars needed to mature. Bitterness often reflected a medicinal value or hazard. Saltiness was necessary for life to keep body fluids in balance. Sweetness was also life supportive, like the sweetness in amniotic fluid or breast milk. And umami also represented the essence of life, since the umami taste is protein-based, and the root word for protein is the Greek word proteios, ¯ which means primary.

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As chemical substances that are added to foods and beverages to create specific and desirable effects, flavor enhancement ingredients have been used since ancient times to preserve foods and make them more palatable. One such flavor ingredient is salt with its multitude of culinary uses and preservation qualities. In the 21st century, as the amount of sodium in the diet is debated due to its relation to hypertension and other conditions and diseases, other flavor enhancement ingredients have come to the forefront. This trend is also due to increased food processing and the interest in trendy snacks and other convenience foods. Sensory agents that include colorants, flavorings and sweeteners are escalating in the food supply. Some are natural flavor derivatives while others are formulated or manufactured. Natural flavor derivatives may be convenient, familiar and easy to obtain and use. These include the following ingredients that were highlighted in this chapter: • • • • • • • • • • • • • • • • • •

Citrus Coconut/coconut products Concentrated Fruit Purees, Jams, Jellies and Sauces Dairy Products Dry rubs Extracts and Flavorings Herbs and Spices Chilies and Other Peppers Garlic and Onions Horseradish Mustards Vinegars Mint Nuts and Seeds Teas Turmeric Vegetable Purees Wine

The descriptions, benefits and concerns about the following formulated or manufactured sensory agents were also provided: • • • • • •

Autolyzed yeast extracts Guanylic Acid Hydrolyzed Proteins Maltodextrin MPG MSG

It is important to note that both sets of flavor enhancement ingredients may have their places in aging diets to help to improve taste, desirability, ingestion, satisfaction and memorability. It is up to aging individuals and their medical care team and care providers as to which of these may be beneficial to their diets.

MANNER OF SPEAKING Adenosine Monophosphate (AMP) (50 -adenylic acid) Aged Garlic Extract (AGE) Ageusia Aging Allicin

nucleotide; component of nucleic acids and ADP, AMP and ATP; used in flavor enhancement garlic supplement that is made by submerging raw garlic in ethanol and storing for 20 months to stabilize the sulfur compounds absence of taste process of growing old or maturing major biologically active component of garlic; key component in the broad-spectrum of antibacterial activity

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Allyl Isothiocynate (also known as Mustard Oil) Armoracia lapathifolia Gilib (also known as Armoracia Rusticana) Anosmia Apigenin

Ascorbic Acid (also known as Vitamin C) Aspartame (NutraSweet) Autolyzed Yeast Extracts Benzoates (also known as Salts of Benzoic Acid) Bioavailability (BA) Blooming Butylated Hydroxyanisole (BHA) Butylated Hydroxy Toluene (BHT) Camellia Sinensis Chinese Restaurant Syndrome

Citric Acid Clarified Butter Coconut Oil (also known as Copra Oil)

Cre`me Cultured Buttermilk Curcumin

Curing Dairy Milk Diacetyl Direct Food Additives

Dysgeusia Dysphagia Disodium Guanylate (GMP)

colorless oil that is responsible for the pungent taste of mustard perennial plant of the Brassicaceae family; a root vegetable used as a spice for flavoring absence of smell naturally occurring plant flavone that is abundant in common fruits and vegetables; thought to possess anticancer, antiinflammatory and antioxidant properties antioxidant vitamin that is found in food and beverages; may be used as a dietary supplement common artificial sweetener in some foods and beverages; a methyl ester of the aspartic acid/phenylalanine dipeptide substances that result when yeast is broken down into its constituent parts; naturally contains free glutamic acid widely used food preservatives in many foods and soft drinks degree and rate that substances are absorbed into living systems or made available at locations of physiological activities steeping herbs and/or spices in fat before the liquid is used to extract more flavor antioxidant; widely used by the food industry as a preservative to help prevent oils from oxidizing and becoming rancid fat-soluble synthetic compound that primarily functions as an antioxidant and preservative, mainly to preserve fats species of evergreen shrub or small tree; buds and leaves are used to produce teas for enjoyment, health benefits and stimulant properties also known as MSG symptom complex; a set of symptoms that some people may experience after consuming Chinese food; may be implicated with MSG weak organic acid that naturally occurs in citrus fruits; commercially produced by the fermentation of sugar; used as a flavoring and setting agent pure butterfat without the milk proteins and water that are normally found in regular butter; less likely to burn or spoil edible oil that is extracted from the meat or kernel of mature coconuts; high in saturated fats, resistant to rancidity and wide applications, particularly baking French for cream; refers to cream-like preparations buttermilk that is created by fermenting pasteurized low- or nonfat milk so the milk sugars convert into lactic acid bright yellow biologically active polyphenolic compound found in turmeric; a cosmetic ingredient food coloring and flavoring and herbal supplement food preservation and flavor process; achieved by the combinations of nitrates, nitrites, salt and/or sugar and fish, meats and vegetables milk produced by animals, such as buffalos, camels, cows, equines, goats, sheep and yaks, as opposed to plant-based milks an organic compound; a yellow or green liquid with a deeply buttery flavor food additives that are often added during food processing; adds nutrients, help processing or preparation, increases appeal and/or maintains freshness distortion of normal taste medical term that describes difficulty swallowing natural sodium salt of the flavor-enhancing nucleotide guanosine monophosphate (GMP); used in conjunction with glutamic acid

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MANNER OF SPEAKING

Disodium Inosinate (IMP) Drying Dry Rubs Dysomia Extracts Fermenting Flavorants Flavors Flavorings Flavor Enhancement Food Additives Food Enhancers Generally Recognized as Safe (GRAS) Ghee Glucose Transporters (GLUTs) Glucosinolates Glutamic Acid

G-Protein-Coupled Receptor 120 Greek Yogurt

Guanylic Acid (also known as Guanosine Monophosphate (GMP)) Half-and-Half Hydrolyzed Vegetable Proteins (HVP) and Hydrolyzed Plant Proteins (HPP) Hypogeusia Hyposmia Indirect Food Additives

Inosine Monophosphate (IMP) (inosinic acid) Kefir L-Glutamate

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disodium salt of inosinic acid; used as a flavor enhancer in combination with MSG removal of water or other solvents from a liquid, solid or semisolid by the process of evaporation; inhibits decay and concentrates flavor mixture of dried herbs and spices that is directly rubbed onto fish, meats or vegetables to lock in moisture and flavor; contributes a surface crust distortion of normal smell substances that are produced by use of a solvent, such as ethanol or water to extract another constituent; savory or sweet depending on raw material metabolic process whereby sugar is consumed without oxygen; produces alcohol gases and/or organic acids substances that impart flavor to other ingredients; alter flavor characteristics distinctive tastes of beverages, foods or formulations additions to beverages and foods for imparted savoring addition of substances to enhance, intensify or nullify the flavor of foods and beverages substances that are added to foods or beverages to enhance appearance, nutritive qualities, taste and other characteristics (also known as flavor enhancers); bring out the flavors in a wide range of foods, often without adding flavors of their own designation by the US FDA that substances are considered safe by experts and exempt from food additive requirements type of clarified butter that is heated to remove the milk solids and water; common in South Asian and Middle Eastern cuisines group of membrane proteins; support the transport of glucose across plasma membranes natural components of pungent plants; causticness from mustard oils that are released when plants are chewed, cut or damaged amino acid for protein synthesis; salts and carboxylates referred to as glutamates; contributes to healthy digestive and immune systems and energy production protein that functions as a receptor for unsaturated long-chain free fatty acids; has an important role in regulating lipid and glucose metabolism yogurt that has been strained to remove the liquid whey and lactose; a thicker-textured yogurt with more protein and saturated fat and less sodium and carbohydrates than regular yogurt nucleotide used as a monomer in RNA; biosynthesized as a flavor enhancer mixture of one-half cream and one-half milk mixtures of amino acids and other substances such as peptides or salt; obtained by vegetable protein hydrolysis; used for meat or savoring flavoring diminished sensitivity to taste the diminished sensitivity of smell additives that indirectly come into contact with foods; may include adhesives, coating components, paper and paperboard components, polymers and adjuvants and production aids nucleotide involved in purine metabolism; precursor and metabolite of adenosine; used in flavor enhancement fermented milk beverage made from cow’s milk; fermented with a yeast/ bacteria fermentation starter nonessential amino acid naturally occurring in the L-form; most common excitatory neurotransmitter in the CNS

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Lamiaceae Lard Maltodextrin Manufactured Flavor Enhancers Mirepoix

Mint Monopotassium Glutamate (MPG) Monosodium Glutamate (MSG) Natural Flavor Enhancers Nitrates and Nitrites

Parabens Phenolic Compounds

Phenylketonuria (PKU) Piperine

Polyphenol Oxidase

Pork Fat Puree or Pureed Ripening Sinigrin

Smoke Points Sodium-Glucose Cotransporters (SGLT1) Sour Cream Suet Sulfites Suprathreshold Concentrations Tallow

6. FLAVOR ENHANCEMENT INGREDIENTS

an organic white and water-soluble compound; produced both naturally and synthetically; primarily found in sour milk products and sourdough bread; also produced when glucose is broken down and oxidized family of flowering plants identified as mint or deadnettle fat from the abdomen of a pig; rendered and clarified for culinary use polysaccharide produced from starch by partial hydrolysis; used as a food additive commonly in candy and soft drinks flavor enhancers other than natural; used to enhance taste, such as glutamic acid, MSG or MPG flavorful combination made of diced carrots, celery and onions, saute´ed in butter; used as an aromatic base to flavor sauces, soups, stews and other mixtures aromatic herb of the genus Mentha, as in peppermint or spearmint, used as flavoring in baking and cooking in beverages, foods and as a garnish potassium salt of glutamic acid; used as a flavor enhancer sodium salt of glutamic acid; used as a flavor enhancer flavor enhancers other than manufactured; include fats, sodium/salts and sugars and those that create bitter and umami tastes compounds that are naturally found in foods and added to processed foods as preservatives; prevent meat discoloring and contribute a salty taste group of compounds used as preservatives in cosmetics, foods and pharmaceuticals chemical compounds with a hydroxyl group bonded to an aromatic hydrocarbon group; closely associated with nutritional and sensorial qualities of fresh and processed plant foods rare inherited disorder; causes the amino acid phenylalanine to increase in body; may initiate major health and developmental problems common organic compound used as a flavoring agent, and in the synthesis of organic compounds, including pharmaceuticals; occurs naturally in black pepper with a burning, peppery taste bifunctional, copper-containing oxidase; causes rapid polymerization of oquinones to produce black, brown or red pigments (polyphenols) that cause fruit browning another name for lard (see Lard) smooth, thick pulp processed from fish, fruit, meat, vegetables and/or other ingredients; the process of preparing a puree process by which fruits achieve their desirable color, flavor, palatability, quality and other textural qualities natural glucosinolate found in some plants of the Brassicaceae family that include Brassica nigra (mustard seeds); may have anticancer, antibacterial, antifungal, antiinflammatory and antioxidant properties temperatures at which oils begin to burn and smoke family of glucose transporters that are located in the intestinal mucosa of the small intestine dairy product that is made by fermenting regular cream with lactobacilli bacteria hard white fat that is located on the kidney and loins of cattle, sheep and other animals; used to make tallow and as an ingredient in cooking salts of sulfurous acid; a preservative that is widely used for its antioxidant and antibacterial properties concentration of a substance or stimulus that is above the specified threshold hard and fatty saturated fat that is made from rendered beef or mutton fat

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REFERENCES

Tartrazine Taste Bud Cells CD36 Turmeric (Curcuma Longa)

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synthetic lemon yellow azo dye; primarily used as a food coloring taste bud cells that serve to detect dietary fats and its contribution to fat preference rhizomatous herbaceous perennial plant that is a member of the ginger family; key ingredient in many Asian recipes with purported antiinflammatory benefits measure of a wine’s gaseous acids that contribute to the smell and taste of vinegar tart and uniquely texturized dairy product; produced by the bacterial fermentation of milk

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Combination of flavor enhancement and chemosensory education improves nutritional status in older cancer patients. J Nutr Health Aging 2007;11(5):43954. ,https:// www.ncbi.nlm.nih.gov/pubmed/17657366. [accessed 05.09.18]; Mathey M-FAM, Siebelink E, de Graaf C, Van Staveren WA. Flavor enhancement of food improves dietary intake and nutritional status of elderly nursing home residents. J Gerontol A 2001;56(4):M2005. Available from: https://doi.org/10.1093/gerona/56.4.M200, ,https://academic.oup.com/biomedgerontology/article/56/4/M200/ 619955/Flavor-Enhancement-of-Food-Improves-Dietary-Intake. [accessed 05.09.18]. [3] Schiffman SS. Intensification of sensory properties of foods for the elderly. J Nutr 2000;130(4):927S30S. Available from: https://doi.org/ 10.1093/jn/130.4.927S ,http://jn.nutrition.org/content/130/4/927S.full. [accessed 05.09.18]. [4] U.S. Food and Drug Administration. 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[15] Jayasinghe SN, Kruger R, Walsh DCI, Cao G, Rivers S, Richter M, et al. Is sweet taste perception associated with sweet food liking and intake? Nutrients 2017;9(7):750. ,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537864/. [accessed 05.09.18]. [16] Enhancing taste: how it works, Scientific American, ,https://www.scientificamerican.com/article/enhancing-taste-how-it-works/. [accessed 09.05.18]. [17] Kanwal JK. Brain tricks to make food sweeter: how to transform taste perception and why it matters, Harvard University, The Graduate School of Arts and Sciences Blog, January 11, 2016, ,http://sitn.hms.harvard.edu/flash/2016/brain-tricks-to-make-food-taste-sweeterhow-to-transform-taste-perception-and-why-it-matters/. [accessed 09.05.18]. [18] Spence C, Harrar V, Piqueras-Fiszman B. Assessing the impact of the tableware and other contextual variables on multisensory flavour perception. Flavour 2012;1:7. Available from: https://doi.org/10.1186/2044-7248-1-7, ,https://flavourjournal.biomedcentral.com/articles/10.1186/2044-7248-1-7. [accessed 05.09.18]. [19] Gray N. Study suggests why salt can boost sweet taste perception, Monell Chemical Senses Center, March 8, 2011, ,http://www.foodnavigator.com/Science/Study-suggests-why-salt-can-boost-sweet-taste-perception. [accessed 09.05.18]. [20] Chaudhari N, Landin AM, Roper SD. A novel metabotropic glutamate receptor functions as a taste receptor. Nat Neurosci 2000;3:11319. [21] Beauchamp GK. Sensory and receptor responses to umami: an overview of pioneering work. Am J Clin Nutr 2009;90(3):723S7S. Available from: https://doi.org/10.3945/ajcn.2009.27462E, ,https://www.ncbi.nlm.nih.gov/pubmed/19571221. [accessed 05.09.18]. [22] Bachmanov A. Umami: fifth taste? Flavor enhancer? A neuroscientist’s view of the most complex of taste qualities. Perfumer Flavorist, 2010;35:527, ,http://www.monell.org/images/uploads/Bachmanov_umami_review. [accessed 05.09.18]. [23] Cheatham R. No salt, low salt and sea salt!, Prepared Foods, April 11, 2014. ,http://www.preparedfoods.com/articles/113953-no-saltlow-salt-and-sea-salt. [accessed 05.09.18]. [24] Crowe K. UMAMI in foods. EAL Workgroup, ,https://www.andeal.org/vault/2440/web/Umami%20in%20Foods%20White%20Paper. pdf. [accessed 05.09.18]. [25] Green BG. Chemesthesis: pungency as a component of flavor. Trends Food Sci Technol 1996;7(12):41520. Available from: https://doi. org/10.1016/S0924-2244(96)10043-1, ,https://www.sciencedirect.com/science/article/abs/pii/S0924224496100431. [accessed 17.09.18]. [26] Jung A. Healthy eating: the magic ingredient that reduces your sodium intake and boosts flavor, Reader’s Digest. Enthusiast Brands, LLC; 2018, https://www.rd.com/health/healthy-eating/lemon-sodium-intake/. Fruits & Veggies. More Matters. About the buzz: use lemons instead of salt?, ,https://www.fruitsandveggiesmorematters.org/use-lemons-instead-salt.; 2007 [accessed 17.09.18]. [27] Borek C. Antioxidant health effects of aged garlic extract. J Nutrition 2001;131(3):1010S5S. Available from: https://doi.org/10.1093/jn/ 131.3.1010S, ,http://jn.nutrition.org/content/131/3/1010S.full. [accessed 05.09.18]. [28] Randle WM. Onion flavor chemistry and factors influencing flavor intensity. Spices 1997;4152. Available from: https://doi.org/ 10.1021/bk-1997-0660.ch005, ,http://pubs.acs.org/doi/abs/10.1021/bk-1997-0660.ch005. [accessed 09.05.18]. [29] Wine Savvy. 10 Surprising ingredients you probably didn’t know were in your wine, September 30, 2014, Wine Cooler Direct, ,https:// learn.winecoolerdirect.com/surprising-wine-ingredients/. [accessed 05.09.18]. [30] Food-Info. E626: guanylic acid. Food-Info.net is an initiative of Wageningen University, The Netherlands, ,http://www.food-info.net/ uk/e/e626.htm. [accessed 05.09.18]. [31] CBC News. Hydrolyzed vegetable protein: what it is, where it’s found, ,http://www.cbc.ca/news/technology/hydrolyzed-vegetableprotein-what-it-is-where-it-s-found-1.944579.; 2010 [accessed 09.05.18]. [32] International Glutamate Information Service. Foods for the Elderly. Glutamate can make a helpful contribution to nutrition for the elderly by making many foods more appetizing and appealing, ,https://glutamate.org/benefits/foods-for-the-elderly/. [accessed 05.09.18]. [33] Schiffman SS, Graham BG. Taste and smell perception affect appetite and immunity in the elderly. Eur J Clin Nutr 2000;54(3):S5463. ,www.nature.com/ejcn., ,http://citeseerx.ist.psu.edu/viewdoc/download?doi 5 10.1.1.456.8483&rep 5 rep1&type 5 pdf. [accessed 05.09.18]. [34] Seasoned Advice. How does pepper enhance/increase the saltiness of a dish? ,https://cooking.stackexchange.com/questions/49710/ how-does-pepper-enhance-increase-the-saltiness-of-a-dish. [accessed 0.09.18].

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7 Flavor Enhancement Techniques

PHOTO: CW Vinegar. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: While I am more adventurous in my meal selections, by 5:00 pm I am too tired to eat. I try to eat my main meal earlier. B.E.

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O U T L I N E Summary

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Introduction

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Sensory Issues and Flavor-Enhancing Techniques

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Aging Issues and Culinary Techniques

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Overview

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Sensory Matters Vision (Sight) Vision and Aging Vision and Food Choices Visual Appearance Colors Color Enhancement Plate Presentations Food Combinations Food Shapes Food Textures Food Arrangements Food Focus Food Portions Plate Garnishes Audition (Sound) Hearing Loss and Aging Social Ramifications of Hearing Loss

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Food Intake and Hearing Loss Enhancing Food Intake Through Sounds Enhancing Auditory Cues Background Sounds Food and Beverage Sounds

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Olfaction (Smell) Food and Beverage Smells Smell Training Smell-Enhancement Techniques Gustation (Taste) Food and Beverage Tastes Taste Training Taste Enhancement Techniques Somesthetics (Sensations) Temperature, Movement, Pain, Pressure and Touch Tactile Sensations

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Culinary Techniques for Flavor Enhancement Techniques and Tastes

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Digest

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LEARNING OBJECTIVES 1. Differentiate among the range of flavor enhancement techniques used for common and specialized consumption and especially designed for aging populations. 2. Consider flavor enhancement techniques in relation to healthy, aging individuals versus those with disease states or physical disabilities. 3. Distinguish which of the flavor enhancement techniques are principally suited for changes in chemosensory perception during aging. 4. Devise individualized and group approaches for flavor enhancement that meet changes in aging olfaction, gustation and other sensory considerations. 5. Gauge targeted flavor enhancement practices with regard to food, beverage and meal satisfaction, nutritional intake, health and well-being.

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SUMMARY To principally examine the available flavor enhancement techniques that are generally and specifically designed for the aging, from common everyday foods and beverages to novel manufactured products, and determine their use for improving aging dietary intake.

INTRODUCTION Beyond the ingredients described in Chapter 6, Flavor Enhancement Ingredients, other approaches for improving the flavor of foods and beverages for the aging include the understanding and applications of flavorenhancing techniques to improve perceptions, consumption, satisfaction and repeat usage.

SENSORY ISSUES AND FLAVOR-ENHANCING TECHNIQUES Flavor enhancement techniques employ the use of all of the sensory modalities including audition, olfaction, pain, taste, temperature, touch, vision and others. This may be especially true for the aging when sensations may be on the decline. In particular, sight (vision) may be affected by the adjustments of lightness and darkness in environments; hearing (audition) by the alteration of the sounds in rooms or at meals; smell (olfaction) by the manipulation of the odors in settings or during meals; taste (gustation) by the exploration of various taste sensations during meals and snacks; and touch (somesthetics) by the investigation of the uses of cold, heat, movement, pain and pressure in relation to food and beverage consumption, utilization and enjoyment. Specifically: • • • • •

Vision (sight)—needs to be addressed for aging eyesight. Audition (sound)—compels consideration for decreased hearing. Olfaction (smell)—requires adaptation for sensory decline. Gustation (taste)—necessities individualization for diminishing perception and interest. Somesthetics (sensations)—dictates the detection and identification of everyday foods and beverages.

Each of these sensory modalities may have individual or collective effects on aging people. Plus, their roles in eating behaviors may be unknown or misunderstood. This may be because they have not been addressed, or because they were inadequately handled. This chapter will address each of these sensory modalities and suggest achievable and realistic outcomes.

AGING ISSUES AND CULINARY TECHNIQUES The main objectives for learning, developing, executing and evaluating specific culinary techniques are to create flavors for all people to enjoy, especially for the aging demographic. This is so that aging persons and care providers may learn how to create, balance and structure flavors so that foods and beverages are desired, enjoyed, remembered and repeated. This is especially important for aging palates where eating and drinking are sometimes forgotten or neglected. The foundation of this process lies within the flavor enhancement ingredients discussed in Chapter 6, Flavor Enhancement Ingredients, and builds on the flavor-enhancing techniques that are featured in this chapter that have the potential to unveil and uplift these flavor enhancement ingredients into prominence. A person does not have to be a trained chef nor a dedicated cook to achieve flavorful foods and beverages. By learning (or reviewing) an array of time-tested flavor enhancement techniques along with their creative applications, the declining tastes and interests in foods and beverages among the aging may be revitalized. Recipes and meals may be enhanced into newer or different realms and enjoyed with even greater gusto than during the younger years. Some culinary techniques may seem basic, while others may appear to be innovative. Looking at these techniques with fresh eyes may inspire innovative approaches to foods and beverages if aging palates dictate indifference.

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OVERVIEW This chapter will cover the flavor-enhancing techniques that achieve taste, aroma and texture, prevent fatigue, deliver impact and interrupt normal or expected tastes in surprising, yet agreeable ways. Culinary techniques such as blanching browning, concentrating, marinating and/or finishing and others will be described in detail and with applications for aging palates. Plating and presentation for appealing and enticing appearance will be featured. Other sensory issues such as comfort, environmental considerations, physicality, sounds, textures and other matters will also be highlighted. When it comes to meal satisfaction, there is much more than enhancing ingredients and techniques. This chapter serves to identify and emphasize the conscious and unconscious considerations that are vital for aging attitudes about foods and beverages and changing physiological needs.

SENSORY MATTERS Whether or not people are aging, the sensory issues of vision or appearance, the sounds of foods and beverages and the sensory qualities that are evoked by the contact of foods and beverages, such as olfaction, pain (and other somesthetics such as cold, heat, movement and pressure), taste, touch and temperature should be of consideration. Before foods and beverages can nourish and satisfy consumers, their abilities to evoke sensations should be recognized. Some of these aspects may be genetic in nature, others individualistic. All viable factors should be taken into account. To begin, vision should be addressed for aging eyesight.

Vision (Sight) Vision or sight is the ability to see. Although the sense of sight is not technically considered as a part of taste, it is a component of flavor and influences flavor perception. Thus, the predicted loss of vision during aging may affect food choices, and ultimately nourishment, health and well-being. This is why a closer examination of vision and aging is warranted. Vision and Aging The risks of low vision and blindness increase significantly with age. It has been estimated that by 2030 about 13 million Americans over that age of 65 will have severe visual impairment. Vision loss in the aging may increase the risks of falls and fractures and difficulties in bathing, dressing, walking and identifying medications. It may also exacerbate other conditions and health issues, including chemosensory decline and depression. The four most common age-related eye diseases are age-related macular degeneration (AMD), cataracts, diabetic retinopathy and glaucoma. AMD is the leading cause of vision loss in all groups of people who are aging, and the foremost cause of blindness in Caucasian individuals in the United States. Cataracts and glaucoma are the main causes of blindness among African Americans [1]. Some usable vision is generally defined as “low vision” and may include central vision loss (AMD); side or peripheral vision loss (glaucoma); overall blurring, clouding of images, decreased contrasts (cataracts) light sensitivity; and spotty field of vision (diabetic retinopathy). Low vision may affect the way that foods and beverages appear, interest in eating and drinking and the memories associated with eating experiences. These are critical determinates in the nutrition of the aging, health and well-being. More information about vision changes and the aging can be found in Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging [2]. Vision and Food Choices The phrase, “we eat first with our eyes” (first conceived by Apicius in the 1st century), aptly describes how vision and particularly appearance may affect our perceptions and choices of foods and beverages. With fading eyesight, those who are aging may be less compelled to choose nutritious foods and beverages unless they are brightly colored. This is apparent in human evolution whereby foraging (or the search for

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nutritious foods) has relied primarily on vision, and that color vision may have developed in primates as an adaptation to more energy-rich foods. Vision not only propels the acquisition of nutritious foods and beverages: The sense of vision also plays a crucial role in the attention, pleasure and reward systems, and in the physiological cycles of hunger in those who are aging and others [3]. Visual Appearance Visual appearance and plate presentation are vital considerations in eating experiences and especially for those with aging vision. Factors such as color, dimension, placement, texture and variety may help to determine which foods and beverages appeal and are chosen or refused. Colors The use of colors may be particularly useful to help guide some aging consumers to select, consume and remember specific meals. Colors may play vital roles in the expectations of odor, taste, texture and healthfulness, and provide signs of food preservation, or lack thereof. Colors reinforce freshness, proper cooking techniques and food quality. Patients with Alzheimer’s disease may suffer from deficient contrast sensitivity and have a difficult time distinguishing the plate from the food, or a beverage from the cup or glass. By enhancing the visual contrasts within a dish or beverage, people who suffer from Alzheimer’s disease may be able to increase their food and/or liquid intake. Blue plates may be especially beneficial since red plates tend to elicit avoidance motivation [4]. The main colors of a finished dish should be compatible and as realistic as much as the aging eyes can see. Earth tone colors that are soft and natural may be too diminished for aging eyes to discern. Vibrant colors, on the other hand, may be too excitable. A mix of the two color categories may enhance the natural coloration and subdue some of the bright intensity, and vice versa. Cooking techniques should enhance the colors of some foods, such as caramelized meats that bring out their natural sugars, or blanched or steamed vegetables that emphasize their fresh vibrancies [5]. Altering the hues, intensities or saturation of the colors of foods and/or beverages can help to generate striking effects on their impacts, expectations and subsequent experiences. Other factors that may affect color perception in foods and beverages may include cultural expectations and genetic differences. Color Enhancement Older consumers may want to consume foods and beverages in the same colors that their memories recall. For example, if brown gravy was a deep brown by recollection, then lighter-brown gravy may be unacceptable. A food color may also suggest a food’s flavor, such as orange cheddar cheese or red tomato soup. If the cheddar cheese is white, or if the tomato soup appears orangey or pinkish due to the addition of milk, these color changes may be confusing and/or misleading. The use of the ingredients shown in Table 7.1 may naturally enhance the potentially stimulating colors of foods and beverages, and provide a product’s flavor identity, as may natural food dyes that are based on these ingredients.

TABLE 7.1 Food Colors Derived From Edible Natural Sources Food colors

Edible natural sources

Blue or purple

Black beans, blackberries, blueberries, red cabbage or purple grapes

Brown

Cinnamon, coffee grounds or walnut hulls

Green

Mint, parsley or spinach leaves

Orange

Carrots, paprika or onion skins

Red

Beets, cranberries, elderberries, plums, raspberries and/or strawberries

Yellow

Lemon or orange peels, saffron or turmeric

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Plate Presentations Plate presentations should achieve a balance of colors, shapes and textures in food items that represent a mixture of cooking methods, seasonings, finishing ingredients and garnishes that bring the plate together. Complementary flavors and food groups should balance and harmonize in appetizing configurations. This is evident in the photos of the recipes in Chapter 10, Menus and Recipes That Appeal to Aging Palates. Food Combinations Both simple and complex foods may occupy the same plate. For example, a simply saute´ed chicken breast may be laid aside fried rice or quinoa with colorful chopped vegetables, or a green vegetable such as steamed broccoli or spinach that is topped with a flavorful sauce. Similarly, both simple and complex cooking methods can be used within the same dish to add a variety of dimensions and textures, as long as they achieve compatibility. These are some examples: pan-fried fish (crusty) with boiled baby potatoes dressed with a parsley butter (glossy); roasted turkey (stringy) with saute´ed apples (syrupy) and turkey sausage (crumbly); or Sheppard’s meat pie with braised beef chunks and carrots (chunky) and a mashed potato crust (creamy) successfully combine textures into well-matched wholes. Food Shapes Similarly shaped foods should not be placed near each other because the aging may have a difficult time discerning one from another—or feel that two are too much to consume. For example, one stuffed pepper or summer squash may be sufficient—more may always be added if and when the first serving is consumed. Food Textures The different textures on a plate may include foods that are coarse, smooth, soft or solid, or a combination of these textures. A meal that is mostly composed of custards, purees or molded ingredients may become boring if it is repeated over time. If a diet warrants a mixture of pureed and textured foods and/or beverages, meal interest and/or satisfaction is possible. Food Arrangements The various arrangements of foods on a plate should look tidy and unified. A simply positioned plate within a place setting is easier to distinguish than a patterned plate, and is elegant in its simplicity. A plate that contains all of the food components of a meal that fills the plate may not be as successfully perceived as one where the elements are brought together and featured in the center of the plate. The first configuration does not communicate what each of the elements are, while the second configuration communicates that all of the items belong together and taste well in combination. Examples of simple, yet desirable food arrangements placed on simple, white plates are shown throughout Chapter 10, Menus and Recipes That Appeal to Aging Palates. Food Focus Another plate presentation consideration is the focal point or prominence where the eye is drawn. While the relationship of each of the meal components is critical for determining the focal point of a dish, the view from above by aging eyes should also be taken into consideration. The focal point should be distinct and may indicate the manner in which the dish is to be consumed. For example, a salad may be composed with the protein on top and the lettuce on the bottom. Unless the diner mixes the salad ingredients, the protein will be consumed first. So in this respect, the focal point may be educational to the diner. The focal point of a dish, along with its balance and unity, should also aim to help the consumer move or flow around the plate with hopes that they consume the entire portion. As in the example of the salad, if the portion size is too large, then just the top layer or one side of a dish may be consumed. For this reason, the placements of vegetables and/or cooked grains or potatoes should be important considerations in relation to the protein portion on a plate. It may be prudent to first plate the ingredients and test the flow of the dish before serving in order to determine which plating and focal point is most effective. People who are aging tend to appreciate regularity and repetition, so while asymmetry may be interesting in younger years, symmetry and replication may be more desirable variables to achieve in plate presentation during older years.

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Food Portions Suggested portion sizes, or how much of a food should be plated, may vary from meal to meal and among aging individuals. In general, the portion sizes of foods and beverages should be about those given in Table 7.2. TABLE 7.2

Recommended Portion Sizes of Foods and Beverages

• 3 ounces of meat, poultry or fish or 4 ounces tofu (soybean curd) • 1/2 cup of cooked vegetables, fruits or juice, 1 cup of raw vegetables or fruits or 1/4 cup of dried fruit • 1/2 cup of cooked grains or starchy vegetables, 1 ounce of bread product(s) or 1/3 cup of cooked legumes (dried beans) • 1 cup of milk or yogurt • 1 teaspoon of butter or margarine, or 1 tablespoon of salad dressing or nuts Examples of plated dishes based on these recommended portion sizes include the following: • 1/2 cup garlic-mashed potatoes (base layer), topped with 1/2 cup cooked green beans (middle layer), with a 3-ounce portion of sliced chicken laid over the green beans (topmost layer and the focal point). • 1/2 cup cooked quinoa with 1/2 cup chopped, cooked cauliflower and broccoli (base layer), topped with a 3-ounce portion of lamb stew (middle layer), with 1/4 cup dried raisins and apricots over the formation (topmost layer and the focal point). A vegetarian option may be: • 1/2 cup of cooked brown rice and herbs (base layer), topped with 1/3 cup of cooked legumes or 4 ounces of tofu (middle layer), and sprinkled with 1 tablespoon of toasted nuts (topmost layer and the focal point).

Plate Garnishes Garnishes can be used to enhance plate presentation to add color, interest, taste and texture as long as they harmonize with the foods and accurately represent what is contained within the dish. For example, a spring of parsley is an appropriate garnish if parsley is minced, chopped, pureed or used whole within the recipe. A spring of cilantro may be more culturally correct for Hispanic dishes, and a spring of basil may recognizably communicate a Mediterranean-based dish. But an orange slice that is used as a garnish when there is not any orange in a dish may be a misuse of a plate garnish; furthermore, it may confuse the consumer. Likewise, lemon slices are often misused in this manner, and may be discarded when the plates are cleaned. So while they provide a touch of color and a potential squirt of flavor, they may be wasteful. Additionally, wisely chosen garnishes may help aging eyesight to better connect the garnishes with pleasant food memories, and be motivational to consume the contents of a dish, based in part to this stimulus. As examples, cilantro sprigs, green onions, Kaffir lime leaves and/or lemon grass are so indigenous to Thai cuisine that any of these garnishes could remind diners of pleasant food memories from earlier years. Plated foods and garnishes should also correctly represent the seasons and product availability to ensure brightness, freshness and the continuity of life.

Audition (Sound) Audition or sound is the vibrations that travel through the air or other mediums that may be detected once they reach the ear and stimulate the organs of hearing. Like the sense of sight, the sense of sound may decrease with aging. Many of the desirable properties of foods and beverages may be due, in part, to the sense of sound: consider a carbonated beverage, crispy apple, crunchy cracker, slurpy soup or squeaky cheese. Once these sounds wane with aging, the fullest enjoyment of eating and drinking may dissipate. Taking an indepth look at hearing and aging may be helpful for enhancing the flavor of foods and beverages in their broadest perspectives. Hearing Loss and Aging As with eyesight, the sense of hearing may be compromised as people age. In Chapter 2, Nutritional and Physical Concerns in Aging, aging and hearing loss were discussed. To summarize, about 27% of Americans over the age of 50 years have reported some degree of hearing loss to date, and at age 65, about one-out-of-three people has sustained hearing loss. By 2030 about 50.9% of Americans will be hearing impaired. After arthritis and heart disease, loss in hearing is the third most common physical condition that is considered as a major public health issue [6].

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Hearing loss may be mild, moderate, severe or profound, temporary or permanent and gradual or sudden depending upon the cause for the loss in hearing. Age-related hearing loss, or presbycusis, with its accompanying changes in the inner ear, may be mild or severe, but is always permanent. Noise-induced hearing loss may accompany it, and it may occur suddenly or over time. Tinnitus, or ringing in the ears, may accompany hearing loss and may also be debilitating. The buildup of earwax, ear infections, injury to the ears, objects in the ears, rupture of the eardrums and other conditions that affect the inner or middle ear may exacerbate hearing loss. Social Ramifications of Hearing Loss Hearing loss is considered as an “invisible condition.” This is because face-to-face, people who are hard of hearing may look, seem and/or act fairly normally. However, the invisible condition of hearing loss may be erroneously linked with aloofness, confusion or personality differences, and may be confused with or complicate dementia and other conditions. Hearing loss may also lead to less sociality including dining out, due to confusion from surrounding sounds, and/or fear of asking servers questions regarding menu information. This may be detrimental to the aging psyche and further contribute to social isolationism. Food Intake and Hearing Loss A significant relationship between dietary nutrient intake and hearing loss emerged in early 2000 with effects on the health status of the aging. This relationship was based on information from the National Health and Nutrition Examination Survey (NHANES, 1999 2002) and the Healthy Eating Index (HEI). These tools attempted to quantify the quantity and quality of foods consumed over time, and report overall dietary quality based on estimates of the consumption of dairy products, fruits, grains, meats and vegetables, based on cholesterol, saturated fat, sodium and total fat estimates. There was a statistically significant negative relationship that existed between the HEI score and High Frequency pure tone average ([audiometry] PTA). People who had higher HEI scores tended to have better high frequency pure tone average (HFPTAs) and some Low Frequency pure tone average (PTAs). In general, people who consumed better quality calories had better hearing. Free radicals associated with aging may damage the hearing mechanism (a complex and delicate conglomerate of the tympanic membrane [ear drum], three small bones and the cochlea [where sounds are received]) and contribute to age-related hearing loss. By consuming fewer foods and beverages overall, with an especial focus on antioxidant-rich foods and beverages, some age-related hearing loss may be prevented [7]. Enhancing Food Intake Through Sounds The food properties of many desirable foods and beverages are frequently accompanied by sounds. This may be because sound is an indicator of texture, which often means quality, since quality may demonstrate freshness. Words that capture the sounds of foods and beverages include crispy, crackly, crunchy, fizzy, squeaky and others. For instance, crispy describes a higher frequency biting sound, such as the one that may be experienced when biting French fries. Crunchy may be described as a lower frequency biting sound, such as the one that may be experienced when biting croutons. Fizzy aptly captures the sound of carbonation, as opposed to creamy that best describes the sound of whipped cream that “envelops” the oral cavity in its velvetiness. Even softer foods, such as bananas, breads, mashed potatoes or whipped cream may make inviting sounds when they are bitten, swilled around in the mouth, masticated and/or swallowed. A person may inaccurately express that they “feel” these sounds, but the sensations are mediated more by the noises that these foods and beverages produce. To illustrate: the sensation of carbonation is actually facilitated by the sense of taste from the sour receptors on the tongue, and not by the sense of touch. It is possible, however, to hear the sparkling sound of the bubbles. Other sounds that one may hear when a food is broken or crushed within the oral are typically more forceful (consider the sound of a hard piece of bread or a brittle granola bar). The teeth do not have touch receptors. Sensors in the jaw and the rest of the mouth mostly mediate what is felt. This may be why some auditory cues may help to confirm the textural properties of some foods and beverages. Unfortunately, these cues may diminish as the sense of hearing declines. Some of these cues are conducted through the jawbones to the inner ear, and others may rely on air transmission. The human brain then integrates these sounds that communicate what we feel, both automatically and immediately. The relative importance of sonic or auditory cues for a human’s perception of texture and mouthfeel varies for each particular sensation. This may be another reason why the sensation of sound and its interaction with other sensations is so individualized.

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Enhancing Auditory Cues The texture of foods provides consumers with highly salient cues about a food’s freshness and/or quality. For example, if sweet bell peppers are expected to be crisp and they are soft, the peppers may be perceived as old, spoiled and undesirable. By altering the sounds that occur during the act of eating one may be able to alter the perception of foods and beverages. Sounds may be desirable such as classical music, or undesirable (think about outside noises that may detract from the eating experience). If sounds are manipulated to desirable output, they may add complexity and interest to the eating experience and importantly impact food quality [8]. Background Sounds The background noises in an institutionalized or restaurant setting can be loud and interfere with a person’s ability to taste and enjoy foods and beverages and thus be detrimental to hearing over the long run. The use of noise-canceling headphones or other device that suppress noise and provide music are alternatives. Care should be taken so that these devises do not make people feel more socially isolated. The sound level of the music should be high enough to compensate for decreased hearing, yet not too high as to obscure conversation. Calmer music may help soothe anxious and agitated residents in care facilities and inspire them to consume more at mealtimes. Some people may convincingly associate certain musical notes with colors or particular sounding words with tastes. Familiar sounding commercials, jingles and music that evoke pleasant food memories and well-being may be appealing. Nostalgic sounds may also trigger better times associated with more ample foods and beverage intake. Selecting music that matches the foods, beverages or meals might also be conducive to better consumption since the perception may be more authentic, such as Mexican, Italian or Indian music and the foods and beverages that are associated with these ethnicities [9]. Food and Beverage Sounds Many foods and beverages produce sounds when they are consumed that may be associated with various sensations—both real and imaginary, as shown in Table 7.3. It may be helpful to descriptive words such as these when speaking to aging people about their meals, and to help them recall favorite items or preparations from their younger years. For example, consider the biting sound that occurs when a hot pepper is chewed. This sound may evoke a sensation of spiciness. Likewise, the bubbly sound of a soft drink may arouse a tingling sensation. By planning meals that

TABLE 7.3 Sounds, Foods and Beverages, and Associated Sensations Sounds

Foods and beverages

Associated sensations

Biting

Hot pepper

Spicy

Boiling

Soup

Blistery

Bubbling

Soft drinks

Prickly

Chomping

Hero sandwich

Bulky

Crunching

Carrots

Chewy

Flopping

Pancakes

Fluffy

Frying

French fries

Oily

Gnawing

Turkey leg

Hefty

Grilling

Meat

Savory

Grinding

Whole grains

Gritty

Gulping

Hot dog

Zesty

Gulping

Milk

Liquidy (Continued)

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TABLE 7.3 (Continued) Sounds

Foods and beverages

Associated sensations

Guzzling

Beer

Bubbly

Licking

Ice cream

Yummy

Munching

Apple

Crunchy

Nibbling

Granola

Grainy

Oozing

Melted cheese

Runny

Popping

Popcorn

Crunchy

Pouring

Cream

Silky

Shattering

Ice cubes

Icy

Sipping

Shake or smoothie

Frothy

Sizzling

Bacon

Greasy

Slurping

Cereal and milk

Purity

Slurping

Soup

Cozy

Smashing

Crackers

Crispy

Snapping

Celery

Stringy

Sparkling

Champagne

Tingly

Splattering

Italian beef

Messy

Spraying

Whipped cream

Airy

Stir-frying

Asian food

Chunky

Streaming

Salad dressing

Runny

Sucking

Hard candy

Sticky

Trickling

Honey

Tacky

Whisking

Scrambled eggs

Velvety

incorporate the sounds of foods and beverages and by addressing the sensations that they generate, this may encourage increased interest in certain foods and beverages, and ultimately improve nutrition and overall wellness.

Olfaction (Smell) Olfaction, or the sense of smell, was discussed in Chapter 5, A Smell Primer. What is specific to this chapter is its relation to flavor enhancement. Various types of smells and their effects on olfaction were also featured in Chapter 6, Flavor Enhancement Ingredients. Another approach is the use of olfaction enhancement techniques to combat chemosensory decline in the aging. Odors are often named according to the substances from which they are derived. Examples include a lemony scent that is produced from lemons, such as that in lemon drops; a sugary flavor that is generated from sugar in its many guises, such as blueberry syrup, and a vinegary aroma that is created from vinegar or other vinegar-like substances during fermentation, such as pickles or sauerkraut. Food and Beverage Smells As with the language of sounds that is shown in Table 7.2, words may also communicate certain smells and their associations. The aging may need help distinguishing, assimilating and articulating certain smells depending upon their age and cognition. Dining companions or care providers may provide welcomed assistance by using words that depict aromas, odors and scents. The language of smells and its associated sensations are shown in Table 7.4.

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TABLE 7.4 Smells, Foods, Beverages and Ingredients, and Associated Sensations Smells

Foods, beverages and ingredients

Associated sensations

Acrid

Ginger

Biting, sharp

Airy

Chamomile, mint

Calm, sleepy

Ambrosial

Pineapple-coconut

Seasonal, tropical

Aromatic

Chocolate chip cookies

Delightful, memorable

Balmy

Coconut, rosemary

Sultry, woodsy

Cloying

Cotton candy

Sweetness, indulgence

Comforting

Chicken soup

Soothing, warm

Corky

Aged wine

Musty, preserved

Delicate

Fine herbs (such as chervil, lavender and/or thyme)

Herbal, well-being

Distilled

Herbs extracted in alcohol

Alcoholic, herbal

Earthy

Truffle oil

Savory, delectable

Essence

Stock

Concentrated, intense

Extraction

Orange or rose water

Concentration, fruity or floral

Fermentation

Alcohol

Indulgence, relaxation

Flavorsome

Umami-rich ingredients

Delicious, satisfying

Foul

Bleu cheese

Soapy, strong

Fragrant

Herbs

Perfumed, summery

Fresh

Homemade bread

Comfy, crusty

Fruity

Wine

Complex, intoxicating

Funky

Fenugreek

Disagreeable, strong

Gamey

Duck, goose

Robust, wild

Heady

Garlic

Acerbic, powerful

Hircine

Goat-like

Foul, rural

Incense

Curry

Middle Eastern, spicy

Intense

Hearty gravy

Filling, caloric

Luscious

Rare, prime meat

Delicious, primal

Malty

Beer

Bitter, grassy

Mellow

Cheese, wine

Mature, full-flavored

Muscadine

Grapes

Resiny, woodsy

Elemental

Mushrooms

Dank, moldy

Odorous

Cruciferous vegetables

Bitter, gaseous

Offensive

Durian

Putrid, inexplicable

Perfumy

Rose water

Exotic, scented

Piquancy

Peppers

Fiery, stimulating

Overpowering

Fish sauce

Decomposed, odorous

Pungency

Garlic, onions

Heady, stinky

Robust

Cabbage

Malodourous, pungent

Rancid

Oils

Mellow, unctuous (Continued)

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TABLE 7.4 (Continued) Smells

Foods, beverages and ingredients

Associated sensations

Rank

Canned tuna fish

Fishy, smelly

Redolent

Smoked foods

Barbecued, roasted/toasted

Mineral-like

Boiled eggs

Over-cooked, stank

Smelly

Aged cheese

Old, spoiled

Rotten

Lettuce past prime

Decayed, foul

Savory

Hamburger

Flavorful, satisfaction

Snuff

Barbecue, woodchips

Smoky, palatable

Spicy

Pepper

Piquant, heat

Stinky

Kimchi, sauerkraut

Acidic, tangy

Smoky

Tempeh

Fermented, nutty

Sugary

Cakes, pies, pastries

Sweetness, decadence

Sweet-smelling

Hot chocolate

Chocolaty, richness

Tangy

Citrus fruits, zest

Tartness, freshness

Smell Training Another technique to help improve the recognition and identification of smells by the aging is called smell training. With smell training, areas of the brain may be stimulated to detect, remember or imagine certain smells depending upon the degree of smell loss and the memory of an individual [10]. Repeated short-term exposure to certain odors through smell training may be potentially beneficial for people who have experienced varying degrees of olfactory loss. It is important to note, however, that smell training alone may not necessarily bring about the recovery of a person’s sense of smell. Instead, it may be considered as an adjunct to one’s olfactory abilities. Any recovery of olfaction may help to augment the result of chemosensory decline due to aging and others conditions or damage to the olfactory anatomy. Smell training involves the periodic use of certain aromas so that smells may be detected and identified over time. Smell training may be accomplished with the use of essential oils, such as clove (spicy), eucalyptus (resinous), lemon (fruity) and rose (flowery), which have been used in various smell-training studies. A few drops of each of these oils can be swabbed onto a cotton pad or Q-tip and held about one inch away from each of the nostrils, one at a time. This provides airspaces for the vapors to build and improves the volatility of the odor molecules. The test participant should relax and naturally inhale a few times, with some rests in between. Since eucalyptus and rose are infrequently used in foods and beverages, more common scents such as beef or chicken extract, chocolate, cinnamon, tomato or vanilla may be used in subsequent exercises. Smell training should be repeated multiple times to help recognize, regard and remember certain smells over time. Smell-Enhancement Techniques Some techniques used to enhance the sense of smell may seem obvious or simplistic. It is best to keep in mind that people who are aging may not realize (or choose to realize) that their sense of smell is waning, and that help may be required. Practicing some of these easy techniques may serve to heighten their awareness of aromas, odors, scents and smells without being too intrusive. Be Attuned to What Smell Sensations Remain People who are aging should try to take “smell breaks” to raise their awareness of the smells that exist within their environment. Then these smells could be identified, described and compared to memorable smells to help to activate their smell memory. Both indoor and outdoor smells may be used and compared and contrasted. Either a companion or care provider may provide assistance in the process.

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Deeply Smell Foods and Beverages Another strategy for becoming more aware of smells is to deeply smell foods and beverages before consuming them. Baked goods, coffee or soup provide good mediums to practice smell discernment. People should take deep whiffs of their heated aromas, rest and breathe normally and then smell these substances once again to note any changes in perception. This technique is commonly used to help people who have lost some of their sense of smell and/or memory to remember foods or beverages and to arouse hunger. The volatile aromatic molecules may induce salivation that may trigger other chemical responses, and register as hunger or desirability for certain foods or beverages. In refined restaurants, foods may be domed and then the dome may be removed for the aromas to waft about the diner. At home or in a care setting, foods or beverages may be tented with aluminum foil that can be removed right before serving. Encourage people to then take a deep whiff of the item or meal, and then think about the aromas of the foods and beverages before consuming them. If repeated, this practice may help to improve the detection, identification, enjoyment and memory of certain smells over time, and restore interest in eating [11]. Alternate Nostrils When the human nostrils are stimulated by smells, each nostril registers the smell separately, and then both nostrils transmit these separate messages to the brain for perception and deciphering. This process may switch many times throughout the day, with one nostril more predominant than the other. This dominance contributes to a biorhythm with a direct effect on mood and behavior. Ideally, this is why foods and beverages should be smelled by each of the nostrils, before eating. While this process may seem overwhelming and/or embarrassing to perform, it may be subtle and unobtrusive. Additionally, the nostrils may have some dominance over each other and bear some resemblance to handedness (e.g., the left nostril may be more predominant than the right nostril for identifying smells that corresponds with left-handedness). The ability of the nostrils to fully function and detect odors throughout the day may also be dependent on dryness or moisture in the nose and the environment, a simple cold or flu-like conditions, medications or other disturbances [12]. Exercise or Keep Active The sense of smell may be keener after activity or exercise. The explanation for this phenomenon is not precisely clear. It may be due to the fact that vigorous exercise might open the nasal passages. So a walk before a meal, and for those who are able a bout of aerobic exercise, might be conducive to better smelling that follows. Exercise may also improve brain function and cognition and contribute to sensory health [13]. Make Sure Both Vitamin B12 and Zinc Status Are Adequate Both vitamin B12 and zinc have been associated with the sense of smell. Vitamin B12 is abundant in mostly animal foods, especially dairy products, meats, poultry and seafood. Zinc-rich foods include oysters, lentils, meats, pecans, spinach and sunflower seeds. A vitamin and mineral supplement may be warranted if the intake of either vitamin B12 or zinc is inadequate and is deemed by a healthcare provider [14]. Consider Mucus Production and/or Congestion The notion that certain foods cause more mucus production and/or congestion is debatable and depends upon each individual. It is possible that when people have colds that their sense of smell may be temporarily compromised. This may lead to the assumption that mucus, plus consequential inflammation in the nasal membranes, affects sensitive nerve endings and are deterrents to effective olfaction. While dairy products have been implicated with stuffiness, environmental allergens may be responsible. It may be best to test this assumption on the tolerance of an individual food or beverage, then gradually reintroduce this food or beverage to determine if mucous production decreases. If other circumstances, such as congestion or hay fever, nasal polyps or sinus infections impair the sense of smell, these underlying issues should be treated to help breathing and the sense of smell improve [15].

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Question Pollutants and Assertive Smells Such substances as chemical fumes from gasoline, nail polish or nail polish remover, nicotine smoke, paint or other strong smells may compromise the ability to fully smell properly. By limiting exposure to these substances, the sensitivity to less assertive scents may become more apparent, or return as during the younger years. This concept may also have merit for meal planning. If a meal starts with a very strong and odorous aroma it might be difficult to appreciate other aromas that are milder if they immediately follow the stronger aromas. For example, a cream soup may be successfully followed by meaty entry, but the reverse order in a meal may not be perceived as well. Medications may also distort the sense of smell and taste. However, they should not be eliminated without the advice of a healthcare professional. Over-the-counter medications, especially for colds and flu-like symptoms, may temporary interfere with normal smelling, which may return to usual once they are discontinued [16]. Note Odors That Influence Behaviors, Mood or Work Performance Learned and emotional associations with odors may impact certain behaviors, specific moods, and/or attentionto-work performance. If any of these reactions seem to impede a person’s lifestyle, then they might merit attention. For example, the sulfurous smell of cooked broccoli, Brussels sprouts and cauliflower may be so noxious to some individuals that they may become indifferent to eating a dish or meal whether or not the vegetables appear. The key is to bake, saute´, simmer or steam these vegetables quickly so to curtail their odorous sulfur smell. Then, try serving these vegetables with a little acid, such as lemon juice or vinegar, or even a little sugar to temper their bitterness. Another example is sweet smells, such as those that are released from baked goods. While sweet smells may summon pleasant feelings from childhood, if they are not lessened after a few bites, then attention may fade until the sweet smells and tastes are satisfied. Another potentially noxious smell, that of fermented cheese, may cause someone to develop a stomach upset, while other people may enjoy its sour nature. It is best to note these associations before these smells interfere with the eating process. Know That Few Smells Are Detected in Isolation The senses have an uncanny way of helping each other. For instance, a piece of ripe fruit not only smells ripe, but looks mature in color; it feels ripe when it is shook from the juices within its pulp, and even sounds ripe when it is handled due to the seeds that might have dislodged within its interior. By teaching the aging what to expect with ripeness, their diminished sense of smell may be compensated by information from other senses: obtaining, combining, fluctuating, cataloging and supporting this information along the way. Understand That Noses may be “Educated” Many people may be able to identify odors and demonstrate this ability with the right type of encouragement. The Japanese game of kodo in which players try to guess the names of thousands of scents demonstrates the very limited use that some people make of their olfactory potential. This situation may not be due to disuse as much as it may be due to diminished recall [17]. Given the potential decline in the sense of smell, an individual may be able to be trained to detect and identify smells other than their normal smell vocabulary. This assumes that individuals are motivated, interested and educated to do so. There is value to bring the sense of smell to more conscious attention; to make the best of what remains and to learn what has been missed. While it is true that a relatively small area of the brain is responsible for the olfactory sense, and that humans have fewer smell receptors than most other animals and furthermore that olfactory information is encoded in ways that requires recognition by the brain, in the right circumstances it may be possible for humans to use their sense of smell in unused ways with patience and repetitive practice. Use It or Lose It As with the other senses and other human anatomy, the nose needs to be challenged to continue to function properly. While age is said to diminish odor acuity, individuals may vary enormously. As with most human

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skills, olfaction may function fairly satisfactory over time with continuous use that may be enhanced by training and expanded by the range of a person’s ongoing experiences. Chefs, perfumers and wine professionals tend to use their noses until they are no longer functional in a work capacity, but they may continue to have fairly normal, olfaction capabilities for everyday function. Being well-nourished, with little-to-no medication and relatively healthy brain function and practicing some of the smell-enhancement techniques outlined in this section may keep olfaction at its feasible height [18].

Gustation (Taste) Gustation, or the sense of taste, previously discussed in Chapter 4, A Taste Primer, but similar to olfaction, or the sense of smell, is worth revisiting here. Though highly individualized, both the sense of taste and smell may be enhanced through the use of flavor enhancement techniques. The use of flavor enhancement ingredients to augment the sense of taste was discussed in Chapter 6, Flavor Enhancement Ingredients. More ideas will be presented in Chapter 12, Prime Time Resources for Aging, Taste and Health. Food and Beverage Tastes Contrary to the sense of smell with about 350 receptor subtypes that function in a variety of arrangements to sense about 10,000 odors, the sense of taste is centered around its five basic tastes. The basic tastes, the foods, beverages and ingredients that contain them and their associated sensations are shown in Table 7.5. These may

TABLE 7.5 Basic Tastes, Foods and Beverages and Associated Sensations Basic tastes

Foods and beverages

Associated sensations

Acidic

Citrus fruits and juice

Acerbic

Coffee and tea

Acrid

Dairy milk

Astringent

Soda

Biting

Vinegar

Caustic Pickled Prickly Sour Tangy Tart

Bitter

Artichokes

Acerbic

Citrus fruits

Acrid

Chocolate

Blistering

Coffee and tea

Bracing

Cruciferous vegetables

Burnt

(i.e., broccoli, cauliflower)

Harsh

Sorrel

Pungent Sharp Strong Unsweetened (Continued)

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TABLE 7.5 (Continued) Basic tastes

Foods and beverages

Associated sensations

Salty

Instant noodles

Alkaline

Mixed nuts

Brackish

Pasta sauce

Briny

Pickles

Mineral-y

Salty snacks

Saline Saliferous Salted/salty Saltish Sea-like Sweaty or teary

Sweet

Confections

Candied

Dairy desserts

Candy-coated

Fruit drinks

Cloying

Soft drinks

Fruity

Sport drinks

Nectarous Sacchariferous Sticky Sugarcoated Syrupy Toothsome

Umami

Aged beef

Brothy

Anchovies

Full-bodied

Parmesan cheese

Gamy

Soy sauce

Meaty

Tomatoes

Piquant Robust Savory Toothsome

be helpful when describing foods and beverages for aging people, either in discussion or through the written word in menus and recipes. Taste Training As elucidated in Chapter 4, A Taste Primer, taste research that explores the taste training of both laboratory animals and humans is ongoing. In the future, it may be possible to train individuals to respond to specific tastes, and design recipes and menus that conform to these tastes for both enjoyment and health. On a more practical basis, the basic taste “tests” and “trainings” given in Table 7.6 may be executed with willing aging individuals. The purpose of these exercises is to discover both taste detection and taste identification thresholds that may be compromised by aging.

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Basic Taste Exercises

THE ACIDIC TASTE 1. Serve fresh orange or grapefruit segments without sweetening. 2. Note consumption and preference. 3. Repeat; gradually add sugar or honey in tiny increments until the acidic taste is noticeable and acceptable. THE BITTER TASTE 1. Serve cooked or fresh greens, such as arugula, collard or spinach, with little or no salt or fat. 2. Note consumption and preference. 3. Repeat; gradually add a few drops of flavorful oil and/or a small pinch of salt until the bitter taste is noticeable and acceptable. THE SALTY TASTE 1. Serve sodium-reduced chicken broth with 342 milligrams of sodium per cup, as opposed to regular chicken broth with 554 milligrams of sodium per cup. 2. Note consumption and preference. 3. Repeat; gradually add salt in tiny increments until the salty taste is noticeable and acceptable. THE SWEET TASTE 1. Serve canned fruit in its own juice. 2. Note consumption and preference. 3. Repeat; gradually add a sweetener of choice in deliberate amounts until the sweet taste is noticeable and acceptable. THE UMAMI TASTE 1. Serve plain pasta with olive oil and little salt. 2. Note consumption and preference. 3. Repeat; gradually add tomato sauce and Parmesan cheese to blend until the umami taste is noticeable and acceptable.

Taste Enhancement Techniques By practicing some of the following techniques, the sense of taste may be advanced to the forefront to promote greater appreciation and enjoyment of foods and beverages. Similar to the Smell-Enhancement Techniques just given, some may seem obvious or basic, but are worthy to present in aggregate to encourage their usage. 1. Consider a premeal ritual. An appreciation of the meal to come encourages a person to stop, take pause and visualize. Informing an aging person about the deliciousness to follow (be it a special menu or dish) may increase anticipation for eating. Using tantalizing words to describe menu items may help to improve the “intrinsic interest” of foods and beverages and enhance taste. Perceptions about foods appear to change with repeated, episodic and fixed behaviors. 2. Use memorable photos. The sight of a pleasurable taste experience or mouthwatering foods may stimulate stronger brain activity—particularly in the orbitofrontal cortex—which might make a succeeding taste appear tastier. This could entail photographs of former dinner parties with favored family or guests, or pictures of older products that evoke pleasurable taste memories. 3. Try heavier, rounded tableware. The weight of the tableware may serve to impact the sense of satisfaction from a meal or food, and it may cause the contents taste “richer or more intense.” Heavier dishes and bowls may also convince the brain that their contents are equally dense and thus more filling. Likewise, a small bowl full of food may make a person feel more satisfied even if the portion size is modest. Different sensory stimuli, such as weight, may convey the “weighty” importance of certain foods or beverages and even fullness upon their consumption. In particular, heavier cutlery (if well-handled) may increase a diner’s perception in the “value” of a meal or food. 4. Change the temperature of the tableware. A warm bowl or plate may be comforting and entice diners to “warm up” to the thought of consuming a food or beverage. This may be accomplished by using a dome or a tent made of aluminum foil. A cold dish usually signifies the start or the end of a meal and may communicate beginning and/or closure to individuals with some memory loss. While this may be somewhat impossible to accomplish in large-scale feeding environments, this technique may be beneficial in small group or one-on-one feeding situations. AGING, NUTRITION AND TASTE

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5. Optimize the temperature of foods and beverages. Serving foods and beverages at the right temperature may release their flavor molecules so that they may be tasted effectively. The temperature of foods may also affect the perceptions of certain tastes, such as salty, sour and sweet. A little heat on the tip of the tongue may trigger a sweet sensation, while a little cold may activate a salty or sour feeling, but this may be variable depending upon taste loss and which taste signals are dominant. Generally, the warmer the temperature, the sweeter the taste, so very cold and very hot food or beverage temperatures may not be optimally perceived nor desirable. 6. Alter the colors of foods and beverages. For example, the color red, when used in sweet food and beverage preparations, may cause them to look sweeter than they really are, as opposed to nonred foodstuffs. A few drops of natural food dyes from such substances as beets, plums or purple carrots may perk up muted colors and covey the sweet taste to follow. Red dinnerware may also cause people to consume less, if that is a goal. This may be because the color red is associated with danger and stop signs to many people. 7. Provide hydration. As people age, they tend toward dehydration because they may not perceive thirst as much as they did when they were younger, and may fail to replenish their water losses. Aging people may not comprehend that the saliva inside the oral cavity is vital to taste, and that it initiates the digestion process. To taste foods to their fullest, it is advisable to consume an 8-ounce glass of water every few hours. This is especially necessary if a person is prone to dehydration or if they medications that have dehydrating side effects. By keeping the air humidified, this may also protect against some oral and/or nasal dehydration. 8. Individualize flavor accompaniments. Since taste is such a personal matter with so many individualized parameters, when and if possible provide a number of taste options so that aging taste buds can be tantalized by a variety of ingredients. For instance, a serving of mild chili can be very filling and satisfying on its own, with or without meat. Some embellishments may include grated cheese (that adds calcium, phosphorus, protein and vitamins A and B12); hot sauce such as TABASCO or Sriracha; chopped onions for piquancy; cilantro for freshness and antioxidants; and tortilla strips for texture. By providing an array of these options, the chili may be prepared to one’s own liking, and these additions may encourage its consumption. This can be especially important for satisfying ethnic preferences. 9. Avoid extremes. While certain chemicals may be responsible for the distinctive sensations of coldness, hotness, spiciness and/or painfulness, the composite chemosensory irritation might provide sensory overload to some people and the subtleties of flavor may be lost. Therefore, in the process of layering tastes to heighten flavor (a technique used by most flavor-savvy chefs), chemical extremes should be implemented with care. Chemical irritants, such as carbonation, mint or peppers, with their effects on the mouth, nose and skin that carry sensations by the trigeminal nerve to the brain, might be too potent or “smarting” to some people. Nonetheless, if used in moderation, some people with declining sensitivity to texture may actually like the experience. This will be discussed in the following section on Somesthetics. 10. Destress the eating environment. Short-term stress may cause people to be more sensitive to glucose and salt; perhaps in some relation to chemical responses. While stress may increase taste sensitivity to these substances, it may not be in the manner that is intended. Since stress is a nonspecific biological response to environmental, physiological or psychological stressors with feelings of apprehension, nervousness or worry, stress may not support the replacement of older tastes, nor the introduction of new tastes. Instead, a goal should be to destress the eating environment sufficiently to welcome all tastes and reinforce a pleasurable setting for eating [19].

Somesthetics (Sensations) Somesthetics is an interdisciplinary field of inquiry that incorporates experiential, practical and theoretical disciplines as they interact with bodily awareness, functioning and performance. The somatosensory system is a part of the human sensory system, complete with sensory neurons and pathways that respond to bodily stimuli. Sensory neurons include chemoreceptors, mechanoreceptors, nociceptors and thermoreceptors that are found in the bones, cardiovascular system, epithelial tissues, internal organs, joints, muscles and skin and other locations. These receptors send signals via sensory nerves to the spinal cord for processing and relaying to the brain for interpreting.

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Somatic senses include the sense of touch, proprioception (the sense of movement and position) and haptic perception (the ability to grasp something). A somesthetic approach to the act of eating features taste as an experience and places the pleasures that food creates at the core of the human existence. Without tactile cues that are derived by the sense of touch, people who are aging may be less able to detect the tastes of certain foods and beverages. Tactile cues include sensations of movement, pain, taste, touch, pressure, temperature (cold and heat) and others. Individual sensations may vary. Temperature, Movement, Pain, Pressure and Touch Temperature The temperature of foods and beverages in the oral cavity may create perceptions, inspire actions and arouse memories. About 20% 30% of the US population are known as “thermal” tasters whereby certain areas of the tongue have taste sensations when activated by cooling or heating, even without the presence of foods or beverages. Some individuals respond this way since they seem to be more sensitive to tastes overall or they are supertasters. When foods or beverages are warm, astringency and sourness seem to be perceived more intensely by these individuals and this intensity of flavor may be longer lasting. Bitterness may be perceived as more intense when foods or beverages are cold and flavor intensity may decline faster [20]. Thermal or heat receptors function to help protect the oral cavity from heat damage, modulate the temperature of foods and beverages, and convey this information for processing. Microscopic channels in the taste buds (or TRPm5 a cation channel) appear to be responsible for different taste perceptions at different temperatures (particularly for the transduction of bitter, sweet and/or umami taste). The reaction of TRPm5 in the taste buds is more intense when the temperature of foods and/or beverages is increased. This process sends a stronger electrical signal to the brain that produces enhanced taste. Compromised thermal receptors may affect the way that foods and/or beverages are conceived and consumed. For example, if an individual prefers a hot beverage or soup and it is served lukewarm, the thermal receptors might convey this tepidness to the brain and the beverage or soup may be rejected. Conversely, if the beverage or soup was served hot and the flavor was more intense, then it may be preferred and/or consumed. This preference could also have been a carryover from younger years, based on cultural or family practices, and be particularly meaningful. This process also explains why ice cream is best served slightly warmed so that its sweetness is perceived and why certain beverages, such as beer or wine, should be consumed at the recommended temperatures so that their bitterness may be less apparent. Thus, from an individual standpoint, serving foods and beverages at the wrong temperatures may be detrimental for their consumption, nutritional benefits and health. Investigating individual temperature preferences and working closely with food service or care providers may help those who are aging fully taste foods and beverages as they are intended [21]. Movement The movement of foods and beverages throughout the oral cavity is the result of the tongue rhythmically propelling these substances backward toward the esophagus, and the teeth tearing and grinding foods as they mix with saliva and prepare for digestion. The uneven surface of the tongue with its papillae tends to retard the movement of foods and beverages that gives them more time to affect the taste buds. Ionic movements have the capacity to change the cells’ electrical changes and trigger different chemical messages to the brain. The tips and the sides of the tongue can perform complex movements. The back of the tongue (or the upper surface) has many sensory cells that recognize both taste and touch. Anything that impedes movement within the oral cavity, such as cancer or other dental issues that may include diseases, inflammation, missing teeth or plates, oral injuries or others, have the capacity to affect the perception, communication, identification and appreciation of tastes. By addressing these oral issues, the movement of foods and beverages throughout the oral cavity may be maximized. The movement of the tongue also massages the small glands that are directly underneath it, and help to squeeze out saliva to initiate the predigestion of food into a bolus for swallowing [22].

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Pain The sensation of pain is a safeguard in that it protects the oral tissues from damage from the teeth, and also from chemical and thermal stimuli that might be hazardous. Still, some people may be inclined to seek out painful substances, such as hot chili peppers or kimchi (salted and fermented cabbage and/or radishes) for their assertiveness, element of surprise and thrill. Some speculation surrounds their increased use that is associated when taste and smell are dulled due to aging, certain conditions and/or diseases. While these pain-producers may do more than perk taste and smell (e.g., they may activate opioid receptors, create temporary numbness and may be self-reinforcing), other bodily responses, such as gastrointestinal or neurological, should also be taken into account. Pressure Pressure is the constant physical force that is applied to objects by something that interfaces with it. Pressure may affect the sense of taste in the following instances. To begin, certain types of high blood pressure drugs have been implicated with taste loss. These include diuretics that help the kidneys to excrete sodium and water from the body and angiotensin-converting enzyme inhibitors. Also, taste and smell appear to be affected during airplane flights over 30,000 feet when the cabin is pressurized to adjust for the altitude. Background noise of the plane, lack of humidity, and lowered air pressure are implicated in these changes. First, the atmosphere inside the cabin affects the sense of smell; then as the plane increases in altitude the humidity level falls to less than 12%. The dryness and low humidity may reduce the sensitivity of salty and sweet taste by about 30%. These changes in taste may be coupled with decreased functioning of odor receptors with the result foods and beverages tasting bland. This may be why airline foods may be salted or spiced more heavily to compensate for this apparent lack of taste, and to help make meals seem more robust [23]. Touch The sensation of touch has major functions in food and beverage perception. For one, it distinguishes the texture of a food or beverage and helps the consumer to choose their preferences and dislikes. As an example, raw broccoli is crisp to the “tooth,” steamed broccoli still retains some “bite,” cooked broccoli may be soft yet still toothsome, while pureed broccoli may be perceived as overcooked and/or distasteful. Though a person may dislike raw or steamed broccoli, the broccoli flavor might be subtler when pureed, especially the broccoli is combined with milk or cream to help to temper its bitterness. Textural aversions may be idiosyncratic in that some aversions may be acquired and not genetic determinants. In general, any of the above-mentioned forms of broccoli (or other cruciferous vegetable such as cauliflower or Brussels sprouts) may be better for the diet than no broccoli at all. It might just be a matter of finding the most optimally textured form of broccoli that satisfies the diner. Another example of how texture may affect taste is French fries with their identifiable shape, taste and texture. If potatoes are pureed and reformulated into French fries (as in some foods for the aging), then the unique texture of the French fries may be lost in the process, while the taste and smell of the French fries may still remain. Baked potatoes, potato wedges and mashed potatoes may not equate to French fries as recalled from yesteryear. Once again, it may be just a matter of discovering the best form of potatoes that substitutes or satisfies a craving for French fries. Tactile Sensations Tactile sensations are commonly termed “mouthfeel.” Mouthfeel signifies the sensations of feeling and touch. The many papillae on the tongue are involved in these impressions. They typically inform the eater that the taste (s) are in contrast to what is expected, such as the French fry example just mentioned. In countries outside of the United States, mouthfeel is an important concept of their cuisines, such as in Japan where there are about 400 words to describe food texture. Food is often treated differently than it is in the United States, such as fish with its wide array of textures that help to define its raw and cooked states. Vegetables in Japanese cuisine also have many guises, and this may be one of the reasons why their consumption is favored.

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Mouthfeel Mouthfeel is dependent on previous experiences including culture and traditions, expectations and reality. While new mouthfeel may be taught—particularly for those with mastication and swallowing issues—previous experiences and expectations of the mouthfeel of food may overrule and affect the present reality of how certain foods and beverages may feel and therefore taste [24]. Some mouthfeel or tactile sensations and the foods and/or beverages that help to create them include the ones that are shown in Table 7.7. TABLE 7.7 Tactile Sensations Implicated with Food and Beverage Triggers Tactile sensation

Food and beverage triggers

Biting

Chili peppers and garlic

Coating

Ice cream and yogurt

Cooling

Ice cubes and menthol

Drying

Crackers and breakfast cereals

Puckering

Citrus slices and vinaigrette salad dressing

Stimulating

Oleocanthal in extra virgin olive oil or ginger

Stinging

Carbonated beverages and some candies/gum

Tearing

Roughly cut onions and pepper seeds

Warming

Coffee or tea and soup

If an aging person has tactile issues it may be helpful to first investigate the likes or dislikes of these tactile sensations or others. Then add or delete the corresponding foods and or beverages, and observe any reactions that may affect taste preferences and/or eating behaviors. Chemesthesis Chemesthesis, the chemical sensitivity of the mucous membranes and the skin or tactile burn, may be appealing or repudiating depending upon individual taste. Chemesthetic flavor stimulations result from either chemical activation of the ion channels on sensory nerve fibers, or they may activate epithelial cells to release substance that trigger these nerve fibers. Many of these sensations are mediated by the trigeminal nerve as opposed to the pathways that mediate the sensations of taste and smell. In general, chemesthesis may be effective for taste loss associated with Parkinson’s disease. Ingredients with high level of tactile burn include curry, garlic, ginger, mustard and vinegar, which are most resistant to flavor loss. Foods with low-to-no level of tactile burn include apples, butter and grapes that are most susceptible to flavor loss [25]. Mixtures Few sensations are singular; in fact, most sensations are the result of mixtures, and due to analytic, synthetic or other combinations. While there are five basic tastes there are countless aromas, and even the purest sensing food or beverage is probably an amalgam of many tastes and aromas. A good example is a tomato with its five basic tastes and over 400 volatile compounds. Another example are nuts. Almonds might smell or taste woodsy or bitter depending on their freshness; walnuts may smell or taste earthy or tangy depending on their tannins, and cashews may taste or smell buttery, or strong and sweet due to their intrinsic components. Yet collectively, the smell and taste characteristics of these nuts generally equate with their common names. This conundrum may make it very difficult, especially for the aging, to discern certain smells, tastes and/or textures within mixtures—such as mixed nuts or assorted tomato salad. Some individuals may be able to smell or taste a food or beverage at the same time that they may detect nicotine or perfume scents on a dining companion. Other people may not be able to perceive or to identify competing aromas, scents or tastes. This is one reason the mixtures of foods and beverages may be so difficult to discern by some aging people, and why the eating experience should be as singular as possible. Competing smells and

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tastes should be kept to a minimum—particularly while flavor enhancement techniques are implemented for improved consumption. Mixture Challenges Macronutrients that provide calories (carbohydrates [sugars and starches], fats and proteins) may provide challenges for both smell and taste detection and identification. Many of these are present within the same dish or meal. Most starches are relatively tasteless to humans. As a whole, starches need to be detected by the smells and tastes of other substances that accompany them, such as pasta sauce, buttered potatoes or seasoned rice. The detection and identification of some sugars may be more successful, especially fructose, glucose and sucrose, which the sweetest. Thus, the mixtures of foods and beverages that carry these macronutrients and the environments that they are contained within are probably more instrumental in their sensations than the macronutrients themselves. Micronutrients, such as minerals and vitamins, typically provide a range of disagreeable smells and tastes, but they are usually too dilute in foods and beverages to notice. Minerals are often consumed in their salt forms that may taste bitter, salty and some sweet, and vitamins (especially with enhancement or fortification) may have a chemical-like taste. In general, people should rely on the foods and beverages that carry mixtures of these macro- and micronutrients for sensory stimulation rather than the individual nutrients on their own. In other words, if protein is craved or needed in the diet, flavorful mixtures that combine with proteins should be sought before protein supplements. This is in spite of some of the taste challenges some mixtures might display. Flavorful mixtures require creative culinary techniques and applications that employ a wide range of ingredients to successfully migrate flavors into proteins, carbohydrates and fats. The remaining chapter will cover these culinary techniques and applications for flavor enhancement for people of all ages—especially the aging. Recipe Connections The recipes in Chapter 10, Menus and Recipes That Appeal to Aging Palates, represent mixtures of macro- and micronutrients for sensory stimulation and meal enjoyment. Note their confluence of simple, identifiable ingredients that aging eyes may still discern. The majority of the dishes contain fresh, brightly colored, bite-sized ingredients that stimulate deliciousness and nourishment. Smaller amounts of ingredients that are used judiciously (such as added fats, salt/sodium or sugars) add “missing links” to these mixtures for heighten enjoyment.

CULINARY TECHNIQUES FOR FLAVOR ENHANCEMENT Techniques and tastes are culinary fundamentals for creating foods and beverages that are appetizing, pleasing and satisfying and—traits that are desirable for all consumers, but particularly for people who are aging with chemosensory issues. Cooking methods, cooking skills and resources should be considered when creating meals and menus for aging people, be it one-on-one care provision or large scale. While it is more difficult to individualize eating issues in care facilities, there are more generalized cooking concepts that may be feasible and widely appealing. First of all, cooking methods for flavor enhancement can be chosen from the following list. Overall, they represent a healthy approach to eating and drinking for this age group. Secondly, these cooking methods should elevate the natural flavor of foods and beverages and may be complemented by the flavor-enhancing ingredients that are reviewed in Chapter 6, Flavor Enhancement Ingredients. Thirdly, foods and beverages should be cooked or prepared at their perfect temperatures, appearance and texture to generate their utmost, distinctive tastes and overall flavor for maximum appeal. This requires cooking experience and honed skills, which may be developed over time [26]. Many of the recipes in Chapter 10, Menus and Recipes That Appeal to Aging Palates, indicate cooking times and serving suggestions that include degree of difficult where needed. Most recipes are for beginning cooks.

Techniques and Tastes Acidifying Acidifying is a process that adds an acid, such as citrus juice, peel or zest; fermented ingredients such as pickles, sauerkraut, or yogurt; and vinegar or wine to add a clean, fresh flavor and to help balance, brighten and lift other tastes. By adding acid at the finish of a dish, the appearance, color and taste may be preserved.

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However, too much acidity may be irritating and mouth-puckering unpleasant, as registered by the trigeminal nerve, or it may irritate the gastrointestinal tract. Sweetness, saltiness and fattiness may help to counteract acidity. Adjusting Adjusting is the method of tasting a food or beverage and correcting the flavor as it is prepared and at the finale of the dish. In particular, salt as well as acidity, depth, fat, sugar and/or spices may need to be adjusted. Without a foundation of salt, it may be more difficult to discern other tastes for adjustment. However, the concentrated tastes need to be taken into account—especially salty if there is liquid in the dish that reduces in volume. A prudent approach may be to lightly adjust the ingredients throughout the recipe, then adjust more correctively at the finish. Some chefs and proficient home cooks prefer to salt in gradations throughout a recipe. In general, if food is too salty, then add an acid or sweetener to balance. If food is too sweet, then add an acid or seasonings, also to equalize. If food is too acidic or spicy, then add a fat or sweetener to counterbalance. Alkalizing Alkalinity is the opposite of acidity and it involves water. Alkaline ingredients (such as avocado, baking soda, bananas, greens, raisins and/or sweet potatoes) tend to have more hydroxide ions than hydrogen. In acidic ingredients, the opposite is the case. Many foods have a significant amount of water and this balance of hydroxide and hydrogen ions may be important in how other food components (such as carbohydrates, fats and proteins) may act. “Alkalizing,” or adding alkalinity, may significantly affect the color, flavor and texture of foods. For example, browning may be enhanced, gluten molecules may create stronger bonds and texture may be a little slicker. Too much alkalinity might cause some soapiness in texture. Like acidity, it is best to be judicious when adding alkalinity to recipes in order to achieve the best balance and results [27]. Alcohol (Volatizing) Alcohol may lend acidity, bring out the tastes in foods and beverages and contribute to overall flavor. It may accomplish this by evaporating or volatizing, converting into a vapor state. Molecules of alcohol may carry volatile aromas that rapidly evaporate and perk the nose to appreciate a macerated fruit composition. The effect of alcohol’s volatility is best at a concentration of 1% alcohol or less—otherwise the alcohol aroma may govern. Alcohol also bonds with fat and water molecules; this feature helps to connect aroma receptors that respond to molecules that are dissolved in fat with foods that are primarily composed of water. This characteristic of alcohol is central in brining, marinating and reduction. Aromatic flavor compounds such as garlic and herbs are fat-soluble. Alcohol serves to transport these flavor compounds into ingredients within a marinade, such as protein foods or vegetables. Water-soluble flavors, such as bitter, salty, sour and sweet are also carried by alcohol into the cells of the marinated ingredients, thus improving the overall tastes. When alcohol is used to deglaze a pan after foods are seared, the flavorful fond, or remnants are released. Some of these fragments dissolve in the alcohol, which adds additional flavor. The alcohol that remains depends on the amount of alcohol and heat, cooking and standing time and cookware dimensions [28]. Baking Baking is the process of surrounding food within a hot, enclosed environment. It relies on a combination of cooking methods: radiation from the vessels’ walls and hot air convection. The surface of the food dehydrates and browns, assuming that the temperature is high enough and the ingredients do not interfere. Baked goods may have an earthy appearance and smell and a crunchy exterior, depending again on such factors as the ingredients, temperature and time. During the baking process different chemical reactions may occur. One chemical reaction is caramelization when high heat causes sugar molecules to break down and release water that converts into steam. Another chemical reaction is the production of furan molecules, organic compounds that help to impart a nutty flavor. A third chemical reaction is the formation of maltol, another organic compound that imparts a toasty flavor that is normally pleasantly perceived [29].

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Basting One of the keys for locking in the flavor of protein foods, such as meats, is basting with a water-containing liquid that cools the surface as it evaporates; thus slowing down the cooking process. Basting is prominently used in grilling, roasting and rotissering foods. Pan juices or stock with herbs and spices, with or without alcohol, provide a flavorful base for other tasty ingredients, such as olive oil, soy sauce or tomato paste. Basting ingredients with protein or sugar (such as beer, butter, honey, preserves or wine) tends to promote browning. By adding color, flavor and moisture, these characteristics tend to enhance the flavor, juiciness and tenderness of protein foods, improve palatability and generally prove to be economical measure to take. If an improperly balanced marinade or sauce is used, then basting may cause undesired drying. Blanching The process of blanching is scalding vegetables in boiling water or steam to stop the enzymatic action that may negatively affect their color, flavor and/or texture. Both boiling water and steam blanching may be used for broccoli, sweet potatoes, pumpkin, winter squash or foods of this nature. Blanching also tends to cleanse the surface of vegetables and retard some vitamin losses. Blanching time may vary according to the size and type of the vegetables. If vegetables are overblanched, their appearance, nutrients and texture may be compromised, and they may look as bland and be as mushy as other overcooking endeavors [30]. Bolding This not a bonafide cooking technique; rather “bolding” is an invented word to suggest the use of bold ingredients when preparing and cooking foods for aging palates. These may include common or unusual ingredients such as asafetida, curry, file powder, ginger, Grains of Paradise, horseradish, hot sauce, kimchi, mustard, pimento, Sichuan pepper, sumac and/or others. As was mentioned earlier in this chapter, while these ingredients have the capabilities to perk aging tastes, they should first be used in moderation, especially if there is unfamiliarity, fear of spicy ingredients or the unknown and/or gastrointestinal issues. Once the palate is adjusted to some of these ingredients, then more may be able to be added—once again if tolerated. Braising Braising is a cooking method that helps to transform tougher meats into tender cuts while maintaining flavor and moistness. Another term that is often used interchangeably for braising is “pot-roasting” whereby meats (particularly muscle-meats with connective tissue) are cooked at low heats for extended periods of time and partially submerged in liquid, such as water. The advantages of water as a base medium for braising is that it evenly and rapidly transmits heat, the temperature may be relatively easy to manipulate, the liquid may transfer and transport flavor and it may reduce into a convenient sauce. If vegetables are added to the braising liquid, then their cells may pick up the flavors of what is braised. Brussels sprouts, flat green beans and kale braise particularly well; they may become a flavorful amalgam of tastes along with the braised meat, and are rich in nutrients. Broiling Like grilling, roasting and searing, the cooking technique of broiling provides intense heat to sear the outside of foods, develop intensely flavorful exteriors and retain moisture. In broiling, the heat source is typically from above and largely uses infrared radiation. It is very easy to overchar the food and undercook the inside of the food during broiling since the rate of heat radiation at the surface and heat conduction within the food may be so variable. Like grilling, it may be best to move the food to be broiled to a lower position in the oven to adequately cook it and for maximum flavor. Assuming that the consumer can masticate and moisten food well within their oral cavity, broiling may be a tasty option. Browning Browning is a cooking process and chemical reaction that may flavor a number of different foods and ingredients, such as baked goods, bread crumbs, coffee beans, meats, nuts and others.

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Browning may lock in flavor, change color and produce new flavors and colors altogether; some akin, some different than the original foods and/or ingredients. Types of browning reactions include caramelization, the Maillard reaction and slow browning in moist heat. Some of the flavors that may be produced by browning by caramelization include bitter, butterscotch, caramel, fruity, nutty, Sherry-like, sour and/or sweet. The Maillard reaction may produce some very flavorsome results, such as chocolate, earthy, floral, greenery and savory, as well as flavor-intensive sulfur. Both types of browning, unless they result in burning foods, may be desirable for improving the palates of aging people. Building Like, bolding, “building” is a fabricated term that suggests tastes need to be built upon each other to create an amalgam of flavor. Another expression for flavor building is flavor layering. Flavor layering may involve the combining, complementing, deepening, developing, expanding and even negating of flavors, by using dairy products, fats, fruits, herbs, liquids, proteins, seasonings, vegetables and other ingredients, to create appeal, depth, interest and variety and the potential reappearance in meals and/or menus. An example of building or flavor layering that is common, but may not be apparent to the aging, is lasagna, with its tasteful layering of umami-rich marinara sauce and Parmesan cheese and sweet pasta and ricotta cheese. Another example of building or flavor layering is spanakopita, or Greek spinach pie, a savory pastry that is layered with butter-basted filo dough, chopped spinach, feta cheese, onions or scallions, egg and seasonings that is combined into a salty-umami-y-fatty finish. Caramelizing Caramelizing is a browning process that serves to bring out the natural sweetness in foods and intensify their aromas and flavors. It occurs when high heat causes sugar molecules to break down and release water that converts into steam. With increased cooking, the sugar becomes less sweet, more bitter and darker in color. In the first stage of caramelization, diacetyl, an organic compound that is a yellow or green liquid with an intensely buttery flavor. may form. It gives caramel a butterscotch flavor. The rum-like flavor of esters and lactones are produced next, and then furan molecules with a nutty flavor and maltol with a toasty flavor are created. The result is that foods that are caramelized appear in various shades of brown, and may be tastier than the same foods that are boiled, microwaved or steamed. The full, savory notes and appetizing aromas of caramelization are associated with foods that are browned, grilled, roasted, seared and produced by other cooking techniques of this nature. Chopping Chopping, cutting, dicing and slicing may impact how foods taste. In general, the smaller the cut, potentially the more effective the cooking method and the faster that food should take to prepare. When chopping, it is important to follow the recipe instructions for the desired finished product. For example, a rough cut may convey rusticity, while a smooth cut may impart a velvety texture and a sharp cut may express the precision of taste. Also, many foods emit different chemical aromas when they are cut. If it is possible for diners to partake in food preparation, then they may be privy to a range of aromas that may enliven their appetites. If aging people are still able to cut their own food, then some aromas may be expressed during meals. Concentrating Concentrating flavors generally result in more flavorful products or recipes; however, over-concentrated flavors may be too assertive, bitter, bold or heavy. As flavors become concentrated, aromas may unite as well, and some may be redolent of favorite aromas from the past, while others may be disagreeable and trigger rejection. A long stovetop simmer to boil off water into steam, or an extended saute´ over low heat may chemically alter some of the flavor compounds in recipes and render them insipid rather than fresh. Finding the right cooking method, the ideal cooking time and the right ingredients are instrumental for successful concentrating of flavors. In general, if it is the savory-umami taste that a person seeks, then concentrating may be the technique of choice [31].

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Cutting In addition to what was stated about chopping, the more finely ingredients are cut, the better chance that they will react more flavorfully with the other ingredients in a dish, such as butter or oil, a marinade or salt. Seven vegetable cuts that many chefs master include brunoise, chiffonade, dice, julienne, mince, rough cut and slice. So the correct use of cutting can aid the cook and the consumer. As an example, a brunoise, or julienne cut that is cubed to about 1/16th or 1/8th of an inch for such vegetables such as carrots or celery, or a chiffonade, a cut of ribbon-like slices that is often used to slice leafygreen vegetables or herbs, help to maximize the surface area of the vegetables and/or salad greens for ultimate flavor. This compares to a smaller-sized rough chop or dice. The size that foods are cut may also affect their textures that are also correlated with flavor. A round cut may express succulence, while a square cut may convey precision, a jagged edge may indicate ruggedness, while a smooth edge may imply continuity. Of course, individual perception matters. Likewise, a sliced tomato with more surface area may smell differently than tomato wedges. This is because once a tomato is cut, its cells are broken that release an enzyme that triggers a chemical reaction that yields the aroma of freshly cut tomatoes. More cuts generally equal more fresh tomato aroma “notes.” This may be true of other foods as well, such as cruciferous vegetables, garlic, onions and even freshly cut grass. If less aroma (such as from cruciferous vegetables) is desired, then larger cuts may be preferred [32]. Confiting A confit is the result of slow and gentle cooking of ingredients at low temperatures into a rich and succulent consistency. In a confit, often an ingredient is immersed with a substance that flavors and preserves it. Frequently it is “impregnated” as well as submerged, and flavorings such as herbs and/or spices may be added. “Confiting” was originally used for preservation and taste. Tough cuts of meat are able to tenderize. If stored in a cool place, a confit may be lasting. The meats that are used in confits may also be called confit, such as duck leg confit or confit of goose. Today a confit is popular as a method for concentrating flavor. Duck and goose preserved in fat, fruits preserved in sugary solutions, honey and alcohol, olives preserved in olive oil and vegetables preserved in vinegar are common examples of confits. Italian cuisine incorporates condiment cuisines, such as chili, garlic and onion. Curing Curing is a process by which nitrites, nitrates, salt, smoke, sugar and/or other ingredients are used to flavor and preserve foods, such as fish, meats and vegetables. This is accomplished by withdrawing moisture out of these foods through the process of osmosis to safeguard against pathogens. Osmosis increases the solute concentration in the food and decreases the water potential. It is the reaction of salt or other curing ingredients, and the evaporation through exposure to air that helps to create the intense flavor, firm texture and preservation qualities of cured items. Salt cod, smoked trout and salmon and some sausages such as Italian salumi are example of cured foods. If sodium is a dietary issue, then cured foods may be restricted or limited. Dairy Product Enhancing In many recipes there is a reason to use butter and a reason to use another fat or oil, such as lard or olive oil. There are also reasons to use dairy milk as opposed to nut “milks.” These usages may be considered as “dairy product enhancing.” Dairy milk and dairy products generally impart a “dairy flavor” to boost “dairy notes,” even where dairy is not a characterizing flavor. Dairy notes may be discernible (such as buttery, cheesy, or creamy), compared to subtle (such as astringent, moldy or piquant). Dairy notes may be achieved with liquids (cream, kefir, or milk), powders (milk powder), creams or pastes (yogurt) or slurries. They may create roundedness of other tastes, mask some tastes, provide mouthfeel and deliver their own tastes, depending on how they are added to a food product formulation or recipe, during or after preparation.

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Deglazing Deglazing is a cooking technique by which the browned food residue at the bottom of a pan is removed by dissolving with a liquid. This brown residue is an amalgamation of browned sugars and other carbohydrates and/or proteins, and any rendered fat that may have adhered to a pan due to pan-frying or roasting. Stock, verjuice (a highly acidic juice), water or wine is then poured over this adhesion to act as a solvent. Dairy products are not recommended as solvents since they may curdle from the heat. The resultant mixture may then be incorporated into flavorful gravies, sauces, soups or other food accompaniments. The intense flavor of a deglazed substance is generally from the protein that is fried or roasted, the type of liquid that is used for deglazing and other flavorful ingredients that may include aromatics (substances with distinctive and often pleasing smells, such as garlic or onions), butter, herbs, oil and/or spices. Dry Aging/Wet Aging Fresh beef is aged for a few days after slaughter, and up to several weeks for the natural enzymes to start to break down the muscle tissue and improve flavor and texture. Dry aging is conducted for 15 35 days with direct exposure to circulating air, and under specific humidity and temperature parameters. The result of dry aging yields a denser, yet tender and full-flavored end product. The drawbacks to dry aging include the time that dry aging takes and the significant loss of carcass weight. The opposite of dry aging is wet aging, or aging in cryovac, a vacuum-sealed bag that is used to retain moisture. Wet aging is the most common method of aging beef since it typically takes just a few days (4 10 on the average), and there is little moisture loss. Enriching In culinary techniques, enriching products or preparations means to add ingredient(s) that enhance their character; such as thickening sauces with butter, egg yolks, heavy cream, pureed vegetables and/or starch. In nutrition terminology, enrichment means to add additional micronutrients beyond fortification to foods or ingredients that may be lost during processing. Enriching may or may not add flavor depending on the ingredients that are added, and if they balance or negate the foods or ingredients when they combine. A liaison of egg yolks and cream is often used to finish (and enrich) a sauce to provide extra richness, glistening and/or smoothness. Heavy cream also provides flavor. Butter adds shine and taste. Less fat may be used for a sauce of this nature, but both taste and texture may be sacrificed. Fattening “Fattening” is another constructed word that may be used to designate the addition of fat to a food or recipe to add flavor. Certain fats, such as butter, cream, lard or oil have their own distinct flavors and aromas. One of the ways that fat accomplishes this is by coating the tongue that permits various compounds to come into contact with the tongue for variable degrees of time. This may intensify and/or prolong flavorful experiences with foods or ingredients. Since fats may endure higher heat than water in roasting or saute´ing, they may enable surface browning which may help to develop other types of flavors, such as deepness, earthiness, meatiness, nuttiness, savoriness, saltiness and/or sweetness. Therefore, by adding just enough fat to an ingredient or recipe one may be able to achieve heightened color, flavor and/or texture—with a modest amount of calories if used judiciously. Finishing a dish or recipe is the process by which flavorsome flourishes are added to “finish” or complete the appearance, aroma, taste, texture and/or other components. This may be accomplished by a brush of butter, drizzle of oil, grind of pepper, scatter of salt, sprinkle of freshly chopped herbs, squeeze of lemon or lime juice or others. The purpose of finishing dishes in this manner is to complement and enhance the sensorial properties. Other finishing and flavorful touches may include the use of Asiago, Parmesan or Romano cheese, flavored vinegars, poppy or sesame seeds and/or seasoned bread crumbs. Whatever type of finishing item or process is used, care should be taken so that it enhances rather than overpowers the finished dish. Flavored Oils Oils may be flavored with citrus (such as lemon or orange); herbs (such as basil or rosemary); roots (such as ginger or horseradish); nuts (such as almond or walnut), spices (such as chili pepper or curry powder); or vegetables (such as garlic or shallots).

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Flavored oils may be used for finishing a dish or recipe in small amounts. These oils may serve to brighten the appearance, provide visual contrast and/or add fatty texture, particularly to foods or ingredients that may be lower in fat. The oils tend to adopt the colors of their flavoring agents (such as basil, curry or walnut), so that many hues (generally brown, green, red and/or yellow) are available to enhance the appearance of foods. Flavored oils can be drizzled over a finished dish, or dropped creatively around a plate or bowl without distracting too much from the finished product(s). Frying Frying is a cooking method that involves the use of oil or another fat to add crispness and other textures to foods and ingredients, and to cook food quickly. The advantage of frying foods and ingredients in fats is that they may generally reach a much higher temperature than water to carbonize the contents, caramelize the sugars and sear the exteriors. Frying foods and ingredients may involve many forms: deep-, oven-, pan-, shallow, stir-frying and/or saute´ing. Pan-frying, saute´ing and/or stir-frying generally call for a thin layer of fat or added to a hot surface of a fry pan, griddle or wok. Stir-frying often uses a small amount of oil that is heated quickly to very high temperatures. Shallow-frying uses just enough fat to immerse food and/or ingredients to about one-third to one-half of their dimensions. Deep-frying involves the total immersion of food in hot oil. The fat or oil that is used for frying may penetrate foods or ingredients at various levels, and add calories, flavor, lubrication and/or richness. Often both calories and fat can be excessive. Oven-frying often incorporates foods and ingredients that are coated with oil, batter and/or crumbs that are then roasted in a radiant-heat oven. Since this technique does not use significant amounts of fat or oil, it is mostly use for mock frying—often with fewer calories and fat. Grilling Due to the domestication of fire about 500,000 years ago, grilling has been employed to cook mostly meats and other protein foods—probably at first just caught on the range. Until the 1940s, grilling continued to be an outdoor cooking technique, mostly at campsites and for picnics. By the 1950s, the earlier versions of backyard barbecue grilling came to the forefront. Today, grilling has been a very popular cooking technique in the United States, both outside and inside of the home. One of the many reasons grilling is so desirable by some aging people is that grilled foods may evoke satisfying memories of grilled meals, prevalent during the 1950s [33]. During the cooking technique of grilling, the heat source is below or under the food, as opposed to broiling when the heat source is above the food. Think of grilling as roasting over an open fire or heating coals that then display visible light and intense radiation. A swift and extensive browning on the surface of the food results; usually filled with intense flavors. Ideally the browning rate matches the inner conduction rate so that the food is grilled on the outside, yet cooked on the inside to various degrees of individually preferred perfection. Overly grilled foods with their blackened exteriors, while enjoyed by some, may potentially result in heterocyclic amines that may pose a cancer risk. Herbing “Herbing” is another created term that suggests the use of dried and/or fresh herbs in the preparation and finishing of a dish or an ingredient. Dried herbs may take on the moisture from other ingredients in a recipe and emit their flavor throughout a dish. Fresh herbs, especially when chopped and added at the end of a recipe preparation for garnish and visual appeal, lend a fresh flavor due to the release of their oils, volatiles and other flavor components. Try to ensure that the herbs are compatible with the other tastes in recipes and that they are ethnically correct such as the use of cilantro in some Asian and Hispanic recipes and basil or oregano in some Mediterranean recipes. Keep in mind that some people have aversions to herbs, such as cilantro (with its ostensibly soapy taste) or oregano (with its sensitivity to some women during pregnancy). Infusing The act of infusing involves a flavoring agent, such as brine, broth, dairy products, marinades or oils that coat or steep into other ingredients that and help to transform the flavors. Infusions may contain berries, chilies, cinnamon sticks, coffee, dried fruits, garlic, herbs, nutmeg seeds, nuts, black, red or white peppercorns, spices, tea

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leaves, truffles, vanilla beans and/or other ingredients of this nature. Infusions may become subtle or robust depending upon the flavoring agent and the contents. When warmed or acidic, the infusion may be more flavorful since the flavors of the ingredients may be extracted and infused into the flavoring agent. Pressure cookers may be used for infusion cooking since the pressure permits the flavoring agent (liquid) and flavors (ingredients) to penetrate under pressure, which may enhance the final flavor even fuller. Macerating In cooking, macerating is a process by which liquids are used to breakdown or soften foods and to transmit flavors. Dried, preserved or raw fruits and vegetables and herbs are commonly used for maceration. Ingredients with a high water content, such as some dried or fresh fruits (like raisins or currants, and blueberries or grapes) may just need a sprinkling of sugar or salt to extract their liquid. Sometimes cooking oil is used as the maceration liquid. Flavored alcoholic beverages, such as cordials and liqueurs, are often based on a maceration process. In turn, raisins and other dried fruits are often macerated in alcohol, such as brandy or rum, to enhance their flavor and texture for use in cooked and/or baked items. Layering The concept of layering involves building a dish or recipe through the use of various complementary tastes. This is done to add dimensionality or structure; combine, deepen and/or expand flavors; or refine variations in order to achieve overall flavor. Layering may be accomplished by the use of acids, herbs, liquids, oils, seasonings, spices and/or other ingredients. It may also be achieved through the use of cooking techniques, such as browning, caramelizing, deglazing, pan-frying, saute´ing and/or sweating. One flavor may be achieved through multiple techniques and/or ingredients, or one technique or ingredient may integrate many tastes. Just like a well-built house with its firm foundation, herbs and spices, vegetables, liquids and acids may be layered from a base of ingredients to help build up flavor. Any time that an ingredient is added, it should be well seasoned with the finished product in mind. Strong flavors may radically alter a dish, even with longer cooking time. The use of neutral water may be a flavor robber. Layering with acid has the capacity to add flavor right before finishing, and it may change a flavor profile. Traditional layering techniques as practiced by skilled chefs, coupled with creativity and an astute sense of taste, may help to transform ordinary dishes or recipes into masterful creations. Home cooks may master the technique of layering by practicing some of the methods that are described in this chapter until they become routine, along with the flavor-enhancing ingredients discussed in Chapter 6, Flavor Enhancement Ingredients. Marinating The act of marinating, or soaking foods in a seasoned and often acidic liquid, may result in the breakdown of connective tissue and the denaturing of proteins in foods. The marinade may contain an acidic ingredient, such as citrus juice, vinegar and/or wine, or ingredients that may cause enzymatic action, such as ginger, papaya and/or pineapple. Herbs, oils and spices may also be added. Marinating helps to soften and somewhat transform less-than-prime cuts of meats, poultry or seafood. Small or thin cuts are best. Tender vegetables such as eggplant, mushrooms, yellow squash or zucchini may benefit by gentle marinating, as may some berries, melons and/or orange sections. (Note: Marinated fruit is often referred to as macerated.) The success of marinating may be dependent on whether meats are aged or fresh. Also, both flavor and tenderness may be affected by under- or overmarinating. Apply salt and other seasonings after the foods are marinated and the marinade is discarded to have the greatest residual impact upon flavor. Oven Drying Drying preserves food; it removes the moisture and intensifies the flavor. When moisture is removed from foods, many bacteria, molds and yeast can be prevented from growing. Many fruits and vegetables can be subjected to oven drying as long as there is low humidity, a source of low heat (120 F 150 F) and air circulation. The oven temperature should be set at the lowest setting. Then, fruits and/or vegetables should be cut into 1 /4-inch pieces or slices and placed on a lined sheet pan for about 6 8 hours. Dried fruits and vegetable may be

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used as snacks, and to add color, nutrients, taste and texture to recipes. Examples of oven-dried foods include apricots, bananas, carrots, corn, tomatoes and/or other ingredients. The oven door should be propped oven 2 4 inches and a fan should be placed near the outside of the oven door to improve the air circulation. Oven drying tends to take two to three times longer and requires more energy than drying foods in a dehydrator. An oven thermometer may be needed to ensure the accuracy of the temperature. Options to dry food include a food dehydrator, microwave, toaster oven or sun drying that is especially useful for delicate herbs. Pan-Frying (See Searing) Searing is an incomplete cooking process that often proceeds other steps, such as braising or roasting. In contrast, the cooking process of pan-frying is a complete cooking technique. Pan-frying relies on high heat (in excess of 300 F) to help to seal in the natural juices of fish, meats, poultry and/or shellfish in order to form a flavorful exterior. Pan-frying may be used in baking, braising, grilling, roasting and/or saute´ing to achieve a browned appearance, caramelized crust and a contrast in taste and texture between the food’s crust and its interior. The pan needs to be very hot; then it should be removed from the heat and a small amount of fat, such as butter or oil may be used to lightly coat the surface. If the fat burns or smokes, then it should be discarded. The pan should then be carefully wiped and the process should be repeated with fresh butter or oil. Next, the food should be carefully slid into the pan, and once the exterior is seared or browned, then it should be gently turned to sear the other side until the desired degree of brownness is achieved. Peppering Peppering a dish is the process of employing the pepper plant in its many guises: fresh and/or dried chili peppers, fresh sweet peppers, and black, green, red and/or white peppercorns and their ground varieties. Also, the use of various pepper sauces is a method of adding pepper or heat to a recipe. The purpose of peppering a recipe is to build flavor as the recipe is executed plus to help finish the recipe is after it is prepared. The flavors of pepper will range from subtle to assertive depending upon the type of pepper that is chosen; if it is seeded and deveined, and when it is added in a recipe. Fresh and dried peppers that are added during a recipe have a change to intermingle with other ingredients and dissipate in flavor. If they are added at the end of a recipe, then they may add potent surprises by their flavorful dimensions: bitter taste, as well as heat and pungency. Pickling The use of pickling as a culinary technique helps to preserve the life of a food or ingredient through anaerobic fermentation that is done in brine or through vinegar immersion. Brine is a highly concentrated salt solution in water. The flavor of the end product results from the acidity or salinity of the pickling solution, the fermentation temperature, and the degree of the exclusion of oxygen or the exposure to air. If these measures are not perfected, then discoloration, rotten smell and/or softening may result. Commercially pickled items may be preferred to unsuccessful homemade pickling. Pickling can affect both flavor and texture, and has been used for hundreds of years. Typically eggs, fish, fruits, meats and/or vegetables are pickled, and the resulting foods are often referred to as “pickles.” Sometimes the nutritional value of the pickled foods is increased due to the B vitamins produced by bacteria used for fermentation. Spices such as cinnamon, cloves and/or coriander, fennel and/or mustard seeds and garlic are frequently added during the pickling process. Herbs such as basil, chives, dill, mint, oregano, rosemary, sage, tarragon and/or thyme are often used to infuse the pickling liquids. Poaching Poaching is one of the gentle moist-heat cooking techniques. To poach is to submerge a food or ingredient into a liquid that may be milk, stock, water, wine or a combination of these liquids. Citrus products such as lemon or orange peels, herbs and/or spices are commonly added to the poaching liquid. A relatively low temperature of about 160 F 180 F is used to poach foods, unlike boiling (212 F) or simmering (180 F 205 F), which uses higher temperatures. Foods that are commonly poached include delicate or fragile items such as eggs, fish, fruit and/or poultry since poaching produces little agitation. The resultant poached products are usually moist and tender, and there is less chance for overcooking. The poaching liquid may be reduced in volume to concentrate the flavorsome sauce. However, if salt is used in poaching, beware that it, too, may concentrate in final flavor.

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Punctuating The word “punctuating” is used to describe the practice of employing small amounts of bold-flavored ingredients to “punctuate” or accent a dish or recipe. These ingredients may include black sesame seeds, chopped chipotle pepper or fresh garlic cloves or pomegranate seeds. Also, condiments such as chutneys, flavored mustards, oils and vinegars, horseradish, olives, pickles, salsas, seasoned bean purees and tapenades may provide bursts of flavor when they are selectively used to liven dishes and recipes. Aging tastes might be perked by judicious use of these ingredients that also might instigate favorable food memories, particularly among ethnic clientele who may be accustomed to more impactful foods and beverages. Reducing Reducing is a cooking technique that is accomplished by boiling or simmering a liquid in a pan or dish without a lid, so that the vapors evaporate until the desired volume is attained. The purpose of reducing is to concentrate, intensify the flavor profile, increase the viscosity and/or thicken a liquid. Examples of reducing liquids include broth, fruit or vegetable juice, pan sauce, soup, stock, water, wine or a combination of these liquids. The more components in the liquid to be reduced, then the more time and temperature variations which may occur in the reduction process. Common reductions include consomme´s and gastriques (sauces that have both acidic and sweet components, such as sweet and sour sauces, gravies, pan syrups and/or syrups). They serve to moisten foods and make them more palatable, especially protein dishes that may be more difficult for those who are aging to masticate. Roasting—The Maillard Reaction The purpose of roasting is to bring out the flavor of foods by the use of dry heat, at least 300 F. Hot air that is produced from indirect, diffused heat from an open flame, oven and/or other heat source circulates around the food and helps to evenly cook the food. Roasting is generally used for larger pieces of fish, meat, poultry and/or bulb and root vegetables that require slower cooking times. The foods to be roasted are typically placed on a rack, roasting pan, rotisserie and/or spit. The pan juices that drip off of the roasted item may be mixed with the browned bits that adhere to the pan, deglazed with a liquid and then reduced to maximize the flavor. The Maillard reaction (see Browning), a cooking process that rearranges amino acids and simple sugars inside foods, helps to create these tasty pigments. Fragrant herbs and spices may be added to create a broader, deeper or more defined flavor. Salt and sodium-rich ingredients, such as canned broth or tomatoes, should be minimized so that they do not intensify too powerfully as the roasting juices condense. Salting As discussed in Chapter 6, Flavor Enhancement Ingredients, the judicial use of plain and/or seasoned and finishing salts may be transformational in cooking. Salting has the capacity to add taste and texture, “brighten” or bring out the other tastes of a dish or recipe, breakdown proteins, unite the flavors and turn ordinary creations into memorable taste experiences. Too much salt may be deleterious to those people who have hypertension or kidney issues. It may also overpower the natural flavor of foods and/or ingredients. Salty ingredients, such as anchovies, capers, olives, Parmesan or Roquefort cheese, pickles or sauerkraut with their salty notes may act like salt within a recipe, or can be used as garnish for some dishes—even without the addition of sea salt or table salt. These salty ingredients may also add texture—especially during the final plating where they may suggest that the finished dish is saltier than it really is. Saute´ing The saute´ing method of cooking food involves a shallow pan with a small amount of fat or oil that is placed over a source of high heat. The ingredients to be saute´ed are usually cut into small pieces or they are thinly sliced to facilitate quick and even cooking. Then they are placed in the fat and rapidly cooked. They are often turned over in the process. Typically, the process of saute´ing quickly develops a brown exterior in foods, while it retains an interior that is flavorful, moist and/or textural. Once the ingredients are removed from the saute´ pan, the remaining bits that adhere to the surface of the pan, along with any remaining fat or oil can be deglazed by the use of a liquid such as stock, water and/or wine to create a pan sauce. Saute´ing is unlike pan-frying, whereby more fat or oil is commonly used, and from searing that only browns the exterior of the ingredients.

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Saute´ing is advisable for aromatics, such as garlic and/or onions, and seasonal vegetables, such as asparagus and/or summer squash, to retain their vivid flavors, but it is also handy for whole pieces of protein foods, such as chicken breasts, filets of beef and/or scaloppini or pork or veal. Searing (See Pan-Frying) As mentioned in the discussion of pan-frying, searing is an incomplete cooking process that has the capacity to intensify the colors and flavors of fish, poultry, meats and/or vegetables due to its high cooking techniques. In comparison, pan-frying completes the cooking process. Searing helps to brown the exteriors of many protein-based foods while it seals in moisture; thus, it contributes to their final flavor and texture. Searing may also serve to enrich the residual liquid if a reduced pan sauce or braising liquid is desired. Searing may be used in baking, braising, grilling, roasting and/or saute´ing with different cooking equipment, and varying levels of heat to sear, cook and finish foods. Take precaution, since is easy to burn, char and/or overcook the ingredients during searing, and these results may be disagreeable to aging palates and potentially unhealthy. Seasonings In Chapter 6, Flavor Enhancement Ingredients, various seasonings were discussed for their flavor-enhancing qualities. Some general guidelines for the addition of seasonings that will ultimately depend on individual recipes and/or tastes are provided in Table 7.8. There is a general consensus among culinary specialists that foods should be seasoned as recipes develop and then adjusted at the end of the recipes—when and where this is sensible. TABLE 7.8 Guidelines for Adding Seasonings to Maximize Flavor 1. Add extra seasonings to cold foods. Cold foods may require some additional seasonings in the beginning since the temperature affects aroma and flavor. 2. Allow time for umami-rich ingredients to meld. Ingredients that are high in umami, such as anchovies, bouillon, soy sauce, Parmesan cheese and/or Worcestershire sauce may need time for their glutamates to expand the savory taste. 3. Ensure that seasonings are fresh. Over time, spices will become less potent and not have the flavoring capacity as anticipated. They should be stored in a cool, dry area to delay their deterioration. The general lifetimes of extracts, ground spices, herbs, seasoning blends, seeds and whole spices are as follows: • Extracts: 4 years (except for vanilla, which is lengthier) • Ground spices (such as cinnamon, cumin or nutmeg): 2 3 years • Herbs (such as basil, oregano or parsley): 1 3 years • Seasoning blends (such as garlic salt or lemon pepper): 1 2 years • Seeds (such as flax, hemp, poppy or sesame): 2 4 years (except for poppy and sesame seeds, which is shorter) • Whole spices (such as cinnamon sticks, cloves or peppercorns): 4 years 4. Fix acidity or spiciness with fattiness or sweetness. If a dish is too acidic or spicy, then a fat such as butter, cream or oil or a sweetener, such as stevia or maple sugar, may be used to counterbalance the acidity or spiciness. 5. Meld saltiness with acidity or sweetness. If a dish is too salty, then an acidic ingredient, such as citrus juice or vinegar, or a sweetener, such as honey or sugar, may help to rectify the saltiness. 6. Repair sweetness with acidity or bitterness. If a dish is too sweet an acidic ingredient, such as lemon or lime juice, tomatoes or vinegar minced fresh and slightly bitter herbs, such as parsley or watercress, ground pepper, or powdered coffee may serve to balance this sweetness. 7. Re-pepper at the finish. Pepper may be tempered by heat during cooking, until it is applied at the end of the cooking process when its peppery bite may prevail. 8. Use hearty herbs during the cooking process, delicate herbs to finish. Hearty herbs, such as laurel (bay), marjoram, oregano, rosemary, sage or thyme may fair better if they are added during the cooking process, while more delicate herbs, such as basil, chives, cilantro, dill, parsley or tarragon, may do better if they are added the last moment to retain their color and flavor. 9. Utilize Kosher or sea salt. In some cases, Kosher or sea salt distributes more easily and clings better than iodized salt. 10. Watch out for concentrated ingredients. If too much seasoning is used early in a recipe, then it may concentrate as the dish cooks. It is more difficult to correct a finished dish if this occurs. However, there still may be some options for mild mishaps as expressed in examples 4 6 above. If all else fails, then the recipe may be divided and diluted with a complementary ingredient, such as a reduced-sodium or fat broth.

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Simmering The cooking technique that is called simmering is considered as a lower-impact cooking method—unless foods overcook during the simmering process. Simmering incorporates foods that are submerged into hot liquids that are just below the boiling point of water (212 F). Simmering provides more gentle treatment of foods than boiling and helps to prevent foods from breaking apart and/or toughening. It is usually efficient and rapid when the simmering liquids are brought to a boil, then are reduced to a point when most of the bubbling usually ends. Simmering is useful for cooking a variety of larger and tougher cuts of meats, rice, soups, stews, stock and/or vegetables. Simmering allows the various tastes of the ingredients and the simmering liquid to mingle and layer and create a depth of flavor over a period time. If the simmering water evaporates, the simmered liquid may reduce and concentrate. This could be very flavorful unless some concentrated ingredients intensity distastefully, including those with sodium. Slow Cooking Slow cooking, as it affects flavor enhancement, involves time and the amalgamation of tastes into flavorful compositions. A slow cooker is a countertop electric cooking pot designed to cook (often by simmering) foods at comparatively low temperatures at constant heat (174 F 199 F), and over extended periods of time. It differs from baking, boiling and frying because the temperatures are lower. Slow cookers are designed for beverages, desserts, dips, pot roasts, soups, stews and/or other dishes. The liquid transfers heat from the walls of the cooking pot to the contents and dispenses flavors. Slow cookers are principally designed for convenience. The moist and long cooking process is ideal for inexpensive and tough meat cuts, such as beef chuck, brisket and pork shoulder. Slow cooking helps to gelatinize the meat tissue that makes protein dishes easier to masticate. However, there may be some vitamin and mineral losses (particularly trace minerals in vegetables) due to enzymatic action and heat degradation. Scalding may be problematic due to the large amount of moisture, be it from the cooking liquid, steam, or both of these factors Smoking The main reasons to smoke foods such as fish, poultry and meat are for preservation and to enhance the flavor. The cooking method of smoking is mostly used to cook foods such as bacon, beef brisket, ham, herring, oysters, pork roast, salmon, whole poultry and other foods over a fire. Cheese, chocolate, cocktails, desserts, dried fruits, eggs, herbs, salt, vegetables, yogurt and other ingredients have also benefited by the flavor imparted by this ancient technique of smoking. Home hot smoking is accomplished with a smoker, an outdoor cooker designed for smoking foods. Smoking may also be done in a covered outdoor barbeque grill with a dome, along with a drip pan of water that is placed under the items to be smoked. Often foods are first brined in a salt-water solution to encourage moisture retention. The cooking temperature of smoking should be similar to the temperature that is used by traditional cooking methods for cooking protein foods. Squeezing The concept of squeezing generally infers the manipulation of fresh fruits and vegetables to release their juices. Freshly squeezed citrus juice, for example, may be used in beverages, dressings, marinades and sauces, and the citrus zest may be added to impart additional fresh flavor to many savory and sweet dishes. Freshly squeezed vegetable juices are filled with many vitamins, minerals and phytonutrients. They add color, flavor and texture to an array of sauces, soups, side dishes and even desserts. Though juices are a concentrated source of calories and primarily natural sugars, many are filled with potentially health-enhancing nutrients, such as vitamins A, C and the B vitamins; the minerals folate, magnesium and potassium; and when they include pulp—fibers. It is true that juicing may contribute to faster nutrient absorption than some solid fruits and vegetables that must be first masticated to help to release their juices. This is one of the reasons juicing may be criticized for its possible ill effects on blood sugar levels, and ultimately for its potential to increase weight due to concentrated calories. That aside, freshly squeezed juice adds brightness to dishes with its burst of acidity and color. It also provides water that the body needs to produce energy, and for the promotion of healthy and elastic skin.

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If a blender or juicer is not available, simply cut some fresh fruits, such as lemons or oranges into wedges and hand-squeeze the pulp to help perk up the flavor of bland dishes, especially if they are lower in sodium. If a few shreds of citrus zest are then sprinkled atop the preparation, then the aforementioned tasteless dish may become transformational. Steaming The moist heat cooking technique of steaming works by continually boiling water past the 212 F mark so that it vaporizes into steam. The resultant steam transports heat to the adjacent food that cooks the food from contact. In steaming the food is separated from the boiling water, although the water vaporizes and moisturizes the neighboring food. A steamer rack may also be place inside a wok to create this steaming effect. In double boiling, the food is not directly exposed to steam, and in pressure cooking a sealed vessel is used. Steamed foods include breads, buns and rolls, cakes, confectionery, custards, dumplings, fish, meats, poultry, puddings, rice, seafood, sweets, vegetables and more. Burnt and overcooked foods may be avoided by steaming and additional fat is minimized. Some nutrient and flavor retention favors steaming over boiling. Steaming is also advantageous when it is compared to boiling or simmering because it is gentler without agitation. Delicate foods, such as seafood or some vegetables, may be prepared so that they are colorfully and texturally intact. Stir-Frying The cooking technique of stir-frying originated in China where it was used to quickly fry ingredients in a small amount of oil in a pan with sloped sides, such as a wok. Because the food cooks so quickly, the exterior of the food tends to crisp and brown which seals the flavors and preserves the colors and textures. Firm fish, meats, poultry, tofu and vegetables are suited to stir-frying as well as some cooked grains such as barley, rice or quinoa. To begin stir-frying, ingredients such as garlic, ginger, scallions and/or shallots may be added to hot oil in a wok to rapidly cook and become fragrant. Then protein foods, such as fish or seafood, meats and/or poultry, and sturdier vegetables, such as broccoli, carrots and/or cauliflower are added and stir-fried for short, but varied times. Once the contents are nearly cooked, then seasonings and sauces, vinegars and/or wine may be added alone or with thickeners such as arrowroot, cornstarch and/or water chestnut flour to coalesce. The advantages of stir-frying are that ingredients may retain their fresh color and texture for visual appeal, the degree of tenderness may be controlled and the flavors may be manipulated for the broadest appeal. Sugaring Sugaring, or adding a sprinkling of sugar crystals to baked goods, may give the illusion that foods are sweeter or even higher in sugar. In this manner it may be possible to actually use less sugar than called for in a recipe, since the first bite and mouthfeel may register as sweet-to-very-sweet, depending on the amount of sugar crystals that are used. Sugar may also be sprinkled on bitter green vegetables, such as green beans or kale to help to temper their bitterness and increase vegetable consumption. While this practice may be frowned upon because it adds sugar calories, it has successfully been used to flavor balance, boost interest and stimulate nutrition in long-term care residents. Another use of sugaring is on unripe fruits to help to bring out their natural sweetness. Merely one teaspoon of sugar (or 16 calories) sprinkled on barely ripe berries, citrus fruits, or melons may help to preserve their bright colors, improve their flavors and maintain their tenderness—and add some calories for energy when needed. Sweetening A companion to sugaring is sweetening. While both sugaring and sweetening are intended to add sweetness, sweetening may be accomplished throughout recipes or at their finales, while sugaring implies the final touches that are added to dishes for their appearance, flavor and/or texture. Other sweeteners besides sugar may be used to heighten the sweet taste of recipes and to balance or even camouflage other tastes. Aspects of the sweet taste were covered in Chapter 6, Flavor Enhancement Ingredients. Agave, caramelized ingredients such as onions or stone fruits, dairy products such as cream or milk, dried or fresh fruits such as dates or bananas, honey, molasses, maple syrup, and sweet vegetables such as acorn squash,

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beets, carrots, corn and/or parsnips may all lend their sweetness throughout both savory and sweet recipes and enhance their overall flavors. Sweetness may also be achieved by the use of sweet ingredients, such as almond, caramel, cocoa, cinnamon, nutmeg and/or vanilla. While some of these ingredients are not inherently sweet, they may accompany sweet ingredients and sweet aromas. So by the power of association their use may highlight the sweetness in dishes— even those with little sweetness of their own. For instance, cocoa and cinnamon may suggest sweetness in a mole sauce that is used with turkey or stuffed poblano peppers, but neither of these ingredients is sweet on its own. The perception of sweetness in relation to other ingredients such as garlic, onions and tomatoes in these dishes is what may register instead. Sweating Sweating is a cooking technique that is construed as “underfrying” because the ingredients are not immersed in oil as in frying. Nor is sweating to be confused with saute´ing, since sweating is conducted over much lower heat than saute´ing and little-to-no browning may occur. Sweating is the very slow cooking of finely chopped vegetables such as carrots, celery, garlic, leeks, onions and/or parsnips in a little oil over low heat with frequent stirring and turning. The purposes of sweating these types of vegetables are to ensure that any emitted liquid evaporates and to create and develop a flavor base. The chopped vegetables then tenderize in the oil and take on some of the oil’s richness and become translucent in appearance. Other vegetables are often added at this point to layer flavor, and to add aroma, especially in soups and stews. In total, very little total fat may be acquired. Toasting The cooking technique of toasting is a variation of browning that exposes food to dry heat. Toasting may be accomplished by the use of a barbecue, broiler, grill, open fire and/or toaster. Toasting may also be accomplished carefully in a dry pan, or one that is spread with a little oil over a medium heat. The ingredients should be carefully watched to help to prevent burning. Toasting grains, such as bulgur or rice; nuts such as pine nuts or walnuts; seeds such as pumpkin or sesame, and spices such as fennel or pepper before incorporating them into other ingredients often helps to enhance their flavors—even with additional cooking. This is because toasting releases the natural and aromatic oils of many of these ingredients and brings out their earthy and nutty flavors. Toasting may also add different dimensions of texture that may add interest and variety to recipes [34]. Umami Boosting Adding the umami taste to recipes truly exemplifies flavor enhancement. Not only does the umami taste contribute the savory taste, it may also enhance the other tastes in a recipe or dish, and has the capability of tying the rest of the meal together in flavor so that it tastes like one unified whole. Often, the taste of umami may be the “missing ingredient” that makes a recipe or dish delicious and memorable, such as anchovies in a Caesar salad dressing; bacon in a lettuce, tomato and mayonnaise sandwich; Parmesan cheese rind in a soup or stew; dried tomatoes in a myriad of Italian dishes; or a perennial favorite: a grilled aged beef burger with aged cheddar cheese. When a dish does not seem to come together or be satisfying to aging palates, consider these umami-boosting techniques: 1. Use the natural umami taste that is already present in foods and beverages with savory tastes, such as anchovies, bacon or soy sauce (see Chapter 6, Flavor Enhancement Ingredients, for suggestions). These tend to “melt” or disappear in recipes, lose their identities and become part of the resultant flavors. 2. Add ingredients that are naturally high in the amino acid glutamate, such as aged meats, grape juice, Parmesan/Roquefort cheese, peas, tomato products, seafood and/or walnuts in both cooking and baking. 3. Incorporate umami-potentiating ingredients that act as flavor enhancers, such as autolyzed yeast extract, hydrolyzed vegetable protein, mono-sodium glutamate or soy sauce in product development. Take into consideration potential ingredient sensitivities and/or attitudes about food additives.

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DIGEST Many of these flavor enhancement techniques in this chapter may be easily employed, while others may require more time and ability. If possible, it is important to individualize to appeal to personal tastes and restore food memories. Moreover, some aging individuals might enjoy the crisp outer coating of seared protein foods, while others may have a difficult time chewing and swallowing and prefer foods that are steamed or poached. Conditions, diseases, immobility, medications and a host of other considerations may interplay when flavor enhancement and cooking techniques are chosen. This may offer some explanations why certain people may think that coarse salt or crystalized sugar toppings are appealing, whereas other people might find these avant-garde finishing techniques unappetizing. These wide-ranging opinions in the aging are not so dissimilar to the food likes and dislikes of younger years. Just like feeding children, the attentiveness, care, creativity, perseverance, repetitiveness and positivity of some of flavor enhancement techniques that are highlighted in this chapter may lead to successful eating practices in the aging. In turn, an affirmative response to flavorful foods and beverages by people who are aging may bring better nutritive status, health and well-being [35]. Time, commitment and honed practices may tell. The following chapter, Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging, supports the connections among flavor enhancement ingredients and techniques with specific conditions and diseases among the aging. This information precedes Chapter 9, Culinary Considerations for the Aging, and Chapter 10, Menus and Recipes That Appeal to Aging Palates. Collectively, these chapters provide a cohesive foundation for making knowledgeable, food and beverage choices for both healthy and unwell aging people.

MANNER OF SPEAKING Acidifying Adjusting Age-related Eye Diseases (AREDs) Age-related Macular Degeneration (AMD) Alkalizing/Alkalinity Alcohol (Volatizing)

Baking Basting

Blanching Bolding Braising Broiling Browning Building

process that adds an acid ingredient to other ingredients to balance, brighten or lift other tastes; includes substances such as citrus, tea, vinegar or wine method of tasting a food or beverage and correcting the flavor as it is prepared and at the finale of the dish AMD, cataracts, diabetic retinopathy and glaucoma leading cause of vision loss in all groups of people who are aging addition of alkalinity to substances via alkaline ingredients (such as avocado, baking soda, bananas, greens, raisins and/or sweet potatoes) colorless liquid produced by the natural fermentation of sugars; lends acidity, bring outs the tastes in foods and beverages, and contributes to overall flavor; often by evaporating or volatizing, into vapor states process of surrounding food within a hot, enclosed environment; relies on radiation from a vessels’ walls and hot air convection key for locking in the flavor of protein foods; involves painting food with a water-containing liquid that cools the surface as it evaporates; thus slowing the cooking process process of scalding vegetables in boiling water or steam to stop the enzymatic action that may negatively affect their color, flavor and/or texture use of bold ingredients when preparing and cooking foods, such as curry, ginger, hot sauce, kimchi, mustard or Sichuan pepper cooking method that helps to transform tougher meats into tender cuts while maintaining flavor and moistness cooking method that provides intense heat to sear the outside of foods, develop intensely flavorful exteriors and retain moisture chemical reaction and cooking process that locks in flavor, changes color and produces new colors and flavors concept that tastes are built upon each other to create an amalgam of flavor; also called flavor layering

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MANNER OF SPEAKING

Caramelization/Caramelizing Cataracts Chemesthesis Chiffonade Chopping Concentrating Cutting

Confiting/Confit Cryovac Curing Dairy Foods/Products Deep-Frying Deficient Contrast Sensitivity Deglazing Diabetic Retinopathy Diacetyl Dry Aging Enriching/Enrich

Fattening Finishing Flavored Oils Flavor Layering Fond Frying Furan Molecules Gastriques Glaucoma Grilling Herbing Heterocyclic Amines

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browning process that brings out the natural sweetness in foods and intensifies their aromas and flavors clouding of the normally clear lens of the eye chemical sensitivity of the mucous membranes and skin; when receptors are activated by pain, thermal perception, touch and other sensations preparation of finely cut or shredded leaf vegetables, such as lettuce; often used as garnish cutting into small pieces with repeated sharp blows; generally with a knife reducing substances to their essence of flavors process of reducing ingredients into smaller portions with knives; seven knife cuts include brunoise, chiffonade, dice, julienne, mince, rough cut and slice result of slow and gentle cooking of ingredients at low temperatures into a rich and succulent consistency; for preservation and taste type of packaging technology; allows fresh goods to be kept fresher and longer process by which nitrites, nitrates, salt, smoke, sugar and/or other ingredients are used to flavor and preserve fish, meats and vegetables beverages and foods produced from the milk of dairy animals cooking method whereby food is submerged into hot fat, most commonly oil deficiency in sensitivities between contrasting forms to be seen cooking technique by which the browned food residue at the bottom of a pan is removed by dissolving with a liquid diabetes complication that affects the eyes; caused by damage to the blood vessels of the light-sensitive tissue at the back of the eyes (retina) organic compound; a yellow or green liquid with a strong buttery flavor; used for flavor enhancement process by which large cuts of meats are aged from several weeks to months before trimming and cutting adding ingredient(s) that enhance the character or nutrients of substances; such as thickening sauces with butter, egg yolks, heavy cream, pureed vegetables or starch, or micronutrients, such as calcium or vitamin D adding fat or oil to a mixture or product to add flavor, texture or both qualities process by which flavorsome flourishes are added to “finish” or complete the appearance, aroma, taste, texture and/or other components of dishes oils that are flavored with herbs, spices, or other ingredients, such as almond, avocado, hazelnut, sesame or walnut cooking process of combining, deepening and/or expanding the flavors in a recipe browned particles that remain on the bottom of a pan when protein foods exposed to heat; incorporated into flavorful sauces use of oil or fat to add crispness and other textures to foods and ingredients and to cook food quickly organic compounds that help to impart an aromatic nutty flavor sauces that have both acidic and sweet components, such as sweet and sour sauces, gravies, pan syrups and/or syrups group of diseases that have the potential to damage the eye’s optic nerve; may result in vision loss and/or blindness form of cooking that involves dry heat applied to the surface of food, commonly from above or below adding dry or fresh herbs to preparations to enhance flavor chemicals formed when muscle-meats are cooked by high-temperature methods, such as grilling or pan-frying, often over open flames

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High Frequency Pure Tone Average (HFPTA) or Pure Tone Average (PTA) Haptic Perception Infusing Kimchi Kodo Macerating/Macerated Maltol Marinating Mouthfeel Layering Low Vision Oleocanthal Osmosis

Oven Drying/Oven Dried Oven-Frying Pain Pan-Frying Pan-Searing (or Searing) Peppering Pickling Poaching Presbycusis Pot-Roasting Pressure Proprioception Punctuating Reducing Roasting

Salting Saute´ing Searing (or Pan-Searing)

key hearing test that is used to identify hearing thresholds; high frequency is in the region of 3000 Hz; low frequency is in the region of 500 Hz ability to grasp something flavoring agents, such as brine, broth, dairy products, marinades or oils that coat or steep into other ingredients; help to transform flavors Korean side dish made from fermented and salted vegetables; often cabbage and radishes Japanese game in which players try to guess the names of thousands of scents process by which liquids breakdown or soften foods and transmit flavors naturally occurring organic compound; primarily used for flavor enhancement soaking foods in a seasoned and often acidic liquid tactile sensations in the oral cavity; signify the sensations of feeling and touch cooking process of layering tastes to achieve integrated flavor condition caused by eye disease; visual acuity is 20/70 or poorer in the better-seeing eye; cannot be corrected or improved with regular eyeglasses natural phenolic compound found in extra virgin olive oil; responsible for burning sensation process by which molecules of a solvent pass through a semipermeable membrane from a less concentrated solution into a more concentrated solution use of the oven to remove the moisture and intensify the flavor of foods frying food, usually meat, in a cooking vessel in the oven unpleasant sensation that may range from mild and localized discomfort to all-over anguish frying ingredients in a small amount of fat or oil in a pan cooking technique that cooks the surfaces of food at high temperatures until caramelized crusts form adding pepper before, during or after preparing and cooking a recipe culinary technique; preserve; the life of foods and/or ingredients through anaerobic fermentation; prepared in brine or through vinegar immersion submerging foods or ingredients into liquids such as milk, stock, water, wine or a combination, and cooking at low heat age-related hearing loss slowing cooking meat that has first been browned in a covered dish, often with vegetables process of cooking food in a sealed vessel known as a pressure cooker by use of water or other cooking liquid sense of movement or position practice of employing small amounts of bold-flavored ingredients to “punctuate” or accent a dish or recipe boiling or simmering liquids in pans or dishes without lids, so the vapors evaporate until the desired volume is reached dry heat cooking method; use of hot air from indirect, diffused heat from an open flame, oven and/or other heat source; circulates around foods and evenly cooks them use of salt before, during or after the cooking process to heighten the salty taste and/or enhance other tastes cooking method of quick frying in a little hot fat or oil in a shallow pan over relatively high heat incomplete cooking process; sears or browns the exterior of ingredients, most often protein foods, such as meats

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REFERENCES

Seasonings Shallow-Frying Simmering Slow Browning

Slow Cooking Smoking Smell Training Somesthetics Somatic Senses Somatosensory System Squeezing Steaming Stir-Frying Sugaring Sweetening Sweating Tactile Cues The Maillard Reaction Tinnitus Toasting TRPm5 Umami-ing Verjuice Wet Aging

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herbs, pepper, salt and/or spices added to foods and beverages to enhance the flavors cooking of food in a small amount of pre-heated fat or oil in a shallow pan or on a flat surface cooking process whereby foods are kept just below boiling when cooking or heating cooking method that involves longer and slower browning generally of protein foods such as meats as opposed to quicker cooking, as in stir-fried dishes cooking process that often uses a crock pot or Instant pot; simmers foods and/or beverages at lower temperatures, such as baking boiling or frying process of browning, cooking, flavoring or preserving foods by exposing them to smoke; use of burning or smoldering material, most often wood use of smells to determine smell losses and the degree of odors that are needed for perception discipline involved in the roles of bodily experiences in esthetic appreciation senses that include proprioception (the sense of movement and position), the sense of touch and haptic perception part of the sensory system; concerned with the conscious perceptions of movement, pain, position, pressure, temperature, touch and vibration physical manipulating of ingredients (especially fresh fruits and vegetables) to release their juices cooking technique that involves continuously boing water until it vaporizes into steam that cooks adjacent foods or ingredients Chinese cooking technique; ingredients quickly fried by constant stirring in a wok with a small amount of oil over high heat use of sugars to bring out the sweet taste and/or balance other tastes in a recipe or ingredient process for increasing the sweet taste by use of natural or manufactured sweeteners gentle heating of vegetables in a small amount of butter or oil; causes released liquids to evaporate sensations of movement, pain, taste, touch, pressure, temperature (cold and heat) and others chemical reactions between amino acids and reducing sugars; provides browned foods with distinct flavors perceptions of noise or ringing in the ears; symptom of underlying conditions, such as circulation disorders, hearing losses and/or injuries browning in foods due to exposure to radiant heat; result of a Maillard reaction transient receptor cation channel; essential for transduction of bitter, sweet and umami tastes adding umami-rich ingredients (such as miso soup, tomatoes, Parmesan cheese, soy sauce to dishes to increase the umami taste) sour juice from crab applies, unripe grapes and other fruits; used in cooking to increase acidity aging foods in cryovac, a vacuum-sealed bag that is used to retain moisture; most common method of aging beef

References [1] Congdon N, O’Colmain B, Klaver CC, Klein R, Munoz B, Friedman DS, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol 2004;122(4):477 85. [2] Centers for Disease Control and Prevention, National Center for Health Statistics. Trends in vision and hearing among older americans, ,http://www.afb.org/section.aspx?SectionID 5 68&TopicID 5 320&DocumentID 5 3374&rewrite 5 0.; 2001 [accessed 04.09.18].

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[3] Barth FG. Insects and flowers: the biology of a partnership (M. Ann Biederman-Thorson, Trans.). Princeton (NJ): Springer; 1985; Apicius (1936). Cooking and dining in Imperial Rome (c. 1st Century; J.D. Vehling, Trans.). Chicago (IL): Springer; Spence C, Okajima K, Cheok AD, Petit O, Michel C. Eating with our eyes: from visual hunger to digital satiation. Brain Cogn 2016;110:53 63. [4] Dunne TE, Neargarder SA, Cipolloni PB, Cronin-Golomb A. Visual contrast enhances food and liquid intake in advanced Alzheimer’s disease. Clin Nutr 2004;23:533 8. [5] Raats M, De Groot L, van Asselt D. Food for the aging population. Woodhead Publishing; 2016. Technology & Engineering, 412 pages, ,https://books.google.com/books?id 5 24V4CgAAQBAJ&pg 5 PA40&lpg 5 PA40&dq 5 color 1 and 1 the 1 appearance 1 of 1 food 1 and 1 aging 1 people&source 5 bl&ots 5 t35ZKIrXGm&sig 5 Gn6w3OZG_wtFveA6-MjfGamAz1s&hl 5 en&sa 5 X&ved 5 0ahUKEwidg Oz6m6_WAhVK4oMKHZJ3CMgQ6AEINTAC#v 5 onepage&q 5 color%20and%20the%20appearance%20of%20food%20and%20aging% 20people&f 5 false. [accessed 11.09.18]. [6] US Department of Health & Human Services, National Institutes of Health. Age-related hearing loss, ,https://www.nidcd.nih.gov/ health/age-related-hearing-loss.; 2018 [accessed 04.09.18]; HearUSA, Hearing loss facts. “The invisible handicap”—a growing national problem. HearUSA, ,https://www.hearusa.com/hearing-loss-facts.aspx.; 2018 [accessed 04.09.18]. [7] Spankovich C, Le Prell CG. Healthy diets, healthy hearing: National Health and Nutrition Examination Survey, 1999 2002. Int J Audiol 2013;52(6):369 76; American Academy of Audiology. Thoughts on diet and hearing loss, March 12, 2014, Opinion Editorial by Douglas L. Beck, AuD, ,https://www.audiology.org/news/thoughts-diet-and-hearing-loss.; 2014 [accessed 11.09.18]. [8] Bonnell M. Add color, crunch, and flavor to meals with fresh produce. Hospitals 1966;40(3):126 30. [9] Spence C, Michel C, Smith B. Airplane noise and the taste of umami. Flavour 2014;3(2); Spence C, Shankar MU, Blumenthal H. Sound bites: auditory contributions to the perception and consumption of food and drink. In: Bacci F, Melcher D, editors. Art and the senses. Oxford University Press; 2010. p. 207 37; Spence C. Hospital food. Flavour 2017;6(3). Available from: https://doi.org/10.1186/s13411017-0055-y; Spence C, Piqueras-Fiszman B. The perfect meal: the multisensory science of food and dining. 1st ed. Wiley Blackwell; 2014. ,https://www.amazon.com/gp/product/1118490827/ref 5 as_li_qf_sp_asin_il_tl?ie 5 UTF8&camp 5 1789&creative 5 9325&creative ASIN 5 1118490827&linkCode 5 as2&tag 5 ediblgeogr-20&linkId 5 7MRB7G2NOL5ZWH5Z. [accessed 07.09.18]. [10] Plailly J, Delon-Martin C, Royet JP. Experience induces functional reorganization in brain regions involved in odor imagery in perfumers. Hum Brain Map 2012;33(1):224 34. Available from: https://doi.org/10.1002/hbm.21207. [11] Rupini RV, Nandagopal R. A study on the influence of senses and the effectiveness of sensory branding. J Psychiatry 2015;18:236. Available from: https://doi.org/10.4172/Psychiatry.1000236. [12] Harvard Health Publishing, Harvard Medical School. Allergic rhinitis: your nose knows, ,https://www.health.harvard.edu/diseasesand-conditions/allergic-rhinitis-your-nose-knows.; 2018 [accessed 04.09.18]. [13] Schubert CR, Cruickshanks KJ, Nondahl DM, Klein BEK, Klein R, Fischer ME. Association of exercise with lower long-term risk of olfactory impairment in older adults. JAMA Otolaryngol Head Neck Surg 2013;139(10):1061 6. Available from: https://doi.org/10.1001/ jamaoto.2013.4759. [14] Mayo Clinic. Symptoms, loss of smell. Mayo Clinic Staff 1998-2018 Mayo Foundation for Medical Education and Research (MFMER), ,http://www.mayoclinic.org/symptoms/loss-of-smell/basics/causes/sym-20050804. [accessed 07.09.18]. [15] Byron E. Life & style: uncork the nose’s secret powers, The Wall Street Journal, February 20, 2013, ,http://www.wsj.com/articles/ SB10001424127887323696404578300182010199640.. [16] BetterHealthChannel. Anosmia—loss of smell. In: What factors affect individual odour perception? Sydney: Environmental Odour Laboratory, University of NSW; 1999, ,http://www.wsj.com/articles/SB10001424127887323696404578300182010199640.; Pines M. The mystery of smell—finding the odorant receptors. Seeing, hearing and smelling the world. Chevy Chase (MD): Howard Hughes Medical Institute; 1997. New York State, Department of Health. Odors & Health, ,https://www.health.ny.gov/publications/6500/index.htm.; 2018 [accessed 07.09.18]. [17] JapanZone, Kodo. The way of incense, 1999 2018, ,https://www.japan-zone.com/culture/kodo.shtml. [accessed 07.09.18]. [18] Smell of fresh bread and fast food influences behavior. Bakeryandsnacks.com, last updated 19 July 2008, ,http://www.foodnavigator. com/Science/Smell-of-fresh-bread-and-fast-food-influences-behaviour.; 2005 [accessed 07.09.18]. [19] Vohs KD, Wang Y, Gino F, Norton MI. Rituals enhance consumption. Psychol Sci 2013;24(9):1714 21. Available from: https://doi.org/ 10.1177/0956797613478949. [20] Bajec MR, Pickering GJ, De Courville N. Influence of stimulus temperature on orosensory perception and variation with taste phenotype. Chemosens Percept 2012;5(3 4):243 65. [21] Talavera K, Yasumatsu K, Voets T, Droogmans G, Shigemura N, Ninomiya Y, et al. Heat activation of TRPM5 underlies thermal sensitivity of sweet taste. Nature 2005;438(7070):1022 5. [22] Menche N, editor. Biologie anatomie physiologie. Munich: Urban & Fischer Elsevier; 2012; Pschyrembel W. Klinisches Wo¨rterbuch. Berlin: De Gruyter; 2014; Schmidt R, Lang F, Heckmann M. Physiologie des Menschen: mit Pathophysiologie. Heidelberg: Springer; 2011; PubMed Health. How does the tongue work? Last Update: August 23, 2016; Next update: 2019. ,https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072591/.; Breslin PAS. An evolutionary perspective on food and human taste. Curr Biol 2013;23(9):PR409 418. Available from: https://doi.org/10.1016/j.cub.2013.04.010, ,http://www.sciencedirect.com/science/article/pii/S0960982213004181.. [23] DW. Lufthansa investigates the science of airline food, ,http://www.dw.com/en/lufthansa-investigates-the-science-of-airline-food/a6114748.; 2010 [accessed 11.09.18]; Moskvitch K. Future: why does food taste different on planes? ,http://www.bbc.com/future/ story/20150112-why-in-flight-food-tastes-weird.; 2015 [accessed 11.09.18]. [24] Mouritsen O, Styrbæk K. Translated by Mariela Johansen. Mouthfeel: How texture makes taste (Arts and traditions of the table: perspectives on culinary history), ,https://www.splendidtable.org/story/mouthfeel-the-effect-of-sensation-and-texture-on-the-flavor-of-food.; 2017 [accessed 04.09.18]. [25] Stuckey B. Taste what you’re missing: the Passionate Eater’s Guide to why good food tastes great. New York: Free Press; 2012. p. 169 70. [26] Bartoshuk LM. Sensory factors in eating behaviour. Bull Psychonom Soc 1991;29(3):250 5. ,https://link.springer.com/content/pdf/ 10.3758%2FBF03342692.pdf. [accessed 04.09.18].

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[27] McGee H. Changing food by changing its pH. The power of alkalinity. Pop Sci, ,https://www.popsci.com/adding-alkalinity-food#page-2.; 2015 [accessed 04.09.18]. [28] Fine Cooking Editors. Food Science: Alcohol’s role in cooking. Fine Cooking. The Taunton Press, Inc., ,http://www.finecooking.com/ article/alcohols-role-in-cooking.; 2018 [accessed September 11, 2018]; USDA Table of Nutrient Retention Factors Release 6, Prepared by the Nutrient Data Laboratory, Beltsville Human Nutrition Research Center (BHNRC) Agricultural Research Service (ARS), US Department of Agriculture (USDA), ,http://www.ars.usda.gov/nutrientdata.; 2007 [accessed 04.09.18]. [29] Smith B. Education, chemical reactions that occur during baking, Hearst Seattle Media, LLC, seattle pi, ,http://education.seattlepi.com/ chemical-reactions-occur-during-bakingfur.; 2018 [accessed 11.09.18] [30] So easy to preserve, 6th ed. 2014. Bulletin 989, Cooperative Extension Service, The University of Georgia, Athens. Revised by Andress EL, Harrison JA. Extension foods specialists. ,http://nchfp.uga.edu/how/freeze/blanching.html. [accessed 04.09.18]. [31] Wayt Gibbs W, Myhrvold N. Cooking that sucks, vacuum pumps in the kitchen, ,https://www.scientificamerican.com/article/cooking-that-sucks/.; 2011 [accessed 04.09.18]. [32] Beans C. The salt: What’s On Your Plate: Food for Thought. Slice, dice, chop or julienne: does the cut change the flavor? ,http://www. npr.org/sections/thesalt/2016/07/11/485235765/slice-dice-chop-or-julienne-does-the-cut-change-the-flavor.; 2016 [accessed 04.09.18]. Spiegel A. Cooking: final cut: the way you chop vegetables actually affects how they taste. The tasting table, ,https://www.tastingtable. com/cook/national/cutting-vegetables-chopping-flavor-taste-npr.; 2016 [accessed 04.09.18]. [33] A brief history of grilling, foodnetwork.com, ,https://www.foodnetwork.com/recipes/articles/a-brief-history-of-grilling.; 2012 [accessed 11.09.18]. [34] Academy of Nutrition and Dietetics. 7 Ways to enhance the flavor of your meals, Reviewed by Wolfram T, Eat Right, ,http://www.eatright.org/resource/food/planning-and-prep/cooking-tips-and-trends/enhancing-the-flavor-of-your-meals.; 2017 [accessed 04.09.18]. [35] Hevrdejs J. Amp up dull dishes with easy tricks that add flavor, balance. Tribune Newspapers, January 18, 2012, ,http://www.redefiningdomestics.com/welcome/2015/2/essential-flavor-enhancers-for-cooking. [accessed 04.09.18].

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C H A P T E R

8 Meeting Nutritional and Disease-Specific Needs of Aging

PHOTO: Swiss Chard. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I have no sense of smell. Most foods are tasteless to me. I can’t eat plain foods and enjoy them.

M.H.

O U T L I N E Summary

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Introduction

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Healthy Eating for Aging

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Major Nutrients Calories Protein Fats Carbohydrates

252 252 252 253 253

Minerals

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Vitamins

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Water

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Aging, Nutrition and Taste. DOI: https://doi.org/10.1016/B978-0-12-813527-3.00008-9

General Considerations for Meeting Nutritional Needs in the Aging Conditions and Diseases of Aging: Overviews, Dietary Considerations, Supplements and Support Systems Alcoholism and Interrelated Conditions (High Blood Pressure, Infections and Liver Disease/Damage) Alcoholism Interrelated Conditions: High Blood Pressure, Infections and Liver Disease/Damage Food Allergies, Intolerances and Sensitivities (See Immune Function) Alzheimer’s Disease and Dementia Anemias

249

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254 254 254 255 256 257 258

© 2019 Elsevier Inc. All rights reserved.

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Arthritis (See Osteoarthritis and Rheumatoid Arthritis) Cancers Cardiovascular Health Celiac Disease and Gluten-Free Diets Chronic Kidney Disease [Chronic Renal (Kidney) Disease, or Chronic Renal Failure] Consistency-Altered Diet Dehydration Diabetes Failure to Thrive Gastrointestinal Health Gout Hepatic/Liver Disease High and Low-Protein Diets HIV/AIDS Hypertension Immune Function (See Food Allergies, Intolerances and Sensitivities) Inflammation

259 260 261 262 263 264 265 266 267 267 268 269 270 271 272 273 274

Kosher and Halal Dietaries Lactose Intolerance Malnutrition Oral Disease Osteoarthritis and Rheumatoid Arthritis (See Arthritis) Palliative Care Phenylketonuria Pressure Ulcers Pulmonary Disease Sarcopenia Vegetarian, Lacto-ovo Vegetarian and Vegan Diets Weight Loss and Weight Gain Aging Itself

275 276 277 278 279 280 281 281 282 284 285 286 287

Digest

288

Manner of Speaking

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References

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LEARNING OBJECTIVES 1. Associate diseases and conditions of aging with nutrient-specific requirements. 2. Connect specific diseases and conditions of aging with foods, beverages, supplements and support systems. 3. Identify resources that address diseases and conditions of aging with attainable solutions. 4. Recognize eating, drinking, health and lifestyle practices in the aging that favorably contribute to disease prevention. 5. Inspire proactivity in aging populations to take charge of diet and health for quality aging and less strain on the US healthcare system.

SUMMARY To distinctively connect specific nutritional needs, conditions and disease states in the aging with foods, beverages, supplements and support systems that may meet nutrient deficiencies, dietary guidelines, drug interactions, ethnic preferences and/or other specialized requirements.

INTRODUCTION While aging is a normal phase of the human lifecycle, it has specific nutritional and disease-specific needs, just like the age-related phases of infancy, childhood, adolescence, pregnancy, lactation and middle age command. During aging, the human body slows down, body systems including sensory may be compromised and along with immobility these factors collectively contribute to aging needs for fewer calories, more of certain nutrients and less of others. AGING, NUTRITION AND TASTE

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HEALTHY EATING FOR AGING

Aging people tend to either eat less or consume too many calories in comparison to their activity level, and tend to make different food choices than they did when they were younger as they age. The consumption of foods and beverages with B vitamins, calcium, iron, vitamins C and E and zinc tends to decline during aging, and increase the risk of diet-related illnesses that depend on these nutrients. In this chapter, many of the specific nutritional needs, disease states and conditions of aging will be illuminated, with specific requirements and mechanisms by which these needs may be met. This is with the understanding that few dietary measures, supplements or support systems have the capabilities—independently or jointly, to stop the aging processes and/or to cure the diseases and conditions that are associated with aging. These recommendations are based on current research where indicated, or are generally recommended practices that have served the test of time. Prudency is always advised about nonmedical strategies. It is best to speak with medical providers first before initiating any self-treatments [1].

HEALTHY EATING FOR AGING A measure for healthy eating during aging is the Dietary Reference Intakes (DRIs) for Americans 51 70 years to Greater than 70 Years. The DRIs are nutrient reference values developed by the Food and Nutrition Board, Institute of Medicine, National Academies of Sciences, Engineering, and Medicine. The DRIs serve as a guide to nutrition and provide the scientific basic for the development of US and Canadian food guidelines. The DRIs are specified according to age, gender and life stage for more than 40 nutrients and substances. The Dietary Reference Intakes for Americans 51 70 years and Those Greater than 70 Years follow in Table 8.1 [3]. TABLE 8.1

Dietary Reference Intakes (DRIs) for Americans 51 70 years, and Those Greater Than 70 Years

Nutrients

Female requirementsa

Male requirementsa

Calcium

1000 mg/day

1000 mg/day

Carbohydrates

100 g

100 g/

Protein

0.66 g/kg

0.66 g/kg

Vitamin A

500 μg

625 μg

Vitamin C

60 mg

75 mg

Vitamin D

10 μg

10 μg

Vitamin E

12 mg

12 mg

Thiamin

0.9 mg

1.0 mg

Riboflavin

0.9 mg

1.1 mg

Niacin

11 mg

12 mg

Vitamin B6

1.3 mg

1.4 mg

Folate

320 μg

320 μg

Vitamin B12

2.0 μg

2.0 μg

Copper

700 μg

700 μg

Iodine

95 μg

95 μg

Iron

5 mg

6 mg

Magnesium

265 mg

350 mg

Molybdenum

34 μg

34 μg

Phosphorus

580 mg

580 mg

Selenium

49 μg

45 μg

Zinc

6.8 mg

9.4 mg [2]

a

Expressed in amount/day.

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MAJOR NUTRIENTS Calories As people age, their activity levels generally decline. This decreased activity is often coupled with decreased muscle mass and increased fat stores. In general, unless aging people are very active, they may need fewer calories than they did during their middle-aged years. This amounts to about 1600 daily calories for inactive women, and about 2000 daily calories for inactive men. With activity, aging women should consume about 1800 daily calories, and active aging men should consume about 2200 daily calories.

Protein Protein needs may decrease with aging, but some aging people who experience sarcopenia, a disease associated with a loss of muscle mass and strength, may require a closer look. As a whole, healthy aging people should consume about 10% 35% of total calories from protein, or about 46 56 daily grams. This equates to a daily intake of about 0.8 1.0 gram of protein per kilogram body weight daily. Examples of protein intake levels for both aging women and men are shown in Table 8.2., followed by the protein content of some common foods to meet these levels. TABLE 8.2

Protein Intake Ranges (10% 35% Total Daily Calories) for Aging Women and Men

Women

Men

Inactive Daily Calorie Requirement:

Inactive Daily Calorie Requirement:

1600 daily total calories

2000 daily total calories

Daily Protein Need Based on

Daily Protein Need Based on

Daily Caloric Requirement:

Daily Caloric Requirement:

10% total calories 5

10% total calories 5

160 calories from protein

200 calories from protein

or 40 grams of protein daily

or 50 grams of protein

Active Daily Calorie Requirement:

Active Daily Calorie Requirement:

1800 daily total calories

2200 daily total calories

Daily Protein Need Based on

Daily Protein Need Based on

Daily Caloric Requirement:

Daily Caloric Requirement:

35% total calories 5

35% total calories 5

280 calories from protein

770 calories from protein

or 70 grams of protein daily

or 193 grams of protein daily

Protein Content of Common Foods to Meet Daily Protein Levels: 3 ounces cooked white meat chicken

30 grams

3 ounces cooked white meat turkey

28 grams

3 ounces cooked beef round roast

25 grams

3 ounces canned tuna

24 grams

3 ounces cooked lamb

21 grams

12 large cooked shrimp

17 grams

1

/2 cup low-fat cottage cheese

13 grams

3 ounces cooked fish (such as cod or sole)

12 grams

2 ounces Mozzarella cheese

12 grams

2 tablespoons peanut butter

8 grams

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Fats It is prudent for aging people to keep dietary fat intake to 20% 35% of total calories. This amounts to about 320 560 daily calories from dietary fat for inactive women, and about 400 700 daily calories from dietary fat for inactive men, and about 360 630 daily calories from dietary fat for active women and about 440 770 daily calories from dietary fat for active men. The majority of dietary fats should be derived from monounsaturated fatty acids as found in avocadoes; canola and olive oils; fish and seafood; lower-fat dairy products; some nuts such as almonds and/or walnuts; green leafy vegetables such as purslane, peanuts; peanut butter and peanut oil; and sesame seeds and their oil [4].

Carbohydrates In general, about 45% 65% of total daily calories should be supplied by carbohydrates in aging diets. This amounts to a range of 720 1040 daily calories from carbohydrates for inactive women and 900 1300 daily calories from carbohydrates for inactive men, and 810 1170 daily calories from carbohydrates for active women, and 990 1430 daily calories for active men. The majority of these carbohydrates should be derived from complex carbohydrates that include legumes, such as Great Northern and garbanzo beans, starchy vegetables such as corn or sweet potatoes and whole grains such as brown rice quinoa. This is because simple sugars such as glucose and fructose in some candies and soft drinks prompt a quick insulin response and glucose tolerance in people who are aging declines, which means that there is less tolerance. More complex carbohydrates should help glucose regulation since they are slower to digest and metabolize. Another benefit of some complex carbohydrates is their fiber content that is especially needed by aging people to help to regulate elimination. Fresh and dried fruits, legumes (dried beans and peas), fresh vegetables and ancient and whole grains are preferred sources of fiber to meet a goal of 21 grams of dietary fiber per day for aging women and 30 grams of dietary fiber per day for aging men. Added sugars in food products should be kept at a minimum. If an enhanced sweet taste is desired, consumers may choose to add a controlled amount of a sugary ingredient to their foods.

MINERALS Minerals are certain substances that are necessary in small amount for body maintenance. While many minerals for the aging were described in Chapter 2, Nutritional and Physical Concerns in Aging, two minerals are of particular importance here: sodium and potassium. Both of these minerals are also electrolytes and are subject to fluid imbalances—common in aging people from dehydration, environmental factors, medications and other issues. Aging people should try to limit their sodium intake to about 1500 milligrams daily and increase their potassium intake to about 4700 milligrams daily. Sodium is prevalent in fast and processed foods and potassium is found in many fruits, milk and milk products and vegetables. The correct balance of sodium and potassium is necessary for the prevention of bone loss, hypertension and kidney stones.

VITAMINS Like minerals, vitamins are also required in small amounts for normal growth and development. While more information on vitamin needs and healthful aging can be found in Chapter 2, Nutritional and Physical Concerns in Aging, attention should particularly be given to adequate calcium and vitamin D for optimal bone health. About 1200 milligrams of dietary calcium through food and beverage sources such as green leafy vegetables, and vitamin D-fortified dairy products, fruit juices and plant “milks” are recommended daily. Aging people who are over 75 years of age should consume about 20 micrograms of vitamin D. Additionally, aging people over 75 years of age should consume about 2.4 micrograms of vitamin B12 through fortified cereals and/or supplements. Vitamin B12 is essential for healthy blood and nerves and may be related to cognitive function. A deficiency of vitamin B12 may lead to megaloblastic anemia that results in tiredness and/or weakness.

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WATER Fluids, and especially water, are needed everyday by all people, particularly those who are aging people. Fluids help digestion, nutrient absorption and elimination. With aging, the sense of thirst is sometimes compromised. Medications may complicate conditions. The requisite six to eight (8-ounce) glasses of water are recommended daily along with these suggested tips for increasing hydration, shown in Table 8.3. TABLE 8.3 Tips for Increasing Hydration in the Aging • Add fluids throughout the day. Keep a glass or bottle of water handy at most times. • Check the color of urine as a measure of fluid needs. If it is concentrated and dark, this may be a sign for increased consumption. It may also signify the residue of highly colored foods and/or beverages or be the aftermath of medications. • Consult with a medical provider for atypical water needs: additions, restrictions or other requirements. • Consume a glass of water before and after exercise. • Drink a full glass of water with medications (if specified). • Drink at least one glass of water for each alcoholic beverage that is consumed. Some beer may be an exception. • Include unsweetened beverages daily other than water. While some of these beverages (such as coffee or tea) may be dehydrating, they may still add to total daily fluid intake. • Increase water consumption when the temperature is hot. • Increase fluid consumption if feverish, or as recommended by a healthcare provider. • Take sips of fluids between bites of food at meals or snacks—unless this is too filling [5].

GENERAL CONSIDERATIONS FOR MEETING NUTRITIONAL NEEDS IN THE AGING While no one diet is perfect for everyone, and though dietary recommendations are just that, references to measure dietary intake for prospective health and well-being, they still provide a framework for aging diets. The recipes that can be found in Chapter 10, Menus and Recipes That Appeal to Aging Palates, mostly fall within these dietary recommendations. Of course, individual tastes and preferences may prevail. Other considerations about the nutritional and physical concerns of the aging that may affect their nutritional and disease-specific needs were expressed in Chapter 2, Nutritional and Physical Concerns in Aging. These include appetite and hunger, economics, medical and medication interactions, proper mastication and the procurement and preparation of healthy foods and beverages, among other matters. This chapter will focus on the many of the conditions, diseases, dietary considerations, supplements and support systems of the aging, and attempt to provide some general strategies for their implementation.

CONDITIONS AND DISEASES OF AGING: OVERVIEWS, DIETARY CONSIDERATIONS, SUPPLEMENTS AND SUPPORT SYSTEMS Alcoholism and Interrelated Conditions (High Blood Pressure, Infections and Liver Disease/Damage) Alcoholism Overview Alcohol may affect older individuals differently than younger ones. Older people may feel the effects of alcohol sooner because they may be dehydrated, or they may take medications that are counter-indicated with alcohol consumption (such as aspirin, some cough syrups, painkillers and/or sleeping pills). As a result, aging people who consume alcohol may become dizzy, lose their balance and have higher incidents of accidents, especially automobile, falls and/or fractures. Over time, drinking too much alcohol may lead to some types brain damage, certain cancers, immune system disorders and/or liver damage. Some health conditions such as diabetes, high blood pressure, memory loss,

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mood disorders, osteoporosis and/or stroke may worsen. Some medical conditions, such as changes in blood vessels and the heart may be difficult to discover and treat, and they may be exacerbated by alcohol. And too much alcohol over time may contribute to confusion and forgetfulness that may be mistaken for Alzheimer’s disease or dementia [6]. Dietary Considerations Well-Balanced Diet A well-balanced diet with fruits and vegetables, healthy fats and oils, lean proteins, legumes, low-fat dairy products, nuts and/or nut butters and whole grains is recommended since alcohol may impair the body’s ability to digest and utilize nutrients. Thiamine or Vitamin B1 for the Brain Alcohol ingestion may inhibit the effective absorption of some B vitamins, among other vitamins and minerals. B vitamins are responsible for converting foods into usable energy. Long-term alcoholism in the aging may contribute to a condition known as Wernicke Korsakoff syndrome or alcohol-related dementia that may affect the body’s ability to produce thiamine. Without thiamine, the brain may be unable to store new memories and cognition may be impaired. Common food sources of B1 include beef, eggs, legumes, nuts, oats, oranges, peas and pork. Vitamin E Some reports of vitamin E deficiency in people with alcoholism and the effects of dietary vitamin E therapy exist. This may be because alcohol ingestion is thought to promote lipoperoxidation and alter cellular antioxidant mechanisms [8]. Common food sources of vitamin D include almonds, avocadoes, cooked spinach and other leafy greens, safflower oil and sunflower seeds. Supplementation may improve serum vitamin D levels. Vitamins A and D, Calcium and Magnesium for the Bones Alcohol is a diuretic that may agitate the condition of osteoporosis and increase the risk of hip fractures. Additionally, alcohol consumption may decrease osteoblasts (bone-forming cells). Attention to the bone vitamins, (vitamins A and D) along with the bone minerals (boron, calcium, copper, magnesium, phosphorus, silicon, strontium, vanadium, and zinc) is particularly important with alcoholism. Supplements Supplements may be prescribed to replenish some nutritional deficiencies that are the result of alcoholism, particularly as alcoholics begin recovery programs. This may be necessitated since the early days of recovery may bring difficulty eating and drinking. Of especial importance during this period of time may be the minerals magnesium, selenium and zinc. Support Systems Alcoholics Anonymous and Others Anxiety, chronic illness, depression, disabilities, isolation and other factors may lead to alcoholism in the aging, or exacerbate existing alcoholism. If alcoholism is an issue, the counsel of a family therapist, healthcare professional, support group, trained counselor or program such as Alcoholics Anonymous may be helpful for support and to provide assistance for accessing healthy meals.

Interrelated Conditions: High Blood Pressure, Infections and Liver Disease/Damage High Blood Pressure High blood pressure, or hypertension, increases the risk of strokes. Alcoholism has the capacity to raise blood pressure. A prudent antihypertensive diet for the aging, without exceeding 1500 milligrams of sodium daily, may be warranted. This is particularly important for aging African Americans, and for those people with chronic liver disease and/or diabetes.

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Infections Excessive alcohol consumption is related to immunosuppression, since alcohol may weaken the body’s ability to produce disease-fighting white blood cells and lower its resistance to fight infections, such as pneumonia. Antioxidant vitamins such as vitamins A, C and E may be justifiable. Liver Disease/Damage Alcohol exposure may elevate liver enzymes that may lead to alcoholic hepatitis, cirrhosis or fatty liver. Because the liver in aging people does not function as effectively as in younger individuals, alcoholics may be more susceptible to liver damage. Keeping dietary fats in moderation may also be warranted [7].

Food Allergies, Intolerances and Sensitivities (See Immune Function) Overview Allergic reactions are one of the most common immunological diseases. They are also widespread and fast growing and may be chronic. As people age, allergic expressions may increase—some older manifestations, while others may be newly founded. Immediate hypersensitivity (type I) is the most common, widespread and fast-growing chronic human health condition. This may be due to environmental changes in the most recent decades that may include climate, dietetic, mode of delivery, pollution and/or shapes of microbial colonization patterns. Epigenetic and microbiological triggers should also be considered. The onset of allergic diseases in the aging is driven by immunosenescence, or the loss of homeostasis at the molecular, cellular and systemic levels in response to extrinsic and intrinsic challenges, with increased susceptibility to chronic inflammatory diseases [9]. Dietary Considerations The most frequent allergic reactions to foods by aging people occur after consuming allergic or sensitivityprovoking beverages and/or foods and after exercise. Implicated beverages and foods may include some fish, fruits, nuts, shellfish and/or vegetables. Chronic alcohol consumption and drug ingestion are among risk factors for sensitization to food allergens. Food allergies may present the following symptoms: cutaneous (such as angioedema, eczema or urticarial); gastrointestinal (such as cramping or diarrhea); and general anaphylactic reactions and/or respiratory (such as asthma or rhinitis). Allergy to peanuts and/or tree nuts may occur later in life. The symptoms may range from a mild rash to anaphylaxis, so avoidance may be critical. Lactose resistance or intolerance may also escalate during aging. The aging stomach may not be able to break down this sugar found in dairy products, which may lead to gastrointestinal issues. Many lactose-free dairy products including plant-based “milks” are now available to help serve this growing concern. As people age, their ability to break down alcohol may also be compromised. This inability to tolerate alcohol may lead to some kidney, intestine and/or stomach difficulties. Gluten intolerance is another mounting concern during aging. In some instances, it might be diagnosed as Celiac disease (see Celiac Disease and Gluten-free Diets). Many beverages and foods now exist to meet this growing disorder. Preventive dietary approaches for dealing with food allergies and sensitivities are shown in Table 8.4. TABLE 8.4 Dietary Approaches for the Prevention of Food Allergies and Sensitivities • Avoid cross-contamination by washing cutting boards, dishes and utensils that may transfer allergens. • Check with restaurants for allergy-free meals and kitchen practices. • Eliminate suspected beverage and food allergens. • Ingest a whole food, allergen-free diet. • Modify recipes to exclude dairy products, gluten, nuts and/or peanuts as needed. • Read food labels to detect suspected or confirmed food allergens. Data from https://prod.poz.com/basics/hiv-basics/hiv-nutrition.

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Supplements While insufficient evidence exists about alternative therapies for food allergy development in the aging, there may be some measures to take to help to improve food allergy sensitivity and management. To begin, any nutritional deficiencies in iron, vitamin D and/or zinc should be addressed. A daily multivitamin and mineral supplement may be considered as a prophylactic measure. Coenzyme Q10 is an antioxidant that may be deficient in some aging individuals with recurrent food allergies. Omega-3 fish oil with docosahexaenoic acid (DHA) may potentially reduce histamine release and promote food allergy sensitization. L-Glutamine and probiotics with Lactobacillus acidophilus and Bifidobacterium may help to promote intestinal health. It is advisable to confer with a healthcare provider before initiating any of these supplemental measures to prevent contraindications, interactions with other drugs or supplements and/or to prevent overdosing. Support Systems If there are lifelong food allergies, the support of an allergic team of specialists during aging is paramount. If new allergies are suspected, primary care providers should refer to aging patient allergy specialists. Care providers should look for traditional allergic symptoms, such as itchy eyes, a runny nose or sneezing, then take affirmative actions, since unattended allergic symptoms may aggravate preexisting conditions, such as cardiovascular problems or lung disease. Traditional antihistamine use may be dangerous to some aging people, since it may provoke confusion, dizziness, drowsiness, dry mouth and eyes and/or urine retention that may lead to urinary tract infections. Also concerning is that these common over-the-counter medications may lead to potentially dangerous drug interactions that may affect vital body homeostasis and/or contribute to falls. Careful supervision by healthcare providers is urged.

Alzheimer’s Disease and Dementia Overview Alzheimer’s disease and its contribution to dementia are complex disorders, with multi-risk factors that may include age and genetics. Still, there are measures that at-risk aging people may undergo to help challenge, nourish and comfort their brains and live preventive and productive lives. Prudent measures include a healthy approach to diet, blood pressure and cholesterol control, mental stimuli, moderate alcohol consumption (if it is consumed), quality sleep, regular exercise, smoking cessation, socialization, stress management, supplements as justified and weight management. Dietary Considerations Preventive dietary approaches to nourish the brain and the body include the following foods and beverages, supplements and other defensive measures: • Colorful Fruits and Vegetables The inclusion of colorful fruits and vegetables is recommended, especially berries, cruciferous vegetables such as broccoli and Brussels sprouts and leafy greens, due to their phytonutrient compositions. • Green Tea The ingestion of green tea is proposed to enhance memory, mental alertness and arrest brain aging. • Mediterranean-Type Diet The consumption of a Mediterranean-type diet, with fish, fruits, legumes, nuts, olive oil, vegetables and whole grains to help to reduce the risks of cognitive impairment is advised. These foods tend to be higher in brain nutrients, such as docosahexaenoic acid, lutein, omega-3 fatty acids, quercetin, vitamins A, C and E and zeaxanthin. • Omega-3 Fatty Acids (Omega 3s) The addition or continuation of omega-3 fatty acids from flaxseeds, oily fish, such as herring, mackerel, salmon, sardines, tuna and/or trout and walnuts with DHA is suggested. Omega 3s may reduce cognitive impairment and dementia. • Sugars The reduction of refined and sugary carbohydrates that may spike blood sugar is advocated, since sugars in excess may contribute to inflammation.

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• Trans Fats The avoidance of trans fats in some baked goods, fried foods, creamers, margarines, refrigerator doughs and snacks is encouraged. Trans fats may contribute to inflammation and produce free radicals that are contraindicative to brain health. • Wine Consumption Moderation in red wine in consumption is warranted; however, heavy alcohol consumption may accelerate brain aging and raise Alzheimer’s risks. Supplements Healthcare providers may suggest any of these supplements to augment these preventive dietary approaches. As with any dietary supplement it is prudent to consider its use with regard to disease state(s), health status, possible side effects, potential drug interactions and other influencers. • B vitamins, vitamin C and vitamin E to help lower homocysteine, an amino acid linked with increased risk of Alzheimer’s disease. • Fish oils with omega-3 fatty acids (see above for food sources). • Folic acid, vitamin B12, vitamin D and magnesium to support brain health. • Turmeric in supplemental form, although the connection with brain health is not conclusive. Support Systems Developing and maintaining strong social networks is one of the more fundamental strategies for healthy brain maintenance and Alzheimer’s disease prevention. This is because humans are social individuals by nature and by-and-large their brains thrive during socialization. Methods to increase socialization include the attendance of community events, connection through social media, engagement in group classes, interaction with neighbors, inclusion in clubs, social groups or senior centers and/or volunteerism. Socialization is also important for meal consumption and enjoyment [10].

Anemias Overview The most common causes of anemia in the aging are anemia of chronic disease or disorder and iron deficiency. Folate deficiency, gastrointestinal bleeding, medication interactions, myelodysplastic syndrome (a group of disorders that are caused when the production of blood cells is interrupted) and vitamin B12 deficiency are some of the causes of anemia in the aging, as measured by serum ferritin. The onset of signs and symptoms of anemia in the aging may be deceptive. Dyspnea (shortness of breath), fatigue, headaches, low blood pressure, pallor and/or weakness may be overlooked and compensated. Worsening apathy, cognitive impairment, congestive heart failure and dizziness may be other non-apparent signs of anemia. Dietary iron absorption problems and loss of blood in the stood may also be contributory. Nutritional deficits from poor dietary intake and/or weight loss may also be causative, even with vitamin and minerals supplementation [11]. Dietary Considerations • Dark leafy green vegetables, such as broccoli and kale, and legumes are also naturally good sources of folate. Folate may also be added to some cornmeal products, enriched pasta and white flours to improve its availability to the diet. • Foods with significant iron content include fish and shellfish, milk, poultry, meats (especially red meats) and pork. Nonmeat sources of iron include dried fruits, such as apricots, prunes (dried plums) and raisins; iron-fortified cereals and breads; peas, lentils and legumes; and spinach and other dark leafy green vegetables. • Orange juice with vitamin C helps to increase iron absorption, as does carrot juice with vitamin A. • Tea consumption may interfere with iron absorption due to its tannin content that acts as a chelator and binds to iron, thus inhibiting its absorption [12]. Supplements • Folate supplementation in the event of a poor diet or alcoholism may be reasonable, as determined by a care provider.

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• Oral vitamin B12 (about 1000 μg per day) may alleviate some pernicious anemia, if absorbed. If vitamin B12 is not absorbed, intramuscular injections may be given on an individual basis. Support Systems Family or care providers may watch for and note any changes in attention, balance, breathing, energy and/or facial color in the aging (though these symptoms may also be signs of other conditions and/or diseases). Vitamin B12 injections may be handled individually or by care providers.

Arthritis (See Osteoarthritis and Rheumatoid Arthritis) Overview Arthritis is not a singular disease; rather, it is an informal description of joint pain and/or joint disease. While there are considerable types of arthritis and related conditions, common symptoms of arthritis may include decreased range of motion and pain, stiffness and/or swelling in joints, with mild to severe discomfort painfulness. There may be permanent joint pain that affects the fingers, hips and other essential joints that may in turn affect the ability to perform everyday activities, such as stair climbing or even walking, or even involve the eyes, heart, kidneys, lungs and/or skin. Osteoarthritis is the most common type of arthritis. Rheumatoid arthritis and psoriatic arthritis are examples of inflammatory arthritis. The primary difference between osteoarthritis and rheumatoid arthritis is the nature of both diseases. Osteoarthritis is a degenerative condition that may be the result of the wear and tear on the joints and cartilage throughout the years. This may be due to certain jobs or sports that involve repetitive motions, or as a result of older injuries. It may also have genetic roots. Osteoarthritis may produce inflammation, but its primary disability is due to the destruction of joint cartilage. In comparison, rheumatoid arthritis is an autoimmune disorder that may cause inflammation in the joints throughout the body. It generally develops in people who are between the ages of 30 60 years of age, while osteoarthritis often develops later in life. The exact causes are uncertain; environmental, genetic, hormonal and/or lifestyle factors such as obesity or smoking may be factors. Both osteoarthritis and rheumatoid arthritis may be chronic and noncurable. Their prognoses and treatments may differ. Psoriatic arthritis, a form of arthritis that affects some people who have the skin condition psoriasis, may require join replacement surgery, medication to reduce inflammation and/or steroid injections. Joint problems may begin before skin lesions occur. Dietary Considerations First and foremost, a decrease in excess body weight may help to relieve joint pressure and reduce the incidence of arthritis-related discomfort and/or pain. Next, an examination of one’s diet may be prudent. While there may be no magic or quick solution for rheumatoid arthritis, some connections may exist between certain foods and inflammation. A good start is a plant-based diet, with approximately two-thirds from fruits, vegetables and whole grains and the remaining onethird from low-fat dairy products and lean protein sources. Cold-water fish such as herring, mackerel, salmon, trout and tuna, with omega-3 fatty acids may act as inflammatory substances to ease some morning stiffness and relieve certain joint pain. The fibers from fruits, vegetables and whole grains may help to reduce the levels of C-reactive protein, an indicator of inflammation. Additionally, extra-virgin olive oil contains a compound called oleocanthal that may block the enzymes that may contribute to inflammation [13]. Supplements Some medications that are prescribed for arthritis may interfere with some nutrient absorption. Vitamin and mineral complexes and other nutrient supplements may augment a well-planned anti-arthritis diet, but most require the advice of a registered dietitian/nutritionist or medical professional. Fish oil supplements may offer some tender joint pain relief and relieve some morning stiffness, and may allow some people to reduce some of their reliance on conventional medications, but there may also be

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side effects. For example, fish oil may interact with certain medications such as some that are taken for hypertension. Selenium levels may be lower than normal in some people with rheumatoid arthritis. Selenium is a mineral that is found in some shellfish such as crab or oysters and whole-grain wheat products. The benefits of selenium are found in its antioxidant qualities, but selenium intake may increase the risk of developing diabetes, so a healthcare provider should be consulted for this and any other supplementation. Vitamin D is another nutrient that may help to lower the risks of rheumatoid arthritis, particularly in older women. It may be that the consumption of vitamin D through eggs, fortified breads and cereals and low-fat milk among other sources and/or vitamin D supplementation may help in the regulation of the immune system [14]. Support Systems The objectives for the treatments of both osteoarthritis and rheumatoid arthritis are pain reduction, symptom management and the prevention of further joint destruction. Both occupational and physical therapies may be employed to assist in the adjustments that may be necessary in everyday routines, and for overall mobility improvement. These may include arthritis-focused activities and exercise, overall development of healthy living habits, and/ or weight management. By implementing strategies that include these actions with the help of a healthcare team, some relief may be realized.

Cancers Overview Aging is marked by an overall decline in body cells, organs, tissues and systems—one of which is immunity, and the decline in the body’s ability to fight certain conditions and diseases. Another condition is an increase in hyperplasia, or cells that proliferate inappropriately. Cancer is not one, but a set of phenotypes and diseases of aging that may occur about mid-point in life. There are many contributing internal and external factors that include cellular senescence, a phenomenon by which cells cease to divide. Environment and lifestyle play very important roles in cancer protection and health. Making wise dietary choices, such as the reduction of processed foods and those with many chemical additives, might be significant and preventative. Dietary Considerations The preventive dietary approach to many types of cancer is dietary control, which is achieved by the quantity of calories that are consumed, as well as the quality of the diet. • Some cancer specialists consider calorie restriction as an effective intervention for healthy aging and cancer prevention. This approach should be discussed with a healthcare provider so that caloric intake is still adequate. • A Mediterranean-type diet, with a focus on plant-based foods, has generally been associated with decreased cancer risks and mortalities. Mediterranean-type diets generally feature a higher consumption of fruits, legumes, vegetables and whole grains, including their fibers and phytonutrients; a liberal use of extra-virgin olive oil; a lower intake of saturated animal fats, red meats and processed meats, poultry and dairy products; an abundance of herbs and spices that replace some salt and higher-sodium ingredients; and moderate consumption of red wine with main meals. Though it may be difficult to assess the extent of adherence to dietary directives in Mediterranean-type diets— especially by aging people—the depth of their potential impact still appears to be significant [15]. Supplements Dietary supplements should not replace a healthy diet nor be used to prevent cancers per se. Since some people may have difficulties meeting their nutritional needs while they are engaging in pre-, during and post-cancer therapies, supplements may be useful.

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Supplemental antioxidant beta-carotene, lycopene, vitamins A, C, E, folate and selenium may support the immune system. The B complex vitamins that include vitamin B12, vitamin D and calcium, as well as curcumin/turmeric and fish oils may also be considered within a comprehensive diet plan. Sometimes supplements may interfere with the effectiveness of specific therapies during cancer treatments, so supplements should be considered in a total cancer treatment and care plan. Support Systems Aging people with varying types of cancers may need help with daily activities, such as dressing, maintaining a place of residence, shopping and/or meal preparation and traveling to appointments. A health assessment is essential to determine which aspects of life are still attainable and where help might be sought. A healthcare team should provide a myriad of care options that may include comprehensive treatment and address emotional, financial and lifestyle concerns. Staying safe during treatment (such as attending to sensory concerns of eyesight, hearting, taste and smell); preventing falls; and addressing drug needs and interactions should be priorities. Dietary care plans with attention to weight changes and varying nutrient needs should be under the auspices of nutritional care professionals.

Cardiovascular Health Overview Like other muscles, organs and systems of the human body, there is a general slowdown and/or wearing of the cardiovascular system as people age. The cardiovascular system facilitates the circulation of blood, carbon dioxide, hormones and nutrients (such as amino acids and electrolytes) and especially oxygen back and forth among body cells to combat disease, maintain homeostasis, normalize temperature and pH (acid-base balance) and provide nourishment. With aging, fibrous tissue and fatty deposits may develop, and the natural pacemaker of the heart may lose cells that may slightly lower the heart rate. The heart may also increase in size—particularly the left ventricle. As the heart wall thickens, the amount of blood that the chamber is capable of holding may decrease and slowly fill. As a result, the electrocardiogram of older people may display some arrhythmias, or abnormal rhythms; the heart muscle cells may degenerate, the valves may thicken and stiffen and heart murmurs may be perceived. The blood vessels and the blood may also undergo changes with aging. Baroreceptors that monitor and normalize blood pressure may become less sensitive that may bring about orthostatic hypotension, a condition whereby blood pressure falls upon standing from a lying or sitting position. The capillary walls may thicken and nutrients and wastes may slowly exchange. The aorta, or main artery of the heart, may stiffen and decrease in flexibility, which may require the heart to work harder. Blood volume may also decrease since there is less total body water with aging. Red blood cells may respond to illness or stress more slowly, and since white blood cells decrease in number, this may reduce immunity or the capacity to ward off infections. Dietary Considerations Some dietary interventions may prevent or even treat cardiovascular disease in aging as alternatives to drugs. These include calorie restriction; dietary restriction (that includes carbohydrate, fat and/or protein restriction with or without calorie restriction); fasting (or the complete absence of food intake); and/or fasting mimetics (pharmacological agents that may trigger some fasting responses). A comprehensive lifestyle change that consists of a low-fat vegetarian diet, mild-to-moderate exercise, stress management and group support may show provide cardiovascular improvements. So may the Mediterranean diet that is filled with heart-healthy omega-3 fatty acids (mainly found in fish and ground flaxseeds); phytonutrients (mostly found in resveratrol in red grapes and wine); monounsaturated fats (principally found in canola and olive oils); complex carbohydrates and fibers (largely found in fresh fruits and vegetables, legumes and whole grains); and low saturated fats (chiefly from rich red meats and dairy products). Research is ongoing [16].

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Supplements Folate, vitamins B6 and B12 are necessary for homocysteine metabolism and are related to coronary heart disease. In general, people who consume a diet that is high in folate from citrus fruits, green leafy vegetables and legumes; vitamin B6 from protein foods that include eggs, lean meats, legumes, nuts and seeds, poultry and soyfoods; and vitamin B12 also from protein foods that include dairy products, fish and shellfish, meats, poultry and some vitamin B12-fortified soy-based grain and meat substitutes; may have less risk of myocardial infarctions or strokes. Vitamin and/or mineral supplements to prevent disease and/or increase longevity may seem like easier measures to take rather than procuring and consuming these foods. However, serious adverse effects may occur from toxicity or interactions with medications. If supplementation is necessary, then it should be under the guidance of a healthcare practitioner within the dosages that are provided by the DRIs [17]. Support Systems The procurement of Mediterranean diet-style foods and beverages may pose accessibility, budgetary, preparation and/or consumption issues. Family or support staff may be needed to obtain, prepare and ensure that the right amounts of each of the food groups are available. Switching food habits that focus more on a plant-based diet that is lower in overall fat and higher in fibers with plenty of water is a good start. Weight loss, regular activity and exercise, smoking cessation, stress management and regular medical attention are cardiovascular health-enhancing measures that may require a preventive and supportive team of family, friends, care providers and/or healthcare practitioners.

Celiac Disease and Gluten-Free Diets Overview Celiac disease, a chronic autoimmune condition in genetically predisposed individuals that was once considered a disease of youth, may affect people of any age, and is growing at an increased rate among the aging. Celiac disease occurs more in women than in men who are aging. Celiac disease may produce a spectrum of conditions that cover a single symptom, such as anemia accelerated osteoporosis or osteomalacia, to severe malabsorption with potentially severe nutritional deficiencies. Symptoms may range from intestinal to micronutrient disorders. Intestinal difficulties may include abdominal bloating, discomfort and pain, diarrhea, flatulence and/or weight loss. Micronutrient disorders include high levels of ferritin and erythrocyte sedimentation rate that are suggestive of systemic inflammation; deficiencies of calcium and vitamin D that may lead to decreased bone mass; malnutrition that may lead to hypoalbuminemia (also present with ascites and edema); and/or celiac hepatitis. Dermatitis herpetiformis is more common in men than women, with a pruritic rash on the extensor surfaces of the buttocks, elbows, knees and/or scalp. Autoimmune thyroid disorders are often associated with celiac diseases, with the majority of people displaying hypothyroidism. The risks of intestinal lymphoma are also higher in celiac patients. The gluten-free diet is vital for managing these and other signs and symptoms of celiac disease. Other similar medical conditions that might require a gluten-free diet include the following: • Gluten ataxia, also an immune disorder, may affect the nerve tissues and result in difficulties in muscular control and voluntary muscle movement. • Non-celiac gluten sensitivity may include abdominal pain, bloating, constipation, diarrhea, “foggy brain,” headaches and/or rashes, but this sensitivity may not damage the tissues of the small intestine as in celiac disease, and while the immune system is involved, the process may not be well defined. • Wheat allergy is a food allergy that results from the human immune system mistaking gluten as a foreign invader, much like bacteria or viruses. The human body’s immune system creates antibodies to gliadin and glutenin (the smaller proteins in wheat that change shape, bind and form gluten) that may create responses by the immune system. Breathing difficulties, congestion and other allergic-type symptoms may ensue. Dietary Considerations The treatment of celiac disease through foods and beverages depends upon strict adherence to a gluten-free diet. A gluten-free diet excludes foods, beverages and ingredients with the protein gluten.

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Gluten is found in grains and their derivatives that include barley; Brewer’s yeast; oats (in some instances); rye; wheat (that includes durum, einkorn, emmer, farina, farro, graham, kamut, semolina, spelt and wheat berries); malt; triticale (a hybrid between rye and wheat); wheat starch; and potentially others. Enriched wheat flour, farina, graham flour, self-rising flour and semolina are some of the wheat flours that contain gluten. Amaranth, arrowroot, buckwheat, corn, cornmeal, flax, hominy (corn), miller, quinoa, rice, sorghum, soy tapioca (cassava root) and teff may be included on a gluten-free diet (but there may be some exclusions), as well as eggs, fruits, lean and non-processed fish, meats and poultry, legumes, many low-fat dairy products and/or vegetables. A gluten-free diet may present some implementation challenges. If people not used to a gluten-free diet over their lifetime, it may be difficult for them to alter their dietary habits when they are older. Their finances and social support system may also be lacking to afford any specialized foods and beverages and provide help. Plus, the ability to shop for gluten-free foods and beverages may be limited. From a nutritional standpoint, the removal of gluten from one’s diet may change the overall intake of fibers, minerals, vitamins and other essential nutrients. The degree of dietary shortfalls may depend on the gluten sensitivities. Medical and/or nutrition specialists should address any of these shortfalls. Supplements Gluten-free products are usually not fortified and thus vitamin and/or mineral supplementation may be needed. Over-the-counter and prescription medications may use wheat gluten to bind the pharmaceuticals. “Wheat” must be stated on the label. Support Systems Aging people with celiac disease and/or gluten sensitivity should have a support team comprised of care providers, community and/or family members who may be able to interpret a patient’s medical and nutritional consultations and translate this information into realistic and achievable protocols. The gluten-free diet should be as individualized as possible. Direct communication between a facility’s dietary and food service staffs should be facilitated. Food labels should be thoroughly read and deciphered for any ingredients that contain gluten. Gluten-free products should be stored away from products that contain gluten to prevent any confusion. Food preparation and food storage areas should be cleaned and ensured of any cross-contamination. Likewise, cooking equipment and dishes should be well washed and stored separately, if possible. If people dine out, then restaurant menus should be carefully reviewed for gluten-containing foods and beverages, and any inquiries should be made in advance.

Chronic Kidney Disease [Chronic Renal (Kidney) Disease, or Chronic Renal Failure] Overview Chronic kidney disease (CKD) is more prevalent in the aging, and is characterized by poor health outcomes and higher healthcare costs. CKD is considered a major risk multiplier among people with diabetes, heart disease, hypertension and/or stroke. Chronic kidney disease or failure, as opposed to acute kidney disease or failure is a slow, gradually progressive disease. The glomerular filtration rate is a test that is used to detect how the kidneys are functioning. It usually declines with aging. Without intervention, progressive kidney function loss may require dialysis. Dialysis is a process that removes excess solutes, toxins and water from the blood. People with advanced CKD may also be at greater risk of myocardial infarction, stroke and/or death. With intervention and management, aging people with a CKD prognosis may be better able to control the metabolic consequences of CKD, such as acidosis, anemia and hyperphosphatemia; lower the risk of cardiovascular events; slow the loss of kidney function; and potentially prevent kidney failure [18]. Dietary Considerations Medical nutrition therapy for chronic kidney disease includes controlling blood pressure by reducing sodium intake, managing diabetes and reducing protein intake, if it is excessive. Consuming less sodium may help to reduce blood pressure and may slow down CKD. This is because one of the kidneys’ roles is to filter sodium out

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of the body and into the urine. Compromised kidneys may not be able to filter sodium as well as healthy kidneys, which may cause sodium retention and increase blood pressure. People with CKD should reduce their sodium intake to 1500 milligrams daily. In addition to a low-sodium diet, to help manage sodium it is recommended that people should take the following measures that are shown in Table 8.5. TABLE 8.5

Preventive Dietary Measures for People With Chronic Kidney Disease

• Be careful about dining out • Keep a food diary to track sodium. • Limit canned, convenient, frozen and processed foods. • Read food labels for sodium. • Restrict beverages that contain sodium. • Substitute fresh herbs and spices for sodium. • Watch for weight changes.

Higher protein intake may lead to intraglomerular pressure and hyperfiltration that may damage the glomerular structure or aggravate CKD. A low-protein diet is sometimes recommended. In contrast, the protein needs for people who undergo dialysis may be elevated due to protein losses. Higher biological value proteins, such as eggs, fish, meats and poultry, tend to produce fewer nitrogenous waste products. Supplements Low-protein diets supplemented with essential amino acids or their ketoanalogs may be useful for the transition to dialysis. Low-protein diet management in lieu of dialysis may help to enhance psychological adaptation to dialysis, preserve residual renal function and/or reduce costs. Adequate calorie (energy) and protein intake should be safeguarded to help prevent protein-energy wasting. These considerations may necessitate supplementation as well. Support Systems Higher degrees of social support tend to assist survival rates in people with chronic kidney disease. Involvement of this order may contribute to better access to healthcare, decreased depression, enhanced perception of life quality, higher survival, improved compliance with prescribed therapies and strengthened physiologic effects on the immune system [19].

Consistency-Altered Diet Overview Aging people who have difficult chewing, managing food in the oral cavity and/or swallowing may benefit by a consistency-altered diet. These difficulties may be brought about by absence of teeth and/or loose dentures, cancers, cerebral palsy, dementia, head or neck injuries, sore gums, stroke or other age-related conditions. The diagnosis is often dysphagia. One of the major concerns is the aspiration or inhaling of food into the lungs from foods that are poorly masticated. This may lead to pneumonia, respiratory infections and/or other disorders. Dietary Considerations A modified consistency diet provides foods that are physically altered from their normal forms, such as chopped, ground or pureed, based on individual food preferences and conditions and disease states. Favorite dishes such as bread products, casseroles or stews may be chopped or pureed. Starches may be cut into small pieces, mashed or pureed. Fruits and vegetables may be chopped, mashed, pureed or steamed. Meats and meat substitutes should be cooked with moist heat; then chopped, ground, pureed or sliced. Dairy products should be grated, melted or pureed. Dry items may be moistened with light gravies, milk, juice, sauces and/or soup to improve acceptance.

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Cornstarch, cream, flour, half-and-half, ice cream, instant potatoes and/or powdered milk may be used for thickening if calories permit, or pureed baby food may add bulk, calories and nutrients. Taste and flavor may be as normal. If foods and beverages are properly chosen then nutritional needs may be met. Supplements Liquid nutritional supplements are fairly widely available that supply calories for energy, protein to help the body build tissues and vitamins and minerals to support body processes. They may be helped in pureed diets, mechanical soft diets and/or for dry mouth conditions. Some are high in calories and ready-prepared beverages. Others are powders that may be mixed into beverages and/or foods. Many are lactose-free for people who are lactose intolerant. Before self-prescribing nutritional supplements, the type of supplement should be reviewed with a healthcare provider to ensure if the calorie, carbohydrate, protein and water levels are compatible with any current medications and conditions or disease states. Support Systems The treatment plan for consistency-altered diets is usually individualized and framed by a healthcare team that typically includes one or more doctors, nurses, occupational therapists, radiological physicians, registered dietitian/nutritionists, speech pathologists and others who collaborate to create a diet plan with a safe consistency that may be tolerated and progressed to a regular diet [20].

Dehydration Overview Dehydration is common in the aging since a person’s sense of thirst lessens and the kidneys are not able to conserve body water as well. Other factors that may provoke or worsen dehydration include chronic urinary incontinence, memory, mobility, swallowing problems and housing issues that may affect access to fluids. Without replenishment the body may not have enough water and other fluids for proper functioning. Medications, including diuretics and those that are used for cardiac conditions and hypertension, may compound dehydration and its effect on blood pressure. Dehydration may cause a dry, sticky mouth, decreased urine, headache, lightheadedness, sleepiness and/or tiredness in addition to thirst. In extreme, dehydration may lead to confusion, delirium or unconsciousness, severe thirst, fever, irritability, little or no urination, low blood pressure, rapid heartbeat and/or very dry mouth, mucous membranes and/or skin. Dietary Considerations Aging people should try to consume enough water and foods that are high in water content that include many fruits and vegetables. The Centers for Disease Control recommends that adults consume eight (8-ounce) glasses of water daily, and the Institutes of Medicine recommends even more. People with chronic medical conditions, such as congestive heart failure, should consult with their healthcare providers regarding fluid needs. Alcohol and caffeine may affect dehydration, and caffeine may worsen overactive bladder symptoms [21]. Supplements Sometimes fluids with electrolytes are recommended, such as bouillon, commercial rehydration solutions, juices, sports drinks and/or tea, but care should be taken so as not to disrupt the balance of the body’s electrolytes. Moderate to more severe dehydration may need to be treated with intravenous fluids, and severe dehydration may require additional intervention measures to support the kidneys including short-term dialysis. Support Systems Family members and care providers should frequently offer regularly scheduled beverages to aging people in their care—particularly water and those beverages that are preferred in small amounts. Overuse of alcohol or caffeine should be noted and reported if abusive. Any continence issues that affect fluid intake should also be addressed.

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Diabetes Overview Type 1 diabetes is an autoimmune disease that is a combination of genetic factors and environmental triggers. It often affects children and young adults and may start suddenly. People with type 1 diabetes will require supplemental insulin on an ongoing basis since the pancreas does not produce it. The cause of type 2 diabetes is multifactorial: lifestyle factors such as inactivity and obesity often interplay. This type of diabetes is more common in adulthood. People who have type 2 diabetes may only need supplemental insulin for the later stages of this condition when the body stops producing enough insulin or can no longer use glucose effectively. Impaired glucose tolerance often parallels aging, and in older adults it is not uncommon to experience hyperglycemia, or high blood glucose and insulin resistance, which is associated with changes in body composition, such as obesity, coupled with physical inactivity. Diabetes is a major growing public health concern in the aging US population, with about one-third of the aging US adult population affected. Undiagnosed cases and prediabetes are also of concern. Because people with diabetes are living longer and diabetes management is complicated with coexisting medical conditions, clinical management may be challenging. Other diabetes-related conditions and diseases such as acute myocardial infarction and stroke, renal disease and vision and hearing impairment may exacerbate the complexities of diabetes management. Dietary Considerations Diabetes management in the aging is basically similar to younger adults: the management of hyperglycemia or high blood sugar and risk factors is essential. Glycemic goals should be individualized to decrease dehydration, impaired cognition and vision and increased risks of infections that may contribute to functional decline. Medical nutrition therapy should be tailored to meet a person’s medical, lifestyle and personal factors and include self-care management education. Obese older adults could benefit from calorie restriction and increased physical activities. Underweight older adults may require a contrasting dietary prescription. This individualized variability for diabetes management is recognized in the American Diabetes Association 2017 Standards of Medical Care in Diabetes. Individual meal plans that include a wide variety of foods and beverages that help to avoid dehydration and unintentional weight loss and normalize blood sugar levels is preferred before a “one-size-fits-all” diet regimen. A more liberalized diet approach, along with medication therapy as required for glycemic targets, may also help to make the eating experience more pleasurable and less stressful for this growing group of aging patients with diabetes [22]. Supplements Type 2 diabetes is characterized by defects in β-cell function. As a result, the hormone insulin may be necessary in either oral or injectable forms. The safety of insulin usage, side effects and interactions with other medications and supplements needs to be carefully instructed and closely monitored to advert any potential side effects. Aging diabetics with poor appetites and/or those who have undergone weight loss may find that nutritional supplements that provide calories, proteins, minerals and vitamins to be beneficial. Understandable dietary and/or medical supervision and follow-through are essential—particularly with regard to insulin modifications. Support Systems Diabetics who are aging represent a mixture of people who live independently in assisted care facilities, nursing homes, private homes and/or senior communities. They may run the gamut from obese to frail, unfit with comorbidities and functional disabilities to very fit and healthy and mentally cognizant to confused. Support systems need to take all of these variables into account as they assess the efficacy and safety of different therapies. The prevalence of diabetes in hospitalized patients is a growing concern due to the cost of diabetes-related care, since insulin is the preferred treatment for older hospitalized diabetics. It is critical that there is a smooth transition to outpatient diabetes care and suitable instruction in home self-management skills [23].

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Failure to Thrive Overview Failure to thrive is a multifactorial, nonspecific display of fundamental and potentially dysfunctional mental, physical and/or psychosocial conditions. In the aging, failure to thrive is characterized by weight loss of more than 5% of body weight, combined with decreased appetite, physical inactivity and/or poor nutrient intake. Failure to thrive is frequently associated with dehydration, depression, immune system dysfunction and/or low cholesterol. Common diseases and/or medical conditions that may precipitate failure to thrive include cancer metastases, chronic lung disease, chronic renal insufficiency, chronic steroid use, cirrhosis, congestive heart failure, diabetes, gastrointestinal surgery, hip or other large-bone fractures, inflammatory bowel disease, myocardial infarction, pneumonia, rheumatologic disease, stroke, urinary tract infections and/or tuberculosis. Dietary Considerations One of the main pathophysiologic constituents in failure to thrive is malnutrition that may display as loss of functional skills, psychological decline and/or weight loss. The following eight “D” factors have been identified to determine the etiology of failure to thrive; some with nutritional roots* that may require attention and improvement, while others that may necessitate supplemental consideration. • These include Diseases*, Dementia*, Delirium, Drinking Alcohol*, Drugs*, Dysphagia*, Deafness* (and other sensory* deficits such as blindness), Depression*, Desertion (or social isolation), Destitution and Despair. • *Diseases, Dementia, Drinking Alcohol, Drugs, Dysphagia, Deafness and Depression covered in Dietary Considerations throughout this chapter. Supplements A review of medications that are taken on a regular basis for the many chronic diseases and medical conditions is paramount to deal with failure to thrive, along with medical, nutritional, psychological and social assessments. Environmental assessment may also be beneficial. Nutritional supplements and medications may then be recommended to augment current care, stabilize further decline and/or promote responses. Treatments, including supplements, should focus on what is identifiable with low-risk interventions due to the frailty of individuals with failure to thrive. Since failure to thrive commonly occurs near to death, the potential benefits of interventions should be measured against the risks of supplemental treatments. Support Systems It is important that aging people who are diagnosed with some-to-many of the mental, physical and social symptoms that manifest in failure to thrive be seen by a healthcare provider to evaluate the cause(s). Steps then may be taken to address each of the issues, and support system members may be identified for collaborative care. A team approach may include a mental health professional, physical therapist, registered dietitian/nutritionist, speech therapist, social worker, and/or primary care provider [24].

Gastrointestinal Health Overview Common digestive problems may increase as people age as different organs and systems slow down and diminish in their functionality. This may cause food to move more slowly through the stomach, intestines and colon. Common gastrointestinal disorders that may escalate in range and scope with aging may include appendicitis, atrophic gastritis, bloating, constipation, cramps, decreased gastric acidity, diarrhea, diverticular disease, gallstones, gastritis, gastroesophageal reflux disease (GERD), hemorrhoids, irritable bowel syndrome, pain, pancreatitis, polyps, problems with the mouth and the esophagus and/or ulcers. GERD occurs when stomach acid backs up into the esophagus that may generate heartburn, sore throat or even erode tooth enamel.

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One type of gastrointestinal disease, diverticulosis, is prevalent in the aging. Diverticulosis arises when small pouches within the colon lining protrude along weakened areas in the intestinal walls. If inflamed, diverticulitis may result and bring abdominal pain, chills, cramping, fever, nausea and/or vomiting. Treatment may require a liquid diet and/or medications as prescribed by a healthcare practitioner. The regular use of nonsteroidal anti-inflammatory drugs (NSAIDS) for arthritis and chronic pain may lead to ulcers or bleeding in the stomach. Any sign of blood in vomit or stool should be investigated. Chewing and swallowing problems due to dementia, Parkinson’s disease or stroke may also put stress on the gastrointestinal tract and require dietary modifications. Dietary Considerations Foods that are high in dietary fiber may be able to prevent or reduce constipation and ease the symptoms of diverticulosis. These include fresh fruits and vegetables, legumes and whole grains. By consuming plenty of fluids throughout the day to appease thirst, the gastrointestinal tract may maintain its functionality and regularity. If a person takes diuretics, more fluids by mouth may be necessary as dictated by a healthcare professional. A healthy weight should be maintained to place fewer burdens on the digestive organs. A limitation of dietary fats, more whole and less refined foods, decreased sugars and sodium and limited foods, beverages and other substances that might aggravate the gastrointestinal tract (such as carbonated beverages and/or assertive spices) may be helpful for maintaining its health and reliability. GERD may be controlled by eating earlier in the evening, limiting fast and fried foods, losing weight and taking certain medications, such as those for blood pressure at certain times to help decrease the symptoms of heartburn. Supplements Check medications as many common ones may contribute to constipation. For example, calcium channel blockers that are sometimes prescribed for hypertension or high blood pressure may be constipating, as may narcotic pain relievers that may slow the gut activity. Probiotics, found in supplements and fermented foods such as kefir, pickles, sauerkraut and yogurt, may carry different strains of bacteria that may help to increase indigenous flora in the digestive tract and aid various digestive problems. Prebiotics are the indigestible dietary fibers that probiotic bacteria use to fuel their growth and proliferation. Prebiotics are food ingredients that may be found in foods and some beverages that are rich in dietary fibers. These include asparagus, bananas, chicory root, dandelion greens, garlic, Jerusalem artichokes, leeks, onions and/or wheat bran. Although food sources are recommended, supplements are available. Support Systems Activity is important for gastrointestinal health. Instead, as people age they tend to be less active or inactive due to arthritis, breathing difficulties, depression or illnesses that may require bed rest, isolation, joint replacement, movement compromises and/or weight initiatives. A family member or friend may help to support a regular activity/exercise program. Regular health screenings may be needed to detect some gastrointestinal symptoms that may be “silent” and unnoticeable until they manifest into more complicated issues. Dietary support to procure, prepare and consume the most beneficial foods and beverages for dietary support of gastrointestinal diseases may help to provide invaluable benefits [25].

Gout Overview The condition of gout is a painful inflammatory type of arthritis that results from uric acid crystals that are deposited in joints and soft tissues. It often is accompanied by obesity and other conditions that are common during aging, such as diabetes, heart disease and/or kidney disease and the use of diuretics. Binge drinking, family history, increased age, male gender, medicines including cyclosporine and levodopa, diuretics, lead toxicity, low-dose aspirin, obesity, organ transplant, thyroid issues and other factors may increase

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the risk of gout. In turn, these may increase one’s risk of metabolic syndrome, a group of health problems that may include abdominal obesity, high blood pressure and/or low HDL-cholesterol (which is protective against heart disease). Dietary Considerations Purines are chemical compounds normally found in foods and beverages that the body converts into uric acid. The limitation of foods and beverages with purines is recommended for the management of gout. Rich purine foods include beer*’ gravies, organ meats (heart, kidney, liver and sweetbreads) and venison; foods with saturated fats (such as full-fat dairy products and/or fatty meats) that inhibit the body’s ability to metabolize purines; seafood (particularly anchovies, herring, mackerel, scallops and/or other shellfish); and foods and beverages with high fructose corn syrup (such as some confections and sodas). *Other alcohol reduction or elimination may also be prudent since alcohol may inhibit the body’s ability to eliminate uric acid. Supplements Medications that lower uric acid may help to reduce inflammation and pain and reduce future attacks of gout. The use of NSAIDs may be effective under medical care. Supplements that contain yeast or yeast extract should be avoided. Support Systems Lifestyle changes that include movement and weight loss may produce some effectiveness in the relief of some symptoms of gout. Family, friends and/or care providers may be needed for implementation and support during the most painful and movement-inhibiting periods.

Hepatic/Liver Disease Overview Aging is associated with the gradual alteration of the hepatic structure and function and changes in the liver cells. It may also increase the risks for severity and poor diagnosis of several types of liver diseases that may include alcoholic liver disease, hepatitis C, liver transplantation, nonalcoholic fatty liver disease (NAFLD) and/or others that may be caused by a buildup of fat in the liver cells. NAFLD is one of the most common liver diseases in contemporary society. As a whole, liver volume decreases related to a decline in the blood flow; there is a slight decrease in serum albumin concentration, and neural fat and cholesterol volumes in the liver gradually expand. Steatosis, or fatty liver, may lead to inflammation. Fibrosis is where persistent inflammation may cause scar tissue. Cirrhosis, where the liver tends to shrink in size and becomes scarred and/or lumpy, may lead to liver failure and/or liver cancer. Symptoms may run from a dull or aching pain under the right side of the ribs, to fatigue, unexplained weight loss and/or to weakness. A diagnostic exam is typically required for detection. The treatment for NAFLD in the aging may require different or longer interventions as when people were younger. Dietary Considerations People with NAFLD should aim to lose weight and exercise to maintain weight loss and fitness. A lowglycemic diet is recommended which is one that limits quickly digested carbohydrates, such as concentrated sugars and products that are manufactured with refined flours. Ascites, or the accumulation of protein-containing fluid in the abdomen, is typified in advanced liver disease. Sodium and water restriction are normally advised, which may be unpalatable and/or poorly tolerated by some people. Certain adverse reactions and disruptions to fluid balance homeostasis may result and lead to orthostatic hypotension, which may be aggravated by the use of diuretics. Other medical conditions such as diabetes, cardiovascular disease, metabolic syndrome, obesity and/or hypertension should be treated. The use of medications should take the presence of NAFLD into consideration.

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Supplements Supplemental docosahexaenoic acid, one of the omega-3 fatty acids, has been known to halt the progress of nonalcoholic steatohepatitis (or NASH). Nonalcoholic steatohepatitis (NASH) is characterized by fibrosis, liver inflammation and/or oxidative stress. DHA supplementation may not be able to achieve full remission of NASH, but it may help to halt its worsening. Omega-3 fatty acids serve to regulate biological pathways, including fatty acid synthesis, oxidation and breakdown into blood triglycerides. DHA performs a role in the repair of liver damage. Folate deficiency is believed to affect NAFLD as well as a lower level of vitamin B12. Decreased folate may cause a disturbance in hepatic methionine metabolism that has been shown to promote hepatic steatosis [26]. Support Systems Treatment and support for nonalcoholic fatty liver disease should be focused on lifestyle modification with management of the comorbid associated diseases that were previously cited. Online groups exist for fatty liver disease support to help aging individuals and care providers. Likewise, the Fatty Liver Foundation provides information about the condition with resources for its support [27].

High and Low-Protein Diets Overview Protein is a key nutrient for muscular health in the aging (see Sarcopenia). A loss or reduction in skeletal muscle may lead to increased morbidity and mortality, directly or through the development of chronic diseases such as cardiovascular disease, diabetes and/or obesity. Concurrently, obesity has increased among the aging throughout the past several decades, due to changes in body composition with aging (a higher percentage of body fat and a lower percentage of muscle mass). Too much protein and too little protein both seem to have both short- and longer-term consequences. Yet, aging people appear to be less responsive to the anabolic stimulus of low doses of amino acids as when they were younger, and may require increased protein. Increased protein intake may improve muscle health, maintain energy balance, promote weight management and prevent sarcopenia. Finding the right level of absorbable and metabolically useful protein is key. Dietary Considerations The consumption of dietary protein within the upper level of the US Acceptable Macronutrient Distribution Range or AMDRs (as much as 30% 35% of total calories) may be beneficial for aging people. However, this amount of daily protein may be difficult to consume by the aging. More longer-term studies that assess the effectiveness of this level are needed. A protein intake between 1.2 and 2.0 grams/kilograms/day is reasonable to consider for aging adults. The Recommended Dietary Allowance of 0.8 grams/kilogram/day is well below this recommendation. Adequate protein depends on a specific evaluation for critically ill patients. Proteins with high nutritional value, plant or animal, should be evaluated for usage. It may also be important for aging adults to consider their total calories intake when deciding upon a high-quality protein source to integrate into their diets. This is especially important when considering the protein qualities of animal proteins versus those of plant proteins on vegetarian diets. This is because the caloric intake that is needed to meet the essential amino acid requirements from plant sources is generally considerably higher. Distributing protein and calories throughout the day, and especially between morning and lunch, may optimize protein balance. A protein-sparing effect may also be met by a regular physical exercise regimen [28]. Supplements Easily digestible, high-quality proteins supplements with a high proportion of essential amino acids may be warranted to enhance muscle protein anabolism and take some of the burden off of dietary protein on its own.

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Whey protein supplements with such ingredients as calcium, creatine, fish oil and/or vitamin D, when consumed on a regular basis in ready-to-drink formulations, along with exercise may serve to improve lean body mass and physical strength. Still, it might be better to try to use regular food to maintain a person’s weight, and use supplements between meals as snacks, or to add calories and nutrients, rather than as meal replacements on their own [29]. Support Systems Rather than immediately turn to protein supplements, it is important for healthcare providers to attempt to determine the reasons for loss of interest in food, or muscle or weight loss. A variety of conditions and/or diseases, such as dementia, depression, dysphagia, dulled senses of taste and smell, ill-fitting dentures, thyroid disease and/or ulcers may be accommodated or treated to address any underlying issues. Then nutritional supplements may be individually coordinated according to dietary needs. Instead of commercial supplements, healthcare providers may consider healthy shakes or smoothies with high-quality protein as some of the recipes featured in Chapter 10, Menus and Recipes That Appeal to Aging Palates. Since prescriptions, over-the-counter drugs and/or vitamin and mineral supplements may conflict with oral nutritional supplements, the services of a registered dietitian/nutritionist may assist in the dietary assessment of high- or low-protein diets, any possible excesses or inadequacies.

HIV/AIDS Overview HIV, or the Human Immunodeficiency Virus, is a sexually transmitted infection that has the capacity to cause a chronic inflammatory condition. This condition may stress the already weakened immune system and the antioxidant capabilities that may accompany aging. AIDS, or Acquired Immunodeficiency Syndrome, is a chronic and potentially life-threatening condition that is caused by human immunodeficiency virus (HIV). Due to improvements in the effectiveness in antiretroviral therapy, aging people with HIV may be able to keep the virus suppressed if they are diagnosed early in their intervention. Many aging people with diagnosed or undiagnosed HIV infections have been living with this disease state for years. In fact, assuming that they maintain a suppressed viral load and are on treatment, aging people with HIV infections may be living healthier and longer lives than at the start of the epidemic more than 30 years ago. With longer life expectancies, many characteristics that are associated with aging, such as alterations with cognitive and physical abilities, increased susceptibility to stress, many medications and multiple chronic conditions and/or diseases may be expected with HIV acquired individuals. These may include cardiovascular disease, certain cancers, HIV associated neurocognitive disorders, liver disease and/or lung disease. Also, HIV may increase the risk of chronic inflammation (see Inflammation) that may exacerbate a number of health conditions that such as lymphoma and type 2 diabetes. And HIV may affect critical brain functions and result in decreased attention, cognition, memory and/or motor skills and increased depression and/or psychological distress [30]. Dietary Considerations Diet and exercise are important strategies to implement to help reduce inflammation and support the immune system in people who are aging with HIV. The Ideal diet is disputed. Certain recommendations seem sensible. These include those dietary dictates that given in Table 8.6. Supplements Despite excellent attention to diet, nutritional supplements may be necessary, as determined by a healthcare provider. There may be slower progression of disease in people with higher nutrient levels—some that may be difficult to achieve through diet alone. These include the amino acids cysteine and methionine, antioxidant nutrients that supple vitamins C and E; bioflavonoids such as catechin, hesperidin, quercetin and rutin; carotenoids that include beta-carotene, lycopene

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TABLE 8.6 Dietary Suggestions for Aging People With Human Immunodeficiency Virus (HIV) • Consider variety and color in beverage and food selections that tend to be higher in protective phytonutrients. • Emphasize fruits, fish, legumes, vegetables and whole grains. • Focus on a wide variety of foods and beverages on a daily basis; more whole foods than those that are processed and/or nutrient-poor. • Get plenty of protein for a stronger immune system. • Include an abundance of water. • Individualize diets as needed to maximize calorie and nutrient intake. • Limit meats; ensure the meats that are consumed are lean. • Reduce fried foods, processed foods and added sugars. • Use healthy fats from avocadoes, nuts and olive oils. • Watch caloric intake [31]. If weight is an issue, check with a health care provider. Data from https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/dash-diet/art-20048456.

and the xanthophylls; coenzymes such as Q10; enzymes such as catalase, glutathione and superoxide dismutase; and trace minerals such as copper, manganese, selenium and zinc. Of utmost importance is that nutrients work in tandem to raise the levels of glutathione, an intracellular antioxidant that works to defend the body cells, augment immune function and shield the liver during toxin breakdown. Support Services Since aging individuals may experience greater isolation and/or loneliness, it is essential for aging people with HIV to have access to support systems that include mental health services. Community centers, healthcare providers and/or HIV service organizations may help to locate or provide such services. Accessing these services may cause some stigma, which in turn may affect some quality of life. More information may be found in Chapter 12, Prime Time Resources for Aging, Taste and Health. Aging HIV affected Individuals may be able to utilize some of the tools while they preserve some constructive behaviors and positive self-image.

Hypertension Overview Hypertension is a common condition in aging adults. Control rates of hypertension are lower than in younger years. Hypertension is often referred to a “silent killer” because externally people may not show signs of this disorder; internally warning signs may include blood spots in the eyes, dizziness, headaches, facial flushing, nosebleeds and/or other symptoms. Hypertension has historically been defined as blood pressure that is higher than 140 (systolic)/90 (diastolic) mm Hg. In 2017, the ACC/AHA High Blood Pressure Guidelines lowered the definition of hypertension to 130/ 80 mm Hg, and stated that high blood pressure should be treated earlier in some patients with lifestyle changes and with medication. Some health benefits, such as reduced risk of heart attacks and/or strokes, may be derived by reducing systolic blood pressure from high (160 180 mm Hg) to moderate (140 150 mg Hg). Dietary Considerations Some nondrug approaches have been used to help lower blood pressure. It is possible that they may benefit nutrition and health in other ways. To help manage blood pressure without medications, a DASH Diet approach is recommended, with plenty of fruits and vegetables, low-fat dairy products, sodium and sugar reduction, the engagement in physical activities such as walking most days of the week, and weight loss, if needed. It is indicated in Table 8.7. In addition, the Standard DASH diet recommends up to 2300 milligrams of sodium daily. The Lower Sodium DASH diet recommends no more than 1500 milligrams of sodium daily. Hydration for normal body functioning is essential. More fluids may be required depending upon medications.

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TABLE 8.7 Highlights of the DASH Diet Food or beverage

Number of servingsa for 2000 daily calories

Grains and Grain Products (focus on whole grains)

7 8

Fruits

4 5

Vegetables

4 5

Low- and Non-Fat Dairy Products

2 3

Lean Fish, Poultry, Meats

2 or less

Legumes, Nuts and Seeds

4 5/week

Fats and Sweets

Limited (five servings or fewer weekly) [32]

a

An average serving is about /2 cup of cooked grains, or 1 slice of bread; 1 medium piece of fresh fruit, 1/2 cup of cooked fruit, or 3/4 cup of juice; 1 cup of raw leafy green vegetables, or 1/2 cup of cooked vegetables; 1 cup of milk or yogurt, or 11/2 ounces of natural cheese; 2 3 ounces of cooked lean fish poultry or meats, 1/2 cup of cooked legumes, or 2 tablespoons of nut butter. 1

Supplements In general, medications (alone or combined) that might be effective in lowering blood pressure in younger persons might be riskier for older adults. These include beta blockers that may slow down the heart rate even further. In combination, some medications may also increase the risks of kidney failure and even death. Diuretics (also called “water pills”) may be prescribed by a healthcare practitioner, alone or with blood pressure regulators, such as calcium channel blockers (CCBs). CCBs may also improve some memory scores in patients over 60 years of age [33]. Dietary supplements may affect blood pressure and also change how blood pressure medication works, so it is important that a healthcare provider knows about these, in addition to over-the-counter drugs and/or other medications. It is essential to take blood pressure mediation at the same time daily unless prescribed otherwise. Dosages should not be doubled if missed. Likewise, they should not be stopped unless advised. Support Systems A consideration for the treatment of hypertension should be a person’s underlying risks of cardiovascular disease. These potential risks should be of vital importance for the healthcare provider and team to review. Treatment goals for hypertension should then be individually based on the benefits and disadvantages (if any) of different blood pressure targets. The hypertension healthcare team should provide instructions about the correct methods of careful blood pressure measurement through the use of validated devices, good techniques and at least two measurements that are obtained on two occasions. Out-of-office blood pressure measurements are recommended to confirm blood pressure in conjunction with telehealth counseling or clinical interventions, when and/or where they are needed. A healthcare practitioner or team may also provide information about alcohol and caffeine reduction, smoking cessation and/or weight loss [34].

Immune Function (See Food Allergies, Intolerances and Sensitivities) The immune system is a network of cells, organs and tissues that work in tandem to help to protect the human body. White blood cells (WBC or leukocytes) seek out and destroy disease-causing substances and/or organisms. Immune function is a state in which the human body recognizes foreign substances and attempts to neutralize them before they are harmful. Allergies and allergic conditions and diseases occur due to active immune systems that react to seemingly harmless substances in the environment in mild to acute manners. As the population ages worldwide allergy manifestations in aging people are anticipated to increase [9]. For more information about allergies and immunity, see the section Food Allergies, Intolerances and Sensitivities earlier in this chapter.

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Inflammation Overview Acute inflammation is the early and sometimes immediate responses by the human body to potentially harmful bacteria or to injuries to body tissues. In acute inflammation, damaged cells, foreign invaders (such as bacteria and viruses), irritants and/or pathogens bombard the body and activate blood vessels, immune cells and/or molecular mediators to respond and assist restoration. Acute appendicitis or bronchitis, infected ingrown nails, infective meningitis, physical trauma, sinusitis, skin abrasions, sore throat from cold or flu and/or tonsillitis may activate acute inflammation. Chronic or systemic inflammation is typically longer term and due more to “use and abuse” than to acute conditions or injuries. Factors that may contribute to chronic inflammation include alcohol ingestion, diet, drug use, environmental conditions, genes, inactivity, oral health, smoking, stress, weight and/or “autoimmune” diseases. Autoimmune diseases are illnesses that may occur when human body tissues are attacked by the immune system. Chronic inflammation may be caused by pathogens that the body has a complicated time destroying. The onset may be slow; starting from days and lasting from months to years. Symptoms of chronic inflammation may include abdominal pain, chest pain, fatigue, fever, joint pain, mouth sores, rashes and/or others. Examples of conditions, diseases and situations that may be caused by, or create chronic inflammation may include active hepatitis, arthritis (gouty, osteo, psoriatic and/or rheumatoid), asthma, Crohn’s disease, chronic peptic ulcer, diverticula disease, fibromyalgia, periodontitis, sinusitis, tuberculosis, ulcerative colitis and others [35]. Dietary Considerations One of the most important and often overlooked modes of prevention, treatment and control for inflammation is diet and nutrition. The building blocks of a Mediterranean-type diet provide the foundation for antiinflammatory eating: whole grains and other fiber-rich carbohydrates; healthy fats with omega-3 fatty acids; lean proteins that include legumes and fatty fish; and antioxidant-rich vitamins and minerals—particularly those that are found in citrus fruits, cruciferous vegetables (such as broccoli and Brussels sprouts) and green leafy vegetables (such as arugula and kale). Other substances, such as chocolate, coffee and/or tea, round out a spectrum of preventive antiinflammatory measures, in addition to fermented foods, herbs and spices and pre- and probiotics, along with adequate hydration and supplements (if required). The reduction and/or elimination of foods and beverages with refined sugars are emphasized to control inflammation, besides those that are breaded, fried, salted or heavily sauced; vegetables from the nightshade family (such as bell peppers, chilies, eggplant, potatoes and/or tomatoes); butter, lard, margarine and/or poultry skin; bacon and higher-fat cuts of meat, such as sausages or spareribs; and higher-fat foods, such as fried chicken or French fries. Hard evidence for one type of antiinflammatory diet over another may be lacking, but collectively some of these methods may be effective. As with pharmaceuticals and supplements, it is best to check with a healthcare provider to avoid any diet drug interactions. Supplements There are many drugs that can help decrease joint pain, inflammation, overall discomfort and swelling, independently or synergistically. These include antimalarial medications, biologic drugs, corticosteroids, diseasemodifying antirheumatic drugs and/or nonsteroidal antiinflammatory drugs. Cannabis, ginger, harpagophytum procumbens (aka devil’s claw, grapple or wood spider), hyssop and turmeric are herbal remedies that have been used in different guises to treat various types of inflammation. The use of pharmaceuticals and herbs to treat inflammation should be under the guidance of healthcare professionals. Support Systems The treatment of chronic inflammation may involve a combination of therapeutic approaches that create an arsenal of proactive measures to offset or control its development. These may include behavior modification, diet, exercise, medications, medications, physical therapy, rest, sleep, yoga or in some cases, surgery. Efforts

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should be taken to avoid or modify the activities that aggravate or induce the most pain, and correct, control and/or slow the conditions or the disease processes.

Kosher and Halal Dietaries Overview A Kosher diet is traditionally based on certain laws in the Jewish religion that specify which foods and beverages can or cannot be included in the diet, as well specific requirements for the preparation and service of Kosher foods. These laws are referred to as Kashrut (in English, Kosher). They are found in the Torah (the first five books of the Hebrew scriptures) and explained in the Talmud (the body of Jewish ceremonial and civil law and legend). They are monitored by rabbis who are Kosher supervisors or Mashgiach who examine foods to ensure that proper handling and processing are followed. Jewish people who keep the laws of Kashrut do so throughout the year. Certain holidays generally require a different set of dietary requirements. In comparison, Halal, or the Islamic dietary laws, are found in the Qur’an (the Islamic sacred book) and the Sunnah (the body of social and legal custom and practice of the Islamic community). There are similarities and differences with the Jewish dietary laws of Kashrut. For example, Halal foods are considered to be free from any component that Muslims are prohibited from consuming according to Islamic law. Halal foods are also those that have been processed, made, manufactured, produced and/or stored by using equipment, machinery or utensils that have been cleansed according to Islamic law. Some foods are also exclusionary, or Haram. These include alcoholic drinks and intoxicants, bacon, carnivorous animals, enzymes, gelatin, lard, L-cysteine, lipase, non-Halas animal shortening, pork, rennet, stock, synthetic, tallow and/or unspecified meat broth, among some others. Dietary Considerations Some examples of Kosher or Kashrut (proper and fit) approaches to food and beverage consumption are featured in Table 8.8. In comparison to Kosher or Kashrut, some examples of Halal (permissible) approaches to food and beverage consumption are provided in Table 8.9. TABLE 8.8 Kosher Requirements That Conform to Dietary Regulations • Certain types of meats are restricted from eating. These include camels and pigs with cloven hoofs. • Dairy products cannot be served or consumed within meals, or in certain proximity to meals. The consumption of dairy products and meats on the same day must be alternated or spaced out. Additionally, dairy products must come from Kosher animals. • Domesticated fowl are permitted, but predatory and scavenger birds are not. Goose, rabbits and wild hens are excluded. Kosher fish must have fins and scales. Shellfish, mollusks and squid are excluded. • Eggs must be checked for the presence of blood. • Fresh produce requires inspection for insects that may take shelter within the leaves. For this reason, artichoke leaves cannot be consumed, but their bottoms may be. ALSO . . . • Common pareve foods (neither meat nor dairy) may include coffee, eggs, fish, fruit, grains, unprocessed juices, pasta, soft drinks, some candies and snacks, tea and/or vegetables. Some wines are acceptable. • Foods may lose their pareve status if they are processed in meat or dairy equipment, or when additives or preservatives are used. • Cookware, serving utensils and serving items must be deemed Kosher and used only for specific foods and beverages, such as only for dairy products or meats. This rule usually necessitates two sets of preparation utensils and serving and dining tableware. • Specific types of butchering are applicable to all meats and fowl that must be painless and quick so that they are humane. All traces of blood must be soaked and removed.

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TABLE 8.9 Halal Requirements That Conform to Dietary Regulations in Comparison to Kosher or Kashrut • Almost all insects are prohibited. • Gelatin is permissible from a permissible animal. • Halal permits the mixing of meats and dairy products. • If enzymes come from non-Halal sources, then they are prohibited. • In Halal, like Kosher or Kashrut, swine is prohibited. • Muslims consider the entire cattle or sheep as Halal if they are suitably slaughtered. In Kashrut, only the forequarter of cattle or sheep is considered as Kosher. • Some animals that are allowable in Halal are also permitted in Kashrut, such as bovines (bison, buffalo, cows, goats, oxen and/or sheep). • Substances may not contain alcohol of any kind. • When animals are slaughtered, the name of G-d is pronounced (in contrast to a special rabbi, called the Sachet, who is trained for slaughtering Kosher animals, and who does not recite G-d’s name). • Within Halal, only sea creatures that have scales are considered as Halal, but some crustaceans, such as prawns and shrimps are the exceptions. (This is in contrast to Kosher where no seafood is permitted.)

Supplements If a person is ill or whose life is in danger, they may use non-Kosher medication if an equally effective Kosher medication is not easily available. This includes an elderly person who has the flu, or someone who has diabetes, a heart condition, an infection other than a skin condition, kidney disease, severe depression, substantially elevated blood pressure or other serious conditions of this nature. Multivitamins may contain non-Kosher ingredients such as vitamins A, D and E and the antioxidant betacarotene, which may be mixed with non-Kosher gelatin. Single vitamins, such as vitamin C supplements, should be certified Kosher, as should herbal and/or homeopathic remedies. Often medicines contain lactose as a bulking agent. If needed, lactose-containing medicines should be consumed no sooner than one hour before eating meat. Support Systems Jewish sources mandate that Jewish children take care of their aging parents’ physical and psychological needs, or they may arrange care in assisted living facilities, homes or nursing homes. This may be the result a number of factors that may include the demise of the extended family, increased numbers of aging people, coupled with increased longevity and the mobility of contemporary society. Respecting the Kosher dietary laws and practices is a natural and humane practice. Supplying parents with their basic needs of food and water as they remember and are accustomed is also an act of honor. But the act of adhering to a Kosher diet during aging may be daunting for aging people and their care providers and families as well. In Islamic food preparation, the utensils and kitchens that are involved in food production, preparation, cleanup and storage must be deemed as Halal, and they must be sanitized as such in an Islamic manner before they can be confidently used. Like in Kashrut, these necessary steps, and the shopping, preparation, service and cleanup of Halal foods and beverages may be formidable as life proceeds and people often live in isolation [36].

Lactose Intolerance Overview The ability to digest lactose, the sugar in milk and other dairy products, may decline as one ages. This may be affected by genetics. For example, Northern Europeans may be able to maintain their levels of lactase as they age, while people whose genetic background is African or African American, Arabian, Asian, Italian, Greek or Jewish may not be as fortunate. Insufficient lactase may lead to lactose intolerance, a condition that may be characterized by bloating, cramps, diarrhea, pain and/or other gastrointestinal issues. Another reason for lactose intolerance may include foods and/or beverages other than dairy products that may contain lactose. These may include some baked goods, breads, candies, cookies, deli meats, drink mixes,

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instant soups, margarines, pancake mixes, ready-to-eat breakfast cereals and/or salad dressings. Also, the rapidity of foods that pass through the gastrointestinal tract may result in some lactose intolerance. Some people may have low lactase levels as they age, while others may be able to digest some dairy products due to digestion by the bacteria in their large intestines. Dietary Considerations Certain aging people who are lactose intolerant may be able to consume small amounts of hard cheeses such as cheddar or Swiss that tend to contain less lactose than softer cheeses. Some fermented dairy products with probiotics that are rich in essential amino acids, minerals and vitamins may also improve the digestibility of lactose. Probiotics may help to increase healthy bacteria in the gut and may aid digestion. For example, kefir (a sour-tasting beverage that is made with fermented cow’s milk), contains folate, magnesium, thiamin and vitamins B12 and K. Cottage cheese, goat cheese, kefir and yogurt, depending on their varieties, may be easier to digest than other dairy products, and may still deliver vital nutrients. Other calcium-rich foods that may be included in the diet if dairy products are not tolerated include green cruciferous vegetables, green leafy vegetables, sardines and/or canned salmon. Vitamin K-rich foods include basil, broccoli, Brussels sprouts, cabbage, cucumbers, green leafy vegetables and/or scallions, and vitamin B12 is mostly found in animal foods, and in some fortified breakfast cereals. Supplements Calcium and/or vitamin D supplements may be needed to prevent the deficiencies from inadequate consumption of these nutrients. Digestive enzymes that contain lactase may assist in efficient digestive functioning. Support Systems Online support groups offer individual and group advice and support for people with lactose intolerance. A lactose intolerance global network also exists to help people across Africa, Asia and the Middle East who may be plagued by a range of lactose intolerance debilities. Care providers should be on the alert for gastrointestinal symptoms associated with dairy ingestion, and incorporate foods and beverages with essential nutrients (such as calcium, protein and vitamins A, D and K) into diets that are still required in their absence.

Malnutrition Overview While some people who are aging may be active and fit, others may be quite frail with incapacitating diseases and conditions. Malnutrition may be at the root of these disorders. Malnutrition is simply the state of being poorly nourished. It may be cause by the lack of one or more nutrients (undernutrition) or by the excess of nutrient (overnutrition). Either state may be witnessed in communities, hospitals, residential care and/or in individual homes. Though malnutrition is not exclusive to aging populations, many changes due to the aging process may promote malnutrition. These may include chemosensory changes in smell and taste, declining health, deteriorating dental health, decreased physical activity, inability to access and prepare foods and beverages and propensity to other chronic and complex conditions and diseases. Dietary Considerations Dysphagia, dentition and other oral health problems; disease states (such as certain cancers or cardiovascular disease); drug interactions; gastrointestinal disorders; infections (such as urinary tract or certain viruses); loss of taste and smell; poor appetite; neurological disorders; and/or physical disabilities (such as arthritis or respiratory disorders) may precipitate or further malnutrition. So may the inability to shop for and prepare food, the lack of isolation or loneliness, poverty and proper nutrition knowledge, as well as anxiety, bereavement, confusion, depression and/or dementia. Hospitalized risk factors of malnutrition may include the detection of unpleasant sights, smells and sounds related to foods and/or beverages, conflicting cultural or religious diet requirements, food service choices and/or

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preparations, higher nutrient requirements, limited time for meals, missing dentures, the need for assistance in eating and/or slower eating altogether. Supplements Nutritional support may be helpful in some cases to reverse weight loss and even promote some weight gain, if needed. Since aging may change the metabolic responses to nutritional support, it may take longer to reverse weight loss and achieve weight gain. Because anxiety may heighten conditions that precipitate malnutrition, eating in a quiet place and taking time to eat may be helpful. The practice of giving small, balanced and satisfying meals and snacks that are offered frequently throughout the day without competing liquids may be too slow for significant weight gain, and dietary supplements with calories, protein, minerals and vitamins may be required to boost these nutrients. Support Systems There may be a direct relation between the degree of malnutrition and the increased lengths of stay in hospitals and other institutions, as well as with the potential return to “outside life.” It is not uncommon for malnourished aging people to be readmitted into facilities for improvement beyond their frailties. This is why the healthcare team that addresses malnutrition both independently and as part of the bigger aging picture is crucial, and a very important challenge for the US healthcare system. By encouraging healthier and tastier food and beverage choices, snacking on healthy foods and beverages, making foods and beverages taste great again through flavor enhancement, adding supplements if they are needed and participating in daily physical and social activities, malnutrition can gradually turn into wellnutrition over time.

Oral Disease Overview As people age, their dental health may suffer due to physiologic changes that are associated with aging, poor oral hygiene and baseline health status that may be complicated by conditions such as diabetes and hypertension. Cognitive, physical and sensory impairments may make oral self-care and follow-up communications and education challenging and/or confusing. As a result, conditions such as dry mouth (xerostomia), coronal and root caries and periodontitis may ensue. A concurrent condition might involve oral bacteria that may be inhaled into the lungs and contribute to pneumonia. Aging people may have sensitivity to the analgesics and anesthetics that are used in dentistry, and their medications may interfere with prescriptions and/or treatments. Dietary Considerations Aging people should be encouraged to consume more water so that their oral cavity is constantly moisturized. Beverages such as acidic fruit juices, alcohol, coffee, carbonated soft drinks and/or tea may irritate dry mouth conditions. They should be reduced or eliminated as much as possible. To improve oral health, foods such as almonds, apples, carrots, celery, cheese, leafy greens and/or yogurt should be included. If loose dentures impair chewing functionality, prepare these and other foods to the degree of fork-tender, or consider strategically located implants for better chewing. Supplements Over-the-counter oral moisturizers, such as mouthwash or oral spray, may help to reduce dry mouth conditions. Sugar-free gum or lozenges may be used to activate saliva production. A dental professional may choose to apply a fluoride gel or varnish to teeth to protect against dental caries. Support Systems Care providers should try to help aging people to maintain regularly scheduled dental appointments for cleaning and maintenance. Dental visits for people who are over 62 years of age may be able to detect early signs of oral cancer. Aging people should be encouraged to keep their mouths as clean as possible, and they may need to

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be reminded to brush and floss their teeth daily. A home or facility humidifier may be used to help to keep the air moisturized.

Osteoarthritis and Rheumatoid Arthritis (See Arthritis) Osteoporosis and Osteomalacia Overview Osteoporosis is a systemic skeletal disease characterized by bone and mineral loss, or a decrease in bone density. Osteoporosis risks are also influenced by epigenetic factors (heritable changes in gene expression that do not involve DNA sequential changes), environmental and genetic causes. Bones that are weakened by osteoporosis may be more likely to break. Broken bones may lead to serious health problems when people are aging—particularly in the hip and wrist, because these injuries may lead to disability and/or decrease independence. After menopause, when estrogen levels drop, there may be an increase in bone loss. Since men generally have more developed muscles in their body that stress bones, they commonly have less osteoporosis—but they may become some osteoporotic during their lifetime. Osteomalacia is also known as “adult rickets,” which is characterized by weakening of the bones and rounding of the spine. Osteomalacia may be caused by inadequate sun exposure, or a lack of dietary vitamin D. It often leads to bone fractures. Dietary Considerations Important nutrients for bone health include calcium, vitamins A, C, D and K, copper, iron, fluoride, magnesium and zinc. Calcium functions as a building block for bones, and vitamin D helps the bones to absorb calcium. Dairy products provide calcium, as does calcium-fortified orange juice; green leafy vegetables (such as broccoli, kale and spinach); plant-based milks (such as almond or soy); seafood (such as blue crab, canned salmon, clams, ocean perch, oysters and shrimp); some fortified breakfast cereals; and tofu. Vitamin D is available in products that are fortified with this vitamin, such as some breakfast cereals, certain fish (such as salmon, sardines and tuna), orange juice and some plant-based milks. Sources of the other bone-building nutrients are shown in Table 8.10. TABLE 8.10

Food and Beverages Sources of Bone-Building Nutrients

• Calcium—calcium-fortified orange juice, dairy products (such as cheese, milk and yogurt), green leafy vegetables, plant-based milks, seafood (such as canned salmon and sardines) some fortified breakfast cereals and tofu • Vitamin D—certain fish (such as canned tuna or sardines, or cooked salmon), fortified breakfast cereals, fortified dairy milk, eggs, orange juice and some plant-based milks • Copper—clams, sunflower seeds and lentils • Fluoride—canned sardines with bones, grape juice and tea • Iron—clams, fortified breakfast cereals and blackstrap molasses • Magnesium—almonds, peanuts and spinach • Vitamin A—beef liver, carrots and butternut squash • Vitamin C—strawberries, oranges and sweet bell peppers • Vitamin K—parsley, broccoli and spinach • Zinc—oysters, beef, baked beans

Supplements A blood test for the vitamin 25-hydroxy vitamin D measures the amount of vitamin in the body. Then vitamin D intake can be assessed and supplementation recommended if deemed necessary by a healthcare professional. Many medications and supplements propose to combat bone loss, including calcium citrate and calcium carbonate, which vary in their absorption potential. If there is a genetic predisposition to osteoporosis, they may be initiated earlier in life as a precautionary measure. The advice of a healthcare professional should be sought.

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Support Systems Aging people should be encouraged to perform weight-bearing exercises such as dancing, jogging or walking so that the muscles pull on the bones and foster tissue density. Aging people should also quit heavy drinking and smoking that may weaken the bones and precipitate falls. A living area that is accommodated for support and the prevention of trip hazards, especially in the bathroom and bedroom may help some fall prevention. It is important to coordinate medical attention, treat cardiovascular, neurological and pulmonary diseases and evaluate medications that might precipitate the risks of falls and fractures. By approaching osteoporosis as the multifaceted disease that it is, there might be less fracture risk, continued independence, more quality of life and decreased mortality from its debilitating outcomes.

Palliative Care Overview Palliative care is a multidisciplinary approach to the specialize care that aging people may require during lifelimiting condition and/or diseases. Since the diagnoses are usually terminal, the focus of palliative care is more on providing symptomatic relief from the pain and mental and physical distress as people reach their demise so that quality of life may be preserved for patients and their care providers and families. Dietary Considerations As diseases progress, many palliative care patients may develop nutritional problems, or nutritional issues may worsen. These issues may both psychologically and physically impact palliative care patients and their care providers. Conditions of particular concern include chronic obstructive pulmonary disease, progressive neurological conditions and/or some advanced cancers. Decisions about the feeding of people with these conditions should be patient-centered. Some nutritional intervention options may include enteral or parenteral nutrition, food modifications and/or nutritional supplements. Certain options may have ethical or legal implications, so the consul of skilled providers in end-of-life decision-making should be sought [37]. Supplements The interest in nutritional supplements for palliative care patients that decrease inflammation, provide disease-fighting nutrients, reduce oxidative stress and other functions may be common; however, many factors should be considered before their use. Commercially available nutritional supplements may be difficult to obtain, expensive and/or inappropriately prescribed. Individualized circumstances should be taken into account, such as the desire of the patient, legal documents, the stage of a patient’s illness and/or the desires of family members. Overall health outcomes, progression of illnesses and quality of life should also be taken into consideration. Support Systems Palliative care is usually provided by a collaborative team of specially trained healthcare practitioners that work in conjunction with primary care specialists for multilayers of support. This coordinated care may be delivered with or without curative treatments. This team approach may specialize in treating serious illnesses such as Alzheimer’s disease, Amyotrophic Lateral Sclerosis, certain cancers, congestive heart failure, kidney disease, Parkinson’s disease and/or others. It may address anxiety, appetite loss, constipation, depression, fatigue, nausea, shortness of breath, sleep difficulties and other issues that may be distressing. Close communication about treatment choices, goals and options, along with coordinated efforts among care providers, families, the palliative care team and patients are crucial for nurturing care and life quality during this trying time.

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Phenylketonuria Overview Phenylketonuria (PKU) is a rare birth defect that causes the amino acid phenylalanine to build up in the body. Normally an enzyme is responsible for phenylalanine breakdown. When people with PKU consume foods with protein or aspartame, an artificial sweetener, serious health problems may occur. People who have PKU may continue to receive healthcare throughout their lifespans. If aging people have stopped following a PKU diet, they may benefit from seeing a healthcare professional. This involvement may help to improve any behaviors, mental functioning and/or slow damage to the central nervous system that may have resulted from high phenylalanine levels. Dietary Considerations A diet for PKU may consist of a phenylalanine-free medical formula (see Supplements) along with carefully measured amounts of breads, cereals, fruits, pasta and vegetables. This is because the amount of protein in these foodstuffs needs to be lower than normal. Foods that contain large amounts of phenylalanine (phe) tend to be higher protein foods that include eggs, fish, legumes, meats, milk and other dairy products, nuts and seeds and poultry. It is not unusual for people with PKU to consume a vegetarian-type diet that is filled with low-phe beverage and foods. Special phenylalanine-free formulas are devised to supply enough calories, protein, vitamins and minerals to support other beverage and food intake. Supplements (See Dietary Considerations) Phenylalanine-Free Formulas Support Systems Social Support, Attitude and Management is an approach to PKU management. Social support helps to provide the necessary assistance by healthcare providers, family, friends, networks, social workers and others so that people with PKU may achieve their metabolic goals. The development of a positive attitude is also essential for metabolic control. By surrounding PKU patients with a constructive support network, this may help to foster better self-control, healthier drinking and eating habits and more creativity in beverage and food selections and combinations. The management of PKU is all about PKU diet implementation that includes both the best diet and right formulation for individualize needs. By working with a registered dietitian/nutritionist, a person with PKU may be able to discover the wisest choices and plans for their particular requirements. This may involve the creation of positive dietary habits and dietary organizational strategies that comply with their lifestyle for optimal PKU management.

Pressure Ulcers Overview Pressure ulcers are injuries to the skin and often to the underlying tissues that results from prolonged pressure. Pressure ulcers may become a common problem in aging people who are frail, those who are overweight or others who have incontinence—and particularly those people who have conditions that limit their abilities to alter their positions. Pressure ulcers may lead to serious infections that may be life threatening. Pressure ulcers may develop on the ankles, back, elbows, heels, hips, shoulders, spine and/or tailbone. Such factors as aging skin, chronic diseases, functional impairment, infections, malnutrition and pressure on the back of the head and/or the ears may contribute to pressure ulcers and their development. Predisposing factors may include anemia, low albumin, low body mass index and/or low protein [38]. Dietary Considerations Consuming a healthy diet and staying well hydrated may prevent and/or alleviate some symptoms of pressure ulcers. Care should be taken to consume enough calories to maintain one’s weight; that protein intake

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(from dairy products, eggs, fish and shellfish, legumes, nuts and seeds, meats and poultry) is sufficient; and that 6 8 cups of water (about 1.5 L) are consumed daily. The amino acid arginine found in peanuts, pork, poultry, pumpkin seeds and other protein foods is thought to be involved in wound healing. If someone has diabetes, then good blood glucose control may help in wound healing. Hyperglycemia associated with sepsis and poorly controlled blood sugar may increase infection and impede wound healing. Vitamin C plays many roles in the formation of new tissues and in would healing. Berries, broccoli, citrus fruits, sweet bell peppers and/or tomatoes offer vitamin C. Zinc is also important in wound healing, specifically in the enzyme-catalyzed reactions of protein synthesis. Specifically, zinc deficiency may interfere with proper would healing and wound strength. Epithelialization (the formation of granulation tissue into an open wound) and cellular proliferation may be compromised. Zinc may be found in eggs, dairy products, green leafy vegetables, legumes, red meats and/or unrefined cereal grains. Dietary iron protects against iron deficiency anemia. Anemia may prevent the body tissues from receiving enough oxygen. Dried fruits, iron-fortified cereals, liver and other organ meats, poultry, and red meats are good sources of iron to help to correct certain anemias. To help to increase iron absorption, these foods should be consumed these foods with a source of vitamin C (see sources previously cited), and try to avoid tea that may interfere with optimal iron availability and usage. B vitamins are coenzymes in energy reactions that are needed for energy metabolism and wound healing. In particular, thiamin (B1), riboflavin (B2), pyridoxine (B6) and pantothenic acid (B5) are vital for optimal wound healing. Supplements Nutritional supplements may be recommended by healthcare providers to ensure adequate calories (energy) and protein to help to heal the pressure sores. Other than the inclusion of the protein sources that were previous stated, methods to increase protein include the addition of dried milk powder to enrich liquid milk, grated cheese to casseroles, potatoes and soups, soy or nut butters to smoothies and the consumption of protein or meal replacement bars. Zinc supplements may enhance wound repair in people who are biochemically zinc deficient other than normal circumstances. A daily multivitamin and mineral supplement may support dietary efforts to help to obtain enough woundhealing nutrients, especially if a healthy diet is poorly consumed. If oral supplementation is inadequate, then enteral feeding may be considered [39]. Support Systems Aging people may require help to keep their skin clean and dry. They may need to change their positions every few hours, and use pillows and other devices, such as foam or gel seat cushions, or a foam mattress to relieve pressure on certain body parts. In frailty is an issue, then factors that may affect the consumption of regular meal patterns with high-calorie foods, high protein and between meal snacks should be evaluated. These may include difficulty in body positioning, poor dentition and/or reduced manual dexterity. If any of these issues become increasingly problematic, food fortification strategies that supplement texture-modified diets may be required.

Pulmonary Disease Overview There is higher prevalence of changes in the pulmonary and respiratory systems and chronic obstructive pulmonary disease (COPD) in aging populations. This may be due to age-associated changes in the function and structure of the lungs that may include the alteration of the muscles that aid respiration, decrease in the volume of the thoracic cavity and the reduction of lung volume. Additionally, the aging may find it difficult to clear particles from the lungs through mucociliary elevation, and there may be changes in immune function that may increase the susceptibility to infections. Also, premature aging may enhance the susceptibility of the lungs to tobacco smoke exposure that may contribute to the development of emphysema, the destruction and enlargement of air spaces that often occurs with chronic bronchitis.

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Dietary Considerations Breathing requires more energy (calories) for aging people who have COPD. This is one of the reasons why a healthy weight should be maintained. If an aging person with COPD is overweight, the heart and lungs may have to work harder for greater oxygen demands. If an aging person is underweight, then a person with COPD may feel tired and/or weak and be more prone to infections. Protein is essential to help to build and maintain muscles and to create antibodies. Vitamin D may support respiratory health in aging people who have COPD. Sources of vitamin D include dairy products, fish with omega-3 fatty acids, fortified soymilk, tofu and vitamin D-fortified cereals. While dairy milk may not directly contribute to phlegm production, it may cause the phlegm to thicken within the throat. Attention to water intake may help to reduce the thickness of phlegm. Six to eight glasses of water daily may keep mucous thin and easier to extricate. Overeating that produces bloating or gas should be avoided, since it might make breathing more uncomfortable. So may the consumption of apples, avocadoes, broccoli, Brussels sprouts, cabbage, carbonated beverages, cauliflower, corn, cucumbers, leeks, lentils, melons, onions, peas, peppers, pimentos, radishes, scallions shallots, soybeans, and/or fried, greasy or heavily-spiced foods. Supplements Antioxidant vitamin A plays important roles in proper lung development early in life, and in the repair of damaged lung tissues later in life. Vitamin D may be able to inhibit inflammatory responses, modulate the activity of immune cells and regulate airway smooth muscles. Vitamin E levels tend to be lower in smokers, which may increase their susceptibility to free radical damage. Low levels of antioxidant vitamins C and E have been associated with increased dyspnea (shortness of breath), phlegm and wheezing. Other supplemental measures that support respiratory health include those listed in Table 8.11.

TABLE 8.11

Prospective Supplements for Respiratory Health

• Coenzyme Q10—also known as ubiquinone, a compound that helps to generate cellular energy; may act as a powerful antioxidant in people with chronic obstructive pulmonary disease (COPD) who have low levels of COQ10. • Ginseng—the root of a plant that is traditionally used in Chinese medicine to treat respiratory symptoms; may be a potential adjunct therapy for COPD. • L-Carnitine—an amino acid derivative that functions in energy metabolism; may help to modulate immune function, support glucose and fatty acid metabolism and prevent wasting syndrome. • N-Acetylcysteine—a substance that helps the body to produce glutathione, an important antioxidant precursor; may help to dissolve mucous and repair some oxidative damage. • Omega-3 fatty acids—unsaturated fatty acids mainly found in fish oils; may help to build healthy cell membranes, protect against inflammatory reactions and/or repair body tissues. • Resveratrol—an antioxidant and antiinflammatory primarily found in grapes and wine; may have some protective qualities in opposition to asthma and COPD. • Sulforaphane—a compound that is found in cruciferous vegetables, such as broccoli and Brussels sprouts; may be able to augment the antiinflammatory effect of corticosteroids that are used for COPD. • Zinc—a mineral with levels that tend to be lower than normal in some aging people with COPD; may provide some improvement with supplementation.

Support Systems Aging people with COPD should be encouraged to breathe deeply before eating; clear their airways before eating; consume small meals instead of larger ones so that the stomach does not fill up too much, and the lungs have room to expand; drink liquids at the end of meals in order to prevent bloating; eat when seated to ease pressure on the lungs; eat slowly; and select foods that are easy to chew. Other strategies include rescue inhalers and inhaled or oral steroids help control symptoms and minimize further damage [40].

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Sarcopenia Overview Sarcopenia, or the degenerative loss of skeletal muscle mass and muscle function or strength at a rate of 0.5% 1% per year after age 50, is often linked with aging. Sarcopenia is an important cause of functional decline and independence in aging people. There are many factors that are contributory that may include chronic illness, decline in activity, fatty infiltration, hormonal changes, inflammatory pathway activation, neurological decline and/or poor nutrition. Biological systems may also be causative (such as the angiotensin system in skeletal muscle, apoptosis and mitochondrial decline). Decline in activity and nutritional intake are targeted areas for therapy. Due to increased chronic disease, fatigue and pain, those who are aging are less inclined to be active. Rheumatological conditions may be associated with the decline in skeletal muscle mass and sarcopenia, most likely due to high levels of inflammatory cytokines, small proteins that are related to pathological pain. Inactivity with decline in adequate protein and calorie intake, as well as overnutrition in sarcopenic obesity, may advance the loss of muscle mass and function. There remains lack of consensus regarding pharmaceutical intervention [41]. Dietary Considerations Since the aging are at risk of consuming inadequate protein (at a minimum of 0.8 grams/kilogram/body weight daily, or about 35% of total energy intake), care should be taken to provide enough protein daily to stimulate protein synthesis, as well as to maintain other body functions that rely on protein. Those who are aging also tend to produce less muscle than when they were younger due to metabolic changes. For this reason and others, about 1.0 1.5 grams/kilogram/body weight daily of dietary protein that is spread out throughout meals and snacks is a more likely goal for the aging. For example, if a person weighs 175 pounds then they would require about 80 119 grams of protein daily, ideally spread out throughout the day in 3 5 meal or snack increments. Aging people with chewing problems may be adverse to the concentrated forms of animal protein: fish and seafood, meats and poultry. Dairy products are likely choices, unless there is diagnosed lactase intolerance or milk protein allergy. A variety of sources of protein may be tried in cooking and baking that include legumes (dried beans, lentils and peas); cheese; powdered milk; whey protein or yogurt; hard boiled eggs; high-protein snack bars or meal replacement bars; nuts and nut butters, peanuts; seeds; and/or wheat germ [42]. Supplements One of the most widespread nutrient deficiencies in aging is vitamin D deficiency, particularly 25-hydroxyvitamin D [25(OH)], which decreases with age. Sarcopenia with low muscle strength is particularly vulnerable, and in fact, supplementation of vitamin D may help to improve muscle strength at dosages as determined by a healthcare provider. Powdered commercial protein supplements with the amino acid leucine added to milk or hot cereal may also be beneficial. Leucine is one of the most advantageous amino acids in that it is a precursor for protein synthesis. It stimulates the associated intracellular pathway and triggers muscle growth. Whey protein is beneficial because it offers the right amount of amino acids that are proportional to skeletal muscle. Creatine supplementation may be useful for people with sarcopenia. Angiotensin-converting enzyme inhibitors, androgen receptor modulators, growth hormone and testosterone therapy are other types of pharmacologicals and therapies that show varying degrees of success in improving sarcopenic symptoms. Research is ongoing [43]. Support Systems Aging people with sarcopenia may require a variety of support that include one-on-one care providers for disabilities and/or muscular weakness. Resistance and strength training to decrease frailty, improve functional ability and prevent future decline is recommended for a minimum of three times weekly, and optimally most days.

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Aerobic activities such as biking or walking, balance and flexibility exercises, occupational therapy, physical therapy and strength training may also be incorporated to improve balance, endurance, flexibility and especially for muscular strength.

Vegetarian, Lacto-ovo Vegetarian and Vegan Diets Overview A primarily plant-based diet as vegetarian, lacto-ovo vegetarian or lacto-vegetarian may be healthy for aging people if it is well chosen. In general, a vegetarian diet is plant based and excludes meats (fish, meats and poultry). A variety of options may include dairy products, eggs and/or fish. A lacto-ovo vegetarian diet includes both dairy products and eggs in addition to its plant-based cuisine. A lacto-diet includes only dairy products, plus its plant-based foundation. A vegan diet excludes all animal-based proteins. It may be more complicated but achievable with good intent, smart execution and support, if needed. But in some cases, vegetarians of any kind may have nutrient intakes that are lower than optimal to protect against certain chronic diseases. On the other hand, if vegetarian and vegan diets are well chosen, they may be low-to-devoid of cholesterol and saturated fats that are implicated with certain types of cancer. Some vegetarian diets may also result in lower levels of LDL cholesterol and blood pressure, which may help to decrease hypertension, ischemic heart disease and type 2 diabetes. When calories are compared, many plants often have fewer calories than meats, so some vegetarian diets have the capacity to decrease the body mass index. So plant-based diets have the potential to achieve many preventive milestones for aging people—assuming that they are planned and executed very well.

Dietary Considerations One of the major benefits of a well-chosen plant-based diet is the rich nutrient profile that it affords with more fibers and phytonutrients—particularly antioxidants. In general, a well-planned vegetarian diet is filled with nutrient-dense foods that means portion-to-portion they may carry more nutrients than calories. As calorie needs decrease with aging, this feature may ensure that even on low-calorie vegetarian diets nutrient needs are met. Adequate protein intake is paramount, particularly with regard to other conditions of aging, such as sarcopenia with its degenerative loss of bone density and skeletal muscle mass, quality and strength. Extra emphasis should be placed on vegetable sources of proteins, such as green leafy vegetables, legumes (beans, peanuts and soybeans), nuts and seeds. Protein-dense foods that are high in the amino acid lysine, such as peanuts and soyfoods are important inclusions. Bone mass preservation is essential; sufficient calcium and vitamin D intake are contributory. These nutrients are typically associated with dairy foods and may be more challenging to obtain in vegan diets. However, wellselected vegetarian and vegan diets may also be ample in magnesium and vitamins A and K, which are also essential for bone health. Calcium-rich foods for vegans include fortified juices and plant milks; leafy green vegetables (that include bok choy, collard greens, kale and turnip greens); and tofu that is produced with calcium sulfate. Vitamin D may be found in some fortified breakfast cereals, plant milks and orange juice. Daily sunlight exposure may also be beneficial to help obtain this vitamin [44]. Omega-3 fatty acids are beneficial in the prevention of Alzheimer’s disease, heart disease, rheumatoid arthritis, stroke and a number of other health issues. They are abundant in fatty fish in the forms of eicosapentaenoic acid (EPA) and DHA, but vegetarians and vegans may have a harder time obtaining adequate levels. Flaxseeds, leafy green vegetables, walnuts and vegetable oils contain alpha-linolenic acid that may be converted to the omega-3 fatty acids EPA and DHA in smaller quantities. Vitamin B12 has essential body roles in central nervous system maintenance, DNA creation, metabolism and red blood cell formation. A vitamin B12 deficiency may lead to megaloblastic anemia with symptoms of disorientation, memory loss, numbness in the extremities and trouble walking. Vitamin B12 is mostly found in

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animal-based foods and in some fortified foods; however, its bioavailability from plant-based foods may be compromised due to absorption difficulties [45].

Supplements While the need for DHA and EPA supplements is controversial, marine algae supplements that contain DHA and EPA may be helpful for obtaining these preventive fats, which are primarily found in fatty fish. The absorption of vitamin B12 is questionable, even in meat-eating adults; therefore, vitamin B12 supplements and foods and beverages that are fortified with vitamin B12 may be necessary as proposed by a healthcare practitioner. Since protein, calcium and vitamin D are so critical to help prevent the degenerative loss of bone density and skeletal muscle mass, quality and strength, if the diet is deemed inadequate in these nutrients, supplements may be considered. The review and recommendation by a healthcare professional is urged.

Support Systems Maintaining the right balance of calories as one ages is also important as the body slows, and there is less muscle to burn calories. If a vegetarian or vegan diet is higher in discretionary calories from alcohol, snacks and/ or sweets, then weight may increase in spite of this apparently healthful diet plan. More emphasis should be placed on nutrient-dense foods such as fruits, vegetables and whole grains to maximize nutrients and minimize extra calories. Exercise is also critical to ensure that “calories in equals calories out,” and that balance and flexibility are maintained and heart and muscles are optimally used.

Weight Loss and Weight Gain Overview Weight loss or weight gain in the aging is not uncommon. The loss of lean body tissues in the muscles is referred to as atrophy. There may be cellular losses in the kidneys and liver, and fluid losses in some tissues. Bones may lose their minerals and decrease in density. However, the amount of body fat generally increases as people age, particularly around the internal organs in the center of the body. In contrast, the amount of fat right under the skin may decrease, so the hair, nails and skin may become fragile. The body may decrease in height proportional to the loss of bones, joints and muscles. These changes generally equate to changes in total body weight. Total body weight tends to decrease after 55 years of age for men (related to decreased testosterone, the male sex hormone), and after 65 years of age in women, as fat replaces lean body mass. Lifestyle choices may sway these equations. Since calories ingested should equal calories spent for weight maintenance, too many calories and/or too little exercise may mean excess weight or underweight. This is why an activity and exercise program, healthy diet, and limited or no alcohol are important undertakings for weight control and maintenance throughout the senior years. Unintentional weight loss may be associated with potentially significant health outcomes, increased mortality and/or progressive disability. Unexplained weight gain may be the result of fluid retention, also known as edema, which may be associated with heart failure, hormonal disorders or kidney disease or the side effects of medications, such as antidepressants, antipsychotic medications and/or corticosteroids [46].

Dietary Considerations Caloric needs decrease after age 70, due to reduced energy requirements, metabolism and movement. According to the 2015 2020 US Dietary Guidelines, the estimated calories needs per day by age, sex and physical activity level are shown in Table 8.12.

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TABLE 8.12

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Estimated Daily Calorie Needs of Aging Men and Women

Sedentarya males aged 51 76 and up need approximately 2000 2200 calories per day. Sedentary females aged 51 76 and up require about 1600 calories per day. Moderately activeb males aged 51 76 and up need approximately 2200 2400 calories per day. Moderately active females aged 51 76 and up require about 1800 calories per day. Activec males aged 51 76 and up need approximately 2400 2800 calories per day or more depending upon the activities. Active females aged 51 76 and up require about 2000 2200 calories per day or more depending on the activities [47]. a

Sedentary is defined as a lifestyle that includes only the physical activity of independent living. Moderately active is defined as a lifestyle that includes physical activity that is equivalent to walking about 1.5 3 miles daily at 3 4 miles per hour, in addition to the activities of independent living. c High activity is defined as vigorous workouts at least one hour and 15 minutes weekly, participating in such activities as biking on hills, high-intensity aerobics, jogging, playing basketball and/or swimming laps. b

Supplements The use of oral supplements, such as high-calorie and/or high-protein beverages, to halt or reverse unintentional weight loss and encourage food intake may be warranted. Oral supplements may aid in short-term weight gain and improved anthropometric, biochemical and quality-of-life parameters. If too few calories are of issue, more calorie-dense, nutritious foods such as avocadoes, nut and seed butters, potatoes and yams may be incorporated into the diet. The opposite is true if calorie intake is too large: more lower calorie choices—especially in the rich dairy products, fats and meat categories should be substituted. Some calorie restriction has demonstrated antiaging and age-related disease benefits. Resveratrol, a phytochemical found in red wine and red grapes, has been shown to stimulate sirtuins, much like how a specific sirtuin, SIRT1, operates in the brain to delay aging. It is speculated that sirtuin accomplishes this by inducing the hippocampus to initiate changes in skeletal muscle, similar to what may happen under dietary restriction. However, high levels of sirtuins may have side effects, such as anxiety and panic disorders, so they may not be a panacea for living longer and/or disease free. A broad-spectrum vitamin and mineral supplement may also be a necessary safeguard, as considered essential by a healthcare provider. The use of pharmacologic agents for the treatment of weight loss in the aging may be limited in usefulness, especially in light of side effects [48]. Support Systems Counseling and encouragement to consume a healthy diet may be essential before the use of oral supplements, since the latter may be perceived as easier and preferred. Still, the aging should be urged to use oral supplements between meals rather than during meals when they may fill up and decline food. This practice may help to reduce the suppression of appetite at meals and enable increased total daily calorie intake. Care providers should try to ensure that people in their care consume the dietary staples vegetables of dairy products, fish, fruits and vegetables, healthy fats and oils, lean meats and whole grains in reasonable portion sizes. By helping with the procurement, preparation and presentation of these foods and beverages and supplying companionship, they offer a strong nutrition and feeding foundation for health and well-being [49].

Aging Itself As discussed in Chapter 2, Nutritional and Physical Concerns in Aging, the aging process itself and the conditions and diseases of aging bring their own sets of dietary considerations, supplements and support systems. Until we as a society and global population view aging as its own specialized entity, and dedicate the necessary funding, healthcare and research needed for its myriad of conditions and diseases, we will collectively be coping with aging at high costs of all kinds instead of embracing it. This is a reverse mindset that is worth exploring at many levels.

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DIGEST It is possible to age healthfully. By consuming a well-balanced diet throughout the formative years throughout middle age and into the advance years, people may be able offset some of the aging processes. However the nutritional and physical concerns in aging, along with the chemosensory changes that are highlighted in Chapter 2, Nutritional and Physical Concerns in Aging, and Chapter 3, The Senses, Chemosensory Changes and Aging, are fairly universal. Keeping fit with activities and exercise; avoiding alcohol, nicotine and other drug-like substances; being mindful of environmental factors, such as solar radiation and toxic chemicals that include lead and pesticides; practicing stress management; and preserving social networks may be positive antiaging actions in which to engage. Despite these efforts, a number of conditions and/or diseases are common in aging people, which were identified in this chapter, along with overviews of their maladies, dietary considerations, possible supplements and necessary support systems. While not failsafe, some of these strategies may help in the prevention, management and/or recovery of these lifecycle occurrences. It would be helpful if the flavor enhancement principles outlined in Chapter 6, Flavor Enhancement Ingredients, and Chapter 7, Flavor Enhancement Techniques, could be applied to each of these conditions and/or diseases, but the fact remains that some are so narrow in their scope of limitations that each and every ingredient and/or technique may not be applicable. In general, it may be best to speak with a registered dietitian/nutritionist or healthcare provider about the intent to incorporate flavor-enhancing ingredients or techniques into dietary approaches for prevention, maintenance or recovery of certain conditions and/or diseased. Among the dietary and supplement considerations in this chapter, and those found in Chapter 6, Flavor Enhancement Ingredients, and Chapter 7, Flavor Enhancement Techniques, an interactive approach for meeting the nutritional and disease-specific needs of aging people may be realized.

MANNER OF SPEAKING Ascites Acute Inflammation Acute Kidney Disease/Failure Acquired Immunodeficiency Syndrome (AIDS) Alcoholics Anonymous (AA) Allergies Androgen Receptor Modulators Angiotensin-Converting Enzyme Inhibitors Antiretroviral Therapy (ART) Arginine

Arthritis Alcohol-Related Dementia Amyotrophic Lateral Sclerosis (ALS) [also known as Motor Neuron Disease (MND)]

accumulation of fluids in the peritoneal cavity; leads to abdominal swelling heat, immobility, pain, redness and swelling in response to tissue injury; short-term process condition whereby the kidneys abruptly stop filtering waste from the blood spectrum of conditions; triggered by infection by HIV international mutual aid fellowship that enables members and others to achieve sobriety condition in which the immune system reacts abnormally to foreign substances compounds that may block or stimulate key receptor in body tissues involved with muscles and strength pharmaceutical drugs used for the treatment of congestive heart failure and hypertension medication(s) used to treat HIV amino acid; functions in cellular division, hormone release, immune function, removing ammonia from the body and wound healing inflammation of the joints and/or joint disease; may result in pain, stiffness and/or swelling form of dementia; result of excessive, ongoing consumption of alcoholic beverages that advances neurological damage disease that leads to death of neurons that control the voluntary muscles

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MANNER OF SPEAKING

Anemia of Chronic Disease or Disorder (ACD)

Angiotensin System (also known as the Renin-Angiotensin-Aldosterone system) Anthocyanin Aorta Apoptosis Arrhythmias (also known as cardiac dysrhythmia) Atrophy Autoimmune Disease Calcium Carbonate

Calcium Channel Blockers (CCBs)

Calorie Restriction (CR) Celiac Disease Celiac Hepatitis Cellular Senescence Chelators Chronic Bronchitis Chronic Kidney Disease (CKD) (also known as Chronic Kidney Failure) Chronic Obstructive Pulmonary Disease (COPD) Chronic or Systemic Inflammation (SI) Cirrhosis Citrate Consistency-Altered Diet C-Reactive Protein (CRP) Curcumin Cytokines

DASH Diet

289

type of anemia that commonly occurs with chronic illnesses or infections; may be generated by cancer or inflammatory diseases hormone system that helps to regulates blood pressure and fluid balance blue, red or violet flavonoid water-soluble pigment found in plants; associated with disease protection main artery of the human body; supplies oxygenated blood to the circulatory system death of cells; normal controlled incidence of multicellular organisms improper heat beats; may be irregular, too fast or too slow bodily process of wasting (reabsorption and breakdown of tissue); may involve apoptosis disease where the immune system of the body attacks and damages healthy cells odorless, tasteless crystal or powder that occurs in nature; used therapeutically as a phosphate buffer in hemodialysis patients; also a calcium supplement medication that disrupts the movement of calcium through calcium channels and dilutes the arteries; makes it easier for the heart to pump reduction of food intake with the avoidance of malnutrition autoimmune disorder in genetically predisposed people in which ingestion of gluten leads to smell intestine damage mild periportal inflammation induced by gluten process by which normal cells cease cellular division in response to various stressors small molecules that bind very tightly to metal ions type of COPD; symptoms include coughing, difficulty breathing and/or mucous production gradual loss of kidney function over long-term period group of lung diseases that block airflow; create breathing difficulties long-lasting inflammation due to pro-inflammatory cytokines from immune-related cells late-stage fibrosis (scaring) of the liver; chronic alcoholism and/or hepatitis contributors key intermediate in metabolism; also acid found in citrus fruits; used as chelating agent and flavoring dietary plan that includes foods and beverages in physically altered forms protein produced by the liver; blood test marker for inflammation substance in turmeric (member of the ginger family); purported antiinflammatory and antioxidant properties cell signaling molecules; aid cellular communication in immune responses; stimulate cells towards infection, inflammation and trauma dietary pattern to prevent and control hypertension; promoted by the US National Heart, Lung and Blood Institute chronic skin condition caused by reaction to gluten ingestion

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Dermatitis Herpetiformis (also known as DH and Duhring’s disease) Diallyl Disulfide Dialysis Dietary Restriction (DR) Diuretics (also known as “water pills”)

Docosahexaenoic Acid (DHA) Dysphagia Dyspnea Edema Electrocardiogram (ECG) Electrolytes Emphysema Epigenetic Factors Epithelialization Erythrocyte Sedimentation Rate (ESR) (also known as Sed Rate) Failure to Thrive Fasting Fasting Mimetics Fibrosis Gastroesophageal Reflux Disease (GERD) Gliadin

Glomerular Filtration Rate (eGFR) Gluten

Gluten Ataxia

Gluten-Free Diet Glutenin Gout Halal Harpagophytum Procumbens (also known as devil’s claw, grapple or wood spider)

organosulfur compound derived from allicin, found in garlic and related plants dietary pattern that is higher in protein and restricts high amounts of phosphorus, potassium and sodium substances that help rid the body of sodium and water, often by the kidneys releasing more sodium into the urine; used to treat hypertension and other conditions omega-3 fatty acid; primary constituent of the brain, retina and skin; mostly acquire by diet difficulty swallowing shortness of breath condition of excess body water; collects in cavities or tissues test that measures the electrical activity of the heat and its beats body minerals in blood, tissues, urines and other body fluids with electric charges; essential for normal body functioning long-term, progressive lung condition; causes shortness of breath heritable changes in gene expression that do not involve DNA sequential changes formation of granulation tissue into an open wound blood test that may indicate inflammation in the body, associated with some autoimmune diseases, cancers and infections undesirable weight loss or insufficient weight gain, particularly in infants intentional abstinence or reduction from the consumption of food and/or beverages over a period of time pharmacological agents that may trigger some fasting responses thickening and scarring of connective tissue in an organ or tissue, often in response to injury digestive disease in which bile or stomach acid irritates the lining of the esophagus class of proteins present in wheat or other cereal grains; primary antigen that leads to inflammatory reaction in the small intestine test that measures kidney function; determines stage of kidney disease family of proteins in grains such as barley, rye, spelt and wheat; two main proteins are glutenin and gliadin (responsible for most reactivity) rare neurological autoimmune condition that involves the human body’s reaction to gluten; may irreversibly damage the cerebellum dietary approach that excludes all forms of the protein gluten protein complex; responsible for the elasticity and strength of doughs form of arthritis; characterized by inflammation, redness, severe pain and tenderness in joints permissible foods and beverages according to Muslim laws genus of plants in the sesame family

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MANNER OF SPEAKING

Hepatic Liver Disease HIV-Associated Neurocognitive Disorders (HAND) Human Immunodeficiency Virus Homocysteine Hyperfiltration Hyperglycemia Hyperphosphatemia

Hyperplasia Hypertension Hypoalbuminemia Hypothyroidism (also known as low or underactive thyroid) Immediate Hypersensitivity (Type I) Immune Function

Immune System

Immunosenescence Inflammation

Intraglomerular Pressure Ketoanalogs Lacto-ovo Vegetarian Lactose Intolerance Low-Protein Diet (LPD) Kashrut (Kosher) Kefir Malnutrition

Mashgiach Medical Nutrition Therapy (MNT)

Mediterranean-Type Diet

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inability of the liver to function normally; may include jaundice, pain and/or swelling spectrum of neurocognitive dysfuntion associated with HIV infection; sometimes first sign of AIDS virus that causes AIDS amino acid produced by body and in blood; high levels increase risks of heart disease marker of early renal damage in prediabetics excess of the sugar glucose in the bloodstream; sign of prediabetes and diabetes electrolyte disturbance with elevated phosphate level; causes include chronic kidney disease hypoparathyroidism and/or metabolic or respiratory acidosis enlargement of organ or tissue due to reproduction of cells; may be early cancer marker high blood pressure; increases risks of heart disease and stroke condition characterized by low blood levels of albumin condition characterized by low blood levels of albumin that makes up human blood plasma allergic reaction that occurs to a host that has been previously sensitized within minutes of exposure to an antigen how the human body recognizes and defends itself against bacteria, viruses and other potentially foreign and/or harmful substances network of cells, organs and tissues that serve to protect the human body from disease-causing organisms and/or substances gradual deterioration of the immune system; develops by the progression of age localized physical condition that results in heat, painfulness, reddening and/or swelling; reaction to infection and/or injury pressure in the glomerular capillaries within the renal corpuscles of the kidneys nitrogen-free analogs of essential amino acids plant-based consumer who includes dairy products and eggs inability to digest the milk sugar lactose lower protein dietary; used for CKD to help lower glomerular filtration rate decline and maintain nitrogen balance proper or correct set of Jewish religious dietary laws; used to “keep Kosher,” or consume fitting foods fermented milk drink; prepared with a yeast-bacterial fermentation starter lack of adequate nutrition by the human body; usually results from the lack of food or a poor diet with too low, too high or poorly balanced nutrients Jewish person who supervises the Kashrut (Kosher) products in a food service establishment nutrition counseling, diagnostic and therapy services for the purposes of disease management; supplied by a Registered Dietitian/Nutritionist eating plan inspired by dietary intakes of resident in Mediterranean countries; focuses on plant-based foods and

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Megaloblastic Anemia

Mitochondrial Decline Modified Consistency Diet Myelodysplastic Syndrome Nonalcoholic Steatohepatitis (NASH) Non-Celiac Gluten Sensitivity Nonsteroidal Antiinflammatory Drugs (NSAIDS) Oleocanthal Omega-3 Fatty Acids (Omega 3’s)

Oral Disease

Orthostatic Hypotension Osteoarthritis Osteomalacia Osteoporosis Overnutrition Palliative Care Periodontitis Phenylalanine

Phenylketonuria (PKU)

Polyphenols Prebiotics Pressure Ulcers (PU) (also known as pressure sores) Probiotics

Purines Psoriasis

beverages, such as fruits, legumes, nuts, vegetables and whole grains condition caused by the inhibition of DNA synthesis during red blood cell production, and poor vitamin B12 absorption from foods decrease in mitochondria, the energy needed for cellular activity and growth; correlated with age-related diseases dietary approach that provides foods in physically altered forms, such as chopped, ground or pureed group of disorders activated by poorly formed blood cells, or defective cells condition in which fat builds up in the liver condition with symptoms that are similar to celiac disease; improve when gluten is eliminated from the diet class of drugs that decrease fever and inflammation, prevent blood clots and reduce pain natural phenolic compound found in extra-virgin olive oil; reported antiinflammatory properties essential fatty acids with potential health benefits for the blood vessels, brain, endocrine system, immune system and lungs; mainly found in fatty fish, flaxseeds and supplements variety of diseases that involve the oral cavity; two main lead to tooth destruction or tooth loss: dental caries (cavities) and periodontal (gum) disease low blood pressure when standing degenerative joint disease or “wear and tear” softening of bones caused by impaired bone metabolism; due to deficiency in calcium or vitamin D condition of fragile bones with increased vulnerability for fractures form of malnutrition; nutrient intake overprovided for normal development, growth and/or metabolism multidisciplinary approach to specialized medical care for people with serious illnesses to improve quality of life gum disease; common infection that damages the bones and soft tissues that support the teeth nonessential amino acid found in protein foods; helps reduce pain and treat vitiligo (loss of pigment in skin); precursor to neurotransmitters rare inherited disorder that causes phenylalanine to build up in body; may lead to behavioral problems, intellectual disabilities and/or seizures phytochemicals with many potential health-promotion properties; found in a wide variety of fruits and vegetables nondigestible food ingredients that promote the growth of beneficial intestinal microorganisms localized injury to the skin and underlying tissues; result of friction, pressure and/or shear microorganisms (bacteria and yeast) with purported gastrointestinal, skin and other benefits; found in dietary supplements, foods such as yogurt and skin creams chemical compounds in foods that the human body converts into uric acid; may cause gout (painful form of arthritis) ongoing autoimmune disease; characterized by patches of irregular skin with patches and scales

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REFERENCES

Psoriatic Arthritis Qur’an Rheumatoid Arthritis Sarcopenia Sexually Transmitted Infection (STI) (also known as sexually transmitted diseases or STDs) Sirtuins

Social Support, Attitude and Management (SAM) Steatosis Sulforaphane Sunnah Torah Trans Fats (also known as trans-fatty acids) Type 1 Diabetes (also known as juvenile or insulin-dependent diabetes) Type 2 Diabetes (also called adult-onset diabetes) 25-hydroxyvitamin D [25(OH)] Ubiquinone (also known as Coenzyme Q10)

Undernutrition Uric Acid

Vegan Diets Vegetarian Diets Vitamin 25-Hydroxy Vitamin D Xerostomia Wernicke Korsakoff Syndrome (WKS) Wheat Allergy

293

form of inflammatory arthritis that affects people with psoriasis; may lead to joint damage Islamic sacred text; contains dietary laws autoimmune disorder; affects lining of joints and causes painful swelling; may result in bone erosion and joint deformity degenerative loss of skeletal muscle mass and muscle function or strength—quality or state of being strong diseases or infections spread by bacteria exchanged during sexual relations class of age-related proteins; regulate numerous cellular and organismal functions, including cellular death, inflammation, longevity and metabolism toolkit to help manage PKU; involves attitude, manageability, social support fatty liver; buildup of fat in the liver phytochemical found in cruciferous vegetables, especially broccoli sprouts; credited with anticancer properties body of established beliefs, customs, practice and traditions of the Islamic community parchment scroll; contains five books that form the basis of Jewish law and practice type of unsaturated fat; mostly industrially produced from vegetable fats; increase risk of heart disease and stroke chronic condition whereby the pancreas produces little or no insulin chronic condition that affects the manner the body processes glucose (blood sugar) indicator of vitamin D level in the body vitamin-like substance naturally made by the body; potent antioxidant; important for cellular development and functioning lack of sufficient nutrients in the body; deficiency of calories or protein waste product created when body breaks down purines found in high-protein foods; associated with diabetes, gout and kidney stones diets that exclude all animal products plant-based diets; includes only foods from fruits, grains, legumes, nuts and seeds and vegetables measure of vitamin D in the human body dry mouth and dry mouth syndrome; change in saliva or saliva flow with no identifiable cause neurological disorder; caused by deficiency in the B vitamin thiamine allergic reaction to foods containing wheat proteins; typically outgrown by adulthood

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PHOTO: Tomatoes. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I used to love my Mother’s cinnamon cake, but no longer seem to tolerate its spiciness. Instead, I have plain cake or fruit. S.G. O U T L I N E Summary

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Twenty Strategies and Uses for Addressing Changes in Tastes and/or Smells Strategy #1: Amplify Food Flavors Strategy #2: Use Culinary Herbs and Spices Strategy #3: Focus on Moist-Heat Cooking Methods Strategy #4: Create Healthy Comfort Foods Strategy #5: Plan and Prepare Meals and Snacks Strategy #6: Create “Finger Foods” (for Dexterity Issues) Strategy #7: Make the Most of Modified Texture Foods Strategy #8: Include Higher-Fiber Foods and Beverages Strategy #9: Lower Total Fat and Switch to Other Fats, Oils and Fatty Ingredients Strategy #10: Lower Sodium and Replace Salty Foods and Beverages With Reduced-Sodium Ingredients

Aging, Nutrition and Taste. DOI: https://doi.org/10.1016/B978-0-12-813527-3.00009-0

Strategy #11: Lower Sugar and Replace with Naturally Sweetened Foods and Beverages Strategy #12: Construct Bite-Sized Food Portions Strategy #13: Create Visually Appealing and Ethnically Correct Garnished Foods Strategy #14: Prepare Foods for Easy Chewing Strategy #15: Maximize Aroma, Color, Taste and Texture Strategy #16: Select Canned, Frozen and Packaged Foods and Beverages With Care Strategy #17: Use Acidic Ingredients Prudently Strategy #18: Address Hydration Strategy #19: Consider Lack of Appetite/Fullness Strategy #20: Address the Entire Dining Experience

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LEARNING OBJECTIVES 1. Acquire and integrate measures to help to amplify food flavors for greater acceptance and enjoyment by the aging. 2. Create age-appropriate and individualized meal and menu plans that incorporate some of this book’s recipes concepts and others. 3. Detail particular steps to moisten foods, add fiber and decrease fats and oils, salt/sodium and sugars and other measures if and where needed. 4. Distinguish specific conditions and diseases of aging that may be bettered by culinary modifications. 5. Identify specific culinary and baking techniques that harmonize with aging diets.

SUMMARY To tangibly comprehend cooking and baking techniques that will be more desirable and palatable for aging palates, contribute to food and beverage appeal, ingestion and ongoing attraction and be easy-to-prepare, economical, memorable, recognizable and simplistic.

INTRODUCTION As the generation of baby boomers moves into the next phases of their lives, they may bring food memories, ethnic foods and cuisines, novel new foods and beverages, various diets and/or food experiences into their later years. This may result in a multitude of considerations to meet their various and often demanding food and nutrition preferences and needs. Because aging people are generally living healthier and longer than in previous generations, many aging people are relatively fit and healthy, functional and independent. As a result, one set of culinary approaches for healthy aging versus those with disease does not seem to fit. Aging people with certain conditions or disease states were discussed in Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging. This chapter discusses culinary strategies that may help to address changes in taste and/or smell with aging. Exceptions are given for certain conditions and/or diseases. Recipes and menus are highlighted that may be individualized for specific needs. By and large, the ideas expressed here do not require previous culinary knowledge. They are simple to implement and require a modest amount of preparation time. By employing a “food first” mindset, some matters of taste may be rediscovered, meal enjoyment may prosper and health and well-being may be appreciated.

TWENTY STRATEGIES AND USES FOR ADDRESSING CHANGES IN TASTES AND/OR SMELLS Debate still exists about declining taste and/or smell in the aging, especially when it occurs, with what frequency and which tastes and/or smells decline before others. It is commonly accepted, however, that most body systems decline with aging, including the sensory, with a variety of probable repercussions. These 20 chemosensory strategies are universal in nature and may be tailor made for specific conditions and/or disease states where indicated. In addition, a wealth of culinary and nutritional information is contained within this chapter to collectively help guide aging people, their care providers, family members and healthcare professionals to “Let food be thy medicine and medicine be thy food.”—Hippocrates, Father of Modern Medicine B431 BC.

Strategy #1: Amplify Food Flavors If tastes and/or smells decline with aging, by amplifying the flavors of foods and beverages, they may be more appealing and desirable to consume.

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These flavorful ingredients help to make plain foods more interesting by amplifying their aroma, color, taste, texture and other attributes. Useful examples of dishes that incorporate these ingredients are also provided. Chutney Chutney typically refers to a group of sweet and spicy condiments. It is similar to relish and salsa. Chutney usually contains fresh, chopped fruits or vegetables and seasonings. Uses: Use chutney with Indian-type dishes, such as in curries; bread, cheese and/or cold meats, such as in sandwich spreads; eggs, fish, game, lamb, pork or poultry, such as in accompaniments; or with pita bread, such as in dips. Coulis Coulis is a thick sauce that is combined with pureed and strained fruits and/or vegetables. The difference between a coulis and a sauce is that a sauce is a liquid that is often thickened to use as a condiment or as an accompaniment for foods. • A fruit coulis may be used cold or warm in desserts, with meats or vegetables or as a base for other sauces or soups. • A vegetable coulis is often served warm with vegetables or meats, and may also be used as a base for other sauces or soups. The color and flavor of coulis often take on the main ingredients. Uses: Use fruit coulis for desserts, such as blueberry, cranberry, raspberry or strawberry coulis over cheesecake, crepes, French toast, ice cream, souffle´s, oranges, pancakes or waffles. Use vegetable coulis for meat or vegetable dishes, such as tomato coulis for grilled fish, pasta or tomato soup. Extracts and Extractions Extracts and extractions are often used synonymously; however, there are subtle differences. • Extracts are substances that are made by extraction with a solvent such as ethanol or water. The alcohol generally burns off or evaporates and the substance remains in concentrated form. • Extractions are methods to separated desired substances. They are also referred to as the compounds from the skin of grapes that may impart body, color or tannin—especially in wine. Extracts may be sweet or savory: • Sweet extracts tend to be mixtures of alcohol, flavors and oils. They include almond, lemon, peppermint and vanilla, among others. • Savory extracts are generally concentrated reductions of meats or poultry. Both types of extracts function as intense flavor enhancers—which is why just a little is needed. Uses: Almond, lemon, savory and tea extracts have a myriad of uses: • Use almond extract to add a nutty flavor to baked goods, such as pastries or pies, and in some Middle Eastern meat stews, Indian sweet rice puddings and/or curries. • Use lemon extract with fish or shellfish, pork and poultry, with or without herbs, or with cakes, frostings, muffins and/ or pies to impart a lemony flavor. • Use savory extracts, such as chocolate or cinnamon, in coffees, dessert sauces and with entre´es (such as mole sauce). • Use tea extracts in beverages and in piquant sauces for protein foods (such as tea-brined meats or poultry). Oils Nut, seed and vegetable-based oils may be relatively odorless and tasteless, such as canola or safflower, so they may not interfere with the flavor of a dish. Or they may be very aromatic and flavorful, such as extra-virgin olive oil or nutty walnut, hazelnut, or sesame oils, which may impart distinct flavors that should be accounted for in finished dishes. • Flavored oils are generally neutral oils that contain palatable ingredients, such as basil, garlic and/or truffles. They may also be infused with citrus fruits, herbs, spices, wine and other ingredients. • Infused oils, such as basil, chili, coconut or garlic, are best if they are used at the last minute for their lingering assertiveness.

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Uses: The use of aromatic olive oil, alone or with Balsamic vinegar, herbs and/or spices, and often Parmesan cheese as a dip for crusty bread is common appetizer, and may appeal to aging tastes. This may be the result of the umami taste from the Balsamic vinegar and Parmesan cheese, or the unctuous mouthfeel of the olive oil. Almond, avocado, coconut, ginger, hazelnut, olive, sesame, walnut and other oils such as these may be used to drizzle overcooked pasta, roasted potatoes and other vegetables, scrambled eggs, seafood, soft cheeses and/or soups to help finish dishes. Infusions Infusions are extractions of flavors from foods at temperatures under boiling. Oils and vinegars may be infused with savory or sweet flavors, such as basil, chili, chives, garlic, lemons and/or raspberries. The infused oils and vinegars can then be used in other recipes for dressings, marinades, salads, sauces, soups and more. Uses: Herbal and vinegar-based infusions have a multitude of uses. • Herbal infusions may be used in coffee and/or tea, along with spices such as cinnamon or vanilla. • Vinegar infusions may be made with dried or fresh herbs, such as basil or rosemary. Oil infusions may be produced with fresh leaves, such as chives, dill, mint, oregano, rosemary or tarragon, and/or whole spices, such as cardamom, cinnamon, cloves, cumin or star anise. Water infusions may be created with fresh herbs, fresh fruits and/or vegetables, such as apples, berries, lemons, limes, oranges and watermelon, or carrots, cucumbers and whole herbs. If ground herbs or spices are used, they should be strained with a cheesecloth before bottling. Juices Fresh juices may be dribbled over foods to impart a sweet, tart or sweet/tart flavor, and to balance flavor. Squirt fresh lemon juice over broccoli or fish: it serves to balance the bitterness of the broccoli and the sweetness of the fish. Juices may also be reduced to achieve both a concentrated flavor and syrupy consistency. Reduction works well with sweeter juices, such as apple or white grape juice. Herb and vegetable juices may also be reduced; then used to flavor stocks, sauces or glazes. Keep in mind that the colors of fruit and/or vegetable juice reductions may also concentrate in intensity or dullness. Uses: Citrus juice may be used in marinades for tenderizing, rather than traditional vinegar or wine-based marinades, such as for lemon chicken or sole. Citrus juice may also replace some or all of the vinegar (such as apple cider, rice or white wine vinegar) in a salad dressing or vinaigrette; deglaze pans; add a sour-sweetness to braising liquids; or hold its own in citrus glazes, fruit toppings, ice cubes and/or smoothies. Small whole citrus fruits may be used to stuff fish or poultry carcasses. Some citrus combinations (such as grapefruit and Balsamic vinegar) might appear to clash. Also beware of adding citrus to dairy products that may cause curdling, or to a sauce that is still cooking, since it may discolor or turn bitter. Marinades Marinades are seasoned liquids that help to flavor and moisten foods. They are generally used before cooking, and frequently have an acidic ingredient, such as citrus juice, vinegar, yogurt (with lactic acid) or wine. Marinades also serve to partially digest tougher cuts of protein (consider the effect of hydrochloric acid on protein in the stomach during digestion). The advantage of using a marinade is that additional fat may not have to be added during cooking. The marinade could be used to baste the foods to prevent drying. Most marinades only contribute a modest amount of fat calories. Uses: Soy sauce adds umami taste in marinades for grilled meat, since it supplies assertive salty and umami tastes against charred flavors. A soy marinade that is made with ginger, honey and lemon is tasty on grilled fish and seafood, and lends an Asian-style taste. A salty-sweet marinade with soy and pineapple works well with beef, poultry or vegetable kebabs. The use of fruit juices (see above) in marinades marries well with fish and seafood, and reduces to a flavorsome glaze. Powerful Cheeses Parmesan and other aged, hard, powerful cheeses such as Asiago or Romano, typically have a rich nutty flavor. They are often encased in an inedible and toughened rind that can be used as a flavor enhancer in some recipes and then discarded. Its umami flavor may be imparted in long-simmered dishes, such as braises, legumes, soups and/or stocks. Uses: By switching to a higher-flavor cheese, less may be more, that means a little may be used to help achieve a great deal of flavor. A little bit of Bleu cheese, extra-sharp Cheddar, Feta, goat cheese, Gorgonzola, Parmesan, Romano or smoked cheese may offer a punch of flavor when reduced-fat cheese is too bland in a recipe, or too much is needed to impact flavor. AGING, NUTRITION AND TASTE

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The key is to sprinkle rather than smother a dish with higher-flavor cheese to let the colors, tastes and textures of the other ingredients come through. Since some of these flavorful cheeses may be higher in calories and total fat than desired, balance these levels with lower-fat and/or higher-fiber ingredients, such as fruits, legumes, vegetables and/or whole grains. In this manner, flavor may be augmented without sacrificing too many calories or fat. Purees Purees are a general term for fruits, legumes or vegetables that have been passed through a sieve and are formed into a soft paste or thick liquid. Purees may be used to thicken sauces or soups, or as dips, side dishes and/or spreads. Uses: Smoothies are often made from pureed fruits and vegetables, such as those that are found in Chapter 10, Menus and Recipes That Appeal to Aging Palates. So are some cream soups, such as cream of asparagus, mushroom or potato. Pumpkin and squash purees are used in some pies and quick breads; marinara sauce can be made chunky or pureed; some salsas are pureed and some fruit sauces are pureed and served over cakes, or dairy and nondairy desserts. Purees may be used for people with chewing and swallowing problems (see The Consistency-altered Diet in Chapter 8: Meeting Nutritional and Disease-Specific Needs of Aging). The degree of pureeing may be individualized. Reductions Reductions are liquids that have been reduced in quantity by evaporation. Reduction both concentrates flavors and thickens liquids, such as in sauces. Uses: The more that stock is reduced, the more concentrated that it becomes, and the more intense flavor is developed. One needs to decide how concentrated and intense a reduction liquid needs to be in order to balance a dish, rather than overwhelm it. This may be highly individualized. However, if the liquid is salted before reduction, then the sauce may be too salty, and this saltiness may be too salty on its own and may unnecessarily bring out other less desirable flavors. Certain liquids are more sensitive to heat, such as those with dairy products or sugary ingredients. To avoid burning, reduction should be done at a simmer. Relishes Relishes are cooked or pickled chopped fruits or vegetables that are mixed together in a sauce. In comparison, chutneys are a type of relish. Relish is normally made with vegetables, while chutney is mostly made with fruit. Uses: Some examples of recipe combinations that utilize relish include cranberry relish with turkey, corn relish with pork chops and roasted beet and horseradish relish with beef and tomato relish with fried or poached eggs. A recipe for TomatoCarrot Relish may be found in Chapter 10, Menus and Recipes That Appeal to Aging Palates. Rubs Rubs are types of marinades that may be dry or wet (pastes). • Dry rubs may include blends of herbs, spices and other ingredients, such as cocoa or coffee, that are rubbed onto the exterior of fish, meat, poultry and/or vegetables. They serve to add flavor, seal in flavor and insulate it, and protect the natural juices from leaking out and drying out the proteins. As a result, little additional fat needs to be used. • Wet rubs, called pastes, may be mixed with mustard, oil, vinegar, water or other flavorful liquid, such as stock, to produce a flavorful crust on protein foods. Uses: A variety of rubs may be blended and applied to foods might include a: • Curry rub with curry powder, cumin, garlic, lemon pepper and turmeric. • Mexican rub with ingredients such as black pepper, cumin, instant espresso powder, smoked paprika and unsweetened cocoa. • Moroccan rub with cumin, cinnamon, ginger, red pepper and sweet paprika. • Peppercorn rub with black and red pepper, oregano and garlic. • Southwestern rub with cumin, chipotle chili powder, cinnamon, garlic and sweet paprika. Rubs may be easily made with or without salt for reduced-added salt diets; however, salt may siphon off tenderizing fluids.

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The recipe for Herb and Lemon Blend for Marinades in Chapter 10, Menus and Recipes That Appeal to Aging Palates, may be used as a dry rub, if desired. Salsas Salsas are various cold vegetable-based sauces, generally of Italian, Latin American or Spanish origins. Some salsas may be thin and pureed, while others may be chopped and chunky. Chilies, fruits, herbs and spices may be added to the vegetable mixtures. Roasting or toasting some of the ingredients may help to caramelize their surfaces and add depth of flavor. Salsas may be used as sauces for many protein dishes, or they can be served on their own as dips. Uses: The use of salsa in culinary application may have started as a garnish for some robust meats, such as beef or pork, but salsa has now moved into recipes, and might total as much as one-half cup or more per recipe. If salsa is used in this manner, it may add as much as one fruit or vegetable serving to a day’s intake, along with antioxidants and phytochemicals, such as lycopene in tomatoes and potassium that is needed to balance the level of sodium in the body. As a condiment, salsas provide very little fat or carbohydrate calories, with about half of the sodium content as ketchup. Plus, it comes in different strengths: mild, medium and hot for various palates. So think of salsas as a possible ketchup alternative for some burgers, chicken and/or potatoes. Combine fruits and vegetables in salsas, such as avocados, black beans, chili peppers, cilantro, corn, cucumbers, lemon, lime, mango, peaches or pineapple for even more interest, taste and texture. Salsas may be used around or over fried, poached or scrambled eggs; in gazpacho, legume soups or stews; ground beef or poultry casseroles; quiches or scalloped potatoes; over chops or fish; or along with stuffing or cooked greens. See the recipe for Better Broccoli in Chapter 10, Menus and Recipes That Appeal to Aging Palates, for a tasty idea that incorporates salsa. Sauces Sauces are liquids, or semisolid liquids with a thickening agent, such as flour or cornstarch and seasonings. Sauces may also be prepared by reduction. Sauces can be used to moisten food and add flavor. The French call white sauce, brown sauce and butter sauce “mother” sauces, because they are the basis for other sauces. Gravy, mayonnaise, simple pan sauces, tomato, vinaigrette and sweet sauces such as caramel, chocolate, custard, fruit and sabayon are useful to enhance the flavor of plain-tasting or simple foods. But easy does it: use the least amount to impart the most taste. They can also be slimmed down in calories, fats and sugars. Uses: There are healthful sauces—not just sauces that are laden with calories, fats and/or sodium. Consider sauces that can flavor and add moisture to simple and yet drier proteins, such as fish, lean meats, skinless poultry and seafood. These include thinned and smooth almond sauce; chutney; guacamole; harissa (Tunisian chili sauce made with dried chilies, caraway seeds and garlic and other ingredients); hummus; masala; pesto (made with basil, pine nuts and olive oil and other ingredients, salsa); tahini (made with garlic, sesame seed paste and other ingredients); and tzatziki (made with cucumbers and Greek yogurt and other ingredients). One of the advantages of using sauces such as these is that many are derived from ethnic cuisines and may appeal to diverse diners. Stocks and Broths Stocks and broths are often confused and used interchangeably. • Stocks are the backbone of many older classic and modern dishes. They are flavorful liquids made with a combination of ingredients that may include bones or other connective tissues from beef, fish or poultry and a mirepoix with herbs, spices and water. A mirepoix is a French term for “mixture.” It is generally a ratio of 50% onions, 25% carrots and 25% celery (fennel, leeks and/or tomatoes may also be added). Besides being flavorful, the finished stock is filled with gelatin from the bones, which provides structure and body to the stock, and gels when it is chilled that may be used as a flavorful accompaniment. The color and flavor of stocks are determining factors in how the final dish both looks and tastes. Caramelizing the bones and vegetables before they are added to the water usually produces a brown stock. It is hearty, so it typically used in meat-based dishes. A white stock tends to be more delicate, and this is the reason why it may be useful for fish dishes. A vegetable stock may be made without bones. To create a depth of flavor, a variety of vegetables, herbs and

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spices may be used. Vegetables, such as mushrooms, peas and/or tomatoes, may be used to contribute more of a meaty quality. The smell of very aromatic vegetables, such as broccoli or Brussels sprouts, may offset the flavor of finished stocks. Their smell is due to the decomposition of compounds called glucosinolates that may be distasteful to some people. • Broths may also be referred to as au jus, essence, nage and/or tea. Broth is a thin liquid made by straining and reducing the cooking liquid in which foods such as meats are cooked. Stocks differ from broths in that they tend to be a little heavier because without the bones there may not substantial body. This difference may just be a matter of preference; however, the texture may affect flavor perception. Broth is sometimes served in a small pool underneath the main ingredient or entre´e. Vegetable or fruit juice may also be used in this manner. Canned beef, chicken or vegetable stock is sometime referred to as broth. Reduced-fat and -sodium versions may be versatile in some recipes, such as those found in Chapter 10, Menus and Recipes That Appeal to Aging Palates. Bone broth (technically a stock made by simmering bones, herbs and vegetables) has become popularized for it health-enhancing aspects, but its accolades for gut, immune and joint health may not be totally founded. Still, bone broth is used by some people to remedy colds by loosening mucus—much like the capacity of hot chicken soup. Uses: Both stocks and broths may be used as cooking mediums for grains, such as quinoa or rice, or for pasta; as braising liquids for poultry or vegetables; or as sauces or soup bases. By reducing broths or stocks, the residual liquid may turn thick and even syrupy—particularly if they naturally contain sugars. Broths and stocks may also be converted into gravies by reduction, or with slurries (thickened mixtures of water and cornstarch or flour). Vinegars Vinegars add acidic taste and help to balance flavor in recipes. Generally, the more aged the vinegar, the deeper the flavor. Vinegars include apple cider, Balsamic, champagne, distilled white, malt, rice, sherry and red and white wine vinegars, among others. • Flavored vinegars are vinegars that are infused with fruits, grains, herbs (such as basil or tarragon), spices, vegetables (such as chilies or onions), wine and/or other ingredients. They may be fruit-flavored or savory. Flavored vinegars may be used to impart the acidic taste and a range of colors to dishes. Uses: Vinegars tend to have distinct personalities, much like their base ingredients, such as mildly sour rice vinegar to boldly umami-rich aged Balsamic vinegar. Use vinegars for a sweet-sour effect in barbecue sauce, baked beans, cabbage slaw, glazes, marinades, over berries, in reductions, salad greens and in soups and stews (especially legumes). Note: Aside from the uses for oils and vinegars that were previously discussed, flavored oils and vinegars may be used around the rims of dishes for color and a hint of richness or a touch of acidity, respectively. A few drops or streaks of flavored oils or vinegars may also be informative to the eater: they may indicate the tanginess or sumptuousness of the rest of the dish to be savored. Wine, Beer and Spirits Wine, beer and spirits that are distilled from almost any foods that contain sugar may be used to enhance the flavor in cooking and baking without contributing too many calories. If these alcoholic beverages are added during cooking, the alcohol may burn off (dependent upon how much alcohol is used, the proof and volume of the alcohol and the length of the cooking time). The contrasting flavors of the alcoholic beverages generally require time to mingle with the other ingredients. If alcoholic beverages are added early in the cooking process, then their flavors may dissipate. If they are applied at the end of the cooking process, their flavors may dominate the finished dishes, so thoughtful use is suggested. Uses: Whether beer, gin, rum, sake or wine is used in recipes, alcoholic beverages may add a complex depth of flavor and amplified pleasure. The more aged the alcoholic beverage, the more potential for the umami taste. Also, alcohol bonds with both fat and water molecules that helps to carry both aromas and flavors. Beer, spirits and wine may also be used as flavor enhancers in marinades for meats, and as flavorful bases when they are reduced into sauces. In particular, the use of beer in bread recipes may serve to flavor and moisten, or it may provide a flavorful medium for beer batter, such as in fried fish.

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Brandy, port and red wine, and harder spirits that may include gin, mescal, rum, tequila, vodka, whiskey and others, may be used in some sauces, or to glaze some baked goods or grilled meats. If used, they should complement, not overwhelm recipes. Lighter and clearer spirits, such as gin or tequila, may be better matched with seafood or white meats, and darker alcoholic beverages, such as stout or whiskey, may be best matched with darker cuts of beef or pork. Wine-soaked fruit may be a solution for the use of over-ripe fruit. Its sweetness and umaminess from the alcohol may perk some tastes and motivate fruit consumption.

Strategy #2: Use Culinary Herbs and Spices Another culinary strategy for changing tastes and/or smells during aging is the use of culinary herbs and spices. Some aging people might be unfamiliar with the range of those that are available, both fresh and dried. They may be more accustomed to salt and pepper, a sprig of parsley, slice of lemon, or maybe a seasoned salt that were used to season and/or garnish the foods. Learning about culinary herbs and spices may unveil a host of flavoring and seasoning opportunities. The following categorizations provide the basis for their applications. Culinary Herbs Culinary herbs are aromatic plants. Their leaves, stems, and flowers are used in cooking and baking to impart flavor. In comparison, medicinal herbs are commonly used for treating disease. Mostly all parts of the plant are used. Culinary spices are strongly scented seeds, bark, roots and/or fruits that are used to add flavor and aroma to dishes. General guidelines for cooking with culinary herbs and spices are given in Table 9.1. TABLE 9.1 General Guidelines for Cooking With Culinary Herbs General Uses of Culinary Herbs • Use only enough culinary herbs so that the taste or aroma of the main ingredient in a dish is not masked. • Do not use culinary herbs to disguise poor quality foods. Dried Herbs • Amounts. Because their flavor is concentrated, use less dried herbs than fresh. Each herb is slightly different. This is a general rule for using dried herbs: • About 1/4 teaspoon ground herbs equals about 3/4 to 1 teaspoon of crumbled herbs, which equals about 2 4 teaspoons of fresh herbs. • Handling. Generally add dried herbs and spices at the beginning to middle of the cooking process so they may impart their flavors over time and soften. • Heat and light. Dried herbs are convenient and available in most grocery and specialty food stores. Their shelf life varies, as long as they are away from heat and light. • Lifetime and storage. Typically, dried herbs, leaves and flowers and whole spices may last about 1 2 years. Seeds may keep about 2 3 years. Whole roots (such as galangal or ginger root) may stay about 3 years. Ground herbs and their leaves and spices may store about 1 year. Fresh Herbs • Adding. Mostly add fresh culinary herbs at the end of the cooking process to retain both color and flavor. • Applying. Typically fresh culinary herbs should be added to cold dishes, such as cheeses, dips, dressings or vegetables; then refrigerated for several hours or overnight, and brought to room temperature before serving. The exception is basil, which may become bitter in this process. • Cleaning. To clean fresh culinary herbs, gently rinse them under cold water; then shake them to remove excess water, or gently spin them in a salad spinner. Place the washed culinary herbs in a slightly dampened paper towel and refrigerate in the vegetable drawer for shortterm storage. • Growing. Fresh herbs may be grown inside or outside, or can be purchased at some grocers and specialty food stores. Use only fresh, unblemished leaves and discard those that have wilted or have a spoiled scent. • Mincing. Fresh culinary herbs should be finely minced for some recipes because more of the volatile oils will be released. Minced culinary herbs (such as chervil, chives, parsley and/or tarragon) that are added as a garnish to food after cooking are called fines herbs. Fine herbs are particularly tasteful on lighter dishes, such as fish, poultry or vegetables. • Mixing. Try mixing mild and strong culinary herbs together to complement, such as delicate thyme and assertive rosemary. • Tying. Fresh culinary herbs (such as bay leaf, parsley and/or thyme) may also be tied into a bundle, called a bouquet garni, and cooked with dishes such as soups or stews; then discarded.

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Culinary Herbs, Herb Blends and Applications Uses. The applications of culinary herbs and herb blends in recipes are shown in Table 9.2. While some herbs may be common (such as basil, dill, parsley or oregano), others may seem unusual (such as cilantro, garlic chives, lemon balm or tarragon). Keep in mind that many ethnic cuisines depend upon these herbs and other more obscure ones, and that they may be the missing links between a mundane dish and one that is memorable. These culinary applications represent a wide range of their uses and possibilities. TABLE 9.2 Culinary Herbs, Herb Blends and Applications Culinary herbs

Applications

Angelica

Cakes, chartreuse and gin

Basil

Minestrone, pesto and tomatoes

Bay

Braises, sauces, soups and stews

Borage

Salads, soups, stews and vegetables

Caraway

Akvavit, cheese, rye bread and sauerkraut

Chervil

Carrots, poultry, salads and seafood

Chives

Eggs, salads, soups and stews

Cilantro

Caribbean, Chinese, Indian, Mexican, Thailand and Vietnamese cuisines

Dill

Baked vegetables, pickles and savory pastries

Epazote

Indian and Mexican cuisines

Fennel

Eggs, lamb, pickles, sausages, sauces and stews

Garlic chives

Eggs, fish, poultry, potatoes and shellfish

Horseradish

Cocktail sauce and wasabi

Hyssop

Meats, salads and soups

Lavender

Infused syrups, lamb and poultry

Lemon balm

Eggs, fresh fruit, salads and soups

Lemon verbena

Custard desserts, fruit, herbal teas and South American cuisine

Lovage

South European cuisine

Marjoram

Beans, eggplant, poultry, seafood and tomatoes

Mint

Dessert and beverage garnishes, lamb, poultry and vegetables

Oregano

Greek, Italian, Mexican cuisines and tomatoes

Parsley

Almost every food, except desserts and/or garnishes

Rosemary

Chicken, lamb, seafood and vegetables

Sage

Fresh or cured pork, poultry and vegetables

Salad Burnet

Dressings and salads

Sorrel

Pureed soups and sauces

Summer Savory

Beans, stews, meat dishes and vinegar infusions

Tarragon

Eggs, chicken, fish, salads and vegetables

Thyme

Poultry, root and tuber vegetables

Winter Savory

Beans, lentils, meats, poultry and tomatoes

Culinary herb blends

Applications

Bouquet garni

Sauces, soups and stews

Fine herbs

Cheese, eggs, fish, game, meats, salads, sauces, soups, stews and vegetables

Herbes de Provence

Fresh vegetables, fish, game meats, soups and stews

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Culinary Spices and Applications Like culinary herbs, culinary spices may lose their flavor when exposed to air and/or heat. Ground spices may age faster than whole spices since more of their surface area is exposed to air. Ideally for the most flavor, spices should be ground as they are needed, such as nutmeg to top soup or pudding right before serving. Ground spices should be purchased in small amounts and replaced as they lose their potencies. Uses. The applications of culinary spices and spice blends are shown in Table 9.3. As with culinary herbs, some culinary spices (such as chilies, cinnamon, mustard or vanilla) may be quite common, while others (such as anise, caraway, cumin and saffron) may be more esoteric, but worth the experimentation for flavor enhancement. TABLE 9.3 Culinary Spices, Spice Blends and Applications Culinary spices

Applications

Allspice

Breads, braised meats, cakes, cookies, marinades, meats, pickled foods, stewed fruits and tomato sauce

Anise

Italian breads and cookies

Annatto

Indian, Spanish, Mexican cuisines, meat and rice

Capers

Fish, game and sauces

Caraway

Poultry, casseroles and meats

Cardamom

Baked goods, curries and fruit dishes

Chiles

Indian, Indonesian, Korean, Mexican, Szechuan, Tex-Mex and Thailand cuisines

Celery Seed

Cole slaw, potato salad and pickles

Cinnamon

Cookies, Greek, Indian and Moroccan cuisines, pie and rolls

Cloves

Hams, pickles, sauerkraut and spice cake

Coriander

Baked goods, Indian, Scandinavian and Middle Eastern cuisines and stews

Cumin

Indian, Latin American and Moroccan cuisines

Fennel

Bouillabaisse, pork stew, roasts and sausages

Fenugreek

Ethiopian, Indian and Moroccan cuisines

Ginger

Asian and British cuisines

Juniper

Boar, lamb, venison, sauerbraten and sauerkraut

Mustard

Dressings, pickling, marinades and sauces

Nutmeg

Breads, cookies, custard, eggnog, squash and spice cakes

Paprika

Creamed sauces, deviled eggs, fish, salads and sausages

Pepper

Wide applications, as with salt

Poppy seeds

Cakes, cookies, noodle dishes, strudel and yeast breads

Saffron

Breads, rice, chicken and breads

Sesame seeds

Breads, crackers, Asian and Mediterranean cuisines

Star Anise

Baked goods and Asian cuisine

Turmeric

Asian cuisine, curries and stews

Vanilla

Baked goods, ice cream and sauces

Culinary spice blends

Applications

Chinese five-spice

Chinese and Vietnamese cuisines powder

Curry

Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Indonesian, Malaysian, Thai, Chinese, other South Asian and Southeast Asian cuisines

Pickling spice

Pickles

Quatre-epices

Charcuterie and stews

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Strategy #3: Focus on Moist-Heat Cooking Methods A third strategy for improving the senses of taste and smell in the aging is to focus on moist-heat cooking. In general, people who are aging may benefit from moist-heat cooking methods that include boiling, poaching, simmering and steaming to soften foods and aid in chewing and swallowing. Combination techniques, such as braising and stewing and slow cooking may also be favored. As a whole, moist-heat cooking methods may rely on broth, stock, water or steam, and they often require the submergence of food and ingredients in liquid ingredients. In particular: Boiling The process of boiling relies upon heat that is first transferred by conduction heat (direct transfer of heat from one solid to another) from a heat source to a cooking vessel, and then by convection heat (transfer of heat though fluids) to a liquid that is contained within the cooking vessel. • An advantage of boiling is that the high heat and rapidly moving water in boiling cooks foods quicker than by poaching or simmering. • A disadvantage of boiling is if foods are boiled too long, they may lose nutrients, especially if the cooking water is discarded. EXAMPLES: Eggs, legumes, pasta, potatoes and rice are foods that benefit from the boiling process. Poaching Poaching, like boiling, also uses conduction heat from a heat source that is transferred to a cooking vessel, and then convection heat via a poaching liquid. The poaching liquid may be broth, stock, water or a combination of these liquids. • Advantages of poaching are that generally tender foods, such as eggs, fish and/or vegetables, may be poached for short cooking times, and additional fat is not required. When poached to the right degree of doneness, poaching may be able to produce both tasty and nutritious foods that absorb the flavor of the cooking liquid in relatively little time. • Disadvantages of poaching are that over poaching may contribute to stringy or toughened eggs, fish, meats or poultry, and overcooked fruits or vegetables. Also, once removed from the poaching liquid, foods and/or ingredients may become dry. • Another disadvantage of poaching is that the flavor of food may not be deep, since there is usually not caramelization (the browning of sugars, mostly on the exterior of foods and ingredients). EXAMPLES: Very delicate foods, such as eggs, fish, fruits, white meat poultry and/or tender vegetables may be poached in flavorful broth or stock, and in more unusual liquids that may include lemon juice, milk, sugar syrup, vinegar, wine or combinations of these ingredients. While water may be used for poaching, the flavor is neutral. Simmering Like boiling and poaching, simmering uses convection heat that has been first been transferred by conduction heat to a vessel from a heat source. The temperature of the cooking liquid is higher than in poaching, and the liquid is typically more agitated. • An advantage of simmering is that this process may be used for tougher cuts of proteins, or foods that may require more time to cook beyond poaching. Like poaching, the flavor of the simmered food may be affected by the cooking liquid. • Disadvantages of simmering are that the temperature is higher and the duration is longer than in poaching. Both drawbacks have the potential of creating nutrient loss. EXAMPLES: Chili, soups and stews that utilize less tender cuts of meats frequently use simmering to cook foods and ingredients. Food that is prepared in a crock-pot is generally simmered. Steaming Steaming also uses heat transfer by convection and conduction heat, much like the aforementioned moistcooking methods of steaming and simmering. In steaming, foods are placed in a steamer basket or colander and

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then carefully lowered over steam that is produced by a boiling liquid. A lid that is placed over the cooking vessel may quicken the steaming process. • An advantage of steaming is that foods may be steamed until just “fork tender,” which helps retain the nutrients that may filter into the cooking water, such as vitamins and minerals. • Another advantage of steaming is that it does not require additional fats. • Disadvantages of steaming are that steamed foods may take longer to prepare properly, and that foods may look unappealing if they are over-steamed. EXAMPLES: Fish (such as crab or sole), meat (such as ham or lamb), puddings, rice, sauces and/or vegetables (even fragile vegetables such as lettuce or mushrooms) may be steamed in a steamer basket or double boiler. Combined Cooking Methods A combination of cooking methods may be used to first brown grains, proteins and/or vegetables by convection heat; then to continue to cook these foods in liquid by conduction heat. • An advantage of a combination of cooking methods is that this approach may be used for less tender cuts of meats and/or fibrous vegetables that may take a longer time to cook. • Disadvantages of a combination of cooking methods are that they may generally be more time consuming, and that may require more advanced cooking skills. EXAMPLES: Braising and Stewing Braising and stewing normally use a combination of dry and moist-heat cooking methods. Braising Braising uses dry and moist-heat cooking methods. First, less tender cuts of meats are commonly browned in fat or oil at high temperatures. Then, vegetables and seasonings are generally added; normally with a liquid or sauce of some complementary. The heat is then reduced, and the pan is covered with a lid to continue the cooking process. Braised foods are then cooked by simmering in the liquid or sauce, and then by steaming from the steam that is released by the simmering liquid and captured by the lid. The process may be long and slow until the ingredients are tender. • An advantage of braising is that as long as fat can be removed or reduced either during or after braising, then braising may be considered as a healthier cooking process. • The disadvantage of braising is that braised dishes may be fatty. To make a braised dish healthier, it could be cooked in advance; then cooled. Any visible fat should then be removed, and the dish may be reheated before serving. • Another disadvantage of braising is that the cooking process may be more time consuming than desired. EXAMPLES: Braised foods include beef bourguignon (in red wine), beef brisket, coq au vin (chicken with wine), goulash, pot roast, sauerbraten and/or Swiss steak that are braised in various flavorful liquids. Stewing Like braising, in stewing a flavorful liquid or sauce is added to ingredients, and then the ingredients usually simmer in the liquid or sauce until they are tender. The differences between stewing and braising are that (1) smaller pieces of foods are used for stewing, and (2) in stewing, pieces of the ingredients are normally blanched, or quickly cooked in a boiling fat, liquid or oil. • The advantage of stewing is that the cooking time is shorter than braising due to the smaller pieces of food that are used that facilitate faster heat transfer. • The disadvantage of stewing, like braising, is the potential for fatty residue. Like braising, the stew should be cooled and the fat should be removed before using to help make the stewed dish healthier. Then the stew should be reheated before serving. EXAMPLES: Typical stewed foods may include root vegetable combinations of carrots, onions and potatoes, along with poultry, sausages, seafood and/or tougher cuts of meats that are suitable for slow cooking, such as chuck, flank, brisket, rump and/or round.

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Slow cooking Slow cooking is used to deconstruct tougher cuts of meat, as well as some fruits, grains, legumes and/or vegetables. An acidic ingredient, such as tomato juice, vinegar or wine, helps to break down proteins and round out food flavors with its acidity. The types of slow cookers that are currently popular are more advanced than the earlier versions of the 1940s when they were initially called “crock pots.” To some people, this convenient cooking appliance represented the liberation of women from the kitchen into the workforce. Today, the technological advances in slow cooking have wider appeal with even greater applications. For example, some “instant” types of these appliances may act as multicookers that may be able to keep food warm, prepare rice to yogurt, pressure cook, saute´, slow cook and/or steam ingredients—all in one device. • An advantage of slow cooking is that more inexpensive, leaner cuts of meat with more connective tissues may be used at lower temperatures. Another advantage of slow cooking is that no additional fat needs to be added. The foods and ingredients normally create their own sauce, and nutrients are usually retained. • The disadvantages of slow cooking are that some meats and vegetables may meld and become more tasteless if they are overcooked. Plus, there may be some vitamin and trace nutrient losses. EXAMPLES: Foods and ingredients that may benefit from slow cooking include more substantial cuts of meats and poultry, legumes, root vegetables and/or sausages. A wide variety of recipes that include beverages, breads, desserts and dips may be prepared in a slow cooker.

Strategy #4: Create Healthy Comfort Foods There are certain foods and beverages that may provide comfort during the aging process, evoke fond memories and provide relief for certain conditions and diseases. They tend to be favorite foods from childhood that have a positive association with home, family and/or friends. In general, comfort foods include those that may provide feelings of consolation or well-being, and elicit emotional support that might manifest in physical comfort. This may be because people tend to focus on and remember more positive emotions and situations as they age, and comforting foods and beverages may be at the core. Often comfort foods are prepared in a simple or traditional style. This varies among individuals and ethnicities, so it is difficult to ascertain which comfort foods and beverages fit all needs, and to develop particular sensory profiles for these items. Many people are comforted or soothed by salty, smooth, soft, sweet and/or unctuous food experiences, as those that may be found in foods such as applesauce, mashed potatoes and puddings, with oral-somatosensory qualities or “mouthfeel.” Olfactory cues, such as experiences in aromatherapy, may also be perceived as comforting, such as warm aromatic tea or essential oils. Some general suggestions for comfort-type foods and beverages that may be adapted according to individual desires and needs are shown in Tables 9.4 9.7. Suggestions for healthier meal preparations are also provided. Although these dishes may be consumed anytime throughout the day, their inclusion in regularly scheduled meals and snacks are encouraged for appetite and weight control and blood sugar maintenance, among other reasons. TABLE 9.4

Comfort Foods for Breakfast or Brunch

• Almond, Cashew, Sunflower or Peanut Butter Food memories: Peanut butter and jelly sandwiches. Modern updates: Use nut and/or seed “butters” on whole-grain bread or toast; top with sliced ripe bananas or thinly sliced apples or pears, if desired. Real fruit jam or preserves or honey may be used in moderation if sugar calories permit. Or add a spoonful or two of nut butter into cooked cereals, pancake or waffle batter to enhance their nutrients, taste and/or texture. • Coffee Beverage memories: Morning tonic and/or after-dinner relaxation. Modern updates: Think of coffee as more than a morning invigorating beverage. Serve coffee with low-fat cream, ice milk or milk; or almond or soy milk and a touch of sweetener, such as agave, honey or stevia (also see Smoothies). For people who prefer their coffee black, consider a flavored coffee, such as cinnamon or vanilla, to help buffer its bitterness. (Continued)

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TABLE 9.4 (Continued) • Eggs Food memories: Inexpensive and filling. Modern updates: Prepare eggs that are hard-boiled, in an omelet, poached or scrambled atop whole-grain toast with a little butter, or on French toast, oatmeal or waffles, as shown in Oat Waffles with Berry Compote with Lemon and Ginger in Chapter 10, Menus and Recipes That Appeal to Aging Palates. Use hard-boiled eggs for more than garnishes, as they are packed with protein and other nutrients, such as the Bvitamins, folate, phosphorus and selenium. For people who must control their cholesterol, opt for egg whites that can be found in liquid and/or powdered forms in many markets. • French Toast Food memories: Weekend sweet treats. Modern updates: Use whole-grain bread, egg whites and light butter to save both calories and fat and increase fiber; prepare in a nonstick pan, or bake, then broil to desired brownness. Cinnamon, nutmeg and/or maple or vanilla extract may be added to the egg white mixture to enhance the flavor. The recipe for Whole-Grain French Toast with Pears in Red Wine in Chapter 10, Menus and Recipes That Appeal to Aging Palates, features French toast with a red wine compote. • Oatmeal Food memories: Hearty and heart-healthy. Modern updates: Make whole-grain oats with ground flaxseeds for extra fiber, with or without antioxidant-packed berries and sprinkled cinnamon. For a twist, consider savory oatmeal with chives and sundried tomatoes, as pictured in Savory Oatmeal with Eggs, also in Chapter 10, Menus and Recipes That Appeal to Aging Palates. Instead of an egg, other cooked protein foods may be added to oatmeal or other cooked grains like farro or quinoa (or buckwheat groats that are actually a grass not a grain), such as grilled chicken, ham or tofu. • Poached Fruits Food memories: Digestive aids. Modern updates: Select dried or fresh poached fruits (or a combination of the two) with their skins, if they are tolerated. Packaged fruits in 100% fruit juice are convenient and portion-sized. Some are used in the recipes in Chapter 10, Menus and Recipes That Appeal to Aging Palates. Poached fruits may be topped with low-fat yogurt and a sprinkling of chopped nuts for a more complete side dish, or over granola or cooked oatmeal for a more substantial breakfast or brunch entre´e. • Whole-Grain Pancakes or Waffles Food memories: Sunday morning breakfast or brunch. Modern updates: Incorporate whole-grain flours mixed with ground flaxseed or pumpkin puree to increased nutrients and fiber. Serve with fresh berries or chopped fruit and/or low-fat Greek yogurt. The waffle recipe in Chapter 10, Menus and Recipes That Appeal to Aging Palates—Oat Waffles with Berry Compote with Lemon and Ginger provides a good example. • Yogurt Parfaits Food memories: Facsimile on frozen desserts. Modern updates: Layer cereal (such as bran or granola) with dried or fresh fruit, fruit that is fresh-frozen or fruits that are canned in 100% fruit juice. Additional dried fruit, finely chopped nuts, pomegranate, sesame or sunflower seeds or even chocolate morsels may be used to provide a crunchy garnish. See additional breakfast and brunch ideas in Chapter 10, Menus and Recipes That Appeal to Aging Palates.

TABLE 9.5 Comfort Foods for Lunch • Chicken, Egg, Salmon or Tuna Salad Food memories: Handy use of leftovers. Modern updates: Incorporate low-fat mayonnaise and minced fresh vegetables such as celery, onion and sweet red pepper into higher-protein salads to provide color, texture, taste and improve their relatively bland image. Dried fruits, such as cherries, cranberries or raisins offer additional color and texture, and nutrients such as beta carotene, calcium, iron, niacin, magnesium, potassium, vitamin E and dietary fiber. Sliced almonds, pistachios or walnuts may be added for extra crunch and their antioxidant benefits if chewing is not an issue. (Continued)

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TABLE 9.5

(Continued)

• Hummus Food memories: None to some people; others, their homelands. Hummus, a mixture of ground chickpeas that are blended with tahini, or sesame seed paste, is a staple in many Mediterranean-type diets, and is fairly available throughout the United States. It may be used as a dip, sandwich spread or vegetable filling, or thinned as a salad dressing. Modern updates: Instead of chickpeas, hummus may be prepared with other cooked legumes, such as black beans, Great Northern beans, green peas or lentils, or added into grain dishes, salads and/or soups for added fiber, phytonutrients and vegetable protein. The flavors may need to be adjusted. • Potatoes Food memories: Substantial; part of a “balanced” meal, such as steak and potatoes. Modern updates: Mix small Yukon gold or russet potatoes with light butter, low-fat cottage or ricotta cheese, or reduced-fat sour cream. Chopped green onions may be added for color, crunch and/or piquancy. • Sandwiches Food memories: Lunchtime standbys. Modern updates: Melt low-fat cheddar or Swiss cheese on whole-grain bread that is toasted, not fried, in butter, margarine or oil. This might be reminiscent of a grilled cheese sandwich with less fat. • Soup Food memories: Inexpensive and filling anytime of day. Modern updates: Prepare broth, consomme´, chicken noodle or chicken rice, lentil or pea, tomato-based or vegetable soups; serve warm-to-hot to release volatile aromas; top with bright or crunchy garnishes, such as chopped basil, chives or parsley, Parmesan cheese or seasoned croutons. Try a drizzle of flavored oil on the top, such as chili or garlic. • Quiche Food memories: Special occasion brunches with European flair. Modern updates: Use egg whites or a combination of whole eggs and egg whites to reduce cholesterol; fill with chopped vegetables, herbs and/ or mushrooms; add just enough cheese such as goat, low-fat mozzarella or Parmesan to bind. Sprinkle with chili powder or smoked paprika for additional color and flavor. See additional lunch ideas in Chapter 10, Menus and Recipes That Appeal to Aging Palates.

TABLE 9.6

Comfort Foods for Dinner

• Baked or Grilled Fish Food memories: Friday food; often fried. Modern updates: Select neutral-tasting cod, sole or tilapia, or heartier-tasting mackerel, salmon or trout with omega-3 fatty acids; simply season with salt and pepper; cook only until opaque; serve with lemon to mask any briny flavor. • Baked Beans Food memories: In familiar cans; paired with hot dogs. Modern updates: Add smoked paprika to create a deeper barbeque-like taste, and a drizzle of honey or molasses for color and sweetness. To add a sweet-sour flavor, try some Balsamic vinegar to help balance the syrupiness. • Beans and Rice Food memories: Southern favorite; economical. Modern updates: Mix cooked whole-grain brown rice with red or black beans; saute´ in vegetable oil rather than pork fat; add chicken, turkey or vegetarian sausage if desired, since this vegetarian combination is substantial enough. • Burgers Food memories: Thriftier versions of beefsteak, a 1950s luxury. Modern updates: To make “better” burgers (lower in calories, cholesterol, total and saturated fat), use thin, 3-ounce patties made from lower-fat ground beef, chicken or turkey or vegetarian patties made from legumes and grains, such as black beans and quinoa. If desirable, top with silky avocado, soft tomato slices and/or tender lettuce and serve inside a softer whole-grain bun, if desired. • Braises, Chowders or Stews Food memories: Succulent methods of extending tougher cuts of proteins. (Continued)

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TABLE 9.6 (Continued) Modern updates: Think leaner and tastier than remembered. Combine braised skinless chicken legs with onions and small red potatoes, and a small amount of lemon juice or vinegar to offset any fat and lend acidity; prepare lean beef stew with carrots, peas and root vegetables such as celery root, parsnips, turnips; or clam or shrimp chowder with lower-fat dairy products, such as reduced-fat milk, or fat-free cream or halfand-half, that provide the illusion of more creaminess. • Chicken and Dumplings Food memories: Satisfying and starchy. Modern updates: Use lean skinless chicken breasts and extra hearty vegetables, such as carrots, corn or peas with fewer dumplings. Or, traditional dumplings may be made mini-sized, with a combination of whole-grain and white flours with chopped herbs for color and flavor. • Chicken Pot Pies Food memories: From hot lunches to simple dinners—beef and vegetable pot pies are also favorites. Modern updates: Use part whole-wheat pastry flour for crust; pack full of vegetables, such as pearl onions, sugar snap peas or summer squash; substitute cream or half-and-half with lower-fat milk or comparable dairy products to bind and still provide a creamy mouthfeel. • Chicken Wings Food memories: Generally barbequed or fried. Modern updates: Blend traditional barbecue sauce with Balsamic vinegar, curry paste, ginger, hot sauce, honey, lemon juice, molasses and/or red pepper; eliminate breading and oil for frying; instead, bake, braise, broil or grill. Scatter with sesame seeds for an Asian or Middle Eastern touch. • Chili Food memories: Often from a can; a hearty extender for ground beef or pork. Modern updates: Use ground chicken or turkey with legumes, such as black or red beans, onions, chipotle or sweet bell peppers and tomatoes; add chocolate or coffee to deepen flavor, such as in mole sauce. • Fish Cakes or Patties Food memories: Crab cakes in the northeastern United States, salmon patties in the northwest; a convenient, lower-fat protein stretch morphed into main meals. Modern updates: Use canned crabmeat, salmon or tuna with finely minced vegetables, such as onions, celery or sweet bell pepper; bake or fry in a sparse amount of vegetable oil. • French Fries Food memories: While French fries supposedly date back to the 1600s in Belgium, a certain fast food empire brought them to the forefront in the 1960s, along with their companion hamburgers. For a relatively low cost, the tastes and flavors of fat, salt and starch could be enjoyed from a handy sack. Modern updates: Select zucchini or sweet potato sticks that are seasoned with herbs and baked, not fried; top with a splash of hot sauce, if desired. Salt is not necessary. Sprinkle with low-fat cheese and/or cooked legumes for more protein. • Fried Chicken Food memories: Boldly seasoned and battered, then pan-, deep- or pressure-fried; popular Sunday fare. Modern updates: Choose white meat skinless chicken that is baked not fried, with a crust that is made of whole-grain breadcrumbs, or a combination of almond flour and coconut milk for gluten-free satisfaction. • Green Bean Casserole Food memories: Creamy mouthfuls filled with canned green beans and fried onion ring topping. Modern updates: Use fork-tender fresh or fresh-frozen green beans that are combined with fresh, saute´ed mushrooms; blend with a cream-type soup low in sodium and fat; then cover with garlic or onion-flavored whole-grain crouton crumbles. • Greens Food memories: Frozen spinach or collards, traditionally served with smoked meat and/or cornbread. Modern updates: Prepare beet, dandelion, kale, kohlrabi or turnip greens with chicken, turkey or vegetarian bacon or sausage; saute´ in vegetable oil instead of pork fat. • Lasagna Food memories: Rich and hearty—a very ample and economical meat or meatless meal. Modern updates: Use whole-grain lasagna noodles or thinly sliced strips of eggplant or zucchini; incorporate a higher proportion of vegetables versus low-fat ground beef, chicken or turkey in marinara-type sauce. Skip the white sauce; cut back on the amounts of cheese and swap with lower-fat varieties. • Mashed potatoes Food memories: Creamy pools of melt-in-your-mouth potato puree; often with well of flavorsome gravies. Modern updates: Use cooked and mashed cauliflower or cannellini (white) beans in part or to fully substitute for mashed potatoes; add chopped green onions or herbs, such as cilantro or parsley and gently saute´ed garlic, if desired. Gravy is not necessary with this type of flavor enhancement. (Continued)

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TABLE 9.6

313

(Continued)

• Meatballs Food memories: Along with hamburgers and meatloaf, simple meatballs (with or without spaghetti) were considered “good old American fare” of post-war United States. Modern updates: Use chicken, lean meat, turkey or texturized vegetable protein; combined with oatmeal and moist and flavorful vegetables, such as garlic, onions and/or sweet bell peppers; bake to brown, rather than fry. • Meatloaf Food memories: An American staple and a classic comfort food, much like apple pie. Conjures home cooking, family, festivities and often better days. Modern updates: Use lean ground beef, chicken, pork or turkey (or a blend) with oatmeal and egg whites to bind; combine with grated carrots, finely minced onion and/or sweet bell peppers for color, moisture and taste. For a vegetarian version, use ground mushrooms, pureed legumes and/or texturized vegetable protein in place of lean poultry or meat. • Pasta Food memories: Before the term “pasta” became popularized, starchy configurations such as bowties, egg noodles, lasagna noodles, macaroni, shells, spaghetti and others primarily accompanied tomato sauce in side dishes. Noodles were flat; often served with Asian dishes. Spaghetti was long for twirling. Macaroni was often served with “gravy.” As ethnic foods permeated the country, pasta took shape. Modern updates: Substitute enriched elbow macaroni with whole-grain elbow macaroni for twice the dietary fiber; add a higher proportion of vegetables, such as artichoke hearts, broccoli, carrots, peas, tomatoes and/or zucchini to round out the starchiness of the pasta, and for color, fiber, moisture and nutrients, or use spaghetti squash instead of pasta for a nonstarchy base. Newer varieties of pasta are higher in protein made with legumes such as chickpeas or soybeans and blended with vegetables such as mushroom and spinach to amplify their color, nutrients and taste. • Pizza Food memories: Pizza “pies” were thin or thick depending on which part of the country that one resided. Italian immigrants who settled in Chicago, New York City, Philadelphia, Saint Louis and other cities popularized its gooey spicy, starchy and tomato-y contents. Modern updates: Instead of a bread-like crust, try one that is made from an oversized tortilla, whole-wheat shell, or even a cauliflower crust; cover with a reduced-sodium marinara sauce; layer with assertive low-fat cheese that may include Parmesan or Pecorino, and top with aromatic vegetables, such as roasted garlic, onions and mushrooms, for a meaty umami taste. • Roasted Chicken Food memories: Friday night dinner and/or Sunday afternoon lunch may evoke roasted chicken, sometimes with potatoes or rice, and a requisite canned or frozen vegetable. Often, the fattiest of chickens were used for flavor, such as capons. Consuming the skin was common. Modern updates: Reduce portion size and add extra vegetables, such as carrots, mushrooms, onions, sweet potatoes, and/or white potatoes during roasting; sprinkle with dried or fresh hearty herbs, such as marjoram, oregano, rosemary, sage or savory; baste with a little olive oil rather than butter. To lower fat, remove the skin before eating. • Shepard’s pie Food memories: Way to repurpose leftovers from Sunday roast; a beef or lamb pie, typically cooked in gravy with such vegetables as carrots, celery and peas; often covered with mashed potatoes; sometimes topped with grated cheese. Modern updates: Use lower-fat ground meat and/or pureed cauliflower (see Mashed Potatoes); add additional chopped vegetables, such as green beans, corn or sweet bell peppers; cheese may be optional depending on the creaminess of the mashed potatoes. • Shrimp and Grits Food memories: A memorable breakfast dish, reminiscent of the southeastern US coast; creaminess due to butter, cheese and often bacon/bacon fat and saltiness from dairy and pork products and a classic staple ingredient, shrimp. Modern updates: Prepare whole-grain grits with chicken or vegetable stock and olive oil or light butter; use a leaner cut of pork, such as Canadian bacon, to retain a smoky flavor; broil or grill the shrimp to add color and texture; use just a little very sharp cheese for more taste with less quantity. • Sloppy Joes Food memories: Ground beef and tomato sauce is a combination of the umami or savory taste that often equals deliciousness. Called a “loose meat sandwich” in the Midwest, and sometimes a “Cuban specialty” in the southeast, Sloppy Joes were associated with acceptance, economics, heartiness, nutrition and taste. Modern updates: Try lean ground chicken or turkey instead of beef; add vegetables, such as carrots, garlic, mushrooms, onions, spinach, sweet bell peppers and/or tomatoes into reduced-sodium tomato sauce; include fresh herbs, such as oregano or thyme, and spices such as chipotle pepper, cumin or curry powder; serve on whole-grain buns. • Stuffed Peppers Food memories: Common to many cuisines that include Danish, Hungarian, Indian, Korean, Mexican, Philippine, Romanian, Spanish and Tunisian; flavor varies from mild to spicy; ordinarily bell peppers stuffed with a variety of ground meats, cooked grains and/or vegetables, with or without cheese, egg, or sauce; like meatloaf, stuffed peppers may evoke memories of home. Modern updates: Use all or part brown rice mixed with lower-fat ground beef or poultry; combine with fresh-frozen vegetables mixtures, such as carrots, green or lima beans and peas; top with thinned tomato puree or tomato sauce; heighten taste with cinnamon, cumin, paprika and/or parsley. See additional dinner ideas in Chapter 10, Menus and Recipes That Appeal to Aging Palates.

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TABLE 9.7 Comfort Foods for Snacks • Apple Pie (and other Fruit Pies) Food memories: Simultaneously sweet and tart, with flaky or crumbly crusts, these works by mothers, grandmothers and/or significant others are feasts for the eyes and stomachs. Their aromas may often be equally appealing and unforgettable. Modern updates: Use just one crust or crumbled topping; reduce sweeteners by about one-half and increase sweet spices, such as cinnamon or nutmeg, to help compensate. • Apple (or other fruit) Crisps: Mix apple slices with a little sweetener and lemon juice to help freshen fruit; top with granola or oats, dried fruit such as cranberries or raisins, and finely chopped nuts, if tolerated; dot with light butter, and sprinkle with cinnamon and/or nutmeg, if desired. • Pumpkin Pie: Consider a crust-less version, or one that is made with ground graham crackers; fill with a lower-fat custard that is made from reduced-fat milk and a combination of whole eggs and egg whites. • Birthday Cake Food memories: Heavily frosted with colored flowers, layered with sweet fruit preserves, and filled with chocolate, yellow or white cake throughout, sweet birthday cakes usually recall equally sweet times with family and/or friends. Modern updates: Use chopped, grated or shredded fruits and/or vegetables, such as bananas, carrots, cherries or zucchini for fruitcake, or pureed beets or black beans for chocolate-like cake. Try part whole-wheat pastry flour that is enhanced with ground nuts, seeds or wheat germ. Frost with thinned low-fat cream cheese or ricotta rather than buttercream. • Bread Pudding Food memories: Frugal cooks combined stale, leftover bread with fruits such as apples or raisins; added rich custard sauce mixed with brown sugar; melted butter, oil or even suet overall; then served ice cream or whipped cream on the side for a decadent finale. Modern updates: Replace challah, croissants or doughnuts with crusty whole-grain French bread; swap heavy cream with reduced-fat cream, half-and-half, dairy milk or nut “milk”; substitute caramel sauce with some agave syrup or honey; add dried fruit, nuts, spices such as cinnamon, mace, nutmeg or vanilla and a touch of bourbon, if desired. • Brownies Food memories: Chocolate lovers yearn for bittersweet tastes and dense, cake-like textures of brownies; whether cake-y or fudgy, made with chocolate chips, cream cheese, frosting and/or nuts and with or without powdered sugar, ice cream or whipped cream. Modern updates: Use cocoa powder that is lower in total fat than some baker’s chocolate; try black bean brownies that are enhanced with pureed black beans for more fiber, phytonutrients and protein; add hazelnuts, pine nuts or pistachios for color, crunch and/or antioxidant benefits. • Chocolate Chip Cookies Food memories: Favorite chocolate morsels nestle within sweet cookie dough, along with the tastes and textures of brown and white sugar, butter, vanilla and often nuts or oats in almost every mouthful; reminiscent of unforgettable home baking. Modern updates: Enhance chocolate chip cookie recipes with pureed bananas, ground flaxseed or cooked quinoa to add fiber, nutrients and texture; utilize dark chocolate for its antioxidant value. • Coffee Cake Food memories: Sweet and aromatic yeasty bakery fare, commonly consumed with “coffee and . . .”; versions run the gamut from cinnamon walnut to sugarglazed fruit preserves. Modern updates: Sprinkle cinnamon-flavored sugar crystals over the top of coffee cakes rather than sugar icing. The use of baking soda yields a more cake-like texture, while yeast is more bread-like, and sour cream imparts a tarter flavor and activates baking soda for leavening. • Dips Food memories: First to appear in US snacking history in the 1960s; preceded by cocktail “spreads” for canape´s or hors d’oeuvres; morphed into variations that included cheese, clam, mushroom and the ubiquitous onion dip, commonly consumed with potato chips. Modern updates: Use Greek yogurt, hummus, pureed avocado or salsa as dip bases instead of cream cheese or sour cream to help reduce fat. Nut butters blended with applesauce or pureed bananas transform into nutrient-packed dips for fresh fruit slices, graham crackers or wafers. • Ice Cream Food memories: Summertime foods offer trigger nostalgia for ice cream with all of its flavors, aromas and accompaniments; cold/creamy/sweet/fun connote the tastes and feelings that are aroused from ice cream, powerfully linked to autobiographical memory; reminiscent as after-dinner treats, the county fair and/or the neighborhood ice cream truck. Modern updates: Substitute frozen yogurt, gelato (Italian-style ice cream that is made with milk, not cream), ice milk, sherbet or plant-based frozen desserts for less fat; top with chopped dried or fresh fruits, minced nuts or dark chocolate morsels; freeze peeled ripe bananas, then puree and use as ice cream base. • Smoothies Food memories: US Baby Boomers enjoyed the onset of smoothies in the late 1960s, mostly from health food stores and some ice cream vendors; originally made from fruit, fruit juice and ice, then ice milk for “fruit shakes.” Modern updates: Chocolate, coffee, frozen yogurt, Greek or traditional yogurt, herbal or nutritional supplements, nut butters, protein powder (including whey), a variety of sweeteners (such as agave, honey or stevia) and/or tea may be added for taste and their nutritive content, and ground chia or flaxseeds for their fiber and thickening properties [1]. AGING, NUTRITION AND TASTE

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See additional ideas for quick, nutrient-filled smoothies and other snacks in Chapter 10, Menus and Recipes That Appeal to Aging Palates.

Strategy #5: Plan and Prepare Meals and Snacks If aging people reside in care facilities, then the cycle menus, medical protocol and/or staff availability may dictate their meals and snacks. Individualized diets such as gluten-free, low-fat, low-sodium and others may require standardized foods and beverages. However, if aging people are in free-living situations, either in care facilities or on their own supported by care providers, family or friends, it might be easier to customize menus for meals, snacks and/or beverages. Based on the Comfort Foods for Breakfast or Brunch, Lunch, Dinner and Snack ideas just provided in Tables 9.4 9.7, meal and/or snack ideas follow in Tables 9.8 9.11 for people without diet limitations or physical restrictions, such as chewing, digesting and/or swallowing. For those people with diet restrictions, the help of a registered dietitian/nutritionist may be needed. TABLE 9.8

Ten Healthful and Comforting Breakfast or Brunch Ideas

1. Banana or zucchini bread with low-fat cream cheese and warmed apple slices. 2. Egg white frittata with chopped kale or spinach. 3. Egg white quiche with mushrooms. 4. Greek yogurt and berry parfait with bran cereal topping. 5. Hard-boiled eggs with lean sliced ham and pineapple tidbits (in own juice). 6. Hot quinoa cereal with chopped dates or figs. 7. Oatmeal with bananas and low-fat yogurt. 8. Peanut butter on whole-grain toast and with sliced peaches. 9. Poached egg on whole-grain English muffin with stewed plums. 10. Whole-grain French toast with low-fat cottage cheese and no-sugar added fruit preserves.

TABLE 9.9

Ten Healthful and Comforting Lunch Ideas

1. Chicken, egg, salmon or tuna salad with yogurt-based salad dressing. 2. Chicken soup with escarole or mustard greens, and cannellini or Great Northern beans. 3. Chopped Greek salad with low-fat feta cheese and olive oil-based vinaigrette. 4. Egg drop or miso soup with sea vegetables, such as kelp or kombu, scallions and tofu. 5. Fresh and dried fruit salad with sweet/sour dressing, and sesame or sunflower seeds. 6. Lentil or split pea soup with celery, garlic, onion and/or parsley, and low-fat chicken, turkey or vegetarian sausage. 7. Marinated three-bean salad, enhanced by minced garlic, dill pickles and/or red onions. 8. Mediterranean cracked wheat salad (tabbouli), with bulgur wheat, mint, parsley and tomatoes in a lemon and olive oil vinaigrette. 9. Multivegetable soup with legumes, such as garbanzos or pinto, and grated Parmesan cheese. 10. Squash soup, such as butternut or pumpkin, with cinnamon or nutmeg and reduced-fat sour cream or yogurt.

TABLE 9.10

Ten Healthful and Comforting Dinner Ideas

1. Crock-pot cooked chicken with hearty root vegetables, such as carrots, celery corn and/or potatoes. 2. Crock-pot prepared chickpea or lentil curry with chilies, garlic, onions and/or sweet bell peppers. 3. Saute´ed or grilled salmon with mustard-yogurt sauce or tropical fruit salsa. 4. Skillet meal with whole-wheat pasta, lean ground beef, tomatoes and Italian or Mexican seasonings. 5. Stir-fried vegetables such as broccoli, onions and/or sweet bell peppers with tofu and peanut sauce. 6. Stir-fried vegetables with lean beef, fish, pork, poultry or seafood and fresh basil or scallions. 7. Stuffed bell peppers, zucchini or eggplant with brown rice and lean ground meat or meat substitute. 8. Turkey chili with chopped onions, corn tortilla strips and/or low-fat cheese. 9. Vegetarian black or red bean chili with diced red onions, sweet bell peppers and/or tomatoes. 10. Vegetarian skillet meal with brown rice, legumes, sweet bell peppers and/or tomatoes.

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Ten Healthful and Comforting Snack Ideas

Coffee smoothie with banana and low-fat yogurt and cinnamon or nutmeg dusting. Chocolate peanut butter shake with low-fat milk or yogurt and bran or wheat germ. Fruit smoothie with berries and bananas, with or without protein supplement. Green pea hummus with garlic, tahini (sesame seed paste) and whole-wheat pita bread triangles. Green tea smoothie with avocado and kiwifruit. Nut or seed butter spread, such as almond or sunflower, on thinly sliced apples or pears. Refried black or red bean dip with salsa and unsalted corn chips. Sliced tomato and mozzarella cheese stack with pesto dollop. Spreadable low-fat herbed cheese on mini brown rice “cakes” or crackers. Tinned fish, such as herring, sardines, salmon or tuna, on thin dark rye bread.

To further employ these lists and to build a healthy daily menu, select one item from each of the meal or snack categories. Try not to repeat ingredients at subsequent meals. For example, though a person may enjoy eggs, a frittata for breakfast and egg salad for lunch, or lentil soup at lunch and black bean chili for dinner may be repetitious. A wider variety of foods and beverages may provide a better array of nutrients, and promote more taste and interest in eating. Another approach to meal planning is to round out these meals and snacks with simple nutritious accompaniments for eating, not merely for garnishing. For example, fruit cubes or vegetable strips may be served alongside simple sandwiches; cubes of lean beef, ham, skinless poultry, seafood or tofu may be served beside simple salads or soups’ and legume or nut butters may be offered together with whole-grain breads or crackers, rather than or in addition to butter, margarine or olive oil. Additionally, a hearty snack that has some carbohydrate, fat and protein, such as hummus or refried bean dip, or a smoothie with yogurt, fruit and a scoop of nut or seed butter or whey protein, has more sustenance than a glass of fruit juice or a piece of fruit or bread on its own. Meal planning for the aging may be simplified by approaching each meal or snack as a “mini-meal” with this carbohydrate 1 fat 1 protein approach. It may also yield more energy producing, nourishing and sustaining meals rather than haphazard food and/or beverage selections.

Strategy #6: Create “Finger Foods” (for Dexterity Issues) The creation of interesting and tasty handheld or “finger foods” for aging people is much like what is required for feeding children. Finger foods for the aging should be easy to handle and consume without silverware. They should also be visually and tastefully appealing, and still be considered as dignified adult food. This may be particularly important for aging people who have dexterity (skill performing hand-related tasks) issues. • Finger Breads, such as whole-grain pita bread or tortillas, may be cut into quarters or slices, and if chewing is not an issue, gently toasted with or without additional fat, such as flavored oil. • Fruit and vegetable sweet breads, such as carrot or zucchini; cheese biscuits, pancakes, scones and tiny whole-grain muffins also constitute finger foods. They may be warmed before serving to heighten flavor. • Cereal, granola and/or meal replacement bars should be comfortably soft enough for chewing. • Finger Fruits, such as bananas, grapes, apple or pear slices and orange wedges may be peeled (if needed) and sliced thin enough for sufficient mastication and to prevent choking. • Use a little lemon juice to prevent browning, and a little sugar (if desired) to help bring out sweetness. • Serve with nut or seed butters or flavored yogurt for dipping. • Finger Proteins, such as cooked chicken or turkey strips, cocktail sausages, eggs prepared omelet-style and cut into strips or squares, fish sticks, pizza cut into bite-sized pieces, meatballs, mini sandwiches such as canned fish, hamburger sliders and/or peanut butter and jelly, and mini-quiches are valuable protein sources. • Dairy or vegetarian cheese may be cut into strips and served “as is,” or with finger fruits and/or finger breads (see above). • While deli-type meats are convenient protein additions, they may also be higher in sodium for some diets. • Finger Vegetables, such as bite-sized lightly cooked broccoli or cauliflower, boiled new potatoes or potato wedges, cherry tomatoes, cucumbers, sugar snap peas, summer squash and/or sweet bell peppers may be served on their own, or with flavorful, lower-fat dairy or legume-based dips. • Fresh is best to maximize flavor; look for convenient sealable packaging. • The use of salt-free herb and spice blends, such as Herb and Lemon Blend for Marinades in Chapter 10, Menus and Recipes That Appeal to Aging Palates, may help to enhance their acceptability. AGING, NUTRITION AND TASTE

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Strategy #7: Make the Most of Modified Texture Foods Modified texture foods (MTFs) are commonly used in long term care facilities for aging people who may require nourishment, yet not have a choice of what they consume. This may be due to degenerative diseases that affect their chewing and/or swallowing, dementia or the aftermath of strokes. Unfortunately, some modified texture foods are associated with undernutrition. They may stem from the fact that some foods may not be adequately ground, so their resultant textures may be challenging to swallow. Other problems with modified texture foods may have to do with their quickness to implement due to refusal or slowness to eat, self-feeding difficulties and/or uncooperativeness. If an aging person is not ready for MTFs, then they may be resistant to their usage and these problems may ensue. If the capability to orally manipulate food and safely swallow it resumes, then more thickened foods with adjusted textures may be gradually integrated under the guidance of a skilled healthcare practitioner. While knowledge gaps, patience and/or time are some of the determining factors in MTF success, nutritional, sensorial and/or acceptable factors must still be considered when feeding this segment of the aging population. In other words, care must be taken to uplift the dining process, even if modified texturized foods are the vehicles. The pleasures of eating and drinking, including food memories and appealing desires, must not be forsaken [2].

Strategy #8: Include Higher-Fiber Foods and Beverages Dietary fiber (also known as roughage) is the indigestible portion of foods and beverages that originates from plants. Soluble fibers tend to delay gastric emptying and may result in a feeling of fullness. Insoluble fibers typically provide bulk and give volume and weight to the byproducts of digestion as they move through the intestines and exit during defecation. Soluble fibers include some fruits (such as apples, avocados, bananas, berries, figs, pears, plums, prunes and/or quinces); grains (such as barley, oats and/or rye); legumes [such as peas, lupins (in Mediterranean cuisine) and/or soybeans]; nuts and seeds (such as almonds, chia, flax and/or psyllium); and vegetables (such as broccoli, carrots, Jerusalem artichokes, onions and/or sweet potatoes). Insoluble fibers include some type of bran (such as corn or wheat); fruits and their skins (such as avocadoes or unripe bananas); legumes (such as beans or peas); lignans (polyphenols in flax and/or sesame seeds); nuts; potato skins; and/or whole grains. To learn how to incorporate both soluble and insoluble fibers in cooking and baking, Twenty Methods to Increase Fiber in Cooking are presented, followed by Ten Methods to Increase Fiber in Baking. Keep in mind that manipulating the ingredients in baking recipes may be tricky since the balance of ingredients are usually precise and the final products may suffer. In the case of extra fiber, the end products may be denser unless compensatory measures are taken. Twenty Methods to Increase Fiber in Cooking 1. Add legumes to meals several times weekly, such as bean casseroles, chickpea hummus, lentil or pea soup or stew or vegetarian chili. One-quarter cup of legumes adds about 5 grams of dietary fiber per serving. 2. Briefly cook vegetables until they are still crisp or fork-tender. (Plants contain cellulose and pectin that are softened by heat.) A test of chewing capability and digestibility is to be able to mash the vegetables fairly easily against the roof of the mouth. It may be easier to chew vegetables that are firm, yet tender rather than crunchy or stringy, as when they are raw. Plus, aromas may be heightened. Still, preferences may reign. 3. Choose whole or multigrain grain breads, cereals and/or crackers first before refined wheat varieties. If 100% whole grains are too difficult to chew, then mix whole-grain cereal with an equal amount of lower-fiber cereal and then gradually transition to more whole-grain content. Likewise, use multigrain breads with mixed flours and crackers that are mostly whole-grain with just a bit of softness. A sandwich may be made with whole-grain and fortified white bread, again to eventually transition to two slices of whole-grain bread. Aim for about 3 5 grams of fiber per slice of bread. 4. Combine ancient grains for fiber content, texture and overall interest. For example one-half cup of cooked bulgur and spelt each contain about 4 grams of dietary fiber; the same amount of farro yields about 7 grams of dietary fiber; pearl barley, sorghum and wheat berries supply about 5 grams of dietary fiber for the same measure; and teff contains about 3.5 grams of dietary fiber per one-half cup serving. Many ancient grains are

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gluten-free for aging people who have gastrointestinal disorders. They also may offer novel tastes and textures to dishes. Consider high-fiber snacks such as popcorn or baked chips made with legumes. The fiber contribution may be only a few grams due to their volume, but it may multiply. Discover bean spreads. Bean (legume) spreads, such as chickpea or pea hummus, add color, fiber, moisture, taste and texture to breads, crackers and/or raw or partially cooked vegetables. Perk up their bland color with pureed or finely diced green or red sweet bell pepper, paprika or freshly minced parsley. Drink fiber-rich beverages that are made by blending whole fruits (including their edible skins and small seeds) with fruit juice, ice cubes, yogurt or water. Still, focus on serving water with meals (about 8 16 ounces per meal) to support the use of dietary fiber in the body. Go easy with acids. If acids (such as lemon juice, tomato sauce or vinegar) are added to recipes, this acidity might make foods firmer. While citrus fruit juice and/or vinegar are recommended to help to brighten foods, this potential change in texture should be taken into account for the final recipe’s appearance and consistency. Include the skin of fruits and/or vegetables whenever possible, such as apple skin in applesauce, scrubbed carrot or cucumber skin in salads and peach, pear and/or plum skin in fruit salads. Make sure that the pieces are small enough to chew and swallow well. The fiber content will vary. Integrate dried fruits as much as possible into baked, cooked and/or fresh dishes. (See Method #18 for adding dried fruits to brown rice.) Dried fruits provided a concentrated source of dietary fiber: 1/4 cup of dried apricots contains about 4.25 grams of dietary fiber; 1/4 cup of dried figs contains about 3.3 grams of dietary fiber; and 1/4 cup of raisins contains about 1.25 grams of dietary fiber. Incorporate fiber-rich breadcrumbs into coatings instead of breadcrumbs that are made with refined white flour, or to replace some of the flour in savory pie crusts and/or quiches. Keep potato skin on but wash first; eat potatoes whole or mashed along with their skin, if chewing is not an issue. About one-half of the total amount of fiber in an average-sized potato is located within the skin. Mix chia, flaxseeds, poppy or sesame seeds, wheat bran or wheat germ into some baked goods or salads for an average of 2 5 grams of fiber per tablespoon (depending on their form, size and/or type), plus color and crunch. Preserve texture: Avoid adding alkaline ingredients, such as baking soda, to vegetables or fruits, to retain their color and/or texture, since this action may make some of the other ingredients soggy and destroy certain nutrients. Replace high-fiber ingredients with about one-half of the ingredients in some recipes for individuals with higher-fiber needs. For example, replace about one-half of the amount of canned applesauce or fruit cocktail (commonly served when chewing is difficult) with finely diced skinned apples or pears. This substitution not only adds more fiber, it may also sustain some of the familiar tastes and textures of the canned fruit. Top cereals, whole-grain pancakes or waffles with berries, fresh fruit with skin or nuts and seeds (if stomached), rather than by syrup alone. One-third cup of a high-fiber cereal adds about 5 8 grams of dietary fiber per serving. One-half cup of berries contributes about 4 grams of dietary fiber per serving. In comparison, just two tablespoons of pancake syrup adds about 120 calories that are mostly from sugar. Use oats for cereal, as a side dish, for breadcrumbs, over casseroles or within meatballs or meatloaf. Onehalf cup of cooked oats provides about 150 calories with about 3 4 grams of fiber. Substitute brown rice for white rice in some recipes, including certain grain-based side dishes and/or desserts. Cooked whole brown rice contributes about 90 calories and 2 grams of dietary fiber per 1/2 cup of cooked brown rice. Use one cup of cooked brown rice for a rice salad with chopped fresh or lightly cooked vegetables that totals at least twice this amount of fiber. Or, add chopped dried fruits to cooked brown rice before serving (see Method #2). Treat fiber-rich ingredients as salad toppers. For example, use avocadoes, blueberries, chickpeas, dried fruits and/or nuts or seeds instead of salty croutons or tortilla strips to enhance appearance, nutrients and/ or texture. Make sure that they are in bite-sized pieces and relatively easy to masticate. Use whole fruits and vegetables whenever possible, unless they are juiced in which the skins are incorporated. For example, use small vegetables, such as baby carrots, patty pan squash or pearl onions in hearty soups or stews, and apricots, berries and/or grapes in fresh fruit salads or in smoothies. Utilize fiber-rich ingredients as thickeners for some sauces. For example, incorporate pureed cauliflower or white potatoes into some sauce recipes instead of cornstarch or white flour. Note that this measure may also add some taste and/or texture, so the final product should be taken into consideration.

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Ten Methods to Increase Fiber in Baking 1. Add finely chopped nuts such as almonds, hazelnuts, pecans, pistachios or walnuts, into brownies, cookies, muffins and/or cakes recipes to help increase their fiber content to varying degrees. Take note: when nuts are mixed into batters, their texture may soften. 2. Blend flours. Barley flour, bread flour, oat flour, rye flour, whole-wheat flour and whole-wheat pastry flour should add more fiber, nuttiness and sweetness in baking when these flours are blended with all-purpose flour. But some of these flours are lower in gluten that is responsible for bread to rise, so this is an additional reason why these flours should be used in combination with all-purpose flour. 3. Experiment with specialty flours, such as sweet coconut flour that contains about 5 grams of fiber in 2 tablespoons. One tablespoon of chia flour (produced by grinding chia seeds) contains about 6 grams of fiber. About one-quarter to one-third of the wheat flour in a recipe may be replaced with a specialty flour such as amaranth, quinoa or teff that does not contain gluten. However, different baking properties must be taken into account before substitutions are made, such as the total gluten-content, and whether or not the chosen specialty flours yield firm or delicate finished products. 4. Incorporate fruit and vegetable purees. A puree of apples, avocadoes, bananas, hummus, pears, pumpkin, red lentils, sweet potatoes and/or yams may be able to decrease fat calories, increase fiber and other nutrients and replace some of the sweeteners in recipes. About two-thirds of the total amount of butter, oil or shortening may be able to be replaced in this manner. 5. Increase certain fibers to add crispness or retain moisture in breadstuffs, such as in some softer, but higherfiber white breads or tortillas. Other fibers may be substituted for some of the fats in breadstuffs that serve to lower calories, increase satiety and/or improve nutrients. Appearance, aroma, color, crumb and acceptability may be influenced, due to differences in mixing, proofing and baking times and finished textures. 6. Integrate ground nuts for additional flavor, nutrients and texture. Ground almonds and ground walnuts each contain about 3.5 grams of fiber per one ounce. If they are ground into nut “butters,” then their fiber content will increase to about 3.2 grams of fiber per 2 tablespoons of almond butter and about 1.9 grams of fiber per 2 tablespoons of peanut butter (peanuts are legumes, not nuts). 7. Mix fiber-rich ingredients into savory or sweet crusts. Incorporate whole-grain breadcrumbs or crushed whole-grain crackers, such as bran or graham, into pie shells, along with herbs or spices, or incorporate some fiber powder into the crust ingredients for thickening. Be careful however, since a small amount of fiber powder may be sufficient. Experiment first by mixing a little fiber powder into a glass of water and observing its thickening capabilities before using too much and regretting the outcomes. 8. Try cocoa powder. About 6 tablespoons of low-fat cocoa powder provides about 5 grams of fiber and may be used in some brownie and other chocolaty desserts recipes (other ingredients may require adaptations). 9. Use resistant starch to add fiber to baked items without imparting color. Resistant starch is a type of starch that is not fully broken down by the human body; rather it is turned into short-chain fatty acids by intestinal bacteria that may be used for energy. It may also have some gastrointestinal benefits. By using resistant starch, a white or cream crumb color may be achieved, with a neutral taste and low water-holding capacity. 10. Utilize oats if they complement recipes. Raw rolled oats contain about 9.6 grams of fiber per one cup. Oat flour adds about 8.9 grams of fiber per one cup. A typical oatmeal cookie recipe may necessitate about 3 cups of rolled oats combined with 2 cups of flour, often white, which provides about 4.4 grams of fiber per cup. By changing the white flour to whole-wheat flour, adding 1 cup of finely chopped walnuts and 2 cups of raisins, the total fiber content of a recipe with these proportions may total around 48 grams, with about 1 gram of fiber per cookie [3].

Strategy #9: Lower Total Fat and Switch to Other Fats, Oils and Fatty Ingredients Fats and oils are very important to taste, texture and pleasure, among other attributes. Equally important is that fats function as a major nutrient, along with carbohydrates, proteins, vitamins and minerals. In fact, fat is a vital secondary energy source when carbohydrates are not available to the body, and fats play critical roles in metabolic functions and nutrient absorption. In cooking, fats and oil serve as a cooking medium, flavoring tool and as a main ingredient. As a cooking medium, fats and oils may be heated to high temperatures to help brown ingredients and create crispy crusts. Browning has the capacity to impart earthiness, meatiness, nuttiness, savoriness and sweetness (see Maillard reactions).

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As a flavoring, fats and oils have the ability to carry flavors, enhance tastes and enrich textures. Fats typically coat the inside of the mouth and encourage aromatics to linger longer. A number of volatile aroma and flavor compounds are fat-soluble (some vitamins and minerals depend upon this feature of fats for their uptake). This is one of the reasons flavorful ingredients, such as garlic and onions, are saute´ed in a little fat or oil to release their flavors early on in recipes, and why fat is used to baste fish, poultry or even meats during their cooking processes. As a main ingredient, fat tends to impart a rich taste and mouthfeel. Fat also seems to elicit sounds (think about the sounds of crisp foods that seem to “crackle and pop”). By eliminating all fats and oils in recipes to save calories and/or fat grams, the tastes and textures of recipes and their memorability may suffer. Many of the flavors of meats come from the distinctive lipid (fat) profiles in animals, such as a steer compared to a lamb or a pig. They may also be dependent upon an animal’s feed; be it grass, corn or other substance. Grass-fed animals may be leaner with less fat, so the cooking methods that are used may require fat, moisture or both. Culinary experience, ingredients and desired tastes and textures will determine which cooking methods and/or fats or oils are needed. Some recipes may benefit by a combination of fats that are used judiciously. They may start with butter or olive oil for saute´ing, and then require some additional fat or oil for finishing. As stated, this is to initially carry flavor, and then to call attention to flavor. For example, a neutral oil may be fine to meld garlic and onions, but a very flavorful olive oil might supply an luscious finish. If fat is a dietary or health issue, then be judicious with the amounts of fats or oils that are used, but try not to entirely eliminate them. Other methods to reduce total fat or change the type of fat from saturated to unsaturated fatty acids are given in Table 9.12. They depend upon specific recipes and individual needs and tastes. TABLE 9.12

Ingredient Substitutions to Reduce Total Fat, Change the Type of Fat and Preserve Taste

• Bacon—Use Canadian, soy, turkey bacon or smoked lean meats, such as Italian or Spanish ham, like Iberico or Parma, to replace bacon in some recipes. • Butter—Use applesauce or prune puree as a substitute for fat in baking. Also, choose nonhydrogenated and/or trans-free margarine or shortening, vegetable oil or whipped butter (with more air and less fat) as a butter substitute in certain recipes. • Cream Cheese—Use low-fat cottage cheese, Neufchatel cheese, reduced-fat cream cheese or low-fat ricotta cheese for regular cream cheese in selective recipes. • Cream Sauce—Use evaporated skim milk, milk-based soups, pureed plain vegetables (such as cauliflower, lima or white beans, or potatoes), pureed silken tofu or soy milk as an alternative for cream sauce in related recipes. • Eggs—Use agar-agar (algae-based gelatin), applesauce, arrowroot powder, aquafaba (the liquid from cooked legumes), blended silken tofu, buttermilk, carbonated water, commercial egg replacers, egg whites, ground flaxseeds or chia seeds, mashed bananas, nut butters, plain yogurt, soy lecithin, vinegar and/or baking soda in part or combination as an egg substitute in certain recipes. • Ground Beef—Use extra-lean or lean ground beef, ground chicken or turkey; extend ground beef with bran cereal, brown rice, legumes, oats, Parmesan cheese, texturized vegetable protein or whole-grain breadcrumbs for some or all of the ground beef in comparable recipes. • Mayonnaise—Use almond butter, hummus, low-fat plain Greek yogurt, mashed avocado, mustard, olive oil, pesto, reduced-fat mayonnaise, salad dressing or vegan mayonnaise for regular mayonnaise in similar recipes. • Milk—Use fat-free or reduced-fat milk, blended and thinned fat-free or reduced-fat cottage cheese, evaporated skim milk, reconstituted evaporated skim milk powder or unsweetened almond, rice or soy milk for whole dairy milk in equivalent recipes. • Oil-Based Dressings (such as vinaigrette)—Use acidic fruit juices such as lemon, lime or orange, broth or stock, flavored vinegars or wine in some recipes that may benefit from less fat and more acid. • Sour Cream—Use low-fat varieties of buttermilk, cottage cheese, cream cheese, evaporated milk, sour cream, plain yogurt with or without baking soda, lemon juice or vinegar to create sourness with less fat than some sour cream varieties [4]. Data from https://www.healthline.com/nutrition/egg-substitutes#section10.

Strategy #10: Lower Sodium and Replace Salty Foods and Beverages With Reduced-Sodium Ingredients Like fats and oils, lowering the sodium content of foods and beverages may be challenging because eliminating salt in cooking (and sodium which is a component of salt and a constituent of other ingredients) will likely diminish flavor, too. It is true that salt adds a particular saltiness to foods and beverages, but it also enhances the perceptions of other tastes and brings them together, or it eradicates those that are less desirable. Consider a pinch of salt in a sweet dessert (such as salted caramel) or on meats to bring out their umami taste. Salt may also be used to help foods taste moister. An example of this function is the use of salt on chopped or minced vegetables as they saute´ in fat or oil. This practice may delay browning and create liquid and/or steam for cooking, which may be desirable for people with chewing issues. AGING, NUTRITION AND TASTE

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Salt should be added to meats before they are cooked, since the salty taste may permeate more than when it is sprinkled throughout the cooking process. However, chefs still recommend this practice to help build flavor. When salt is first added to the cooking water of starches, such as pasta, potatoes or rice, it will usually be absorbed—even if the cooking water is discarded. As long as other salty ingredients are then added, such as tomato sauce that is naturally higher in sodium, no additional salt should be needed. Keep in mind that salt is a mineral that helps to alter the chemical reactions in foods. Tasting and adjusting the salt level throughout the cooking process may help to achieve the right amount of salt. This is unless the taster has lost some taste sensitivity. Also, by layering salty ingredients this may help to achieve a fuller salty finish—sometimes without the presence of salt itself. Consider a homemade Caesar dressing that is built with anchovies, Parmesan and Worcestershire sauce. Even a reduced-sodium version may be impactful. Some general methods for reducing the amount of salt and sodium in cooking are given in Table 9.13. TABLE 9.13

General Techniques to Reduce Salt and Sodium in Cooking

• Add more bland, rich, starchy, or unseasoned ingredients to increase the total volume of finished dishes. Example: If a pasta sauce is too salty, then add more cooked pasta, one cup at a time and mix, then adjust the flavor with fresh herbs such as basil or oregano and/or spices such as black or red pepper. A little grated or shredded Parmesan cheese may be used to top, but it is also a source of sodium. • Balance recipes with additional acid or fat, such as olive oil or vinegar, if calories permit. Example: In addition to the extra pasta as in the first example, saute´ed mushrooms, such as porcini or Portabella in extra-virgin olive oil, will add the umami taste and texture to help balance the saltiness. Plus, a splash of Balsamic vinegar will add an uplifting finish. • Divide recipes in half and correct the amount of salt in one-half of the recipe so that there is a second batch to adjust, if necessary. Example: In the first half of the pasta recipe, try increasing the amount of pasta, and in the send half of the pasta recipe, try the saute´ed mushrooms in olive oil and/or the Balsamic vinegar finish; then compare the two preparations for the least salty tasting version. • Remove some of the ingredients that may not have been affected by over-salting, such as braised meats or legumes, and then repurpose them in a lower-sodium medium, such as unsalted broth or stock. Example: Remove the pasta; rinse in a colander with water to remove some of the salty sauce. Use a lower-sodium sauce, dilute the original or dress with a garlic-flavored olive oil.

Look for salt and sodium in the ingredients given in Table 9.14, along with lower salt and sodium options. Plus learn how to enhance the taste of salt by using alternative ingredients. TABLE 9.14

Common Ingredients That Contain Salt and/or Sodium

• Canned Sauces, Soups and Packaged Mixes—Use low- or reduced-sodium varieties; choose packaged and/or prepared foods by comparing sodium levels; look for the lowest amount of sodium on the ingredient label that still delivers the most taste. • Canned and Frozen Vegetables—Since salt is often used in processing, look for no-salt added on food labels; choose products without sauces that are generally higher in sodium. • Canned Legumes (Beans)—Drain and rinse canned beans a few times to help reduce sodium as much as 40%. • Condiments—Select reduced or low-sodium versions of ketchup, salad dressings, olives, pickles, relish, salsas and/or soy sauce if they are available; do not oversalt recipes with these ingredients to compensate. • Cooking Methods—Utilize braising, broiling, grilling, saute´ing and/or searing to enclose certain ingredients, such as fish, meats, poultry and vegetables, and bring out their natural flavors, including the inherent saltiness of proteins. • Flavor Enhancers—Use citrus juices, herbs, garlic, onions, spices and/or vinegars to boost flavors when sodium is cut in half or less in recipes; ensure that the recipes still make senses and are balanced. • Food Additives and Preservatives (such as sodium citrate and sodium phosphate)—Look for ingredients such as these that are salts; use fresh ingredients as much as possible to keep sodium from mounting. • Fresh and Frozen Poultry—Use products that have not been injected with sodium solutions that may appear as broth, saline or sodium solution on ingredient labels. (The sodium level of unseasoned fresh proteins should be about 100 milligrams or less per four ounces.) • Lower-Sodium 1 Higher-Sodium Ingredients—At first, use equal amounts of lower-sodium ingredients with higher-sodium broths, soups and/or tomato-based sauces to help adjust palates to less sodium; then adjust. • Potassium-Containing Foods (such as bananas, cantaloupe, greens, kidney beans, nonfat yogurt, oranges, potatoes, sweet potatoes, tomatoes and/or white beans)—Combine potassium-rich foods with higher-sodium ingredients to help counterbalance the effects of sodium on blood pressure. • Seasoned Salt—Favor herb or spice blends, or a combination of seasoned salt and herb and spice blends for a saltier taste with less sodium; some salt substitutes tend to be higher in potassium. • Soy Sauce—Utilize reduced-sodium soy sauce, tamari sauce or a combination of regular soy sauce and reduced-sodium soy sauce to help flavor Asian recipes, or in meats, soups, stews and/or vegetables. • Table Salt—Try course sea salt with larger crystals than table salt (and slightly less sodium due to the crystal size), herb or spice blends or table salt that is mixed with some sea salt or herb or spice blends [5].

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Strategy #11: Lower Sugar and Replace with Naturally Sweetened Foods and Beverages Like fat, sugar is a source of calories, but unlike fat, sugar contains about half of the amount of calories per gram (9 calories per gram for fat and 4 calories per gram for sugar). Reducing added sugars to the minimum while preserving the sweet taste should be an aim for many savory and sweet recipes. Many aging people may benefit by fewer calories and less sugar without affecting good taste. Like fat and salt, when a person decides to consume less sugar they may tend to cut it out of their diet altogether. However, sugar has many purposes in the diet other than energy and in cooking. Diabetics need to be particularly cognizant of dietary sugars and blood sugar, which was discussed in Chapter 8, Menus and Recipes That Appeal to Aging Palates. In cooking, sugar tenderizes by absorbing water and inhibiting gluten development and starch gelatinization, assists in the recrystallization of candies, caramelizes under heat, delays egg protein coagulation, enhances the smoothness of ice cream, helps stabilize egg foams, improves the appearance and tenderness of canned fruits, incorporates air into shortening, interacts with proteins and starches during baking and cooking, postpones the discoloration of frozen fresh fruits, prevents the spoilage of some jellies and preserves and regulates fruit gels and speeds yeast growth. To successfully reduce sugar in cooking, one must be cognizant of the fact that some of these functions may fail. In general, the total amount of sugar may be reduced by about one-third in some recipes without too many negative consequences—especially when it is not one of the major ingredients. Initially, a person may want to reduce this figure in half, say 10% 15% of what is listed in a recipe, taste the result and then cut further. When adding sugar to recipes, such as fruit-based desserts, it may be wise to try 1 tablespoon of sugar or other sweetener at a time due to the wide variations in fruit sweetness. As sugar “melts” it helps to lure the natural juices from the fruits, so this step may be compromised if an inadequate amount of sugar is used. It may be safe to reduce some of the sugar in quick breads (such as banana, carrot or zucchini) since they only need to brown at the tail end of a typically lengthy baking period. This may also be the case for some no-bake bars and quick-bake cakes and cookies (but their shelf-life may be reduced since sugar contributes to moisture). The amount of sugar in frozen dessert and ice cream creations may be more of a delicate balance since sugar prevents frozen items such as these from freezing solid and helps to develop smooth and creamy texture [6]. Ideas to help reduce sugar in the diet and in cooking and baking, and still maintain the sweet taste and overall flavor are given in Table 9.15. TABLE 9.15

Ingredients that Evoke the Sweet Taste

• Chocolate or Cocoa Powder—Use in dried or liquid forms to provide complexity to sweetness along with bitterness and/or umami. • Dried Fruits and Purees (such as apricots, dates, figs or prunes, or applesauce or mashed bananas)—Mix chopped or pureed dried fruits into both baked and savory dishes, and fruit purees to replace some fat and sugars in some cookies and muffins. • Fruits Canned in Heavy Syrup—Utilize fruits canned in their own 100% juice in some instances to replace fresh-frozen or even freshly cut fruit. Take the moisture content into consideration when reworking recipes. • Fruit-Flavored Yogurt—Blend plain low-fat yogurt with fresh or dried fruits or nonsugar-added fruit preserves. • Glazes—Combine unsweetened jams with fruit juice or water instead of using sugar glazes. Or sprinkle baked goods with sweet and spicy sugar blends (see the section Naturally Sweet/Spicy Spices and Extracts) to give the illusion of more sweetness. • Naturally Sweet/Spicy Spices and Extracts (such as allspice, cardamom, cinnamon, cloves, ginger, mace and/or nutmeg, and almond, maple or vanilla extracts)—Use during the preparation of savory and sweet recipes to help camouflage the loss of sweetness, and after to sprinkle on top of finished dishes to enhance the flavor further. • Other Sweeteners—Substitute agave, honey or stevia for up to one-third of the sugar called for in a recipe. When substituting liquid sweeteners for dry sweeteners, then some of the liquid in recipes may need to be adjusted. • Powdered Milk—Replace up one-fourth of the granulated white sugar in some baking recipes with dry milk powder that is naturally sweet from the milk sugar lactose. • Smoothies—Use fresh, fresh-frozen and/or fruits canned in their own juice, either alone or in combination with nut milk, soy milk or yogurt, and with or without ice as a beverage, refreshing dessert, or snack. Frozen ripe fruit, such as bananas or berries, help provide an additional burst of natural sweetness and viscosity. • Sugar Substitutes—Experiment with natural sugar substitutes, such as agave nectar, blackstrap molasses, brown rice syrup, coconut sugar, date sugar, date palm sugar and/or stevia. They vary in taste, their roles in recipes and performance; subsequently, each of these sugar substitutes may affect the flavor and functionality of final dishes or formulations. Other sugar substitutes may be found in discussions that regard diabetes throughout this book. • Syrup—Use natural fruit syrups that are reduced in sugar, honey or pureed fruit. At about 60 sugar calories per tablespoon, extra syrup adds up. Instead, foodstuffs such as French toast or pancakes may be lightly spread with one of these items, then rolled or folded and eaten out of hand.

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Strategy #12: Construct Bite-Sized Food Portions Even a smaller portion than 6- to 8-ounce servings (such as 3 4 ounces of fish, poultry or meat) may be overwhelming for smaller appetites. It might be better to serve smaller amounts and then offer more depending on individual needs. The number of pieces and the portions of foods may impact internal reward mechanisms and satiety. Multiple pieces of food may be more filling and rewarding than even the smallest serving, yet they may equal the same number of calories. For example, if three ounces of beef are served as a beef filet, versus cubed in beef stew, the beef stew may feel as though more beef is consumed. Apparently, the number of items that are consumed cues some people to the quantity of food and their feeling of fullness. On the flip side, if someone is allotted only 3 4 ounces of protein per meal, then cutting this amount into multiple, smaller, but still energy-dense pieces may cause her to think she has more to consume to be satiated. The key is to individualize as much as possible for correct perception and consumption. Table 9.16 shows some higher protein, vitamin and mineral-rich additions to the diet that are available in smaller and often more versatile sizes. TABLE 9.16

Higher-Protein, Smaller-Sized Protein Additions to the Diet

• Animal Proteins. Three-ounce portions of lean beef, fish, pork or poultry provide about 22 26 grams of protein, on average. • Cheese, such as low-fat cheddar, mozzarella or Swiss, provides about 8 grams of protein per one ounce (one slice or one cubic inch). Lowfat cottage cheese provides about 14 grams of protein per one-half cup. • Chopped fish, ground beef, minced chicken or shredded pork tend to be lighter than chunks with less protein (about 4 or more grams of protein per ounce, versus 6 or more grams of protein per ounce). • Eggs provide about 6 grams of protein per whole egg or about 4 grams of protein per egg white. • Cooked legumes contribute about 8 grams of protein per one-half cup serving. • Low-fat milk supplies about 8 grams of protein per 8-ounce glass. • Low- or nonfat yogurt provides about 13 grams of protein per 8-ounce serving. • Nonfat dry milk powder adds about 3 grams of protein per 1 tablespoon. • Nutritional supplements (in the form of drinks or shakes) may contribute about 10 15 grams of protein or higher. They may be dairy or soy-based depending on consumer needs. Many offer an array of vitamins and minerals, but calories and/or carbohydrates may be high. • Nuts, such as almonds or walnuts, contribute about 7 grams of protein per 1 ounce, which is about one-fourth cup. Peanut butter adds about 4 grams of protein per 1 tablespoon. • Soy substitutes, such as crumbles or burgers, supply about 10 15 grams of protein or more per 3-ounce portion. Soy yogurt delivers about 8 grams of protein per one (8-ounce) container [7]. Data from https://www.foodnavigator.com/Article/2012/07/18/Bite-size-foods-are-more-rewarding-suggests-study#.

Strategy #13: Create Visually Appealing and Ethnically Correct Garnished Foods Garnishes are substances that are used for decoration or embellishment of foods and/or beverages. They function as eye-appealing representations that inform diners of upcoming tastes and textures. This is why the same ingredients used as garnishes should appear in recipes, and be identifiable as such. For example, a piece of curly parsley is typically placed on a plate to add some greenery and texture, but it may seldom be consumed. By switching to a smaller piece of broad-leaf or Italian parsley and then using it minced or chopped in the dish, consumption may increase. However, if the diner is accustomed to a sprig of cilantro rather than parsley, then cilantro should be used in its place to foster consumption. A few long strands of herbs, such as chives, or a cluster of basil may also be perceived as colorful and tasty, if consumed. Kale with its deep green color and ruffled leaves is visually impressive and conveys its antioxidant, vitamins and minerals content that may also be reflected within a dish, as do beet greens, red chard and/or sprouts. A bright green garnish of fresh mint may also lightly infuse a fruit-based dessert, or cold or hot beverages. Another example of a garnish that coordinates with a finished dish is an orange or red-colored carrot, sweet bell pepper, pumpkin or squash soup. By using a carrot curl, sweet bell pepper strip or pumpkin or squash seeds, or even a slice of cooked squash pulp, the recognition of the soup and its desirability may be heightened. Similarly, a lemon wedge often accompanies grilled fish or vegetables for visual appeal and taste if it is actually squirted. It may rarely be used, yet a squeeze of lemon juice adds acidity and aroma and brightens the taste of foods that may be less desirable, such as fish or cruciferous vegetables like broccoli or Brussels sprouts. Instead of lemon, a slice of lime may be used for Hispanic cuisines, or a slice of orange may accompany some Asian or Caribbean dishes. A thick cucumber or zucchini slice, or half of a lemon, lime orange or tomato may be

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used as a receptacle for some sauces that may accompany protein foods, such as a light butter or cream sauce, mayonnaise, salsa or soy sauce/tamari. Garnishes may also help to fill the empty spaces on a plate and convey that the dish is more substantial than it truly is. This may be important when smaller portion sizes are served so that they do not look so isolated on a plate. Using a swirl of sauce alongside a small portion of dessert, for example, may help to give the illusion that there is more than meets the eye. Generally odd numbers of ingredients look better on a plate with one of the aforementioned garnishes. Brilliant white plates provide backdrops for foods, ingredients and their garnished so that they look more vibrant. For more ideas, see the garnishes used in Chapter 10, Menus and Recipes That Appeal to Aging Palates, and Chapter 11, Cooking Aids, Tableware Tips and Dining Advice [8].

Strategy #14: Prepare Foods for Easy Chewing Chewing and/or swallowing problems may result from discomfort or stiffness in the jaw muscles, insufficient saliva, mouth pain and/or problems with dentures or teeth. Dysphagia (difficulty swallowing) may cause a delay in the swallowing process. Problems with the throat or the pharynx (the membrane-lined cavity that lies behind the nose and mouth and connects to the esophagus) might result in swallowing difficulties coupled with coughing or choking. Other than working with a speech pathologist who specializes in swallowing disorders, some changes in culinary techniques might help these disorders. Taste, temperature and texture matter for chewing and/or swallowing problems. As discussed in Chapter 7, Flavor Enhancement Techniques, taste should be maximized for eating enjoyment and diminished for certain taste aversions. Temperature should be neither too hot nor too cold, but just enough to maximize taste. Generally speaking, heat will transfer aroma and taste molecules better than cold solutions. Texture should be interesting enough to avoid boredom without being too chunky or pureed. What this means for the planning and preparation of meals and snacks is that they should have a diversity of taste, temperature and textural experiences. Providing mashed potatoes that are sumptuous and warm, alongside tenderly textured meat, with a smooth avocado salad and a tart lemon ice dessert offers a variety of taste, temperature and texture encounters. Diners should then be encouraged to switch bites within the same meal to help prevent boredom, and to help engrain the delicious memories of each bite and the meal in its entirety. The oral cavity needs to stay moistened in order to help ease swallowing. This may be challenging for some people who produce less saliva. Having a sip of water before the beginning a meal, and sipping water throughout a meal may help to moisten any dry foods, and maintain their moisture as they are masticated and swallowed. While water is best, as long as a liquid is not unusually bubbly or filling it may serve to help foods move along the alimentary canal. Sometimes water or thin liquids may provoke coughing. In this case, an over-the-counter liquid thickener may be added to water or liquid that should not alter the appearance or taste of the foods. Antihistamines found in some allergy, cold medications and/or sleeping aids may also dry the oral cavity as well as the eyes and nose, potentially affecting the sensations of sight and aroma, which also dictate flavor. Foods should be cut into the tiniest shapes possible without losing the notion of their origin. Bite-sized pieces are generally best, but sometimes even this size may be too large or too small. “Finger foods” (see Strategy #6: Create “Finger Foods”) may need to be smaller than normal. Individualization needs to be explored. Diners should be encouraged to select and eat one piece of food at a time, and very slowly—ideally in a nonstressful environment. They should also sit upright before, during and after meals, with their head slightly tilted forward to facilitate normal digestion. If moving food from the mouth to the back of throat is problematic, a slightly reclined position may be necessary with the assistance of a care provider. Distractions should be eliminated, especially for people who are in the early stages of dementia, or have had a stroke. Even if swallowing is problematic, people should be encouraged to try to swallow as much as possible. It might take as much as two or three swallows for each bite of food or sip of beverage. By alternating bites with sips of water, then resting and/or gently clearing or coughing to open and relax the throat; taking a breath before bites or sips, or gently sucking liquid through a small glass, short straw or small opening in a lid, the process of swallowing may be simplified and more manageable. Soft foods may also be recommended for people who have undergone abdominal, head or neck surgery or for people who are undergoing chemotherapy or radiation. The use of a food processor or blender should help modify the consistency of some foods and beverages. Other culinary techniques may include chopping, grinding, grating, steaming or stewing to help to diversify the

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tastes and textures of foods without sacrificing too many nutrients. Beef, poultry or vegetable stock may be added to moisten foods, along with a conservative amount of chutneys, dressings, gravies, relishes or sauces. Diners should be encouraged to consume smaller more-nutrient-dense meals or snacks and more frequently if calories permit. Some suggestions are shown in Table 9.17. TABLE 9.17

Smaller Nutrient Dense Meals

Breakfasts • Cooked cereals, such as whole oats or whole-grain wheat, may be easier to masticate than crunchy cold cereal—even if softened by milk. *Consume smaller mouthfuls. • Fresh, ripe, skinless and softened fruits: avocadoes, bananas, kiwifruit, melon, some berries and/or stone fruits (such as peaches, pears and plums) may be tolerated; canned fruit in their own juice (such as applesauce, fruit cocktail, mandarin oranges, peaches, pears and/or pineapple), may be incorporated into some breakfast recipes. *Mash some cooked fruits if necessary. • Plumped dried fruits that have been soaked in warmed fruit juice or water may be included as needed for color, fiber, flavor and interest. *Blend some dried fruits if needed. • Soft breadstuffs, such as low-fat muffins, pancakes or waffles, or soft wheat breads with spreads, such as butter, margarine or seedless jams or jellies, may be favored. *Avoid foods that thicken and interfere with swallowing. Lunches and Dinners • Avoid difficult-to-chew breadstuffs, such as bagels, bread sticks, croutons, hard rolls and/or taco shells, as well as hearty French, pumpernickel, rye or sourdough breads—especially those with seeds. *Use firmer breadstuffs for bread pudding or French toast once they are softened by egg custard or other liquids. • Choose lighter and softer desserts, such as angel food or pound cake, fruit compotes, fruit cups, fruit ices, yogurt and fruit parfaits and fat-free or low-fat ice milk or other frozen specialties. *Select desserts carefully: While desserts may be convenient options for people with chewing and swallowing difficulties, many are devoid of nutrients and higher in sugars, so select appropriately. • Combine small amounts of softened solids fats, such as butter, margarine or lard, mayonnaise or sour cream into dishes to add flavor and moisture, without over-fatty tastes. *Be skimpy with fat: While the judicious use of fat may be flavor-enhancing, it is calorific and concentrated. • Include lean, but still tender proteins, such as boiled, poached or scramble eggs, lean ground or top round beef or pork loin, mashed legumes, skinless poultry, soft fish without bones and/or tofu. *Minimize beef and other “jerkies,” fried meats, nuts and seeds and their “butters” and sausages as required. • Incorporate well-cooked starches: noodles, pasta, potatoes and/or rice into casseroles, soups or stews. *Use starches cooked “al dente” or “to the tooth” as tolerated. • Serve mashed, pureed and/or well-cooked vegetables, such as carrots, finely chopped green beans, spinach and summer or winter squash and skinless baked, boiled or mashed potatoes. For tender salads, offer skinless and seedless ripe tomatoes and soft lettuces (such as Bibb or Boston). *Mix in some textured vegetables if chewable. • Use delicate dairy products that still have some body, such as Greek yogurt or low-fat cottage cheese. *Use with care if the milk sugar lactose provokes gastrointestinal symptoms. *Include reduced-fat shredded or sliced cheese in small amounts as long as it is not rubbery or stringy [9].

Strategy #15: Maximize Aroma, Color, Taste and Texture Utilize Maillard Reactions and Caramelization Maillard reactions help to create and determine the appearance, aroma, color, flavor, nutritional value, shelflife, taste and texture of many foods and/or beverages. They have the capacity to affect breads and bakery products, coffees, chocolate, confectioneries, roasted meats and snack products, among others. Caramelization is unlike the Maillard reactions in that sugars are heated to high enough temperatures in the absence of proteins to produce caramel color and flavor. Like the Maillard reactions, caramelization also depends on low moisture conditions. Most Maillard reactions occur during conditions of low moisture and at temperatures that are above 130 C; typically when food is baked, grilled or roasted. These browning reactions have the ability to impart appealing colors and lend a complexity of flavors. During initial Maillard reactions, small volatile molecules are responsible for aromas. More complex reactions contribute to golden-to-brown colorations. The sense of smell that is produced by these reactions will often inform diners about the aromas of foods before the colors convey their identities.

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Maillard reactions may also signal deterioration during storage and loss of viability in some flours, powdered milks and/or seeds. People who have lost some of their sense of taste and smell might not be able to notice these changes. One of the challenges in considering Maillard reactions and caramelization in cooking and baking is that both of these methods use low moisture conditions and may result in drier products, albeit tastier. A challenge in cooking for the aging is to combine the Maillard reaction and caramelization with some moist-heat cooking techniques for intermediate-type results. As examples: • Browning meats first in the cooking process helps to initially change their color and flavor. Then by stewing, their appearance, aroma and taste typically develops further while their texture softens. Since browning equates with flavor, try to keep breads, cakes and pies in the oven until they are lightly browned. Then check for evenness; rotate the items and continue baking until the exteriors are uniformly browned and golden (generally if fat is present). • Roasting fruits, meats and vegetables brings out their natural flavors first before other ingredients are added. Grilling or roasting fruits and/or vegetables in a very hot oven or grill caramelizes and sweetens their skins and adds a smoky flavor. Before they are grilled if they are brushed lightly with canola oil to handle the heat, then they should not dry out. A sprinkle of fresh or dried herbs will add flavor. Salt may be drying. Then these robustly flavored fruits and vegetables may be added to chilies, soups or stews for additional taste dimensions, and will benefit from the other moister ingredients. • Slow cooking tends to retain many flavors and nutrients. High and very high heat that is too intense or quick may backfire and destroy flavors. Reserve this power for boiling water or searing meats if needed; then cook most foods and/or ingredients at lower temperatures for longer cooking times while preserving the most flavors and nutrients. Crock pots, instapots, pressure cookers and slow cookers utilize this cooking principle—plus many are easier to use and more economical than when they were first introduced. • Toasting helps to bring out the flavor in grains, nuts and whole spices, among other foods and ingredients. By toasting ingredients before cooking them longer, then natural oils and flavors may be released, in addition to the development of a tan-to-brown hue and delicate-to-rich texture. By toasting bread then lightly buttering it, the earthiness of the bread may meld with the softness that the butter imbues. Other Methods to Heighten Flavor • Maximize the “Fond” The fond is the concentrated substance that remains at the bottom of a fry pan, Dutch oven or saute´ pan after foods are roasted, saute´ed or seared. It forms when protein foods are exposed to heat and brown and turn crusty. The fond contains an intense essence of flavor. With the addition of broth, stock, water or wine the fond provides the foundation for simply pan gravies, sauces, soups or stews—without the need for additional fat and/or starch to thicken. • Add Crunch Normally crunch is added with moderate-to-heavy breading and deep fat-frying. Aging people may not be able to tolerate the heaviness of the coating, nor the calories or fat. Other cooking methods may prove to be healthier while still tastier. • Air frying is a technique that utilizes circulating hot air via a convection fan to cook food with fewer calories and less fat. Depending on culinary skills and costs, an air fryer might be beneficial. A healthy use of an air fryer is to cook French fries with next-to-no oil. • Deep frying with little coating at very hot temperatures (under smoke points around 400 F) permits foods to cook rapidly and absorb relatively less oil. While this technique is not advocated, if it is implemented, then use a neutral oil, such as canola with a high smoke point and low level of saturated fats, a heavy-bottomed pot or deep saute´ pan and a slip-on thermometer with extreme care. • Dusting is a method that adds crunch and retains a tender interior of foods. Lightly dust an ingredient in flour or breadcrumbs, then saute´ to brown. Panko, or Japanese breadcrumbs, are larger in size than traditional breadcrumbs, so conceivably less may be needed to help attain their delicate crunch [10].

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Other relatively simple techniques to employ to heighten aroma, color, taste and texture include the following: • Add hardy herbs early in the cooking process, such as marjoram, oregano, rosemary, sage or thyme, for maximum flavor and to help to soften their potentially tough leaves or stems. Delicate herbs such as basil, chives, cilantro, fennel or tarragon should be added right before serving to maximize their freshness, color, taste and texture. • Combine certain foods to deepen flavor and increase the nutrients that are absorbed. For example, add a little healthy fat (such as olive oil) and a little acid (such as lemon juice) to leafy greens for their bitter tastes to mellow and to increase the absorption of fat-soluble flavonoids from the leafy greens. Vitamin C from fruits (especially citrus fruits) and vegetables enhances the absorption of iron from dried fruits, eggs, legumes and/ or lean meats. Healthy fats, such as avocadoes and olives and their oils, along with seeds and whole grains work together to enhance vitamin E absorption when they are paired with legumes, nuts or soy, such as in falafel (chickpea patties) or some veggie burgers. Tomatoes prepared with olive oil support the bioavailability of lycopene, a naturally occurring antioxidant. • Heat solid fats to the hottest possible temperature that will safely cook foods or ingredients without smoking (when liquid fat shimmers and gently bubbles). This includes butter, margarine or lard. Once foods are added, the temperature generally will lower and the foods or ingredients may steam instead of saute´. • Refrain from discarding the seeds from tomatoes as well as their surrounding tissues, if they are tolerated as they are very flavorful. If extra moisture is an issue in a recipe, this may be motivation to remove the seeds and some of the tissues. • Refrigerate or freeze butter and nuts, refrigerate nut and seed oils and keep other vegetable oils in a cool, dark location to maintain their aroma, freshness and taste. • Use hot fat or oil to “bloom” or deepen the flavor of dried herbs or spices. This helps to intensify and transfer their flavors to the fat or oil itself. If aromatic garlic and/or onions are to be saute´ed, herbs and/or spices may be added to the saute´ mixture once the aromatics are nearly browned or tender. • Use a pinch of sugar on lean protein foods, such as fish, skinless poultry or seafood, to help to bring out the sweetness of the proteins and accelerate the browning process. Wait until necessary to prepare garlic and onions. These aromatics release sharp aromas and strong favors that may either diminish or intensify over time. Plus, their phytonutrients are strongest when they are first cut [11].

Strategy #16: Select Canned, Frozen and Packaged Foods and Beverages With Care Canned, frozen and packaged foods and beverages offer convenience and economy. Some are also lower in fats and oils, salt and sodium and sugars, and are higher in fibers. Many are enriched or fortified with antioxidants, vitamins, minerals and other potentially health-enhancing substances. In general, follow these strategies to help to determine if certain products fit specific dietary regimens. If in doubt, check with a nutrition professional, such as a registered dietitian/nutritionist. To Decrease Fats and Oils 1. Look for these terms on a food label or within an ingredient list that indicate the presence of fats or oils: • Cholesterol—a compound of the sterol type that is only found in animal products such as cheese, eggs, fish, meats, milk, poultry and/or seafood. • Essential Fatty Acids—fatty acids that cannot be made by the body in sufficient quantity; must be supplied by the diet. • Fats—lipids that are solid at room temperature, such as butter or margarine. • Hydrogenated or Partially Hydrogenated Oils—the result of hydrogen that is added to liquid vegetable oils under pressure in a process called hydrogenation; results in a more solidified fat. • Lecithin—a group of yellow-brown fatty substances that occur in both animal and plant tissues; attract both fatty substances and water. • Monounsaturated Fatty Acids—fatty acids with one point of unsaturation. • Oils—lipids that are liquid at room temperature, such as canola or olive oils. • Omega-3 and 6-Fatty Acids—polyunsaturated fatty acids that must be consumed through the diet; therefore named “essential fatty acids”; important components of cellular membranes. • Phospholipids—dietary lipids that are similar to triglycerides; contain the mineral phosphorus.

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• • • •

Polyunsaturated Fatty Acids—fatty acids with many points of unsaturation. Saturated Fatty Acids—fatty acids that are fully saturated. Sterols—dietary lipids with structures that are similar to cholesterol. Total Tat—the total amount of various fats and oils that are contained within a beverage, food product or ingredient. • Trans Fatty Acids—fatty acids that are formed during hydrogenation; banned in the United States. • Triglycerides—the major form of dietary lipids; made of glycerol and three fatty acids. • Unsaturated Fatty Acids—fatty acids with one or more points of unsaturation. 2. Also search for these common ingredients that usually indicate the presence of fats and/or oils: • Butter—a dairy product with up to 80% butterfat; solid when chilled and often at room temperature. • Chicken Fat—the fat from chicken that is obtained by rendering and processing; also the skin of chickens. • Coconut Oil—an edible oil that is extracted from the kernel or meat of coconuts from the coconut palm. • Ghee—Clarified Butter—pure butterfat made from the milk of buffalos or cows after the milk solids and water are removed. • Margarine—a food product that may be used as a butter substitute; made from vegetable oils and/or animal fats; does not contain cholesterol. • Nut and Seed Oils (such as avocado, olive, sesame, sunflower and/or walnut)—vegetables oils that are obtained from the nuts or seeds of plants, rather than from the fruit or pericarp (tissues that surround the seeds, such as in grapes, oranges or tomatoes). • Pork fat (Lard)—a soft white solid or semisolid fat from the abdomen of a pig; rendered and clarified for use in baking and cooking. • Shortening—a type of fat that is made from vegetable oils, such as cottonseed or soybean; solid at room temperature; often used in baking to achieve a flaky or “short” texture, or for frying; more closely related to margarine than butter. • Suet—raw, hard fat of beef or mutton that is located around the kidneys and loins; used to make tallow and as an ingredient in cooking to help lighten batters, such as those used in steamed puddings and sweet mincemeat. • Tallow—a hard fatty substance that is primarily made of triglycerides; produced from the rendered animal fat of beef and mutton; primarily used in candles, lubricants, margarine and soap. • Tropical Oils (Palm Oil and Palm Kernel Oil)—oils of tropical origin that are high in saturated fatty acids; often used in commercially prepared baked goods, confections and/or snack products. • Vegetable Oils (such as Canola, Corn, Peanut, Safflower and Soybean)—oils that are derived from the fruits, seeds and leaves of plants; liquid at room temperature. • Vegetable Shortening—fat that is made from vegetable oil; solid or semisolid at room temperature; often white or yellow-white in color and neutral in flavor; less prone to rancidity since it is a saturated fat. 3. Consider the labeling guidelines for choosing foods and beverages that contain fats and oils that are shown in Table 9.18. TABLE 9.18

Deciphering Fat and Oil Labeling

Qualifications

Label statement

TOTAL FAT LABELING Less than 0.5 grams fat per serving

Fat free, zero fat, no fat, without fat; dietary insignificant, negligible or trivial source of fat

Less than 3 grams fat per serving

Low in fat, less fat, contains a small amount of fat, low source of fat

At least 25% less fat per serving than the original food item (original product may not be “low fat”)

Reduced fat, less fat

SATURATED FAT LABELING Less than 0.5 grams saturated fat and Less than 0.5 grams trans fatty acids per serving

Saturated fat free, zero saturated fat, no saturated fat, without saturated fat; dietary insignificant, negligible or trivial source of saturated fat

1 gram saturated fat or less per serving and 15% or less calories from saturated fat

Low in saturated fat, less saturated fat, low source of saturated fat, contains a small amount of saturated fat

At least 25% less saturated fat per serving than the original item (original product may not be “low saturated fat”)

Reduced saturated fat, less saturated fat (Continued)

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(Continued)

Qualifications

Label statement

CHOLESTEROL LABELING Less than 2 milligrams cholesterol per serving

Cholesterol free, zero cholesterol, no cholesterol, without cholesterol; dietary insignificant, negligible or trivial source of cholesterol

20 milligrams cholesterol or less per serving

Low in cholesterol, less cholesterol, contains a small amount of cholesterol, low source of cholesterol

At least 25% less cholesterol per serving than the original item (no claims may be made about cholesterol if the item contains more than 2 grams saturated fat)

Reduced cholesterol, less cholesterol [12]

To Decrease Salt/Sodium 1. Look for these terms on a food label or within an ingredient list that indicate the presence of salt or sodium in foods and/or beverages: • Disodium phosphate—stabilizes and buffers quick-cooking cereals and processed cheese. • Monosodium glutamate, or MSG—enhances the flavor in meats and vegetables. • Sodium alginate—gels chocolate milk, ice cream and jams. • Sodium benzoate—preserves condiments that include relishes, salad dressings and sauces; fruit juices and soft drinks. • Sodium caseinate—emulsifies coffee creamers, ice cream and milkshakes; binds processed meats. • Sodium citrate—buffers, emulsifies and flavors gelatin desserts, ice cream, jams and yogurts. • Sodium hydroxide—softens and loosens fruit and vegetable skins, such as olives. • Sodium nitrite—cures meats and sausages. • Sodium propionate—inhibits mold in breads, cakes and pasteurized cheese. • Sodium saccharin—sweetens beverages and candies. • Sodium sulfite—bleaches fruits prior to coloring, such as maraschino cherries; preserves dried fruits, such as prunes. 2. Also, look for these common ingredients that indicate the presence of salt or sodium: • Bouillon—such as beef, fish, poultry or vegetable. • Canned poultry and fish—such as chicken, salmon and tuna, and shellfish such as crab, clams, lobsters, oysters, scallops and shrimp. • Common ingredients—such as baking soda and baking powder. • Condiments and dressings—such as ketchup, mayonnaise, mustard, pickle relish and salad dressings. • Gravies—such as brown, cream, egg, chocolate, giblet, mushroom, onion, red-eye or vegetable gravy. • Luncheon and cured meats—such as bacon, bologna, Canadian bacon, chicken, corned beef, dried fish, dried meats, frankfurters, ham, liverwurst, pastrami, salami, sausages and turkey products. • Marinades—such as acidic marinades (made with citrus or tomato juice); dairy marinades (made with buttermilk or yogurt); or enzymatic marinades (made with bromelain or papain found in kiwi, papaya or pineapple). • Meat tenderizers—such as the enzyme that is found in figs, fresh ginger root, kiwis or enzymatic marinades (see above); may be used in commercial tenderizing products. • Packaged foods and beverages—such as baked goods, cold and instant hot cereals, Dutch process cocoa, instant cocoa mixes, rice or noodles with seasonings and sauces (that include instant au gratin or scalloped potatoes, rice pilaf, and Ramen noodles), snack foods (that include chips, crackers, popcorn and pretzels), soups and soup mixes and stuffing mixes. • Prepared entre´es—such as canned and/or frozen dinners and entre´es that include chili, hash and stews; entre´es with sauce and seasoning mixes that include beef and rice or macaroni and cheese and TV-type dinners. *Note: Entre´es designed for popular diet programs are frequently reduced in sodium. Compare and contrast the Nutrition Facts Panels for their sodium content and other nutrients. Sometimes sodiumreduced entre´es are higher in some fats and other nutrients to compensate.

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• Processed cheese and cheese products—such as American and some Swiss cheese; higher-sodium cheese, such as blue cheese, cottage cheese, feta, Parmesan and Roquefort cheese; and some milk-based drinks, such as those that contain buttermilk or kefir and yogurt beverages. • Seasoned salts—such as celery, garlic or onion. • Sauces—such as barbecue, chili, cocktail, pasta, smoke-flavored, soy, steak, teriyaki, tomato and Worcestershire sauce. • Soy protein products—such as miso and marinated tofu; contain both naturally occurring sodium with additional sodium due to processing. 3. Consider the labeling guidelines for choosing foods and beverages that contain salt and sodium that are shown in Table 9.19. TABLE 9.19

Deciphering Salt and Sodium Labeling

• Contains a small amount of sodium—140 milligrams (mg) of sodium or less per serving. • Dietarily insignificant source of sodium—less than 5 mg of sodium per serving. • Less sodium—140 mg sodium or less per serving. • Light-in-sodium—at least 50% less of sodium per serving than an average amount of the same food that does not have sodium reduction. • Lightly-salted—50% less sodium added during processing than normally added to the original food item; if food is not “low-sodium” the package must state this fact. • Low-sodium—140 mg or less of sodium per serving. • Low source of sodium—140 mg sodium or less per serving. • Negligible source of sodium—less than 5 mg of sodium per serving. • No-salt added—no additional salt added to product during processing; must declare “This is Not A Sodium-Free Food” on information panel if food is not “sodium free.” • No sodium—less than 5 mg of sodium per serving. • Reduced or less sodium—at least 25% less sodium per serving than an average amount of the same food that does not have sodium reduction. • Salt-free—less than 5 mg of sodium per serving. • Sodium-free—less than 5 mg of sodium per serving. • Trivial source of sodium—less than 5 mg of sodium per serving. • Unsalted, without added salt, no-salt added—no additional salt added to product during processing; must declare “This is Not A SodiumFree Food” on information panel if food is not “sodium-free.” • Very-low sodium—35 mg or less of sodium per serving. • Without sodium—less than 5 mg of sodium per serving. • Zero sodium—less than 5 mg of sodium per serving [12].

To Decrease Sugars 1. Look for these terms on a food label or within an ingredient list that end with the suffix “-ose” and indicate the presence of sugars: • Glucose, dextrose, fructose, lactose, levulose, maltose, polydextrose and/or Sucrose 2. Also, look for these common ingredients that indicate the presence of sugars: • Brown sugar, concentrated fruit juice sweetener, confectioner’s sugar, corn syrup, corn sweeteners, date sugar, fruit-juice concentrate, granulated cane juice, high fructose corn syrup or sweeteners, honey, invert sugar, maltodextrin, maple syrup, molasses, powdered sugar, raw sugar, turbinado sugar and others. Other terms for sweeteners that may appear on food labels include and added sugars, alternative sweeteners, nonnutritive sweeteners and nutritive sweeteners. • Added sugars are sugars and caloric sweeteners added to foods and/or during processing or preparation. • Alternative sweeteners are substances added to foods and/or that contain little to no calories. They include non-nutritive sweeteners and sugar alcohols, such as manitol, sorbitol and xylitol. • Non-nutritive sweeteners are synthetic compounds that contribute an intensely sweet taste and few-to-no calories in comparison to white sugar. These include aspartame, acesulfame-K, neotame, saccharine and sucralose, among others. • Nutritive sweeteners are substances that contribute energy in the form of carbohydrate calories. 3. Consider the guidelines shown in Table 9.20 for choosing foods and beverages that contain sugars.

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TABLE 9.20

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Deciphering Sugar Labeling

• Dietarily insignificant source of sugar—less than 0.5 milligrams (mg) of sugar per serving. • Less sugar—at least 25% less sugar than the original item. • Low sugar—see “reduced sugar” and “sugar free.” • Negligible source of sugar—less than 0.5 mg of sugar per serving. • No sugar—less than 0.5 mg of sugar per serving. • No-sugar added—no sugar or ingredients containing sugar added during processing; must state if food is not “low calorie” or “reduced calorie.” • Reduced sugar—at least 25% less sugar than the original item. • Sugar free—less than 0.5 mg of sugar per serving. • Trivial source of sugar—less than 0.5 mg of sugar per serving. • Without sugar—less than 0.5 mg of sugar per serving. • Without added sugar—no sugar or ingredients containing sugar added during processing; must state if food is not “low calorie” or “reduced calorie.” • Zero sugar—less than 0.5 mg of sugar per serving [12].

To Increase Dietary Fibers 1. Many foods and ingredients are sources of dietary fibers, both insoluble and soluble that include the following: • Foods withinsoluble fibers include avocadoes, bananas, cauliflower, celery, grapes, green beans, kiwifruit, legumes, nuts and seeds, tomatoes, zucchini, whole grains and others. • Foods withsoluble fibers include apples, avocadoes, barley, berries, broccoli, carrots, figs, flax, Jerusalem artichokes, legumes, nuts (especially almonds and some walnuts), oats, onions, pears, plums, psyllium, prunes and sweet potatoes, among others. 2. Look for these terms on a food label or within an ingredient list that indicate the presence of insoluble and soluble fibers: • Beta-glucan, carboxymethlycellulose and cellulose, chicory root, cottonseed, edible bean powder, fructoand galacto-oligosaccharides, inulin, methylcellulose, modified resistant starch, oligofructose, pea fiber, pectin, polydextrose, polyfructans, psyllium, resistant starch, detrin, maltodextrin, rice bran, soluble corn fiber or dextrin, soy fiber, wheat bran, xanthan gum and others. 3. Consider these guidelines for choosing foods and beverages that contain fiber: • The US Food and Drug Administration regulates food products that carry the following health claim for fiber: “Low-fat diets rich in fiber-containing grain products, fruits, and vegetables may reduce the risk of some types of cancer, a disease associated with many factors.” • This claim is restricted to foods that are grain products, fruits or vegetables that contain dietary fiber are low-fat and are a good source of dietary fiber, without fortification. 4. Look for the categories shown in Table 9.21 that identify foods and beverages as low, good or high sources of dietary fiber. TABLE 9.21

Identifying Dietary Fiber Labeling

• Low Source of Dietary Fiber—If the contents contain less than 2.5 grams of fiber per serving, or 5% of the Daily Value (DV). The Daily Value of fiber is 28 grams per day based on a 2000 daily calorie diet. • Good Source of Dietary Fiber—If the contents contain 2.5 4.9 grams of fiber per serving, or about 10% of the DV for fiber (see above). • High Source of Dietary Fiber—If the contents contain 5 grams of fiber or more per serving, or 20% of the DV for fiber (see above). • “More” or “Added Fiber”—Foods and/or beverages need to have at least 2.5 grams more or added fiber, as compared to the reference or regular food [13].

Strategy #17: Use Acidic Ingredients Prudently Sometimes when fat, sodium or sugar is reduced in recipes the flavor becomes “flat.” A small amount of an acidic ingredient, such as lemon juice, tea, tomato juice, vinegar and/or wine, may be able to improve the flavor and contrast with foods or ingredients that are too heavy, rich, salty or sweet. This is referred to as “brightening” the flavor.

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Freshly squeezed citrus juice is more fully flavored than citrus juice that is canned or bottled. This is why a squirt of lemon juice, a splash of vinegar, or a few drops of wine are recommended at the end of some recipes. The acidity may be first perceived, while the detection and identification of other tastes may follow. Citrus zest provides a similar sensation that may be longer lasting. The zest is the thin, colored outer edge of the citrus peel. It contains aromatic compounds that lend tang to dishes or ingredients—especially to desserts, fish, lemon curd, some vegetables, such as broccoli or Brussels sprouts, and whipped cream. Add the whey from Greek yogurt (the thin liquid that often settles to the surface of milk apart from the curds) into no-knead bread for a sourdough-like tanginess, and to help to extend the shelf life. Minced garlic and onions may be soaked in vinegar for a few minutes before they are added to vinaigrette salad dressing. The vinegar serves to mellow the garlic and onion flavors, and it helps to soften their cellular structures.

Strategy #18: Address Hydration The concept of hydration is different than the technique of cooking with moist-cooking techniques. Hydration is the process of replacing fluids in the body. Hydration is critically important to aging people because it ensures that enough fluids are provided each day for health and well-being. Whether fluids are consumed before, during or after meals or snacks is highly individualized. Also personalized is whether or not medications need to be consumed with meals, and how much liquids are needed for their proper use and assimilation. Overall, liquids help in digestion by moistening foods and making them easier to swallow. Liquids work in conjunction with fibers for smooth transit of foods throughout the gastrointestinal tract, and in the elimination of waste products. The stomach and intestines rely on gastric and pancreatic juices to digest foods, and also to move their components throughout the gastrointestinal system to be absorbed and converted into energy, or stored for later use. Adequate hydration may support the feelings of satiety or fullness that may lead to meal or snack satisfaction and resistance to overeating. This assumes that the liquids are noncaloric, such as plain or flavored bottled, tap or sparkling water. Fruit juices are concentrated sources of sugar and calories. Soft drinks also contain sugar calories, but with few-to-no other nutrients. Diet sodas are filled with sugar substitutes and other taste enhancing, but nonnutritive ingredients. So eight (8-ounce) glasses of water daily is the best hydration strategy. Since the aging tend to produce less saliva, adequate hydration may also help to improve saliva production. Saliva carries aromas and tastes, so sufficient hydration is vital for better tasting and smelling foods and beverages.

Strategy #19: Consider Lack of Appetite/Fullness Lack of appetite (the desire to eat) is common in older persons. Decreased appetite may contribute to nutritional deficiencies and/or weight loss and lead to poor health outcomes and increased mortality. This decrease in appetite in aging people is sometimes referred to as “anorexia of aging,” or may be the response to acute illness, changes in psychological functioning (such as in the digestive system), chronic diseases, medications and/or social circumstances. People who complain of a dry mouth could be offered sips of water and counseled to avoid foods that are too dry. If people are constipated, then their healthcare provider should evaluate their fluid consumption and correct any bowel movement irregularity to help improve their comfort level. This may also serve to improve their food intake. Acute and chronic infections and medicines should be addressed, and any food-medication interactions should be explored. An impaired sense of taste and/or smell should be investigated, and flavors should be enhanced where they are conceivable and desirable. People should be encouraged to consume a wide variety of foods instead of repeatedly consuming the same foods. Smaller, nutrient-dense portions should be offered more frequently than larger, calorie-dense meals. Depression and/or dementia should be evaluated for their potential effects upon appetite and satiety.

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Aging people may complain of quickly feeling full upon eating, and as a result may consume less at meals or snacks. This may be because their stomach may decrease in size and/or function. Plus, their brain may receive signals of fullness from digestive hormones secreted by the gastrointestinal tract after meals. These digestive hormones include cholecystokinin released by the intestines in response to food that is consumed, and leptin produced by fat cells that communicate with the brain about satiety, and the body’s longrange energy needs based upon its energy stores. Leptin also interacts with dopamine in the brain, a neurotransmitter that helps to produce pleasurable feeling after eating. When people eat too quickly, these digestive hormones may not operate with total effectiveness. There is a fine line between not having an appetite and feeling full quickly. By understanding the reasons why both of these conditions occur, healthcare providers and those responsible for feeding the aging can be more cognizant of individualized needs, and adjust their culinary approaches, dietary protocols, feeding practices and nutritional goals accordingly [14].

Strategy #20: Address the Entire Dining Experience The dining environment may be affected by the multiperception of taste through all of the senses. In particular, when aging eyes fail, other senses may be employed (or even relied on) to broaden the dining experience, such as hearing that includes background music and sounds, and touch that includes the feel of flatware, dinnerware, drinking vessels, table linens and the like. Foods and beverages also make sounds, such as the crunch of chips or popcorn, the fizz of carbonated drinks, the sizzle of meats, the slurp of soups and the snap of carrots and other raw vegetables. The way that people describe food sounds may also matter. This is because the brain is constantly detecting correlations among foods and beverages and the environment. The actual sounds or mention of sounds via menus or by dining companions may help consumers to assess how the degree of flavor in foods and beverages. Both the sounds that foods and beverages produce, along with the textures that they convey have the capacity to integrate and influence perception. Also, hearing and seeing information about the sounds of foods and beverages may trigger food memories. The textures of foods and beverage often communicate freshness. For instance, older fruits and vegetables may be limp, having lost their inherent crunchiness. On the other hand, older bread may be too crunchy or difficult to chew. Changing the textures in a meal may help to prevent boredom or fatigue. By encouraging older diners to eat “around the plate” and not concentrate on one type of food at a time, they may be able to enjoy the different textures that the meal provides without filling up on one particular food group before another that might be more nutritious. An example is the preference for starchy breads, pastas, potatoes or rice before vegetables or proteincontaining foods and/or beverages [15]. For an additional discussion on how the dining environment may influence the total dining experience, check out Chapter 11, Cooking Aids, Tableware Tips and Dining Advice.

DIGEST By the time that someone has reach the later years of their lives, they may not be interested in learning about new foods and/or beverages, different cooking techniques, revised dietary strategies and/or unique health protocol. Some people might be able to manage their senior years in relatively good health without too many dietary, physical or health transformations. Other people may not be as fortunate and require many alterations to their lifestyle; some of which may be disruptive and/or disturbing. Making lifestyle changes in the twilight years may be both mentally and physically challenging and result in resistance to change. This is why a supportive team of care providers, family members, friends and healthcare professionals is so essential for continuity of care as people age. Add a culinary specialist and/or Registered Dietitian to the mix, and these additional team members may supply the missing links that are necessary for dietary changes, improved mental and physical health and well-being. Much attention is devoted to feeding children by attending to their likes and dislikes and discovering tasty foods and beverages that appeal to their often fussy tastes and eating behaviors. Similar attention should be paid

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to the other end of the lifecycle—those who are aging, with the same personal attention, diligence and respect for a human life. In this chapter, a host of culinary strategies are given to provide ideas, incentives and inspiration for aging people and if available, their supporters. They run the gamut from basic culinary skills to instinctive measures, to more collective undertakings. Until we embrace the need to address aging with a holistic, food-focused and activity driven mindset, we may be restricted by the limitations of this phase of the lifecycle, rather than empowered by it. It’s a challenge worth taking; as a start, by engaging in some of the initiatives that are encouraged in this chapter.

MANNER OF SPEAKING Added Sugars Agar-Agar Air Frying Alternative Sweeteners Anorexia of Aging Aquafaba (AF) Au jus Bloom Boiling Bouquet Garni Braising Bromelain Broths Caramelization Cholecystokinin (CCK) Chutney Conduction (Thermal Conduction) Convection Coulis Culinary Herbs Culinary Spices Deep Frying (Deep Fat-Frying) Dietary Fiber Disodium Phosphate Dopamine

sugars and syrups that are added to beverages or foods when they are processed or prepared jelly-like substance; obtained from red algae; plant-based gelatin cooking process that utilizes hot circulating air to surround food and heat by convection sweeteners other than sugar that provide a sweet taste; often with less food energy (calories) loss of appetite and/or decreased food intake later in life; paradigm of geriatric syndromes viscous water of legumes; may be used as an egg binder or whipped as an egg white substitute French culinary term for “with juice”; dishes prepared with meat and broth or light gravy made from meat “juices” softening of gelatin in cool liquid before using it in a recipe rapid vaporization of liquid when heated to its boiling point herb bundle tied with sting; used to prepare casseroles, soups, stews and/or stocks; infused aromatic flavor cooking process by which foods is lightly fried than stews slowly in a closed container enzyme found in pineapple juice and stem; thought to reduce inflammation, especially in the nose and sinuses liquids that have had meat cooked in it; made by simmering meat, mirepoix and aromatics in water; typically seasoned cooking process that relies upon the oxidation of sugars to produce brown colors and nutty flavors digestive hormone released with secretin when digested food in the stomach reaches the first part of the small intestine spicy condiment made from fruits or vegetables combined with spices, sweetener and vinegar; originated in India transfer of heat energy from one solid to another transfer of heat by fluid motion between an object and its environment when it is heated thin fruit or vegetable puree; used as a sauce leaves of plants that can be used either fresh or dried to flavor foods and/or beverages seasonings derived from the aromatic seed, bud, bark, berry or flower used to flavor foods cooking method whereby foods or ingredients are submerged into hot fat or oil type of carbohydrate that cannot be digested by the enzymes of the human body; indigestible portion of plant foods; soluble and insoluble food additive that stabilizes and buffers quick-cooking cereals and processed cheese neurotransmitter that helps control the human brain’s reward and pleasure control centers

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MANNER OF SPEAKING

Dysphagia Essence Extracts/Extractions Fine Herbs Finger Foods Flavored Oils Fond Gelato Ghee Infused Oils Infusions Insoluble Fibers Juices Leptin Maillard Reactions Marinades Meat Tenderizers Medicinal Herbs Mirepoix Modified Texture Foods (MTFs) Moist-Heat Cooking Methods Monosodium Glutamate (MSG) Mother Sauces Nage Nonnutritive Sweeteners (NNSs) Nutritive Sweeteners Oral-Somatosensory (“Mouthfeel”) Panko Papain Pastes

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medical term to describe difficulty swallowing aromatic extract that is concentrated, such as almond, truffle or vanilla substances made by the extractions (removal) of raw materials; concentrated flavors with alcohol (ethanol) or water combination of finely chopped chervil, chives, parsley and tarragon; used to season mildly-flavored dishes; mainstay of French cuisine foods served in forms and styles to be eaten with the fingers blended oils (often by infusion) with aromatic compounds French for “base”; browned bits and caramelized drippings of meats and vegetables that are often stuck to the bottom of pans after roasting or saute´ing Italian-style ice cream; made from cream, milk and sugar; more milk than cream clarified butter; created by skimming milk solids from melted butter, originated from India oils with extracted chemical compounds or flavors from plants that were steeped over time resultant liquid (alcohol, oil or water) of infusing process fibers that promote the movement of materials through the digestive system and increase stool bulk; include some legumes, nuts, wheat bran and flour and vegetables liquids obtained from or existing in fruits and/or vegetables hormone made from adipose (fat) cells; assists the regulation of energy balance; inhibits hunger chemical reactions among free amino acids and reducing sugars when heated; creates distinctive browning and flavor savory and usually acidic sauce; used to soak fish, meats and/or vegetables to imbue flavor and tenderize contents processes or substances that reduce the toughness of meats; breaks down meat fibers and softens the proteins for easier chewing herbs used for medicinal purposes; use of plants or plant extracts to assist bodily functions and/or treat illness diced vegetables (typically carrots, celery and onions) that are cooked for long periods of time over gentle heat in butter or oil without browning foods that are altered in texture for easier and safer chewing and/or swallowing cooking methods that use liquid, steam or water to transfer heat to food; include boiling braising, poaching, pot roasting, steaming and stewing food additive that enhances the flavor in meats and vegetables basic sauces that serve as bases of other sauces; include Be´chamel, Espagnole, Hollandaise, Tomato and Veloute´ aromatic flavored court bouillon or stock; used for poaching delicate foods, such as seafood substances that taste sweet; are low or have no calories; offer no-to-few nutritional benefits; replace sugar in some recipes and/or formulations substance such as sugars and sugar alcohols; add carbohydrates to foods and/or beverages and calories to the diet physical sensations in oral cavity produced by specific foods and/or beverages Japanese breadcrumbs with flaky, light texture; often used to coat baked or fried foods enzyme in fruit, latex, leaves and roots of papaya plant; catalyzes breakdown of proteins by hydrolysis (addition of water) semiliquid colloidal aggregations, emulsions or suspensions used in food preparations or as spreads; commonly aromatic or spicy, such as curry pastes, fruit preserves or nut pastes fruit wall or ripened ovary or fruit of plants; sometimes consists of three layers: endocarp, epicarp and mesocarp passage from mouth and nose to the esophagus and larynx; fosters transfer of swallowed liquids and solids

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Poaching Pork Fat (Lard) Purees Reductions Relishes Resistant Starch (RS) Roughage Salsas Sauces Shortening Simmering Slow Cooking Sluries Sodium Alginate Sodium Benzoate Sodium Caseinate Sodium Citrate Sodium Sodium Sodium Sodium Sodium

Hydroxide Nitrite Propionate Saccharin Sulfite

Soluble Fibers Steaming Stewing Stocks Suet Tallow Teas Texturized Vegetable Protein (TVP) or Texturized Soy Protein (TSP) Tropical Oils

moist-heat cooking process; involves cooking by submerging food in liquid, such as milk, stock, water or wine fat from the abdomen of a pig; rendered and clarified for baking and cooking; generally soft, white and creamy blended, crushed, ground, pressed or sieved fruits, legumes or vegetables result of thickening and intensifying the flavor of liquid mixtures, such as juice, sauce, soup or wine by boiling or simmering cooked and pickled condiments; often made with chopped fruits, herbs and/or vegetables, such as chutney and pickled cucumber relish starch that is not digested in the small intestine; passes to large bowel; provides substrate for fermentation dietary fiber; indigestible portion of food derived from plants; soluble and insoluble sauces typical of Mexican cuisines; often spicy and tomato-based cream, liquid or semisolid substance served on or with food; add flavor and moistness solid fat, such as butter, lard, margarine or vegetable shortening; used to make shortcrust pastries and prevent the formation of gluten in baked goods gentle cooking technique wherein foods are cooked in hot liquids just below boiling cooking at a low temperature over an extended period of time; often uses a slow cooker (similar to a crock pot) thick mixtures of equal amounts of flour and water; used for preparing sauces, soups and stews food additive that gels chocolate milk, ice cream and jams food additive that preserves condiments that include relishes, salad dressings and sauces; fruit juices and soft drinks food additive that emulsifies coffee creamers, ice cream and milkshakes; binds processed meats food additive that buffers, emulsifies and flavors gelatin desserts, ice cream, jams and yogurts food additive that softens and loosens fruit and vegetable skins, such as olives food additive that cures meats and sausages food additive that inhibits mold in breads, cakes and pasteurized cheese food additive that sweetens beverages and candies food additive that bleaches fruits prior to coloring, such as maraschino cherries; preserves dried fruits, such as prunes dietary fiber; dissolves in water to form a gel-like substance; found in apples, barley, carrots, citrus fruits, oats, peas, psyllium and other substances cooking process in which boiling water vaporized into steam that transports heat to nearby food for cooking to desired doneness cooking process that uses simmering or slow boiling to cook solid foods and/or ingredients, such as meats, seasonings and vegetables; often served with resultant gravy liquid bases for sauces and soups; often prepared by simmering animal bones and aromatics in water, wine or other liquid ingredient hard white fat located around the kidneys and loin of beef or mutton; used to create mincemeat, pastries, puddings and other preparations fatty substance that is made from rendered beef suet; primarily composed of triglycerides; may be stored without refrigeration, unlike suet aromatic beverages produced from tea leaves by infusion with boiling water; various plants parts used to prepare cold or hot beverages defatted soy flour product; often used as a meat analog or extender coconut, palm kernel or palm oil; higher in composition of saturated fatty acids; often used in commercially prepared baked good confections and snack products

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sour-tasting liquids that contain acetic acid; created by the fermentation of dilute alcoholic liquids such as beer, cider and/or wine soup stock composed of chicken or veal without colored seasonings; often used in white sauces

References [1] Jackel D. 18 Quick and easy meals for seniors. Care.com, Inc.; 2018. Available from: https://www.care.com/c/stories/5445/18-quickand-easy-meals-for-seniors/ [accessed 06.09.18]; Spence C. Comfort food: a review. Food Sci 2017;9:105 9. Available from: https://doi. org/10.1016/j.ijgfs.2017.07.001. [2] Keller H, Chambers L, Niezgoda H, Duizer L. Issues associated with the use of modified texture foods. J Nutr Health Aging 2012;16(3):195 200. [3] BAKERpedia. Fiber. ,http://bakerpedia.com/ingredients/fiber/. [accessed 06.09.18]; American Association of Cereal Chemists. The definition of dietary fiber: report of the Dietary Fiber Definition Committee to the Board of Directors of the American Association of Cereal Chemists. Cereal Foods World 2001;46:112 26; DeVries JW, Prosky L, Li B, Cho S. A historical perspective on defining dietary fiber. Cereal Foods World 1999;44:367 9; “Dietary Fiber.” Accessdata. FDA. Gov. Food and Drug Administration; 2016; Almeida EL, Chang YK, Steel CJ. Dietary fibre sources in frozen part-baked bread: influence on technological quality. LWT—Food Sci Technol 2013;53 (1):262 70; 21CFR101.81. CFR-Code of Federal Regulations Title 21; 2016; Review of the scientific evidence on the physiological effects of certain non-digestible carbohydrates. The Food and Drug Administration, ,https://www.fda.gov/Food/LabelingNutrition/ucm610115. htm.; 2018 [accessed 06.09.18]. [4] McDonell K. Healthline: Nutrition: Evidence based: 13 effective substitutes for eggs, ,https://www.healthline.com/nutrition/egg-substitutes#section10.; 2017 [accessed 06.09.18]. [5] American Heart Association. How to reduce sodium, ,https://sodiumbreakup.heart.org/how_to_reduce_sodium.; 2018 [accessed 06.09.18]. [6] Ruben. Ice cream science: sugar in ice cream, ,https://www.sugar.org/images/docs/sugar-functional-roles.pdf.; 2017 [accessed 12.09.018]. [7] FOODnavigator.com. Bit-size foods are more rewarding, suggests study. Last updated on March 14, 2017, ,https://www.foodnavigator. com/Article/2012/07/18/Bite-size-foods-are-more-rewarding-suggests-study#.; 2012 [accessed 06.09.18]. [8] Jensen K. Types of garnishes for food. Leaf.tv, ,https://www.leaf.tv/articles/types-of-garnishes-for-food/.; 2018 [accessed 06.09.18]. [9] Goad K. WebMD, What to do if it’s hard to chew or swallow. Reviewed by William Blahd, ,https://www.webmd.com/healthy-aging/ features/eating-problems#1.; 2016 [accessed 06.09.18]. [10] Northwest edible life. 14 easy ways to bring ore flavor to your food, Cooking by Erica, ,https://www.nwedible.com/14-easy-ways-tobring-more-flavor-to-your-food/.; 2015 [accessed 06.09.18]; Copeland L. The chemical reactions that make food taste awesome. University of Sydney, ,http://blogs.discovermagazine.com/crux/2016/06/03/the-chemical-reactions-that-make-food-taste-awesome/#. WnCzFGaZP5Y.; 2016 [accessed 06.09.18]. [11] Lifehaker. Ten simple tips to make food taste better. America’s Test Kitchen, ,https://lifehacker.com/ten-simple-tips-to-make-foodtaste-better-1649821924.; 2014 [accessed 06.09.18]; Zelman KM. Flavor-boosting tricks add spark to healthy cooking. WebMD Weight Loss Clinic-Feature. Reviewed by Louise Chang on December 15, 2006; Guttersen C, author, The sonoma diet and the sonoma diet cookbook; Shadix K, president, Nutrition and Culinary Consultants, ,https://www.webmd.com/food-recipes/features/flavor-boostingtricks-add-spark-to-healthy-cooking#1.; 2006 [accessed 06.09.18]. [12] Institute of Medicine. Appendix BFDA regulatory requirements for nutrient content claims 1. In: Front-of-package nutrition rating systems and symbols: phase | report. Washington, DC: National Academies Press; 2010, ,https://www.ncbi.nlm.nih.gov/books/ NBK209851/.. Food label claims and guidelines, MyFoodDiary.com, ,https://www.myfooddiary.com/Resources/label_claims.asp.; 2018 [accessed 06.09.18]. [13] U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. A food labeling guide—Appendix C; 1994 (Editorial revisions October, 2009), ,http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/ FoodLabelingNutrition/FoodLabelingGuide/ucm064919.htm.. [14] Pilgrim AL, Robinson SM, Sayer AA, Roberts HC. An overview of appetite decline in older people. Nurs Older People 2015;27(5):29 35; MacDonald A. Why eating slowly may help you feel full faster. Harvard Health Blog, ,https://www.health.harvard.edu/blog/why-eating-slowly-may-help-you-feel-full-faster-20101019605.; 2010 [accessed 06.09.18]. [15] Sifferlin A. Why we like food that makes noises. TIME.health, ,http://time.com/3759953/sound-flavor-taste/.; 2015; Shreeves R. You perception of food is altered by environmental factors. MNN.com, ,https://www.mnn.com/food/healthy-eating/blogs/your-perception-food-altered-environmental-factors.; 2016; Pisano W. 3 Secrets to gourmet senior nutrition: cooking with love. A place for mom, ,https://www.aplaceformom.com/blog/2013-2-14-gourmet-senior-nutrition-secrets/.; 2013 [accessed 06.09.18].

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C H A P T E R

10 Recipes and Menus That Appeal to Aging Palates

PHOTO: Measuring cups. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I sometimes ask for a taste of a sauce when I dine out to make sure that I enjoy it—and can tolerate its taste. I.G.

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LEARNING OBJECTIVES 1. Identify eight different classifications of recipes (Starters, Soups, Salads, Entre´es, Sides, Desserts, Beverages, Finishing Touches and Leftovers) and why they are designed for aging palates. 2. Indicate which specialized ingredients within these recipes enhance flavor, entice appetite and/or evoke food memories. 3. Demonstrate how these recipes may be adapted for specialized needs and tastes. 4. Recognize how flavor enhancement may be applied as a tool for selective eaters. 5. Inspire the use of flavor enhancement by individuals and care providers to prepare healthy, age-forward recipes.

SUMMARY To creatively assist to make Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging, and Chapter 9, Culinary Considerations for the Aging, relevant and useful for aging people, their care providers, or food service operators.

INTRODUCTION Aging baby boomers are products of the mid-20th century when more intact families congregated for real homecooking. This is why homemade-type meals may be so comfortable and familiar to this aging group of people, and why some of these recipes may sound so appealing. Another consideration to take into account when preparing foods and beverages for aging people is their economics. People who are now aging are living longer, and many are privileged to be able to afford a wide and diverse range of foods and beverages, thanks to greater income potential, life experiences, travel and work. Other people may have more limited budgets for a host of reasons. To meet this range of financial considerations, the recipes are mostly economical and practical. Some recipes contain diet-specific or ethnic ingredients to meet diverse interests and nutritional needs. Substitutions and modifications are always provided. Healthy aging has propelled the development of these recipes, as featured in the recipe notes. There are reasons, for example, that certain fruits, vegetables, lean proteins, whole grains and healthy fats are chosen before other ingredients. Then there are the “occasional” ingredients that are used in small amounts for flavor and enjoyment. For instance, salt is used in specified amounts to help bring out flavor, as are butter or sugar. When taken in context, these ingredients offer interest and taste and sometimes are reminiscent of earlier times. The recipe categories are as follows: • STARTERS: Little Appetizer Bites and Heartier Helpings • SOUPS: Light and Wholesome

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LIST OF RECIPES (HIGHLIGHTED RECIPES ARE ACCOMPANIED BY PHOTOS)

• • • • • • • • •

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SALADS: Fiber and Nutrient-Rich ENTRE´ES: Animal and Vegetable Options SIDES: Simple Vegetables and Wholesome Grains DESSERTS: Healthful and Memorable BEVERAGES: Functional and Filling BREAKFASTS: To Start the Day or Anytime FINISHING TOUCHES: Dressings, Marinades, Sauces and Relishes that Increase Palatability LEFTOVERS: Practical, Economical and Tasteful MOVING ON: Eating Out/Carrying In

LIST OF RECIPES (HIGHLIGHTED RECIPES ARE ACCOMPANIED BY PHOTOS) The following list represents the depth and breadth of recipes that are included in this chapter. They have been designed to reflect the culinary, food science and nutritional recommendations throughout this text. Color photographs accompany many of these recipes to showcase their colors, textures and serving ideas. Each recipe contains these features: Category, Prep Time, Technique, Equipment, Description, Basic Tastes, Featured Ingredient, Ingredients, Instructions, Yields and Serving Sizes, Nutrient Analysis, Nutrient Modifications, Substitute Ingredients, Optional Ingredients, Recipe Variations and a “Why” Question about the recipe. They may all be adapted to fit individual needs. STARTERS: Little Appetizer Bites and Heartier Helpings 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

Buffalo Wing-Style Pizza Tuna and Caper Spread With Cucumbers Tomato Tuscan Salad With Ricotta Cauliflower and White Bean Pate Salmon Mash SOUPS: Light and Wholesome Egg Lemon Soup Mushroom Barley Soup Cucumber Pepper Buttermilk Soup Coconut Fish Chowder Tortellini Potage SALADS: Fiber and Nutrient-Rich Turkey Salad With Grapes “New Age” Potato Salad Spinach Salad With Chunky Garlic Dressing (see Finishing Touches) Brussels Sprouts Salad Chickpea Salad With Pita Triangles ENTRE´ES: Animal and Vegetable Options En“lite”tened Beef Sandwiches Chicken With a Kick Baked Salmon With Mustard Sauce Sweet and Spicy Lamb Saute´ed Tofu Patties SIDES: Simple Vegetables and Wholesome Grains Better Broccoli Fruit-Nut Squash Convenient Couscous or Quinoa Roasted Cauliflower With Shallots and Raisins

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25. Zucchini With Yogurt Basil Sauce DESSERTS: Healthful and Memorable 26. “Renewed” Orange Slices With Berry Sauce 27. Blueberry and Fig Crumble 28. Rice Pudding With Pears and Almonds 29. Strawberry, Banana and Almond Butter Crepes 30. Chocolate Yogurt and Orange Mousse BEVERAGES: Functional and Filling 31. Mango Yogurt Shake 32. Mock Sangria 33. Peanut Butter, Banana and Coffee Blend 34. Green Pick-Me-Up 35. Cucumber Berry Grape Quencher BREAKFASTS: To Start the Day or Anytime 36. Banana Nut Oat Bran Muffins 37. Mushroom and Cottage Cheese Omelet 38. Savory Oatmeal With Eggs 39. Oat Waffles With Berry Compote With Lemon and Ginger 40. Whole-Grain French Toast With Pears in Red Wine FINISHING TOUCHES: Dressings, Marinades, Sauces and Relishes that Increase Palatability 41. Chunky Garlic Salad Dressing 42. Just Enough Bleu Salad Dressing 43. Honey-Mustard Sauce 44. Tomato-Carrot Relish 45. Herb and Lemon Blend for Marinades With: a. Basic Vinaigrette, and b. Herb and Lemon Blend Ranch Dressing STARTERS: Little Bites and Heartier Helpings When older people’s appetite signals that they are interested in something to eat but they fill up easily, a “little bite” may provide a tasty and nourishing snack, or even a small entre´e by doubling the portion size. If Little Bites are doubled in portion size into heartier helpings, or flanked by a vegetable and/or fruit, they may be transposed into easy and nutritious meals. STARTERS 1. 2. 3. 4. 5.

Buffalo Wing-Style Pizza Tuna and Caper Spread With Cucumbers Tomato Tuscan Salad With Ricotta Cauliflower and White Bean Pate Salmon Mash 1. Buffalo Wing-Style Pizza Category: Starters Prep Time: Including baking is 1 hour Technique: Baking Equipment: Oven, small bowl, baking sheet

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PHOTO: Buffalo Wing-Style Pizza. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: One of the most favored taste combinations in the United States since the mid-1900s are Buffalo wings, unbreaded chicken wing sections that are generally deep-fried and coated with a vinegar-based cayenne pepper hot sauce and melted butter. Buffalo wings are served hot, alongside celery sticks and/or carrot sticks, with either Bleu cheese or Ranch dressing for dipping. This version is based on similar ingredients and tastes, but it is updated and is fresher and healthier, with its lower fat ingredients and preparation, and in pizza form—popular then and now. Basic Tastes: The chicken is roasted to bring out umami; the sauce is spicy-hot, which activates more of a sensorial reaction; the Bleu cheese and Ranch dressings are sweet and cooling; and the celery provides texture throughout its crunchiness. Dice or mince the celery for easier eating. Featured Ingredient: No-Salt Added Seasoning Blend No-salt added seasoning blends rely on herbs, spices or a combination of the two for blends that do not depend on sodium for flavor. This is a challenging feat, since a little sodium is often needed to bring out other tastes. There is sodium in this recipe without adding salt. It can be found in the chicken, pizza shell, salad dressing, celery and cheese. A popular spicy no-salt added seasoning blend may include such ingredients as black pepper, chili powder, cilantro, cumin, dry mustard, garlic powder, onion powder, oregano and paprika. Find one with appealing flavor. Ingredients: 12 ounces chicken, skinless, roasted, and cut into pieces (about 2 cups) 1 tablespoons spicy no-salt added seasoning blend (such as spicy jalapeno)

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1 prebaked 14-ounce (12-inch diameter) pizza shell 1/3 cup reduced-fat Bleu cheese or Ranch salad dressing 1 /2 cup celery, cut into diagonal slices 1 cup shredded reduced-fat Monterey Jack or Mozzarella cheese Instructions: Preheat oven to 450 F. Place chicken pieces in small bowl; sprinkle spicy no-salt added seasoning blend to cover; mix well. Place prebaked pizza crust on large, ungreased pizza pan or baking sheet. Lightly spread salad dressing of choice over pizza crust. Top with seasoned chicken mixture, sliced celery, and shredded reduced-fat cheese of choice. Bake on center rack in preheated oven for 9 11 minutes, or until cheese melts and edges of pizza crust are browned. 7. Cut pizza into six wedges. 8. Serve hot.

1. 2. 3. 4. 5. 6.

Yield and Serving Size: Makes 6 (2-inch) wedges. Nutrient Analysis: 298.15 calories, 25.99% calories from fat, 8.61 g total fat, 2.33 g saturated fat, 53.83 mg cholesterol, 32.89 g carbohydrates, 1.5 g fiber, 23.67 g protein, 769.04 mg sodium Nutrient Modifications: • To lower total fat: Use less reduced-fat salad dressing, cheese and/or chicken. • To lower sodium: Use less reduced-fat salad dressing and/or cheese. • To lower carbohydrates: Use a smaller portion size. Prepared salad dressing and cheese tend to be higher in sodium. Another option is to cut the pizza into 8 (2-inch) wedges that will decrease other nutrients as well. Substitute Ingredients: Celery leaves may be used in place of the diagonally cut celery stalks if chewing is problematic. A lower fat Mexican cheese such as Queso Quesadilla or Asadero may replace the Monterey Jack or Mozzarella cheese. Optional Ingredients: Dried oregano or basil may also lend their earthy, Mexican and Mediterranean tastes. One-half to 1 teaspoon may be sprinkled over the pizza crust. Why a Seasoning Blend? This recipe can be prepared without a seasoning blend, or with just one or two herbs, such as basil or oregano. But the final product may taste like macaroni without cheese, peanut butter without jelly or corned beef without rye: it may keep a person wanting more. This is one of the reason why in seasoning blends the sum of the product is often more successful than the individual parts, or the herbs themselves. Additionally, a single herb (if not favored) may result in a disappointing dish, while a combination, such as a seasoning blend, layers the tastes of many herbs and spices into a complex flavor. The final product creates a fuller sensation that helps to make a recipe delicious and memorable. It may also evoke a favorite herb or spice from a memorable dish, or camouflage a distasteful one. 2. Tuna and Caper Spread With Cucumbers Category: Starters Prep Time: 15 minutes Techniques: Stirring and blending Equipment: Medium bowl

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PHOTO: Tuna and Caper Spread With Cucumbers. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Tuna is a convenient protein food that can be found in individual portion sizes in pouches or cans. It is generally available in these varieties: prime fillet solid white albacore tuna in water, solid white albacore tuna in water, chunk light tuna in water and chunk light tuna in oil. Other types of packaged tuna may include tuna with one of the following ingredients or combinations: chipotle and olive oil, jalapenos and olive oil, sundried tomatoes and olive oil, omega-3 prime fillet, pesto and olive oil, ginger, soy and olive oil and very low sodium varieties—to suit a multitude of tastes and nutritional needs. Basic Tastes: This recipe blends the briny taste of tuna with salty capers, anchovies and sundried tomatoes, along with a jolt of red pepper. Lemon lends freshness. Cucumbers and whole-grain crackers provide texture with their crunch. A softer option may be sliced zucchini with rice crackers that seem to “melt” rather than crunch. Featured Ingredient: Sundried Tomatoes Sundried tomatoes add umami to recipes since tomatoes are naturally high in glutamate, which increases during the drying process. Tomatoes that are dried generally need to be rehydrated in liquid, such as water or oil, with or without herbs and spices. Then they can be used whole, chopped or minced as they do not require further cooking. Rehydrated tomatoes and add color, taste and texture to recipes. Though sundried tomatoes tend to be higher in sodium, a small amount is all that is needed for these flavor-enhancing measures. Ingredients: 1 can (5 ounces) tuna, packed in oil 1 /4 cup fresh parsley, chopped 2 teaspoons capers, drained, rinsed, dried and chopped 2 anchovies, minced

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1 teaspoon sundried tomatoes, packed in oil and minced 1 teaspoon fresh lemon juice 1 /4 teaspoon red pepper flakes 1/8 teaspoon salt 1 /4 teaspoon freshly ground black pepper Fresh cucumber slices and/or multigrain crackers to serve Wedge of fresh lemon for garnish Instructions: 1. 2. 3. 4.

Place tuna and oil into a medium-sized bowl. Flake tuna and mix with oil. Add remaining ingredients to tuna-oil mixture and mix until desired consistency. Serve with fresh cucumbers, multigrain crackers and wedge of lemon, if desired. Yield and Serving Size: Makes 6 (3/4-cup) servings, 2 tablespoons each

Nutrient Analysis: 72.06 calories, 38.38% calories from fat, 3.07 g total fat, 0.67 g saturated fat, 12.33 mg cholesterol, 1.16 g carbohydrates, 0.24 g fiber, 9.74 g protein, 553.09 mg sodium Nutrient Modifications: • To lower sodium: Decrease capers, anchovies and/or sundried tomatoes. Each of these three condiments tends to be higher in sodium. Substitute Ingredients: This recipe can be made with other canned fish, such as mackerel, salmon or sardines. Replace the capers and sundried tomatoes with pimento stuffed green olives. Use one-half to 1 teaspoon of anchovy paste, or eliminate the anchovies and add a few drops of Worcestershire sauce. Optional Ingredients: To add another element of texture, some finely minced onion and/or celery may be added. The finer the texture, the easier to chew and the more the tastes and textures merge. Recipe Variations: Serve a mixed green salad with a scoop of Tuna and Caper Spread to create a small-sized salad, or add chopped or steamed vegetables and a hard-boiled egg for an entre´e-sized salad. Why Capers? Capers are the unopened buds of a Mediterranean shrub. They are usually pickled and often salted—sometimes heavily, which requires rinsing. When used in small amounts, capers help to provide a salty note without adding too much extra salt. Plus, their green color and chewy texture adds interest to bland-looking and -tasting tuna spread. Large capers may be tougher, more acidic and/or stronger in flavor. Chopped olives may be used in place of capers. Fresh or dried thyme contributes an earthy, pungent flavor, too. 3. Tomato Tuscan Salad With Ricotta Category: Starters Prep Time: 1 hour, plus 20 30 minutes for salad to blend before serving Techniques: Toasting, browning Equipment: Oven, baking sheet with rim, large bowl, plates

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PHOTO: Tomato Tuscan Salad With Ricotta. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: A Tuscan salad, sometimes referred to as a Panzanella, is comprised of bread and tomatoes, occasionally herbs such as basil or oregano and often garlic and/or onions. It is frequently dressed with olive oil and vinegar, such as red wine or Balsamic. This type of salad provides a good use of leftover bread and ripe tomatoes. Tuscan salads combine familiar tastes and textures that are often associated with Mediterranean diets. Ingredients such as chopped zucchini or cucumber can be added for their fresh accents. Mushrooms can lend an earthy element. Ricotta, a soft cheese also associated with Mediterranean cuisines, provides creaminess despite its lower fat variety. Basic Tastes: Tomatoes provide all of the basic tastes: acidic, bitter, salty, sweet and umami. Toasting the bread brings out umami; however, softer bread may be easier to chew. Balsamic vinegar is full of umami. The deep leafy greens have bitterness, subdued by the umaminess of the Balsamic vinegar. Featured Ingredient: Balsamic Vinegar Balsamic vinegar (also known as aceto balsamico in Italy) is a concentrated, dark and deeply flavored vinegar that is partially or fully made from grape must (freshly pressed grape juice). It is often dribbled on Parmigiano Regianno cheese or mortadella sausage, or on eggs, fish, fruits, meats, pasta or rice dishes to help to bring out their complex flavors. Balsamic vinegar is even consumed on its own to finish a meal! The more aged the Balsamic vinegar, the deeper the umami flavor in recipes, such as this one. Ingredients: 5 cups crusty or stale whole-grain bread, cut or torn into 1/2-inch pieces 2 pounds ripe medium-sized tomatoes, cut into 1/2-inch pieces 1/3 small red onion, peeled and diced 3 tablespoons aged Balsamic vinegar 2 tablespoons extra-virgin olive oil, plus additional for drizzling 3 /4 teaspoon salt 1 /2 teaspoon freshly ground pepper 1 teaspoon dried basil, crushed 1 cup fresh baby spinach leaves, stems removed 8 tablespoons (1/2 of 16-ounce container) light ricotta cheese Freshly ground black pepper Instructions: 1. Preheat oven to 375 F. 2. Place pieces of bread in a single layer on a rimmed baking sheet; bake until dry and lightly golden in color, about 20 minutes.

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Combine tomatoes, red onion, Balsamic vinegar, olive oil, salt, pepper and basil in a large bowl. Add toasted bread pieces and baby spinach; mix to combine. Let mixture blend 20 30 minutes for liquid ingredients to soften bread pieces. Divide mixture evenly among four plates. Top with 2 tablespoons low-fat ricotta cheese per serving. Drizzle with olive oil and top with freshly ground black pepper. Yield and Serving Size: Makes 10 cups, 4 (21/2 cup) servings, each

Nutrient Analysis: 313 calories, 38.21% calories from fat, 13.29 g total fat, 3.85 g saturated fat, 17.4 mg cholesterol, 36.54 g carbohydrates, 6.52 g fiber, 15.54 g protein, 757.55 mg sodium Nutrient Modifications: • To lower total fat: Use less olive oil; do not drizzle to finish. • To lower sodium: Use less salt. • To lower carbohydrates: Decrease the amount of whole-grain bread, and/or slightly decrease the serving size. This appetizer salad may also be prepared without the whole-grain bread. Substitute Ingredients: Fresh chopped basil leaves may be combined with the baby spinach leaves. Red wine vinegar may replace the Balsamic vinegar. A sweeter onion (such as Vadalia) may be swapped for the red onion. A softer type of bread may be substituted for the toasted whole-grain bread, but with less fiber. Different tomato varieties may be used, such as Italian plum or cherry. Optional Ingredients: Chopped, fresh vegetables such as celery, cucumber or summer squash can add additional crunch. Mushrooms may be saute´ed until just tender, and added after the bread has soaked up the marinade. The temperature of the salad may vary from warm to cool; however, if it is served at room temperature, then the tastes may mingle, and the overall flavor may be better perceived. Why Freshly Ground Black Pepper? Sanskrit records proclaim black pepper as one of the world’s most important spice plants, and its reputation still lives today. Black pepper is now cultivated in tropical regions worldwide. Its pungency comes from the volatile oil, piperine and resin. Freshly ground black pepper is best because the flavorful oil is immediately released once the peppercorn is crushed. Black pepper increases saliva and gastric juices that serve to improve appetite and aid digestion. After the initial impact, the pungency of black pepper may actually serve to cool the taste. The amount of black pepper that a person uses depends on their taste preference, which may change from younger years. 4. Cauliflower and White Bean Pate Category: Starters Prep Time: 60 minutes Techniques: Baking, pureeing Equipment: Oven, large bowl, spoon, baking sheet food processor

PHOTO: Cauliflower and White Bean Pate. r 2019 Grace Natoli Sheldon. Reprinted with permission.

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Description: Cauliflower is a member of the Brassica oleracea family that also includes broccoli, Brussels sprouts, cabbage collard greens and kale. Cauliflower is a popular ingredient that can be substituted for potatoes and other starches, but with fewer carbohydrates. Cauliflower can be baked, boiled, fried, pickled, roasted, steamed or consumed raw. Especially when cauliflower is baked or roasted, it develops more savory flavor, as in this versatile recipe where it is satisfying as an appetizer pate, or can be used as a sandwich spread. Basic Tastes: The Brassica genus may seem extremely bitter to some individuals, while these vegetables may not seem as bitter in taste to others. This may be due to the gene phenylthiocarbamide that may affect taste perception. By baking the cauliflower, then blending it with olive oil to help moderate its bitterness, and adding salt, pepper and smoked paprika, the finished recipe becomes more moderate in flavor and smoother, rather than assertive and chunkier in texture. Featured Ingredient: Garlic Garlic (Allium sativum) is a species in the onion genus Allium. It is related to chives, Chinese onions, leeks and onions. Garlic generally conjures an image of pungency, spiciness and/or intolerance. After cooking, the garlic flavor tends to soften and dissipate into its surrounding ingredients, such as bread, butter or oil, onions or tomatoes. Other than its taste attributes, the consumption of garlic has been associated with the prevention of cardiovascular diseases and some cancers, yet results have been contradictory. This potential association is likely due to the phytonutrient content of garlic; particularly flavonoids and sulfur-containing compounds: allicin, alliin, ajoene and diallyl sulfate. Ingredients: 1 medium cauliflower head, trimmed and cut into 1/2 to 1-inch pieces 5 fresh garlic cloves, unpeeled 3 tablespoons extra-virgin olive oil, separated, plus more for drizzling 3 /4 teaspoon salt 1 /4 teaspoon pepper 1 /2 teaspoon smoked paprika 1 (15.5-ounce) can white beans (such as cannellini), rinsed, drained and patted dry 1 /4 cup fresh parsley, minced 1 teaspoon lemon zest 1 tablespoon fresh lemon juice 1 /4 cup chicken or vegetable stock Smoked paprika, to garnish Sliced zucchini and/or multigrain crackers, to serve Instructions: Preheat oven to 375 F. In large bowl, mix cauliflower pieces and unpeeled garlic with 2 tablespoons of extra-virgin olive oil. Season cauliflower, garlic and extra-virgin olive oil mixture with salt, pepper and smoked paprika. Spoon mixture into a rimmed baking sheet in a single layer. Bake for 25 30 minutes, or until slightly browned; stir halfway to prevent sticking. Cool. Carefully remove the whole garlic cloves and either remove the peels or discard entirely. Combine the cauliflower pieces, peeled garlic (if used), parsley, white beans, 1 tablespoon of extra-virgin olive oil, lemon zest, lemon juice and chicken or vegetable stock and process in a food processor until desired consistency. 8. Spoon into bowl; sprinkle with smoked paprika. 9. Serve with sliced zucchini and/or multigrain crackers, if desired.

1. 2. 3. 4. 5. 6. 7.

Yield and Serving Size: Makes 3 cups, 12 (1/4 cup) servings, each Nutrient Analysis: 84.52 calories, 35.57% calories from fat, 3.34 g total fat, 0.63 g saturated fat, 0 mg cholesterol, 10.92 g carbohydrates, 2.98 g fiber, 3.64 g protein, 182.07 mg sodium Nutrient Modifications: • None necessary.

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Substitute Ingredients: Different varieties of cauliflower may change the appearance of this recipe. For example, Cheddar cauliflower (which is golden to orange in color) contains more beta-carotene than white cauliflower; Purple of Sicily cauliflower contains more violet (when raw) to striking green (when cooked) in appearance; Romanesco cauliflower may appear greener and taste nuttier; and Snowball Y cauliflower may seem more delicate, nutty, sweet and white. Optional Ingredients: While smoked paprika is called for in this recipe, red paprika may be used. Smoked paprika adds a real depth of smoky flavor, much like bacon, so it may appeal to people who like this taste, vegetarians who may miss a smoked taste, or those who avoid pork for religious reasons. Either type of paprika adds interest through its color and taste, which is slightly bitter and rich in umami. Cucumbers can be used rather than zucchini. This pate may also be used to stuff hallowed-out tomatoes, potatoes or squash. Why White Beans? White beans, either canned and rinsed or raw and cooked, are versatile in burgers, chili, dips, stews and on their own. They are filled with protein and fiber, affordable and pretty plain tasting, no matter which size or variety is chosen (including Baby lima beans, Cannellini beans, Great Northern beans or Navy beans). White beans are creamy and comforting, too, and can add a luxurious touch to recipes, such as Cauliflower and White Bean Pate. 5. Salmon Mash Category: Starters Prep Time: 30 minutes, plus 30 60 minutes to chill Techniques: Heating gelatin, blending Equipment: Food processor or blender, small saucepan, refrigerator, plates Description: Salmon Mash may invoke memories of homemakers back in the 1950s with the time and kitchen skills to prepare long and complicated recipes. Fast forward to the 21st century where yesterday’s recipes are sought after, but updated for convenience, taste and time. This recipe relies upon the attributes of unflavored gelatin, the accessibility of smoked salmon, and the versatility of reduced-fat sour cream or cre`me fraiche to model the 1950s version. Salmon is rich in heart-healthy omega-3 fatty acids and vitamins B12 and D and selenium. It is also a good source of biotin, choline, fatty acids, niacin, omega-3 fatty acids, pantothenic acid, potassium, protein, phosphorus and vitamin B6, which makes it a compact source of many vitamins, minerals and other potentially health-enhancing substances. Basic Tastes: King, or Chinook, salmon tastes meaty and pure with ample fat. Coho salmon is firm and rich with a gamy flavor. Atlantic salmon is fatty, full-flavored and versatile. Red, or sockeye salmon is also fatty with distinctive deep orange-red color, density and full-flavor. Pink salmon is lower in fat and tastes delicate, sweet and subtle. Chum salmon tends to have a neutral taste that makes it ideal for canning, curing or smoking. When salmon is mixed with creamy and sweet sour cream or cre`me fraiche, along with lemon juice for brightening, the salty-umami tastes of salmon become smoothly and brightly amplified. Featured Ingredient: Dill Dill originated in southern Russia and West Africa. An annual in the carrot family, dill is valued for its feathery leaves and seeds. Its leaves are used as an herb and its seeds are used as a spice in recipes and formulations. As a culinary herb, dill somewhat resembles the flavor of fennel, with both milder and warmer effects. As a spice, dill is often used in pickling and in vinegar. Dill has a nice affinity with cream cheese, egg dishes, fish (such as salmon or tuna), lamb, potatoes and soups. This recipe for Salmon Mash contains dill both with the salmon mousse and as an edible garnish. Ingredients: 3 tablespoons cold water 1 teaspoon unflavored gelatin from 1 (1/4-ounce) package 4 ounces smoked salmon (not lox-style), roughly chopped 11/2 teaspoon fresh dill, minced 3 /4 cup reduced-fat sour cream 1 tablespoon fresh lemon juice 1 /2 teaspoon salt 8 thick tomato slices 8 Romaine lettuce or spinach leaves, for serving AGING, NUTRITION AND TASTE

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Dill sprigs, for garnish Multigrain crackers, for serving Instructions: 1. Combine smoked salmon, reduced-fat sour cream or cre`me fraiche, minced dill and lemon juice in bowl of food processor or blender; puree until desired consistency. Reserve in bowl. 2. Place cold water in small saucepan. 3. Sprinkle with unflavored gelatin; stir and soften about 5 minutes. 4. Pour mixture into small saucepan; heat gently over low heat and stir until gelatin dissolves. 5. Remove saucepan from heat to cool slightly, but still liquidy. 6. Slowly stream cooled gelatin mixture into bowl with smoked salmon mixture; with motor running, blend until just combined. Remove bowl. 7. Chill Salmon Mash in refrigerator for 30 60 minutes, or until set, before serving. 8. Line 4 plates with 2 lettuce leaves and 2 tomato slices. 9. Spoon 1/4 cup salmon mouse over each tomato/lettuce bundle. 10. Garnish with fresh dill sprigs. 11. Serve immediately with multigrain crackers, or cover with food wrap and refrigerate. Yield and Serving Size: Makes 1 cup, 4 (1/4 cup) servings, each Nutrient Analysis: 124.59 calories, 52.16% calories from fat, 7.22 g total fat, 3.3 g saturated fat, 21.4 mg cholesterol, 5.81 g carbohydrates, 0.87 g fiber, 9.67 g protein, 560.53 mg sodium Nutrient Modifications: • To lower sodium: Decrease salmon, sour cream or cre`me fraiche and/or the number of tomato slices. Keep in mind that a decrease in salmon and/or sour cream may affect the consistency of the recipe. Another strategy is to reduce the serving size by one-half—a small amount, but very tasty. Substitute Ingredients: Other types of salmon may be used for stronger or subtler flavors (see Basic Tastes). Or other types of smoked fish such as Black Cod, Bluefish, Chub, Herring, Mackerel, Sablefish, Tuna, Trout, Whitefish or Whiting may be used. The amounts of unflavored gelatin, lemon juice, reduced-fat sour cream or cre`me fraiche, salt and pepper may have to be adjusted to compensate for different fish tastes and textures. Optional Ingredients: Sliced red onion and Kalamata olives provide acidic, crunchy, fatty and salty accompaniments for this lettuce, tomato and fish puree appetizer. Add hard-boiled eggs and sliced radishes and serve with softer rye or pumpernickel bread for a more ample salad or entre´e. The tastes combinations may be very reminiscent to some people, but with a different texture as a mash (a traditional type of food preparation in England) to accommodate any eating difficulties. Why Smoked Salmon? Smoked fish has a long history (dating back to about 2000 BC) of use in food preservation and flavoring. Smoking and salting are almost interchangeable; both are particularly suited to oily fish, such as salmon in this recipe. Smoked salmon has a tender, slightly moist texture and a mild-to-strong flavor. A squirt of lemon or a grind of black pepper may help to bring out its flavor and mostly balance its saltiness. SOUPS: Light and Wholesome Soups may be either light openings or bigger meals. Portion sizes count. To introduce a meal, the serving size of most soups may be a 1-cup portion. On their own, soups may be a 2-cup serving or more, depending upon the ingredients and appetite. Keep in mind that most soups are liquid-based and may be filling—crowding out other foods and beverages and nutrients. This is why the commentaries that accompany the recipes are so important for menu planning. SOUPS 6. 7. 8. 9. 10.

Egg Lemon Soup Mushroom Barley Soup Cucumber Pepper Buttermilk Coconut Fish Chowder Tortellini Potage AGING, NUTRITION AND TASTE

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6. Egg Lemon Soup Category: Soups Prep Time: 30 minutes Techniques: Heating, reduction Equipment: Range, large saucepan, soup bowls Description: The ancients considered eggs pivotal to life. American Indians thought that a golden egg housed a great spirit that created the world. Chinese, Egyptians and Finnish people relate similar stories. This is because eggs are nutrient storehouses and fit heart-healthy diets. Eggs are inexpensive sources of vitamin D (that is difficult to attain in aging diets), high-quality protein, and lecithin, a natural emulsifier or thickener. When blended with lemon juice, eggs thicken this nourishing soup. Add leftover poultry or fish to transform this cup of soup into an entre´e portion. Basic Tastes: Lemon juice cuts through the saltiness and richness of the chicken broth and egg. It has a light, cleansing astringency. While there are multiple tastes in each mouthful of this soup (acidic from the lemon juice, bitter from the parsley, salty from the chicken broth and saltiness and sweetness from the pasta, cornstarch and egg), the full impact is intensely clean. Featured Ingredient: White Pepper Like black pepper, white peppercorns are the fruit of the pepper plant. Unlike black peppercorns, white peppercorns are picked when they are almost ripe and sundried black, and then their outer layer is removed before or after drying. White peppercorns sometimes taste hotter than black peppercorns, but with less complex taste. They also tend to develop bitter and/or stale tastes quicker than black peppercorns. This might be due to their lack of protective coating. White pepper has traditionally been used in light-colored dishes, such as this recipe for esthetic reasons. This practice may have originated in French cuisine. Some types of white pepper are also common in Chinese, Swedish and Vietnamese cooking. This recipe has Mediterranean origins. Ingredients: 8 cups reduced (33% less) sodium chicken or vegetable broth 1 /2 cup rice or orzo pasta 1 large egg, plus 1 egg white, beaten 1 tablespoon cornstarch, dissolved in 1 tablespoon cold water Juice of 2 lemons (about 4 tablespoons) 1 /2 teaspoon salt 1 /2 teaspoon white pepper 1 tablespoon fresh parsley, chopped Lemon wedges Instructions: 1. 2. 3. 4. 5. 6. 7. 8.

Pour reduced-sodium chicken or vegetable broth into a large saucepan; bring to a boil. Add rice or orzo; reduce heat, cover and cook until tender, about 15 minutes. Add 1-cup hot broth, 1 tablespoon at a time to beaten egg mixture; stir constantly. Return egg broth mixture into saucepan; reduce heat to low. Simmer soup until broth thickens, about 10 minutes. Slowly add cornstarch water mixture into egg broth mixture; stir constantly until further thickening. Add fresh lemon juice, salt and white pepper. Spoon into six bowls; sprinkle with fresh chopped parsley and serve with lemon wedges. Yield and Serving size: Makes about 71/2 cups, 6 (11/4 cup) servings

Nutrient Analysis: 85.16 calories, 10.99% calories from fat, 1.04 g total fat, 0.25 g saturated fat, 35.17 mg cholesterol, 15.52 g carbohydrates, 1.57 g fiber, 2.86 g protein, 389.08 mg sodium Nutrient Modifications: • To lower sodium: Use slightly less salt; however, reduced-sodium broth incorporated in this recipe, and taste may suffer.

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Substitute Ingredients: A vegetarian version of Egg Lemon Soup can be made with vegetable stock; however, eggs are essential for body and consistency. Quinoa may be substituted for the rice or pasta, plus it provides more protein than either of these starchy carbohydrates. Optional Ingredients: Steamed vegetables such as broccoli, carrots, celery or onions may be added once this soup is thickened. However, adding vegetables such as these too soon may affect the soup’s consistency. Why Orzo? Orzo, also called risoni, is a small type of rice-shaped pasta that can be made from either white or whole-grain flour. It is popular in Arabic, Greek, Israeli, Italian, Spanish and Turkish cuisines. Like rice, orzo provides another starchy cereal grain option for soups, salads, stews and as a side dish. But orzo has a different texture than rice and may vary in cooking time and temperature required for preparation. Both orzo and rice are usually enriched with B vitamins and iron, so both grains are economical and handy ways of obtaining these nutrients. 7. Mushroom Barley Soup Category: Soups Prep Time: 30 minutes Technique: Simmering Equipment: Oven, baking sheet with rim, range, large saucepan, soup bowls

PHOTO: Mushroom Barley Soup. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Both mushrooms and barley have a heartiness that fits with cold climates and long winters. This may be due to their earthiness and economy—filling for relatively little cost. When mushrooms and barley are combined in this recipe, this combination provides an ample and flavorful start before an entre´e salad or light main dish. Traditionally Mushroom Barley Soup is prepared with beef, or at least beef bones. This version is created with chicken or vegetable broth without skimping on body, depth of flavor or texture. Basic Tastes: Mushrooms are natural umami-rich ingredients. Once the barley is toasted, the browning brings out umami and evokes another earthy layer of deliciousness. The Parmesan cheese builds even more umami taste, while the olive oil melds the ingredients with its richness. Featured Ingredient: Mushrooms Mushrooms have the uncanny name of “toadstools,” probably due to their diminutive size and shape. This expression possibly goes back to about AD 1400 1600. While typical mushrooms are the fleshy, spore and fruit-bearing body of fungi (specifically the order Agaricales), they come in a variety of shapes and sizes—and not all are toadstool in appearance. Mushrooms generally are produced above the ground or on food sources.

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Raw crimini mushrooms are mostly water with little carbohydrates, fat or protein. They are rich sources of B vitamins such as niacin and pantothenic acid and the minerals selenium and copper, and moderate sources of phosphorus, potassium and zinc. The vitamin D content of mushrooms is related to their postharvest treatment. Mushrooms are used extensively in Chinese, European, Japanese and Korean cuisines and are noted for their “meatiness,” particularly in plant-based diets. Ingredients: 1 tablespoon olive oil, plus more for garnish 11/4 pounds cremini (white) mushrooms, trimmed, cleaned and sliced 1 medium carrot, peeled and small diced 1 medium yellow onion, peeled and chopped 2 cloves garlic, peeled and minced 1 /2 teaspoon dried thyme 1 /4 teaspoon salt 1 /4 teaspoon pepper 41/2 cups 33% less sodium chicken or vegetable broth 2 cups tap water 1 cup quick-cooking barley 1 /2 cup fresh parsley, chopped 1 tablespoon lemon juice Grated Parmesan cheese and/or extra-virgin olive oil, to garnish Instructions: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Preheat oven to 375 F. Spread quick-cooking barley onto a rimmed baking sheet in a single layer. Toast until browned about 10 minutes; stir as needed. Remove from oven and cool. Pour 1 tablespoon olive oil into large saucepan; heat over medium heat. Add sliced mushrooms, diced carrots, chopped yellow onion, minced garlic, dried thyme, salt and pepper; stir to blend. Cook mixture; stir periodically until vegetables soften, about 6 8 minutes. Add the toasted barley, broth of choice and tap water to saucepan; bring to boil. Reduce heat to simmer; cook until mixture is tender, about 10 minutes. Remove saucepan from heat; stir in fresh parsley and lemon juice. Spoon soup into bowls; garnish with grated Parmesan cheese and dribble extra-virgin olive oil, if desired.

Yield and Serving Size: Makes 7 cups, 7 (1-cup) servings, each Nutrient Analysis: 149.44 calories, 16.2% calories from fat, 2.69 g total fat, 0.44 g saturated fat, 0 mg cholesterol, 30.16 g carbohydrates, 6.51 g fiber, 6.19 g protein, 183.20 mg sodium Nutrient Modifications: • None necessary. Substitute Ingredients: Carrots may not be common to the type of Mushroom Barley Soup that is fondly remembered. Diced carrots are added to this version since they add color to what otherwise may be a dreary bowl of soup. (Color is important for aging eyesight.) Dried porcini mushroom may be reconstituted with water or broth, and substituted for part of the cremini mushrooms for an even more pronounced mushroom (and umami) taste. Grains such as rice or quinoa may be substituted for the barley, but the soup may lose its distinctive taste, texture, quality and memorable attributes. Optional Ingredients: Chopped celery may be added along with the other vegetables, and its leaves may be chopped and added at the end of the recipe in place of parsley. A few drops of soy sauce and/or dry sherry may be added to finish and increase the salty and umami perceptions, thanks in part to their natural amino acid glutamate. Why Quick-Cooking Barley? Quick-cooking barley is pearl barley that has been steamed and dried during processing, so that it can speedily add bold and hearty taste to recipes, such as Mushroom Barley Soup. Quick-cooking barley provides a good source of fiber, with 5 AGING, NUTRITION AND TASTE

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grams of dietary fiber and 3 grams of soluble fiber per 1/3 cup of cooked uncooked barley. Like rice, barley generally doubles in size once cooked. Quick-cooking barley is also cholesterol and sodium free. 8. Cucumber Pepper Buttermilk Soup Category: Soups Prep Time: 20 minutes Technique: Blending Equipment: Blender or food processor, soup bowls

PHOTO: Cucumber Pepper Buttermilk Soup. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Creamy looking and tasting soups may not actually be high in fat and calories. This Cucumber Pepper Buttermilk Soup is a good example. It relies on reduced-fat buttermilk for its salty-sour creaminess, expanded by blended cucumbers and sweet red bell pepper for volume and color. Buttermilk-based soups such as this one are generally served before meals as refreshing starters and hunger dissipaters. Yet, they may transform into entre´e soups with the addition of cooked seafood or poultry. Plus, buttermilk-based soups are capable of holding their own with their array of vitamins and minerals that include calcium, iron, magnesium, phosphorus, potassium, sodium and zinc. Basic Tastes: Buttermilk is sour, fermented milk, caused by lactic acid that is created during the fermentation of lactose. Cucumbers are bitter, particularly if they are older. This is why the cucumber skin should be peeled. Sweet red bell peppers are acidic and sweet. They turn this soup into a pinkish-red color, depending on the color of the pepper. Scallions or chives are bitter and sharp. Olive and avocado oils are rich and unctuous. The addition of cooked seafood or poultry adds sweetness to this soup, and in the case of fish, some brininess. Featured Ingredient: Olive Oil While olive oil is calorific like other oils and fats, the composition of fatty acids are more heart and health favored. One tablespoon of olive oil is comprised of 14 grams of total fat, 2.2 grams of saturated fatty acids, 1.8 grams of polyunsaturated fatty acids and 10 grams of monounsaturated fatty acids—a fatty acid profile that is considered to be heart healthy. Extravirgin olive oil is usually used to “dress” salads, vegetables and other foods that might thrive by a few drops. The aroma of olive oil is critical to its flavor. It may have a fruity aroma, like the smell of green or ripe olives, freshly cut grass or the tropics. Extra-virgin olive oil may also produce a pungent or peppery sensation or bitterness. This is because extra-virgin olive oil is made from uncured olives with varying degrees of bitterness depending on the ripeness of the fruit. But once extravirgin olive oil is paired with other ingredients, such as the sweetness of sweet red bell pepper or buttermilk in this recipe, the bitterness is tempered and the mellowness endures. Ingredients: 2 medium English cucumbers 1 medium sweet red bell pepper, seeded and chopped, plus 2 tablespoons reserved for garnish 2 cups reduced-fat buttermilk

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1 tablespoon extra-virgin olive oil, plus 2 teaspoons for garnish 3 /4 teaspoon salt 1 /2 teaspoon ground white pepper 3 dashes hot pepper sauce 2 scallions, thinly sliced, including the green stems Cooked seafood or poultry, optional Instructions: 1. 2. 3. 4.

Thinly slice 12 cucumber rounds with skin for garnish, set aside. Peel and seed the remaining cucumbers. Dice half of one cucumber, set aside. Roughly chop the remaining cucumbers. Place roughly chopped cucumbers in bowl of blender or food processor; add chopped sweet red bell pepper, reduced-fat buttermilk, 1 tablespoon olive oil and salt and pepper. 5. Blend until smooth, about 1 2 minutes. 6. Divide mixture among 4 soup bowls; spoon in diced cucumbers and reserved sweet red bell pepper. 7. Garnish each bowl with 3 sliced cucumber rounds and scallions; drizzle with remaining olive oil. Optional: Add chunks or shredded seafood or skinless poultry to convert into entre´e soup. Yield and Serving Size: Makes 4 cups, 4 (1-cup) servings, each Nutrient Analysis: 150.27 calories, 47.97% calories from fat, 8.01 g total fat, 2.43 g saturated fat, 10 mg cholesterol, 14.56 g carbohydrates, 1.65 g fiber, 6.48 g protein, 576.6 mg sodium Nutrient Modifications: • To decrease total fat: Do not drizzle with olive oil to garnish. Substitute Ingredients: Other cucumbers may be substituted for English cucumbers, such as Armenian, garden, Japanese, or slicing cucumbers Squash, such as yellow squash or zucchini, may also be substituted for the English Cucumbers. Cornichons, gherkins, Kirby and lemon cucumbers may be better for pickling. Plain, low-fat or skim milk yogurt may be substituted for the buttermilk; however, the soup may need to be thinned with a little stock or water, and then seasonings may need to be adjusted to compensate. Optional Ingredients: Sour milk-based soups such as Cucumber Pepper Buttermilk Soup can support the additional of sweet seafood, such as cooked scallops or shrimp, either as a garnish or as a substantial addition. Plan on about 4 5 large scallops or 5 6 jumbo shrimp for a standard entre´e serving. A vegetarian option could exclude the seafood and add cubes of avocado and avocado oil in place of the olive oil. Large cooked white beans such as Greek Gigantes would be another nutritious addition. Why Drizzle Olive Oil Over Soup? One would think if a dish was made correctly, then nothing would need to be added to finish the recipe or before presentation. This is not necessarily the case, because people “eat with their eyes,” appearance counts and sometimes the plainness of a dish can elevated by a little color and/or texture before its consumption. The same may be the case with a little hot sauce or soy sauce, or in the example of Cucumber Pepper Buttermilk Soup, a little olive oil. The olive oil topper conveys to the diner that olive oil is a component of this recipe, and it communicates the suspected richness to come. But this soup is relatively low in fat, so the olive-oil topper works as an illusion. It may be equally successful in salads, stews and vegetable dishes that are naturally low in fat. If calories are a consideration, then it may be eliminated. 9. Coconut Fish Chowder Category: Soups Prep Time: 60 minutes Techniques: Blending and pureeing Equipment: Range, large saucepan, slotted spoon blender or food processor, soup bowls Description: Many varieties of coconut soup exist throughout world cuisines, with or without fish. These include laksa (Peranakan), sayur lodeh (Javanese), soto (Indonesian) and tom kha kai (Thai and Laotian) that may often be savory and served cold or hot. Inignit (Visayan) and kolak (Indonesian) are sweet coconut-based dessert soups. Coconut and fish have a natural affinity; the richness of

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coconut blends with the mildness of the fish and camouflages most of the fishiness. Cauliflower, corn and red pepper add color and texture, while red pepper flakes contribute heat. Lime provides acidity and cilantro is reminiscent of tropical climates. Basic Tastes: The opacity and rich taste of coconut is attributed to its high fat content that is mostly comprised of saturated fatty acids. Coconut milk is often characterized as floral, nutty or sweet, which attributes may be lost in processing. The onion and lime lend acidity, while the red pepper is vibrantly colored against the sweet cauliflower and corn. A tropical flavor blend results that is pleasant warm or cool. Featured Ingredient: Red Pepper Flakes (also known as crushed red pepper) Red pepper flakes may be feared or flaunted for their fierceness. This is why they are often called for in very small quantities in recipes such as Coconut Fish Chowder. As a condiment, red pepper flakes and crushed red pepper consist of both dried and crushed red chili (cayenne-type) peppers rather than ground. Some mixtures are flaked while others contain a high ratio of seeds—thought to be more intense. Their flavor is due more to their intensity rather than their taste that might be secondary, especially if they are older. Crushed red pepper may offer less of a bite since their surface area is smaller than red pepper flakes. Ingredients: 1 tablespoon vegetable oil, such as canola 2 cloves garlic, minced 1 medium yellow onion, finely chopped 1/8 to 1/4 teaspoon red pepper flakes, to taste 11/2 teaspoons sea salt 1 /2 teaspoon white pepper 11/2 cups water 1 (10-ounce) package frozen cauliflower florets 1 (10-ounce) package frozen corn kernels 1 fresh sweet red pepper, stemmed, seeded and diced 1 (13.5-ounce) can reduced-fat coconut milk 1 pound skinless mild fish fillets, such as flounder, haddock or red snapper 1 /2 cup fresh lime juice (about the juice of 3 limes) 1 /4 cup fresh cilantro or parsley, chopped Instructions: 1. Pour canola oil into large saucepan; heat over medium heat. 2. Add finely minced garlic, chopped yellow onion and red pepper flakes; cook about 5 minutes; stir often until garlic and onion are soft. 3. Add water, frozen cauliflower, frozen corn kernels, and diced red pepper; stir to mix. 4. Bring mixture to boil; reduce heat and simmer until vegetables are tender, about 4 5 minutes. 5. Remove saucepan from heat; with slotted spoon, carefully transfer about 11/2 cups of vegetable mixture into bowl of food processor or blender. 6. Add reduced-fat coconut milk to the blender or food processor; blend until smooth. 7. Add fish fillets to any remaining liquid and vegetables in saucepan; simmer until cooked through and opaque, about 5 minutes. 8. Add vegetable puree back into saucepan; stir thoroughly and gently break fish fillets into bite-sized pieces. Heat on medium heat until warm. 9. Remove saucepan from heat; stir in fresh lime juice. 10. Spoon soup mixture into 8 bowls; top each with chopped cilantro or parsley. Yield and Serving Size: Makes 8 cups, 8 (1-cup servings) each Nutrient Analysis: 193.33 calories, 39.38% calories from fat, 8.46 g total fat, 2.49 g saturated fat, 32 mg cholesterol, 15.46 g carbohydrates, 2.32 g fiber, 16.52 g protein, 489.98 mg sodium Nutrient Modifications: • To lower total fat: Use one-half reduced-fat coconut milk and one-half water. • To lower sodium: Use less sea salt.

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Substitute Ingredients: Plain yogurt, whether it is made from almond milk, cow’s milk or soy milk, is commonly used as a substitute for coconut milk. It is creamy and thick in consistency, but tends to be more acidic. Silken tofu or a vegan creamer may also be used as an alternative to coconut milk. Potatoes may be swapped for cauliflower, but they contribute more carbohydrate calories and may yield a thicker soup. Optional Ingredients: Celery and/or carrots are two common vegetables that appear in fish chowders. Seafood, such as clams, mussels, scallops or shrimp, can replace or be added to the fish fillets. The quantity of fish and seafood may have to be adjusted (such as onehalf pound of fish fillets and one-half pound of seafood), or the ratio of fish to vegetables may be disproportionate. Ultimately it is up to individual taste and appetite. Why Frozen Corn Kernels? Frozen vegetables are generally picked at their peak in nutrients right after being harvested. As long as they are not overcooked, they are ordinarily economical and handy to add to recipes, such as this Coconut Fish Chowder. Plus, frozen corn kernels add color and texture to otherwise bland mixtures. Avoid overcooking frozen corn kernels because they may become mushy in texture. This is why some of the frozen corn kernels are pureed for texture and to impart a chunky texture. 10. Tortellini Potage Category: Soups Prep Time: 25 minutes Technique: Boiling Equipment: Range, large saucepot, soup bowls

PHOTO: Tortellini Potage. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Tortellini are ring-shaped pasta that look navel in shape. For this reason tortellini are often called ombelico or “belly buttons.” They normally appear as a pasta course, but are often found in soups—generally broths, unlike this creamy mixture. Tortellini is often stuffed with a mixture of meats, such as pork loin or prosciutto and/or cheese, unlike tortelloni which often contain only cheese. Plus, tortellini may be served with a sauce or in a broth, while tortelloni are seldom served in a broth. This recipe has five easy steps and uses frozen tortellini, along with frozen mixed vegetables and frozen

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crabmeat or shrimp and bottled clam juice or chicken or vegetable broth. Reduced-fat cream cheese adds creaminess and a dairy-rich component. Basic Tastes: Clam juice, the basis of many fish soups, provides a briny and salty base, as does the frozen fish. The heartier frozen vegetables (carrots, onions and potatoes) versus the frozen vegetable combinations of broccoli, cauliflower and carrots, or baby corn, broccoli, carrots and sugar-snap peas, will determine if the tastes are fresher versus deeper. The no-salt spicy herbal blend adds aromatics without additional sodium. Though the reduced-fat cream cheese provides sweetness and creaminess, it can be swapped for a vegetarian-friendly cream cheese-like product, or eliminated altogether (see Substitute Ingredients). Featured Ingredient: Parsley Parsley is considered as the most popular herb in European cooking. The long history of parsley as a taste purifier and health aid has been claimed since Grecian and Roman times. In the Middle East, parsley is revered as a vegetable, and in the Far East the Chinese refer to parsley as a similar-looking herb, “Chinese parsley,” also known as cilantro. Flat-leaf parsley is generally preferred in cooking, while curly parsley is typically reserved as a garnish for appearance. The best flavor of parsley is in the stems, which are often used to flavor stock for soup, sauces or stews. Ingredients: 4 (8-ounce) bottles clam juice or 1 (32-ounce) box vegetable or chicken broth 1 tablespoons spicy no-salt added seasoning, such as spicy jalapeno 1 /2 teaspoon salt 2 (9-ounce) packages refrigerated or frozen cheese tortellini 1 (16-ounce) package frozen mixed vegetables (such as broccoli florets, cauliflower and carrots) 1 (8-ounce) package frozen or refrigerated cooked crabmeat or shrimp 1 (8-ounce) package reduced-fat cream cheese, room temperature Chopped parsley, to garnish Instructions: 1. Pour clam juice or vegetable or chicken broth into a large saucepot; add herbal seasoning and bring to boil. 2. Reduce heat to medium; cook about 3 minutes. 3. Add the salt, tortellini, frozen vegetables and crabmeat or shrimp and stir; cook over medium heat about 4 minutes, or until the tortellini are tender. 4. Remove soup from heat; gently stir in reduced-fat cream cheese until blended. 5. Pour into 6 bowls; garnish with chopped parsley. Yield and Serving Size: Makes 9 cups, 6 (11/2 cup servings), each Nutrient Analysis: 276.4 calories, 29.92% calories from fat, 9.13 g total fat, 4.47 g saturated fat, 106.27 mg cholesterol, 30.9 g carbohydrates, 3.73 g fiber, 18.27 g protein, 896.02 mg sodium Nutrient Modifications: • • • • •

To lower total fat: Use nonfat cream cheese. To lower saturated fat: Use nonfat cream cheese. To lower cholesterol: Use freshly cooked whitefish rather than seafood. To lower carbohydrates: Use a greater proportion of vegetables than pasta. To lower sodium: Use less salt or reduced-sodium chicken broth. Do not add frozen seafood (but this step decreases the ample amount of protein).

Substitute Ingredients: For a vegetarian version, use vegetable broth instead of clam juice. Most vegetable broths are darker in color than chicken broth so the soup may have a darker appearance. Swap cubes of tofu for the seafood and a vegetarian or vegan cream cheese substitute, or keep the soup clear. Garnish with chopped chives or scallions and float hard-boiled egg slices over the top, if desired. Optional Ingredients: Beef broth, ground beef or pork tortellini and a hearty frozen vegetable medley, along with the spicy seasoning can transform this recipe into Beef Broth With Tortellini or Pasta in Brodo. A little Parmesan cheese adds salty-sweetness,

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somewhat correspondingly to the use of the reduced-fat cream cheese in this recipe for Tortellini Potage. Reduced-fat ricotta cheese is another creamy dairy alternative. Why Bottled Clam Juice? Many professional and some home cooks have stock on hand for braises, chowders, dressings, poaching liquids, sauces, soups, steaming liquids and other uses. Bottled clam juice may function as a replacement for a fish stock, or fumet in some recipes. It delivers a briny base, much like a longer cooking fish stock would provide. Because clams are naturally rich in the amino acid glutamate with its umaminess, bottled clam sauce has flavor-enhancing capabilities. Unfortunately, bottled clam juice usually has a sizeable amount of sodium, so the rest of the salt/sodium in a recipe should be taken into account and may require modification. SALADS: Fiber and Nutrient-Rich 11. 12. 13. 14. 15.

Turkey Salad With Grapes “New Age” Potato Salad Spinach Salad With Chunky Garlic Dressing Brussels Sprouts Salad Chickpea Salad With Pita Triangles

SALADS Salads are a convenient way to eat a daily abundance of fruits and vegetables. These salads are high in antioxidants, minerals and vitamins for cellular protection, fiber for healthy digestion and weight management and protein for muscle maintenance. If the portion sizes are doubled, or if protein is added to some of these salads, then they can be converted into entre´es. Add a little hearty bread and a fruit-based dessert and a humble salad can transform into a satisfying meal. 11. Turkey Salad With Grapes Category: Salads Prep Time: 30 minutes Technique: Combining Equipment: Medium-sized bowl, salad plates Description: While turkey is often considered as a once-yearly entre´e at Thanksgiving, turkey is a versatile protein that can be used more than as a lean sandwich filler. Consider this recipe for Turkey Salad With Grapes, where smoked turkey breast (or leg) is diced and added to a lower fat yet creamy mixture of yogurt and mayonnaise, along with crunchy celery and purple grapes and a blend of fragrant dried herbs. This versatile recipe may benefit from leftover turkey, chicken, ham or bits of other Thanksgiving ingredients. It may also be reminiscent of mayonnaise-based salads of the 1950s or 1960s—yet a healthier version. Basic Tastes: Astringent ingredients, such as grapes tend to cut through opposing flavors. In this recipe, the grapes serve to counter the anticipated richness of the mayonnaise, except in this case it is low-fat mayonnaise. Plain, low-fat yogurt serves a similar purpose. Dijon mustard adds a salty, sharp, and strong bite, while the little bit of apricot jam balances with its sweetness. The smokiness of the turkey creates a depth of flavor from the umami taste. Featured Ingredient: Grapes, Grape Juice or Wine Grapes and wine have ancient roots in Armenia, China, Georgia, Greece, Iran and Sicily where it was consumed for medicinal, religious and social purposes. Perhaps these ancient people discovered that a handful of fermented grapes or decanter of grape juice boosted their heart health as well as their spirits! This could be due to the flavonoid content of grapes that prevents blood from clotting and cells from disease. Try Concords, Emperors, Malagas, Muscats, Flame Tokays or Ribiers for both taste and texture—or a mixture of these varieties to enhance the appearance and texture of this recipe. Ingredients: 1 tablespoon plain, low-fat Greek yogurt 2 teaspoons low-fat mayonnaise 1 /2 teaspoon Dijon mustard 1 teaspoon apricot jam 1 cup smoked turkey breast or leg, skinless and diced 1 /2 cup seedless purple grapes, halved 2 tablespoons celery, minced 1 /4 teaspoon white pepper 1 /4 teaspoon celery seed AGING, NUTRITION AND TASTE

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/2 teaspoon dried tarragon 1 teaspoon fresh lemon juice 2 tablespoons almond slices 4 large romaine lettuce or spinach leaves

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Instructions: 1. Combine plain, low-fat yogurt, low-fat mayonnaise, Dijon mustard and apricot jam in a medium-sized bowl. 2. Add diced turkey breast or leg, halved purple grapes, minced celery, white pepper, celery seed, tarragon, lemon juice and sliced almonds; mix thoroughly. 3. Spoon onto romaine lettuce or spinach leaves on salad plates to serve. Yield and Serving Size: Makes 2 cups, 4 (1/2-cup) servings Nutrient Analysis: 133.55 calories, 23.59% calories from fat, 3.5 g total fat, 0.66 g saturated fat, 41.9 mg cholesterol, 7.2 g carbohydrates, 0.74 g fiber, 19.57 g protein, 1011.84 mg sodium Nutrient Modifications: • To lower sodium: Use regular turkey breast, not smoked. Decrease the amount of Dijon mustard. Substitute Ingredients: Coarse-grain mustard may replace Dijon mustard; another light-colored fruit jam, such as peach, may be substituted for apricot jam; hickory chicken or ham may be used instead of smoked turkey breast or leg; dried rosemary or thyme may be substituted for tarragon (both of these herbs are earthier, while tarragon is sweeter); and jicama may replace the celery. When substituting these ingredients, try to replace the originals with items of similar texture and taste. Optional Ingredients: Curry powder and mango chutney transform this recipe into a Middle Eastern dish. Consider eliminating the celery seed and tarragon and adding curry powder to taste (about 1/4 1/2 teaspoon). Swap 1 teaspoon of mango chutney for the apricot jam and use about 1/4 cup of sliced almonds throughout the salad instead of as a garnish. Why Smoked Turkey Breast (or Leg)?* Turkey breast is naturally low in total fat, saturated fat and cholesterol. But these features may cause turkey breast to be dry and tasteless. Smoking adds another dimension to its flavor. Like smoked fish, smoking has been used since medieval European times to preserve and impart taste to many types of preserved meats. Thanks to modern technologies, today foods are smoked mostly for flavor. Smoked turkey adds a deep, intricate, multidimensional flavor to recipes such as Turkey Salad With Grapes. *Note: If smoked turkey breast is unavailable, smoked skinless turkey leg may be used; however, the fat content will be higher. Regular turkey breast may be used for people who need to monitor their sodium intake. 12. “New Age” Potato Salad Category: Soups Prep Time: 30 minutes Technique: Emulsifying Equipment: Range, 2-quart saucepan, large bowl

PHOTO: “New Age” Potato Salad. r 2019 Grace Natoli Sheldon. Reprinted with permission.

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Description: Starchy potato salad, thick with mayonnaise or salad dressing, has been a perennial sandwich accompaniment since the mid-20th century. It may have originated in Germany, yet German potato salad is typically served warm with a vinegar and herb dressing. European settlers and soldiers may have contributed their version to the United States, and then Americans added creaminess and chopped vegetables, such as pickles and pimentos. This recipe uses low-fat mayonnaise, crunchy fresh green beans, sweet red bell pepper and green onions—indeed a “new age” approach for this longtime favorite. Basic Tastes: The tartness of yogurt, sharpness of mustard and creaminess of mayonnaise unify the tastes and textures of the fresh vegetables and provide a contrast to the plain, sweet potatoes. The Dijon mustard adds both tang and saltiness so little additional salt is required. Do let the various tastes blend so the flavor is fuller and unified. Featured Ingredient: Potatoes Americans have ranked white potatoes one of their most satisfying vegetables; however, fried potatoes are usually the preferred choice. Boiled and/or baked white potatoes are fat-free, with more protein, vitamin C and fiber than apples, and they are packed with age-defying antioxidants right under their skin. The thin, nutrient-filled skins of red potatoes contain B vitamins (especially vitamin B6); fiber (about 3 milligrams per medium red potato); iron (about 6% of the recommended Daily Value per serving); potassium (about 969 milligrams per medium red potato); and vitamin C (about 45% of the recommended Daily Value per serving). Ingredients: 1 (24-ounce) package red-skinned potatoes with skin, cut into 1/2-inch cubes (about 3 4 cups) 1 (5-ounce) package green beans, cut in 1-inch pieces (about 3/4 cup) 1 medium sweet red bell pepper, diced (about 1/2 cup) 1/3 cup light mayonnaise 1/3 cup plain low-fat Greek yogurt 1 tablespoon Dijon mustard 4 green onions, chopped 1 /2 teaspoon salt 1 /2 teaspoon freshly ground black pepper Fresh chopped parsley, to garnish Instructions: 1. 2. 3. 4. 5. 6. 7. 8.

Put potatoes into a 2-quart saucepan; cover with water and bring to boil. Reduce heat, cook until fork-tender, about 10 minutes. Add green beans and red bell pepper; continue cooking until slightly tender, about 1 2 minutes. Drain vegetables; rinse with cool water to halt cooking. Mix reduced-fat mayonnaise, plain and low-fat yogurt, Dijon mustard, salt and pepper in large bowl. Place drained potatoes, green beans, red bell pepper and green onions into bowl. Add mayonnaise and yogurt-based dressing; mix thoroughly. Garnish with fresh chopped parsley. Yield and Serving Size: Makes about 6 (1-cup) servings

Nutrient Analysis: 150.06 calories, 14.75% calories from fat, 2.46 g total fat, 0.41 g saturated fat, 2.99 mg cholesterol, 27.28 g carbohydrates, 3.23 g fiber, 4.2 g protein, 287.57 mg sodium Nutrient Modifications: • To lower carbohydrates: Use fewer red-skinned potatoes. • To lower sodium: Use less Dijon mustard. Substitute Ingredients: For those who may be limiting their carbohydrate intake, cauliflower may be substituted for the red-skinned potatoes. Other colored sweet bell peppers may be used to provide color and texture. Chives may be substituted for green onions for piquancy and color. Alternative flavored-mustards may be exchanged for Dijon, but the allover color may also be affected. Optional Ingredients: Add four ounces of firm fish, lean ham or skinless poultry to transform this salad into a protein-rich, substantial and relatively economical entre´e. Fresh or dried basil, dill or parsley mixed into the salad dressing and absorbed by the potatoes may augment the mildness of this salad and add bitter, peppery notes.

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Why Dijon Mustard? This French-style mustard is pale yellow and strong, with less additional flavoring than English mustards, where strong mustard is the norm. The sharp taste in mustard is similar to the compounds that create the tastes of the cabbage family. The vinegar in mustard preserves its pungency and flavor. Dijon mustard adds piquancy to bland foods such as potatoes and is an excellent accompaniment to plain proteins. For those people who love texture in their accouterments, coarse or country-style mustard may be substituted. Herbal mustard, such as basil or tarragon, provides additional aromatic taste. 13. Spinach Salad With Chunky Garlic Dressing Category: Salads Prep Time: 15 minutes Technique: Concentrating flavors Equipment: Large bowl, spoon, small bowl, container

PHOTO: Spinach Salad with Chunky Garlic Dressing. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: There are other ways to consume spinach than the often overcooked, army-green preparation that some people may remember. Fresh baby spinach is bright green, crisp, just slightly bitter and provides a nice accompaniment to creamy, fullflavored salad dressings like this Spinach Salad With Chunky Garlic Dressing. Plus, baby spinach is often prewashed and packaged in resealable bags and containers. This simple salad with complimentary tastes also lends itself to other heartier greens, such as arugula, broccoli “slaw,” Brussels sprouts, various types of chard or kale. Basic Tastes: Within the salad itself, the baby spinach may taste somewhat bitter depending on its age, with some salty and umami undertones. The red onion is acidic and pungent, the mandarin oranges are sweet and the eggs provide the umami taste. In the salad dressing on its own, garlic is both pungent and slightly oily. Besides its garlicky taste, it functions to smooth the sourness of the yogurt and sweeten the bitterness and blandness of the cucumber. Featured Ingredient: Spinach Raw spinach is mostly water, with less than 4% carbohydrates, protein and fat. Raw spinach is low in calories and provides a rich source of vitamins A, C and K, folate, iron, magnesium and manganese, and a good source of the B vitamins riboflavin and vitamin B6, vitamin E, calcium, potassium and dietary fiber. Savoy spinach has dark green, crinkly and curly leaves. Flat or smooth-leaf spinach is broad and smooth as is the baby variety. Semisavoy spinach is a hybrid with somewhat crinkly leaves. Spinach has a moderate amount of oxalates, naturally occurring substances that may interfere with its nutrient absorption. However, the natural vitamin C content in the salad ingredients and dressing may help to improve its uptake. 13a. Spinach Salad Ingredients: 8 ounces baby spinach, washed, dried and stemmed 1 small or one-half of large red onion, thinly sliced (about 3/4 cup) 1 /2 cup canned Mandarin oranges in 100% fruit juice (well drained), or water 4 hard-boiled eggs, quartered AGING, NUTRITION AND TASTE

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Instructions: 1. Combine baby spinach, thinly sliced red onion and mandarin oranges in large bowl; gently toss to mix. 2. Spoon 1/2 to 1 cup Chunky Garlic Salad Dressing over the spinach salad ingredients; toss well to coat. Reserve additional dressing. 3. Garnish with quartered hard-boiled egg slices. 4. Serve with additional dressing, if desired. 13b. Chunky Garlic Salad Dressing Description: The pungency of garlic has the capacity to add pizzazz to plain foods and perk up their tastes. This may be because garlic acts as a flavor catalyst. One of the functions of garlic in a recipe is to blend with a taste and ignite a change in it. When garlic is paired with lemon as in Chunky Garlic Salad Dressing, it helps to make the lemon taste more lemony. Garlic meshes with onion powder that also highlights the lemony taste. Add more garlic or hot pepper sauce if one’s taste requires an even greater “bite.” Ingredients: /2 cup plain, low-fat Greek yogurt 1 /2 medium cucumber, peeled, seeded and grated 1 tablespoon apple juice concentrate 1 /2 teaspoon onion powder (or 1 teaspoon minced onion) 1 /4 teaspoon garlic powder (or 1 clove garlic, minced) 1 tablespoon lemon juice Hot pepper sauce, if desired 1

Instructions: 1. Combine all ingredients in small bowl and mix well. 2. Spoon over Spinach Salad or pour into container; cover and refrigerate. Yield and Serving Size: 1. Spinach Salad makes about 4 (1-cup) servings, each Nutrient Analysis: 104.18 calories, 46.22% calories from fat, 5.35 g total fat, 1.5 g saturated fat, 211 mg cholesterol, 7.28 g carbohydrates, 2 g fiber, 8.35 g protein, 115.4 mg sodium Nutrient Modifications: • To lower cholesterol: Use only egg whites. 2. Chunky Garlic Salad Dressing makes about 1 cup, 8 (2-tablespoon) servings, each Nutrient Analysis: 146.96 calories, 1.53% calories from fat, 0.25 g total fat, 0.05 g saturated fat, 0 mg cholesterol, 24.85 g carbohydrates, 0.96 g fiber, 13.46 g protein, 57.25 mg sodium Nutrient Modifications: • To lower calories: Reduce portion size. Substitute Ingredients: Greek yogurt is used for its tanginess; however, plain low-fat yogurt may suffice for its creaminess and range in tang. By using fresh garlic and onions instead of garlic and onion powders their flavors should be more pronounced. White grape juice concentrate may be substituted for apple juice concentrate. Fresh or dried basil, dill, marjoram, oregano or parsley should help to transform this Chunky Garlic Dressing into a Green Goddess style salad dressing, without the anchovies. Optional Ingredients: For a creamier touch, a few tablespoons of low-fat mayonnaise may be added. Or Blue or Roquefort cheese added in crumbles, chunks or granulated form may be used to enhance the pungency and sharpness. A few drops of Worcestershire sauce or vinegar may add some umaminess to the mixture, but may somewhat to mostly alter the color. Why Apple Juice Concentrate? Undiluted 100% fruit juice concentrates, such as apple, grape or orange, may add concentrated natural fruit sweetness with relatively few calories to beverages, desserts or sauces. Fruit juice concentrates keep well in the freezer and require little storage space.

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A small amount can be used at a time; then resealed for future use. In some locations, mixed fruit juice concentrates may be available, such as apple-pear or orange-pineapple. Be careful that they do not stray too much from the intended tastes of a recipe. 14. Brussels Sprouts Salad Category: Salads Prep Time: 15 minutes Technique: Combining, refrigerating Equipment: Large bowl, small bowl, refrigerator

PHOTO: Brussels Sprouts Salad. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Like the other members of the Brassica family (broccoli, cabbage, cauliflower, kale and mustard, for example), Brussels sprouts are typically the vegetables that one loves to hate. This may be due to their brashness and odor; thanks to the compound phenylthiocarbamide that is either perceived as bitter or insensitive depending on genetic predisposition. Still, the nutrient contributions of this vegetable family are admirable: particularly vitamin C, soluble fiber and the anticancer substances sulforaphane and selenium. Brussels Sprouts Salad is indeed a fresher approach to Brussels sprouts of yore, and worth trying. Basic Tastes: This salad balances the bitterness of Brussels sprouts with the richness of olive oil and the tanginess of both apple cider vinegar and Dijon mustard. Parmesan cheese adds umami to the earthiness of Brussels sprouts, and dried cherries or cranberries supply tanginess and sweetness. Featured Ingredient: Apple Cider Vinegar Apple cider vinegar is comprised mostly of apple juice whereby the fruit sugar has been converted into alcohol by yeast. Yeast transforms the alcohol into acetic acid that is both sour tasting and strong smelling. Apple cider vinegar can be used in baking, cooking, salad dressings (as in this recipe) and as a preservative. Historically, apple cider vinegar has been used in kitchen medicine as a “remedy” since Hippocrates’ time (about c.460 to c.370 BC). This attribute may be the result of its polyphenol content—antioxidants that may restrain cellular damage. Ingredients: 1 (9-ounce) bag of shredded Brussels sprouts, or 21/4 cups* 1 /2 teaspoon salt 1 /2 teaspoon black pepper 2/3 cup dried cherries or cranberries 1 /4 cup (1/2 ounce) shredded Parmesan cheese 2 green onions, thinly sliced 2 tablespoons sliced almonds 1 /4 cup extra-virgin olive oil 3 tablespoons apple cider vinegar 2 teaspoons Dijon mustard Instructions: 1. Add shredded Brussels sprouts, salt, pepper, dried cherries or cranberries, shredded Parmesan cheese, green onion and almonds into a large bowl. Mix well to combine.

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2. Combine extra-virgin olive oil, apple cider vinegar and Dijon mustard in small bowl; pour salad dressing over Brussels sprouts mixture and blend well. 3. Refrigerate to blend flavors; stir occasionally. *Note: As an option, the shredded Brussels sprouts may be saute´ed slightly in 1 to 2 tablespoons of olive oil to help mellow and soften their bite. Less olive oil may then be necessary for the salad dressing. Yield and Serving Size: Makes 5 cups, 5 (1-cup) servings, each Nutrient Analysis: 242.64 calories, 45.17% calories from fat, 12.18 g total fat, 2.26 g saturated fat, 2.02 mg cholesterol, 29.29 g carbohydrates, 9.21 g fiber, 3.65 g protein, 343.83 mg sodium Nutrient Modifications: • To lower calories, total fat, carbohydrates, and sodium: Reduce the portion size to 1/2-cup, and place over leafy-green lettuce. Substitute Ingredients: Shredded broccoli spears, cabbage, carrots or kale can be substituted for the Brussels sprouts, or used in combination. A quick saute´ in flavorful olive oil may assist their digestibility and temper their assertiveness. Optional Ingredients: If nuts are easy to chew and digest, then toasted and chopped English walnuts or hazelnuts may provide additional color, crunch and interest. A squirt of fresh lemon juice may add brightness and link the other tastes. Thyme or rosemary could be added to help bring out the earthiness of this salad, while the addition of basil or parsley would emphasize its freshness. Why Dried Cranberries? Cranberries are very tart berries when they are fresh. Usually when cranberries are dehydrated they are sweetened and a concentrated source of energy, along with some loss of vitamins A and C. In Brussels Sprouts Salad dried cranberries add color, texture, dietary fiber and they retain some antioxidants. They provide a nice contrast to the deep green color of the Brussels sprouts and their commanding taste. 15. Chickpea Salad With Pita Triangles Category: Salads Prep Time: 1 hour Technique: Saute´ing Equipment: Range, large saucepan

PHOTO: Chickpea Salad With Pita Triangles. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Chickpeas, also known as garbanzos, Bengal grams or Egyptian peas are legumes that originated in the Middle East. In the United States, chickpeas are common in Hispanic and Middle Eastern cuisines. Chickpeas are nutrient-dense with their rich content of dietary fiber, folate, iron, phosphorus and protein, and moderate amounts of magnesium, thiamin, vitamin B6 and zinc. Most of their fat is unsaturated. This Chickpea Salad can be served as a salad course, stuffed into pita bread as a sandwich filling or enhanced by the presence of cooked protein, such as diced or shredded lean pork or poultry. AGING, NUTRITION AND TASTE

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Basic Tastes: When blended with tasty spices such as coriander, cumin, cinnamon or cloves and onion, garlic and bell peppers in a creamy yogurt sauce, this salad mixture conjures exotic global cuisine. Chickpeas are fairly bland on their own—even if they are canned and rinsed. Since about one-third of their content is carbohydrate, the tasty spiced yogurt dressing should balance their mild and sweet simplicity. Featured Ingredient: Turmeric Turmeric, considered as a spice, is actually a rhizomatous and herbaceous perennial plant of the ginger family, native to Southeast Asia. The main constituent of turmeric is curcumin. Turmeric and curcumin have been used for thousands of years in Ayurvedic, Siddha, Unani and traditional Chinese medicine. Subsequently, turmeric is common in many Asian dishes for its distinctive earthy aroma, slight bitterness, mustard-like pungent taste and bright yellow-orange color. Ingredients: 2 tablespoons canola or olive oil 1 teaspoon each ground coriander and ground cumin* 1 /4 teaspoon each ground cinnamon and ground cloves 1 /2 teaspoon turmeric 1 /2 teaspoon curry powder 1 small red onion, minced 1 clove garlic, minced 1 each medium sweet green and red bell pepper, stemmed, seeded and chopped 2 medium stalks celery, trimmed and diced 2 (15.5-ounce) cans chickpeas, drained and rinsed 1 cup plain nonfat or low-fat yogurt, plus additional for garnish 2 green onions, trimmed and minced 1 medium tomato, seeded and chopped 1 /2 teaspoon salt 1 /2 teaspoon pepper Bibb or Boston lettuce leaves Fresh cilantro or parsley, chopped for garnish Plain Greek yogurt, for garnish Pita triangles or pita pockets, for stuffing (optional) *Note: As an option to the spice mixture in this recipe, a spice mixture such as Za’atar that is available at some specialty stores may be substituted, with adjustments to taste. Instructions: 1. 2. 3. 4. 5. 6. 7.

Heat canola or olive oil in large saute´ pan. Add coriander, cumin, turmeric, curry powder, cinnamon, cloves, onion and garlic; mix until well blended. Cook until onion and garlic are soft. Stir in chopped red and green bell peppers and diced celery; cook an additional 5 minutes or until slightly soft. Remove saute´ pan from heat. Stir in drained chickpeas, yogurt, minced green onions, chopped tomatoes, salt and pepper; blend well. To serve, spoon chick pea and vegetable mixture over Bibb or Boston lettuce leaves and garnish with chopped cilantro or parsley and/or plain Greek yogurt, if desired. 8. Serve with pita triangles or stuff into pita halves, if preferred. Yield and Serving Size: Makes 7 cups, 7 (1-cup) servings, each Nutrient Analysis: 276.89 calories, 22.82% calories from fat, 7.02 g total fat, 1.07 g saturated fat, 0 mg cholesterol, 40.34 g carbohydrates, 10.95 g fiber, 15.4 g protein, 200.86 mg sodium Nutrient Modifications:

• To lower calories and/or sodium: Reduce portion size to 1/2-cup. Substitute Ingredients: Chickpeas add crunchy interest to salads, soups and entre´es and when they are pureed and blended with tahini, olive oil, lemon juice, salt and garlic they convert into a creamy dip called hummus. Some of the chickpeas may be pureed to aid digestibility and then mixed with whole chickpeas for textural interest. Other canned legumes, such as lima or white beans may be used. AGING, NUTRITION AND TASTE

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Optional Ingredients: Lemon juice adds acidity and freshness, as does thinly sliced red onion. A finely chopped chili pepper, red pepper flakes or a little harissa, a North African chili pepper paste comprised of both hot and sweet peppers with caraway, coriander and garlic, will raise the intensity and flavor. Why Bibb or Boston Lettuce? Both Bibb and Boston lettuce are the same variety: Butterhead. However, Bibb lettuce is slightly smaller than Boston lettuce. Still, both types of lettuce may be used interchangeably due to their similar flavors and textures. With their smooth and tender textures and mildly sweet leaves filled with vitamins A, C and K, they provide handy ingredients for many salads, sandwiches and wraps, such as in Chickpea Salad. ENTRE´ES: Animal and Vegetable Options 16. En“lite”tened Beef Sandwiches 17. Chicken With a Kick 18. Baked Salmon With Mustard Sauce 19. Sweet and Spicy Lamb 20. Saute´ed Tofu Patties ENTRE´ES When people of “a certain age” were growing up, meals probably revolved around the “center of the plate.” Starches, such as pasta, potatoes or rice and cooked vegetables generally were flanked by proteins; primarily beef, poultry or pork, and secondarily by lamb or fish. Protein portions were about the right portion size for the time—about 3 4 ounces. While years progressed and the United States prospered, so did portion sizes that coincided with the growth of the American waistline. As people age and their caloric needs decrease, it becomes prudent to whittle down the portion sizes of protein foods and “beef up” the accompaniments. These recipes entre´es provide just the right amount of protein, with plenty of nourishing vegetables and/or wholesome carbohydrates to complement. BEEF As a child of the 1950s or 1960s, beef might have been the center of the plate. During the counterculture 1970s when vegetarianism was elevated to the forefront, though beef was still prominent, vegetable proteins ascended in popularity. Today, beef still reigns in popularity in the US diet, though both vegetarianism and veganism continue to be on the rise. While massive portions of beef may not be prudent or justified as far as calories and fat are concerned, beef may have its place in many diets. 16. En“lite”tened Beef Sandwiches Category: Entre´es Prep Time: 30 minutes Techniques: Saute´ing, boiling, and simmering Equipment: Range, nonstick skillet

PHOTO: En“lite”tened Beef Sandwiches. r 2019 Grace Natoli Sheldon. Reprinted with permission.

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Description: Beef is a great source of iron and zinc for primetime protection, maintenance and repair. Seven lean cuts of beef rival a skinless chicken breast in fat: eye of round, top round, round tip, top sirloin, bottom round, top loin and tenderloin. By combining low-fat beef with onions, peppers and mustard, a simple beef sandwich such as this one suddenly bursts with flavor. To coincide with the current relaxed US culture, it is time to think out of the box and consider sandwiches as entre´es—especially those that contain ingredients that combine food groups, with healthier fats, leaner proteins and vitamin and mineral-rich vegetables. This En“lite”tened Beef Sandwich is a good example of a unification that succeeds in this endeavor. Basic Tastes: The right proportion of aromatic and sweet vegetables (mild green chili peppers and sweet bell peppers) blend with the salty, beefy broth and assertive Dijon mustard to form a hearty amalgam of flavor—despite the shortage of fat. The overall flavor in these En“lite”tened Beef Sandwiches is loaded with umami, thanks to the beef and beef broth. Featured Ingredient: Chili Peppers Not all chili peppers are hot—in fact, they run the gamut from mild to excruciatingly intense packaged in a variety of colors, shapes and sizes. While chilies are known to add heat and spiciness to dishes, it is a substance called capsaicin and its related compounds that actually contribute to their intensity. Capsaicin binds with pain receptors in the mouth and throat and has the capacity to evoke discomfort, heat and pain. Some people prefer its strength while others may only be able to tolerate a miniscule amount. This recipe for En“lite”tened Beef Sandwiches uses canned mild green chili peppers, considered to be low (and potentially more tolerable) on the Scoville heat unit scale. Ingredients: 1 tablespoon olive oil 1 medium yellow onion, peeled and thinly sliced 1 medium sweet red bell pepper, stemmed, seeded and thinly sliced 1 medium sweet green bell pepper, stemmed, seeded and thinly sliced 1 (2.5-ounce) can mild green chili peppers, drained and thinly diced 1 cup low-fat beef broth, divided into 2 (1/2 cup) portions 1 /2 pound lean beef (such as eye of round, sirloin tip, top or bottom round roast or top sirloin steak), sliced into 1/4-inch strips 1 long (about 26 39 inches) whole-grain Italian or French bread, halved lengthwise and crosswise into four pieces 4 teaspoons Dijon mustard Freshly ground black pepper, to taste Instructions: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Scoop out bread quarters, leaving 1/2-inch shells. Spread 1-teaspoon Dijon mustard into each bread shell. Add the olive oil to a 12-inch nonstick skillet; warm over medium heat. Add sliced onions and sweet red and green bell peppers; cook about 3 minutes until tender, stirring frequently. Stir in diced chili peppers and 1/2 cup beef broth. Bring to boil; reduce heat, cover and simmer about 3 minutes. Remove lid; increase heat, add beef strips and just enough reserved beef broth to moisten if mixture appears dry. Reserve any additional beef broth. Cook beef strips just until tender, about 3 5 minutes. Divide mixture evenly in quarters and spoon into bread shells. Add freshly ground black pepper to taste. Serve any pan liquid and/or reserved beef broth on side, or drizzle over sandwiches.

Yield and Serving Size: Makes 4 (2- to 3-ounce) open-faced sandwiches, each Nutrient Analysis: 283.91 calories, 25.8% calories from fat, 8.14 g total fat, 1.55 g saturated fat, 33 mg cholesterol, 33.14 g carbohydrates, 3.66 g fiber, 18.53 g protein, 618.43 mg sodium Nutrient Modifications: • To lower calories: Use one slice of bread, less lean beef and more vegetables. • To lower total fat: Use less olive oil and lean beef.

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• To lower carbohydrates: Use one slice of bread. • To lower sodium: Use low-sodium beef broth and less Dijon mustard. Substitute Ingredients: A sweet onion, such as Vidalia, may help to buffer the flavor of the peppers. While a whole-grain baguette will provide more heartiness than a refined wheat baguette, the latter may be softer for chewing issues. The baguette could be slightly toasted to add a crisped texture and some additional umami taste. A horseradish-based mustard could be used to add spiciness and vinegary notes. Optional Ingredients: A sliced dill pickle will add its salty, sour and sweet tastes as well as its crispness, crunchiness and juiciness. Or, for a different direction in taste and texture, add a few slices of ripe avocado for its creaminess and to balance the peppery tastes. Likewise, sliced, ripe olives may provide similar functions. Plus, both the avocado and the olive add colorful interest. Why Chili Peppers? Wild chilies were cultivated thousands of years ago in Mexico for their spiciness. Their use spread throughout the world after the Columbian exchange in the 15th and 16th centuries. Chilies were valued for both their food and traditional medicine properties. From a taste standpoint, chilies produce an immediate sensation in the throat and the back of the palate, and a slower and longer lasting sensation on the tongue and middle palate, which may be pleasantly tolerated over time. Chilies impact flavor, not just hotness. Their flavor may be mild, subtle and attractive to some people—and tolerated by others. And the warmth that chili peppers generate may actually stimulate the appetite, taste buds and digestion [1]. POULTRY Cleaning and cutting whole chickens (before deli turkey and chicken were even conceived), may have resulted in uneven cuts and portion sizes and many unhappy cooks. Today, perfectly cut and trimmed poultry in a variety of shapes and sizes is a given. This is convenient, economical, and handy since chicken is a low-fat, highprotein food and ingredient. And it is easier today to purchase whole or skinless poultry for just one or two servings. Boneless chicken or turkey breasts or tenders are almost no-fuss with countless preparation options. Just keep the poultry moist and tender, like the recipe for Chicken With a Kick that follows. 17. Chicken With a Kick Category: Entre´es Prep Time: 40 minutes Technique: Baking Equipment: Oven, baking pan Description: Chicken is a very reliable source of protein, especially lighter and skinless cuts, such as skinless, boneless chicken breasts and wings. Nevertheless, sometimes the taste and texture of these cuts may become tiresome. It is fortunate that relatively plain-tasting chicken takes on other tastes so well. By adding a “kick” to standard chicken, this may perk aging taste buds and appeal to ethnic preferences. The amount of spices can be individualized and controlled as tolerated. By serving Chicken With a Kick with a starchy accompaniment, such as naturally sweet brown rice or Yukon gold potatoes, the spiciness may be tamed. A little sweet low-fat sour cream, cre`me fraiche or crema may also provide this calming effect. Basic Tastes: When strong flavors are combined, such as salsa and mustard, they may have the impression of canceling each other out and they may also “soften” after cooking. In reverse, to help make these stronger flavors pop, add a little more of each of these flavorful ingredients right before serving. A little brown sugar (as this recipe requires) also buffers spiciness and helps sweeten the stronger tastes. Besides, sweet spicy tastes are common in beloved barbeque sauce, which is so popular in US dishes. Featured Ingredient: Salsa Salsa is more than just dipping sauce for salty chips. Salsa has become an integral ingredient in Mexican and Southwest US cuisines to boost flavor. Perk up plain chicken breasts, fish or meats with some mild salsa and they transform flavorwise. Add some fresh diced fruit, such as mango or pineapple, and the flavor transforms with a tropical touch. Pico de gallo or salsa fresca, made with cilantro, fresh chilies, lime juice, onions and tomatoes, helps to create even fresher flavor combinations. Salsa verde is usually made with cooked tomatillos. Salsa negra is made from dried chilies, garlic

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and oil. The variations of salsa are seemingly endless. For an extra “kick” to enliven taste buds, try medium or hot salsa as taste dictates. Ingredients: Nonstick cooking spray 1 cup mild salsa 1 tablespoon brown sugar 1 /2 tablespoon Dijon mustard 4 (4-ounce) skinless chicken breasts Chopped fresh cilantro or chopped scallions to garnish, if desired Instructions: 1. 2. 3. 4. 5. 6.

Preheat oven to 450 F. Lightly spray a 13 3 9 3 2 baking pan with nonstick cooking spray. Mix first three ingredients in a small bowl. Place chicken breasts in prepared baking pan; pour sauce over chicken. Cover with aluminum foil. Bake about 30 minutes until chicken breasts are tender, or until chicken is no longer pink. Garnish with chopped fresh cilantro or scallions, if desired. Yield and Serving Size: Makes four (4-ounce) servings

Nutrient Analysis: 211.2 calories, 17% calories from fat, 4 g total fat, 1 g saturated fat, 109 mg cholesterol, 7.3 g carbohydrates, 1 g fiber, 35 g protein, 986.48 mg sodium Nutrient Modifications: • To decrease sodium: Use fresh salsa. Reduce the amount of Dijon mustard. Substitute Ingredients: A wide variety of salsas can be used depending on the heat, spiciness and texture that is desired. Bottled salsas offer a range of options and while fresh is flavorful from fresh onion, peppers and tomatoes, then care should be taken for proper refrigeration to prevent foodborne illnesses. The same is true about the addition of fresh fruit in salsas: once fresh salsa with mango or pineapple is used, then it should be discarded. Other types of sugar or sweetener and mustard may be substituted that may create different flavor finales. Optional Ingredients: A few chopped olives, some grated cheese or slivers of avocado may be added to help to transform this simple recipe to a more complex Mexican-inspired dish. A spoonful of low-fat sour cream, cre`me fraiche or crema will lend a sweet taste, silky texture and rounded flavor. For people who can tolerate crunch, some toasted tortilla strips offer another texture and topping. Why Brown Sugar? Brown sugar is actually white sugar sprayed with molasses to look brown. Due to the molasses, brown sugar also contains a small amount of protein and minerals—particularly calcium, iron, magnesium and potassium. Brown sugar has a deeper, richer taste than white sugar and tends to impart color in recipes. It both tones down and rounds out spiciness, acidity and bitter ingredients and produces a mellower taste. Brown sugar acts as both a primary and secondary taste in recipes: as itself and as an unidentified flavor that has the capacity to make a dish more complex and interesting, such as its use in Chicken With a Kick. FISH Fish and shellfish are generally healthy protein choices since they tend to be lower in calories, total fat and saturated fatty acids, but higher in omega-3 fatty acids, vitamins B2 (riboflavin) and D, and the minerals iodine, iron, magnesium, potassium and zinc with their potential health-enhancing properties. A number of health associations recommend fish consumption at least two times weekly as a part of a healthy diet. Salmon is an excellent example, especially if it is wild from its natural environment in some lakes, rivers and oceans. 18. Baked Salmon With Mustard Sauce Category: Entre´es Prep Time: 40 minutes Techniques: Thickening, baking Equipment: Oven, baking pan, saucepan, shallow dish

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PHOTO: Baked Salmon With Mustard Sauce. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Eating small amounts of fatty fish, such as salmon, sardines or trout, may decrease the risk of heart disease, prolong the lifespan of people who have had heart attacks and help arthritis—thanks in part to omega-3 fatty acids that are found in fish fat. A 4-ounce portion of salmon contains 236 calories with 15 grams of fat (3.5 grams of saturated fat, 4.4 grams of polyunsaturated fat and 4.3 grams of heart-healthy monounsaturated fat, and about 1 gram of omega-3 fatty acids), with 23 grams of protein. Salmon is more affordable and milder than ever with some pungent mustard sauce, this recipe may make help change a meat eater into a fish enthusiast. Basic Tastes: Soy sauce with its umami taste helps to round out food flavors. Because different tastes are sensed and tasted differently, soy sauce helps to promote the juxtaposition of fatty, garlicky, spicy and sweet tastes and textures for a fuller flavor experience. Pineapple juice helps to bring acidity to this recipe for Baked Salmon With Mustard Sauce, and the sharpness of Dijon mustard and garlic add a pleasantly startling flavor dimension. Featured Ingredient: Pineapple Juice Pineapple juice has been heralded for its ability to boost the immune system, improve digestion, protect against certain cancers, rectify skin damage and reduce cataract formation. One cup of pineapple juice contain about 132 calories, with 63% of an adult’s daily need for manganese, 42% of the Daily Value for vitamin C and 10% or more of folate, thiamine and vitamin B6. Bromelain, an enzyme that is contained in the pineapple stem and juice, helps to digest and breakdown proteins, may function to reduce some inflammation. As a result, bromelain has a tenderizing effect, unless canned or cooked. Ingredients: Nonstick cooking spray 2 tablespoons regular or low-sodium soy sauce 2 tablespoons 100% pineapple juice 1 tablespoon Dijon mustard 2 cloves garlic, peeled and minced 1 pound salmon, skinned and cut into four fillets 2 green onions, chopped Instructions: 1. Preheat oven to 350 F. 2. Coat a 13 3 9 3 2 baking pan with nonstick cooking spray.

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3. Combine the soy sauce, pineapple juice, Dijon mustard and minced garlic in saucepan; mix well. 4. Cook over medium heat until slightly thickened, about 3 5 minutes; stir often. Cool. 5. Place salmon in a shallow dish with a lip. Spoon sauce over salmon; turn fish to coat. Refrigerate salmon, covered, at least 15 minutes. 6. Transfer salmon to prepared baking pan; reserve sauce. 7. Bake salmon about 25 minutes, or until it flakes easily; baste salmon with reserved sauce about halfway through cooking. 8. Remove salmon from oven; sprinkle with chopped green onions. Serve immediately with any remaining sauce. Yield and Serving Size: Makes about 4 (4-ounce) portions Nutrient Analysis: 248.83 calories, 50.64% calories from fat, 14 g total fat, 2.8 g saturated fat, 70.4 mg cholesterol, 2.55 g carbohydrates, 0.33 g fiber, 25.43 g protein, 425.55 mg sodium Nutrient Modifications: • To lower calories, total fat and sodium: Reduce portion size. Substitute Ingredients: Other types of fatty fish, such as lake trout or mackerel, or meaty fish such as cod, halibut or tuna may be substituted for the salmon. Wild salmon (sometimes called “red” or Sockeye, may also be an option, but may be more expensive and it tends to have a deeper, more pronounced flavor). Low-sodium soy sauce will still impart the umami taste with less sodium, as will less Dijon mustard. In the process of cutting back ingredients that contain sodium, try to find the balance so that flavor is not sacrificed. Optional Ingredients: Small bits of pineapple may also be added to the sauce. A convenient method to add both pineapple juice and pineapple bits is by using canned pineapple tidbits in its own juice. Chives may be substituted for the green onions. Chopped parsley and cilantro are two other suitable bitter greens; however, the acidic and sharp onion finale may be absent in the finish. Why Soy Sauce? Soy sauce is made from soybeans, wheat and salt. Besides tasting salty, soy sauce also has a meaty umami taste from its natural glutamate, that helps imbue food with a full, savory mouthfeel. Soy sauce often connotes Asian cuisine and for good reason: Many Asian people have valued soy sauce since 1100 BC for its enriching properties. Soy sauce can be used in place of salt in some recipes. When blended with garlicky, sweet, spicy and tart ingredients, soy sauce helps to bring out their characteristic and become less prominent. LAMB Lamb has a notable nutrient profile with vitamins B3 and B12, iron, phosphorus, selenium and zinc. Many cuts of lamb have few calories and less saturated fat than some cuts of beef. Plus, lamb is a good source of omega-3 fatty acids that touted as an antiinflammatory for brain health, cancer, heart disease and other conditions and diseases. A good portion of the fat in lamb comes from oleic acid, best known for its prevalence in Mediterranean diets and its connection with the reduced risks of heart disease. Also, lamb is a good source of conjugated linoleic acid that is associated with enhanced immune function, improved blood sugar regulation, preserved bone mass, reduced inflammation, weight loss and other functions. Oleic Acid—naturally occurring, odorless, colorless oil; found in borage oil, canola oil, evening primrose oil, flaxseed oil, grape seed oil, macadamia oil, olive oil (less in virgin olive oil), peanut oil, pecan oil, sea buckthorn oil, sesame oil and sunflower oil; implicated in cancer prevention and cholesterol reduction. Conjugated Linoleic Acid—group of chemicals found in the fatty acid linoleic acid; beef and dairy products major sources; associated with enhanced immune function, improved blood sugar regulation, preserved bone mass, reduced inflammation, weight loss and other functions. 19. Sweet and Spicy Lamb Category: Entre´es Prep Time: 45 minutes Technique: Stewing Equipment: Range, saucepan

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PHOTO: Sweet and Spicy Lamb. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Lamb is sometimes an afterthought in the US diet, behind more popular cuts of beef and pork. It may be that people did not grown up with lamb in their dietary repertoire or that lamb was too expensive. Lamb is generally tender, especially when prepared in a recipe such as Sweet and Spicy Lamb where it stews with moist and aromatic ingredients. These include dried apricots and prunes, garlic, herbs and spices, onions and sweet bell peppers. Lemon juice helps to brighten this assortment of ingredients, enhance its sweetness and temper its slightly assertive-tasting flavor. Basic Tastes: Moroccan spices often include allspice, cinnamon, coriander, ginger, turmeric and/or white pepper that serve to create an exotic and spicy flavor. With its bright yellow-orange color, turmeric also impacts the surrounding ingredients. Dried, reconstituted fruits render their sweetness, and onions, sweet bell peppers and tomatoes donate their acidity. No wonder dishes such as Sweet and Spicy Lamb are so complex and arresting. Featured Ingredient: Allspice Allspice is native to Mexico and Central America where it is also referred to as pimenta. The cured, unripe berry resembles a dark-brown peppercorn. Allspice is an important ingredient in Caribbean cuisine, especially in Jamaica where it is used in jerk seasonings, and in Middle Eastern cooking to flavor meat and stew dishes as this one. Allspice is used today in commercial sausage preparation, curry powder and for pickling. In the 1600s, British explorers believed that allspice combined the flavors of cloves, cinnamon and nutmeg. One or more of these spices may be substituted for allspice in somewhat similar proportions, but the aroma and tastes of this finished recipe may be less complex and intriguing. Ingredients: 5 tablespoons canola oil or extra-virgin olive oil 11/2 pounds boneless leg of lamb, cut into 1-inch cubes 1 /2 teaspoon salt 1 /2 teaspoon pepper 1 large yellow onion, skinned, halved and thinly sliced 4 garlic cloves, peeled and thinly sliced 1 /4 teaspoon allspice 1 /2 teaspoon turmeric 1 /2 teaspoon smoked paprika 1 /2 cup dried apricots, halved 1 /2 cup dried prunes, pitted and halved 1 (14.5-ounce) can whole peeled tomatoes in tomato juice, including the juice 1 each medium sweet green and red bell pepper, stemmed, seeded and diced 1 /2 cup fresh parsley, chopped, plus additional for garnish 2 tablespoons fresh lemon juice Couscous, rice, or quinoa to accompany (if desired)

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Instructions: 1. Heat oil in a large saucepan over high heat. 2. Add lamb cubes; season with salt and pepper. 3. Cook until browned, about 3 5 minutes; with a slotted spoon, carefully transfer lamb cubes from saucepan to platter; cover and keep warm. 4. Reduce heat to medium; add sliced onion and garlic, stir and cook until softened, about 4 5 minutes. 5. Add allspice, turmeric, paprika, dried apricots, prunes, tomatoes, and sweet bell peppers to onion and garlic mixture; partially cover and simmer until sauce thickens, about 12 15 minutes, stirring occasionally. 6. Add browned lamb cubes back into saucepan; stir and cook until thoroughly heated, about 1 minute. 7. Stir in parsley and lemon juice. 8. Spoon overcooked grains, such as couscous, rice or quinoa (if desired). 9. Garnish with additional chopped parsley. Yield and Serving Size: 8 (1/2-cup servings), each Nutrient Analysis: 347.56 calories, 51.87% calories from fat, 20.03 g total fat, 6.75 g saturated fat, 71.40 mg cholesterol, 19.78 g carbohydrates, 2.93 g fiber, 23.29 g protein, 316.49 mg sodium Nutrient Modifications: • To lower calories and total fat: Reduce the amount of canola or olive oil. • To lower cholesterol: Reduce the amount of boneless lamb. • To lower sodium: Use about one pound of fresh tomatoes instead of the can of whole peeled tomatoes. Substitute Ingredients: Dried peaches may be substituted for the dried apricots, and raisins or sultans may replace the dried prunes, which are actually called dried plums. Sultans are essentially produced from the same grape as raisins, but the difference lies in their drying. Smoked paprika may be substituted for the turmeric. While the color may be similar, it may lend a smokier flavor. Cilantro may be used instead of parsley for a more touch. While a cooked grain is a familiar accompaniment, this dish may be served with whole-grain pita bread to soak up its aromatic and flavorsome sauce. Optional Ingredients: If chewing nuts is not problematic, then sprinkling of chopped pistachios to finish this dish brings an additional Middle Eastern flair. Hot sauce such as harissa (a Maghrebi hot chili pepper paste) may be served on the side to rev up the spiciness—otherwise a few shakes of red pepper flakes may yield a similar effect. Why Apricots? The Chinese have appreciated the virtues of apricots since about 2000 BC when they were first cultivated. Chinese people used apricots in both sweet and savory dishes to create a sweet, or a sweet-and-sour effect. Today, this succulent fruit still plays a similar role in Asian cookery and in other ethnic cuisines that include lamb and poultry dishes and rice-type pilafs. Apricots are among the most nutritious fruits. They are particularly rich in beta-carotene that converts into protective vitamin A in the body and in potassium—so vital for blood pressure regulation. Due to their high fiber-to-volume ratio, dried apricots are often suggested for sluggish digestion. VEGETARIAN Back in the hearty meat-eating days of the 1950s, a vegetarian entre´e might have been considered as unusual. Then came the 1960s when vegetarianism was de rigueur. For nearly 50 years, a myriad of healthy vegetarian and vegan entre´e recipes have surfaced that stand on their own for their interest, nutrient content, taste and texture. Some recipes are based on old standards, such as cheesy nut loaf and Italian restaurant-style eggplant, while others are plant-inspired innovations that may tempt diehard meat eaters—such as quinoa burgers or shiitake mushroom-filled pasta. Some easier vegetarian recipes follow that still deliver great taste without an ounce of meat. 20. Saute´ed Tofu Patties Category: Entre´es Prep Time: 1.5 hours, including marinating time Techniques: Marinating and pan-frying Equipment: Large bowl, refrigerator, nonstick skillet

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PHOTO: Saute´ed Tofu Patties. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Tofu, or soybean curd, is made from soybeans and filled with calcium, fiber, potassium and protein. It is generally cheeselike in appearance and odorless in aroma. The flavor of tofu is dependent upon processing and added ingredients, such as Asian or herbal seasonings. Tofu easily absorbs flavors such as the gingery marinade in Saute´ed Tofu Patties. The techniques for making tofu have developed from its homemade versions of the 1960 and 1970s, and both its taste and texture have tended to benefit. Tofu can be found in it handy tubs within the produce section of many markets, often by the Asian, Middle Eastern or vegetarian products. Basic Tastes: Citrusy, salty, spicy and vinegary flavors commingle to infuse practically tasteless tofu with their fascinating, incorporated tastes. By marinating tofu in this blend of ingredients, it absorbs their tastefulness and generates distinctive aroma and flavor. Onions are acidic and sharp against the tofu, and the lemon and orange juices and rice vinegar help to build a salty-sour-sweet flavor profile. Featured Ingredient: Rice Vinegar Rice vinegar, made from fermented rice, tends to be light in color and delicate and sweet in flavor from its glutinous rice base. Rice vinegar is frequently used in basic vinaigrettes, fresh vegetable slaws, pickles and sweet-and-sour Asian-inspired recipes, such as this marinade for Saute´ed Tofu Patties. Cloves, ginger, orange peel and sugar are often added to rice vinegar for additional zest. Rice wine is made in a fermentation process. It utilizes yeast to transform the sugars in glutinous rice into alcohol. In rice vinegar, bacteria are added to convert the alcohol into acid.

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Ingredients: 2 (8-ounce) packages extra firm tofu, or 1 (1-pound, 2-ounce) package tofu, drained and pressed with a weight for 10 15 minutes to remove moisture 1 cup fresh bean sprouts, roughly chopped 3 green onions, diced 3 cloves fresh garlic 1 /4 cup fresh basil, chopped 1 medium stalk celery, diced 1 (8-ounce) can water chestnuts, drained and chopped 1 egg white 1 cup whole-wheat breadcrumbs, divided 1 2 tablespoons olive oil Snow peas (also called Chinese pea pods), steamed Marinade: 2 tablespoons regular or low-sodium soy sauce 1 /4 cup rice vinegar 1 /4 teaspoon ground ginger 1 /4 cup orange juice concentrate 2 tablespoons lemon juice Instructions: 1. Place the extra firm or pressed and drained block(s) of tofu into a large-sized bowl. 2. Mix marinade ingredients (soy sauce, rice vinegar, ground ginger, orange juice concentrate and lemon juice) together; pour over tofu blocks. 3. Turn tofu blocks over in marinade to absorb the liquid. 4. Cover; refrigerate about 30 60 minutes, turning once. 5. Drain marinade and reserve; mash tofu. 6. Mix mashed tofu with bean sprouts, green onions, garlic, basil, celery, water chestnuts, egg white and 1/2 cup of the breadcrumbs. 7. Mold mixture into 12 patties. With the remaining breadcrumbs, pat both sides of the patties with breadcrumbs. 8. Prepare a nonstick skillet with olive oil just to coat; heat on medium heat. 9. Pan-fry tofu patties on each side until lightly browned. 10. Serve with reserved sauce and steamed snow peas. Yield and Serving Size: Makes 12 (3-inch patties); 6 (2-patty) servings, each Nutrient Analysis: 209.29 calories, 22.28% calories from fat, 5.18 g total fat, 0.6 g saturated fat, 0 mg cholesterol, 29.59 g carbohydrates, 4.13 g fiber, 12.75 g protein, 204.63 mg sodium Nutrient Modifications: • To lower sodium: Use low-sodium sauce. Reduce the amount of reserved sauce for serving. Substitute Ingredients: Low-sodium soy sauce may be exchanged for regular soy sauce to help reduce the sodium level of this recipe. Apple cider vinegar with its faint apple and woody flavor may be substituted for rice vinegar, but it may deepen a more acidic dimension. Likewise, pineapple-orange juice concentrate may create a more tropical flavor profile than the orange juice alone. Chopped snow peas can be used to replace one-half cup of the bean sprouts to add more color and texture. Both the fresh bean sprouts and snow peas may exude some liquid during pan-frying. This may necessitate less olive oil, but the liquid may interfere with browning. Optional Ingredients: Asian ingredients such as basil, cassia (cinnamon), cilantro, coriander, chilies, cloves, cumin, galangal, garlic, ginger, lemongrass, spearmint, star anise and turmeric can be used additionally or interchangeably to uplift the Asian notes of this recipe. Better to use them in small quantities at first to make sure that their tastes complement and delight.

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Why Ginger? Ginger exudes flavor and is praised for its curative properties. While ginger probably originated in Southeast Asia, it was highly prized by the Romans for its medicinal value. Its pungency, aroma and flavor vary according to where it is cultivated. Fresh ginger root may be quite “heady”—a little may withstand quite far. A small ginger root stores well once it is refrigerated and sliced as needed. Dried ginger is convenient, but it tends to pack less punch. Either form of ginger may overpower a dish, so easy does it. A light-handed dose, as the amount that is recommended in this recipe for Saute´ed Tofu Patties, has the capacity to add dynamism to plain tofu and a distinctive Asian accent. SIDES: Simple Vegetables and Wholesome Grains 21. 22. 23. 24. 25.

Better Broccoli Fruit-Nut Squash Convenient Couscous or Quinoa Roasted Cauliflower With Shallots and Raisins Zucchini With Yogurt Basil Sauce

VEGETABLES: LIGHTER AND HEAVIER Many people grew up hating vegetables, or they only consumed a basic repertoire of corn, green beans, peas and/or potatoes. Unfortunately this limited exposure to vegetables may have persisted and vegetables such as fresh asparagus, broccoli, kale, spinach, and squash have “gone by the wayside.” This is untimely because most vegetables are filled with important vitamins and minerals such as folic acid, calcium, iron, magnesium and potassium; defensive antioxidants, such as vitamins A, C and E, that help to guard the body against disease; and fiber to help regulate sluggish digestion. Lighter vegetables, such as broccoli, spinach, summer squash or tomatoes, can add color, texture and flavor to meals without overfilling eaters. Heartier vegetables, such as corn, peas, potatoes or winter squash, similarly to hearty vegetable-based soups, can be transformed into meals with the addition of a little leftover fish, poultry, or meat or legumes—plus a fruit-filled dessert or a dairy-based beverage if appetite dictates. PASTA: FRESH AND FORTIFIED Some people may still refer to pasta as noodles or macaroni from their childhood. Today the word “pasta” is fairly universal in scope, but with local, regional and even national interpretations. It is typically interpreted as a dried shaped dough that cooking in boiling water and served with a sauce. Fresh pasta is uncooked, so it should be carefully prepared and consumed as soon as possible to help to prevent any foodborne illness. Check the labels of packaged pasta for the myriad of ingredients, such as durum or hard wheat; enriched with legumes, soy flour or folic acid for extra nutrition; mixed with herbs, olives, spinach, squid ink or sundried tomatoes; or produced with alternative grains or gluten-free, since this might affect the cooking times and preparations. Pasta recipes may combine cheese, low-fat proteins, vegetables and even fruit to sneak in additional nutrients and complement the carbohydrate content. Reduce the portion size to one-half or one cup of cooked pasta per serving, and it may be an economical and satisfying accompaniment for baked, broiled or roasted entre´es. Or increase the portion size, complemented by a hearty protein-rich sauce. The options are almost limitless! GRAINS: WHOLE AND HEARTY World cuisines are based on grains, yet some Americans may have a love hate relationship with grain-based foods, including pasta. Though some individuals have a diagnosed allergy to gluten (the protein in barley, bulgur, couscous, farina, graham flour, kamut, rye, semolina, spelt, triticale, wheat and wheat germ) as in celiac disease, some people may avoid grains for weight-control issues. In reality, some people do tend to eat too many grain-based dishes and prefer processed varieties instead of fiber-rich heartier ones, such as whole-grain breads and breadstuffs and ancient whole grains. Grains are the staff of life: they provide balance to meals, energy and are inexpensive and filling. A slice of bread, cooked cup of rice, couscous, pasta or quinoa and a few slices of cheese, fish, meat or poultry are the basics of satisfying and balanced meals. Skimping on grain-based dishes may lead to hunger and lack of energy throughout the day. Learning how to incorporate healthier and tastier grain dishes into one’s diet is vital for health and well-being—and delicious, too.

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ROOT VEGETABLES: UNDERGROUND DELICIOUSNESS Vegetables such as beets, carrots, celery root (or celeriac), garlic, ginger, kohlrabi, Jerusalem artichokes, jicama, kohlrabi, onions, parsnips, radishes, rutabaga; red, sweet and white potatoes, turnips, yams and yucca are considered root vegetables because they grow underground and absorb nutrients from the soil. Many root vegetables contain antioxidants, such as beta-carotene, vitamin A, B vitamins such as vitamin B6, vitamin C and folate, as well as the minerals calcium, iron, potassium and dietary fiber. Some are lower in stored carbohydrates, such as celery root or turnips, and may be swapped for those that are higher in carbohydrates, such as some potatoes if personal taste and diet command. Many root vegetables appear in older recipes that are reminiscent of homecooking in bygone years. Their preparation can be lightened so that they may be enjoyed and still contribute to well balanced, satisfying and tasteful and meals. 21. Better Broccoli Category: Sides Prep Time: 10 minutes Technique: Microwaving Equipment: Microwave, microwave-safe baking pan with lip, microwave-safe wrap

PHOTO: Better Broccoli. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Native to Mediterranean cuisines, broccoli has been dubbed the “Italian asparagus,” perhaps because in Latin brachium means arm, branch or shoot. Broccoli is valued for its taste and health. It is a very good source of choline, vitamins A, B6, C and E, dietary fiber, copper, manganese, phosphorus and potassium, and a good source of calcium, iron, magnesium, niacin, omega-3 fatty acids, protein, vitamin B1 and zinc. Though quick steaming helps to retain these nutrients, microwaving broccoli (as in this recipe) also cooks these spears and florets quickly. A little mayonnaise mellows any residual bitterness and salsa imparts a tomato-based sharpness for a flavorful surprise. This recipe for Better Broccoli is loosely based on the concept of Thousand Island salad dressing with its mayonnaise and chili sauce to dress salad ingredients. Basic Tastes: Check bottled salsa for one that contains garlic, since garlic has the capability of altering the way that one tastes broccoli. Garlic sweetens its bitterness and earthiness. Plus the umami from the tomato salsa improves the perception of saltiness though no additional salt is added to this recipe. The fat content of the mayonnaise may help to override any remaining bitterness, plus the mayonnaise brings salty-sweet tastes of its own. Featured Ingredient: Tomatoes Many salsas contain some form of tomatoes: cooked, crushed, diced, raw, paste, pureed, roasted, sauce, stewed, sundried, whole and others. Concentrated and ripe tomatoes are higher in umami due to higher levels of glutamic acid.

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Tomatoes also boast a “meaty” flavor and unique crimson color—the same color of blood, ironically the essence of animal life that is packaged in a fruit. The inners of tomatoes that include their membranes and seeds tend to have an even stronger umami aftertaste than the outer parts or skins. Bottom line: Make sure the entire fruit is consumed! Ingredients: 1 pound broccoli flowerets 1 cup water 3 /4 cup low-fat mayonnaise 1 /4 cup mild salsa Chopped cilantro, for garnish Instructions: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Put broccoli into a microwave-safe baking pan or dish with a lip. Pour water over broccoli. Loosely cover with microwave-safe wrap; vent at one corner. Microwave on High (100% power), about 6 minutes. Carefully remove wrap; drain broccoli and arrange on platter. While the broccoli is cooking or soon after, mix mayonnaise and salsa in small bowl. Spoon one-half cup mayonnaise-salsa dressing over broccoli. Serve reserved dressing on side. Garnish with chopped cilantro. Yield and Serving Size: Makes 4 (1-cup broccoli and 1/4-cup sauce) servings, each

Nutrient Analysis: 139.31 calories, 54.66% calories from fat, 8.46 g total fat, 1.39 g saturated fat, 10.09 mg cholesterol, 15.31 g carbohydrates, 3.05 g fiber, 3.58 g protein, 180.05 mg sodium Nutrient Modifications: • To lower total fat: Reduce the amount of low-fat mayonnaise. • To lower sodium: Reduce the amount of salsa or use fresh salsa. Substitute Ingredients: Other cruciferous vegetables such as cooked asparagus spears, bok choy, Brussels sprouts, cabbage wedges, cauliflower, radishes or turnips may be substituted for the broccoli. Low-fat Greek yogurt may be exchanged for about one-half of the mayonnaise, except the taste may be tangier and less reminiscent of Thousand Island or Russian-type salad dressing that were so popular in younger years. Optional Ingredients: The salsa-mayonnaise topping may be enhanced by the addition of similar ingredients, such as freshly chopped or minced cilantro, chilies, garlic, onions or tomatoes. Or, more atypical ingredients may be added that include diced mangoes, nectarines, peaches, pineapple. Chopped avocado or olives add color and creamy texture and flavor that might mix well with the mayonnaise. A dash of cayenne pepper or hot sauce may contribute more fieriness, if desired. Why Salsa and not Chili Sauce? Salsa is a piquant relish commonly found in Latin American cuisines. Typical ingredients include chili peppers, garlic, onions, and tomatoes. The intensity of salsas ranges from mild to very hot. In contrast, chili sauce contains a mixture of onions, tomatoes and sweet and/or hot peppers that are simmered in a vinegar and sugar mixture. The resultant flavor is sugary and vinegary and the sauce is generally milder than salsa. Chili sauce is also blended to be smoother than some salsas. It may also contain spices such as allspice, cinnamon, cloves or ginger, whereas salsas may contain additional ingredients such as cilantro, cumin, lime, paprika and/or oregano. Personal tastes and ethnicities may shape choices. 22. Fruit-Nut Squash Category: Sides Prep Time: 35 minutes Technique: Mixing and baking Equipment: Oven, 8-inch square baking pan

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PHOTO: Fruit-Nut Squash. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Winter squash, such as acorn or butternut, is often an underrated and overlooked vegetable. In its natural whole state, winter squash is tough skinned and requires a longtime to prepare. However, fresh-frozen cubed winter squash may be quickly prepared—as in this recipe for Fruit-Nut Squash. Winter squash provides vitamin A and beta-carotene, in addition to vitamins B1, B5, B6 and C, dietary fiber, folate, iron, manganese and potassium at around 143 calories per 3.5 ounces or 100 grams. Winter squash pairs nicely with sweet fruits, such as pineapple and oranges. Dried fruits, such as dates, prunes or raisins provide tasty, nutrient-dense pairings. Anytime yogurt can be added to a recipe it delivers a boost in calcium—so essential for aging dietary needs. Basic Tastes: Cinnamon adds a spicy perception, plus it blends with the sweet tastes in Fruit-Nut Squash. Cinnamon has a peppery quality of its own. It contributes an additional earthiness when it is combined with the root vegetable winter squash. Vanilla extract adds mellowness, and the pineapple/Mandarin orange segments produce a tropical quality with their acidity and sugary tastes. Toasted nuts lend their umami taste and crunchy texture. Featured Ingredient: Vanilla Extract Vanilla extract is a solution that contains a flavor compound called vanillin. To produce pure vanilla extract, vanilla bean pods are steeped and infiltrated with ethanol and water. Vanilla extract is commercially available in Bourbon, Madagascar, Mexican and Tahitian varieties. Unlike vanilla extract, natural vanilla flavoring has very little or no alcohol. Vanilla extract is widely used for commercial and home uses as a flavoring—particularly for baking, ice cream and smoothies. Its taste runs from buttery to nutty. Ingredients: Nonfat cooking spray 1 10-ounce package cubed fresh-frozen winter squash (such as acorn), defrosted 2 tablespoons low-fat plain yogurt 1 /2 teaspoon cinnamon 1 /2 teaspoon vanilla extract 1 /2 cup pineapple chunks in 100% pineapple juice, drained 1 /2 cup Mandarin orange segments in own juice, drained 1 /4 cup toasted chopped walnuts or pecans Instructions: 1. 2. 3. 4. 5. 6. 7.

Preheat oven to 350 F. Prepare an 8-inch square baking pan with nonfat cooking spray. Mix defrosted cubed squash, yogurt, cinnamon and vanilla extract together in a medium bowl. Add pineapple chunks and Mandarin orange segments. Pour mixture into prepared baking pan. Place in oven; heat for about 20 minutes, or until hot throughout. Sprinkle with toasted chopped walnuts or pecans. Yield and Serving Size: Makes 3 cups, or 6 (1/2-cup) servings

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Nutrient Analysis: 78.18 calories, 37.41% calories from fat, 3.25 g total fat, 0.29 g saturated fat, 0 mg cholesterol, 11.74 g carbohydrates, 1.61 g fiber, 2.34 g protein, 9.63 mg sodium Nutrient Modifications: • None necessary. Substitute Ingredients: Coconut or almond extract may be substituted for the vanilla extract and still preserve the tropical flavor of this recipe for Fruit-Nut Squash. Sliced grapes could replace the pineapple or the orange segments. Acorn squash could be replaced by butternut squash—with about 33 calories less per 1-cup serving: 82 calories in one cup of butternut squash versus 115 calories in 1 cup of acorn squash. Optional Ingredients: The addition of herbs or herb blends, such as a combination of more mildly-falvored chervil, chives, parsley, savory and/or thyme, or more strongly-flavored basil, marjoram, rosemary tarragon and/or sage may create either subtle aromatic or bold exotic flavors. Canned apples or pears in their own juice may blend better with the first set of herbs, while dried fruits, such as apricots, dates or figs, may mix better with the heartier spices. Why Walnuts? Romans paid a high price for walnuts because they symbolized fertility and continuity and resembled acorns, which were prized in traditional Roman cooking for their outstanding flavor and gelatin-like consistency. The French use walnuts in soups; Italians use walnuts in pesto (a garlic basil walnut or pine-nut sauce); and Middle Easterners use walnuts in stews and hummus, a legume-based dip. Americans tend to use walnuts mostly in sweet desserts and breads; however, Fruit-Nut Squash is a flavorful savory-sweet side dish to add to ones repertoire and enjoy as years progress. 23. Convenient Couscous or Quinoa Category: Sides Prep Time: 30 minutes Techniques: Toasting and boiling Equipment: Oven, nonstick baking tray with lip, medium saucepan, medium bowl, container

PHOTO: Convenient Couscous or Quinoa. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Contrary to popular opinion, couscous is neither a grain nor pasta. Couscous is a type of wheat that is steamed, not boiled and ready to serve in a few minutes. Simply add instant couscous to boiling water; remove from heat, then let swell and fluff. Couscous blends well with mushrooms and onions, aromatic spices such as ginger or garlic, or dried fruits, nuts, and pungent onions, as in this recipe for Convenient Couscous or Quinoa. Per 1-cup serving, couscous contains 176 calories, 0.25 grams of total fat, 5.95 grams of protein, 36.46 grams of carbohydrates, 2.2 grams of dietary fiber and 0.16 grams of sugar. Couscous makes a great side dish for grilled or roasted meats, poultry or fish. Quinoa is a tasty and nutritious alternative (see Substitute Ingredients).

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Basic Tastes: Peanuts take on a slightly different identity in the presence of salty and/or sour tastes. Salt, sharp green onions, sweet apricots and golden raisins collaborate to attain an evenhanded contrast to the peanut flavor. Featured Ingredient: Cumin Many aging people grew up in families where cumin was a foreign entity. To others who experienced ethnic households (particularly Eastern Mediterranean), cumin was a common ingredient, both ground cumin or as whole seeds. Cumin has a distinctive, earthy and warming aroma and taste, and lends it character to other ingredients in chilies, curries, gravies, pickles, soups and stews and even pastries. It is sometimes confused with caraway, though is it hotter, lighter and larger in appearance. Ingredients: Nonfat cooking spray 1 (10-ounce) box instant couscous (about 5 cups cooked) or quinoa 1 /2 cup golden raisins 1 /2 cup dried apricots, diced 1 /2 cup green onions, diced 1 /2 cup peanuts or cashews, roughly chopped 1 /4 cup fresh parsley, chopped (or 1 tablespoon dried, crumbled) 1 /2 teaspoon ground cumin 1 /2 teaspoon salt Freshly ground pepper Instructions: 1. Preheat oven to 450 F. 2. Prepare a nonstick baking tray with a lip with nonfat cooking spray. Add couscous or quinoa; spread evenly. 3. Put the couscous or quinoa-filled baking tray into oven and toast, stirring until evenly browned (about 8 minutes); remove and cool. 4. Cook couscous or quinoa according to package directions in a medium saucepan. 5. Combine raisins, diced apricots and green onions, roughly chopped peanuts or cashews, parsley, cumin, salt and pepper in a medium bowl. 6. Add cooked couscous or quinoa; mix thoroughly. 7. Use immediately or place into a container; cover and refrigerate. (Couscous or quinoa can be consumed either cool or slightly warmed.) Yield and Serving Size: Makes about 10 (1/2-cup) servings Nutrient Analysis: 190.33 calories, 18.77% calories from fat, 3.97 g total fat, 0.50 g saturated fat, 0 mg cholesterol, 34.28 g carbohydrates, 2.97 g fiber, 5.95 g protein, 122.32 mg sodium Nutrient Modifications: • None necessary. Substitute Ingredients: Quinoa originated thousands of years ago in the Andean mountains of South America. Quinoa is a complete protein-rich (14 grams of protein per 3.5 ounces or 100 grams) and gluten-free flowering plant in the amaranth family that is grown as a grain crop. Quinoa is also a rich source of B vitamins, dietary fiber, manganese, phosphorus and magnesium that help supply energy and are important for muscle and nerve function. Quinoa has a nutty taste that easily takes on herbs and spices, or holds its own. It can directly be substituted for couscous or rice. Optional Ingredients: If chopped or diced sweet bell peppers are added to the diced dried fruit and nuts this will add a touch of color and texture. So will chiffonades (long, thin strips) of fresh basil, kale or spinach. While they are more expensive than peanuts, toasted pine nuts, alone or in combination with almonds, impart a Middle Eastern flair. Many dried fruit varieties are available in convenient resealable packages, such as dried cranberries, cherries, dates, figs and/or mangoes that would provide interesting, nutritious and tasteful additions.

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Why Apricots? The origin of apricots is uncertain. Apricots were cultivated in Armenia, Greece and Persia in ancient times. Reportedly, the Chinese knew about the virtues of apricots since around 2000 BC. They used apricots in both sweet and savory dishes to lend their sweetness, or to create sweet-and-sour effects. Today, this succulent fruit still plays a similar role in Asian cookery, and in other ethnic cuisines that include lamb and poultry dishes and rice pilafs. Apricots are among the most nutritious fruits. They are particularly rich in beta-carotene that converts into protective vitamin A in the body, vitamin E, iron and potassium. Apricots should be very ripe to maximize their fragrance and flavor, or dried when their relative concentrations of nutrients increase. 24. Roasted Cauliflower With Shallots and Raisins Category: Sides Prep Time: 50 minutes Technique: Roasting Equipment: Oven, nonstick rimmed baking sheet, medium bowl Description: Cauliflower has been popularized for its flavor, texture and versatility—most recently as a potato substitute. This is because cauliflower contains fewer calories and carbohydrates per 1-cup serving than cooked potatoes: Potatoes (per 1-cup serving)

Cauliflower (per 1-cup serving)

113 calories

25 calories

0 grams total fat

0 grams total fat

26 grams total carbohydrates

5 grams total carbohydrates

2 grams dietary fiber

3 grams dietary fiber

2 grams sugars

2 grams sugars

2 grams protein

2 grams protein

In this recipe for Roasted Cauliflower With Shallots and Raisins, cauliflower and shallots are roasted to bring out their umami taste, temper bitterness and emit sweetness. Then the cauliflower is mixed with herbs, Dijon mustard, dried breadcrumbs and sweet raisins for an herbal and crunchy topping that is opposed to the roasted cauliflower shallot mixture. Basic Tastes: Bitter tempered by umami (roasted cauliflower and shallots and dried breadcrumbs); salty (Dijon mustard) tempered by sweet (raisins); and herbal (rosemary and thyme) tempered by fatty (extra-virgin olive oil) tastes all merge to create a filling, hearty, savory and satisfying side dish. Featured Ingredient: Rosemary Rosemary is a woody perennial herb that is common in Mediterranean-type climates. It is often used in heartier dishes, such as roast chicken, lamb, pork or turkey and in stuffing for these protein foods. Rosemary tends to have an astringent taste and distinctive mustard-like aroma. When used in grilling, rosemary chars and has a deeply herbal and woody taste and appearance. Its woody character is often used in conjunction with skewered vegetables, such as cherry tomatoes, mushrooms and pearl onions. Ingredients: 1 medium head cauliflower, core removed, broken or cut into florets 2 large shallots, thinly sliced or 1 medium red onion, peeled and thinly sliced 3 tablespoons extra-virgin olive oil, separated 1 /2 teaspoon dried rosemary, softened first in extra-virgin olive oil 1 /2 teaspoon dried thyme, also softened first in extra-virgin olive oil 1 /4 teaspoon salt 1 /4 teaspoon pepper 2 teaspoons Dijon or country mustard 1 cup dried whole-grain breadcrumbs 1 /4 cup golden raisins

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Instructions: 1. Preheat oven to 425 F. 2. Place cauliflower and shallots (or red onions) on a nonstick rimmed baking sheet. 3. Pour 2 tablespoons of extra-virgin olive oil over cauliflower; add softened rosemary, thyme, salt and pepper; toss to evenly coat. 4. Place baking sheet with coated cauliflower mixture in oven; roast about 15 minutes, stirring midway, until browned. Remove from oven. 5. Mix mustard and 1 tablespoon of extra-virgin olive oil together in a medium bowl. 6. Add dried breadcrumbs and golden raisins; blend well. 7. Spoon breadcrumb-raisin mixture over cauliflower and shallots (or red onions). 8. Return cauliflower and breadcrumb-raisin mixture to oven and roast an additional 10 minutes, or until it is golden and tender. Yield and Serving Size: Makes 5 cups, 5 (1-cup) servings, each Nutrient Analysis: 186.99 calories, 21.18% calories from fat, 4.4 g total fat, 0.66 g saturated fat, 0 mg cholesterol, 32.54 g carbohydrates, 6.08 g fiber, 5.23 g protein, 200.93 mg sodium Nutrient Modifications: • To lower sodium: Reduce the amount of Dijon or country mustard. Substitute Ingredients: Cauliflower florets and “riced” cauliflower are available in some US markets in the fresh produce or frozen food departments. About 11/2 cups of cauliflower florets equal one pound head of cauliflower. For every one cup of roughly chopped cauliflower, exchange with 3/4 cup of premade cucumber “rice” or crumbles. One medium sweet white onion, such as Vidalia, may roast and mellow similarly as the shallots. Sultans or currants may be substituted for the golden raisins. Optional Ingredients: Ground nuts, such as walnuts or almonds, may be mixed into the dried breadcrumbs for a nuttier finish. Carefully roasting this ground nut meal will help to bring out is nutty flavor and umami, and alter its texture. To finish, a sprinkling of the same nuts, but chopped instead of ground, will add a heartier appearance and texture. Why Shallots? If a person only grew up only eating yellow onions, then shallots may seem foreign. While shallots are members of the allium family along with red, white and yellow onions, they are formed more like a garlic head and cloves than onions. Jersey (“false” shallots) are larger than “true” shallots with their subtler flavor. Small white onions may be substituted. In general, the flavor of shallots differs from onions in that they are more delicate, softer and less abrasive, but they are also deeper, with garlic undertones. 25. Zucchini With Yogurt Basil Sauce Category: Sides Prep Time: 30 minutes Techniques: Broiling Equipment: Broiler, rimmed baking sheet, platter Description: Though zucchini is in the squash family, it is further designated as a summer squash like yellow squash, with less carbohydrate than its winter squash cousins and pumpkins. Zucchini runs the gamut from light to dark green. Golden zucchini squash are deep yellow or orange in color. While zucchini squash is botanically considered as a fruit due to its seeds, zucchini is often used in vegetable preparations—usually savory and sometimes sweet as in zucchini bread. When broiled and topped with a Greek-style yogurt sauce with herbs and lemon, Zucchini With Yogurt Basil Sauce has a rounded, mouthwatering flavor, reminiscent of other Middle Eastern inspired dishes. Basic Tastes: Zucchini is mild in taste; however, once it is broiled, the umami in zucchini builds, and its sweet taste generally comes forward. Greek yogurt is tangy-sweet; lemon provides acidy; brightly hued mustard presents it assertiveness and tanginess;

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and basil imparts its peppery qualities. The fresher the ingredients, then the livelier the finished flavor. While the tastes in Zucchini With Yogurt basil Sauce are cooling in general, they blend, compliment and warm equally as well over grilled or roasted proteins, such as grilled steak or roasted chicken. Featured Ingredient: Greek Yogurt Greek yogurt is generally strained to remove its whey (or milk protein) so that the remains have a thicker consistency and distinctive sour taste. It is available in full-fat, low-fat and fat-free varieties in the United States, whereas extra butterfat and/or powdered milk may be added to enhance yogurt in Middle Eastern countries. Greek yogurt may contain higher protein density than regular plain yogurt, when compared in equal amounts. The principal protein once the whey is removed is generally casein, a phosphoprotein commonly found in cow’s milk. If lactose (milk sugar) or dairy milk (milk protein) allergies are issues, soy or nut milk-based yogurt may be substituted. Ingredients: Nonfat cooking spray 1 tablespoon extra-virgin olive oil 4 medium zucchini, halved 1 /2 teaspoon salt, divided 1 /4 teaspoon pepper 1/3 cup low-fat plain Greek yogurt 1 tablespoon lemon juice 1 /4 teaspoon dried oregano 1 /4 teaspoon ground mustard 1 /4 cup fresh basil leaves, chopped Instructions: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Turn broiler to high. Prepare a rimmed baking sheet with nonfat cooking spray. Arrange zucchini halves in a single layer on the baking sheet, skin side down. Brush cut side with olive oil; season with 1/4 teaspoon salt and black pepper. Broil zucchini about 8 10 minutes until browned. Be careful to avoid blackening. Place broiled zucchini in a single layer on a platter and keep warm. Combine remaining 1/4 teaspoon salt, Greek yogurt, lemon juice, oregano and mustard in a small bowl. Top zucchini with yogurt sauce. Garnish with fresh chopped basil leaves. Yield and Serving Size: 4 (2-zucchini halves) servings, each

Nutrient Analysis: 60.16 calories, 48.17% calories from fat, 3.22 g total fat, 0.53 g saturated fat, 0 mg cholesterol, 5.2 g carbohydrates, 1.07 g fiber, 3.83 g protein, 309.47 mg sodium Nutrient Modifications: • To reduce sodium: Use less salt. Substitute Ingredients: Yellow zucchini or yellow squash may be substitute for green zucchini squash, or a combination of the two different types of summer squashes may be used. Nondairy yogurt may be substitute for the Greek yogurt, but it may not be as thick or tangy and the allover flavor of the Yogurt Basil Sauce may change. Fresh oregano may be used in part for the basil, as it has an assertive flavor. Optional Ingredients: In this recipe for Zucchini With Yogurt Basil Sauce, zucchini combines with fairly ordinary ingredients, such as Greek yogurt and herbs, to create a succulent dish. To add some crunch and if tolerated, toasted and finely chopped almonds, pine nuts or pistachios may be added to finish this dish. For those people who enjoy the tanginess of fresh lemon, lemon wedges may be served alongside for squirting. And for diners who enjoy the pungency of fresh garlic, one small minced garlic clove may be added into the sauce, or broiled with the zucchini to somewhat reduce its bite.

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Why Black Pepper? Many recipes call for salting and peppering the ingredients—some recipes to start, other recipes to finish. There is good reason for this direction: When used in the beginning of a recipe, black pepper has an ability to dissipate in color, taste and texture. If used at the end of a recipe, such as strawberries with black pepper and balsamic vinegar, it lends its fiery taste, especially if it is freshly ground. Black pepper is one of the most traded and desirable spices in the world for its flavor and use as a traditional medicine. It spiciness is attributed to the chemical piperidine. DESSERTS: Healthful and Memorable 26. 27. 28. 29. 30.

“Renewed” Orange Slices With Berry Sauce Blueberry and Fig Crumble Rice Pudding With Pears and Almonds Strawberry, Banana and Almond Butter Crepes Chocolate, Yogurt and Orange Mousse

DESSERTS Simple or even more substantial desserts may not have to be excluded simply for calorie, fat or sugar concerns. The recipes in this section include healthy ingredients within reasonable calorie ranges that are designed for smaller appetites. They are filled with nutrient-rich fresh and dried fruits, fruit juices and grains that compliment meals. Most of these recipes depend on the ripeness of fruit for sweetness—some have just an extra hint of sweetening. These desserts may also transform into small meals or snacks, paired with a nutritious dairy or plant-based beverage. This may be especially the case for people who like to consume most of their calories earlier in the day, but desire a mini meal for supper. 26. “Renewed” Orange Slices With Berry Sauce Category: Desserts Prep Time: 10 minutes Techniques: Blending and toasting Equipment: Blender or food processor, spoon, large serving dish

PHOTO: “Renewed” Orange Slices with Berry Sauce. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: The oranges in this recipe are brightly colored citrus fruits that are filled with vitamin A for healthy eyesight, vitamin C for immunity and folic acid for red blood cell formation. Oranges are actually 20 million year-old berries. Berries are full of safeguarding antioxidants, such as ellagic acid, that help to prevent normal cells from changing into cancerous ones. This tangy berry puree, offset by a little sugar, creates a fresh twist to plain orange slices, with its ruby-red color and uneven texture.

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Basic Tastes: In “Renewed” Orange Slices With Berry Sauce, berries are used to create “flavor gestalt”—a burst of full flavor that may help to perk up tired tastes. The riper berries, the better for maximum flavor impact. A little granulated sugar tempers the acidity of both the berries the oranges, and orange extract brings out the natural orange flavor of the orange slices. Toasted, chopped nuts add some umami taste. These may be exclude if people having chewing and/or swallowing problems. Featured Ingredient: Orange Extract Orange extract is a citrusy extraction of alcohol, orange rind and water. It has a stronger taste than orange juice and conveys a clean, fresh and orangey taste in both savory and sweet recipes, including baked goods, liqueurs, marmalades and marinades. One teaspoon of orange extract equals about 1 teaspoon of freshly grated orange peel, or about 1 tablespoon of orange liqueur, such as Grand Marnier. Ingredients: 11/2 cups raspberries or strawberries 2 teaspoons granulated sugar 1 /2 teaspoon orange extract 4 medium navel oranges, peeled, seeded and sliced 2 tablespoons walnuts or pecans, toasted and chopped (optional) Instructions: 1. 2. 3. 4. 5.

Put berries into the container of a blender or bowl of a food processor. Add sugar and orange extract; pulse until slightly thickened. Arrange orange slices on a large serving dish. Spoon berry sauce over orange slices. Sprinkle with chopped nuts, if desired. Yield and Serving Size: Makes about 4 (1-cup) servings, each

Nutrient Analysis: 124.26 calories, 4.2% calories from fat, 0.058 g total fat, 0 g saturated fat, 0 mg cholesterol, 25.23 g carbohydrates, 6.1 g fiber, 1.68 g protein, 1.84 mg sodium Nutrient Modifications: • None necessary. Substitute Ingredients: Unsweetened, fresh-frozen berries that are thawed and drained may be substituted for fresh berries. Both the orange slices and the berry sauce may be served slightly warmed to bring out their flavors. Orange-flavored liqueur may replace the orange extract. A granola-type cereal may be used instead of the chopped nut topping. Optional Ingredients: The orange slices and berry sauce may be served on top or alongside plain cake, such as angel food or pound cake. A dollop of whipped cream adds color, fat and texture at relatively few calories (about 8 calories per tablespoon, with about 0.67 grams of total fat). In comparison, one tablespoon of plain nonfat Greek yogurt contains about 13 calories, with 0 grams of total fat. Other citrus fruits may be added, such as slices of blood oranges or pink grapefruit. The amount of sugar may need to be adjusted. Why Granulated Sugar? Opposing tastes have the capacity to highlight each other. In this recipe, granulated sugar is used to offset the acidity of the oranges and berries—even when they are ripe and in season. Opposing tastes, or sensations of sweet and salty and sweet and hot may act in similar ways—counterbalancing and accentuating. So sometimes when sugar is added to recipes it serves to bring out certain tastes by toning down other more pronounced tastes and by creating taste unification. 27. Blueberry and Fig Crumble Category: Desserts Prep Time: 1 hour Technique: Baking, mixing Equipment: Oven, 9-inch baking dish, small bowl

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PHOTO: Blueberry and Fig Crumble. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Blueberries are often considered one of the healthiest berries. This may be due to their antioxidant content with carcinogen-fighting anthocyanins that produce the blue, mauve, pink, red and violet color of flowers, fruits and vegetables. Figs are ancient, highly nutritious, yet underutilized fruit that are filled with calcium, fiber and natural sugars. Commercial fig bars lend their sweetness to this convenient, one-dish dessert that can function for breakfast or snacks. The oat topping contains both cinnamon-spiced oatmeal and whole-wheat flour for additional fiber and hearty flavor. Basic Tastes: Fig puree imparts concentrated sweetness and distinctive taste that is only slightly reminiscent of fresh figs. The fig puree in Blueberry and Fig Crumble draws in some of the berry liquid, and in turn takes on its tangy flavor that is offset by the sweet nuttiness of the almond extract. Featured Ingredient: Figs Figs are an ancient fruit, native to Western Asia that thrives in warm countries in the Middle East and western United States. Figs can be consumed either dried or fresh, each with different tastes and textures for eating out of hand, or for using in savory and sweet recipes. Both types of figs are good-to-rich sources of dietary fiber and calcium, copper, manganese, pantothenic acid and potassium. Their chewiness and gumminess lends interesting textures to recipes such as Blueberry and Fig Crumble. Ingredients: Nonfat cooking spray 2 teaspoons corn starch 1 /4 cup water 1 /4 cup fruit juice concentrate, such as apple or white grape 1 /2 teaspoon almond extract 3 cups blueberries, fresh or frozen, defrosted 3 fig bars, crumbled Oat Topping (recipe follows) Low-fat frozen yogurt or ice cream, if desired Oat Topping 3 /4 cup old-fashioned oats 1 /4 cup whole-wheat flour 1 teaspoon ground cinnamon 2 tablespoons maple syrup 11/2 Tablespoons unsalted butter, melted

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Mix old-fashioned oats, whole-wheat flour and cinnamon in small bowl. Make well in center of mixture. Pour in maple syrup and melted butter; stir until well blended into small pieces. Crumble evenly over blueberry fig filling. Bake as directed in Blueberry and Fig Crumble. Instructions:

1. Preheat oven to 350 F. 2. Coat a 9-inch square baking pan with nonfat cooking spray. 3. Combine cornstarch, water, fruit juice concentrate, and almond extract in small bowl; mix well to evenly distribute cornstarch. 4. Add blueberries and crumbled fig bars into large bowl; stir to mix. 5. Pour cornstarch mixture over blueberries and crumbled fig bars; stir to blend well. 6. Spoon mixture into baking prepared pan. 7. Prepare Oat Topping as directed (recipe follows). Spread over blueberry and fig filling. 8. Bake, uncovered, about 35 40 minutes until thickened and browned. 9. Let set about 5 minutes before serving. 10. Top with low-fat frozen yogurt or ice cream, if desired. Yield and Serving Size: Makes 31/2 cups, 7 (1/2-cup) servings, each (with Oat Topping) Nutrient Analysis: 340.47 calories, 18.77% calories from fat, 7.1 g total fat, 2.58 g saturated fat, 9 mg cholesterol, 63.71 g carbohydrates, 5.09 g fiber, 5.27 g protein, 31.63 mg sodium Nutrient Modifications: • To lower calories and carbohydrates: Reduce the serving size, and/or use less Oat Topping. Substitute Ingredients: Both red raspberries or blackberries may be substituted or mixed with the blueberries in this recipe; however, the total amount of berries should not exceed 3 cups. While almond extract adds a nutty aroma and taste, vanilla extract adds sweetness and tropical notes. Different types of fig bars may replace traditional fig bars; however, keep the other ingredients in mind, especially the type of berries that are chosen. Compare the carbohydrates, including fiber, sugar and whole grains and choose the brand with the highest amount of fiber and whole grains, and the least amount of sugar without too much sacrifice of taste. Optional Ingredients: A little unsweetened whipped cream may be used instead of low-fat frozen yogurt or ice cream to top individual servings, or a wedge of low-fat cheese may be served alongside. A sprinkle of toasted nuts, such as chopped pecans or walnuts, adds another layer of color, taste and texture for people with intact chewing ability. Why Low-Fat Frozen Yogurt or Ice Cream? The cool, creaminess of low-fat frozen yogurt and/or ice cream made from dairy or nondairy products, and often combined with various flavors, fruits, and nuts, add a luxurious mouthfeel to grainy-textured bars, cakes and/or cookies. This dessert is satisfying on its own, but both taste and texture are elevated to another level with a frozen confection such as low-fat frozen yogurt, ice cream or whipped cream. This is especially true if the Blueberry and Fig Crumble is consumed warm, immediately after baking when the flavor is at its maximum. 28. Rice Pudding With Pears and Almonds Category: Desserts Prep Time: 55 minutes Techniques: Boiling, simmering, toasting Equipment: Range, medium saucepan, heavy saucepan with lid, heavy fry pan,* bowls *Note: May require help for lifting.

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PHOTO: Rice Pudding With Pears and Almonds. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Rice pudding is often associated as a comfort food with its creamy consistency and sweet taste. This recipe for Rice Pudding With Pears and Almonds replaces white rice with brown rice, teams it with delicately poached pears in sweet spices, and tops it with toasted almonds. To bring out the rice taste even more, rice milk is used, but another nut or dairy milk may be substituted. Toast the almonds to bring out their nutty, umami flavor and crunchy texture. This pudding can also be served for breakfast brunch or as a snack with some simple cookies or sweet bread, such as carrot or zucchini. Basic Tastes: The ingredients in rice pudding that supply sweetness include the rice itself, raisins, sugars in the dairy or plant milk, apple juice and pears. Only one tablespoon of granulated sugar is used in Rice Pudding With Pears and Almonds, primarily to bring out the other sweetness that is tempered by lemon peel and spiced by cinnamon and nutmeg. Featured Ingredients: Lemon Rind, Peel and Zest The thin, colored outside coat of the lemon fruit is technically referred to as the zest and sometimes it is called the rind. Lemon rind includes the zest and some of the white underlying pith that tends to be bitter and unpleasant. For this reason, it is not often used in recipes. Lemons should be first washed very well to remove any dirt or impurities. Lemon peel adds a refreshing aroma and zest to recipes and contains some vitamins and minerals, such as vitamin C, calcium, potassium, and fiber. Ingredients: 3 /4 cups uncooked medium grain rice (such as Italian Arborio) 11/2 cups water 1 /4 cup golden raisins 3 cups low-fat milk or rice beverage

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1 cup apple juice 1 /4 cup sugar 1 /4 teaspoon salt 2 large ripe Bosc pears, peeled, cored and chopped 11/2 cups water to cook rice, plus water to cover pears 1 tablespoon sugar 1 /2 teaspoon ground cinnamon 1 /4 teaspoon ground nutmeg 1 teaspoon lemon zest, grated 1 /2 teaspoon vanilla extract 1 /4 teaspoon Kosher or sea salt 1 /2 cup chopped almonds, toasted 1 cup lemon-flavored low-fat yogurt, to serve Instructions: 1. Combine rice with 11/2 cups water in medium saucepan, bring to a boil, then reduce heat and simmer for 10 minutes. 2. Add the raisins, milk or rice beverage, apple juice, 1/4 cup sugar and 1/4 teaspoon salt to the cooked rice. Bring to a low simmer for 20 30 additional minutes, until thick and creamy; stir often. 3. While the rice is cooking, place the pears in heavy saucepan; add water to cover, sugar, cinnamon, nutmeg, lemon zest, vanilla and Kosher or sea salt. 4. Cover with lid; cook over low heat until pears soften, about 10 15 minutes. 5. Place almonds in heavy fry pan; toast over low heat until slightly browned, about 5 10 minutes. 6. Spoon rice pudding into eight bowls; top with cooked pears, sprinkle with toasted almonds and 2 tablespoons of lemon-flavored yogurt. Yield and Serving Size: Pudding makes 4 cups (81/2 cup) servings, each. Sauce makes 11/2 cups 8 (3 tablespoons) servings, each. Nutrient Analysis: 203.70 calories, 16.44% calories from fat, 3.72 g total fat, 0.98 g saturated fat, 5.44 mg cholesterol, 38.39 g carbohydrates, 2.91 g fiber, 5.96 g protein, 204.04 mg sodium Nutrient Modifications: • To lower calories: Reduce the serving size and/or the amount of sauce per serving. • To lower carbohydrates: Reduce the amount of raisins and/or lemon-flavored yogurt. • To lower sodium: Reduce the serving size, as some of the ingredients naturally contain sodium, and yet are integral components of this recipe. The sea salt in the sauce may also be reduced to a pinch. Substitute Ingredients: Almond, oat or other plant-based milk may be substituted for the dairy or soy milk but note that the flavor may likely change. Likewise, cooked apples may be substituted for the cooked pears and chopped, toasted English walnuts instead of the chopped almonds pair well with the other flavors. Optional Ingredients: A teaspoon of almond extract may be added along with the pears when cooking to infuse the almond flavor that ties into the chopped toasted almond garnish. Cinnamon can be sprinkled over each serving of Rice Pudding With Pears and Almonds that is reminiscent of traditional rice pudding with its spicy topping and warm-colored appearance. Why Kosher or Sea Salt? Though Kosher salt is also made from sodium chloride, like common table salt, it has a larger grain size. Ideally, less Kosher salt may be used in comparison to table salt since the grains are larger. Kosher salt is the result of the evaporation of seawater. The chemical residue, including mineral content varies depending on its source. As a whole, Kosher salt does not contain the common additive iodine that is in iodized table salt. To some people, the taste of Kosher salt is improved without this additive, and its briny, sea-like taste prevails. 29. Strawberry, Banana and Almond Butter Crepes Category: Desserts Prep Time: 30 minutes

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Techniques: Blending, browning, processing Equipment: Range, medium bowl, crepe pan or heavy nonstick skillet, food processor or blender Description: A crepe is a thin pancake that can be stuffed with sweet or savory fillings. Strawberry, Banana and Almond Butter Crepes are made with white whole-wheat flour. They can also be made with buckwheat flour, similar to blinis or Russianstyle pancakes. These crepes are lightly pan fried in a nonstick skillet, then spread with almond butter, chopped almonds and bananas and topped with almond “cream” based on frozen bananas and almond butter. Basic Tastes: This recipe offers a complexity of tastes, and this is what makes its resultant flavor so appealing. To begin, strawberries are both sour and sweet, depending on their degree of ripeness. Bananas may be both sweet and starchy, also due to their readiness when their starches convert into sugars. Almond butter is simultaneously bitter and fatty, and it may also suggest an umami taste if the almonds are first roasted. The whole-wheat crepe may also convey earthiness, along with the nutmeg. Just a touch of vanilla provides a sweet note. Featured Ingredient: Almond Butter Almond butter is more of a paste than traditional butter. What makes almond butter butter-like is that it is spreadable. Like peanut butter, almond butter may be crunchy or smooth, raw or roasted and stirred or nonstirred. Almond butter provides vegetable protein is an excellent source of vitamin E, fiber and magnesium, and a high source of calcium, iron, manganese and monounsaturated fatty acids. It is generally favored by people who are allergic to peanuts, or by those who wish to reduce their saturated fat intake (almond butter has about one-half of the amount of saturated fat than peanut butter). Ingredients: 3 large eggs 1 /2 cup reduced-fat milk 1 /2 cup white whole-wheat flour, sifted 2 tablespoons granulated sugar 1 /4 teaspoon nutmeg, plus additional for garnish Nonstick cooking spray 1 medium banana, sliced, plus 1/2 ripe banana, sliced 10 fresh strawberries, hulled and sliced, plus 6 whole strawberries, stemmed and sliced 1 medium frozen banana 1 tablespoon almond butter 1 /4 teaspoon vanilla extract 1 /4 teaspoon Kosher or sea salt Freshly grated nutmeg, to garnish Instructions: 1. Whisk eggs with reduced-fat milk in a medium bowl; add whole-wheat flour, sugar and nutmeg; whisk to blend and reserve. 2. Heat crepe pan or heavy small nonstick skillet over medium-high heat; spray with nonstick cooking spray. 3. Add about 1/4 cup crepe batter to coat bottom of skillet, move pan in a circular motion to coat with the batter. 4. Brown crepe about 30 seconds; flip and brown reverse side. Remove from pan; keep warm, wrapped in a clean kitchen towel. 5. Repeat process until all batter is used, wiping the pan with a clean paper towel after each crepe, and spraying the pan with more nonstick cooking spray as needed. 6. Evenly divide banana and strawberry slices among the crepes. 7. Blend frozen banana, almond butter, vanilla extract and Kosher or sea salt in a food processor or blender until thickened. 8. Place a spoonful of banana almond cream mixture over bananas and strawberries in each of crepe; roll to close. 9. Garnish crepes with additional banana slices and whole strawberries; dust with nutmeg. Yield and Serving Size: 6 crepes (1 [5- to 6-inch] crepe) each Nutrient Analysis: 165.3 calories, 25.1% calories from fat, 4.61 g total fat, 1.13 g saturated fat, 106.5 mg cholesterol, 26.81 g carbohydrates, 3.19 g fiber, 6.36 g protein, 142.39 mg sodium

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Nutrient Modifications: • To lower cholesterol: Use two egg whites for one whole egg. Substitute Ingredients: Ready-made crepe pancakes may be found in the frozen food department of some markets. Apples, pears or other berries such as blue or blackberries may be substituted for the bananas and strawberries. Cashew butter or peanut butter may replace the almond butter, unless peanut allergies are of concern. Optional Ingredients: Banana almond cream may be warmed in a small saucepan over low heat if desired. Add reduced-fat chicken or turkey sausage and a dairy milk or plant-based beverage to transform this recipe into a flavorful brunch or light supper entre´e. Or dribble a bittersweet chocolate sauce over the crepes to add a bitter taste, agreeably alter its appearance and balance its sweetness. Why Nutmeg? Nutmeg has been favored for centuries in Indonesia and West Indies curries for its warm, nutty taste. It has also been used in beverages, cakes and milk dishes in Britain, and in vegetable dishes, including mashed potatoes and spinach, in Scandinavia. In the United States nutmeg sometimes appears with pineapple and in seafood dishes. Nutmeg is favored because its aroma and taste enhance the sweetness in a recipe. But the aroma and flavor of nutmeg disappear quickly once it is pulverized. This is why the amount of nutmeg in this dish might seem higher than average. It is also a reason to grate a nutmeg seed right over a dish to finish. A cream sauce is particularly delicious prepared in this manner. 30. Chocolate Yogurt and Orange Mousse Category: Desserts Prep Time: 50 minutes Techniques: Blending, heating and cooling Equipment: Range, heat-resistant medium bowl, medium saucepan, cups

PHOTO: Chocolate Yogurt and Orange Mousse. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Many people have a love hate affair with chocolate—especially when it is used in creamy desserts. However, numerous restaurants select to offer a chocolate dessert on their menus, such as a chocolate mouse or tart, for chocolate diehards. This recipe for Chocolate Yogurt and Orange Mousse merges the delectable qualities of chocolate with the healthful attributes of low-fat plain yogurt, fresh orange juice and Mandarin orange segments. To treat this dessert as a tasting and not as a full serving, serve it in 1/4-cup demitasse or espresso cups to reduce its ample portion size. AGING, NUTRITION AND TASTE

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Basic Tastes: Bittersweet Bittersweet sounds like an oxymoron: neither truly bitter not sweet; rather, two opposing tastes that may simultaneously taste both painful and pleasant. Both the bitter and the sweet tastes balance and complement each other and enhance both savory and sweet flavors. For example, in addition to chocolate, the sweet flavor of vanilla is often successfully used in combination with the bitter and strong flavors of some sweeter curries, chutneys and salsas. And the bitter tones of coffee merge successfully with the sweet flavors of cinnamon, cardamom, dried fruits, nutmeg and vanilla. So bittersweet helps people appreciate bitterness when they may not enjoy it on its own. Featured Ingredient: Chocolate Chocolate is so pleasing to many people, due in great part to its bittersweet taste and creamy mouthfeel. The good news is that chocolate may be used in healthy desserts without overwhelming the palate and adding too many calories or fat. Plus, cocoa beans contain polyphenols called flavonoids (especially catechins), which are similar to those in with their antioxidant properties and potential heart protection. Chocolate also contains small amounts of calcium, copper, iron, magnesium, phosphorus and vitamin E. The fat in chocolate is from cocoa “butter” (mostly saturated fatty acids), and caffeine is present in trace amounts. Ingredients: 6 ounces bittersweet chocolate (70% or more cacao), finely chopped 1 /2 cup low-fat milk 1 tablespoon fresh orange juice 1 cup low-fat plain (or Greek) yogurt Canned Mandarin oranges in own juice and orange zest, to garnish Chopped pistachios, to garnish Instructions: 1. 2. 3. 4. 5. 6. 7. 8.

Put finely chopped chocolate pieces into a medium bowl that can withstand heat. Pour milk into medium saucepan; bring to boil (prevent heat from scorching milk and pan). Pour milk over chocolate pieces to melt (about 1 2 minutes). Stir until smooth. Add yogurt to medium bowl; blend until smooth. Add orange juice and blend. Spoon into 6 demitasse or espresso cups; refrigerate until set, about 30 minutes. Garnish with a few chopped Mandarin orange segments, orange zest and chopped pistachios, to serve. Yield and Serving Size: 11/2 cups, 6 (1/4-cup) servings, each

Nutrient Analysis: 181.60 calories, 56.42% calories from fat, 11.36 g total fat, 7.67 g saturated fat, 1 mg cholesterol, 22.60 g carbohydrates, 1.92 g fiber, 6.6 g protein, 24.3 mg sodium Nutrient Modifications: • To lower calories, total and saturated fat: Use plain or nonfat milk and/or Greek yogurt. However, this action may affect the consistency and/or texture of the mousse. Substitute Ingredients: While bittersweet chocolate is higher in antioxidants than milk chocolate, milk chocolate may be substituted. Skim milk may replace the low-fat milk, but this step may affect the creaminess. For additional tang, low-fat Greek yogurt may be used. Cranberries, cherries, raspberries and strawberries all pair with the bittersweet chocolate. Any one of these juices may be substituted for the orange juice. The mousse may then be topped with dried cranberries or dried cherries instead of the Mandarin orange segments. The grated orange zest will still suffice and provide a colorful contrast. Optional Ingredients: A few shavings of bittersweet chocolate may add continuity in taste to the bittersweet chocolate in the mousse. Some chopped, toasted pistachios may add a colorful and crunchy finish for people who can tolerate nuts and desire a little more texture to balance the creaminess of Chocolate Yogurt and Orange Mousse. Why Mandarin Oranges? Though reddish-orange Mandarin oranges may look like tangerines with their small oblate size, with sweeter and stronger taste, they are botanically varieties of common oranges. The reason for the term “Mandarin” or “Mandarine” is unclear. It may relate to the yellow color of some mandarin dignitary’s robes, and are considered traditional symbols of abundance and good fortune. While Mandarin oranges are commonly consumed fresh in desserts, entre´es and salads, canned mandarin segments have the bitter white pith removed and are conveniently packed in their own juice or water—avoid the sugary syrup. AGING, NUTRITION AND TASTE

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BEVERAGES 31. 32. 33. 34. 35.

Mango Yogurt Shake Mock Sangria Peanut Butter, Banana and Coffee Blend Green Pick-Me-Up Cucumber Berry Grape Quencher

BEVERAGES Beverages can be more than water, coffee, tea and soft drinks. Nutritious beverages abound: fruit and vegetable juices, nonalcoholic quenchers, protein-boosted drinks, shakes, smoothies and many more. Nonetheless, the problems with many beverages are that they may fill people up and avert prospective food calories and nutrients. Fortunately, nutritious beverages may be central within healthful meals. Flanked by a simple salad, sandwich or soup or a fruit-based dessert many of the beverages in this section may be pivotal as components of mini-meals. Furthermore, if chewing and swallowing are challenging, then beverages such as these may be rescue strategies for needed calories, nutrients and health. NOTE: These beverages are relatively small in serving sizes. If calories permit, their serving sizes may be doubled. Also, it is suggested that they are to be served over ice cubes. If these drinks are too cold, the additional ice cubes may be eliminated and the blended beverages may be used “as is.” 31. Mango Yogurt Shake Category: Beverages Prep Time: 7 minutes Technique: Blending Equipment: Blender or food processor, glasses Description: The popularity of yogurt as a health and longevity aid may be traced, in part, to the last century. A microbiologist proposed that the lactic acid bacilli found in yogurt contained life-extending properties and helped to delay mental deterioration and senility. Besides its potential health benefits, yogurt’s taste and texture are unique: tangy and creamy. In this recipe for Mango Yogurt Shake, when yogurt is combined with tropical fruit nectar, such as mango or papaya, the tanginess of yogurt is balanced by the sweetness of mango. Mango is a good source of vitamins A and C, two antioxidants that attempt to combat aging. Basic Tastes: Mango and papaya nectar are sweet with viscosity. When they are “cut” with acidic yogurt, the resultant taste is smooth with a hint of sweetness and tanginess. Orange extract adds a citrusy note, and the ground ginger topping presents a spicy start. Even neutral ice cubes serve a purpose: Once pulverized, they provide a vehicle for the other tastes. Featured Ingredient: Ground Ginger Ground ginger is the dried powder form of the subtropical ginger plant, known for the underground stem or rhizome. Ginger is closely related to cardamom, galangal, and turmeric. Its unique flavor and fragrance are derived from its natural oils, including gingerol, with it prospective antiinflammatory and antioxidant effects. Ginger is often used to flavor baked goods, such as gingerbread and gingersnaps, beverages such as ginger ale and beer, and sweets such as fruit tarts, pound cake and pumpkin pie. Both ground and fresh ginger are prevalent in Asian and Indian cuisines. Lemon and lime pair with ginger, as does cinnamon and nutmeg. One-eighth teaspoon of ground ginger may be substituted for each tablespoon of fresh grated ginger in some recipes. Ingredients: 1 /2 cup plain nonfat or low-fat Greek yogurt 3 /4 cup mango nectar, chilled 1 /2 teaspoon orange extract 5 6 ice cubes, or as needed, plus additional ice cubes for serving (optional) Ground ginger for dusting Orange slice, if desired Instructions: 1. 2. 3. 4.

Put yogurt, nectar and orange extract into container of blender or bowl of food processor. Cover and blend on high speed about 1 minute, or until smooth. Add ice cubes one at a time; blend until desired consistency is reached. Fill two 8-ounce glasses with ice cubes, if desired. Pour Mango Yogurt Shake into glasses over ice cubes, if desired, or serve without ice. AGING, NUTRITION AND TASTE

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5. Top with powdered ginger. 6. Garnish with orange slice, if desired. Yield and Serving Size: Makes 2 (4- to 5-ounce or about 1/2-cup) servings, each. Nutrient Analysis: 81 calories, 0% calories from fat, 0 g total fat, 0 g saturated fat, 0 mg cholesterol, 14.78 g carbohydrates, 0.38 g fiber, 6 g protein, 27.88 mg sodium Nutrient Modifications: • None necessary. Substitute Ingredients: Peach, pear or guava nectar may be substituted for the mango or papaya nectar. Greek low-fat yogurt could be used for more tanginess. Cinnamon or nutmeg may replace the ground ginger. Lemon extract may be used to replace the orange flavor. Optional Ingredients: Powdered milk or protein powder may be mixed with the yogurt to improve the nutrient profile of this drink and increase the protein calories for those who may need a flavorful boost. A small mint sprig may be used for garnish or to refresh the breath. Why Tropical Fruit? Tropical fruit, such as mango, papaya or guava, are both acidic and sweet, and lend a fresh change from the more common citrus fruits: orange, grapefruit and pineapple. The more colorful the fruit, generally the higher the vitamin A and C content. Color is usually a dramatic feature of ripe tropical fruit, so the appearance of this Mango Yogurt Shake may be visually stimulating if the fruit is mature. Tropical fruits are now available in many markets year round, and their juice can be discovered individually sized in handy cans—great for nontropical climates! Many have added sugar, so be label conscious. 32. Mock Sangria Category: Beverages Prep Time: 18 minutes Technique: Blending Equipment: Large pitcher

PHOTO: Mock Sangria. r 2019 Grace Natoli Sheldon. Reprinted with permission.

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Description: Sangria is a beverage that originated in Portugal and Spain. It commonly contains alcohol, such as red or white wine, brandy or flavored liqueur, with or without orange juice or sparkling water, and chopped fruit, such as apples, berries, cherries, lemons, melon, nectarines, oranges, peaches or pineapple. Some versions of sangria are even blended. This version of Mock Sangria is alcohol-free and relies on purple grape juice in place of red wine. Basic Tastes: Grape juice, like wine, provides a bittersweet umami taste and helps to unify the acidic tastes of the lemon and orange juice as well as their tangy fruits. If there is too much acidity, a liquid sweetener such as honey or agave nectar might serve to balance. Featured Ingredient: Grape Juice Concord grapes (the most dominant type of grape juice in the US market) contain a phytonutrient called resveratrol that functions as an antioxidant. Resveratrol reportedly aids in cancer prevention by promoting the destruction of damaged and older cells and the growth of newer and healthier cells. Resveratrol also helps to regulate liver enzyme activity to help reduce potential carcinogens, lessen potential destructive inflammation and encourage healthy blood vessel functioning. Besides wine and grape juice, resveratrol is also present in grape extract and grape powder. Ingredients: 1 quart 100% Concord grape juice Juice of 1 lemon (about 4 tablespoons) Juice of 2 oranges (about 8 tablespoons) 1 quart sodium-free sparkling water 1 medium orange with skin, washed and diced 1 medium lemon with skin, washed diced 5 large strawberries, sliced 2 tablespoons honey or agave nectar, optional Orange slices, to garnish Ice cubes to serve, if desired Instructions: 1. 2. 3. 4.

Combine all of the juices and sparkling water in a large pitcher. Sweeten with honey or agave nectar as needed. Add diced fruit and strawberries; garnish with orange slices. Serve 1-cup servings immediately over ice cube-filled glasses, if desired, or chill. Yield and Serving Size: Makes about 10 (8-ounce or 1-cup) servings, each

Nutrient Analysis: 94.43 calories, 1.05% calories from fat, 0.11 g total fat, 0 g saturated fat, 0 mg cholesterol, 24.11 g carbohydrates, 1.47 g fiber, 0.84 g protein, 25.33 mg sodium Nutrient Modifications: • None necessary. • Honey and/or agave nectar may be eliminated to reduce carbohydrates. Substitute Ingredients: White grape juice or apple juice could be substituted for the purple grape juice, but with potentially less phytonutrient benefits. Pineapple juice may be substituted for one of the citrus juices. Grapefruit juice may interfere with some pharmaceuticals. Seedless grapes may replace the cherries. While liquid sweeteners dissolve and disperse best, a granulated-type sugar may be used to sweeten, if needed and if adequately stirred to disperse. Optional Ingredients: Chopped fresh fruits, such as apples or pears may be added to the fruit mix. Generally firmer fruits are able to withstand the acidity of the fruit juices better than softer ones that may cloud and thicken the Mock Sangria. Still, soften fruits may be easily masticated, so the selection of fruit should be individualized for taste and any physical limitations.

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Why Lemon Juice? Fresh lemon juice is a common accompaniment for fish and seafood. Middle Eastern food relies on lemon juice as an essential flavoring. But lemon juice is equally important for the sourness and acidity that it lends to tropical fruits, such as avocado, guava or papaya. Lemon juice acts as a flavor catalyst to help bring out natural fruit flavors. It is often interchangeable with vinegar in many recipes and has an affinity to eggs. Lemon juice balances salty flavors—some say that it “brightens” them. When applied to cut apples or pears, lemon juice helps to prevent browning and only slightly changes their taste. Defrosted, fresh-frozen lemon juice is fine in a pinch for this Mock Sangria recipe and its invigorating flavor balancing. 33. Peanut Butter, Banana and Coffee Blend Category: Beverages Prep Time: 10 minutes Technique: Blending Equipment: Blender or food processor, glasses

PHOTO: Peanut Butter, Banana and Coffee Blend. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Peanut butter may bring recollections of childhood peanut butter-and-jelly sandwiches with milk—an economical and nutritious mainstay of many US families. This recipe for Peanut Butter, Banana and Coffee Blend is an adult version with a favorite jam and coffee in addition to the milk. Dry milk powder or protein powder enhances the protein content even more. Banana and natural jam may conjure sweet memories. All together, these ingredients unite for a satisfying and nutritious beverage or an in-between mini-meal, with or without the addition of a few simple cookies or muffin, such as a Banana Nut Oat Bran Muffin (recipe follows in this chapter). Basic Tastes: Peanut butter is typically salty and earthy in taste and creamy to crunchy in texture, so it pleases many taste and textural needs. (Sometimes peanut butter is unsalted, so this may change its taste perception.) Milk, milk powder and/ or protein powder have sweet taste bases that are enhanced by the sweetness of the banana and the little bit of jam. A

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touch of cocoa powder to top each serving adds a hint of chocolate and its bitter-sweetness, so this beverage may even camouflage as a dessert. Featured Ingredient: Peanut Butter Peanuts are botanically considered as legumes, not nuts. Yet, peanuts are considered as one of the eight allergens. While some people have true allergies to peanuts and peanut butter, others may benefit by its ease, economy and nutrients. In 2 tablespoons of peanut butter there are 8 grams of protein, 16.1 grams of total fat (with 7.7 grams of heart-healthy monounsaturated fat), 6.4 grams of total carbohydrates and 1.9 grams of dietary fiber. The vitamin E in peanut butter provides 14% of the Daily Value; niacin supplies 21% of the Daily Value; and manganese furnishes 23% of the Daily Value. The amount of peanut butter in this recipe supplies about twice of all of these amounts. Ingredients: 1 cup low-fat milk 1 teaspoon nonfat dry milk or protein powder 1 tablespoon instant coffee powder 1 /4 cup natural creamy peanut butter 1 medium ripe banana 1 teaspoon natural apricot jam 10 ice cubes, as needed, plus additional ice cubes to serve, if desired Cocoa powder, for dusting Instructions: 1. Blend the low-fat milk, dry milk or protein powder, coffee powder, peanut butter, banana and jam in bowl of blender or food processor; process until smooth. 2. Add one ice cube at a time; process until desired consistency is reached. Fill four 8-ounce glasses with ice cubes, if desired; divide Peanut Butter, Banana and Coffee Blend equally among glasses; dust with cocoa powder. Yield and Serving Size: Makes 4 (4-ounce or 1/2-cup) servings, each Nutrient Analysis: 156.70 calories, 25.09% calories from fat, 8.74 g total fat, 2.22 g saturated fat, 3.21 mg cholesterol, 15.12 g carbohydrates, 1.72 g fiber, 6.87 g protein, 36.52 mg sodium Nutrient Modifications: • To lower total fat: Use reduced-fat peanut butter. Substitute Ingredients: Soy or nut beverages may be used instead of dairy milk, along with a plant-protein powder. Other creamy nut butters such as almond or cashew may also be substituted. Instead of jam, a few pitted dates may be added for sweetness, some fiber and nutrients that include copper, manganese and potassium. A few instant coffee crystals instead of cocoa powder add a bitter topping for some coffee aficionados. Optional Ingredients: If a frozen banana is used, then fewer ice cubs may be needed to create a cold beverage. However, the ice cubes are also included to help to thin the Peanut Butter, Banana and Coffee Blend, so increase as desired. Besides cocoa powder, cinnamon or nutmeg can be added to top this beverage—or a small amount may be added before blending for a more exotic impression. Why Coffee Powder? Coffee powder dissolves completely; just a little adds a bitter undertone to this recipe. Espresso powder may be substituted for additional robust earthiness. Decaf coffee powder may be substituted. Plus coffee contains beneficial antioxidants with disease-fighting potentials. 34. Green Pick-Me-Up Category: Beverages Prep Time: 15 minutes Techniques: Blending Equipment: Blender or food processor

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PHOTO: Green Pick-Me-Up. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Growing up, many people likely found the taste and texture of spinach to their dislike, and this memory may have persevered. In this Green Pick-Me-Up neither the taste nor the texture is reminiscent of childhood aversion. Instead, fresh baby spinach is blended with creamy avocado and tart green apple, along with sweet apple or white grape juice to balance any bitterness. A touch of peppery basil adds an adult finish to entice spinach naysayers. The perky green color is fresh and suitable for spring or summer, hot climates or to help transpose shut-ins to brighter days. Basic Tastes: Spinach has bitterness, but baby spinach is somewhat sweeter and not as tough as the older leaves may be. Apple or white grape juice lend their sweetness, and the green apple supplies both acidity and “greenness,” which may also be slightly bitter, highly aromatic, refreshing and sharp. The avocado imparts a creamy, fleshy oiliness that is more texture than taste. Featured Ingredient: Avocado The avocado is a fruit due to its large singular seed. It is commonly cultivated in subtropical climates in Central and South America, the Mediterranean and in California where it is referred to as the “alligator pear” due to its shape and roughly textured exterior. While avocadoes have a significantly higher fat content than other fruits (such as berries or stone fruits like apricots and peaches), their fat is mostly comprised of heart-healthy monounsaturated fatty acids. The interior of an avocado is subtle, but distinctive in taste, and its texture is silky-smooth when ripe. These attributes help to make an avocado particularly suitable for pureeing in this Green Pick-Me-Up recipe. Ingredients: 1 cup fresh baby spinach 11/4 cups apple or white grape juice 1 /2 medium avocado, skinned and pitted 1 small green apple (such as Granny Smith), skinned, cored and diced 1 cup ice cubes, as needed, plus additional ice cubes for serving, if desired Fresh basil sprig, for garnish, if desired Instructions: 1. Blend all ingredients except basil in bowl of blender or food processor until smooth. Use only enough ice cubes to reach desired consistency. 2. Pour into four glasses 8-ounce glasses filled with ice cubes, if desired. 3. Garnish with basil, also if desired. Yield and Serving Size: Makes 4 (4- to 5-ounce or about 1/2-cup) servings, each Nutrient Analysis: 96.98 calories, 17.74% calories from fat, 3.79 g total fat, 0.54 g saturated fat, 0 mg cholesterol, 16.32 g carbohydrates, 2.77 g fiber, 0.83 g protein, 11.19 mg sodium AGING, NUTRITION AND TASTE

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Nutrient Modifications: • None necessary. Substitute Ingredients: Baby kale might be too pungent as a substitute for spinach, but other tender greens such as arugula, bok choy leaves or watercress, a herb that is a member of the mustard family with small, peppery flavored leaves, may be substituted. Other firm and tart apples such as Cortland or Fuji (a little sweeter in taste) may suffice for the green apple. A mint sprig can be swapped for the basil for a refreshing finish. Optional Ingredients: For those who like herbal flavor, fresh basil, cilantro, dill, fennel, lemongrass, parsley, oregano, thyme or rosemary could replace some of the baby spinach, or a small amount of their dried versions in addition to the baby spinach may enhance the overall flavor. Amounts may vary dependent on the age of the herbs and the preferred aroma and taste combinations. As a whole, start on the conservative side with 1/4 1/2 teaspoon of crushed dried herbs and 1 2 tablespoons of fresh, chopped herbs per recipe—usually in addition to the baby greens. The amount of ice cubes may need adjustment. Why a Pick-Me-Up? When blood sugar falls and people want a quick source of energy, then they often turn to something sweet, such as a soft drink or candy. While this practice will rapidly raise blood sugar, it may not serve to sustain energy over time. Thus, blood sugar may fall again and require another dose of energy. A healthy pick-me-up may contain ingredients to help maintain energy, such as fruits or vegetables with fiber and a small amount protein (in the case of this Green Pick-Me-Up, the spinach and apple), or fat (as provided by the avocado). This is because both protein and fat take longer to digest than the sugar alone; thus the resultant pick-me-up and sustenance effects. 35. Cucumber Berry Grape Quencher Category: Beverages Prep Time: 10 minutes Techniques: Blending Equipment: Blender or food processor, glasses

PHOTO: Cucumber Berry Grape Quencher. r 2019 Grace Natoli Sheldon. Reprinted with permission. AGING, NUTRITION AND TASTE

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Description: Sometimes is it difficult to consume enough fluids—especially in dry or hot Months, or when isolated inside in dry conditions. By ingesting this Cucumber Berry Grape Quencher with its mixture of tastes that just burst inside the mouth, it can be both hydrating and spirit lifting. The cucumber is 95% water, with potassium and the antiinflammatory fisetin; berries provide beneficial antioxidants; and the nonfat or low-fat yogurt offers both a calcium and vitamin D boost. Plus, the blended quencher contributes to total daily fluid intake, so needed for aging metabolism and body processes. Basic Tastes: Cucumbers are clean, crisp and refreshing, and when the bitter skin and seeds are removed then their bitter taste is moderated. Berries are acidic and sweet, depending on their degree of ripeness. Likewise are grapes, with their bitter skin and sweet interiors. Greek yogurt adds tanginess and silkiness that serves to temper and unite bitterness, acidity and sweetness. Featured ingredient: Another Look at Ice Cubes Ice is merely frozen water, but it has many applications in cooking. In this blended beverage recipe (like the others in this section on Beverages) the use of a few ice cubes serve to thin out this Cucumber Berry Grape Quencher without necessarily lowering the temperature. The consistency can be controlled by the amount and size of ice cubes that are added. Ice cubes can also be floated on the surface of this quencher for people who prefer their beverages chilled. Bite-sized pieces of mint, berries or grapes can be frozen within the cold water before freezing for an attractive surprise. But do make sure that they are small enough to help avoid choking. Ingredients: 1 /2 large cucumber, peeled, seeded, and cut into 1-inch pieces (about 1 cup)* 1 cup frozen blueberries or blackberries 1 cup purple grape juice 1 /2 cup nonfat or low-fat plain Greek yogurt 1 cup ice cubes, plus additional ice cubes for servings, if desired Fresh mint sprig and/or cucumber slices, for garnish, if desired *Note: Reserve one 1-inch piece; cut into 3 slices for optional garnish. Instructions: 1. 2. 3. 4.

Blend all ingredients (except mint sprig) in bowl of blender or food processor until. Add ice cubes (as desired) to blender or food processor and process for more liquid consistency. Pour into three 8-ounce glasses filled with ice cubes, if desired. Garnish with cucumber slices and/or mint, also if desired. Yield and Serving Size: Makes 3 (4-ounce or 1/2-cup) servings, each

Nutrient Analysis: 105.87 calories, 0.6% calories from fat, 0.07 g total fat, 0 g saturated fat, 0 mg cholesterol, 22.2 g carbohydrates, 1.87 g fiber, 4.87 g protein, 20.67 mg sodium Nutrient Modifications: • None necessary. Substitute Ingredients: Instead of blue or blackberries, other high antioxidant berries could include be substituted, such as red or black raspberries. Cranberries may be too acidic and require more sweetening. Purple grape juice can be replaced with white grape juice for a less intense color, but the array of phytochemicals may be less. Basil, lavender or rosemary can be used as a garnish, or a tiny amount may be frozen inside the ice cubes. These actions may elevate this Cucumber Berry Grape Quencher into a celebratory and memorable drink. Optional Ingredients: By affixing a cucumber spear, berry and/or grape to a straw or stirrer to serve on top or alongside this beverage, it visually communicates the ingredients that are contained within it. Plus, it provides a nibble of the ingredients with their crunch and fiber before or after consuming its contents. Why Mix a Fruit With a Vegetable in This Beverage? Cucumbers are actually the “fruit” of plants in the gourd family, much like melons, pumpkins and squash. Cucumbers contain seeds that are removed before they are blended into this quencher. Botanically speaking, fruit are seed-bearing structures that develop from the ovaries of flowering plants, while vegetables are derived from other parts AGING, NUTRITION AND TASTE

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of plants that include leaves, roots and stems. So this recipe really doesn’t mix fruit and vegetables; rather, it combines fruit and fruit! BREAKFASTS: To Start the Day or Anytime 36. 37. 38. 39. 40.

Banana Nut Oat Bran Muffins Mushroom and Cottage Cheese Omelet Savory Oatmeal With Eggs Oat Waffles and Berry Compote With Lemon and Ginger Whole-Grain French Toast With Pears in Red Wine

BREAKFASTS: Break-the-“Fast” Nutritious breakfasts are designed to break the overnight fast during sleep and start the day, or serve as minimeals in larger portion sizes. There are persuasive reasons why aging people should eat breakfast. First, the breakfast meal generally breaks a long night’s fast and restores low blood sugar. Second, breakfast eaters may have more stamina to fuel their day. And third, many breakfast foods are rich in dairy products, eggs, fiber, fruits, meats and whole grains—a handy way to obtain valuable nutrients. It is the mix of healthy fats, proteins and wholesome carbohydrates that are contained within these foods and beverages that count. 36. Banana Nut Oat Bran Muffins Category: Breakfasts Prep Time: 30 minutes Techniques: Whisking, baking Equipment: Oven, muffin pan, two medium bowls

PHOTO: Banana Nut Oat Bran Muffins. r 2019 Grace Natoli Sheldon. Reprinted with permission.

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Description: Banana Nut Oat Bran Muffins are a good way to start the day with their fiber-rich oat bran, bananas and walnuts and protein-filled low-fat milk and egg whites. This recipe supplies 3.83 grams of dietary fiber per muffin, and is a good way to meet the Daily Value of 25 grams, based on a 2000 daily calorie diet. It is easy to premix the dry ingredients in this recipe, then store them until needed. When ready to prepare, just add the last five “wet” ingredients (skim milk, bananas, egg whites, canola oil and vanilla) as the recipe instructs and complete the preparation. Basic Tastes: Oat bran is earthy and may also have some bitter notes. The turbinado sugar has a little earthiness as well. If it is replaced with white sugar, then its subtle molasses taste might dissipate. The same holds true for the walnuts, which become particularly distinctive in bitterness and umaminess when they are toasted. Skim milk, bananas and vanilla extract add their sweetness to balance all of the bitterness, and canola oil delivers just enough fullness to help balance the dryness of the oat bran. Banana Nut Oat Bran Muffins are a more delicious and nutritious recipe than the name implies, and worth the effort to prepare and ingest. Featured Ingredient: Oat Bran Oat bran only contains the bran of seeds, as opposed to whole grains that contain the bran, germ and the endosperm, or outer layer of seeds. A 100-gram serving of dry oat bran contains more than 15 grams of dietary fiber—about one-half of the daily requirement. The purpose of dietary fiber is to help improve cholesterol levels, increase the bulk of stools and bowel frequency and regulate blood sugar and satiety, or fullness. Oat bran can be added to hot cereals or grains dishes, used as a flour substitute and/or stirred into casseroles, ground meats, soups and stews. It should be added in small amounts at first for the body’s digestive system to adjust. Ingredients: Nonfat cooking spray or vegetable oil 21/4 cups oat bran 1/3 cup turbinado sugar (light brown sugar may be substituted) 11/2 teaspoon cinnamon 1 tablespoon baking powder 1 /4 cup walnuts, finely chopped 2/3 cup skim milk 1 2/3 cups bananas (about 3 large), mashed 2 egg whites, lightly beaten 2 tablespoon canola oil 1 teaspoon vanilla extract Instructions: 1. 2. 3. 4. 5. 6. 7.

Preheat oven to 425 F. Prepare a 12-cup muffin pan with nonfat cooking spray or vegetable oil. Mix oat bran, sugar, cinnamon, baking powder and walnuts in a medium bowl. Whisk skim milk, mashed bananas, egg whites, canola oil and vanilla extract in another medium bowl. Gently mix wet ingredients into dry ingredients. Fill each muffin cup about 2/3 full with batter. Bake 16 18 minutes, or until lightly browned and center springs back to touch. Yield and Serving Size: Makes 12 (about 21/2-inch) banana nut oat bran muffins, each

Nutrient Analysis: 142.98 calories, 34.37% calories from fat, 5.46 g total fat, 0.66 g saturated fat, 0.67 mg cholesterol, 26.84 g carbohydrates, 3.83 g fiber, 4.81 g protein, 17.56 mg sodium Nutrient Modifications: • The carbohydrates from the bananas, oat bran, skim milk and sugar are integral to this recipe. • To lower carbohydrates: Prepare smaller muffins with less batter. Substitute Ingredients: Other dry sweeteners may be substituted for the turbinado sugar, but some of the molasses taste may be sacrificed. A combination of cinnamon and nutmeg may be used, such as one teaspoon of cinnamon and one-half teaspoon of nutmeg. Two

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types of walnuts are available: Persian or English and the black walnut that is higher in flavor. Olive oil may replace the canola oil for a deeper, richer flavor and slightly more monounsaturated fatty acids. Optional Ingredients: Nut-based milk or nut flour will add a subtle, nutty flavor. Nut-based flour, such as almond, may be substituted for up to 25% of the grain flour in a recipe without noticing too much of a textural difference. Since nut flour is different in texture and other properties than the oat bran, it is best to add in small increments and note any changes in muffin rise and/or texture. If nuts are tolerated and mastication is fine, sprinkle some additional chopped walnuts on top of each muffin before baking. Why Canola Oil? Canola oil is a vegetable oil that is made from crushed canola seeds. It is low in saturated fat, with just 7% per measure compared 15% for olive oil—also considered a heart-healthy vegetable oil. Canola oil is also high in the omega-3 fatty acid alpha-linolenic acid (ALA). The ALA in canola and flaxseed oil is considered essential because the human body cannot produce it. Because canola oil is genetically modified and may be extracted with solvents, some concerns have been expressed. Canola oil is versatile in cooking and baking. It is light in flavor with a high smoke point and smooth texture and so it is useful for saute´ing, stir-frying, grilling and in marinades, salad dressings and sauces. 37. Mushroom and Goat Cheese Omelet Category: Breakfasts Prep Time: 12 minutes Technique: Beating, mixing, broiling Equipment: Broiler large bowl, medium bowl, ovenproof fry pan or omelet pan, serving plate Description: Mushrooms with their meaty or umami taste tend to make simple ingredients such as eggs or neutral-tasting cheese taste fuller and more satisfying—even without meat, such as bacon or ham. In this Mushroom and Goat Cheese Omelet, brown crimini mushrooms (sometimes called “baby bella” that look like toadstools) are used for their earthy flavor and to provide color contrast against the yellowness of the eggs and the whiteness of the goat cheese. Goat cheese is used for convenience, protein content and its somewhat tangy character, with less fat than some hard cheese, such as Cheddar or Swiss. A little bottled hot sauce may be splashed over the finished omelet to intensify its flavor, for those who require an additional rush of spiciness. Basic Tastes: The sharpness of the onion, sweetness of the goat cheese, meatiness of the mushrooms and assertiveness of the hot pepper sauce merge and mellow in every mouthful. For even more tanginess, try goat cheese with herbs in place of plain goat cheese. The chopped parsley adds a bright green, fresh and bitter topping against the lightly browned omelet that is somewhat softened by its creaminess. Featured Ingredient: Mushrooms Mushrooms are edible fungi, not vegetables. Most are low in calories and fat with some protein and B vitamins. These tasty toadstools have been consumed since prehistoric times. Mushrooms were prized in ancient Rome and Greece for their unique varieties and exorbitance, as some types are still extolled today. Some of the more exotic mushrooms have decreased in price and accessibility—enoki, oyster and shiitake mushrooms are now available in many US markets. The taste of wild mushrooms, such as chanterelles, horn-of-plenty, morels, porcini (or ceps) or the fungus truffles is even more pronounced, mostly due to their glutamate content—most often associated with animal protein foods, such as meats. Ingredients: 1 large egg plus 1 large egg white 1 teaspoon olive oil 1 tablespoon yellow onion, minced 2 medium brown crimini or white button mushrooms, chopped 1 /4 cup goat cheese Dash hot pepper sauce, plus additional to garnish, if desired Nonfat cooking spray Chopped parsley, to garnish

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Instructions: 1. 2. 3. 4. 5. 6. 7. 8.

Preheat broiler on low setting. Beat eggs with olive oil in a large bowl. Mix onion, mushrooms, goat cheese and hot pepper sauce in a medium bowl; add to egg mixture. Prepare an ovenproof fry pan with nonfat cooking spray. (A standard nonstick omelet pan works best.) Heat fry pan or omelet plan; pour egg mixture into pan of choice. Stir eggs only during the first 30 seconds. Cook until eggs are thickened, little visible liquid egg remains, and bottom is browned. Place skillet in broiler 1 2 minutes until top is lightly browned. To serve, slide Mushroom and Goat Omelet onto a serving plate. Garnish with chopped parsley and additional hot sauce, if desired. Yield and Serving Size: Makes one (12-inch) omelet serving, each

Nutrient Analysis: 340.63 calories, 67.37% calories from fat, 25.5 g total fat, 14.2 g saturated fat, 255 mg cholesterol, 4.7 g carbohydrates, 0.6 g fiber, 23.2 g protein, 352 mg sodium Nutrient Modifications: • This recipe is higher in calories, total fat, saturated fat, cholesterol and sodium, due to the whole egg, olive oil, goat cheese and/or hot pepper sauce. • To lower these nutrients/substances: All egg whites may be used; the goat cheese may be substituted with reduced-fat goat cheese or nonfat cottage cheese, and the hot sauce (which is higher in sodium) may be eliminated, or used sparingly. Substitute Ingredients: Reduced-fat goat cheese may be substituted for the regular goat cheese. (Be careful, as some varieties of reduced-fat goat cheese are dry.) While nonfat cottage cheese may also be substituted for the goat cheese, the tanginess may be sacrificed.* Dried mushrooms may be substituted for fresh mushrooms in some recipes, and may lend their umami taste and texture to this Mushroom and Goat Cheese Omelet. Soak one to two tablespoons of chopped dried mushrooms in water to cover. Once soften, drain and use the mushrooms as directed in the recipe. Dried mushrooms have a long shelf-life and a deep, earthy taste. White button mushrooms may also be substituted, but they may lack the depth of flavor that heartier mushrooms deliver to this recipe. Optional Ingredients: A few chopped sundried tomatoes in olive oil may be mixed into the egg mixture. First drain the tomatoes from the olive oil to prevent the egg mixture from becoming too oily and discoloring the eggs. Chopped green onions may also be added to the egg mixture, or sprinkled over the egg surface after broiling to add color and fresh piquancy. If chopped onions are used, then omit the chopped parsley garnish. If sodium is not an issue, then a tablespoon of pitted, chopped ripe olives may be added to the omelet mixture or used as a garnish. Why Nonfat Cottage Cheese? To some people, cottage cheese is a throwback to ladies luncheons of the 1950s and high-protein business meals of the 1980s. But cottage cheese has never disappeared from the dairy case of supermarkets, and for good reason. Cottage cheese supplies a good amount of protein with relatively few calories, and it is reasonably low in cost. In this recipe substitution of nonfat cottage cheese for goat cheese, it is even lower in calories and devoid of fat. Cottage cheese is slightly tangy and surprisingly creamy when warmed, as in this Mushroom and Goat Cheese Omelet. Cottage cheese may be useful when aging gastrointestinal tracts may no longer tolerate regular cheese. This is because the milk sugar lactose is partially broken down by Lactobacillus bacterium. Cultured cottage cheese is a potential source of probiotics for still greater dimensionality and appeal. 38. Savory Oatmeal With Eggs Category: Breakfasts Prep Time: 25 minutes Technique: Boiling, frying Equipment: Medium saucepan nonstick saute´ pan, bowls

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PHOTO: Savory Oatmeal With Eggs. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Oatmeal is filling and nourishing on its own, as are eggs. When these two ingredients are combined, the resultant dish supplies fiber-rich carbohydrates and quality protein with little fat. This is the case of Savory Oatmeal With Eggs that uses quick-cooking rolled oats that are covered with fried eggs, Parmesan cheese and scallions in a handy one-bowl meal. Though the oatmeal and eggs are simply seasoned with salt and pepper, a range of herbs and spices may be added (see Substitute ingredients and Optional ingredients). Rather than fried eggs, poached or scrambled eggs may be prepared. This recipe is both versatile and forgiving in regard to ingredients, meaning that various herbs, spices and/or vegetables may be added and the allover flavor may still thrive. Basic Tastes: As a protein-rich ingredient, eggs impart the umami taste. To bring out the umami taste in the rolled oats they may be toasted before cooking. Parmesan cheese is an ingredient that is also known for its umami content. Scallions add acidity, color and sharpness. Sundried tomatoes uplift the umami quality of this recipe even more and add some richness due to the olive oil. Featured Ingredient: Sundried Tomatoes Sundried tomatoes are the epitome of umami. First of all, tomatoes are known for their five basic tastes: acidic, bitter, salty, sweet and umami. Second, tomatoes and other ingredients benefit from drying to boost their umami quality. This is why sundried tomatoes are needed in such small amounts in recipes. In Savory Oatmeal With Eggs, thin slices of sundried tomatoes preserved in olive oil are used for garnish. They present a ruby-red color, chewy texture and umami-boost in first glance and every mouthful that follows. When packed with basil, garlic or rosemary, sundried tomatoes express even more taste. Ingredients: 2 cups water 1 cup quick-cooking rolled oats 1 /4 teaspoon salt 1 /4 teaspoon pepper Nonstick cooking spray 2 large eggs Salt and pepper to taste* 4 tablespoons shredded Parmesan cheese 2 tablespoons scallions, chopped 2 oil-packed sundried tomato halves, cut into thin slices Instructions: 1. Heat water to a boil in a medium saucepan. 2. Add oats, salt and pepper; reduce heat and simmer about 5 minutes, or until tender. Remove from heat. 3. Coat a medium nonstick saute´ pan with nonstick cooking spray.

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Heat over medium heat. Add eggs and season with salt and pepper to taste*. Cook about 3 minutes, or until egg whites are set and yolks are still runny. Spoon oatmeal into two bowls; top each with 1 egg, 2 tablespoons of Parmesan cheese, 1 tablespoon scallions and one thinly sliced sundried tomato. Yield and Serving Size: Makes 2 (3/4-cup oatmeal with 1 egg on top) servings, each

Nutrient Analysis: 271.74 calories, 34.35% calories from fat, 10.37 g total fat, 16.4 g saturated fat, 218.2 mg cholesterol, 29.92 g carbohydrates, 4.37 g fiber, 10.55 g protein, 554.79 mg sodium *Note: Additional salt and pepper are not accounted for in this analysis. Do not oversalt this recipe during or after preparation since there is salt in the oatmeal. Nutrient modifications: • This is a hearty recipe. The oatmeal can be served in 1/2-cup portions, and then it would make three servings. • This action would lower all of the nutrients. An additional egg would be needed. • To lower the sodium even further: Use 1 tablespoon of Parmesan cheese per serving, and/or eliminate the sundried tomato. Substitute Ingredients: Eggs in many different forms make take the place of each other in this recipe. Consider hard-boiled, poached or scrambled eggs in place of fried eggs, or for those people who are watching their cholesterol, hard-cooked or scrambled egg whites may suffice. Likewise, other cooked grains may be equally as flavorful and somewhat as nutritious as oatmeal. These may include amaranth, brown rice, bulgur, faro, flax, grits, millet, polenta, quinoa and/or wheat berries—with preference to the wholegrain varieties. Optional Ingredients: By adding a savory herb or spice during the preparation of the oatmeal and/or the eggs, this recipe may be transformed in flavor and skew toward ethnic palates. For savory notes, consider the addition of dried or fresh herbs such as rosemary, sage or thyme, and the spices black pepper, cinnamon, ginger or turmeric. Garam Masala is a versatile ingredient that is actually an amalgamation of spices that may include black pepper, cardamom, cinnamon, cloves, coriander, cumin, fenugreek, ginger and/or nutmeg. Garam Masala has both savory and sweet notes. Why Parmesan Cheese? Parmesan cheese is one of the more aromatic, higher umami-rich ingredients (with as much as 1.2 grams of glutamate per 100 grams of cheese)—especially if it is aged. It is a very versatile, hard granular cheese that is made from cow’s milk with crystalline spots that partially consist of the amino acid tyrosine. Due to its mild color, Parmesan cheese is often used to grate over dishes such as Caesar salad, spaghetti and other pasta and risotto. When Parmesan cheese is spooned over Savory Oatmeal With Eggs, it helps to convert fairly simplistic ingredients, such as oatmeal and eggs, into a tasteful, protein-rich nutritious start to the day. 39. Oat Waffles and Berry Compote With Lemon and Ginger Category: Breakfasts Prep Time: 25 minutes (including 15 minutes for Berry Compote With Lemon and Ginger) Techniques: Blending, waffle making, combining, thickening Equipment: Blender or food processor, large bowl, wire rack, baking sheet, medium saucepan Description: It is true that a person may want a waffle maker to make waffles like yesteryear. And it is also true that frozen waffles may afford handy options. But once these waffles are enjoyed they may inspire waffles for breakfast, brunch and light entre´es—surrounded by low-fat dairy products, lean meats, fruits and even vegetables. In this recipe for Oat Waffles and Berry Compote With Lemon and Ginger, the oats are enhanced by protein in the soy flour, and sweetened by the pitted dates in the batter to inspire healthy consumption anytime day or night. Basic Tastes: Rolled oats have an earthy taste and soy flour has a distinctive beany taste (depending on processing) that some people may detest. But the pitted dates with their naturally intensive sweetness, a small amount of salt, and the spiciness of the cinnamon and nutmeg balance the earthiness and beaniness and create unified flavor. The Berry Compote With Lemon and Ginger adds just the right of natural fruit sweetness with its simplicity and tartly spiced flavor.

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Featured Ingredient: Soy Flour Soy flour is derived from ground soybeans. This versatile ingredient is used in commercial food processing and homecooking and baking to improve the protein content of foods and beverages, bring moisture to baked goods, and supply the backbone for some soymilks and texturized vegetable proteins. Used in combination with other grains, soy flour often improves taste and reduces the fat that is absorbed in some fried foods. It there are soy allergies, corn flour may be substituted in some recipes. 39a. Oat Waffles Ingredients: Nonfat cooking spray 3 cups water 6 pitted dates 1 teaspoon vanilla extract 1 /2 teaspoon salt 1 /2 teaspoon ground cinnamon 1 /4 teaspoon ground nutmeg 2 cups rolled oats 1 1 cup rolled oats 1/3 cup soy flour Instructions: 1. Prepare electric or conventional waffle maker with nonfat cooking spray; heat per instructions. 2. Place water, pitted dates, vanilla extract, salt, cinnamon, and nutmeg into bowl of blender or food processor; blend until smooth. 3. Add 2 cups of rolled oats and soy flour; blend until smooth. 4. Pour mixture into large bowl; stir in 1 cup rolled oats. 5. Let mixture sit about 5 minutes. 6. Pour 1 cup waffle batter into hot waffle maker; cook about 21/2 minutes, or until browned and waffle pulls away from the wells of the waffle maker. 7. Transfer waffles to wire rack set on a baking sheet and keep warm in oven. 8. Top waffles with Berry Compote With Lemon and Ginger (recipe follows). 9. Serve immediately with any additional sauce alongside. Yield and Serving Size: Makes 4 (7- to 8-inch square) waffles, each Nutrient Analysis: 362.39 calories, 9.64% calories from fat, 3.88 g total fat, 0.78 g saturated fat, 0 mg cholesterol, 72.77 g carbohydrates, 10.44 g fiber, 12.35 g protein, 5.55 mg sodium Nutrient Modifications: • To lower calories and carbohydrates: Use 1/2 cup of waffle batter per waffle. 39b. Berry Compote With Lemon and Ginger (for Oat Waffles) Ingredients: 1 pound bag fresh-frozen mixed berries 2 tablespoons turbinado or light brown sugar (or equivalent sugar substitute) 1 teaspoon grated lemon zest (or 1/2 teaspoon lemon extract) 1 teaspoon minced fresh ginger (or pinch ground ginger) Instructions: 1. Combine frozen mixed berries, sugar or sugar substitute, lemon zest and fresh or ground ginger in medium saucepan. 2. Cook over medium heat; stir occasionally until berries soften, release their juice, and mixture slightly thickens (about 10 minutes). Serve with Oat Waffles (as directed in above recipe). Yield and Serving Size: Makes 2 cups, 16 (2-tablespoon) servings, each Nutrient Analysis: 156.00 calories, 5.77% calories from fat, 1 g total fat, 0 g saturated fat, 0 mg cholesterol, 37.90 g carbohydrates, 13.02 g fiber, 0 g protein, 0.005 mg sodium

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Nutrient Modifications: • None necessary. • Since this compote is high in fiber, if calories and carbohydrates are not issues, then Berry Compote With Lemon and Ginger is a higher fiber, lower fat topping than some butters or whipped creams—typical waffle toppings. Substitute Ingredients: Corn flour may replace soy flour, but with fewer nutrients. In general the substitution is a scant cup of finely ground corn flour for each 3/4 cup of soy flour, or about a 1:1 ratio of coarsely ground cornmeal to soy flour. In this recipe for Oat Waffles and Berry Compote With Lemon and Ginger slightly more than 1/3 cup of corn flour may be needed to replace the soy flour. The batter may need adjusting with either more corn flour or water. Other spices may be used, such as allspice or Pumpkin Pie Spice, or for a savory twist, herbs such as parsley, rosemary or tarragon may be incorporated. Optional Ingredients: The Berry Compote With Lemon and Ginger may be made with just one type of berry, or with fresh-frozen mangoes, nectarines or peaches. The remaining compote ingredients might remain the same. This tasty compote could also be used on crepes, muffins, pancakes or toast. Low-fat chicken or turkey sausages can be diced and added to this mixture, or served alongside the waffles. A sprinkling of shredded cheese, such as smoked Gouda, may add another creamy and smoky dimension to these waffles, with or without the compote. Why Waffles? Foods that are easily eaten by hand are convenient and often preferred by some aging people who no longer care to cut their food. Plus, the small indentations in waffles capture many toppings, such as the Berry Compote With Lemon and Ginger, if used sparingly. The waffle square can also be transformed into a meal-in-one. Consider melting a slice of cheese over the waffle square, or adding a piece of lean ham or turkey for an open-faced sandwich, or placing a second waffle square on top. A tasty spread, such as reduced-fat wasabi mayonnaise or a little of the compote, will help to transform these simple waffles into fuller meals. 40. Whole-Grain French Toast With Pears in Red Wine Category: Breakfasts Prep Time: 45 minutes (including the red wine sauce) Technique: Browning Equipment: Range, medium saucepan, large-lipped bowl or baking dish, nonstick saute´ pan and large serving platter

PHOTO: Whole-Grain French Toast With Pears in Red Wine. r 2019 Grace Natoli Sheldon. Reprinted with permission.

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Description: From an economical standpoint, the use of leftover bread, eggs, and ripe fruit makes sense to help to avoid food waste. From a nutritional standpoint, the use of whole-grain bread, protein-rich eggs, and spiced fruit lifts both nutrients and flavor. Whole-Grain French Toast With Pears in Red Wine can be consumed to start the day or throughout it, depending on one’s attitude about wine consumption. Grape juice may replace the wine, and honey or agave nectar may be used instead of the granulated sugar with similar results. Canadian bacon or low-fat sausage may raise the protein and expand this dish into a fuller meal if desired. Basic Tastes: The use of whole-grain bread adds earthiness that opposes the sweetness of the Pears in Red Wine sauce. Red wine is colorful, acidic and sweet, and also filled with the umami taste. For a sauce that is both lighter in appearance and taste, white wine or white grape juice may be used. Even reduced-fat half-and-half supplies creaminess and a vehicle for the spiciness of the cloves, ginger and ground cinnamon. Featured Ingredient: Red Wine Red wine is used in this recipe for its ruby-red appearance, full-bodied fruit flavor and nutritional benefits. Red wine contains aromas, color pigments, resveratrol (a polyphenol that is thought to act like an antioxidant), procyanidins and other plant compounds. Polyphenols are found in the seeds and skins of grapes and are highest in concentrations when wine is young. Resveratrol is a polyphenol that is thought to act like an antioxidant and protect the body against cellular damage. Procyanidins are antioxidant-rich polyphenols that may inhibit cholesterol plaque in blood vessels. The procyanidin and resveratrol content of red wine are linked with its reputation for heart health. Petite Sirah has one of the greatest concentrations of procyanidins. Ingredients: 1 cup red wine, such as Petite Sirah 1/3 cup plus 2 tablespoons granulated sugar 3 (about 11/2 pounds) firm pears such as Bosc, halved, pitted and sliced 2 large eggs 1 cup reduced-fat or fat-free half-and-half 1/8 teaspoon salt 1 /2 teaspoon ground cinnamon 1 /2 teaspoon ground ginger 1 /4 teaspoon ground cloves 6 slices whole-grain bread, halved 2 tablespoons unsalted butter Coarsely ground black pepper for garnish, if desired Instructions: 1. Add red wine and 1/3 cup sugar to medium saucepan; cook over medium heat about 10 minutes, or until slightly syrupy. 2. Remove saucepan from heat; add pears and stir to coat. 3. Mix eggs, half-and-half, remaining 2 tablespoons of sugar, salt, cinnamon, ginger, and cloves in a large-lipped bowl or baking dish. 4. Place each whole-grain bread half into bowl or baking dish until it soaks up egg mixture. Turn and repeat until all egg mixture is absorbed. 5. Put one tablespoon of butter in a large nonstick saute´ pan, swirl and heat over medium heat. 6. Add bread halves to bottom of saute´ pan without overlapping or crowding; brown until golden, about 2 3 minutes per side. Repeat with the remaining bread halves. 7. Remove browned bread halves to large serving platter; keep warm. 8. Plate Whole-Grain French Toast and top with Pears in Red Wine; garnish with freshly ground black pepper, if desired. Yield and Serving size: Makes 6 (1-slice bread) servings, each with about 1 2 tablespoons of Pears in Red Wine Nutrient Analysis: 312.46 calories, 18.75% calories from fat, 6.51 g total fat, 2.84 g saturated fat, 80.33 mg cholesterol, 49.7 g carbohydrates, 5.71 g fiber, 6.99 g protein, 217.86 mg sodium

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Nutrient Modifications: • To lower calories, total fat, carbohydrates and sodium: Reduce the portion to 1/2 of a slice of Whole-Grain French Toast and 1 tablespoon of Pears in Red Wine sauce. Substitute Ingredients: For those who need to cut back cholesterol consumption, egg whites may be used. Substitute two egg whites or 1/4 cup egg substitute for one whole egg. Commercial egg whites may be higher in sodium, so salt may need to be reduced in this recipe. Demerara with its toffee flavor, turbinado sugar with some natural molasses and caramel flavor, or brown sugar may replace the granulated sugar, if desired. So may agave nectar (produced from the agave plant), honey or maple syrup, but in lesser amounts since they tend to be more concentrated. Use about two-thirds cup of agave nectar for every one cup of granulated sugar that is called for in a recipe. Optional Ingredients: If chewing is not a problem then chopped nuts, such as toasted almonds, hazelnuts, or walnuts or may be added over the Pears in Red Wine sauce before serving. Also, if calories are not an issue, then a delectable finish might be a dollop of lowfat ricotta cheese or unsweetened whipped cream. The sweetness and creaminess of these dairy products deliver yet another flavor dimension. Why Bosc Pears? If a pear with a more firm and dense flesh is desired for eating out of hand or for recipe inclusion, then Bosc pears are the variety of choice. Bosc pears are ideal for baking, broiling or poaching because they tend to retain their shape and texture more than some other pear varieties. The flavor of Bosc pears tends to hold its own against more assertive flavors such as cinnamon, cloves or nutmeg, like the strong spices in this recipe. On their own, Bosc pears should be consumed at room temperature since their flavor may be better conveyed. The creamy, off-white flesh may then emit an intense honeyed aroma. FINISHING TOUCHES: Dressings, Marinades, Sauces and Relishes to Increase Palatability 1. 2. 3. 4. 5.

Chunky Garlic Salad Dressing Just Enough Bleu Salad Dressing Honey-Mustard Sauce Tomato-Carrot Relish Herb and Lemon Blend for Marinades 1 Basic Vinaigrette Salad Dressing and Herb and Lemon Blend Ranch Dressing

DRESSINGS AND MARINADES Dressings are considered as flavorful sauces that “dress” salad greens and vegetables, and perk interest in eating what lies underneath. Examples of salad dressings include Chunky Garlic Salad Dressing and Just Enough Bleu Salad Dressing (recipes follow). Marinades are also sauces in which fish, meats, poultry, vegetables and other foods are placed into the marinade ingredients to flavor and moisten. Both dressings and marinades typically contain very flavorful ingredients such as herbs, juices, oil, spices and/or vinegars that may cause salivation, help ready foods for digestion, and make harder-to eat foods easier to consume. Examples of marinades include commercial or homemade Balsamic, Teriyaki and/or Jamaican Jerk. The Herb and Lemon Blend that follows in this section can be used in a marinade in combination with acidic ingredients such as citrus juice, tomatoes, vinegar, yogurt and/or wine; along with ingredients that add salty, spicy or sweet notes, such as chili peppers, Dijon mustard and/or honey; with umami-rich soy sauce; and as an accent to fresh herbs, such as basil, parsley and/or thyme, or flowering plants, such as garlic or ginger. SAUCES AND RELISHES Sauces are thick liquids that are usually served with foods; they may add flavor and palatability to dishes, become integral parts of certain dishes themselves, and can be used as condiments. Examples of sauces include be´chamel, a milk-based sauce and hollandaise, an emulsion of butter, egg yolk and lemon or vinegar and Honey-Mustard Sauce (recipe follows in this section). Relishes are condiments that are cooked or pickled, and are often made of chopped or minced fruits, herbs, spices and/or vegetables. Relishes provide texture and bursts of flavor to plain foods to help prevent boredom. Examples of relishes include chutneys, jams, pickle relish and Tomato-Carrot Relish (recipe follows in this section).

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41. Chunky Garlic Salad Dressing Category: Finishing Touches Prep Time: 10 15 minutes Techniques: Blending/combining Equipment: Small bowl, container, refrigerator

PHOTO: Chunky Garlic Salad Dressing. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: The pungency of garlic has the capacity to add vitality to plain foods and perk up tastes. Garlic acts as a flavor catalyst. One of its functions in a recipe is to blend with a flavor and ignite a change in it. When garlic is paired with lemon, then it serves to make a lemon taste lemonier. In Chunky Garlic Salad Dressing fresh garlic accomplishes this burst of lemony taste and more—it creates a fresh and lively accompaniment for simple salad greens, fresh vegetables or even fish, poultry or meats. Basic Tastes: Garlic is both oily and pungent. In Chunky Garlic Salad Dressing, garlic evens the sourness of the yogurt and enlivens the blandness of the cucumber. Fresh garlic also melds with the onion powder and is tempered by the apple juice concentrate. More garlic or hot pepper sauce may be added if one’s taste requires an even greater “bite.” Featured Ingredient: Slicer Cucumbers Cucumbers are plants in the gourd family. Slicer cucumbers are consumed in their unripe green form. Some slicers are long, smooth and uniform in color with tough outer skin that sometimes requires peeling. Pickling cucumbers are grown for pickling with brine, herbs, sugar, spices and vinegar. Picklers are generally bumpier, more irregular, shorter and thicker than slicers. Gherkins (also known as baby dills, baby pickles or cornichons) are smaller than picklers and may also be pickled—mostly in a vinegar medium. Burpless cucumbers are sweeter with thinner skin than other cucumber varieties and may be easier to digest. Ingredients: 1 /2 cup plain, low-fat yogurt 1 /2 large cucumber peeled, seeded and grated (about 1/2 cup) 1 tablespoon apple juice concentrate 1 /2 teaspoon onion powder 1 clove garlic, minced (or 1/4 teaspoon garlic powder) 1 tablespoon lemon juice 1 /2 teaspoon salt 1 /4 teaspoon freshly ground pepper 3 dashes hot pepper sauce, if desired Instructions: 1. Combine all ingredients in a small bowl and mix well. Add hot sauce, if desired. 2. Pour into container; cover and refrigerate until use. 3. Serve over salad greens, cooked or fresh vegetables, or cooked fish, poultry or meats.

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Yield and Serving Size: Makes about 1 cup dressing, 8 (2-tablespoon) servings, each Nutrient Analysis: 146.96 calories, 1.53% calories from fat, 0.25 g total fat, 0.05 g saturated fat, 0 mg cholesterol, 24.85 g carbohydrates, 0.96 g fiber, 13.46 g protein, 57.25 mg sodium Nutrient Modifications: • None necessary. • To lower calories, use 1 tablespoon of Chunky Garlic Salad Dressing. Substitute Ingredients: The aroma and flavor of cucumbers range from mild melon-like to slightly bitter. English, Japanese or Persian cucumbers may be substituted for the standard US varieties with somewhat different aromas, tastes and textures. Young zucchini even looks like cucumbers and may make a decent substitute. If zucchini squash is to replace the cucumber, then retain the skin if it is tender. Celery would provide a similar crunch though different taste. Best to remove some of its fibrous exterior. Green beans and honeydew melon have a similar taste as cucumber, as does the herb borage. The textures, however, make a difference. Optional Ingredients: Any of the aforementioned cucumber substitutes could be added to enhance the flavor of Chunky Garlic Salad Dressing. For example, borage or celery leaves can be chopped and blended into the mixture. Likewise, about 1/4 teaspoon of celery seeds would further impart a celery-like taste. Dried dill contributes an anise-like taste and fresh, chopped dill adds a mildly sharp, green taste. Chopped scallions may advance the onion bite. Why Apple Juice Concentrate? Undiluted fruit juice concentrates, such as apple or grape, have the majority of their water removed from the fruit juice. They are used to add color, flavor and concentrated natural fruit sweetness with relatively few calories to beverages, candies, desserts, frozen novelties, fruit snacks, jams, jellies, sauces and other beverages and foods. Fruit juice concentrates keep well in the freezer. A little can be used at a time, then the container may be resealed for future use. White grape juice concentrate can be used in place of apple juice concentrate. Cranberry, orange and strawberry will add additional color and flavor and may not be as easily swapped. 42. Just Enough Bleu Salad Dressing Category: Finishing Touches Prep Time: 5 minutes Technique: Blending Equipment: Blender or food processor, container, refrigerator Description: Bleu and Roquefort cheeses are aged and highly flavored. Both types of cheese are naturally high in natural glutamates, amino acids that are responsible for a savory taste. Just a little bit of one of these cheeses delivers maximum impact. The other low-fat ingredients in this recipe serve to moderate the calories and the fat. Use Just Enough Bleu Salad Dressing on plain salad greens, such as Bibb or Boston lettuce, to bring out their flavor, or on or bitter salad greens, such as arugula or kale, to help temper it. This dressing is also quite flavorful on starchy, sweet foods, such as baked or mashed potatoes instead of the requisite sour cream that is often served as an accompaniment. Basic Tastes: The opposing flavors in this recipe highlight each other as they simultaneously contrast with each other: acidic (buttermilk and white wine vinegar); salty (Bleu cheese and cottage cheese); and savory (Bleu cheese and white wine vinegar). Freshly ground pepper adds a sharp and peppery bite. Featured Ingredient: Bleu Cheese The flavor of Bleu (also known as Blue) cheese is imparted by the mold Penicillium. Bleu cheese has a distinctive aroma and taste and a characteristic appearance with its blue or blue-gray mold that creates a spotted or veined look. Bleu cheese may be consumed “as is” or crumbled, melted, or spread over other foods. It is a source of protein, vitamin B12, calcium and phosphorus, but Bleu cheese is higher in calories and fat than some cheeses of its kind, with 98.8 calories and 8.0 grams of fat per one ounce. The use of reduced-fat Bleu cheese, or a blend of Bleu cheese with reduced-fat feta cheese may help to reduce some of these calories and fat. Bleu cheese or other cheese of this nature should be labeled “made with pasteurized milk” to help thwart some allergies and/or foodborne illnesses.

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Ingredients: 1 cup low-fat cottage cheese 1 /2 cup low-fat buttermilk 2 tablespoons white wine vinegar 2 ounces Bleu cheese made with pasteurized milk 1 /4 teaspoon freshly ground pepper 1 /4 teaspoon onion powder 1 /4 teaspoon garlic powder Instructions: 1. 2. 3. 4.

Place all dressing ingredients in container of a blender or bowl of a food processor. Cover and blend or process until smooth. Pour into a container; cover and refrigerate to blend flavors. Use over salad greens, fresh or cooked vegetables or simply cooked fish, poultry or meats. Yield and Serving Size: Makes about 11/2 cups dressing, 12 (2-tablespoon servings), each

Nutrient Analysis: 36.72 calories, 41.91% calories from fat, 1.71 g total fat, 1.08 g saturated fat, 5.08 mg cholesterol, 1.51 g carbohydrates, 0.06 g fiber, 3.81 g protein, 150.62 mg sodium Nutrient Modifications: • None necessary. • To reduce sodium, use 1 tablespoon of Just Enough Bleu Salad Dressing. Substitute Ingredients: Gorgonzola, Roquefort or Stilton cheeses are the most common substitutes for Bleu cheese since they are similar in both taste and texture. The texture of some types of feta cheese may similar to some types of Bleu cheese—particularly when crumbled. Goat cheese (che`vre) also produces an interesting alternate. Sour cream or yogurt when thinned with a little milk may be substituted for the buttermilk. Or one tablespoon of lemon juice or vinegar may be added to a scant cup of dairy milk to replace the buttermilk in taste. Optional Ingredients: Chopped chives or scallions will add additional color, texture, and zest. They may be added before or after processing. If they are added during processing, then the dressing may be tinted green. Chopped or minced fresh basil, Italian parsley, oregano, sage or thyme may also contribute supplementary color, taste and texture. Dried herbs, such as any of the aforementioned fresh herbs in dried forms, may impart slightly different tastes and textures. They tend to work best when they are added during preparation with additional time to soften and permeate the dressing. Why Buttermilk? Buttermilk was a fashionable drink in Europe throughout the Middle Ages for its beautification and health-enhancing properties. Today, cultured buttermilk is consumed as a healthful alternative to standard milk because it is slightly fermented, which makes it somewhat easier to digest. Buttermilk has a mildly sour taste that is complemented by the natural glutamates in the Bleu cheese and the creaminess of the cottage cheese. Skip the buttermilk and a taste dimension may be unexploited. 43. Honey-Mustard Sauce Category: Finishing Touches Prep Time: 10 minutes Techniques: Blending/mixing Equipment: Small bowl, container, refrigerator Description: This tasty Honey-Mustard Sauce combines the pungency of mustard offset by the sweetness of honey. The yogurt offers a piquant freshness. This sauce is flavorful on grilled meats or poultry, and also functions well when it is paired with bitter vegetables, such as broccoli or Brussels sprouts or on potatoes as an alternative to butter, margarine or sour cream. The blandness and sweetness of fresh or cooked fish and seafood also provide a compatible pairing. Sturdy fish such as cod, haddock or salmon may hold up better against this robust sauce—more so than delicate fish such as bass, flounder or orange roughy.

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Basic Tastes: Opposite flavors in this sauce serve to cut and balance the total flavor: sweet/sour (honey/vinegar), sweet/salty (honey/ mustard), sweet/spicy (honey/pepper). The compound sinigrin, a glucosinolate (a natural component of pungent plants such as cabbage, horseradish and mustard), is responsible for the pungency of mustard. Featured Ingredient: Honey Mustard Honey mustard is a handy condiment because it is low in calories (about 31 calories per tablespoon), while it is filled with flavor that includes the sweetness of honey with the tanginess of mustard seeds. Though higher in sodium (135 milligrams of sodium per tablespoon), honey mustard is also a versatile ingredient, since so little is needed to supply the sweet, salty and tangy honey-mustard flavor. Acidic ingredients such as vinegar are added to honey mustard to maintain this piquancy. Ingredients: 1 /4 cup honey mustard 1/8 cup white wine vinegar 1 /4 cup plain, low-fat Greek yogurt 1 tablespoon dried dill weed 1 tablespoon honey 1 /2 teaspoon salt 1/3 teaspoon freshly ground pepper Instructions: 1. Mix all ingredients in a small bowl. Use just enough honey to balance the other ingredients. (Due to the use of honey mustard, less honey may be needed.) 2. Pour into a container; cover, refrigerate. 3. Use on grilled fish, meats or poultry or on cooked or fresh vegetables. Yield and Serving Size: Makes about 2/3 cup sauce, 1 (1-tablespoon) serving, each Nutrient Analysis: 24.27 calories, 20.77% calories from fat, 0.56 g total fat, 0.11 g saturated fat, 0.65 mg cholesterol, 4.83 g carbohydrates, 0.20 g fiber, 0.88 g protein, 163.12 mg sodium Nutrient Modifications: • While this recipe is higher in sodium per serving, 1 Tablespoon of Honey-Mustard Sauce may be balanced by serving with: • lower sodium vegetables (such as asparagus, broccoli, carrots, cucumbers, eggplant or summer squash), and/or • fresh fin fish (such as catfish, cod, flounder, haddock halibut, perch, red snapper, salmon, tuna or whiting). Substitute Ingredients: Other types of mustard, such as Spicy Brown, English or German may be substituted for honey mustard, but the amount of honey may need to be adjusted to counterbalance their strength. Yellow mustard may make this sauce more yellow in appearance. This may be fine, since it may also convey the nature of this Honey-Mustard Sauce. Similarly, other varieties of vinegar may be used, such as apple cider, champagne, sherry or white wine—most with slightly differing effects on the final appearance and flavor of this recipe Optional Ingredients: Chopped chives or scallions can be used to add color and piquancy to Honey-Mustard Sauce. Herbs such as basil or rosemary may also handle its assertiveness. Minced garlic may add additional taste and pungency. The addition of a fatty ingredient, such as mayonnaise or olive oil, will serve to round the acidic and tangy tastes and create a more unified flavor and texture. Why Honey? Honey is sugary nectar that is prized around the world in folk medicine, and for its tasteful and potentially healthful qualities. The flavor of honey is volatile and easily destroyed by heating, so it is best used in cold preparations. One tablespoon of honey supplies about 64 calories and 17 grams of carbohydrates. Honey tends to darken foods because its sugars caramelize. But these sugars also attract water that moistens food and makes it easier to digest. It also helps in food preservation: Due to its acidic nature, few bacteria and micro-organisms may be able to survive in its environment.

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44. Tomato-Carrot Relish Category: Finishing Touches Prep Time: 1 hour, including cooking time Techniques: Saute´ing, simmering Equipment: Nonstick saute´ pan, range

PHOTO: Tomato-Carrot Relish. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Botanically speaking, tomatoes are berries. Tomatoes are pulpy and contain seeds and exist as fruits of the vine. Similar to some of their seed-bearing cousins, tomatoes have been present since 200 AD when Egyptians valued posterity (thus, their interest in seeds). Coincidentally, tomatoes are excellent sources of vitamins A and C, important antioxidants that help to defend the body’s cells from disease and promote health and longevity. Tomatoes are particularly high in lycopene, a bright-red carotene and carotenoid pigment that has been linked with decreased risk of digestive tract and prostate cancers. Coupled with carrots, another vegetable known for its vitamin A content (1 medium carrot supplies about 203% of the Daily Value for vitamin A), Tomato-Carrot Relish is appetizing on its own as a side dish, or as a flavorful, nutritious topping on cooked fish, meats or poultry. Basic Tastes: Each herb is important in this recipe because it builds upon the others. In a pinch, commercial Italian Seasoning may suffice for the oregano, basil and thyme. Onion and garlic contribute their powerful punch, along with tomatoes with their five basic tastes (acidic, basic, salty, sweet and umami), and the addition of bay leaf with its bitter and pungent taste and aroma, which is unique and noticeable. Featured Ingredient: Bay Leaves Bay leaves are in the same botanical family as avocado, cinnamon and sassafras. They are the aromatic leaves of bay laurel that are used for their inimitable flavor and fragrance in braises, meats, paˆte´s, puddings, sauces, seafood, soups, stews and vegetable dishes that are common in Brazilian and Mediterranean cuisines. When young, the bay leaves smell and taste fresh and mild. As bay leaves age, their fuller flavor develops that tends to be more floral and herbal, and approaches the characteristics of the herbs oregano and thyme. Globally, bay leaves are used in Indian and Pakistani biryani and in the ground spice mixture Garam Masala. Bay leaves are used whole in French cuisine in bouquet garni, a small bundle of herbs that are mainly used to prepare casseroles, soups, stews and stocks, and in court-bouillon, a flavored liquid generally used for cooking eggs, seafood or vegetables. California bay leaves are much heartier than European bay leaves and may be best used in equally substantial aromatic dishes. Whole bay leaves are nonedible, so they should be remove before serving. Even crumbled bay leaves may cause some chewing and swallowing problems since they often do not soften like some herbs. It is best to remove them before eating.

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Ingredients: 1 tablespoon olive oil 1 /2 medium yellow onion, peeled and chopped 1 clove garlic, minced 4 medium tomatoes, diced 1 bay leaf 1 medium carrot, peeled and diced 1 /2 teaspoon dried basil 1 /2 teaspoon dried oregano 1 /2 teaspoon dried thyme 1 /2 teaspoon salt 1 /2 teaspoon black pepper Instructions: 1. 2. 3. 4. 5. 6.

Pour the olive oil into a nonstick saute´ pan and heat over medium heat. Add onion and garlic; saute´ until softened, about 3 5 minutes. Add diced tomatoes, bay leaf, diced carrot, basil, oregano, thyme and black pepper; stir to blend. Simmer mixture, uncovered about 20 30 minutes, stirring occasionally. Tomato-Carrot Relish should be slightly thick, but juicy at this point. Remove bay leaf. Use immediately alongside or on top of grilled fish, poultry, meats or vegetables, or spoon into a container; cover and refrigerate. Yield and Serving Size: Makes about 1 cup sauce, 2 (1-tablespoon) servings, each

Nutrient Analysis: 33.30 calories, 50% calories from fat, 1.85 g total fat, 0.26 g saturated fat, 0 mg cholesterol, 4.10 g carbohydrates, 0.45 g fiber, 0.75 g protein, 154.17 mg sodium Nutrient Modifications: • None necessary. • While half of the calories are from fat, this only amounts to one tablespoon of olive oil, which gives TomatoCarrot Relish its rounded flavor. Substitute Ingredients: Beets, celery, daikon, parsnip, sweet bell pepper, and/or squash may be used as a substitute for carrots, or in combination. For comparison and ease in substitution, one medium carrot is the equivalent of about 1/2 cup sliced. Other herbs, such as marjoram, parsley, rosemary, sage and/or savory may be substituted for the basil, oregano and/or thyme. It may best to try an herbal blend first before replacing the herbs in this recipe, or do so individually depending upon preference. Optional Ingredients: Finely chopped chili peppers or dill pickles may add acidity, color, heat, and tang to this Tomato-Carrot Relish. Chopped sundried tomatoes may add a deep umaminess and fuller flavor dimension. Any of these ingredients can be added before cooking the relish, or afterward to impact taste and texture by either cooked or fresh ingredients. Why Carrots? Carrots are root vegetables that appear in familiar orange, and less familiar black, purple, red, white and yellow shades. Most varieties of carrots contain valuable antioxidants including carotenoids, hydroxycinnamic acids and anthocyanins with their cardiovascular and cancer protective benefits. Heat may damage some of the phytonutrients; however, beta-carotene (a carotenoid) may be heat-stable. Carrots belong to the same family as caraway, celery, coriander, cumin, dill, fennel and parsley. This may be why dishes that include combinations of these ingredients may taste so pleasing. 45. Herb and Lemon Blend for Marinades Category: Breakfasts Prep Time: Less than 5 minutes Techniques: Blending/combining Equipment: Small bowl, container

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PHOTO: Herb and Lemon Blend for Marinades. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Description: Most people may benefit by a reduction in their sodium intake, since salt is in so many of the foods that we consume. Many salt substitutes vary in flavor and especially in their constituents, some of which may ultimately affect the balance of bodily fluids. For example, some salt substitutes are higher in potassium and the ratio of sodium and potassium in the body should be in balance. Herb and Lemon Blend for Marinades is both flavorful and versatile without consciously tipping this balance. One may want to start with half of the amount of salt and half of the amount of Herb and Lemon Blend for Marinades until the most flavorful combination is reached. Or this herbal blend may be added to a recipe in addition to salt to heighten flavor even more. Basic Tastes: This herbal blend mixes pungent garlic powder with bitter and spicy allspice, basil, black pepper and thyme, and is brightened by lemon and parsley in order to achieve complex flavor and character. The fresher the herbs and spices the better. The main culprits that affect the potency of fresh herbs include heat, moisture, oxygen, sunlight and time. In general, whole herbs may last longer than dried or ground forms. Herbs should be fully dry in airtight containers, out of direct sunlight, and in a cool location for maximum taste and efficacy. Featured Ingredient: Thyme Thyme is an aromatic evergreen herb that is a relative of the mint family. It is used in culinary, medicinal and ornamental applications. In Mediterranean and especially in Italian and Provenc¸al French cuisines, thyme is used in sauces, soups, stews and stock—alone or alongside herbs such as bay leaf, oregano, marjoram, parsley and/or rosemary. The two main types of thyme that are used in cooking and baking include common thyme and lemon thyme, with their highly aromatic, mildly pungent and subtly sweet flavors. Lemon thyme is decidedly more citrusy in flavor and may have more diverse applications. Ingredients: 2 teaspoons dried parsley flakes Zest from 1/2 of a fresh lemon 1 /2 teaspoon garlic powder 1 /2 teaspoon dried basil 1 /2 teaspoon dried thyme 1 /4 teaspoon allspice 1 /4 teaspoon black pepper

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Instructions: 1. Combine all ingredients in a small bowl. 2. Place into a container; cover and store in a cool, dark place. 3. Use to rub on fish, poultry or meats before baking or broiling, or in salad dressings such as Basic Vinaigrette Salad Dressing or Herb and Lemon Blend Ranch Dressing (that follow in this section). Yield and Serving Size: 4 tablespoons, 1 (1-tablespoon) serving, each Nutrient Analysis: 3.94 calories, 11.42% calories from fat, 0.05 g total fat, 0.02 g saturated fat, 0 mg cholesterol, 0.95 g carbohydrates, 0.40 g fiber, 0.21 g protein, 1.71 mg sodium Nutrient Modifications: • None necessary. Substitute Ingredients: The beauty of using allspice is that it already is a spice mixture. Cinnamon, cloves, cardamom, coriander, mace, mustard seeds, nutmeg, red pepper and/or star anise may replace the allspice. By using just one of these ground spices, then the fullness of the allspice blend may be sacrificed. Orange or lime peel as opposed to lemon zest may take the flavor into a different direction and be perceived as more tropical in flavor notes. Optional Ingredients: Interesting additions to herb and spice blends are seeds with their aroma, taste and texture—particularly when they are lightly toasted. This seed herb spice combination may be especially flavorsome in dry rubs for fish, meats, poultry and/or vegetables to help lock in their flavor and moisture and to decrease the need for additional fats or oils. Make sure that these seed herb spice coatings are chewed especially well. People with mastication problems or gastrointestinal issues, such as diverticular disease, may not be able to tolerate the addition of seeds or touch herbs or spices in blends or coatings. Why Allspice? Allspice is mainly cultivated in Jamaica where its taste plays an important impact in Jamaican cuisine. Allspice was bestowed with its name by Spanish explorers who thought that it resembled a cross between peppercorns and berries. The flavor of allspice actually does resemble a mixture of other spices: usually black pepper, cinnamon, cloves and nutmeg. While allspice may add depth to herb blends, such as Herb and Lemon Blend for Marinades, because it is an amalgam of spices it can easily stand its own. The aroma and flavor of allspice are a result of its exotic, natural sweet spicy oil. 45a. Basic Vinaigrette Salad Dressing With Herb and Lemon Blend Category: Finishing Touches Prep Time: 5 minutes Technique: Emulsifying Equipment: Whisk, medium bowl, container, refrigerator

PHOTO: Herb and Lemon Blend Ranch Dressing and Basic Vinaigrette Salad Dressing With Herb and Lemon Blend. r 2019 Grace Natoli Sheldon. Reprinted with permission.

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Description: A simple vinaigrette, such as Basic Vinaigrette Salad Dressing With Herb and Lemon Blend, is a staple salad dressing that can remain refrigerated as needed for salads and vegetables. Many of the bottle salad dressings that are shelf stable have sodium and preservatives that may raise daily sodium intake, and be contraindicated for certain conditions or diseases. This vinaigrette is delicious, economical, simple and pretty universal in preference. Basic Tastes: The balsamic vinegar is filled with acidic and umami tastes; likewise is the Dijon mustard, in addition to its saltiness. Sea salt adds brininess; black pepper contributes pungency; the olive oil adds unctuousness; and the Herb and Lemon Blend for Marinades merges its herbaceous quality. Featured Ingredient: Vinaigrette Vinaigrette is both its own preparation as a salad dressing and an ingredient, as in marinades. While vinaigrette can be prepared with any acidic ingredients, such as citrus juice, tomato juice or vinegar, it is the vinegar that helps to make vinaigrette distinct enhanced by mustard, salt, pepper, herbs, onions or shallots, spices and/or other ingredients. Generally three parts of oil are blended with one part of vinegar, and usually whisked into an emulsion. Mustard also works as an emulsifier. Some vinaigrettes incorporate a small amount of sweetener, such as agave nectar, honey or maple syrup, to help balance the acidity. Ingredients: /4 cup white balsamic vinegar 1 tablespoon Dijon mustard 1/3 cup extra-virgin olive oil 1 /4 teaspoon sea salt 1 /4 teaspoon freshly ground black pepper 1 /2 teaspoon Herb and Lemon Blend for Marinades 1

Instructions: 1. 2. 3. 4. 5.

Whisk balsamic vinegar and Dijon mustard in medium bowl. Slowly drizzle olive oil; continue whisking to incorporate into the vinegar/mustard mixture. Add sea salt, freshly ground black pepper and Herb and Lemon Blend for Marinades; mix thoroughly. Use immediately or refrigerate until use. Whisk or shake dressing in covered container before serving. Yield and Serving Size: Makes 2/3 cup (2-tablespoon) servings, each

Nutrient analysis: 122.83 calories, 90% calories from fat, 12.3 g total fat, 2.05 g saturated fat, 0 mg cholesterol, 2.04 g carbohydrates, 0.02 g fiber, 0.07 g protein, 179.39 mg sodium Nutrient Modifications: • To lower total fat: Use 1 Tablespoon of Basic Vinaigrette Salad Dressing With Herb and Lemon Blend. Substitute ingredients: Try one of these vinegars or flavorful oils in place of Balsamic vinegar or extra-virgin olive oil, respectively. Different tastes will probably prevail. • VINEGARS: Apple cider, champagne, Chinese black, malt, red wine, rice, sherry, tomato or white wine • OILS: Almond, avocado, flaxseed, hazelnut, hemp, peanut, sesame or walnut (canola, corn, grapeseed, safflower and sunflower oils are more neutral in flavor) Optional Ingredients: Since the Herb and Lemon Blend for Marinades is so redolent of lemon and herbs, by adding too many other optional ingredients to this vinaigrette, the overall flavor may be combative. Instead, elevate the lemony taste with some additional lemon zest, and the herb blend with some additional minced fresh herbs, such as parsley or thyme. The total flavor should benefit by the layering of dried and fresh herbs, brightened by the fresh lemon zest. Why Salad Dressing Altogether? In some countries around the world, salad ingredients are consumed on their own, without the additional layer of salad dressings that are often too high in fat and calories. Sometimes just a little quality olive oil and/or a sprinkling

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of sea or Kosher salt are used to help to bring out the flavors of salad greens—and likely to balance some acidity and/or bitterness. In the United States, the use of salad dressings is fairly ubiquitous—sometimes with more salad dressings than salad ingredients. To cut calories and fat while preserving and elevating taste, think less is more: use just enough salad dressing to bring out the natural vitality of fresh salad ingredients without drowning their attributes. 45b. Herb and Lemon Blend Ranch Dressing Category: Finishing Touches Prep Time: 8 minutes Techniques: Blending/combining Equipment: Whisk, medium bowl, container, refrigerator Description: Ranch dressing is a perennial US favorite that is commonly used as salad dressing in its own right to camouflage bitter greens; as a dipping sauce for such raw vegetables such as broccoli, carrots and celery; as an accompaniment for salty and fried snacks, such as chips, chicken wings and French fries; and even as a sandwich spread. This recipe for Herb and Lemon Blend Ranch Dressing is lower in fat and calories thanks to low-fat buttermilk, light mayonnaise and low-fat Greek yogurt without sacrificing taste or popularity. Basic Tastes: The buttermilk contributes acidity and some sweetness; the mayonnaise lends a subtle bitterness that depends on its brand and ingredients. The white wine vinegar and lemon in the Herb and Lemon Blend for Marinades contribute tanginess and freshness. The green scallions offer a little more acidity and pleasant “bite,” balanced by the creamy consistency of the dressing. Key Ingredient: Scallions Scallions (aka green onions, salad onions and spring onions) are members of the Allium onion species. Scallions tend to have a milder taste than some other members, such as garlic, leeks or shallots. Consequentially, scallions are very versatile. They may be cooked or used raw in salads, salsas, and many Asian dishes. When cooked, scallions may be found in curries, noodles, sandwiches, seafood dishes and/or soups. A tempered use of scallions is in scallion oil whereby the green leaves are chopped, lightly cooked and then emulsified in oil, such as olive or walnut. It is generally then used as a finishing oil with its softened oniony flavor and tinge of green coloration. Ingredients: 1 cup low-fat buttermilk 1 /2 cup light mayonnaise 1 /2 cup plain low-fat Greek yogurt 2 teaspoon white wine vinegar 2 medium scallions, minced 1 tablespoon Herb and Lemon Blend for Marinades 3 /4 teaspoon sea salt 1 /2 teaspoon freshly ground black pepper Instructions: 1. Whisk buttermilk, mayonnaise, Greek yogurt, and white wine vinegar in a medium bowl until well blended. 2. Add minced scallions, Herb and Lemon Blend for Marinades and sea salt and freshly ground black pepper; stir to blend. 3. Use immediately or cover and refrigerate for up to 3 days. Yield and Serving Size: Makes 2 cups dressing, 16 (2-tablespoon) servings, each Nutrient Analysis: 29.66 calories, 50.37% calories from fat, 1.66 g total fat, 0.42 g saturated fat, 2.93 mg cholesterol, 2.41 g carbohydrates, 0.07 g fiber, 1.44 g protein, 133.06 mg sodium Nutrient Modifications: • None necessary. • While one-half of the calories are from fat, the total fat, saturated fat and cholesterol content is still low.

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Substitute Ingredients: A flavored mayonnaise, such as black pepper, chive, Dijon, dill, herb, honey mustard, horseradish or sundried tomato, may be substituted for the light mayonnaise. Some of these flavored mayonnaises may also be reduced in fat and/or calories. They may add a different flavor dimension to this Herb and Lemon Blend Ranch Dressing, with few other ingredient changes. One could enhance these types of mayonnaise even further with an additional amount of the ingredient that is highlighted. For example, a chopped sundried tomato may give sundried tomato mayonnaise additional color, punch and texture. Optional Ingredients: The same fresh herbs that are in the Herb and Lemon Blend for Marinades (basil, parsley and/or thyme) may be chopped and added to the dressing before it tops other salad ingredients. Why Refrigerate Only Three Days? Although Herb and Lemon Blend Ranch Dressing is to be refrigerated, due to the dairy products (low-fat buttermilk and plain, low-fat Greek yogurt) and the light mayonnaise, this recipe is considered “perishable,” which means that it is especially likely to decay quickly. While some dairy products, such as yogurt may be able to keep one to 2 weeks refrigerated, once they are combined with other fresh ingredients, such as the scallions in this this recipe, their deterioration time increases. Food safety is such a critical concern for everyone, but especially for the aging. More information about this topic follows in the next section.

LEFTOVERS: PRACTICAL, ECONOMICAL AND TASTEFUL Leftovers, or the repurposing of foods and beverages to help decrease food waste, make economic sense for many diets, particularly for those people who have limited income. Plus, the consumption of leftovers makes environmental sense to help to decrease food waste. Leftovers should not be addressed without a discussion about food safety. Aging adults are at a greater risk for hospitalization and death due to foodborne illness that are mostly due to the physiological changes that are associated with aging. These incorporate changes that affect the gastrointestinal tract, immune system, kidneys, liver, stomach and other bodily systems and organs. Chronic conditions, such as certain cancers and diabetes, may also increase foodborne illness risks.

RISKS OF FOODBORNE ILLNESSES The gastrointestinal tract tends to be more sluggish as people age, which causes food to linger longer in the stomach and intestinal tract and permit bacterial growth. The liver and kidneys may also become compromised during aging, which may cause foreign bacteria and toxins to linger rather than be relatively promptly eliminated. The stomach may not produce enough gastric acid to help reduce bacterial in the intestinal tract, which may actually contribute to increased bacterial growth. The immune system may be slower and less functional to combat foodborne illnesses. This may increase the risks of various illnesses that include simple colds to various type of influenza. Autoimmune disorders may develop whereby the immune system mistakenly attacks and destroys healthy body tissues. The body may heal more slowly with fewer immune cells. And the body’s ability to identify and modify cellular shortcomings may also be compromised with aging. Additionally, food production, distribution and storage trends may also affect the risks of procuring foodborne illnesses. These include more changes from local to international food processing and distribution that may increase exposure to certain pathogens; more meals consumed outside of the home; more convenience foods and complete “meals-to-go”; more hot-and-hold meals and snacks that are purchased from grocery stores, delis and convenience stores; more delivered meals from programs such as Meals on Wheels or from restaurants; and newer, hardier and more invasive pathogens in the environment as a result of food production and handling issues. Symptoms of foodborne illness and their potential impacts may include fever, headache, and/or muscle pain, and be accompanied by abdominal pain, nausea, vomiting and/or bloody or watery stools. In extreme conditions, dehydration, kidney damage, respiratory symptoms and weight loss may also occur. Common foodborne illness pathogens of concern (particularly in people who are aging) include Campylobacter, Clostridium perfringens, Cryptosporidium, Escherichia coli 0157:H7 and E. coli non-0157,

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Listeria monocytogenes, noroviruses and other caliciviruses, Salmonella, Shigella, Toxoplasma gondii, Vibrio vulnificus and Yersinia.

FOODS AND BEVERAGES TO AVOID TO PREVENT FOODBORNE ILLNESSES Foods that are associated with foodborne illness may include contaminated or untreated water; deli salads and/or luncheon meats without preservatives; raw or undercooked meats, poultry or shellfish; raw sprouts (alfalfa, broccoli, clover or radishes); raw or undercooked eggs; soft cheeses that are made with raw milk; some fresh fruits and vegetables and their juices (thoroughly wash before using), and unpasteurized or raw milk. In particular, people who are aging should be cautious of the following beverages, foods and ingredients that are shown in Table 10.1. The origin or source of these beverages, foods, and ingredients, and how they are processed, prepared, and/or stored may also affect the contraction and degree of foodborne illnesses. TABLE 10.1

Foods, Beverages and Ingredients Implicated With Foodborne Illnesses

• Egg products that contain raw or lightly cooked eggs, such as over-easy or sunny-side-up, that may be used in cookie or cake batter, eggnog, homemade ice cream, salad dressings and/or egg-based sauces. • Hot dogs and luncheon meats, unless they are reheated and steaming hot. • Rare ground meats • Raw fin fish and shellfish that include clams, oysters, mussels and scallops, and those that are used in some types of sushi. • Raw sprouts that may include alfalfa, broccoli, clover and radish. • Refrigerated meat spreads or paˆte´s (canned or shelf-stable meat spreads may be consumed). • Refrigerated smoked seafood, unless it is contained in a cooked dish, such as a casserole (canned, smoked seafood may be safely consumed). • Salads that contain homemade salad dressings, such as egg, chicken, potato, turkey or tuna (especially if exposed to temperature over 40 F.). • Soft cheeses that include blue-veined, Brie, Camembert, feta, queso blanco, queso fresco and Panela, unless they are labeled “made with pasteurized milk.”

FOOD SAFETY TIPS FOR PREVENTING FOODBORNE ILLNESS Food safety tips for preventing or curtailing the risks of foodborne illness include these four “Cs”—Clean, Classify, Cook and Chill, as given in Table 10.2. TABLE 10.2

The Four “Cs”—Clean, Classify, Cook and Chill for Foodborne Illness Prevention

• Clean—Keep hands, surfaces, and tools washed and/or sanitized. • Classify—Separate protein foods (such as fish, meats, and poultry) from other ready-to-consume foods (such as dairy products, fruits and vegetables). • Cook—Make certain to cook foods to their safe cooking temperatures: • Eggs and egg dishes—160 F • Fish—145 F • Fresh whole cuts of red meat—145 F • Ground meat—160 F • Pork and ham—145 F • Poultry—165 F In general: Keep hot foods hot (at or above 140 F) and keep cold foods cold (at or below 40 F). • Bring gravies, sauces, soups, and stews to a roiling boil. • Heat leftovers thoroughly to at least 165 F, or until they are hot and steaming. • Put any leftovers into shallow containers for quick cooling. Refrigerate at 40 F or below within 2 hours after using. • Rotate microwaved foods so that they thoroughly are reheated. • Chill—Refrigerate raw foods, such as dairy products, meats and poultry, until they are ready to use. Also refrigerate any leftovers foods quickly once they cool or no later than 2 hours, especially in warmer climates. When in doubt, throw any questionable leftover out [2].

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One function of the Food and Drug Administration Food Code (Chapter 3-603.11) is to advise consumers about the risks of foodborne illnesses. According to this code, restaurants must notify their customers that raw food(s) is/are used in recipes, and if they choose to consume raw or undercooked meats, poultry, seafood, shellfish or eggs that this action may increase their risk of foodborne illnesses. Furthermore, this consumer advisory statement must be posted on brochures, food cases, labels, menus, table tents or other written forms for consumers to read—ideally before consumption.

CREATIVE LEFTOVER CONCEPTS Once the necessary practices to avoid foodborne illnesses have been followed, the creative use of leftovers may be employed to add interest and variety to meals and snacks, create less food waste and save money. These are given in Table 10.3. TABLE 10.3

Creative Use of Leftovers in Healthy Food Preparations

Cooked grains and leftover breadstuffs • Enriched and whole-grain breads: Use dried, cubed and/or crumbed breadstuffs in casseroles, protein coatings, cooked vegetables, bread puddings and/or for croutons. • Enriched and whole-grain brown and white rice: Use rice varieties in casseroles, puddings, soups, salads and stews for enrichment, taste and texture. • Enriched and whole-grain pasta: Use cooked pasta in casseroles, salads, soups and stews for visual interest, satiation and nutrients— especially the B vitamins and fiber. • English muffins, pita bread or tortillas: Use toasted, leftover breads topped with avocado, cheese, herbs and spices or hummus (chickpea spread) for pizza crusts or sandwiches, or to scoop dips and salads. Fresh, fresh-frozen and canned fruits in own juice • Breads and muffins: Use chunky or pureed fruits, such as bananas, blueberries or cranberries, in quick breads and/or muffins. • Cereals: Use chunky or pureed fruits in cooked fruited oatmeal or other whole grains, or atop cold cereals. • Compotes, chutneys or fruit sauces: Use chunky or pureed fruits in savory or sweet accompaniments, such as in applesauce, dried fruit compote or mango chutney. • Pancakes and waffles: Use chunky or pureed fruits, such as apple, banana or blueberry, in pancakes or waffle batter or serve on top of or alongside these familiar breakfast items. • Smoothies: Use pureed fruits, such as banana, mango, mixed berry or tropical fruit, with dairy products, nut “milks” or legume “butters” in blended beverages. • Soups: Use pureed fruits, such as avocado or melon, in cold avocado or melon soups, as a soup course or for dessert. Lean meats and meat substitutes • Casseroles or chili: Use ground beef or tofu with green beans and potatoes for meat or vegetarian “pot pies,” or poultry mixed with legumes, sweet bell peppers, tomatoes and spices for chicken or turkey “pot pies.” • Fillings and stuffings: Use minced roasts, herbs, spices and other flavorful ingredients for burritos, cannelloni, crepes or stuffed vegetables. • Patties: Use cooked fish, vegetables, herbs and spices and eggs in fish cakes or to fill pita bread or wraps. • Salads: Use cooked chicken or turkey, egg or tuna in reduced-fat mayonnaise-based salads or to stuff tomatoes or sweet bell peppers. • Sandwiches: Use sliced beef or poultry or whole pieces of fish with vegetables in-between one or two slices or skinny slices of whole-grain breadstuffs. • Soups, stews, and hearty grain dishes: Use beef broth, saute´ed onions and leftover cheese for French onion soup, or lean beef chunks, carrots and onions overcooked noodles, rice or whole grains [3]. Reduced-fat dairy products • • • • •

Butter: Use in cookies, cakes, piecrusts or shortbread. Buttermilk: Dredge chicken, dress potato salad, incorporate into waffles or marinate meat. Cheese: Melt over potatoes, toast, tortillas or vegetables. Cream: Convert into whipped cream, use in pasta sauce or top fruit desserts. Sour cream or cre`me fraıˆche: Add to soups or stews, enhance cheesecake or puddings, fold into cake batters or frostings or mix with ripe fruits. • Yogurt: Mix into chicken or tuna salad, pesto or salad dressing or blend into beverages. (Continued)

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(Continued)

Vegetables • • • •

Cruciferous vegetables: Use cooked Brussels sprouts, broccoli, cauliflower or kale, marinated or in casseroles, omelets, pastas or soups. Potatoes: Use cooked red, white or yellow potatoes in or on casseroles, salads, soups or stews. Purees: Use cauliflower, mushroom or spinach, or other vegetable purees for thickening sauces, soups or stews or in casseroles. Sauces: Use cooked artichokes, mushrooms or tomatoes, with or without dairy products, starch or fat, to create simple sauces for moistening protein foods and adding nutrients. • Stir fries: Use cooked Asian or root vegetables (see vegetable combinations that follow) for omelets, salads, soups or wraps. • Vegetable combinations: Use cooked Asian vegetables (such as broccoli, pea pods and/or water chestnuts), or root vegetables (such as onions, potatoes and/or winter squash) in gratins, lasagnas, pastas, quiches and/or salads.

MOVING ON: DINING OUT/CARRYING IN Dining Out For relatively healthy and agile aging people, dining out may be customary or a treat. Similar food safety considerations as those practiced at home or in institutional settings should be taken into account. When in doubt, ask about food preparation and “have it your way.” Make sure to read menus for allergens, consumer advisory statements and other disclosures. Though American Association of Retired Persons restaurant deals and senior citizen discounts exist, they may not always guarantee healthy eating options. It may be best to inquire in advance and determine if the menus selections comply with specific dietary needs. To eat out healthfully and safely, older people should follow the guidelines given in Table 10.4. TABLE 10.4

Practical Advice for Eating Out Healthfully and Safely

• Ask questions about food preparation. • Avoid fried foods as much as possible that may be high in fat and calories and/or difficult to digest. • Check menus online, in mailers or other marketing materials. • Choose fruits and vegetables for side dishes before starchy or fatty options. • Consume more calories earlier in the day then when eating out in order to maximize their metabolism and avoid late night indigestion. • Dine early when there is the best light. • Eat slowly and chew food well. • Drink water to moisten food as needed, but not so much as to fill up and prevent other nutritious food consumption. • Plan outings in advance to restaurants and other dining establishments. • Request less fat, salt or sugar where it might be feasible for the kitchen to cut back or out. • Skip the breadbasket: Have bread alongside salads or entre´es to avoid filling up before consuming protein and vegetable-rich courses. • Split portions, take one-half portion back home, and ensure that any leftovers are safely packed. By requesting that one-half portions be packed at the start of a meal, this may help to prevent overeating, plus provide an addition meal for smaller appetites.

Carrying In A similar mindset for dealing with leftover foods that are prepared at home should be exercised for transporting restaurant leftovers back into the home. If restaurant leftovers are to be transported far, then they should be well wrapped and kept either warm or cold depending on their original state. Leftover restaurant meals should never be left in hot environments before they are brought into a home kitchen for eventual consumption. Refer to the previous section on Leftovers: Practical, Economical and Tasteful for specific recommendations.

DIGEST Aging people could “write the book” on what they ate, who they dined with and the constituents of very memorable meals. These meals and comestibles were generally consumed at a time when body systems were operating at their maximum and conditions or diseases were at their minimum.

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The challenges of aging have the potential of affecting all of the body systems, organs and cells as they slow and slough. Addressing these changes by eating and drinking less, differently and more intentionally may help aging people to feel better and thrive. This chapter covered 50 recipes that were categorized into Starters, Soups, Salads, Entre´es, Sides, Desserts, Beverages, Breakfasts and Finishing Touches, with information about safe eating, leftovers and eating out. Each recipe contains information about its basic tastes, featured ingredients, techniques, substitute ingredients, optional ingredients, nutritional analyses and nutrient modifications. Thirty-two finished dishes are captured in color photographs that illustrate the recipe’s appeal, ease and simplicity. Also featured in this chapter was information about Leftovers, Risks of Foodborne Illnesses, Foods and Beverages to Avoid to Prevent Foodborne Illnesses, Food Safety Tips for Preventing Foodborne Illness, Creative Leftover Concepts and Dining Out/Carrying In. While some aging people are in environments where changing tastes and flavor enhancement may be unnoticed or uninformed, this material serves to enlighten aging people, their families, friends and care providers about the phenomenon of chemosensory decline and the tools and techniques to address these changes that represent a cadre of delicious measures.

MANNER OF SPEAKING Be´chamel (White Sauce) Conjugated Linoleic Acid

Food and Drug Administration Food Code (3-603.11) Food Safety Gene Phenylthiocarbamide (PTC) Hollandaise Leftovers Oleic Acid

Piperine Resin Sinigrin

“Mother” sauce of French cuisine; made from a white roux and milk; considered base for other sauces group of chemicals found in the fatty acid linoleic acid; beef and dairy products major sources; associated with enhanced immune function, improved blood sugar regulation, preserved bone mass, reduced inflammation, weight loss and other functions model food code; advises consumers about the risks of foodborne illnesses scientific discipline that involves the handling, preparation and storage of foods to help prevent foodborne illnesses bitter chemical that may also register as tasteless, depending on the genetic makeup of the taster sauce made by an emulsion of egg yolk, melted butter, lemon juice and water; often seasoned with salt and pepper, often white foods and/or beverages that might be leftover from a previous meal or snack naturally occurring, odorless, colorless oil; found in borage oil, canola oil, evening primrose oil, flaxseed oil, grape seed oil, macadamia oil, olive oil (less in virgin olive oil), peanut oil, pecan oil, sea buckthorn oil, sesame oil and sunflower oil; implicated in cancer prevention and cholesterol reduction alkaloid substance responsible for pungency of black and long pepper mixture of organic compounds; exuded from some trees and other plants; component of some black pepper glucosinolate—natural component of pungent plants in the Brassica family, such as cabbage, horseradish and mustard

References [1] Kraft KH, Brown CH, Nabhan GP, Luedeling E, Luna Ruiz JJ, Coppens d’Eeckenbrugge G, et al. Multiple lines of evidence for the origin of domesticated chili pepper, Capsicum annuum, in Mexico. Proc Natl Acad Sci 2013;111(17):6165 70. Available from: https://doi.org/ 10.1073/pnas.1308933111. [2] US Department of Health & Human Services. Food safety for older adults. Foodsafety.gov, ,https://www.foodsafety.gov/risk/olderadults/index.html.; US Department of Agriculture, Food and Drug Administration. Food safety for older adults: a need-to-know guide for those 65 years of age and older. FDA.gov, ,https://www.fda.gov/Food/FoodborneIllnessContaminants/PeopleAtRisk/ucm312705. htm#Eat_home.; 2006; Adamson D. ‘Leftovers’ safety an issue for seniors. Colorado Community Media, ,http://coloradocommunitymedia.com/stories/Leftovers-safety-an-issue-for-seniors,113768.; Thrall L. Safe food for our senior customers. FoodHandler, ,http://www. foodhandler.com/safe-food-for-our-senior-customers/.; 2015. [3] Loving your leftovers. UnlockFood.ca, ,https://www.dietitians.ca/Your-Health/Nutrition-A-Z/Seniors/Cooking-for-One-or-TwoPeople--Creative-Use-of-Lef.aspx.; 2017 [accessed 07.09.18].

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PHOTO: Colored Spoons. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I have a burning sensitivity at the back of my mouth and tongue—so I try to avoid minty toothpaste and mouthwash. G.S.

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Aging, Nutrition and Taste. DOI: https://doi.org/10.1016/B978-0-12-813527-3.00011-9

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Cabinet Hardware and Design Flooring Heating and Cooling Lighting Seating Sinks

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Adjustments of Kitchen Appliances Cooktops, Standard Ranges and Wall Ovens Dishwashers Microwave Ovens Refrigerators and Freezers

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Dining and Living Considerations Environmental Factors Light/Illuminating Factors Sound/Acoustical Factors Touch/Textural Factors Preventing Risks and Injuries

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LEARNING OBJECTIVES 1. Assess different kitchen arrangements and dining conditions to determine which may benefit individuals in home settings. 2. Determine which cooking aids and tableware are useful dependent upon individualized circumstances. 3. Examine limitations for supportive food preparation and tableware that may include emotional, educational, financial, social, type of care and others. 4. Explore techniques for implementing the proper use adaptive cooking aids and tableware. 5. Select the kitchen safety and fire prevention awareness and implementation strategies for aging people.

SUMMARY To collectively provide special attention to address the ease and pleasure of eating and drinking for the aging, with unique tools, concepts and instructions designed for those who need dietary assistance due to behavioral or physical compromises, especially chewing and swallowing, decreased eyesight, reduced manual dexterity and/ or other disabilities.

INTRODUCTION Adjusting a kitchen for aging people who live at home requires some attention to the structures and functions that may commonly be overlooked, such as the appliance levels, handy pantry and at-reach equipment, and

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nonskid surfaces. Smoke detection and fire alarms should be common kitchen appliances, and yet they may be overlooked due to other aging priorities. How to equip a kitchen for aging people who live at home is essential information to learn, implement, evaluate for its effectiveness, and recreate if necessary for kitchen While it may not be imperative to purchase specially designed cooking and baking aids and tableware for the aging, items of this kind may be useful to promote eating and drinking, reinforce confidence and independence and improve mental and physical well-being. As an infant first learns to eat and drink, often those who are aging must relearn these processes, such as after accidents or strokes, during certain conditions and/or throughout specific diseases. Relearning basic eating and drinking skills may be demoralizing and lead to further emotional and behavioral issues that may affect appetite, or the willingness to eat or drink altogether. While the initial outlay of finances, procurement and time that it may take to outfit and prepare a kitchen for the aging may seem daunting, the benefits may overcome the outlay. In this chapter, care is taken to consider these factors and others that may preclude their usage. Furthermore, the identification of items that are particular useful for the aging in relation to cost is noted. Paramount to the dining experience is the environment that includes such factors as equipment, companionship, dinnerware and stemware, furniture, lighting, plating design, sound (music and noises) and the descriptions and language of the meals and settings. Each of these potential influencers will be discussed in context of their changes versus benefits; however, their outcome may be variable based upon individual conditions and other considerations. Kitchen safety and fire prevention are of utmost importance when mobility and chemosensory issues decline. Specially designed equipment aids the aging to help them to function comfortably and safely within their dining and living environments. Even if structural changes are unfeasible, positional changes may be possible. If the sense of smell has diminished in aging people, then the smell of smoke may be compromised. Guidelines are provided for fire prevention to help those who are aging as well as their care providers take guard their environments.

RATIONAL FOR KITCHEN MODIFICATIONS FOR THE AGING Remaining in a family home may place stress and strain on aging people, their adult children and other family members. However, the pleasure and pride that aging people may take in their own surroundings as opposed to care facilities often outweigh any negative concerns. Older adults at a wide range of socio-economic levels may want to stay in their homes as long as possible. But some rooms, such as the kitchen, bedroom and bathroom, may not be equipped to handle their changing needs and often declining capabilities. As the trend to “age in place” continues while the numbers of aging people increase, the dilemma of modifying a kitchen and/or other living space on a limited budget may become pressingly apparent. What follows is a compendium of kitchen modifications that are optimal for aging needs. Following this discussion is one that examines food preparation, baking and cooking aids, and tableware that are specifically designed for aging people. These highlight more economical and practical measures that those who are aging may choose to consider. The final discussion in this chapter focuses on the environment of the kitchen itself, and how it may be augmented to support the aging senses and bring more pleasure to dining experiences.

ADAPTED KITCHEN LAYOUT, FUNCTIONALITY AND SAFETY To many people, kitchens are a memorable place for dining, family gatherings and/or socializing. Whether a room in an apartment or the focus of a home, kitchens are often used as they are already designed, unless someone has the luxury of redesigning them. Making changes to kitchens may increase their usability and safety for aging people. Kitchens may then become the center of importance in a living environment versus the necessary place to eat. To begin, it is important to critically survey the existing kitchen. Are the countertops, cabinets and appliances well positioned? Is the fuse box or circuit breaker wired properly? Are the outlets and switches easy to access and protected by safety socket covers? Are electrical cords covered or securely mounted? Do area rugs have

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rubber-like backings for adherence and can they be easily cleaned from spills? These and a host of other questions should be addressed as people enter their aging years at home or in home-like environments.

MODIFIED KITCHEN LAYOUT Ideally, kitchens should be on the main floor of a living environment and provide easy entry, exit and access within its quarters. There should be plenty of room to maneuver and to use a wheelchair, if necessary. Extra clearance space is especially needed between the appliances, cabinets and walls. The standard clearance in homes is about 36 inches for adequacy, but 40 38 inches of clearance space may allow for greater mobility and minimal damage. Galley or “pass through” kitchens should have at least 40 inches of clearance between the opposing surfaces. Sixty inches may be necessary for especially tight turnaround areas, such as closets.

Kitchen Countertops While the size and shape of kitchen countertops may not be changeable, the ability to redesign these countertops for improved functions and usability is ideal. A standard height of countertops is 36 inches. A 30-inch countertop may be useful for people who need to sit or who are disabled. A 42-inch counter may assist those people who prefer to stand for ease of food preparation. If possible, avoid 90 angles at corners, or on countertops or open shelving to help avoid bruises, cuts and/or bumps. Also avoid blind corner cabinets where access to dishes or pots and pans may be trying, and bending or reaching may also be challenging for rummaging and locating difficult-to-find items. A three-drawer base, traditional Lazy Susan, or corner cabinet organizers with half-moon, kidney-shaped or other sliding shelves may be better solutions. This also holds true for upper-level cabinets: accordion openings and easy-to-reach options are optimal.

Kitchen Cabinets Pullout shelves in lower cabinets may help to reduce back strain and may be efficient for organizing items to be easily seen. Similarly, pull down shelves from upper cabinets may help to reduce the strain of lifting and stretching and the hazards of items falling, breaking and/or injuring the users. Upper cabinets should be mounted about three inches lower than conventional placement. Frequently used items such as cups, dishes and/or commonly used ingredients should be located close at hand.

Kitchen Cabinet Hardware and Design Kitchen cabinet hardware should be judged to help optimize grip and pull. Generally D-shaped handles are better than knobs. A lazy-susan type cabinet may be beneficial for easy view and access. Drawers and cabinets should be closed when they are not in use to avoid any bumps or accidents. Knives and sharp utensils should be safely secured or removed if their safety is of concern.

Kitchen Flooring A kitchen floor should be made out of durable material, yet still be slip-resistance—especially if spills are not easily or quickly cleaned. Any floor covering should be nonglare. Cork, linoleum, rubber and/or wood and smaller tile with more grout lines are products for consideration, since some of these substances may help to prevent slipping accidents. Nonslip tile and low pile carpeting may be easier to clean. A nonslip texture may be added to some existing stone or tile. Hardwood may be easier to roll a wheelchair over than carpeting or tile. Carpet tape and/or throw rugs should be avoided.

Kitchen Heating and Cooling Physical work in the kitchen, be it preparation, baking, cooking or cleanup and produces body heat. If more people are in the kitchen than in the rest of the house, then this may also increase the temperature of the room.

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There should be an easily accessible thermostat in the kitchen that is well illuminated with large dials so that the temperature may easily be adjusted. Lowering the heat to a reasonable level may help to prevent the risks of fainting, lightheadedness and/or overheating to a serious degree. A convenient window air conditioner with easily accessible and manageable controls may be especially valuable in hotter climates. A space heater may be a fire hazard or lead to carbon monoxide poisoning. Consult the Consumer Product Safety Commission for more information about their use and warnings.

Kitchen Lighting Adequate lighting should be over the countertops, microwave, oven, range and sink. Under-cabinet lighting may also be desirable, as well as well-placed night lights and/or motion-detecting lights. Shiny work surfaces may be too distracting. Light switches should be installed at all kitchen entrances if possible.

Kitchen Seating Readily accessible kitchen seating may help in food preparation, dining and even clean up. Chairs should be comfortable, yet sturdy at a height that ensures easy mounting and dismounting and a weight that is manageable for moving if necessary. There should be enough room at a kitchen table for comfort, the easy and safe management of foods and beverages, and room for a wheel chair if needed (or chairs to be repositioned to accommodate one person or more).

Kitchen Sinks The height and location of kitchen sinks may affect muscular exertion. In general, it is best to locate kitchen sinks close to the stove in order to carry fuller pots of water to stovetops. Any spills might become a slipping hazard. If the sink is positioned next to the stove, then this may not be ideal since some useful preparation area may be lost. Some workspace between the sink and the stove may allow for a cutting board and/or transfer area for hotter items. Another option for galley-style kitchens is to place the sink directly across from the stove so that a step or two within a 180 movement may promote easy transport. For people who are wheelchair bound, a roll-under sink may be a consideration. Adjustable counters and sinks that are motorized to accommodate height differentials may be solutions if kitchen redesigns are possible. If possible, sinks should be shallow with hands-free or lever-controlled side-mounted faucets and pullout sprayers. Anti-scald devices may be used to help guard against burning. An easily accessible water-filtering device may be necessary depending on different locations. While a garbage disposal is handy, it may need to be covered to protect aging people from inadvertently inserting their hands.

ADJUSTMENTS OF KITCHEN APPLIANCES Kitchen appliances should be well marked with digital display of temperatures in large type and easy-tomanage and energy-efficient functions. However, while computerized features are innovative, they may be difficult for some aging people to comprehend, so select accordingly.

Cooktops, Standard Ranges and Wall Ovens Cooktops, standard ranges and wall ovens should also be size and height-appropriate if possible, and as close to adjacent countertops to ensure easy and safe transference of cooking equipment. Some cooktops may be available with openings underfoot to accommodate chairs or wheelchairs. Safety cannot be understated. The control panels of cooktops, standard ranges and/or wall ovens should be easy-to-use, well illuminated and offer sound alerts, if possible. Some control panels may use motion-sensor technology for many of these functions. Existing ranges may be retrofit.

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Simple front-mounted controls that are in large type, with easy-to-comprehend one-touch cooking and heighten sounds options are desirable. Color indicators may be available that show when the burners are on or off. Another desirable feature is a lock system for additional control. Automatic shut-off features may be available to help prevent accidental fires. A cooktop fire suppressor that is positioned under the stovetop may help to avert unattended cooking fires. Gas stoves should have automatic shut-off features in the event that the pilot light fails. If any of these protective devises are operative, then the inhabitants should be well informed about their proper usage.

Dishwashers If there is an existing dishwasher, then the height may be of issue, since it may affect the strain of loading and unloading dishes, glassware and/or silverware. Look for models that may have a one-touch operation and may be able to run smaller loads for energy efficiency and practicality.

Microwave Ovens Microwave ovens should also be chosen for usability and safety with easy-to-use control panels. They should be installed at convenient heights to help to easily transfer hot foods and beverages to nearby countertops. Microwave oven doors may open to the left or right; check to make sure that they comply with handedness. Use microwavable dishes that do not get too hot to handle, yet those that ensure even heat distribution.

Refrigerators and Freezers Optimally, refrigerators should be top-mounted with lower freezer storage or side-by-side with refrigerator and freezer functions for aging limitations. They should also have illuminated water and ice dispensers, long D-shaped handles, high lighting within the inside, handy side storage and slide-out visible shelving. Check for any leaks that may create puddles and eventually rot wooden floors or cause linoleum floors to buckle. Also examine for ants, roaches or vermin infestations that may not normally be noticed. A service visit may be warranted. Use nontoxic cleaners and eradicators whenever possible.

POTS, PANS AND COOKING EQUIPMENT When positioned on the cooktops, pots and panhandles should be turned so that they do not hang over the stove and tip over. Double-handled kitchen equipment may help to alleviate this situation and also help with the weight of the pots and pans. Aging people who are still cooking and baking should be alerted about this concern regarding positioning. They should be counseled to wear sleeves that are held with elastic bands. If they were short-sleeved shirts they may be more prone to burns. Some potholders and oven mitts are designed for disabled grips with rubberized exteriors. They should be easily accessible but stored away from heat sources. Any decorative towels and curtains by heat sources should be kept to a minimum.

ADDITIONAL KITCHEN CONSIDERATIONS For aging people with dementia some additional measures may be needed. For example, any superfluous items should be removed from sight and accessibility. Childproof latches and/or locks may also be needed; if so, they should be added to cabinets and/or drawers that contain potentially hazardous items, such as sharp cooking utensils and/or knives. Unbreakable dishes and glassware may be necessary. Some appliances (such as the microwave or coffee pot) may need to be unplugged until care providers may safely use them. Step stools should be removed to prevent undesirable access to unsafe places [1]. Other kitchen tips and techniques for people with dementia include those listed in Table 11.1.

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TABLE 11.1 Kitchen Guidelines for Aging People With Dementia • Attend to emotional and physical needs first before cooking, cleaning, seating or serving aging people with dementia. • Be patient; recollections of eating and drinking memories may take some time. • Eat earlier in the evening to help to prevent sleep disruptions and/or daytime fatigue. • Let children and grandchildren contribute to meals preparation and provide socialization with conversation. • Lower expectations of food and/or beverage intakes; celebrate one food or beverage that is consumed, a mouthful or sip at a time, in the moment that they are ingested. • Reminisce out loud about happier times that included food and/or beverages to help trigger long-term food and beverage memories. • Schedule family meals earlier in the day since people with dementia may “sundown,” or become more confused later in the evening, and they may be more opportunities to interact. • Take food-related events (such as anniversaries or birthdays) to loved ones, rather than expect loved ones to travel. • Talk to aging people with dementia in a direct and straightforward manner about foods and beverages, rather than in the third person, to help them feel more engaged in the eating process [2].

FIRE AND SMOKE SAFETY Fire and smoke safety are concerns for everyone who uses a kitchen, but particularly for those people who are aging and especially for those who have physical disabilities. Table 11.2 lists Physical Fire Promotion Actions and Table 11.3 provides Personal Fire Promotion Efforts. TABLE 11.2 Physical Fire Promotion Efforts • Check all outlets and wiring by using a qualified electrician should to ensure that they are functional and safe. • Confirm that there is a working smoke detector and change the batteries regularly. Aging people who are hard of hearing or deaf should consider the purchase of a flashing or vibrating smoke alarm. • Ensure that kitchen ventilation systems and range exhausts are clean and functional. • Have a handy fire extinguisher close at hand. However, if a smoke alarm sounds, then residents should leave immediately and contact “911” once they are sufficiently away from the residence. • Make hallways and stairs easily accessible and uncluttered. • Monitor movements and appliance switches through automatic stove shut-off systems. These may also send immediate electronic alerts to family members and/or care providers. • Post large-sized emergency numbers on a well-illuminated and accessible surface. • Provide for at least two exits for each room. • Store any flammable liquid outside of the home in a safe environment. Wax candles should be replaced with batteryoperated LED lighting. • Update any fire escape plans according to the capabilities of the resident(s). IF THERE IS A FIRE . . . • Know basic fire instructions: • Avoid: Water is not the best flame extinguisher; nor should water be used for electrical or grease fires. • Use: Dry chemical fire extinguishers are preferable for fire eradication. • Option: Smother a small fire by using a pot lid or baking soda (keep close at hand) for a quick remedy, but make sure that the fire is fully extinguished. Data from http://householdguardians.com/safety-tips/kitchen/top-7-home-safety-tips-for-the-kitchen/.

TABLE 11.3 Personal Fire Promotion Efforts • Avoid cooking and preparing foods in loose-fitting clothing. • Clean up stovetop, oven and/or work surfaces after each meal or snack to avoid a build-up of fat, grease, oil and/or food debris that might attract bacteria and cause flare-ups. • Consider the use of electronic coffee makers and teakettles with understandable “on-off” instructions. • Keep all towels and potholders away from heat sources and cooking surfaces. • Refrain from leaving the house while foods are baking, simmering or roasting. The exception may be the slow cooker or instant-pot, but cooking instructions for these items should be very well understood and implemented. • Stop leaving foods unattended while they are cooking—even for a moment to prevent absentmindedness and burning. • Use two-handled cookware if possible. See recommendations later in this chapter [3]. Data from http://householdguardians.com/safety-tips/kitchen/top-7-home-safety-tips-for-the-kitchen/.

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PREVENTION OF FOODBORNE ILLNESSES IN THE KITCHEN Next to fire safety, one of the other major concerns of aging people in the kitchen is foodborne illness.*** Foodborne illness is a collective term for the diseases that may contaminate foods and/or beverages that may be caused by a variety of bacteria, parasites and/or viruses. Another cause of foodborne illness may be due to potentially harmful chemical or toxins. If aging people have compromised immune symptoms due to medical conditions such as diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome, kidney disease, liver disease, organ transplants or chemotherapy or radiation treatments, they made be more prone to foodborne illness. The most prevalent germs in the United States that may cause foodborne illnesses include the following: • Campylobacter - mainly from raw or undercooked poultry or raw (unpasteurized) milk and contaminated water]; • Clostridium perfringens - mainly from beef or poultry and gravies; • Norovirus - mainly from fresh fruits, leafy greens, shellfish such as oysters and water; • Salmonella - mainly from cheese, eggs, raw or undercooked meats or poultry and unpasteurized juice or milk; and • Staphylococcus aureus (also called staph) - mainly from pastries, puddings, sandwiches and sliced meats; also from unpasteurized cheeses and milk. The topmost food-related five germs most likely to result in hospitalization are: • Clostridium botulinum (also called botulism) - mainly from improperly canned or fermented foods—usually homemade); • Escherichia coli (also called E. coli) - mainly from lettuce, raw or undercooked ground beef, raw or unpasteurized milk and juice, raw spouts and contaminated water); • Listeria - mainly from cold cuts, hot dogs, luncheon meats and pates, melons, raw and unpasteurized milk, raw sprouts, smoked seafood and soft cheeses made from raw milk); • Vibrio - mainly from raw or undercooked shellfish, particularly oysters. The common symptoms of foodborne illness are diarrhea, nausea, stomach cramps and/or vomiting, from mild to life-threatening. If there are severe symptoms, emergency medical care should be sought. Table 11.4 provides some precautionary measures to take or avoid to guard against some food contaminants. TABLE 11.4 Prevention of Foodborne Illnesses in the Kitchen DO Take These Preventive Measures: • Be careful about leaving out certain condiments, such as mayonnaise or creamy salad dressings, that may be present in dairy products eggs and/or certain salads too long without refrigeration. • Check the refrigerator temperature routinely for accuracy. Cold foods and beverages should be refrigerated between 34 F and 40 F or between 1.1 C and 4.4 C. • Cover leftovers effectively and return to the refrigerator or freezer once they are sufficiently cooled. • Discard any questionable foods or beverages if they are in doubt; particularly if there are changes in appearance, mold and/or smell. • Ensure the temperature for reheating foods reaches 165 F or 73.89 C. • Hold frozen foods at no more than 0 F or 217.78 C. At temperatures between zero and 32 F foods deteriorate more quickly. • Hold hot foods to no less than 140 F or 60 C. • Store meats and vegetables separately in the refrigerator in sealed containers. • Use different cutting boards or opposite sides for fish, meats, poultry or vegetables. Many cutting boards are brightly colored and sold in economical mixed-colored packages. DO NOT Engage in These Risky Actions: • Mix meats into the dairy compartments of the refrigerator and vice versa. • Rely on the senses of sight or smell to determine if foods and beverages are safe. This is because some foodborne bacteria may not be able to be seen, smelled or tasted [4].

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RATIONALE FOR ACCOMMODATED COOKING AIDS Cooking aids that are accommodated for aging eyesight and dexterity, such as nonskid plates and cups and weighted utensils, may positively impact everyday activities, such as eating and drinking. As fine motor skills diminish with aging, it may become more difficult to engage in simple tasks, such as using a fork to lift a piece of fruit or vegetable, a spoon to take a spoonful of soup, or a knife to cut a piece of meat. Coupled with other physical challenges that may include arthritis, injury or stroke, and it is no wonder why the interest in eating and/or drinking may wane during aging. This disinterest in eating and drinking may also make a difference among living alone at home, residing with a care provider or living in a group facility—either semi-independently or with assistance. Cooking aids that are designed to assist aging people with eating and self-care help tend to promote the quality of life and the dignity of self-maintenance. Conditions or diseases of the aging that may benefit by their use may include Alzheimer’s disease or dementia, arthritis, frailty, hand tremors, low vision, Parkinson’s disease, stroke, weakness and/or other mobility issues [5].

PREPARATION, COOKING AND DINING AIDS DESIGNED FOR THE AGING OR DISABLED Depending upon the number of decades that one has lived, dining aids for the aging and/or those who are disabled have run the gamut from simple construction to advanced technology. Most of the following preparation, cooking and dining aids are simplistic models; however, some are more technological advances for those who may be so inclined. • Automatic Hand Sanitizers and Soap Dispensers—One of the fastest ways to spread germs is by hand, and one of the easiest techniques to control germs is by hand washing. Unfortunately, the simple task of hand washing may be difficult for some aging people to master as time progresses; therefore, automatized hand sanitizers and soap dispensers might help to make this task easier and repetitive, both before and after meals. Soap dispensaries also make it easier to wipe the area where one eats to guard against foodborne illnesses. • Advantages—Ease and repetitiveness • Disadvantage—Some require hand mobility • Angled Measuring Cups—The angled surfaces in these measuring cups permit the reading of measurement markings by looking straight down into the measuring cups. They eliminate the need to fill, check and readjust the amount of liquid that is to be measured. The handles are soft and nonslip and promote a firm grip for comfort, confidence, convenience and/or safety for aging people with compromised vision or use of their hands. • Advantages—Easy reading, checking and adjusting • Disadvantages—Cost, access and storage • Angled Perching Stools—These all-purpose stools have adjustable arm widths and heights, and angled seats for ease in sitting and rising. They are designed to take pressure off of the feet and back during meal preparation. These stools would benefit people who are aging, disabled and/or those who have undergone hip surgery. • Advantages—Fosters sitting and rising; decreases pressure • Disadvantages—Cost and storage • Antifatigue Floor Mats—Mats such as these are designed to reduce fatigue and decrease foot and lower limb disorders that may be caused by standing on hard surfaces, such as cement or wood floors, for extended periods of time. They may be made of carpeting, rubber, vinyl and/or wood. Despite comfortable qualitymade shoes and floor coverings, standing for extended periods may cause discomfort; sore feet, hips, knees or legs and/or tiredness. Still, the use of mats may lead to falling, tripping and other accidents if they are improperly installed. While antifatigue mats do not eliminate soreness, they may temporarily improve certain conditions. • Advantage—Fatigue reduction • Disadvantage—May cause falling if not well installed

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• Bean Bag Lap Trays—Padded trays tend to stay stable on a person’s lap due to the bean bag on the bottom. They may be used to place beverages, meals, lightweight electronic devices and/or or other lightweight items on one’s lap. Bedridden and/or wheelchair-bound individuals may find their light, yet sturdy weight and contoured shape that conforms to different lap sizes, shapes and heights ideal for eating, reading and/or writing. • Advantages—Stability and convenience • Disadvantage—May be awkward until comfortable • Blenders with Grip Bottoms—Heavy appliances, such as blenders and/or food processors, are indispensable for many kitchen duties, but they tend to be very difficult to move and/or clean. Customized shelving and ready-made inserts to fit into drawers may be constructed in order to pull out heavier items such as these, with limited need for bending, lifting and/or dropping. Pop-up shelving with rubberized nonslip bottoms may also present some viable solutions. • Advantage—Firmly implanted • Disadvantage—Appliances still heavy for use • Bread Spreader Boards—Boards such as these tend to lie flat on tables or work surfaces, and provide handy, secure and useful foundations for spreading butter, jam and other spreadables on breads, crackers, toast and other similarly texturized items. They are typically made of easy-to-clean plastic with a lip to catch crumbs and nonslip feet to prevent them from sliding. They may be useful for the aging with hand or visual impairments, or those people who desire independence in eating. • Advantages—Handy and secure • Disadvantage—Surface must be maintained • Cabinet or Wall-Mounted Jar Openers—Under-cabinet jar and bottle opener are designed for people who may have grasping disabilities and/or compromised motion or strength in their arms or hands. Even without more advanced physical mobility issues, these jar openers may help arthritic users with their additional functionality. Look for products labeled “universal design” or “user-centered design.” • Advantages—Accessibility and convenience • Disadvantage—May be space issue • Color-Coded, Large Number Measuring Cups and Spoons—These brightly colored cups and spoons are easier for fading eyesight and declining memory. They serve to make preparation and cooking more identifiable, correct and fun-filled activities. • Advantage—Help aging eyes • Disadvantage—May be difficult to obtain • Cordless Electric Bottle or Jar Openers—Cordless automated jar openers are operated electronically by pressing and holding a button that activates a motor driver gear system until a cap or lid is loosened. They are compact in size and adjustable to a wide range of different bottle, cap, jar and lid sizes. • Advantages—Convenience and size • Disadvantage—Still requires dexterity • Cut-Resistant Gloves—Anticut gloves are designed to help prevent meal preparation from injuring those who are aging or people who have limited mobility, memory decline and/or muscular weakness. They have the capacity to block burns and cuts due to their composition (often a composite of fiberglass, high-performance material and/or stainless steel) and weight. • Advantages—Burn and cut prevention • Disadvantages—Uncomfortable and unfamiliar • One-Hand Food Preparation Boards with Cutting Aids—These preparation boards allow for increased power and precision in food preparation. They are designed for people with one hand or arm function or weaker hands; sometimes due to poststroke issues. An adjustable clamp may accommodate right or left-handedness, and a cutting guide and serrated knife facilitates controlled and straight cutting. The knifes do not require additional strength to keep the blade upright. The power grips make better use of hand and arm strength. The boards rest on antislip feet with suction pads for nonslip usage. • Advantage—Single-hand operation • Disadvantage—Still require maneuvering

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• Drinking Straw Holders—Drinking straw holders fit over cups or glasses and hold straws stationary. They are of benefit for those people who have limited use of their hands, have trouble moving a glass to their mouth or trouble drinking altogether. • Advantage—Easy of movement • Disadvantage—May cause spillage if incorrectly installed • Easy-to-Grip Preparation Tools (such as Choppers, Graters, Peelers and Scrapers)—Easy-to-grip tools provide broad, cushioned and ergonomic-designed gripping surfaces for people with limited use of their hands due to arthritis or injuries. They serve to keep the hands comfortable so that they may perform tasks with ease. Their soft surfaces may also absorb the shocks of impacts and mitigate loud sounds. Some of these tools may be designed in bright colors that may be easier for aging eyes to see. • Advantages—Comfort and ease • Disadvantage—Access and storage • Easy-Open Canister Sets—These canisters are available in rectangular or square shapes that allow for a onehanded operation—thanks to a push-button mechanism that lifts the lids. People with arthritis or dexterity problems may be able to open and shut these containers without the discomfort or pain of bending their fingers. • Advantage—Handy opening options • Disadvantage—Require some skillfulness • Electric Salt and Pepper Mills—Battery-operated mills are designed for people who want to easily and selfconfidently control the amount of pepper and/or salt in their food. Just one touch triggers the grind mechanism to assist aging hands that may have difficulty twisting handheld kitchen tools. A built-in LED light in some versions illuminates targeted areas and assists aging eyes. • Advantages—Control and ease • Disadvantages—Expense and storage • Electric Water Kettles with Automatic Shut-Off and Boil-Dry Protection—Countertop kettles such as these are easy to use by people with limited strength and restricted mobility due to their ergonomically positioned handles. They help prevent aiming, balancing, lifting and straining difficulties so that hot liquids may be safely controlled for pouring. These kettles are typically perched on stable cradles. Easy-to-read water level indicators, wide spouts, automatic shut-offs and boil-dry protection are other desirable features for people with aging eyes and slower reflexes. • Advantage—Assist hand/arm movements • Disadvantage—Still weighty • Flashing or Vibrating Large-Sized Type Clocks, Food Thermometers, Smoke Detectors or Timers—These devices substitute light, vibration or both sensations for sound or speech output in order to alert a person that a predetermined time period has expired. • Advantage—Assist aging eyes and ears • Disadvantage—Expense • Garlic Mincers—Since garlic is well-regarded for its allicin content that may benefit arthritic sufferers, garlic mincers that are designed for arthritic hands may also be beneficial. Garlic mincers look like garlic presses shaped like domes and easy to grasp. They help a person to roll chopped garlic along a worktop until it is finely minced. Some garlic mincers are mostly plastic and dishwasher safe to help provide easy clean up. • Advantage—Encourages fresh garlic • Disadvantages—Accessibility, expense and storage • Knob Turners for Controls on Appliances—Universal knob turners may help arthritic hands to easily turn control knob switches on dishwashers, microwaves, ovens and other appliances. An ergonomic handle aids grip firmness by one hand or two, and provides comfort. • Advantage—Assist twisting hand movements • Disadvantage—Hand motions still required • Large Print Calendars, Cookbooks and Phones—These conveniently printed items are designed for fading eyesight and/or memory aids. They are especially beneficial in colorful type and if they incorporate colorful markers, display panel, photographs and/or stickers. Aging people with compromised cognition skills such as

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those with Alzheimer’s disease, cerebral vascular accidents (strokes) and head injuries to falls that precipitate confusion, forgetfulness and/or memory loss may benefit. • Advantages—Convenience and readability • Disadvantage—Access LED Faucet Lights—Aging people may benefit from under-cabinet lights to illuminate their work area, as well as LED faucet lights to illuminate water flow and help to prevent burns. In addition, some LED faucet lights glow in a red tone when the water is hot, and in a blue tone when the water is cold. (This feature is similar to the blue and red colorations of water dispenser that dispense hot and cold water, respectively.) People may still confuse the hot water for the cold water if there is dementia. • Advantage—Beneficial illumination • Disadvantages—Expense and installation Lighter-Weight Pots and Pans—Arthritis, carpal tunnel syndrome, degenerative joint disease, hemiplegia (paralysis of one side of body) and hemiparesis (unilateral paralysis), osteoarthritis, rheumatoid arthritis and/ or stroke are conditions that may lead to arm and/or hand weakness and poor grip strength. People with these conditions may consider replacing heavy pots and pans with lighter-weight ones, since they may be easier to lift on a consistent basis and require less grip tightness—also if repeated employed daily. • Advantages—Easier gripping and lifting • Disadvantage—May conduct heat less efficiently Lock-It Down Dining Kits—In these kits, bowls and plates lock onto trays with a simple twisting motion, and the trays may be secured to most tables. Inserts aid table protection. They are designed to help prevent messes and spills and encourage dining independence. These kits are comprised of impact-resistant material that is dishwasher and microwaveable safe. • Advantage—Secure eating area • Disadvantage—Require maintenance Meat Pounders and Tenderizers—Meat pounders and tenderizer flatten and pound meats and poultry, and help make them more palatable and ready to absorb marinades. Angled nonstick heads with easy-to-clean pyramid-shaped teeth are positioned for improved contact, and nonstick handles cushion impact and nestle comfortably in the hands. • Advantage—Tenderize protein foods • Disadvantage—Require hand/arm motions Nonslip Step (Foot) Stools—Stool of this nature are helpful for safe reach wherever some extra height is needed. The nonslip feature works best on linoleum or wooden floors without floor mats. The step(s) is(are) covered with nonslip rubber mats, and handrails provide for sturdy ascent and descent. • Advantage—Aids height accessibility • Disadvantage—May be hazardous Oven Pulls—Aging people, especially those with diseases that may affect the peripheral nerves such as diabetes, may not have an acute sense of touch as normal. Also, they may not withdraw as quickly from heat as during their younger years. As a result, burns may be deeper and more severe. Oven pulls that are made from wood or silicone may help to move oven racks out of a very hot oven for easier access. As long as the oven is at a manageable height, then casseroles and pans may then safely be transferred to heat-protected work surfaces via these oven pulls. • Advantage—Easier access • Disadvantage—Still require skillfulness Oven Rack Guards—These guards help to prevent accidental burns from hot oven racks. They are characteristically made from special fabrics that were developed to protect against fires. These snap-on oven guards fit standard oven racks and usually cover wide areas. They may stay in the oven between uses, and are machine washable. Oven rack guards should not be used under the broiler, during oven cleaning or to remove a hot oven rack. • Advantage—Burn protection • Disadvantages—Some precautions required Over-Bed Portable Tables—Portable tables such as these function as tabletops for meals, and/or for reading or writing areas. Since they are adjustable for different heights and body types, many are able to scoot up and

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over a bed, chair or sofa; thus they are beneficial for individualized needs. Usually levers or handles easily adapt for various heights, and they have convenient, easy-to-handle lock features. • Advantage—Convenience • Disadvantages—Expense and storage Padded Ladles and Spatulas—Padded utensils have built-up handles for people with limited manual dexterity and/or grip strength. Some have finger-fitting spots that help to improve grip even when they are wet. The use of these padded utensils may help to foster independence and improve the participation in simple baking and cooking. • Advantage—Easier movements • Disadvantages—Access, cost and storage Palm Peelers—Using a small knife to peel fruits and vegetables may be dangerous for aging people and using a regular peeler may be challenging for those with hand and/or arm disabilities. Palm peelers may help to reduce the risks of cutting since they are comfort-designed, nestle in the palm of a hand and slip over fingers with soft palm and finger grips. The peelers allow for gentle easy motions, rather than striking actions. They are usually made from molded plastic in ergonomic designs that are safe for people with low vision. • Advantage—Easy use • Disadvantages—Adaptability and availability Pot and Pan Handle Holders—Handle holders easily attach to handles by use of strong suction cups to provide stability and protection from the heat. This allows the pan or pot to be stirred without accidental spills or burns and stable transfer from the stove to a heat-proof countertop. • Advantage—Protection • Disadvantage—Familiarity of use Pot Stabilizers—These items are designed for safety and for self- maintenance. Pot stabilizers help to keep pots stable while stirring and prevent them from sliding. This is especially important if contents are hot water or oil to guard against severe burns or heavy pots accidentally dropping on feet or toes. • Advantage—Safety • Disadvantage—Availability Rocker (Rocking) Knife—Curved-bladed knives are useful for cutting foods such as meat and vegetables in a rocking motion with one hand. They are particularly designed for compromised hand-motion abilities. • Advantage—Help hand/arm issues • Disadvantage—Require learning for correct usage Rubber Handle Faucet Grip Covers and Knobs—Rubberized items allow faucets, handles and knobs to be activated with less effort expended for clamping, gripping and/or twisting. • Advantages—Ease and safety • Disadvantage—Installation Salad Choppers with Gripped Bowls—These devices have soft and nonslip arthritis-friendly and ergonomic handles with stainless steel blades that effectively and safely chop salad greens and vegetables as well as cheese or fruit. The continuous curves are in constant contact with the blades and the rims provide grips for safely turning the bowl. • Advantages—Efficiency and stability • Disadvantages—Expense and storage Serrated Slicing Knifes with Angled Handles—Sometimes referred to as “relief knives,” these knives help to simplify cutting tasks since it provides a better working position than serrated knives with straight handles. They are balanced and do not take additional strength since the power grips may be used with a straight wrist. This position makes for more efficient use of hand and arm strength for people with arthritis or compromised dexterity. • Advantages—Less strain and stress • Disadvantage—Still require hand/arm movements Silicone Grippers—Silicone grippers, adaptors and holders are designed as household arthritic aids to help range of motion and function for aging people with arthritic pain. Silicone grippers run the gamut from those that are used to grip bowls, pans and pots to others designed to grip door knobs, faucets, keys, lights, safety scissors, switches and writing utensils. Some grippers are integral to these items while others are adaptable, such as handle foam and cup and potholders that fit a variety of size utensils and tools. • Advantages—Support hand/arm function and range of motion • Disadvantage—Still require hand/arm mobility

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• Silicone Mixing Bowls—Silicone mixing bowls are designed to stabilize food preparation and make it easier. Food-grade silicone mixing bowls are nonstick and can withstand higher temperatures. Plus, they allow people to incorporate ingredients either straight up or at an angle without the bowls slipping and sliding on countertops. Some silicone bowls may even suction into place and serve as a base for other bowls to conveniently fit inside. • Advantage—Stabilization • Disadvantages—Cost and procurement • Spill-Proof Bottle and Jar Openers—These products allow people to open bottles and jars with one hand and prevent tipping and spilling. They may foster dexterity and encourage independence in preparation, cooking and cleanup. • Advantages—Ease of use and safety • Disadvantage—Some involved • Splatter Screens—Splatter screens are kitchen tools that keep grease contained so that it does not cause stovetop fire or smoke. The soft, comfortable handles lock securely when opened, and the entire apparatus folds for storing. Splatter screens may be of perforated stainless steel or mesh; the former will not clog, and it is easier to clean. • Advantages—Cleanliness and easy clean up • Disadvantage—Encourages fried foods • Talking Devices (such as Kitchen Scales, Microwaves or Ovens)—Sound-activated devices such as these help people with fading eyesight since the weight of food items, or the timing of baked or cooked foods are pronounced out loud. The sound must be loud enough for hearing loss. • Advantages—Helps eyesight and hearing impaired • Disadvantage—Expense • Thickeners—Most thickeners help people with swallowing disorders to swallow substances without aspiration leading to choking, coughing, chest infection or pneumonia. Thickeners may either be gum- or starch-based, in gel or powder forms, and in mild, moderately thick or extremely thick consistencies. • Advantage—Support swallowing difficulties • Disadvantages—Require assistance in prescribing and use • Two-Handed Pots and Pans—Baking and cooking equipment such as these items allow people who are aging to be able to lift and maneuver hot and heavy equipment with more stability. Some are also ergonomically designed with additional grips that are positioned opposite the contoured silicone coated handles. These are to enable the users to adopt neutral grip positions. Certain sets are in stainless steel with tempered glass lids. Lighter-weight lids may also be available. • Advantages—Easier lifting and stability • Disadvantage—Challenging to learn • Vibrating Liquid Level Indicators—Vibrating indicators make noises and/or vibrations when liquids near the tops of cups or glasses. Once the tops are approached, a continuous tone or vibration occurs. These devises are useful for independent aging people, or for those with low vision who wish to pour their own beverages. Some styles may also have their own pouring aids. • Advantage—Sound activation • Disadvantages—Assumes intact hearing; cost • Water Boil Alerts (Boil Control Discs or “Pot Watchers” to Keep Foods from Boiling Over)—Items such as these help to prevent milk and soups from boiling over, and the need to constantly clean stovetops. Some make gentle rattling sounds, while others lie in the bottom of pots and pans to help restrict liquids to a rolling boil and prevent foaming. Depending on the size and the material, they may not be totally effective, so a watched pot may still be best strategy. • Advantages—Prevention and protection • Disadvantage—Still may require mindfulness • Weighted Paper Towel Holders—The sturdiness of weighted paper towel holders prevents these frequently used devices from accidentally tipping over, and potentially falling onto the stove or other hot areas. Some designs allow for a single sheet to be torn off for use by one hand in one stroke, so they may be useful for people with arthritis and other grip and strength issues [6]. • Advantages—Convenient and sturdy • Disadvantage—Expense and space

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TABLEWARE FOR ACCOMMODATED OR DISABLED CONSUMERS Some of the preparation and cooking aids that were previously discussed may also be incorporated as cutlery or tableware for accommodated or disabled people. These include the following items: • Easy-to-Grip Cutlery (such as Forks, Knives and Spoons) These tools provide larger gripping surfaces for people who may have limited use of their hands due to arthritis or injuries. They are designed for hand and arm comfort and ease and to absorb shock. They may also be exempt from bothersome noises. Some of these items may be color-coded for easier identification for people who have diminished eyesight and/or memory dysfunction. • Additional Adapted Cutlery (with and without Adapted Grips) • Angled Cutlery—This type of cutlery offers lightweight utensils that feature built-up handles to increase the comfort of people with painful or weak grasps. It also provides independence and promotes less disordered eating because the food may actually reach the mouth. • Bendable Cutlery—This kind of cutlery offers metal shafts that are easily bent to angles to accommodate hand motions. It affords user comfort; some even utilize rubber built-up handles with stainless steel. While the knives may not bend, instead they may feature a rocker-type design for minimum motion. • Contoured Cutlery—Cutlery of this design contain shaped handles to assist people with restricted finger or wrist movements. The forks and spoons have curved and built-up handles, and the knives have straightbuilt-up handles with angled blades to cut with rocker-like actions. • Ergonomic Handled Cutlery—Cutlery designed ergonomically helps to reduce wrist strain, and to prevent carpal tunnel syndrome, tendonitis and/or fatigue. It also promotes higher control and maneuverability than standard cutlery, so it may be an option for people with rheumatoid arthritis, osteoarthritis and/or osteoporosis who still wish to retain autonomy in eating. • Left- or Right-Handed Cutlery—This type of cutlery is designed for a dominant hand, rather by choice than need, and for delicate and complicated tasks, such as cutting or piercing. Opposite hand cutlery may help individuals who need to switch handedness due to crippling arthritis in one hand or arm, stroke, surgery or other disabling conditions. • One-Handed Cutlery—These forks, knives and spoons are created to position, cut and often fork or spoon food with one hand only if the other hand is incapable of participating. This type of cutlery includes rocker knives with forked ends, and splayed utensils that have spoon-shaped bowls with single- or double-cutting edges and forked ends. • Weighted Cutlery—Weighted cutlery is often available in in stainless steel or heavier metals to help steady the hands of people with slight tremors (such as those in Parkinson’s disease related hand tremors), and to facilitate self-feeding. They often have an ergonomic grip that supports their functionality. • Tableware (Bowls, Dishes and Plates) with Raised Edges—Raised-edged tableware such as these bowls, dishes and/or plates help to facilitate the use of only one hand if necessary. They allow people to push or scoop food onto eating utensils with less difficulty and spillage. These may include: • Bowls and Plates with Guards, Lids and/or Scoops • Use for soups and stews, or salads with top-heavy ingredients. • Glasses with Special Grips, Handles, Lids and/or Straws • Fill with nutrient-rich beverages to increase hydration. • Plates that Hold Fast to Tables • Plate tender protein foods that may still need cutting to discourage movement. • Two-Handed Mugs • Serve soups and/or hot beverages for stability and better tendency for consumption. • Weighted Utensils (also see Easy-to-Grip Cutlery)—These weighted utensils with easy-to-grip features may be incorporated with some of the aforementioned cutlery. They tend to provide more control for the users by counteracting or reducing the hand tremors often associated with Parkinson’s disease. • Coated Utensils—Plastic or rubber-coated spoons are coated to increase the thickness of the bowls to help protect the gums, lips and teeth. They are not recommended for heavy biters. These spoons should be regularly inspected for any damage to the coating that might precipitate microorganisms. • Liftware Utensils—Leveling and stabilizing attachments and handles are designed to assist people with hand tremors or limited hand and arm mobility in order to retain confidence, dignity and independence in

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eating. One version (called “steady”) imparts stableness for hand tremors that may be due to Parkinson’s disease and/or essential tremors. Another version (called “level”) is an assistive device that stays steady as a person’s hand bends, moves and/or twists. It may be useful for conditions such as cerebral palsy, Huntington’s disease and/or poststroke conditions that may impact and limit hand and arm mobility. While technology is rapidly changing, and newer devices for supporting the eating and drinking habits of aging people are frequently conceived or updated, certain considerations must be met. These include the: • Identification of medical issues that may require adaptive equipment. • Modification for individual needs that are based on aging people and their kitchens, dining areas, care providers and/or family members. • Recognition of critical concerns that may benefit from specialized equipment.

OTHER USEFUL MEDICAL AND PERSONAL CARE DEVICES Additional helpful devices that serve to support the medical states and/or conditions of aging people and their adherence to dietary measures for improved health and well-being include the following: • Blood Pressure Monitors—Remote, smartphone-activated and monitored measures of blood pressure variations that may be used inside or outside of homes. • Glucose Monitoring System—Similar to the blood pressure monitors, these glucose monitoring systems help aging people with diabetes (and/or their care providers) to monitor their blood sugar, synchronize these readings with smartphones and transmit this data to health care providers, if necessary. • Indoor Camera—Inside cameras help to monitor dangerous areas of homes where falling or other emergencies may be issues, particularly at night. Indoor cameras may also be monitored by smartphones. Hub and motion sensors are similar devices that detect movements, activate lights and monitor late-night activity. • Medical Alert Systems/Lifelines (also known as Personal Emergency Systems)—These systems/lifelines allow aging people to rapidly notify medical personnel if kitchen accidents or other incidents occur. Some systems feature personal help buttons for home use that are commonly worn around the neck or wrist to detect if emergencies have occurred. Optional functions may include an activity tracker, automatic fall detector, GPS, medication reminder, vital signs monitor (for blood pressure, blood oxygen saturation weight and other indicators) and water resistance. American Association of Retired Persons has guidelines for choosing the most comprehensive system for individual needs. • Medication Minders—These digital pill dispensers resemble a 7-day reminder for medications that must be taken multiple times daily. Some have audio reminders; others feature smartphone notifications. • Smart Thermostat—A “smart” thermostat is one that utilizes smartphone technology to program, adjust and monitor the heating and cooling in an environment. This technology may be an improvement upon older thermostats with smaller fonts that are difficult to see and/or maneuver. • Voice-Activated Devices—Many of the aforesaid devices may be activated and operated by speaking, which may be particularly significant for aging people who have difficulty walking and moving from room to room to activate other devices. Home safety devices, kitchen appliances, window treatments (such as blinds or drapes) and/or thermostats are some of the many voice-activated innovations and conveniences that may be available.

TECHNIQUES TO AVOID VISUAL OVERLOAD IN THE AGING Auditory and visual bombardment may be acceptable for younger individuals, but the aging might find both of these sensual incidences assaulting and/or disorienting. To help prevent visual overload, the following recommendations are encouraged. They are reflected in the photos that accompany the recipes in Chapter 10, Menus and Recipes That Appeal to Aging Palates.

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• Avoid patterned plates so that designs do not confuse the diner as to the contents on a plate or in a bowl. The plain tableware shown in the photos in Chapter 10, Menus and Recipes That Appeal to Aging Palates, are some examples. • Experiment with tableware with color contrast. For example, white plates against a blue mat or tablecloth, or off-white bowls against a green tabletop present more distinction than white-on-white. Dishes that afford color contrast may promote better discernment among the meal components. But be careful that the coloration does not interfere with food or beverage recognition. • Limit utensils, particularly if residents have lost or reduced their eating skills. For example, if a person does not remember how to cut or cannot cut, remove the knife to reduce frustration. Encourage the use of one utensil at a time, such as a fork or spoon to improve efficiency. Or use multipurpose utensils that are able to cut, fork and/or spoon food in one implement. • Serve one food at a time so as not to overwhelm the diner’s palate. A meal of this nature may include one cup of soup followed by three ounces of cooked fish, meat, poultry or a vegetarian entre´e accompanied by one-half cup of cooked vegetables and one small piece of fresh fruit. Too much food that is served at the same meal might be confusing. • Use placemats to help frame plates and define personalized eating space. They may have a bright background against a stark plate or a muted background if the plate is colored. Plain or simple-patterned placemats are best for aging eyes. Make sure they are wiped and sanitized after each use to guard against any foodborne illnesses [7].

DINING AND LIVING CONSIDERATIONS Many a meal or snack can be casually consumed on a bed, chair or couch, or more formally eaten at a table, alone or with company. Aging people may be disabled or too ill to move into dining facilities to eat, or not care. Factors that address different dining environments, lighting, sound and touch may all interplay with the successes or failures of dining experiences. An examination of each of these factors follows.

Environmental Factors The environments where aging person eat, drink and live are critical to the dining experience. Environmental factors may include tangible items such as dinnerware and stemware; kitchen equipment and furniture; ambient and direct lighting; sound (such as music and noise) and textural aspects (such as blinds, carpeting and other floor surfaces, cushions, draperies, lamp shades, and other items that provide tactile qualities.). More esoteric factors that may affect dining experiences include the description and language of meals and their settings; dining companions (such as care providers, family and/or friends); and plating design and presentation. In general, dining and living environments should be devoid of clutter. Even condiments, centerpieces, napkin holders and salt and pepper shakers may be distracting. Furniture should be sturdy to support residents as they stand, sit and rise. Chairs should be firmly rooted without rollers, and with armrests for relaxation and stability [8].

Light/Illuminating Factors As vision begins to fail past 40 years of age, eyesight may be less effective at distinguishing colors, focusing on small type, reacting to glare, seeing distances and/or other eye disorders may be present. Proper lighting within an environment and personal space is essential for the ability to perform the daily tasks required for eating and drinking and home activities, as well as to be safe. With aging, the lenses of the eyes begin to yellow and absorb a higher amount of blue wavelength light. This may cause colors to look distorted. The lenses may also harden, and with this rigidity the ability to focus may suffer. Pupils may decrease in size and permit less light to enter which may necessitate more light. And the ciliary muscles of the eyes may weaken. This weakening, coupled by the rigidity of the lens, compounds the ability of the eyes to focus and to adjust to light differentials.

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About twice of the amount of light is required for aging people as during their younger years. For example, about 1614 lumens of light (total light emitted by a bulb) are needed at kitchen counters by 60-year olds, and 2421 lumens of light are needed by 80-year olds, as compared to 404 lumens of light needed by 20-year olds and 807 lumens of light for 40-year olds [9]. The need for ambient light (global lighting that illuminates an entire room such as a chandelier in a dining room that disperse light all over a room) also increases as people age. This may be achieved by: • Adding ceiling lights, floor or table lamps, light valences, recessed lights and/or wall sconces if and where possible (but avoiding too many recessed lights that may cast shadows). • Adding dimmers where possible to control lighting, and motion active lights or prominent wall switches at a reasonable height for easy access. • Illuminating walls by painting them off-white or white, and using a matte finish to reduce glare (that may cause light to scatter and obscure objects). • Increasing the wattage of light fixtures if possible (but without exceeding the maximum wattage). • Providing natural sunlight by opening blinds, curtains and shades, or adding skylights. • Switching to energy-saving CFL or LED bulbs. Measures to decrease glare also include ensuring good-fitting lampshades, keeping light levels uniform, minimizing shiny surfaces and/or using opaque shades of fabric or glass. Adding task lighting may also aid cooking, handwork and/or reading instructions. This may be accomplished through the use of flexible and portable task lamps with at least 1000 lumens of light [that is at least 80 Color Rendering Index] to help to distinguish true colors. Bulbs should be within the “warm” range of 2900 3500 Kelvin (K) (the color of the light source which in this example is warm yellow) that include incandescent bulbs and others that are recommended for ambient lighting. Task lighting is especially important for the kitchen. It may be achieved with LED under-cabinet lights and should be about 5000K 6500K that may appear blue/white. A light valance or above cabinet rope lights may be used to augment indirect ambient lighting [9].

Sound/Acoustical Factors The direct and ambient sounds in dining environments may affect the comfort level of aging people who have impaired hearing. These hearing-impaired individuals may not be able to enjoy the conversations of their dining companions, so as a result they may feel isolated. The reduction of background sounds may be necessary, particularly where conversational interaction is desirable. At home, it is advisable to tune out noise by turning off the radio or television, and if music is played, making it soothing and wordless (unless special vocals evoke pleasant memories). In institutional settings, speakers should be used sparingly to prevent background interference with normal conversations. People with hearing losses should not sit close to open kitchens or on their peripheries. A centrally located kitchen may be distant enough for adequate hearing but close enough to service diners. Furnishings with materials that absorb sound, muffle noise and reduce echoes may be incorporated into dining rooms, kitchens and living areas to control extraneous noise. These may include acoustical ceiling tile, carpeting, draperies and/or upholstery fabrics that should also be fireproof, skidproof and/or stain-resistant. Aging people with hearing losses may have difficult locating and identifying sound sources, including some warning sounds. This is why visual cues, such as flashing lights or vibrating sensors, may be desirable. (See Flashing or Vibrating Large-Sized Type Clocks, Food Thermometers, Smoke Detectors or Timers earlier in this chapter.) A simple method to help reduce discordant sounds is direct communication with hard-to-hear aging individuals. By moving into a field of vision and commanding eye attention before speaking, and then speaking slowly and distinctly, hearing-impaired people may display better awareness and/or comprehension. Sounds (and the inability to hear noises) have the capacity to interact with other sensorial inputs (olfactory, tactile and/or visual) to complement or potentially compensate for some losses. For example, foods that crunch may integrate with the sense of smell and taste and the sensation of touch, when fresh fruit is consumed. Think of the aroma, crunch and taste of a fresh apple or pear.

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Likewise, a blind individual may hear the sounds of foods to offset their loss of eyesight, such as popping corn or sizzling steak. Hearing-impaired people may rely more on tactile sensations to inform them of how foods and beverages are supposed to sound, such as carbonation, fractured ice or crispy chips. By keeping external sounds to a minimum or nonexistent, and by adjusting for any individual sound sensitivities, some of the effects of age-related auditory deficits on meal enjoyment may be controlled. Beverage and food intake and socialization may show some improvements [10].

Touch/Textural Factors The sense of touch is a powerful sensation but may be overlooked as a viable matter in environments where people age. This may be due to the fact that changes in tactile sensitivity tend to occur later with aging than auditory or visual changes. Touch has the capacity of producing positive emotions that may promote attachment security, general health, happiness, relationship satisfaction, social support and/or well-being [11]. The sense of touch brings awareness of body positions, pain, pressure, temperature and/or vibrations. With decreased blood flow to the nerve endings in the feet, hands, internal organs, joints, muscles and nerve endings and tendons to the spinal cord or brain, aging people may experience differences in temperatures and textures. The spinal cord transmits these nerve signals, and the brain is responsible for the interpretations of these signals.

Preventing Risks and Injuries Minimal differences of sensations may manifest in the inabilities to detect that surfaces are slippery, or to distinguish that water is cold or hot. This may increase the risks of burns, hypothermia and/or frostbite. The reduced ability to detect pressure, touch and/or vibrations may increase the risks of injuries that cause wounds. Some of these may eventually lead to pressure ulcers (sores that develop on the skin due to pressure that cuts off the blood supply). Pain threshold may increase with aging that may make it more difficult to identify pain or its severity. Falls may increase since the ability to discern one’s body position in relation to the floor may decrease. Some of the compensatory protective measures that may be implemented to help prevent injuries if touch is compromised include the following: • • • • • •

Affix a smart thermostat with large font. Cover faucets with protective covers with glow-in-the-dark labels that indicate hot or cold. Fit grab bars and install bathrooms seats if they are affordable and where this is possible. Lower water heater temperature to no higher than 120 F (49 C). Mount protective corners and handles with rounded edges. Use skidproof materials as needed in the bathroom and/or kitchen.

Flooring and window coverings may also impact textural sensations. Blinds, shades and drapes should be lightweight to handle and easily accessible to open and shut for natural light. A light-blocking layer may help prevent the extremities of early morning and late afternoon sunlight from eastern exposures. Flooring should be nonslip and easy on the feet in solid colors or muted patterns to help to reduce any visual ambiguity. Flooring should also contrast in color and textures from the walls and thresholds for clear navigation. A doorway threshold painted a different color altogether may guard against accidental turns. Any torn or worn carpeting on stairs should be immediately replaced to help prevent slippage. Marking the edge of stairs may assist visual orientation. A “landing pad” at the top and bottom of the stairs may be useful. Railings that run along stairways may be added or reinforced for extra support. Round door knobs, while common, may be difficult to grip, so lever adapters that are clamped around these door knobs may be easier to maneuver. Tables and chairs may increase or decrease tactile experiences. While they may be sanitary, hard-surfaced chairs and tables may feel like institutional furniture. Chair cushions, placemats and/or tablecloths that may be more prone to germs may add a more comfortable, homey and/or textural feel. These items should be regularly cleaned or washed and discarded if they are heavily stained with foods and/or beverages.

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This should not discourage their use! Providing aging people with items to touch or fold (such as textured napkins or table coverings, rounded utensils and special dishes) may help to evoke pleasant memories, and promote greater interest in dining and socialization.

DINING ROOMS IN ASSISTED LIVING FACILITIES One of the central spaces in assisted living facilities is the dining room for conversing, eating and drinking and gathering. A supportive dining environment takes the following issues into consideration: familiarity and home-likeness, functional abilities, orientation safety, personal control, privacy, security, sensory stimulation, social interactions and others. Dining rooms may range in ambiance from an upscale hotel restaurant to a comfy home kitchen, and may reflect the identity of the facility and its residents. A dining room with a high comfort level may have linen tablecloths, china tableware, glass water goblets and/or fresh flowers. A more realistic dining area may display washable cloths, plastic tableware and/or artificial flowers that may be still assembled with loving care. By enjoying meals in comfortable environments that are devoid of television, phones, computers and/or other distractions, people who are aging may benefit from attaining certain self-constructs such as those given in Table 11.5. TABLE 11.5 Self-Constructs That Encourage Positive Dining for Aging People • Self-Actualization—The dining environment encourages mindful choices, and positive relationships within dining experiences, with regard to the sense of self and longevity, social integration and/or wellness. • Self-Dependence—The dining environment supplies the foods, beverages and dining equipment that are necessary for eating and drinking, the maximization of self-dependence, and the optimization of selfperformance. • Self-Esteem—The dining environment encourages self-respect and respect for others through effect applications of beverage, food, companion and/or dining choices. • Self-Expression—The dining environment fosters meaningful opportunities for problem solving and cognition and emotional benefits in food and beverage selections, the setting of routines such as meal and/or snack times, the choice of dining companions or lack thereof and encouragement of social interactions among other diners and/or care providers. • Self-Identity—The dining environment encourages residents to choose their ideal dining situations: who to dine with, what to eat or drink, the timing of meals and/or snacks and other factors that may be connected to ethnicity, family preferences and/or meaningful memories. • Self-Preservation—The dining environment distinguishes the biological needs of individuals, whereby beverages and foods sustain life in physically compatible and caring environments.

In a very broad sense, these self-constructs and actualizations may help to alleviate certain conditions and diseases, augment the immune system, improve some nutritional habits and reduce some selective malnutrition. This is because the feelings that may be evoked, while more esoteric in quality, may have the capacity to affect real-life symptoms, conditions and/or disease states. In turn, undesired or unintentional weight loss that may precipitate other conditions or diseases, debilitating falls and injuries and/or depression may be reduced. Chemosensory stimulation, nutrition knowledge, role modeling and social facilitation may individually or collectively stimulate food and beverage intake. However, the effects of such factors as eating location, portion size and labeling are not as well defined [12].

IMPROVING APPETITE WITHIN DINING ENVIRONMENTS TO ENHANCE AGING APPETITES While different conditions, diseases, medications and procedures, along with emotional and mental states may individually and collectively affect the appetite in aging people, there may still be some changes that may be

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made within various dining environments for appetite enhancement. These include the following 15 recommendations: 1. Choose the best dining locations, depending on individual needs. If aging people are at home, is the kitchen or a dining area best? Is the television area away from where dining occurs, or does it detract from focusing on the dining experience? In care facilities, does the dining area facilitate a well-lit table for diners, or are they positioned at the periphery in the darkness? In either dining environment, is there room for a wheelchair for seating and/or maneuvering? 2. Continue feeding efforts with different methods. It may take multiple efforts to prepare beverages, foods and snacks to residents in dining environments that are both appealing and nutritious. By changing the aromas, tastes and textures of foods and beverages, and by altering their compositions, they may become more appealing to aging people. For example, the taste and/or texture of green beans may be disliked, but once they are steamed, chopped and combined with vinaigrette dressing, or saute´ed in olive oil with onions and sweet red bell peppers, their perception and consumption may change. Another example involves the bitter taste that is predominant in bitter vegetables such as arugula, artichokes, broccoli, eggplant and/or kale. Often the sight or smell of these foods may turn off appetites and attitudes. But if they are incorporated into flavorful casseroles, soups or stews, their appearances may change, their bitter tastes may dissipate into other tastes and their subsequent flavors may be enjoyed. 3. Discover ways for care providers and/or residents to contribute. Contribution yields belonging. Meal and snack times provide opportunities to residents to assist in the preparation, serving and/or cleaning up after meals if people are able to participate. Table setting, pulling the chairs out for others, passing lighter-weight bowls or platters of foods and/or the clearing plates may be reserved for sturdier residents. Other people may choose to do mealtime planning, lead an appreciative statement about food before eating, or spearhead an activity that is related to the meal, such as cookie decorating or an ice cream sundae bar. Whatever the role or task, this may heighten resident involvement and activate further interest in eating and drinking. 4. Eliminate distractions. Some people might find that a stack of reading material provides them with a pastime while they eat. To others, a pile of papers may be distracting. The same holds true about television and/or music that may bombard the senses: some people may enjoy its companionship while others may find the noise confusing. At home, choose what is best for the resident. In care facilities, the choice may not be individually determined, but preference should be communicated. 5. Encourage activity. If possible, a short walk before a meal, breath of fresh air or both may invigorate a person’s appetite and bring interest to dining. Moderate exercise may also improve balance, reduce stress and correct sleep problems, which may also help to revitalize the appetite. 6. Engage residents in menu selections. When and if possible it may be helpful for residents to learn about nutritious menu offerings, and for them to partake in their own healthy meal and snack selections. Since one of the factors in improving food and beverage intake is nutrition knowledge, the engagement in menu planning may help to provide residents with a sense of belonging, choice and empowerment in their dining experiences. 7. Enhance all of the senses in the dining experience. These include sight (the appearance of foods and beverages and the table setting); hearing (the music and sounds that occur throughout the dining room and at the table); smell and taste (the chemosensation of foods and beverages and the room aromas); and touch (the somatosensation of foods and beverages and the tableware). Make sure all foods and beverages are served at the best temperature that is possible for dining enjoyment. 8. Establish a regular daily eating schedule for meals and snacks. Residents need to know the schedule when to arrive for meals and snacks, or if this schedule needs accommodation for medications or supplements. A timer with a simple alarm may be set for reminders. Either the resident may be able travel to the dining environment on her/his own, or a care provider may offer assistance.

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9. Increase the nutrient density of foods and beverages. Nutrient density is the proportion of nutrients in foods that are nutrient rich and micronutrient dense. Unless someone is underweight and needs additional calories, nutrient density is more vital than calorie (energy) density, a measure of the calorie content of foods and beverages that is relative to their weight or volume. This may be accomplished by choosing whole foods that are more nutrient dense than calories dense. For example, some entre´e salads combine a three-ounce portion of grilled fish, meat or poultry with one cup of iceberg lettuce and a token tomato slice. Rather than doubling the protein, or adding extra salad dressing at 100 calories per tablespoon, make sure that the greens are deep and leafy and that the tomatoes are ruby red to maximize their nutrient potentials. Refer to Chapter 9, Culinary Considerations for the Aging, andChapter 10, Menus and Recipes That Appeal to Aging Palates, for other nutrient-enhancing and proportional ideas. 10. Know what to look for on a healthy plate for aging people. Consult Chapter 8, Meeting Nutritional and Disease-Specific Needs of Aging, to correlate age-appropriate beverages and foods for the aging with specific nutritional needs, conditions and/or disease states. Then follow the recommended servings and portion sizes for the aging to perceive what comprises a “healthy plate.” 11. Make judicious use of beverages. If fruit juice is provided, limit consumption to small amounts since it is concentrated in sugar calories. Select smoothies to boost calories and nutrients, not to replace them, unless there are chewing and/or swallowing problems. Drink coffee and/or tea after meals or snacks, rather than before, since they may be filling from sweeteners and/or cream or milk, and crowd out other nutrients. 12. Note medication side effects. If residents complain that meals “have off-tastes” medications should be checked for potential interactions. For example, a side effect of some medications might precipitate a metallic taste after eating meat, while other protein foods, such as dairy products, eggs, fish or legumes, may taste more pronounced. Chemotherapy may require a specific set of dietary protocol to combat side effects that may include the chemosensory changes of smell and/or taste. If a medication schedule is known in advance, some dishes may be individualized, but last-minute accommodations may be stressful to residents and the food service staff alike. If some or all medications are discontinued, then some food plans may be redesigned or returned to normal. The assistance of a Registered Dietitian/Nutritionist or other health care professional with dietary knowledge as it relates to specific diseases is recommended. 13. Practice simplicity. Use simple tablescapes with plain tableware to let foods and beverages star with their appealing colors, shapes and textures to accommodate decreasing eyesight. Likewise, scale down the number of ingredients in some recipes to allow the foods to be recognizable. Garnishes should represent the contents of the recipes and communicate to diner what is contained within their mixtures. 14. Promote social interaction at meals and snacks. Scheduling regular attendance in dining environments may encourage more social interactions among other residents, family, friends and/or care providers. Celebrations of birthdays, anniversaries, friendships and other meaningful occasions may help to promote community. If at home, a social network through community, religious or volunteer organizations may be supportive. 15. Use/do not use certain utensils as determined. Though eating with dignity generally means using the same utensils that aging people have used all of their lives, occasionally adaptive utensils may be more helpful. This is because some of the appreciation and enjoyment of foods is conveyed by the sense of touch, and if aging people cannot eat normally with utensils, then this pleasure may be compromised. Many handy adaptive utensils were described earlier in this chapter. Or, serve healthy handheld meals and snacks available as suggested in Chapter 9, Culinary Considerations for the Aging. Sandwiches may have been cut with a fork and knife at some point in culinary history, but the act of picking up and biting the right-sized sandwiches is generation-appropriate and may heighten meal enjoyment.

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Also . . . Take advantage of supplements. While solid foods should be given preference and consumed first for good nutrition, liquid supplements may be warranted if the diet is shortchanged. Liquid supplements should augment, rather than eliminate, a meal to enhance the dining experience. This may be of particular importance in care facilities where socialization and shared meals are featured. The use of texturized foods is both a medical and personal consideration that may be better executed in privacy [13].

DIGEST Whether on a tight budget at home, or with a supportive community of care, age-adjusted cooking aids, tableware and other equipment may enhance the dining experiences of aging people. Resources for accessing many of the items discussed in this chapter can be found in Chapter 12, Prime Time Resources for Aging, Taste and Health. They run the gamut from relatively inexpensive vegetable peelers to costlier ergonomic pots and pans. Still, some favorite worn-out items may be preferred before foreign models. Sometimes, simple changes in the ambiance of dining environments and/or the daily menus can prompt behavioral changes and improve food and beverage intake. Other times, more complex changes may be required to address individual needs and desires. By working with compassionate care providers, family members, food service personnel, friends and/or medical providers, unified strategies may precipitate better-quality consumption. As people live longer in different environments and under diverse circumstances, this may be the norm.

MANNER OF SPEAKING Age (Aging) in Place Ambient Light Campylobacter

Clostridium botulinum

Clostridium perfringens

Cooktop (Stovetop) Fire Suppressors Escherichia coli (E. coli)

Hemiparesis (or Unilateral Paresis) Hemiplegia Hub and Motion Sensors Listeria

Norovirus

term to describe a person who is living in their residence of choice for as long as they live; usually in their home light that is already present before any other light is added infectious disease that is caused by the bacteria of the genus Campylobacter; often due to eating raw or undercooked poultry, contaminated water or unpasteurized milk Gram-positive anaerobic bacterium that may develop in home canned, preserved or fermented foods; may produce the neurotoxin botulinum, a life-threatening bacterial illness that attacks the body’s nervous system spore-forming Gram-positive bacterium; may be found in decaying vegetation, marine sediment, raw meat and poultry and the intestinal tract; may cause gastrointestinal symptoms and complications devices that can be placed under cabinets, custom hoods, microwaves or vent hoods at various heights to suppress fires Gram-negative anaerobic bacterium; transmitted through contaminated food or water or contact with animals; may cause blood, gastrointestinal, respiratory and/or urinary tract infections weakening of one entire side of the body; caused by congenital causes, stroke, trauma, tumors or other factors paralysis of one side of the body; usually on the side opposite the affected part of the brain apparatus that recognizes changes in the environment and notifies the hub that changes have been detected bacteria found in some animals that include cattle and poultry, soil and water; may be present in raw milk; destroyed by cooking and/or pasteurization very contagious virus passed from contaminated food, surfaces, water or infected persons; may cause gastrointestinal illnesses—some with serious complications

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Pot Watcher Pressure Ulcers (also known as bedsores, decubitus ulcers, pressure injuries or pressure sores) Salmonella

Staphylococcus aureus (Staph) Vibrio

cooking tool placed in pot of water; rattle when water is boiling to prevent it from spilling over the edge localized damage to skin and/or underlying tissues; result from friction, pressure and/or shear group of bacteria that commonly cause food poisoning; affects the gastrointestinal tract; typically found in animal and human intestines from contaminated food or water anaerobic bacteria found in the nose, respiratory tract and on the skin; commonly cause of skin and respiratory infections and food poisoning Gram-negative bacteria that may cause foodborne illness; associated with undercooked seafood and seawater

References [1] L Esposito. Holiday dinner with dementia. USNews Health, 2016. ,https://health.usnews.com/wellness/aging-well/articles/2016-1223/holiday-dinner-with-dementia. [accessed 07.09.18]. [2] Kitchen ideas for aging in place. AGEINPLACE, ,https://ageinplace.com/at-home/aging-in-place-home-ideas/kitchen/.; 2018; Somers M. Kitchen safety for seniors. Comfort Keepers, Silver Planet. Web; 2010; Kitchen safety. Age in Place. Web; 2015; Elderly safety considerations for the kitchen, Boomers with Elderly Parents. Web; 2016, ,http://traversecity-615.comfortkeepers.com/Assets/aging/ pdfs/KitchenSafetyforSeniors.pdf. [accessed 07.09.18]. [3] Top 7 home safety tips for the kitchen. Householdguardians, ,http://householdguardians.com/safety-tips/kitchen/top-7-home-safetytips-for-the-kitchen/.; 2016 [accessed 07.09.18]. [4] Seniors and kitchen safety: tips for the. ComfortKeepers; 2004; Kitchen safety for seniors. 2016 Somers M. Kitchen safety for seniors. Comfort Keepers, Silver Planet. Web; 2010; Kitchen safety. Age in Place. Web; 2015; Elderly safety considerations for the kitchen, Boomers with Elderly Parents. Web; 2016; Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Foodborne, Waterborne, and Environmental Diseases (DFWED). Foodborne illnesses and germs. What causes food poisoning? Centers for Disease Control and Prevention, ,http://www.comfortkeepers.com/home/info-center/senior-independent-living/seniors-and-kitchen-safety-tips-for-the-heart-of-t. [accessed 07.09.18]; page last reviewed: December 20, 2017, page last updated: February 16, 2018, ,https://www.cdc.gov/foodsafety/foodborne-germs.html.. [5] Harvard health letter: Tools to make yoiur life easier. Harvard Health Publishing, ,https://www.health.harvard.edu/aging/tools-tomake-your-life-easier.; 2015; Products and services: Hand tremors: adaptive utensils and eating aids. DailyCaring, LLC, ,http://dailycaring.com/hand-tremors-adaptive-utensils-eating-aids/.; 2018 [accessed 07.09.18]. [6] Grant S. Lightweight cookware for the elderly and seniors with ergomonic handles that are easier to use, too! Graying with grace, ,https://www.grayingwithgrace.com/lightweight-cookware-elderly-seniors/.; 2017 2018; The engineering handbook of smart technology for aging, disability, and . . . edited by Helal A, Mokhtari M, Abdulrazak B. John Wiley & Sons, ,https://books.google.com/ books?id 5 NpldsRcAY9oC&pg 5 PA136&lpg 5 PA136&dq 5 vibrating 1 timer 1 device 1 for 1 aging 1 people&source 5 bl&ots 5 5tlrspI7v&sig 5 0peQ3LhanMzUx6BqGL-FZHYYvdM&hl 5 en&sa 5 X&ved 5 0ahUKEwjlkpXjq7zZAhWkpFkKHeT-C2UQ6AEIdzAE#v 5 onepage&q 5 vibrating%20timer%20device%20for%20aging%20people&f 5 false.; 2008 [accessed 07.09.18]. [7] Grant S. Best kitchen utensils for arthritic hands: reducing pain and injuries at the same time. Graying with grace, ,https://www. grayingwithgrace.com/kitchen-utensils-for-arthritic-hands.; 2017 2018; Fillmore D. Dishes and table settings can prevent distracted dining. Gordon Food Service, ,https://www.gfs.com/en-us/ideas/dishes-and-table-settings-can-prevent-distracted-dining.; 2017; Kitchen of the future: remodeling for comfortable aging in place, AgingInPlace. Survey: What makes a community livable? ,http:// www.aarp.org/livable-communities/info-2014/aarp-ppi-survey-what-makes-a-community-livable.html.; 2010 census, ,http://www. census.gov/2010census/.; Fall-prevention measures can keep older adults independent, ,http://www.nsc.org/learn/safety-knowledge/Pages/safety-at-home-falls.aspx.; Your Kitchen is trying to kill you—Injury statistics [INFOGRAPHIC], ,https://www.foodbeast.com/news/your-kitchen-is-trying-to-kill-you-injury-statistics-infographic/.; 2016 aging-in-place report, ,http://www. homeadvisor.com/r/2016-aging-in-place-report/#.WT7rDuvyvIU2017.; Kitchen of the future: remodeling for comfortable aging in place, ,http://www.aginginplace.org/kitchen-of-the-future-remodeling-for-comfortable-aging-in-place/. [accessed 07.09.18]. [8] Shreeves R. Your perception of food is altered by environmental factors. mnn.com, ,https://www.mnn.com/food/healthy-eating/ blogs/your-perception-food-altered-environmental-factors.; 2016 [accessed 07.09.18]. [9] 30 Lighting tips for seniors. How proper lighting will help your aging eyes regain their youthful performance? Lampsusa.com, ,https://www.lampsusa.com/blogs/how-to-and-tips/14251557-25-lighting-tips-for-seniors.; 2018; Light, its use and misuse. Illuminating Engineering Society; 1912, p. 17; Lighting your way to better vision. IES.org; 2009, p. 3; Cordain L, et al. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr 2005;81(2):341 54. What’s the deal with retirement communities? Breeding B; 2014. [10] Christenson M, Taira ED. Aging in the designed environment. Routledge, April 8, 2014, Family & Relationships, 146 pages, ,https:// books.google.com/books?id 5 HfdQAwAAQBAJ&pg 5 PA19&lpg 5 PA19&dq 5 sound 1 in 1 the 1 environment 1 of 1 aging 1 diners& source 5 bl&ots 5 legMpqiaa3&sig 5 sg1usy92AQojXs0a3wFVXFuXIJc&hl 5 en&sa 5 X&ved 5 0ahUKEwjiqr2srMTZAhXwp1kKHXqgAUoQ6AEIQTAD#v 5 onepage&q 5 sound%20in%20the%20environment%20of%20aging%20diners&f 5 false.[accessed 07.09.18]. [11] US National Library of Medicine. Aging changes in the senses, MedlinePlus, ,https://medlineplus.gov/ency/article/004013.htm.; 2018 [accessed 07.09.18]. [12] Brownie S, Horstmanshof L. Creating the conditions for self-fulfilment for aged care residents. Nurs Ethics 2012;19(6):777 89. Available from: https://doi.org/10.1177/0969733011423292.

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[13] Stevenson S. Loss of appetite in the elderly. aPlaceforMom, March 29, 2016. ,https://www.aplaceformom.com/blog/01-23-2013-loss-ofappetite-in-elderly/.; Common aging conditions. 6 Ways to get seniors with no appetite to eat. DailyCaring, ,http://dailycaring.com/ 6-ways-to-get-seniors-with-no-appetite-to-eat/.; 2018; Greenlaw E. Maintaining a healthy appetite. WebMD Feature, reviewed by Cassoobhoy A; 2013 Zelman K, Coste JK (author, Learning to Speak Alzheimer’s), Palmer C. National Institute on Aging web site, “Healthy Eating After 50.” Colorado State University Extension web site, “Nutrition and Aging.” ,https://www.webmd.com/healthyaging/features/maintaining-appetite#1.. Chaudhury H, Hung L, Badger M. The role of physical environment in supporting personcentered dining in long-term care: a review of the literature. Am J Alzheimer’s Dis Other Dementias 2013;28(5):491 500. StroebeleBenschop N, Depa J, de Castro JM. Environmental strategies to promote food intake in older adults: a narrative review. J Nutr Gerontol Geriatr 2016;35(2):95 112. Frankowski AC, Roth EG, Eckert JK, Harris-Wallace B. The dining room as locus of ritual in assisted living. Generations 2011;35(3):41 6. Nutrition and seniors: eating together for healthy aging, SilverMaples, ,https://silvermaples.org/nutrition-and-seniors-eating-together-for-healthy-aging/.; 2017 [accessed 07.09.18]; Ronch JL, Dining, memory and aging: food for thought, ,https://www.pioneernetwork.net/wp-content/uploads/2016/10/Dining-Memory-and-Aging-Food-for-Thought.pdf..

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PHOTO: Kitchen Scale. r 2019 Grace Natoli Sheldon. Reprinted with permission.

Pearl of Wisdom: I would rather eat a little bit of very flavorful food than big portions—why can’t servings be smaller?

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LEARNING OBJECTIVES 1. Recognize the government agencies, educational institutions, medical organizations, social service agencies and other informational and action-oriented groups that function to assist aging people. 2. Differentiate among the diverse options for information and support, based on advice, comparisons, critiques, length of operation, medical and scientific validity, reputation and other variables. 3. Select suitable alternatives based on individualized needs. 4. Utilize knowledge, programs, services, tools and other applications as applicable and needed. 5. Evaluate choices based on fulfillment of individual and/or institutional benefits.

SUMMARY To comprehensibly provide additional resources, from government agencies and educational institutions and other nonprofits to housewares and food and beverage manufacturers, for nourishing aging people enjoyably, healthfully and safely, while attending to their health care and determining disability and end-of-life choices.

INTRODUCTION When aging people and those that care for them require information on such subjects as autoimmune disorders, the brain, dental and oral health, the digestive system, the ears, eyes, nose and throat, the endocrine system, the heart and blood vessels, the kidneys and urinary tract, the lungs and respiratory system, masculine and feminine issues, medical care, mental health, the muscles and bones, the nervous system and the skin, sometimes they do not know where to turn for advice. While the Internet is handy, it may be difficult to discern accurate and reliable health information. Users should consider the sources, try to separate the facts from sensationalism, check the dates of websites to make sure that they are current and/or when the contents were updated, cross-compare ideas and opinions, look for resources and doubt many advertisements. Online diagnoses and/or prescribed therapies should be avoided. So should registering personal information for online care. In this chapter, an array of voluntary, nonprofit and professional organizations are provided with details that (1) describe what these organizations do, and (2) why aging people and/or their care providers, family and friends might be inclined to contact them for more information. Contact information is not provided so that this information is accurate and timely. This may be convenient to locate online or through healthcare providers. Many of these organizations vary greatly in what they deliver, be it education for professionals, guidelines for caregivers or practical tips or techniques for aging people themselves. Specific illnesses, health information, treatment options, physician or specialist referrals, support groups and answers to common questions may be identified and sometimes rectified, or otherwise, not.

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A medical history, physical examination and diagnostic tests are needed before any diagnosis is made and recommended treatment(s) are presented. A second or third opinion is common, especially when a clear diagnosis is not evident; the condition or disease is rare, the side effects may be significant, the recovery demanding and/or the options confusing or compounding. The information that follows should not be construed as an endorsement of any of these resources, but as an opportunity to become enlightened about the many choices that exist.

EDUCATIONAL INSTITUTIONS, ORGANIZATIONS AND SUPPORT GROUPS A THROUGH Z A countless number of educational institutions, organizations and support groups exist in the United States and internationally that are dedicated to aging people and their conditions, diseases, health and welfare. Many have long histories, while others are relatively new or in transition. The following listing from A through Z represents what was current at the time of this writing. Contact the resources for updates.

How to Use These Citations These resources are provided in alphabetical order for easy access. Next to each Name is an Acronym when there is one available. Also provided in italics is a general Subject Area for classification. The Purpose and Value of each entry are then given. The source for each entry is listed in the References at the end of the chapter. For example: NAME AND SUBJECT AREA: Administration on Aging (AOA)—General Information on Aging PURPOSE AND VALUE: Purpose: The Administration on Aging (AOA) is the principal agency of the US Department of Health and Human Services (USDHHS) that is designated to carry out the provisions of the Older Americans Act of 1965 (OAA) as amended. Value: The Older Americans Act of 1965 (OAA) promotes the well-being of older individuals by providing services and programs designed to help them live independently in their homes and communities [and] empowers the federal government to distribute funds to the states for supportive services for individuals over the age of 60 [1].

A Through Z Resources A Academy of Nutrition and Dietetics (AND)—Nutrition Purpose: The Academy of Nutrition and Dietetics is the world’s largest organization of food and nutrition professionals that are committed to improving the nation’s health and advancing the profession of dietetics through advocacy, education and research. Value: Dietetics practitioners work in business, educational organizations, foodservice, healthcare systems, home health care, research and in private practice. As vital members of medical teams in health maintenance organizations, hospitals and long-term care facilities, registered dietitians/nutritionists provide medical nutrition therapy through the use of specific nutrition services to treat chronic conditions, injuries and/or illnesses. Community-based dietetics practitioners provide disease prevention, health promotion and wellness services. The Academy of Nutrition and Dietetics Evidence Analysis Library is an online resource of systematic reviews and evidence-based nutrition practice guidelines for registered dietitian/nutritionists and other members of healthcare teams [2]. Acoustic Neuroma Association (ANA)—Hearing Purpose: The Acoustic Neuroma Association was founded to provide easy-to-read medical materials about the condition of acoustic neuroma, comfort and support. Acoustic neuroma, also called vestibular schwannoma, is a rare, noncancerous tumor that does not metastasize to other parts of the body. It may manifest as tinnitus and often disturbances in hearing in one ear.

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Value: The Acoustic Neuroma Association (ANA) is patient-focused, patient-founded and patient-funded. It serves acoustic neuroma patients, family members, friends and healthcare professionals, and provides information about acoustic neuroma for all treatment types [3]. Administration on Aging (AOA)—General Information on Aging Purpose: The Administration on Aging is the principal agency of the US Department of Health and Human Services (USDHHS) and is designated to carry out the provisions of the Older Americans Act of 1965 (OAA) as amended. Value: The Older Americans Act of 1965 (OAA) promotes the well-being of older individuals by providing services and programs designed to help them live independently in their homes and communities [and] empowers the federal government to distribute funds to the states for supportive services for individuals over the age of 60 [4]. Aging and Disability Resource Centers (ADRCs)—General Information on Aging Purpose: Aging and Disability Resource Centers serve to raise the visibility about the full range of available options for aging and disabled people. They provide advice, counseling and assistance, empower aging and disabled people to make informed decisions about their long-term services and supports, help the aging and disabled access public and private programs and supply objective information. Value: Aging and Disability Resource Centers (ADRCs) throughout the United States seek to address the frustrations that many older adults, people with disabilities and family members experience when they try to learn about and access long-term services and supports. Aging and Disability Resource Centers (ADRCs) provide unbiased, reliable information and counseling to people with all levels of income [5]. Administration for Community Living (ACL): Nutrition Services [US Department of Health & Human Services (USDHHS) Administration on Aging (AOA)]—General Information on Aging Purpose: (also see Administration on Aging) The Administration for Community Living independent living programs work to support community living and independence for people with disabilities. This is so that aging, disabled people may be able to fully participate in society, live with dignity and make their own choices. Value: These independent living programs help to provide resources, support and tools for fully integrating people with disabilities into their communities to promote equal opportunities, respect and self-determination [6]. Aging Life Care Association (ALCA)—General Information on Aging Purpose: The Aging Life Care Association is a nonprofit association that seeks to be the leading community of Aging Life Care Professionals through education, high ethical standards and professional development. Value: The Aging Life Care Association (ALCA) develops expertise, enhances the successes of its members, shares a unique knowledge base, and promotes the interests of the Aging Life Care profession where adults and families live well as they face the challenges of aging [7]. Aging with Dignity (AWD)—General Information on Aging Purpose: Aging with Dignity is a private nonprofit organization with a mission to safeguard the human dignity of people as they age or face serious illness—especially those people who want to plan for care in advance of a health crisis. Value: Aging with Dignity (AWD) offers advocacy (by encouraging public policies that protect the rights of individuals and families), action (through educational workshops to help people care for those who they love and received dignified care in case of serious illnesses) and support (by free information and guidance to families, individuals and organizations). No individual is ever denied any resource because of insufficient finances [8]. Al-Anon—Substance Use and Abuse Purpose: Al-Anon provides help and hope for families and friends of alcoholics that may be affected by a person’s drinking, no matter what specific experiences may be. Value: Many people who attend Al-Anon meetings may be feeling despair, hopelessness, and/or are unable to believe that behaviors or events may ever change. By sharing experiences, hopes and strengths with others who share similar feelings and frustrations, a better way of life and happiness may be reached [9]. Alcoholics Anonymous (AA)—Substance Use/Abuse Purpose: Alcoholics Anonymous is an international fellowship of people who have had a drinking problem. It is apolitical, multiracial, nonprofessional, self-supporting and widely available without age or educational requirements. Value: Membership in Alcoholics Anonymous (AA) is open to anyone who wants to improve their drinking problems. The basic text Alcoholics Anonymous (AA) embodies is Twelve Steps, a group of principles that are spiritual in nature that help to banish the obsession to drink and enable the alcoholic to become happily and usefully whole [10]. Alexander Graham Bell Association for the Deaf and Hard of Hearing (AG Bell)—Hearing

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Purpose: The Alexander Graham Bell Association for the Deaf and Hard of Hearing is an advocate for listening, learning and talking, living independently with hearing loss, and a resource and support network. Value: Alexander Graham (AG) Bell promotes the usage of the spoken language and hearing technology for people who are deaf and hard of hearing so that some people may eventually be able to hear and/or talk. It aims to supply information and support for families, help for appropriately qualified professionals to teach and assist those with hearing loss, and support for policy leaders to effectively address the needs of people with hearing loss [11]. Alliance for Retired Americans (ARA)—General Information on Aging Purpose: The Alliance for Retired Americans is a national grassroots organization that advocates a progressive political and social agenda to ensure social and economic justice and full civil rights for all citizens, so that they may enjoy lives of dignity, personal and family fulfillment and security. Value: The Alliance for Retired Americans (ARA) uses the power of its membership to educate and mobilize aging people to elect leaders that are committed to the improvement of the lives of retirees and older Americans on such issues as consumer protection, health care, housing, prescription drugs, retirement security and transportation [12]. Alzheimer’s Disease Research Center (ADC)—Alzheimer’s Disease Purpose: The National Institute of Aging funds Alzheimer’s Disease Research Centers (ADCs) at major medical institutions throughout the United States to translate research advances into improved diagnosis and care for people with Alzheimer’s disease and discoveries about cures and prevention measures. Value: The Alzheimer’s Disease Research Centers (ADCs) offer information about the diagnosis of Alzheimer’s disease and its medical management, opportunities for volunteers to participate in clinical trials and studies, Alzheimer’s disease resources, services and support groups and other special programs for families and volunteers [13]. Alzheimer’s Association (AA)—Alzheimer’s Disease Purpose: The Alzheimer’s Association is the largest national voluntary health organization that is dedicated to funding research into the causes, prevention, treatments and potential cures of Alzheimer’s disease, along with support for Americans with Alzheimer’s disease and their care providers and families. Value: The Alzheimer’s Association (AA) provides care and support to people who are affected by Alzheimer’s disease and other dementias, along with comprehensive online resources, educational sessions, faceto-face support groups, a library and resource center, with nationwide local chapters, a professionally staffed helpline and online message boards [14]. American Academy of Allergy, Asthma & Immunology (AAAI)—Allergies, Asthma and Immunology Purpose: The American Academy of Allergy, Asthma & Immunology is a professional medical membership organization that is dedicated to the advancement of the knowledge and practice of allergy, asthma and immunology for optimal patient care. Value: Through funding research and training, presenting the latest advances, meeting high standards and recording history, the American Academy of Allergy, Asthma & Immunology (AAAI) serves its members and ultimately the public with the knowledge and tools for optimum care [15]. American Academy of Dermatology (AAD)—Hair, Nails and Skin Purpose: The American Academy of Dermatology is an influential and representative dermatology group that promotes excellence in patience care and leadership in dermatology through advocacy, education and research. Value: Collaboration, creative work, diversity, lifelong learning, patients first, professionalism, rigorous inquiry and social responsibility are the values that the American Academy of Dermatology (AAD) extols throughout all of its programs and initiatives. Information on skin diseases and treatments and how to SPOT skin cancer, hair, nail and skin care and a kid’s zone and library are some of the varied resources [16]. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF)—Head and Neck Purpose: The American Academy of Otolaryngology-Head and Neck Surgery helps members to achieve excellence, and provides ear, nose and throat care through health policy advocacy, professional and public education and research for patient benefits. Value: The medical disorders that are treated by American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) physicians include allergies, chronic ear infections, dizziness, head and neck cancer, hearing loss, hoarseness, nosebleeds, sinusitis, snoring and sleep apnea and swallowing disorders [17]. American Academy of Orthopedic Surgeons (AAOS)—Bones and Muscles Purpose: The American Academy of Orthopedic Surgeons is a provider of musculoskeletal education to orthopedic surgeons through communications, international initiatives, partnerships, research and technology. Value: The American Academy of Orthopedic Surgeons (AAOS) keeps the world in motion though the prevention and treatment of musculoskeletal conditions by strategic efforts in accountability, advocacy, education, membership, organizational excellence and quality and patient values [18].

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American Academy of Periodontology (AAP)—Gums and Teeth Purpose: The American Academy of Periodontology is concerned with the diagnosis, prevention and treatment of diseases that affect the gums and supporting structures of the teeth and in the placement of dental implants. Value: The American Academy of Periodontology (AAP) helps to advance the general health and periodontal issues of the US public and to achieve optimal oral health through awareness (advocacy), membership (resources), science (evidence-based treatments) and viability (collaborations) [19]. American Academy of Sleep Medicine (AASM)—Sleep Purpose: The function of the American Academy of Sleep Medicine is to achieve optimal health through better sleep. Value: The American Academy of Sleep Medicine (AASM) seeks to improve sleep health by the promotion of high-quality patient care through advocacy, sleep education, best practice standards, learning resources, sleep medical care and strategic research [20]. American Association of Diabetes Educators (AADE)—Diabetes Purpose: The American Association of Diabetes Educators services dietitians, exercise specialists, nurses, pharmacists and others to improve diabetes care through innovative education, management and support. Value: The American Association of Diabetes Educators (AADE) creates optimal health and quality of life for persons with, affected by, or at risk for diabetes and other chronic conditions via advocacy and reimbursement, awareness programs, professional development, practice publications and research [21]. American Association of Endodontists (AAE)—Dentistry Purpose: The American Association of Endodontists acts as a global resource for the education, knowledge and research of the profession of endodontics (the study and treatment of dental pulp), its members and the public. Value: The membership of American Association of Endodontists (AAE) is composed of endodontists who are specialists in saving teeth, with specializations in the techniques and technologies to perform root canal treatments and to diagnose and treat tooth pain [22]. American Association of Kidney Patients (AAKP)—Kidney (Renal) Function Purpose: The American Association of Kidney Patients acts as an independent voice of kidney patients since 1969. It is dedicated to the improvement of the quality of life for kidney patients through advocacy, education, the fostering of patient communities and patient engagement. Value: The work of American Association of Kidney Patients (AAKP) has improved the long-term outcomes in the quality of health and the abilities of patients and family members to lead more productive and meaningful lives [23]. American Association of Neurological Surgeons (AANS)—Central Nervous System Purpose: The American Association of Neurological Surgeons is dedicated to the advancement of the specialty of neurosurgical care for the public. Value: The American Association of Neurological Surgeons (AANS) is concerned with the prevention, diagnosis, rehabilitation and treatment of disorders in patients that affect the brain, nervous system, peripheral nerves, spinal column and spinal cord [24]. American Association of Oral and Maxillofacial Surgeons (AAOMS)—Face, Jaw, Mouth and Teeth Purpose: Members of American Association of Oral and Maxillofacial Surgeons are specialists who treat conditions, defects, esthetic aspects and/or injuries of the face, jaws, mouth and teeth through advocacy, education and research. Value: The American Association of Oral and Maxillofacial Surgeons (AAOMS) assures patient care through the advancement, promotion and preservation of the specialty and skills that involve oral and maxillofacial surgery [25]. American Association of Retired Persons (AARP)—General Information on Aging Purpose: The American Association of Retired Persons is a nonprofit membership organization that is dedicated to addressing the needs and interests of people who are 50 years of age and older. Value: Through advocacy, education, information and service, the American Association of Retired Persons (AARP) seeks to enhance the quality of life for members of this age group by promoting dignity, independence and purpose. Member benefits include advocacy, auto services, community, entertainment, family caregiving, finances, health and wellness, home and technology, insurance, jobs and work, magazines and resources, restaurants and travel [26]. American Brain Foundation (ABF)—The Brain Purpose: The American Brain Foundation brings together donors and researchers to help to cure and defeat brain disease.

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Value: The American Brain Foundation (ABF) funds clinical research training scholarships and clinical scientist development awards to study a broad spectrum of brain and nervous system disorders and discover new therapies in specific disease areas. Through a partnership with the American Academy of Neurology, the American Brain Foundation sources the most high-risk, high-reward research on brain disease [27]. American Brain Tumor Association (ABTA)—Brain Tumors Purpose: The American Brain Tumor Association is dedicated to brain tumor education, research and support. Value: The American Brain Tumor Association (ABTA) advocates on behalf of the brain tumor community to help caregivers, patients and their loved ones as they navigate the conditions of brain tumors. The Association funds brain tumor research to help extend, improve and save brain health and lives [28]. American Cancer Society (ACS)—Cancer Purpose: The American Cancer Society is a community-based voluntary health organization that is dedicated to eliminating cancer as a major health problem in the United States by measures to diminish suffering, prevent cancer and save lives through advocacy, education, research and service. Value: The American Cancer Society (ACS) resources include information about cancer detection, guidelines, patient services, prevention and treatment methods that assist cancer patients and their families [29]. American College of Gastroenterology (ACG)—Gastrointestinal Purpose: The American College of Gastroenterology provides its members with accurate and up-to-date scientific information on digestive health and the etiology, symptomatology and treatment of gastrointestinal disorders. Value: Gastroenterologists are committed to the provision of quality patient care for people with GI disorders. To this end, American College of Gastroenterology (ACG) advocates in public policy arenas to help improve the future of clinical gastroenterology and patient outcomes. Patient-centered resources include a patient resource center with communication and education tools [30]. American College of Prosthodontists (ACP)—Teeth, Oral and Facial Structures Purpose: The American College of Prosthodontists advances the art and science of prosthodontics, furthers the specialty of prosthodontics among other dentists, healthcare professionals and the public, ensures quality education, promotes the highest standards of patient care, and provides professional services. Value: Prosthodontists among the American College of Prosthodontists (ACP) serve to restore and replace missing teeth and oral/facial structures with esthetic, functional and natural replacements for conditions such as dental implants, TMD-joint problems, traumatic injuries oral cancer prosthetic reconstruction and others [31]. American College of Radiology (ACR)—Radiological Care Purpose: The American College of Radiology empowers members to advance the practice, profession and science of radiological care through its membership of nuclear medicine physicians, medical physicists, radiologists and radiation oncologists. Value: The American College of Radiology (ACR) radiologists specialize in an array of fields that include breast imaging, cardiovascular, chest, emergency, gastrointestinal, genitourinary, heat and neck, musculoskeletal, neuroradiology, pediatric radiology and others for public benefits [32]. American College of Surgeons (ACS)—Surgery Purpose: The American College of Surgeons is an educational and scientific association of surgeons that serves to improve and safeguard the quality of care for surgical patients in ethical and optimal practice environments. Value: Divisions that are concerned with advocacy, cancer, education, health policy and trauma within the American College of Surgeons (ACS) help member surgeons to keep abreast of specialized surgical subjects in order to best serve their patients [33]. American Chronic Pain Association (ACPA)—Chronic Pain Purpose: The American Chronic Pain Association offers education and peer support in pain management skills for people with pain and their families, friends and healthcare professionals. Value: The American Chronic Pain Association (ACPA) helps individuals who live in chronic pain to live more fully in spite of their circumstances, and heightens awareness among the healthcare community, policymakers and the public about pain-related issues [34]. American Council for Headache Education (ACHE)—Headaches Purpose: The American Council for Headache Education is a nonprofit patient-health professional partnership that is dedicated to advancing the management and treatment of patients with headaches. Value: The American Council for Headache Education (ACHE) serves as an educational resource for healthcare providers who seek patient information materials, resources and tools to help educate and support their patients who have headaches and/or related symptoms [35].

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American Council of the Blind (ACB)—Eyesight Purpose: The American Council of the Blind increases the equality of opportunity, independence, quality of life and security for blind and visually impaired people. Value: The membership of American Council of the Blind (ACB) represents a diverse range of groups within the blind community that includes attorneys, entrepreneurs, families, government employees, students, teachers and others to help reach a variety of needs for blind and visually impaired individuals [36]. American Dental Association (ADA)—Oral Health Purpose: The American Dental Association is a member-run organization that serves as an advocate for oral health, from developing new science to easing regulatory burdens on its members. Value: Through the advancement of the dental profession, the American Dental Association (ADA) promotes preventive and therapeutic dental care, and encourages the use of dental products with the American Dental Association (ADA) Seal of Acceptance that include denture adherents, dental floss, mouth rinses, toothbrushes and toothpastes. The American Dental Association (ADA) Foundation, the philanthropic arm of the American Dental Association (ADA), advocates, provides scholarships and disaster relief to needy members [37]. American Diabetes Association (ADA)—Diabetes Purpose: The American Diabetes Association is a nonprofit network of people with diabetes, their families and care providers, and healthcare professionals who specialize in diabetes. Value: The American Diabetes Association (ADA) seeks to educate the public about diabetes and help those that are afflicted with the disease by delivering services, funding research about its management, potential cures and prevention, giving voice to those denied their rights due to diabetes and providing credible and objective information [38]. American Foundation for the Blind (AFB)—Eyesight Purpose: The mission of the American Foundation of the Blind is to create a world without limits for people who are blind or visually impaired. Value: The American Foundation for the Blind (AFB) serves to advance the understanding of blindness, champion impactful policies and practices, mobilize leaders, and utilize research and data to help expand the possibilities for people with vision loss. It accomplishes these efforts through the development and dissemination of knowledge, engagement and promotion of wide-scale research and the pursuit of strategic relationships [39]. American Gastroenterological Association (AGA)—Digestive Health Purpose: Membership in the American Gastroenterological Association includes individuals who are involved with the advancement, practice and science of gastroenterology that focuses on disorders of the intestines and stomach. Value: The American Gastroenterological Association (AGA) assembles an annual meeting within the fields of endoscopy, gastroenterology, gastrointestinal surgery and hepatology, provides digestive research to help shape the future of GI, and publishes three practice journals. Also, the Foundation for Digestive Health and Nutrition, the philanthropic arm of the American Gastroenterological Association, provides digestive research grants on behalf of the American Gastroenterological Association (AGA) Institute [40]. American Geriatrics Society (AGS)—General Information on Aging Purpose: The American Geriatrics Society is a nonprofit organization of geriatrics healthcare professionals that are dedicated to the improvement of health, independence and quality of life of aging people. Value: The American Geriatrics Society (AGS) provides leadership to healthcare professionals that includes family practitioners, geriatricians, geriatric nurses, internists, physician assistants, pharmacists and social workers for advocating for and implementing programs in patient care, professional and public education, public policy and research [41]. American Health Foundation (AHF)—General Information on Aging Purpose: The American Health Foundation is a nonprofit organization that was founded by healthcare professionals and community advocates, and dedicated to avail educational, medical, psychological and social resources for people with special healthcare needs who may lack access to care. Value: The American Health Foundation (AHF) is committed to increased access to quality healthcare and treatments due to sustainable health policies, public awareness programs, physician knowledge, and access to medicines. Areas of expertise of the American Health Foundation (AHF) include biosimilars (less costly imitations of drugs known as biologics), oncology, policy, rare diseases and vaccines [42]. American Heart Association (AHA)—Cardiovascular Purpose: The American Heart Association is a nonprofit voluntary that supports appropriate cardiac care to reduce the disabilities and deaths that are caused by cardiovascular disease and/or strokes.

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Value: The American Heart Association (AHA) funds innovative research, provides critical information and tools and works for stronger public health policies to try to improve and save human lives [43]. American Hearing Research Foundation (AHRF)—Hearing Purpose: The American Hearing Research Foundation is a nonprofit organization that educates the public about balance disorders and hearing loss, and funds significant research in both of these endeavors. Value: The American Hearing Research Foundation (AHRF) seeks to better understand balance and hearing functions, how they may be regained, and how these functions that remain may be preserved [44]. American Hospital Association (AHA)—General Information on Aging Purpose: The American Hospital Association represents healthcare networks, hospitals and their patients. The American Hospital Association (AHA) serves to promote quality healthcare provision through advocacy activities that include judicial matters, legislative and regulatory debates and national health policy development. Value: The American Hospital Association (AHA) acts to advance the health of individuals and their communities, and is committed to health improvement through healthcare education about issues and trends [45]. American Institute for Cancer Research (AICR)—Cancer Purpose: The American Institute for Cancer Research was founded to advance the idea of cancer prevention through diet, nutrition and physical activity. Value: The American Institute for Cancer Research (AICR) interprets results of research in the global science community to create evidence-based, reliable recommendations to help lower cancer risks; especially ones that people can take to perform steps to prevent cancer and reduce the risks of cancer deaths [46]. American Kidney Fund (AKF)—Kidney (Renal) Function Purpose: The American Kidney Fund is a nonprofit organization that works to help people fight kidney disease and to live disease-free, healthier lives. Value: The American Kidney Fund (AKF) invests in clinical research to help improve the outcomes for kidney patients, provides a spectrum of programs and services that include prevention activities for caregivers, healthcare professionals and especially for patients and lobbies for legislation and policies that serve kidney patients [47]. American Liver Foundation (ALF)—Liver Purpose: The American Liver Foundation advocates, educates, facilitates, promotes, researches and supports the prevention, treatment and possible cure of liver disease. Value: The American Liver Foundation (ALF) provides advocacy and information for patients and their families, education for medical professionals, financial support for medical research and creates public awareness campaigns about liver disease prevention and liver wellness [48]. American Lung Association (ALA)—Breathing and Lung Health Purpose: The American Lung Association works to save lives by improving lung health and preventing lung disease through advocacy, education and research. Value: The American Lung Association (ALA) focuses on four strategic imperatives: (1) to defeat lung cancer, (2) to eliminate tobacco use and tobacco-related diseases, (3) to improve the air that is breathed and (4) to reduce the burden of lung disease on patients and their families [49]. American Medical Association (AMA)—General Information on Aging Purpose: The American Medical Association works to enhance the delivery of care and enables health teams and physicians to partner with patients to achieve better health. Value: The American Medical Association (AMA) seeks to accelerate changes in medical education with visionary partners and bold innovations, collaborate to create health care that helps people live healthier and longer lives and enhance practice efficiency and professional satisfaction by improving the delivery of care [50]. American Mental Health Counselor Association (AMHCA)—Mental Health Purpose: The American Mental Health Counselor Association supplies advocacy, collaboration, education and leadership for its licenses clinical health counselors in community agencies, employee assistance programs, hospitals, managed behavioral healthcare organizations, private practice and substance abuse treatment centers. Value: The American Mental Health Counselor Association (AMHCA) brings counseling skills, developmental approaches and preventative strategies to members of healthcare teams within mental health settings, so they may deliver mental health care on location for needy individuals [51]. American Music Therapy Association, Inc. (AMTA)—Behavioral and Mental Health Purpose: The American Music Therapy Association serves to advance the public awareness of the benefits of music therapy, and increase access to quality music therapy sessions in a wide variety of educational and healthcare settings.

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Value: Through the initiatives and resources of the American Music Therapy Association, Inc. (AMTA), music therapy interventions may be designed to alleviate pain, enhance memory, express feelings, improve communication, manage stress and promote physical rehabilitation and wellness [52]. American Nurses Association (ANA)—Nursing Purpose: The American Nurses Association serves to advance the nursing profession by advocating about healthcare issues that affect both nursing and the public, bolstering the health and wellness of nurses, fostering high standards of nursing practice and promoting an ethical and safe work environment. Value: The American Nurses Association (ANA) exists to safeguard the needs of healthcare consumers and nurses, and advocates for the expertise of nurses in developing policy initiatives to help improve health care for all [53]. American Optometric Association (AOA)—Eyesight Purpose: The American Optometric Association is an advocate for optometric health and an authority on quality eye care. The American Optometric Association (AOA) takes a leading role in patient care with respect to eye and vision care, general health and well-being. Value: The American Optometric Association (AOA) brings extensive training in the diagnosis, examination, management and treatment of ocular diseases, disorders, injuries and systemic diseases of the eyes [54]. American Osteopathic Association (AOA)—Traditional and Manipulative Medicine Purpose: The American Osteopathic Association advances the distinctive practices and philosophies of osteopathic medicine. Doctors of Osteopathic Medicine focus on prevention by gaining a deeper understanding of environmental and lifestyle factors and how they may affect health and well-being. Value: The American Osteopathic Association (AOA) promotes options to pharmaceuticals and surgery that augment scientific and technological approaches to patient care. Additional training in osteopathic manipulative treatment may be employed to help diagnose, prevent and/or treat illnesses and/or injuries [55]. American Parkinson’s Disease Association (APDA)—Parkinson’s Disease Purpose: The American Parkinson’s Disease Association is a grassroots network that is dedicated to fighting Parkinson’s disease and to assisting people with Parkinson’s disease live their lives to their fullest while managing this chronic neurological disorder. Value: Through education, research and support via educational symposia, exercise groups, local resources, online forums, referrals and support groups, the American Parkinson’s Disease Association (APDA) helps people who are impacted by Parkinson’s disease cope with this debilitating and declining condition [56]. American Physical Therapy Association (APTA)—Physical Therapy Purpose: The American Physical Therapy Association represents physical therapists, physical therapy assistants and students of physical therapy who work to improve the health and quality of life of individuals who require physical therapy in their health care. Value: The American Physical Therapy Association (APTA) seeks to optimize movements to help to improve human experiences and societal health. The recognition and validation of movement systems as the foundation of function, potential and structure of the human body are valued [57]. American Podiatric Medical Association (APMA)—Foot and Ankle Health Purpose: The American Podiatric Medical Association supplies resources on ankle and foot health through leadership, legislative advocacy, management, public education and research. Value: Healthy feat and ankles are fundamental to the quality of life and are often the indicators of overall health and well-being. The American Podiatric Medical Association (APMA) is instrumental in keeping patients moving and strong, and is also vital to diabetes prevention and management [58]. American Psychiatric Association (APA)—Psychiatry Purpose: The American Psychiatric Association is committed to academia, psychiatric practice and research that represents the diversity of the psychiatric patients to ensure humane care and effective treatments for all people with mental illness. Value: The American Psychiatric Association (APA) seeks to improve access to and quality of psychiatric services, foster collaboration among all those who are concerned with mental health and illness, improve psychiatric education and training, promote optimal conditions for career satisfaction and practice and research into all aspects of mental illnesses [59]. American Psychological Association (APA)—Psychology Purpose: The American Psychological Association serves to create, communicate and apply psychological knowledge to benefit society and improve people’s lives.

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Value: The work of American Psychological Association (APA) is accomplished through the development and application of psychology, the improvement and management of research methods, and the dissemination and promotion of the discipline of psychology that is grounded in science with everyday life practices [60]. American Red Cross (ARC)—Emergency Services Purpose: The American Red Cross serves to alleviate and prevent human suffering in the face of emergencies by allocating donor funding and mobilizing volunteers. Value: The American Red Cross (ARC) works to deliver vital services from life-saving blood and disaster relief to military families, along with health and nursing, certifications and training to assist in the preparedness of people to respond to emergencies [61]. American Sleep Apnea Association (ASAA)—Sleep Apnea Purpose: The American Sleep Apnea Association is a nonprofit organization that advocates for the interests of sleep apnea patients, promotes the awareness of sleep apnea, and works for continuing improvements in treatments for this potentially serious disorder. Value: Through advocacy, education and research, the American Sleep Apnea Association (ASAA) provides guidance about the diagnoses and treatments of sleep apnea by addressing access-to-care and quality-of-care to improve the outcomes [62]. American Society of Anesthesiologists (ASA)—Anesthesiology Purpose: The mission of the American Society of Anesthesiologists is to provide products and solutions for operational success by way of advocacy, educational resources, health systems leadership, member experience, organizational excellence and quality and practice advancement. Value: The values of the American Society of Anesthesiologists (ASA) are patient safety, physician-led care and scientific discovery to help to raise the standards of the medical practice of anesthesiology and to improve patient care [63]. American Society of Colon and Rectal Surgeons (ASCRS)—Colon and Rectum Purpose: The American Society of Colon and Rectal Surgeons is dedicated to the advancement and promotion of the practice and science of the treatment of patients with anus, colon and/or rectum disease. Value: American Society of Colon and Rectal Surgeons (ASCRS) values high-quality and patient-centered health care through the fellowship of the Society’s members, professionalism and unique knowledge and skills. According to the American Society of Colon and Rectal Surgeons (ASCRS), patients who undergo early screenings for colon and rectal diseases may be more likely to have improved treatment outcomes and survive colorectal cancer [64]. American Society of Internal Medicine (ASIM) (within the American College of Physicians)—Internal Medicine Purpose: The American Society of Internal Medicine is concerned with economic, political and social developments that impact the practice of internal medicine. Value: The American Society of Internal Medicine (ASIM) has broad interests in issues that are related to the costs of medical care, the delivery of medical care, and use of technology, including disparities in payments between cognitive and technological services [65]. American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS)—Plastic and Reconstructive Surgery Purpose: The American Society of Ophthalmic Plastic and Reconstructive Surgery is dedicated to disorders of the eyelids, eye sockets and tear drainage system and facial rejuvenation. Value: The American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) is engaged in education, patient safety, practice management and regulatory affairs. American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) physicians are highly trained and uniquely qualified to improve facial beauty and function and protect ocular health and vision [66]. American Society on Aging (ASA)—General Information on Aging Purpose: The American Society on Aging is a large multidisciplinary community of professionals who work with and on behalf of older people. The American Society on Aging (ASA) helps to promote the well-being of aging people and their families. Value: The American Society on Aging (ASA) membership includes private and public-sector representatives: advocates, educators, service providers, allied health and health specialists, managed care and long-term care personnel, mental health professionals, policymakers and planners, researchers, retirees, social service employees and students [67]. American Speech-Language Hearing Association (ASHA)—Speech, Language and Hearing

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Purpose: The American Speech-Language Hearing Association is a national professional credentialing and scientific association for audiologists, audiology and speech-language pathology support personnel, hearing, language and speech scientists, speech-language pathologists and students. Value: Audiologist members of American Speech-Language Hearing Association (ASHA) specialize in the prevention and assessment of balance disorders and hearing and provide audiological treatments that may include hearing aids. Speech-language pathologist members of American Speech-Language Hearing Association (ASHA) serve to assess, identify and treat speech and language difficulties that may include swallowing disorders [68]. American Stroke Association (ASA)—Stroke Purpose and Value: The American Stroke Association is solely focused on reducing disability and death from strokes. It was created as a division of the American Heart Association to bring together the American Heart Association’s (AHA) stroke-related activities [69]. See American Heart Association (AHA) American Tinnitus Association (ATA)—Tinnitus Purpose: The American Tinnitus Association promotes the potential cures, prevention and relief for tinnitus as evidenced by its core values of compassion, credibility and responsibility. Value: The American Tinnitus Association (ATA) advocates for collaborations to promote awareness, fosters effective public policies, provides education, targets research projects and offers hope and support for the hyperacusis (increased sensitivity to certain frequencies and volume ranges of sounds) and tinnitus communities [70]. American Trauma Society (ATS)—Trauma Purpose: The American Trauma Society is committed to the elimination of disabilities and needless death from injuries. The American Trauma Society (ATS) serves as an advocate for trauma care, prevention and victims and their families. Value: The American Trauma Society (ATS) seeks to prevent injuries whenever possible and to ensure quality treatments if they do occur by immediate response, medical care, rapid transport and qualified immediate medical care and ongoing treatment facilities [71]. American Urological Association (AUA)—Urology Purpose: The American Urological Association promotes high standards of clinical care through education, the formulation of healthcare policy and research. Value: The American Urological Association (AUA) addresses diseases of the female and male urinary tracts and the male reproductive organs. Common clinical problems may include calculi, female pelvic outlet relaxation disorders and urinary incontinence, male infertility, renal transplantations, neurourology, urologic oncology, urinary tract stones and/or others [72]. American Macular Degeneration Foundation (AMDF)—Eyesight Purpose: The American Macular Degeneration Foundation is a nonprofit organization that is committed to fostering information on the prevention and treatments of macular degeneration for living fuller lives. Value: The American Macular Degeneration Foundation (AMDF) offers healthy living information and tips for people with macular disease, and supports researchers who are involved with the potential cures, prevention and treatments of macular degeneration and Stargardt disease (Juvenile Macular Degeneration) [73]. Arthritis Foundation (AF)—Arthritis Purpose: The Arthritis Foundation is a nonprofit organization that champions activities for the arthritis community through access to optimal care, advances in science, community connections and life-changing information and resources. Value: The Arthritis Foundation helps to guide families in developing personalized plans by addressing key issues about arthritis, easing the burdens of arthritis and by providing tracking tools to strengthen their educational and interactive offerings to connect arthritis-afflicted communities [74]. Associated Services for the Blind and Visually Impaired (ASB)—Eyesight and Blindness Purpose: The Associated Services for the Blind and Visually Impaired is a nonprofit organization that inspires independence, self-determination and self-esteem in people who are blind or visually impaired. Value: The services of Associated Services for the Blind and Visually Impaired (ASB) are provided through community action, education, public education, resources and training. Clients stand to benefit by its advocacy and “voice,” directly through alternate formats and human services to help address despair, isolation and/or poverty as a result of blindness or visual impairment [75]. Asthma and Allergy Foundation of America (AAFA)—Asthma and Allergy

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Purpose: The Asthma and Allergy Foundation of America is a nonprofit organization for people with allergies and asthma that is dedicated to improving the quality of patient life through advocacy, education and research to live life without limits. Value: The Asthma and Allergy Foundation of America (ALFA) offers educational programs and tools that include online resources, newsletters and magazines, programs for patients of all ages and for caregivers and healthcare providers, printed materials and tools and resources in Spanish [76]. B Benign Essential Blepharospasm Research Foundation (BEBRF)—Eye and Neurology Purpose: The purpose of the Benign Essential Blepharospasm Research Foundation is to undertake, develop, carry on and promote the search for the cause and cure for benign essential blepharospasm (a neurological condition that is characterized by the forcible closure of the eyelids) and other related disorders and infirmities of the facial musculature. Value: The Benign Essential Blepharospasm Research Foundation (BEBRF) is involved with current methods of treatment, medical information, patient support, research, support groups and symposia that are available for care provider and patients [77]. Better Hearing Institute (BHI)—Hearing Purpose: The Better Hearing Institute conducts research and participates in health and hearing education to help people with hearing loss so that they may benefit from proper treatments. Value: The Better Hearing Institute (BHI) works to affect a culture of “hearing wellness” that fosters appropriate treatments for hearing loss and early detection. It also serves to maximize technologies to make it easier for people with hearing loss to remain active and fully engaged at home and work, in their communities and throughout their social lives [78]. The Brady Urological Institute (BUI)—Urology Purpose: The Brady Urological Institute within the Johns Hopkins School of Medicine was the first urology residency in the United States that was dedicated to the training of academic urologists. Value: Well-developed programs that represent all aspects of adult and pediatric urology at the Brady Urological Institute (BUI) include endourology, female urology, laparoscopy, male infertility and sexual dysfunction, reconstructive surgery, robotics, stone disease urodynamics and urological oncology [79]. C CancerCares—Cancer Purpose: CancerCares is a leading US organization that provides free information and professional support services that are designed to help people to manage the emotional, financial and practical challenges of cancer. Value: Through CancerCares, professional oncology social workers provide free emotional and practical support for people with cancer, care providers, loved ones and the bereaved. Services include community programs, connective education workshops, counseling, financial assistance, publications and support groups [80]. Cancer Research Institute (CRI)—Cancer Purpose: The Cancer Research Institute is a US nonprofit organization that funds cancer research. Value: The Cancer Research Institute (CRI) offers research grants to postdoctoral fellows, investigators at medical institutions and students throughout the world. It also funds clinical trials that test promising immunotherapies for various types of cancers, and convenes scientific conferences for tumor immunologists. The Cancer Research Institute (CRI) also inspires lifelong advocacy, promotes awareness and provides immunotherapy information for cancer-related causes [81]. Catholic Health Association of the United States (CHA)—Health Care Purpose: The Catholic Health Association of the United States is a nonprofit healthcare provider that advances the Catholic health ministry of the United States for compassionate care. Value: The Catholic Health Association (CHA) of the US advocates with the US Administration, Congress federal agencies and policy organizations for affordable and quality health care across a continuum of delivery for all people, especially those in vulnerable populations [82]. Commission on Accreditation of Rehabilitation (CARF)—Rehabilitation Purpose: Commission on Accreditation of Rehabilitation is an international nonprofit organization that is an accreditor of health and human life enhancement services. Value: Commission on Accreditation of Rehabilitation (CARF) assists service providers in demonstrating the value of their services—particularly in cultural competence and diversity, improving the quality of services, and meeting internationally recognized organizational and program standards [83]. Centers for Disease Control and Prevention (CDC)—Disease Prevention

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Purpose: The Centers for Disease Control and Prevention works to protect Americans from health, safety and security threats. The Centers for Disease Control and Prevention (CDC) fights disease and supports communities and US citizens so that they may do the same. Value: The Centers for Disease Control and Prevention (CDC) conducts critical scientific endeavors and responds to dangerous health threats if and when they arise through its efforts in aiding medical care, fighting and tracking disease, nurturing public health and protecting health security [84]. Centers for Medicare & Medicaid Services (CMS) [previously known as the Health Care Financing Administration (FCFA)]—Healthcare Financing Purpose: The Centers for Medicare & Medicaid Services is a federal agency within the US Department of Health and Human Services (USDHHS) that administers the Medicare program and collaborates with state governments to administer Medicaid and other programs. Value: The Centers for Medicare & Medicaid Services (CMS) also administrates the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Clinical Laboratory Improvement Amendments, HealthCare. gov and quality standards in long-term care facilities [85]. Christopher & Dana Reeve Foundation—Paralysis Purpose: The Christopher & Dana Reeve Foundation is dedicated to curing spinal cord injury by funding innovative research and to improving the quality of life for people who are living with paralysis. Value: The Christopher & Dana Reeve Foundation is involved with advocacy, grants and information about paralysis for “Today’s Care, Tomorrow’s Cure” to provide a continuum of hope for individuals who live with paralysis worldwide. This is accomplished through its advocacy and policy programs, information specialists, military and veterans program, peer and family support programs and quality-of-life grants program [86]. Community Health Accreditation Partner (CHAP)—Healthcare Qualification Purpose: Community Health Accreditation Partner is an independent, nonprofit accrediting body for community and home-based healthcare organizations with “deeming” authority granted by the Centers for Medicare and Medicaid Services (CMS). Value: Community Health Accreditation Partner (CHAP) is committed to providing the resources and tools that are needed for an easier and speedier accreditation process to help providers to navigate the future healthcare landscape. Education includes home health, home medical, hospice, infusion therapy nursing, international, pharmacy, private duty and public health [87]. Compassion & Choices—End-of-Life Services Purpose: Compassion & Choices is a nonprofit organization that works to protect and expand end-of-life options; to enable patients’ decisions about their end-of-life care and to ensure the honor of healthcare providers. Value: Compassion & Choices works in communities, legislatures and medical settings to advance policies that allow people to authorize and implement medical aid in dying, empower the public with information and tools and make fully informed decisions about their health care [88]. Commodity Supplemental Food Program (CSFP)—Dietary Supplementation Purpose: The Commodity Supplemental Food Program works to improve the health of low-income aging people who are at least 60 years of age by diet supplementation with nutritious US Department of Agriculture (USDA) foods. Value: The Food and Nutrition Service (FNS), an agency of the US Department of Agriculture (USDA), administers the Commodity Supplemental Food Program. The US Department of Agriculture (USDA) distributes both administrative funds and food to participating states and Indian Tribal organizations [89]. Council of Citizens with Low Vision International (CCLVI)—Eyesight Purpose: The Council of Citizens with Low Vision International is an advocacy membership organization that serves to educate the general public, people with low vision and professionals about the capabilities, needs and potentialities of people with low vision and to establish their rights. Value: The Council of Citizens with Low Vision International (CCLVI) establishes outreach programs, promotes research, and supports the development and expansion of pre-service and in-service training programs to improve the quality and quantity of medical and rehabilitation services [90]. Council for Geriatric Dentistry [formerly the Council of Geriatric Dentistry and the American Society for Geriatric Dentistry (ASGD)], a member of the Special Care Dentistry Association (SCDA)—Dentistry Purpose: The Council for Geriatric Dentistry serves as a resource for oral health professionals who serve patients with special needs through education and networking to increase access to oral healthcare. Members include dental hygienists, dentists, health program administrators, hospitals, nondental health providers, residents and students.

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Value: The Special Care Dentistry Association (SCDA) provides educational opportunities and informational exchanges for oral health professionals to treat special needs individuals. The Special Care Dentistry Association (SCDA) also advocates for national legislation, develops practice guidelines and institutional protocols and shapes dental education [91]. Crohn’s & Colitis Foundation (CCF)—Crohn’s Disease and Colitis Purpose: The Crohn’s & Colitis Foundation is a nonprofit volunteer organization that is dedicated to discovering cures for Crohn’s disease and ulcerative colitis and to improving the quality of life of people with these diseases. Value: The Crohn’s & Colitis Foundation (CCF) empowers patients and their caregivers with patient-centric education, enables medical professionals to keep informed of the newest research, funds underdeveloped areas of research and offers professional education programs and workshops [92]. D Disability & Health Data System (DHDS)—Disability Purpose: The Disability & Health Data System is an online resource that provides instant access to state-level demographic and health data about adults with disabilities. Users may access information about five functioning disabilities: cognitive, independent living, mobility, self-care and vision. Limitation status is also available. Value: User-friendly information is provided within the Disability & Health Data System (DHDS) through features such as data tables, geographic areas and maps that are customized and interactive. Users may also identify health differences among adults with and without disabilities as well as by age, ethnicity, gender and/or race [93]. Digestive Disease National Coalition (DDNC)—Digestion Purpose: The Digestive Disease National Coalition is an advocacy organization that is comprised of the major national professional societies and voluntary organizations that are concerned with digestive diseases. The Digestive Disease National Coalition (DDNC) seeks to increase awareness of digestive diseases within Congress, the media and among the public. Value: Awareness, patient access to care and prevention, and research are three beneficial focus areas of the Digestive Disease National Coalition (DDNC). By cooperatively working to improve access to and the quality of digestive disease health care, the Digestive Disease National Coalition (DDNC) helps to effectuate positive medical outcomes and the quality of life of patients with digestive diseases and their families [94]. E ElderWatch—Crime Reduction Purpose: The American Association of Retired Persons (AARP) Foundation’s ElderWatch engages volunteers to assist older consumers to recognize, refuse and report fraud and scams in financial exploitations. Analogous organizations include the American Association of Retired Persons (AARP) Watch Network and the Federal Bureau of Investigation’s (FBI) Internet Crime Complaint Center. Value: ElderWatch is valuable because aging people with more assets may be more charitable, trusting and vulnerable. Assistance, data collection, education and outreach are employed by ElderWatch to guard against illegal or improper use of assets (home or vehicle) or money by people over 50 years of age [95]. Eldercare Locator—Community Services Purpose: Eldercare Locator is a public service of the US Administration on Aging that connects aging people, their care providers and families with community services. Value: Tools and resources of Eldercare Locator include information on advanced care planning, federal resources, how to check for benefits, long-term care planning and others that enable aging people to live independently in their own communities or with caregiver support [96]. Elderly Nutrition Program [US Department of Health & Human Services (USDHHS), National Institutes of Health (NIH), Administration on Aging]—Nutrition (see Administration on Aging) Emotions Anonymous (EA)—Emotional Health Purpose: Emotions Anonymous is a 12-step program for recovery from emotional and mental illness. This program is a useful complement to mental health treatment, rather than as a replacement for psychiatric medication or psychotherapy. Value: The Emotions Anonymous (EA) provides accepting and comforting group settings for participants to share their experiences without criticism, and respects the confidentiality of its members at all times. Emotions Anonymous (EA) members are of diverse ages, economic status, educational and social backgrounds and races that seek to become well minded [97]. Epilepsy Foundation of America (EFA)—Epilepsy

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Purpose: The Epilepsy Foundation of America is a national volunteer agency that is dedicated solely to the welfare of people with epilepsy and their families. Value: The Epilepsy Foundation of America (EFA) works to ensure that people who experience epileptic seizures are able to participate in all life experiences, to improve how people with epilepsy are accepted, perceived and valued in society and to promote research to help discover possible cures for epilepsy [98]. Eye Bank Association of America (EBAA)—Eyesight Purpose: The Eye Bank Association of America is responsible for the delivery, preparation and recovery of donated eyes for cornea transplants, and research to treat conditions such as corneal scarring and keratoconus (a condition whereby the cornea bulges). Value: The Eye Bank Association of America (EBAA) is dedicated to the restoration of sight through the promotion of eye banking by promulgating accreditation, certifying techniques and supporting medical standards [99]. EyeCare America—Eyesight Purpose: EyeCare America is the public service program of the Foundation of the American Academy of Ophthalmology (FAAO). It serves to provide eye care to medically under served aging people and those who are at increased risk of eye diseases. Value: EyeCare America strives to prevent avoidable blindness and severe visual impairment of the public by facilitating eye care, providing education and raising awareness through medical assistance information and resources [100]. F Food and Nutrition Board (IOM-FNB)—National Academies of Sciences, Engineering and Medicine— Institute of Medicine—Food and Nutrition and Public Health Purpose: The Food and Nutrition Board examines the nutritional well-being of US residents, and provides sound guidance to policymakers and the public about the applications of food sciences and nutrition to improve human health. Value: The Food and Nutrition Board (IOM-FNB) establishes guidelines and principles of good nutrition, provides authoritative judgments about the relationship among food and beverage intake and nutrition on disease prevention and health maintenance, and studies issues of global and national importance about the adequacy and safety of the US food supply [101]. Foundation Fighting Blindness (FFB)—Eyesight Purpose: The Foundation Fighting Blindness seeks to drive research to deliver cures through preventions and treatments of people who are affected by age-related macular degeneration, retinitis pigmentosa (damage of cells of the retina), Usher syndrome and other retinal degenerative diseases. Value: The Foundation Fighting Blindness (FFB) is committed to research that discovers treatments and cures for blinding retinal diseases and vision restoration for patients, and support for families that are affected by blindness within their communities and/or homes [102]. Foundation for Hospice and Home Care (FHHC) (sister organization to the National Association for Home Care & Hospice) (NAHC)—Hospice and Home Care Purpose: The Foundation for Hospice and Home Care represents the aides, nurses, social workers and therapists who serve hospice and home care patients and families in the comfort of their homes. Expanding availability and increasing public awareness of vital services of these individuals are imperatives. Value: Advanced, high-quality care is accessible through the Foundation for Hospice and Home Care (FHHC) for the aged, disabled and dying individuals through community outreach, home care, nursing and patient support [103]. G Gerontological Society of America (GSA)—Gerontology Purpose: The Gerontological Society of America is an interdisciplinary organization that is devoted to education, the practice of the field of aging and research to promote the study of aging, and the dissemination of information to decision makers, the general public and scientists. Value: The Gerontological Society of America (GSA) fosters collaboration among behavioral and social scientists, biologists, economists, humanities and the arts specialists, policy experts, psychologists, researchers, social scientists and social workers to help intersect research and achieve the greatest impacts, foster ingenuity and promote healthy aging [104]. Glaucoma Research Foundation (GRF)—Glaucoma

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Purpose: The Glaucoma Research Foundation is a national nonprofit organization that is dedicated to finding better ways to care for people with glaucoma and to finding a cure for glaucoma—the leading cause of preventable blindness. Significant efforts are devoted to funding innovative glaucoma research worldwide. Value: The Glaucoma Research Foundation (GRF) seeks to prevent vision loss from glaucoma by investing in education, innovative research and support to help find glaucoma cures [105]. Global Coalition on Aging (GCOA)—General Information on Aging Purpose: Within the Global Coalition on Aging, international experts, including economists, policymakers, private sector representatives and social scientists, collaborate to address the opportunities of the aging population to help businesses and governments adapt to massive demographic changes in aging populations. Value: The Global Coalition on Aging (GCOA) fosters informed global discussions about the challenges, discoveries and opportunities of aging to meet the demands of the rapidly changing world population through aligning business strategies and workforce policies, creating platforms, influencing policies and partnering with global institutions and organizations [106]. Go4Life—Exercise and Physical Activity Purpose: Go4Life is a web-based campaign from the National Institute on Aging at the National Institutes of Health (NIANIH) that is designed to motivate people who are 50 years of age or older to help to incorporate exercise and physical activities through balance, endurance, flexibility and strength into their daily lives. Value: Go4Life offers a variety of online, evidence-based resources for aging people, family members, health professionals and organizations and free print materials about exercise and physical activity that are strategized for aging [107]. Guiding Eyes for the Blind, Inc.—Vision Purpose: Guiding Eyes for the Blind provides guide dogs to people who are blind or have vision loss for greater horizons of opportunity and independence. The organization is dedicated to creating and supporting lifechanging connections among people and dogs. Value: All of the services of the Guiding Eyes for the Blind, Inc. are offered free of charge to people and families who are in need and either blind or visually impaired. The Special Needs Program empowers people who have vision loss and additional challenges, such as balance or gait issues, cerebral palsy or muscular dystrophy, with highly customized training for maximum independence and mobility [108]. H Healthfinder.gov—Consumer Information Purpose: Healthfinder.gov is an online free access resource for reliable consumer health and human services that was developed by the US Department of Health and Human Services (USDHHS). Value: Healthfinder.gov offers clearing houses, databases, government agencies, non-for-profit organizations, self-help and support groups and websites with reliable information for the public about aging and other lifecycle events. For example, “Find Services & Information” provides a wide range of searchable options that are alphabetized for convenient access [109]. Hearing Health Foundation (HHF)—Hearing Purpose: The nonprofit Hearing Health Foundation serves to find cures and the prevention of hearing loss and tinnitus through the promotion of hearing health and research. Hearing Health Foundation (HHF) also funds balance research and drives innovations and treatments. Value: The Hearing Health Foundation (HHF) educates the public about the effects of hearing loss and tinnitus on health and life quality through its consumer resources, and provides real-world solutions based on the latest research and technology for better hearing cure options and treatments [110]. HelpPRO.com—Mental Health Purpose: HelpPRO.com is an online comprehensive finder for access to mental health services that include clinicians and organizations. Value: The mission of HelpPRO.com is the ability to match Mental Health clinicians with patients with individual needs. It carefully identifies users’ interests and needs and connects these with therapists’ capabilities. The transparency helps to reduce user anxiety and facilitates meaningful communications for assistance and potential improvement [111]. Henry J. Kaiser Family Foundation (KFF)—Global Health Care/Policies Purpose: The Henry J. Kaiser Family Foundation is a nonprofit, private foundation that focuses on major healthcare issues that face the United States in relation to global health policy. Value: The Henry J. Kaiser Family Foundation (KFF) serves as a nonpartisan source of analysis, facts, information and journalism for the healthcare community, media, policymakers and the public. Topics may include

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disparities policy, global health, health costs, health reform, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), Medicaid, Medicare, private Insurance, the uninsured and Women’s Health Policy [112]. Hospice Foundation of America (HFA)—Hospice Purpose: The Hospice Foundation of America is a nonprofit organization that provides leadership in the development and application of hospice and its philosophy of care. It serves to enhance the US healthcare system about the role of hospice (philosophy and type of care that focuses on the palliation of chronically, terminally or seriously ill people). Value: The Hospice Foundation of America (HFA) offers programs for information on advanced care planning, caregiving, grief, hospice, palliative care, professional development and public education. The public programs are designed to assist individual consumers of health care who are dealing with issues that include caregiving, grief and terminal illness. The Hospice Foundation of America (HFA) also funds research [113]. Huntington’s Disease Society of America (HDSA)—Huntington’s Disease Purpose: The Huntington’s Disease Society of America is a nonprofit organization that is dedicated to improving the lives of people who are affected by Huntington’s disease (an inherited condition in which the nerve cells of the brain break down over time). The Huntington’s Disease Society of America (HDSA) advocacy component advances legislation and policy to raise awareness about Huntington’s Disease by promoting legislation, policies and regulations and by collaborating and partnering with national organizations with common goals. Value: Advocacy, community services, education and research are actions that the Huntington’s Disease Society of America (HDSA) assumes to offer help and outreach to individuals that are affected by Huntington’s Disease and their families and healthcare professionals [114]. I Institute for Disabilities Research and Training (IDRT)—Disabilities Purpose: The Institute for Disabilities Research and Training is dedicated to the improvement of the lives of people with disabilities, their families and service providers through advocacy, research and development, technical assistance and technology. Value: The Institute for Disabilities Research and Training (IDRT) specializes in research and development efforts on behalf of adults who are deaf and hard of hearing. The Institute for Disabilities Research and Training (IDRT) has particular proficiency in American Sign Language (ASL)-accessible computer software and other assistive technological items [115]. International Association of Gerontology and Geriatrics (IAGG)—General Aging Purpose: The International Association of Gerontology and Geriatrics is a nongovernmental organization that supports gerontological research and training. It serves to represent international gerontological organizations. Key opinion leaders are in health and human services, housing and income support, public policy and other areas that affect the quality of life of aging people. Value: The International Association of Gerontology and Geriatrics (IAGG) strives to enhance the highest quality of life and well-being of all aging people as they age at individual and societal levels. It also plays a role in bridging Eastern and Western cultures to benefit the aging, as those who are aging become more significant demographics of national populations [116]. International Council on Active Aging (ICAA)—General Aging Purpose: The mission of the International Council on Active Aging is to improve the quality of life of older adults. It is neither a lobby group nor a policymaker; rather, the International Council on Active Aging (ICAA) connects organizations to future the “Active Aging” movement by staying active and fully engaging in life. Value: Efforts by the International Council on Active Aging (ICAA) are directed at helping businesses excel in serving the 50 1 population, and in assisting this population to serve itself. The International Council on Active Aging (ICAA) champions inclusive environments, products and programs that reflect age-friendly philosophies from the point of view of older adults [117]. International Essential Tremor Foundation (IETF)—Essential Tremors Purpose: The International Essential Tremor Foundation provides hope for the essential tremor community by way of awareness, education, research and support. Value: The International Essential Tremor Foundation (IETF) is a collaboration of educators, friends, healthcare workers, parents, patients, physicians and volunteers. Patient information about common medications, coping with essential tremors, educational programs, research, specialists, support and treatment options is available [118]. International Federation on Ageing (IFA)—Information on General Aging

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Purpose: The International Federation on Ageing is an international nongovernmental organization whose goal is to be the global point of connection for experts who are working to influence age-related policy. Value: The International Federation on Ageing (IFA) strives to collaborate with partners across all sectors and disciplines, create new networks and strengthen connections, mobilize and harness the energy and expertise of its members, and influence age-related policy to improve the lives of aging people [119]. International Foundation for Functional Gastrointestinal Disorders (IFFGD)—Gastrointestinal Disorders Purpose: The International Foundation for Functional Gastrointestinal Disorders is a nonprofit education and research organization, and a resource for reliable assistance, knowledge and support about functional gastrointestinal and motility disorders. Value: The International Foundation for Functional Gastrointestinal Disorders (IFFGD) works with employers, families, investigators, physicians, practitioners, regulators and others to broaden understanding and support, and encourage research about gastrointestinal disorders through advocacy activities, funding research, leadership, professional and public education and raising awareness [120]. International Hearing Society (HIS)—Hearing Purpose: The International Hearing Society represents hearing healthcare professionals worldwide. Its members are involved in the practice of testing hearing and selecting, fitting and dispensing hearing instruments, as well as counseling individuals with hearing issues. Value: The International Hearing Society (HIS) recognizes the need for maintaining and promoting high standards for its members to assist the hearing impaired. The International Hearing Society (HIS) encourages membership competency accreditation, education, specialty-level certification and training [121]. International Psychogeriatric Association (IPA)—Mental Health Purpose: The International Psychogeriatric Association is a diverse mental healthcare team of worldwide professionals that helps older people with all types of mental health issues. Value: Through cutting-edge publications, educational activities, policy formation, scientific meetings and shared perspectives, the International Psychogeriatric Association (IPA) promotes better mental health for older people worldwide, whether they enjoy health aging or cope with physical or mental illness [122]. J Johns Hopkins Center on Aging & Health (COAH)—General Aging Purpose: The Johns Hopkins Center on Aging and Health is sponsored by the Johns Hopkins School of Medicine and Public Health and other core partners for conducting interdisciplinary aging research and training for health improvements, and to establish multidisciplinary science to optimize health in aging. Value: The Johns Hopkins Center on Aging & Health (COAH) research involves the characterization and identification of groups at risks of adverse health outcomes, clinical and population-based studies about the causes and consequences of disabilities, the development of methods for prevention and screening and diseases and frailty in the aging [123]. Joslin Diabetes Center (JDC)—Diabetes Purpose: The Joslin Diabetes Center is world-renowned in diabetes care, education and research that are aimed at the potential cure, prevention and treatment of diabetes. Value: The Joslin Diabetes Center (JDC) develops innovative patient therapies and scientific discoveries in affiliation with Harvard Medical School, and is a National Institutes of Health-designated Diabetes Research Center. An adult clinic with a multidisciplinary approach and eye care provides the most advanced and aggressive prevention and management of diabetes complications, education and medical care. The Eye Institute offers thoughtful and personalized eye care by specially trained and educated physicians and staff [124]. K No listing L Leukemia & Lymphoma Society (LLS)—Leukemia/Lymphoma Purpose: The Leukemia & Lymphoma Society is a nonprofit organization that is dedicated to the elimination of blood cancers through groundbreaking research and innovative approaches in Hodgkin’s disease, leukemia, lymphoma and myeloma. Value: The Leukemia & Lymphoma Society (LLS) provides advocacy for federal and state policies, cutting-edge research, financial assistance, free information and support services that help benefit blood cancer patients [125]. Lighthouse International (LI)—Vision

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Purpose: The Lighthouse International is a not-for-profit worldwide resource for vision impairment and rehabilitation. The Lighthouse International (LI) collaborates with global partners that include the World Health Organization (WHO), the Pan-American Health Organization, and the International Agency for the Prevention of Blindness to address the needs of people worldwide with vision impairment and to meet future age-related vision loss challenges. Value: The Lighthouse International (LI) is engaged in vision advocacy, education, prevention, rehabilitation services and research, and enables people of all ages who are blind or partially sighted to lead more independent and productive lives [126]. Low Income Home Energy Assistance Program (LIHEAP)—Financial Assistance Purpose: As a division of the US Department of Health & Human Services (USDHHS), Administration for Children & Families (ACF), the Low Income Home Energy Association Program helps keep families safe and healthy through initiatives that assist families with their abilities to fund energy costs. Value: The Low Income Home Energy Assistance Program (LIHEAP) provides federally funded assistance in managing the costs that are associated with energy crises, home energy bills and weatherization, and energyrelated minor home repairs. Low Income Home Energy Assistance Program (LIHEAP) also helps to reduce the risks of health and safety disorders that spring from unsafe cooling and heating practices [127]. Lupus Foundation of America (LFA)—Lupus Purpose: The Lupus Foundation of America is a charitable organization that is devoted to solving the disease of lupus (a chronic autoimmune disease) and providing caring support to improve the quality of life for those who suffer from its impact. Value: Through advocacy, awareness, education, research and support the Lupus Foundation of America (LFA) seeks to improve the diagnoses and therapies for the possible cure or prevention of lupus [128]. Lupus Research Alliance (LRA)—Lupus Purpose: The Lupus Research Alliance helps to improve the treatments for lupus and advances toward cures by advocating and raising funds on behalf of the lupus community in the public policy arena. Value: The Lupus Research Alliance (LRA) strives to improve the lives of people who are living with lupus by marshaling new discoveries and supporting scientific discoveries to help to ease the burdens of lives with lupus [129]. M Meals on Wheels America (MWA)—Hunger and Isolation Purpose: Meals on Wheels America is dedicated to senior hunger and isolation by providing advocacy support, education, funding, leadership and research to empower local member programs to strengthen their communities. Value: The Meals on Wheels America (MWA) organization serves communities across American by delivering nutritious meals and offering friendly visits and safety checks so that aging people in America may lead dignified, nourished and independent lives [130]. Medicare Interactive (MI)—Affordable Health Care Purpose: Medicare Interactive is dedicated to assisting people who are on Medicare to understand their benefits and rights; navigate the Medicare system and obtain the health care to which they are entitled to receive. Value: Only available through the Medicare Rights Center (see below), Medicare Interactive provides free and independent references to help older Americans and people with disabilities navigate the complexities of health insurance and obtain affordable health care [131]. Medicare Rights Center (MRC)—Healthcare Assistance Purpose: The Medicare Rights Center is an independent, national nonprofit consumer service organization and source of healthcare assistance and information for people in the United States who are on Medicare. The Medicare Rights Center (MRC) works to ensure access to affordable health care for people who are aging and for those with disabilities. Value: The Medicare Rights Center (MCR) provides information about Medicare advocacy, benefits, cases, changes, counseling, education, options, public policy and resources and opportunities for involvement in consumer advocacy. Changes in Medicare and how these changes may affect health coverage are also addressed [132]. Medicare—Medicare Purpose: Medicare is the official US government program for people with Medicare, the federal health insurance program for people who are 65 years, people with end-stage renal disease and younger people with disabilities.

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Value: Medicare Part A (Hospital Insurance) covers care in skilled nursing facilities, hospice care, patient hospital stays and some home care. Medicare Part B (Medical Insurance) covers doctors’ services, medical supplies, outpatient care and preventive services. Medicare Part C (Medical Advantage Plans) is offered by some private contractual companies [133]. UCSF Memory and Aging Center (MAC)—Weill Institute for Neurosciences—Memory Purpose: The UCSF Memory and Aging Center provides model multidisciplinary care for patients with cognitive problems, and conducts research about the causes and possible cures for degenerative brain diseases. Value: The UCSF Memory and Aging Center educates health professionals, patients and their families about Alzheimer’s disease, frontotemporal dementia (FTD) and related neurodegenerative conditions and seeks solutions to find cures [134]. Mended Hearts (MH)—Heart Disease Purpose: Mending Hearts is a national and community-based nonprofit organization that is designed to inspire hope and improve the quality of life for heart patients and their families through ongoing peer-to-peer support. Local community chapters help to dissuade depression after heart disease diagnosis and encourage lifestyle changes. Value: Mending Hearts provides education, hope and support to all types of heart patients and their families and broadens outreach. MH strives to meet the needs of caregivers, communities, hospitals, individuals and patients through diverse sources that cover age, disease, gender, language and race [135]. N National Academy of Elder Law Attorneys (NAELA)—Legal Issues Purpose: The National Academy of Elder Law Attorneys, Inc., is a nonprofit association that assists bar organizations, lawyers and other groups and individuals who work with aging people and their families. Value: The National Academy of Elder Law Attorneys (NAELA) provides assistance, education, information and networking opportunities to address the many specialized issues that concern legal services for aging people and those who are disabled [136]. National Adult Day Services Association (NADSA)—Care Purpose: The National Adult Day Services Association provides a voice for the adult day services (ADS) sector and is a national hub for adult day services (ADS) providers. Value: The members of National Adult Day Services Association (NADSA) include adult day center providers, corporations, educators, retired workers, students, state associations of providers and others who are involved in building better lives for aging and disabled people in adult day programs. Participation in the National Adult Day Services Association (NADSA) has the capacity to impact communities, families, participants and the nation [137]. National Alliance for Caregiving (NAC)—General Aging Purpose: The National Alliance for Caregiving serves to advance family caregiving through advocacy, innovations and research for chronic and long-term care for aging adults, adults and children with special needs, and injured veterans. Value: The National Alliance for Caregiving (NAC) offers a variety of materials to support family caregivers, ranging from booklets and tip sheets to and conference materials and webcasts. These include adult immunizations resources, brain health toolkits, information on fall prevention and mental health, and other materials for caregivers, patients and professionals [138]. National Alliance on Mental Illness (NAMI)—Mental Health Purpose: The National Alliance on Mental Illness is a grassroots mental health organization that is dedicated to creating and bettering lives for people with mental illness. Value: The National Alliance on Mental Illness (NAMI) incorporates local affiliates, state organizations and volunteers who serve to provide education and support, and raise awareness about mental illness by: advocating, educating, leading and listening [139]. National Alopecia Areata Foundation (NAAF)—Alopecia Areata and Autoimmunity Purpose: The National Alopecia Areata Foundation serves the communities of people who are affected by the autoimmune skin disease alopecia areata that typically causes emotional pain and hair loss. Value: The National Alopecia Areata Foundation (NAAF) exists to support education, research and treatments for people with alopecia areata and to discover possible cures for this disease [140]. National Aphasia Association (NAA)—Aphasia and Language Impairment

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Purpose: The National Aphasia Association serves to help people with aphasia (language impairment) that affects the comprehension or production of speech and reading or writing ability. Aphasia is due brain injuries— often from strokes in aging people Value: The National Aphasia Association (NAA) promotes public awareness and understanding of aphasia, and provides support to health professionals and people with aphasia and their families to enhance life quality [141]. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)—Arthritis, Muscles, Skeleton and Skin Purpose: The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases is to support the research that concerns the causes, prevention and treatments of musculoskeletal and skin diseases through the dissemination of their research progress and the training of research scientists. Value: Diseases of the bones, joints, muscles and skin may affect people of all ages, ethnic and racial populations and economic status. They may also impact minorities and women disproportionately. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) collectively works to understand and treat these conditions and diseases and to help decrease disability, pain, and in some cases, premature death [142]. National Association for Continence (NAFC)—Continence Purpose: The National Association for Continence is a nonprofit organization that is committed to the improvement of life quality of people with incontinence, related pelvic floor disorders and voiding dysfunction. Value: The National Association for Continence (NAFC) advances online forum discussions, facilitates advocacy efforts with the Food and Drug Administration (FDA), publishes information for patients and professionals and spearheads Industry and medical conferences [143]. National Association for Home Care & Hospice (NAHC)—Home Care and Hospice Purpose: The National Association for Home Care & Hospice represents the interests of chronically ill people, those who are disabled and dying of all ages, and also the care providers who deliver hospice and in-home health services. Value: The National Association for Home Care & Hospice (NAHC) places the concerns of infirmed and dying people before corporate and/or institutional concerns. The association advocates on behalf of its membership, fosters high-quality standards of care, promotes collaborations, serves as the unified voice of the hospice and home care, communities and sponsors research, among other functions [144]. National Association of States United for Aging and Disabilities (NASUAD)—General Information on Aging Purpose: The National Association of States United for Aging and Disabilities exists to design, improve and sustain state systems that deliver community and home-based services and to support aging people and their care providers. Value: The National Association of States United for Aging and Disabilities (NASUAD) advocates for comprehensive long-term services and support, assists states with technical assistance for planning and transformation, collaborates for strategic partnerships, convenes communication among decision makers and innovates information for the development of effective policies and programs [145]. National Association for Visually Handicapped (NAVH)—Vision Purpose: The National Association for Visually Handicapped provides services for visually disabled people through low vision consultations. Value: Services that are offered by the National Association for Visually Handicapped (NAVH) include the assistance of patients in finding and learning how to use appropriate visual aids, electronic devices, large print educational materials on common eye diseases, lighting and vision. Referral to eye care specialists and self-help groups are also available through the National Association for Visually Handicapped (NAVH) [146]. National Association of the Deaf (NAD)—Hearing Rights Purpose: The National Association of the Deaf is a US nonprofit civil rights organization of, by and for the deaf and hard-of-hearing individuals. The fundamental basis of this organization is the rights of the US deaf community to collaborate on important issues, have their issues represented, and use sign language in the process. Value: The scope of advocacy of the National Association of the Deaf (NAD) covers early intervention, education, employment, health care, technology, telecommunications and other issues with and without other organizations, including the World Federation of the Deaf (WFD), an international human rights organization [147]. National Association of Social Workers (NASW)—Social Work

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Purpose: The National Association of Social Workers serves social workers by carrying out three main responsibilities: advancing sound social policies, promoting the development of the social work practice and strengthening and unifying the profession of social work. Value: The National Association of Social Workers (NASW) accomplishes its mission while contributing to the well-being of communities, families and individuals through assurance services, educational, philanthropic and scientific activities, political actions and technical advice [148]. National Ataxia Foundation (NAF)—Ataxia (Bodily Movements) Purpose: The National Ataxia Foundation is a nonprofit organization that is devoted to help people with ataxia and their families through education, research and support. Ataxia, a rare, progressive neurological disease, may lead to the loss of full control of bodily movements. Value: The primary purpose of National Ataxia Foundation (NAF) is to help people search for cures for ataxia by promoting the exchanges of ideas and innovation in ataxia detection. Testing and interventions, as identified by the National Ataxia Foundation (NAF), may help to identify the presence of ataxia and discriminate it from other brain disorders [149]. National Brain Tumor Society (NBTS)—Brain Tumors Purpose: The National Brain Tumor Society is committed to discovering better treatments and potential cures for people who are living with brain tumors by affecting actions regarding clinical trials, drug development, legislation, policy and research. Value: The National Brain Tumor Society (NBTS) drives a multifaceted approach to advocating for public policy changes, funding, and influencing discovery and strategic research to achieve the greatest impact, progress and results for brain tumor patients and their families [150]. National Breast Cancer Foundation, Inc. (NBCF)—Breast Cancer Purpose: The mission of the National Breast Cancer foundation is to help women who are affected by breast cancer through early detection, education and support services and to inspire hope. Value: The National Breast Cancer Foundation, Inc. (NBCF) helps and inspires women who are affected by breast cancer through breast health and patient navigation services that include corporate partnering, fundraisers for community support, health resources and mammograms for women in need [151]. National Cancer Institute (NCI)—Cancer Purpose: The National Cancer Institute is the principal agency of the US government for cancer research and training that advances scientific knowledge to help cancer patients live healthier and longer lives. Value: The work of National Cancer Institute (NCI) has helped to decrease the rates of new cancer cases and deaths overall in the last few decades, and to improve the rates of cancer survivors. These trends reflect advances in cancer detection, diagnosis and patient care that are supported by National Cancer Institute (NCI) innovative clinical trials and laboratory research [152]. National Coalition for Cancer Survivorship (NCCS)—Cancer Purpose: Founded by and for cancer survivors, the mission of the National Coalition for Cancer Survivorship is to advocate for quality cancer care for all people who are affected by cancer. Value: The National Coalition for Cancer Survivorship (NCCS) advocates and works with legislators and policymakers to represent cancer patients to improve quality of care and life and to promote policy changes. The National Coalition for Cancer Survivorship (NCCS) champions other cancer organizations to address nationwide public policies, and empowers cancer survivors through publications and programs that promote self-advocacy [153]. National Comprehensive Cancer Network (NCCN)—Cancer Purpose: The National Comprehensive Cancer Network is a nonprofit alliance of leading cancer centers devoted to education, patient care and research for the advancement of effectiveness, efficiency and quality of healthcare delivery for the betterment of patient lives. Value: The National Comprehensive Cancer Network (NCCN) provides comprehensive core resources and state-of-the art cancer treatment information to help patients with cancer select the best treatment options for their various disease states [154]. National Consumers League (NCL)—Consumerism Purpose: The National Consumers League is a private, nonprofit advocacy group that provides businesses, governments and other organizations with the perspectives of consumers about concerns that include food safety, medication and privacy, as well as child labor.

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Value: The National Consumers League (NCL) serves to promote economic and social justice for consumers and workers both in the United States and abroad that involve issues such as health, money and rights, through programs that have included Fraud.org, LifeSmarts and Script Your Future [155]. National Consumer Voice for Quality Long-Term Care—Long-term Care Purpose: The National Consumer Voice for Quality Long-Term Care is a leading voice for consumers who are involved with long-term care. The Consumer Voice helps to ensure that advocates, caregivers, consumers, families are empowered for advocacy and the guarantee of quality care. Value: The Consumer Voice advocates for public policies that support quality care and life, educates and empower consumers and their families, promotes the critical roles of direct-care workers and best practices and supports and trains individuals and groups that promote quality long-term care [156]. National Council on Aging (NCOA)—General Information on Aging (See Older Americans Act that funds critical services to help keep aging Americans healthy and independent.) Purpose: The National Council on Aging helps people who are 60 years of age and older to meet the challenges of aging. The National Council on Aging (NCOA) partners with businesses, governments and nonprofit organizations to help provide advocacy, innovative community programs and online help. Value: The National Council on Aging (NCOA) seeks a caring and just society in which aging people may live with dignity, purpose and security through economic security, education, healthy living, public policy and action [157]. National Council on Alcoholism and Drug Dependence, Inc. (NCADD)—Alcohol and Drugs Purpose: The National Council on Alcoholism and Drug Dependence, Inc. is a voluntary health organization that serves to help families recover from alcoholism, drug addiction and the devastating effects on individual, communities and families and to save lives. Value: The National Council on Alcoholism and Drug Dependence, Inc. (NCADD) provides advocacy and recovery support, community education and mobilization, information and referral services, intervention and drinking driver programs, media and public education campaigns, outpatient and residential treatments and professional and workplace training [158]. National Council on Disability (NCD)—Disabilities Purpose: The National Council on Disability is an independent federal agency that advises the US government about policies, practices, procedures and programs that affect people with disabilities. Value: The National Council on Disability (NCD) fulfills its advisory roles regarding disability issues by convening stakeholders, gathering and analyzing data, engaging and influencing agendas and debates, identifying and formulating solutions for emerging and long-standing challenges and providing tools to facilitate effective implementations [159]. National Council on Seniors Drug & Alcohol Rehab—Alcohol and Drugs Purpose: The National Council on Seniors Drug & Alcohol Rehab is a nonprofit organization that is dedicated to the assistance and education of aging people who struggle with addiction and to their care providers and concerned family members. Value: The primary objective of this organization is to effectively halt the growing silent epidemic of senior addiction through outreach with local providers, such as governments, nonprofits and professional rehab assistance providers [160]. National Dairy Council (NDC)—Dairy Products Purpose: The National Dairy Council is dedicated to healthy communities, foods, people and the planet for current and future generations through dairy-related issues and programs that include farm to table (food waste and sustainable nutrition) and health and wellness (child nutrition and health benefits). Value: Protein and healthy aging are also addressed by the National Dairy Council (NDC) through the inclusion of nutrient-rich foods that incorporate dairy products and regular exercise for healthy and strong bones and muscles [161]. National Diabetes Information Clearinghouse (NDIC)—Diabetes Purpose: The National Diabetes Information Clearinghouse is an information dissemination service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), a part of the National Institutes of Health (NIH). Value: The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports research on many chronic, common and costly conditions that affect health. The National Diabetes Information Clearinghouse (NDIC) works closely with government agencies, the National Institute of Diabetes and Digestive and Kidney Diseases’s (NIDDK) Diabetes Research and Training Centers and the National Education Program

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(NDEP), patient professional and voluntary associations and state health departments to respond to informational needs about diabetes and its management [162]. National Digestive Diseases Information Clearinghouse (NDDIC)—Digestive Diseases Purpose: The National Digestive Diseases Information Clearinghouse is an information dissemination service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Value: The National Digestive Diseases Information Clearinghouse (NDDIC) provides information about digestive diseases to patients who have digestive disorders and their care providers, families and healthcare suppliers through collaborations with agencies and organizations, coordination of resources, publications and other communications [163]. National Elder Law Foundation (NELF)—Legal Services Purpose: The National Elder Law Foundation certifies the practitioners of elder and special needs law. The designation of Certified Elder Law Attorney (CELA) indicates that the qualified bearer keeps current in elder law and special needs continuing education. Value: Certified Elder Law Attorneys practice in mostly every state within the United States and in most major US cities. Other analogous organizations that are represented by Certified Elder Law Attorneys include the National Academy of Elder Law Attorneys, the Academy of Special Needs Planners and the Special Needs Alliance [164]. National Eye Institute (NEI)—Vision Purpose: The National Eye Institute is a part of the US National Institutes of Health (NIH). The mission of National Eye Institute (NEI) is to conduct and support health information dissemination, research, training and other programs that are concerned with blinding eye diseases, mechanisms of visual function, preservation of sight, special health problems and requirements of blind people, and visual disorders. Value: Information and resources on eye health that include age-related macular degeneration, cataracts, diabetic eye disease, glaucoma and low vision are available through the National Eye Institute (NEI), as are materials about the National Eye Health Education Program (NEHEP), clinical studies and National Eye Institute (NEI) innovations in science [165]. National Federation of the Blind (NFB)—Vision Purpose: The National Federation of the Blind is a source for blind people and those with low vision for hope and support for better lives. The National Federation of the Blind (NFB) promotes high expectations, inspiration and self-confidence for people who are blind or losing their vision. Value: The National Federation of the Blind (NFB) helps blind people to find the courage to continue to live their lives after vision loss. It supplies a nationwide network for blind people, with resources and support to assist members to discover the best options for living active and productive lives [166]. National Guardianship Association (NGA)—Guardianship Purpose: The purpose of the National Guardianship Association is to provide education, networking and training opportunities for conservators, fiduciaries and guardians and to promote high ethics, standards and values to ensure nationally recognized standards of excellence. Value: The National Guardianship Association (NGA) protects adults under guardianship by safeguarding that guardians have access to resources and quality education. The association establishes national practice standards for agencies and individuals, and cooperates with other organizations, such as the National Academy of Elder Law Attorneys, to effectuate positive changes in guardianship policy [167]. National Headache Foundation (NHF)—Headaches Purpose: The purpose of the National Headache Foundation is to help alleviate headaches through advocacy, awareness, education and research, and to increase public awareness about headaches and their impacts on individuals, their families and society. Value: The National Headache Foundation (NHF) connects patients with treatments for headaches for greater understanding of the complexity of headache pain and suffering [168]. National Heart, Lung and Blood Institute (NHLBI)—Blood, Heart and Lungs Purpose: The National Heart, Lung and Blood Institute seeks to advance translational research, develop workforce and resources, reduce human disease, and understand human biology as it relates to the blood, heart and lungs. Value: The National Heart, Lung and Blood Institute (NHLBI) seeks to discover challenges, goals and initiatives that shape the diagnosis, prevention and treatment of human diseases, fund lineal trials that examine newer ways to manage diseases and support grants and training of researchers who study the blood, heart and lungs and their corresponding diseases and health [169].

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National Institute on Deafness and Other Communication Disorders (NIDCD)—Deafness Purpose: The National Institute on Deafness and Other Communication Disorders is part of the National Institutes of Health (NIH). In this partnership, the National Institute on Deafness and Other Communication Disorders (NIDCD) conducts and supports behavioral and biomedical research in disordered and normal processes of balance, hearing, language, smell, speech, taste and voice. Value: The National Institute on Deafness and Other Communication Disorders (NIDCD) strives to achieve its mission through funding, research and training that focus on clinical studies, extramural research (grantee programs), intramural research [National Institute on Deafness and Other Communication Disorders (NIDCD) labs], training centers and intramural training on issues that include balance, hearing, health, taste and smell, and language, speech and voice [170]. National Institute of General Medical Sciences (NIGMS)—Disease Purpose: The National Institute of General Medical Sciences supports basic research that raises the understanding of biological processes and positions the foundation for developments in disease, diagnosis, prevention and treatment. Value: The National Institute of General Medical Sciences (NIGMS) provides and supports free educational and scientific resources, research programs, and pre-, undergraduate and postdoctoral programs that ultimately help to strengthen the public appreciation and understanding of science [171]. National Hospice and Palliative Care Organization (NHPCO)—Hospice and Palliative Care Purpose: The mission of the National Hospice and Palliative Care Organization is to lead and mobilize social changes for end-of-life improved care for people and their families who face death, grief and/or serious illnesses. Value: The National Hospice and Palliative Care Organization (NHPCO) believes in collaboration by fostering relationships, excellence by exceeding expectations, respect by honoring others, service by engaging customers, and stewardship by managing resources. It advocates for the terminally ill and their families through collaborations, meetings and symposia, the monitoring of Congressional and regulatory activities, public and professional educational programs and materials, research and technical information resources [172]. National Institute of Allergy and Infectious Diseases (NIAID)—Allergies and Infectious Diseases Purpose: The mission of the National Institute of Allergy and Infectious Diseases is to lead research to prevent, treat and understand allergic, infectious and immunologic diseases. Value: Featured areas of research of the National Institute of Allergy and Infectious Diseases (NIAID) include allergy, immunology and transplantation, antimicrobial resistance, infectious diseases and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). National Institute of Allergy and Infectious Diseases (NIAID) also advances worldwide health through biodefense and related programs, global research and neglected tropical diseases [173]. National Institute of Dental and Craniofacial Research (NIDCR)—Craniofacial and Dental Purpose: The mission of the National Institute of Dental and Craniofacial Research is to improve craniofacial, dental and oral health. Value: The National Institute of Dental and Craniofacial Research (NIDCR) seeks to accomplish its mission by conducting and funding research training and career development, coordinating and assisting relevant research, performing and supporting clinical research, and promoting the timely transfer of knowledge to health professionals, policymakers, the public and joint researchers [174]. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Clearinghouse—Diabetes, Digestive and Kidney Diseases Purpose: The National Institute of Diabetes and Digestive and Kidney Diseases serves to create knowledge about and treatments for chronic, costly and consequential diseases that include diabetes, digestive and kidney diseases. Value: Research areas include diabetes, digestive diseases, endocrine diseases, hematologic diseases, kidney disease, liver disease, metabolic diseases, nutrition-related diseases, obesity and urologic diseases [175]. National Institute of Mental Health (NIMH)—Mental Health Purpose: The National Institute of Mental Health is a federal agency that is involved with research on mental disorders. The vision of National Institute of Mental Health (NIMH) is a world in which mental illnesses are not only prevented but they are cured. Value: The National Institute of Mental Health (MIMH) seeks to transform the treatments and understanding of mental illness through basic and clinical research to discover prevention, recovery and cures for mental illness. This outlook is projected through defining the mechanisms of complex behaviors, charting mental illness trajectories for intervention, striving for cures and prevention and strengthening the public health impact [176].

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National Institute of Neurological Disorders and Stroke (NINDS)—Neurological Disorders and Stroke Purpose: The National Institute of Neurological Disorders and Stroke within the National Institutes of Health (NIH) serves to obtain fundamental knowledge about the brain and nervous system to help reduce the burden of neurological disorders and stroke. Value: The National Institute of Neurological Disorders and Stroke (NINDS) is focused on the following diseases and targeted areas throughout its basic clinical, disease and translational research: Alzheimer’s diseaserelated dementias, cerebral palsy, epilepsy, muscular dystrophy, Parkinson’s disease, stroke, tuberous sclerosis complex and others [177]. National Institutes of Health (NIH)—Biomedical Research Purpose: The National Institutes of Health, as part of the US Department of Health and Human Services (USDHHS), seeks fundamental knowledge about the behavior and natures of living systems and applies this knowledge for health enhancement, life lengthening, and disability and illness reduction. Value: The National Institutes of Health (NIH) develops, maintains and renews scientific human and physical resources, exemplifies and promotes public accountability, scientific integrity and social responsibility, expands knowledge in associated sciences and medicine and fosters fundamental creative discoveries and innovative research strategies [178]. National Institute on Aging (NIA)—General Information on Aging Purpose: The National Institute on Aging, part of the Institutes, Centers and Offices of the National Institutes of Health (NIH) leads wide-ranging scientific efforts to understand the nature of aging and to potentially extend active and healthy years of life. The National Institute on Aging (NIA) is the main US agency that conducts and supports Alzheimer’s disease research. Value: The National Institute on Aging (NIA) endeavors to accomplish its mission through and conducting and supporting behavioral, biological, clinical, economic and genetic research on aging, developing clinician and research scientists that specialize in aging, disseminating information about aging that includes advances in research and providing research resources [179]. National Kidney Foundation (NKF)—Kidney (Renal) Function Purpose: The National Kidney Foundation is dedicated to the awareness, prevention and treatment of patients with kidney disease and their families and healthcare professionals who treat them. Value: The National Kidney Foundation (NFK) focuses on the entire patient through their kidney health, and enhances lives through advocacy, gathering and publishing epidemiologic data, improving outcomes through patient and professional education, increasing access to kidney transplantation, supporting patients, caregivers and organ donors and measuring outcomes and impacts [180]. National League for Nursing (NLN)—Nursing Purpose: The National League for Nursing exists for nursing education to impact the international and national nursing workforce that contributes to healthcare quality and safety. Value: The National League for Nursing (NLN) is a primary source for nursing decisions, education, legislation and regulation that informs teaching practices for diverse populations and identifies and influences issues that are related to nursing education [181]. National Mental Health Consumers’ Self-Help Clearinghouse (NMHCSHC)—Mental Health Purpose: The National Mental Health Consumers’ Self-Help Clearinghouse is a peer-run self-help national technical assistance center that functions in the development of the mental health consumer/survivor/ex-patient movement. Value: The Clearinghouse strives for dignity, opportunity and respect for people who are diagnosed with mental health conditions through communication, consultation and peer-driven services that include advocacy and self-help, deinstitutionalization, fundraising, involuntary treatment, patients’ rights, media use and peer counseling [182]. National Multiple Sclerosis Society (NMSS)—Multiple Sclerosis Purpose: The National Multiple Sclerosis Society helps people that are affected by Multiple Sclerosis (MS) and their families through driving changes through advocacy, professional education through facilitation, programs and services through healthcare personnel and volunteers, and research through funding. Value: The Multiple Sclerosis (MS) Society seeks to help people with Multiple Sclerosis (MS) lead their best lives, to help stop the disease, and to help restore what may have been lost in the process of its development. The Society is focused on connecting Multiple Sclerosis (MS) patients with information and resources, effectuating treatment choices and solutions, and mobilizing individuals and organizations to accelerate progress, generate resources and maximize impact [183].

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National Organization for Rare Disorders (NORD)—Rare Disease Purpose: The National Organization for Rare Disorders is a patient advocacy organization that is dedicated to people with more than 1200 rare diseases, and to the organizations that provide service to these patients. The National Organization for Rare Disorders (NORD) is engaged in the identification, treatment and potential cure of rare disorders through advocacy, education, patient services and research. Value: The National Organization for Rare Disorders (NORD) serves to connect patients and patient organizations with other stakeholders who must deal with formidable financial and medical issues with few resources and little guidance. It drives medical research, family and patient services and supportive policies for needy patients and their families [184]. National Osteoporosis Foundation (NOF)—Osteoporosis Purpose: The National Osteoporosis Foundation is dedicated to the prevention of broken bones and osteoporosis and the promotion of strong bones for life. Value: The National Osteoporosis Foundation (NOF) seeks to reduce human suffering from bone disease. It addresses concerns and issues through advocacy, clinician and public awareness, education and research to advance good bone health to protect future generations [185]. National Psoriasis Foundation (NPF)—Psoriasis Purpose: The National Psoriasis Foundation is a nonprofit with the mission to cure psoriatic disease and improve lives of those afflicted. The National Psoriasis Foundation (NPF) is a leading patient advocacy group for people who are living with psoriasis and psoriatic arthritis. Value: The National Psoriasis Foundation (NPF) is driven to accelerate discovery to cure psoriatic disease, improve health outcomes, and secure resources through access to appropriate treatments, communications, community outreach, supportive research and other initiatives [186]. National Rehabilitation Information Center (NARIC)—Rehabilitation Purpose: The National Rehabilitation Information Center is a gateway to disability and rehabilitation-oriented information for direct, personal and quality interactive information services for the disability and rehabilitation communities. The National Rehabilitation Information Center (NARIC) actively promotes the work of the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Value: The National Rehabilitation Information Center (NARIC) oversees online publications, searchable databases and timely referral data and references and places vital information on disability and rehabilitation into the hands of the users [187]. National Sleep Foundation (NSF)—Sleep Purpose: The National Sleep Foundation is committed to sleep advocacy and education for the improvement of health and well-being for people with sleep issues. Value: The primary goals of the National Sleep Foundation (NSF) are to ensure that the biological processes of sleeping and waking are common knowledge, that homes, schools, transportation and workplaces are designed to be sleep-friendly, that sleep marks a vital sign of health and that sleep science is incorporated into products and services [188]. National Stroke Association (NSA)—Stroke Purpose: The National Stroke Association is a trusted source of free education and resources for the stroke community. The National Stroke Association (NSA) develops programs for acute treatments of strokes and stroke prevention and stroke rehabilitation through life-saving information, survivor empowerment and stroke community quality of life. Value: The National Stroke Association (NSA) assists healthcare professionals, caregivers and stroke survivors as a circle of support for stroke recovery by building a national platform for strokes as a leading cause of death, increasing awareness of life-saving stroke information and impacting survivor empowerment and the quality of life of the stroke community [189]. National Women’s Health Network (NWHN)—Women’s Health Purpose: The National Women’s Health Network strives to improve the health of all women through the development and promotion of critical analyses of health issues to affect polices and support consumer decisionmaking. Value: The National Women’s Health Network (NWHN) believes that evidence must drive health care, health is a human right, health justice demands health equality and women’s lives must be recognized and their physiological experiences must be respected. Aging women’s issues are embedded in these views [190]. Nutrition Services Program (NSP)—Nutrition Services

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Purpose: The Administration for Community Living’s Administration on Aging (AoA) provides grants to help support nutrition services through the Older Americans Act (OAA) Nutrition Program. These include the Congregate Nutrition Program and the Home-Delivered Nutrition Program for healthy group meals. Value: The Nutrition Services Program (NSP) impacts diet quality, security and socialization of participants. Assessment, counseling, education and nutrition screening services are offered through the Aging Network’s meal providers. Links to programs and/or services in chronic disease self-management, falls prevention, homehealth aides and homemakers, home repair and modification and physical activity and transportation options are also available [191]. Nutrition Services Incentive Program (NSIP)—Nutrition Purpose: The Nutrition Services Incentive Program is administered by the Administration for Community Living (ACL) within the Department of Health and Human Services (HHS) of the US government. It serves to delay adverse health conditions, promote health, socialization and well-being and reduce food insecurity and hunger in aging Americans under the Older Americans Act (OAA). Value: The Administration for Community Living (ACL) provides funding to state agencies, Indian tribal organizations and territories. US Department of Agriculture (USDA) foods that are offered to state agencies that administer the Nutrition Services Incentive Program (NSIP) are found within Food Distribution Program websites [192]. O Office of Disability Employment Policy (ODEP)—Disabilities Purpose: The mission of the Office of Disability Employment Policy is to advance opportunities for profitable employment, assure work-related benefits and rights, foster, promote and develop the welfare of all job seekers, retirees and wage earners and improve working conditions. Value: The Office of Disability Employment Policy (ODEP) focuses on employee benefit security, hours and wages, employee protection, unions and their membership, workers’ compensation, and workplace health and safety for businesses, contractors, grantees, job seekers, retirees and workers [193]. Office of Disease Prevention and Health Promotion (ODPHP)—Disease Prevention and Health Promotion Purpose: The Office of Disease Prevention and Health Promotion performs a vital role in US health by setting national health goals and objectives, and supporting educational activities, programs and services that endeavor to improve American health. Value: As part of the US Department of Health and Human Services (USDHHS), the Office of Disease Prevention and Health Promotion (ODPHP) strives to lead disease prevention and health promotion efforts in the United States. The website health.gov is the “home” of Office of Disease Prevention and Health Promotion (ODPHP), and provides an essential resource for health information of all types and for all people [194]. Office of Special Education and Rehabilitation Services (OSERS)—Special Education and Rehabilitation Purpose: The Office of Special Education and Rehabilitation Services is committed to improving the results and outcomes for people with disabilities of all ages. Office of Special Education and Rehabilitation Services (OSERS) has two main program components: The Office of Special Education Programs (OSEP) and the Rehabilitation Services Administration (RSA). Value: Office of Special Education and Rehabilitation Services (OSERS) provides for the education and rehabilitation of children and adults with disabilities so that all Americans with disabilities and their families may be able to thrive in their own communities [195]. Older Americans Act (OAA)—Aging Services (see National Council on Aging) Purpose: The Older Americans Act (signed into law in 1965) funds critical services to help older Americans remain healthy and independent. These include benefits enrollment, caregiver support, health promotion, job training, meals, senior centers, transportation and others. Value: Legislation to reauthorize the Act was enacted by the Senate reauthorization bill and House amendments that were signed into law in 2016. These included highlighting the importance of addressing economic needs, promoting chronic disease self-management and fall prevention, requiring evidence-based disease prevention and health promotion initiatives and supporting the modernization of multipurpose senior centers [196]. Osteoporosis and Related Bone Diseases National Resource Center NIH ORBDBNRC—Bone Diseases/ Osteoporosis Purpose: The NIH ORBDBNRC is a service that is offered by the National Institutes of Health (NIH). It provides health professionals, patients and the public with information and resources on metabolic bone diseases, including osteoporosis.

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Value: The NIH ORBDBNRC is dedicated to increasing the awareness, knowledge and understanding about the early detection, prevention and treatment of osteoporosis and related bone diseases, such as Paget’s disease of bone (a disease that disrupts the replacement of old bone with new bone tissue), and osteogenesis imperfect (group of inherited disorders characterized by fragile, breakable bones) [197]. P Parkinson’s Disease Foundation (PDF)—Parkinson’s Disease Purpose: The Parkinson’s Disease Foundation has national prominence in Parkinson’s disease advocacy, patient education and research for increased federal funding for scientific research to support people with Parkinson’s disease, their caregivers and families through educational programs and support services. Value: The Parkinson’s Disease Foundation (PDF) focuses on the highest levels of support for Parkinson’s disease patients and verifiable outcomes data that are based on validated research. Information and services of the Parkinson’s Disease Foundation (PDF) include a blog, information on financial/insurance/legal matters, materials on the management Parkinson’s disease and patient-centered care, a helpline, Parkinson’s Disease (PD) library and other targeted resources and support [198]. Patient Advocates for Advanced Cancer Treatment (PAACT)—Cancer Purpose: The Patient Advocates for Advanced Cancer Treatments is a nonprofit advocacy organization devoted to discovering solutions for people with prostate cancer. Value: The Patient Advocates for Advanced Cancer Treatment (PAACT) helps direct affected individuals to appropriate medical centers and physicians, increase the awareness of prostate cancer in affected people, and inspire such individuals to participate in their own healing. It does so through advanced methods of detection, diagnostic procedures, evaluations and treatments and through patient communication and information such as their free helpline and newsletter [199]. President’s Council on Sports, Fitness & Nutrition (PCSFN)—Healthy Lifestyles Purpose: The mission of the President’s Council on Sports, Fitness & Nutrition is to educate, engage and empower all Americans to adopt a healthy lifestyle that includes good nutrition and regular physical activity. Value: The functions of the President’s Council on Sports, Fitness & Nutrition (PCSFN) are to disseminate quality information and guidance about healthy lifestyles, expand awareness of and national interest in the benefits of fitness, good nutrition, regular physical activities and sports participation, stimulate programs that promote these pursuits and target all Americans—with particular emphasis on communities and populations with specific disparities or risks [200]. Prevent Blindness America (PBA)—Vision Purpose: Prevent Blindness America is a patient advocate for healthy vision to help address problems that include age-related macular degeneration, blindness, cataracts, diabetic retinopathy, glaucoma, refractive error and/or vision impairment. Prevent Blindness America (PBA) serves to elevate the national dialog around vision and significant health issues that include access, prevention messaging, program development and replication, service integration and surveillance. Value: Prevent Blindness America provides access for professional eye care for low-income families throughout the United States. Funds from Prevent Blindness America (PBA) help to support advocacy and research so that Americans may be able to see well to learn, live independently, play and work by addressing the aforementioned vision-related problems and health issues [201]. Prostate Conditions Education Council (PCEC)—Prostate Cancer Purpose: The Prostate Conditions Education Council serves to conduct awareness, early detection, education and research about prostate cancer and all prostate conditions. Value: The Prostate Conditions Education Council (PCEC) provides prostate cancer awareness and treatment options for all stages of the disease to men and their social networks, caregivers and medical professionals and offers access to free early detection [202]. Q No listing R RecallGuide—Pharmaceutical Information Purpose: RecallGuide is a free service that provides access to critical information about prescriptions that includes drug interactions and side effects, and Food and Drug Administration (FDA) drug recalls and warnings. Data is from credible sources, such as the Food and Drug Administration (FDA) and DailyMed [the official provider of Food and Drug Administration (FDA) label information].

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Value: Information from attorneys, counselors and healthcare professionals through the RecallGuide provide timely opportunities for community sharing and medication tracking [203]. Recovery International (RI)—Mental Health Purpose: Recovery International, a mental health self-help organization, uses behavioral, cognitive, peer-topeer and self-help training to help individuals gain skillfulness for more peaceful and productive lives. Value: Recovery International employs a cognitive behavioral training method to identify and manage negative beliefs, behaviors, feelings and negative thoughts to help reduce emotional distress and the resultant symptoms [204]. Robert and Arlene Kogod Center on Aging—General Information on Aging Purpose: The Robert and Arlene Kogod Center on Aging at Mayo Clinic focuses on individualized care and research about aging bones and muscles, cellular senescence, healthy aging and independent living, regenerative medicine and aging and translation and pharmacology. Value: The Kogod Center on Aging brings clinicians and scientists from each of Mayo Clinic’s three campuses together for collaborations that lead to innovative methods of studying aging. The Center focuses on the goal of increasing healthy lifespan and quality of life for older adults that is measured by freedom of age-related diseases and disabilities and years of independent living [205]. S Scleroderma Foundation (SF)—Scleroderma/Autoimmune Disease Purpose: The Scleroderma Foundation is the national resource for people with scleroderma (a group of autoimmune diseases) through education, research and support. Value: The Scleroderma Foundation (SF) helps scleroderma patients and their families cope with their autoimmune diseases through communication tools, educational information, mutual support programs, a nationwide patient-education conference and networking opportunities, peer counseling, physician referrals and its toll-free helpline [206]. Self-Help for Hard of Hearing People (SHHH)—Hearing Purpose: Self-Help for Hard of Hearing People was founded to help hearing-impaired people with experiences and knowledge for coping skills, and to assist their informed decision-making about the best alternatives for hearing management and hearing losses. Value: Self-Help for Hard of Hearing People (SHHH) endeavors to educate hard of hearing people, their families and friends and the community-at-large about the nature and complications of hearing loss and coping with its consequences, assist hard-of-hearing people so that they may integrate into all aspects of society, and provide such services as advocacy, education, referral, research, support and welfare for the hearing-impaired as they are needed [207]. Senior Farmers’ Market Nutrition Program (SFMNP)—Nutrition Purpose: The Senior Farmers’ Market Nutrition Program awards grants to provide low-income seniors with coupons that may be exchanged for eligible foods at community-supported agriculture programs, farmers’ markets and roadside stands. Value: The Senior Farmers’ Market Nutrition Program (SFMNP) aids and develops in the development of new and additional food and nutrition-related markets, stands and programs, helps to increase the domestic consumption of agriculture commodities, and provides resources in the forms of fresh, nutritious fruits, herbs, honey and vegetables for low-income seniors [208]. Senior Resource Connect (SRC)—General Aging Purpose: The Senior Resource Connect is a service of the Association of Jewish Family & Children’s Agencies (AJFCA). It serves to bring the experience and expertise of the Association of Jewish Family & Children’s Agencies (AJFCA) network to the US public to support aging adults so that they may live with dignity and health in settings of their choice. Value: The Senior Resource Connect (SRC) provides information and resources for aging people, their care providers and families for connections to local service providers throughout US communities. The assessment of current services, determination of possible solutions, and development and implementation of care plans are within the purview of their complex service system [209]. Sjo¨gren’s Syndrome Foundation (SSF)—Autoimmune Disease Purpose: The Sjo¨gren’s Syndrome Foundation focuses on increasing the awareness, education and research about Sjo¨gren’s Syndrome, a systemic autoimmune disease that affects the entire human body.

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Value: The Sjo¨gren’s Syndrome Foundation conducts professional healthcare awareness initiatives, expands general awareness of the disease, manages family and patient seminars and serves as the lead organization for Sjo¨gren’s groups worldwide [210]. Skin Cancer Foundation (SCF)—Skin Cancer Purpose: The Skin Cancer Foundation is an international organization that is devoted to early detection, education, prevention and prompt treatments of skin cancer. It accomplishes these goals by educating the public and medical community about this widespread form of cancer to help to decrease its incidence and mortality. Value: The Skin Cancer Foundation (SCF) creates educational programs and public awareness to help people understand the vital importance of skin cancer prevention through behavior modification, early detection and effective and prompt treatments to reduce the global incidence of skin cancer [211]. Social Security Administration (SSA)—Financial Purpose: The US Social Security administration has provided financial protection for US residents for the majority of their lifetimes. As an antipoverty system, the Social Security Administration oversees disability, retirement and survivors’ benefits by delivering financial support. Value: The Social Security Administration (SSA) helps to maintain the basic financial protection and wellbeing of the US population from birth to marriage and into retirement, including children, retirees, widows and widowers. One of the priorities of the Social Security Administration (SSA) is secure access to information and protection of personal data [212]. Spondylitis Association of America (SAA)—Rheumatic Diseases Purpose: The Spondylitis Association of America seeks to cure ankylosing spondylitis (inflammatory arthritis that affects the large joints and spine) and related diseases, and to empower those who are affected to fully live their lives. Value: Through advocacy, education, research and resources, the Spondylitis Association of America (SAA) serves to help patients, their care providers and families with assistance to live with this potentially debilitating inflammatory condition [213]. Substance Abuse and Mental Health Services Administration (SAMHSA)—Substance Abuse/Mental Health Purpose: The Substance Abuse and Mental Health Services Administration is an agency within the US Department of Health and Human Services (USDHHS) that spearheads public health efforts to further US behavioral health. Value: The mission of the Substance Abuse and Mental Health Services Administration (SAMHSA) is to build strong and supportive communities, reduce the impact of substance abuse and mental illness in the United States by providing services and treatment for people with mental and substance use disorders, prevent expensive behavioral health issues and promote better overall health for all Americans [214]. Supplemental Nutrition Assistance Program (SNAP)—Nutrition Assistance Purpose: The Supplemental Nutrition Assistance Program (SNAP) offers nutrition assistance to eligible lowincome individual and families throughout the United States. Value: The Supplemental Nutrition Assistance Program (SNAP) works with faith-based organizations, nutrition educators, neighborhoods, state agencies and others to confirm that people who are qualified for nutrition assistance make educated decisions about available benefits and programs [215]. T The American Occupational Therapy Association, Inc. (AOTA)—Occupational Therapy Purpose: The American Occupational Therapy Association, Inc. represents the concerns and interests of occupational therapy practitioners and students to assure the quality of occupational therapy services, improve consumer access to healthcare services and promote professional development. Value: The The American Occupational Therapy Association, Inc. (AOTA) advances the profession by educating the public, establishing standards, and serving as an advocate for the health, quality of life and well-being of all people with occupational needs [216]. The Emergency Food Assistance Program (TEFAP)—Emergency Food Purpose: The Emergency Food Assistance Program is a Federal program that exists to support the diets of low-income Americans—including aging people, with free emergency food and nutrition assistance. Value: The Emergency Food Assistance Program (TEFAP) provides administrative services, food and funds to States for dietary supplementation. Through Emergency Food Assistance Program (TEFAP), the US Department of Agriculture (USDA) purchases a wide variety of nutritious, high-quality US Department of Agriculture (USDA) foods and makes these available to State Distributing Agencies. In turn, this food is distributed to food banks, food pantries and local organizations such as soup kitchens that directly serve the public [217].

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The Joint Commission (TJC)—Health Care Accreditation and Certification Purpose: The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) is a US-based nonprofit organization that accredits healthcare organizations and programs. The international branch accredits medical services around the world. Value: Many state governments recognize The Joint Commission (TJC) accreditation as a condition of licensure for Medicaid and Medicare reimbursements. The Joint Commission serves to continuously improve health care for the public across all settings to ensure effective and safe care of the highest quality and value [218]. The Living Bank (TLB)—Organ Donation Purpose: The Living Bank advances living organ donations to help confront organ shortage for life-saving transplants. Value: The Living Bank (TLB) serves as an organ donor registry and provider of organ donation and transplantation education that allows medical professionals to match organs with needy patients. The Living Bank provides critical advocacy, information and support to help to bring hope to transplant recipients and their families and potentially transform lives [219]. U United Network for Organ Sharing (UNOS)—Organ Sharing Purpose: The United Network for Organ Sharing advances organ availability by supporting and uniting the organ sharing communities to benefit patients through education, policy development and technology. Value: The value of the United Network for Organ Sharing (UNOS) is the promotion of healthy, long and productive lives for people with organ failure. It does so by promoting access to equitable transplantation, effective and safe care, expanded organ supply and fair organ allocation [220]. United Ostomy Association of America, Inc. (UOAA)—Ostomies Purpose: The United Ostomy Association of America, Inc. promotes quality of life for people with ostomies (artificial openings created during operations) and continent diversions (internal reservoirs) through advocacy, collaborations, information and support. Value: The United Ostomy Association of America, Inc. (UOAA) supports the education, empowerment, resilience and strength of patients with ostomies and continent diversions who live with emotional and physical challenges, as well as their care providers so that the fullest life quality may be achieved [221]. United Spinal Association (USA)—Spinal Cord Injuries or Disease Purpose: The United Spinal Association is focused on the enhancement of life quality for all people who live with spinach cord injury or disease (SCI/D). The extensive audience includes care providers, loved ones, patients, professionals and veterans. Value: The goals of the United Spinal Association (USA) are to enable active community life and maximize independence for all people who live with spiral cord disease and/or injuries. No one in the scope of the United States is excluded based upon disabilities [222]. United Way Worldwide (UWW)—Charitable Endeavors Purpose: United Way Worldwide is a nonprofit coalition of charitable organizations that pool fundraising efforts and support. The focus of United Way Worldwide (UWW) is concerned with pressing community issues and measurable changes that affect education, health and income. Value: The United Way Worldwide (UWW) collaborates with diverse partners, depending upon issues which might involve businesses, community development, corporations, financial institutions, organized labor, neighborhood organizations, religious communities and/or volunteer associations [223]. Urology Care Foundation (UCF)—Diseases of the Urinary Tract Purpose: The Urology Care Foundation supports urologic research for patients and the public through advocacy, clinical trials, grant programs, publishing and resources for patient education. Value: The Urology Care Foundation (UCF) partners with caregivers, families, healthcare professionals, physicians, the public and researchers to improve and support the detection, prevention and treatment of urological diseases in both men and women [224]. US Department of Health and Human Services (USDHHS)—Health and Well-being Purpose: The mission of the US Department of Health & Human Services is to enhance and protect the health and well-being of all Americans by fostering advances in medicine, public health and social services, and providing effective health and human services. Value: Within US Department of Health and Human Services (USDHHS) is the Administration on Aging (AoA) that encompasses age discrimination, caregiver resources, elder justice, healthy aging behaviors

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and habits, long-term care, Medicaid coverage, Medicare enrollment, retirement planning and social security benefits [225]. US Department of Veterans Affairs Veterans Health Administration—Geriatrics and Extended Care (GEC)—General Information on Aging Purpose: The mission of Geriatrics and Extended Care within the US Department of Veterans Affairs Veterans Health Administration is to honor the preferences of veterans (and caregivers/support personnel) for health, independence and well-being in the face of aging, disability or illness, by advancing expertise, programs and partnerships. Value: Information is available through the Geriatrics and Extended Care (GEC) about decision aids and longterm care services and settings, along with helpful websites and personal stories about how to become involved in shared decisions regarding geriatrics and palliative care; in particular, assistance and long-term services and supports in community, home and facility settings [226]. US Department of Agriculture (USDA) Dietary Guidelines for Americans 2015 2020—Nutrition Purpose: The 2015 2020 edition of the US Department of Agriculture (USDA) Dietary Guidelines for Americans builds from the 2010 edition with timely revisions. It is designed for professionals to help all people ages two and older and their families to consume healthy, nutritionally adequate diets. Value: The information that is contained with the US Department of Agriculture (USDA) Dietary Guidelines is used for the development of Federal food and nutrition programs and health policies, the basis for Federal nutrition education materials designed for the public and Department of Health and Human Services (HHS) and US Department of Agriculture (USDA) food programs, and the general public, including businesses, community groups, the food industry, media and state and local governments. Information on aging is addressed [227]. US Federal Bureau of Investigation (FBI) Fraud Warnings for Seniors—Fraud Purpose: Seniors are more vulnerable to fraud than younger individuals because they are more likely to own their own homes and by-and-large have excellent credit. Seniors may also be less likely to report fraud due to embarrassment or inexperience, they often make poor witnesses and are susceptible to promising product claims. The US Federal Bureau of Investigation Fraud Warnings for Seniors exists for protection. Value: In particular, the Federal Bureau of Investigation (FBI) Common Fraud Schemes provides helpful tips for seniors and their families on what to look for regarding fraud and how to prevent its occurrence. Also helpful are resources on Telemarketing Fraud [228]. US Federal Trade Commission: Consumer Information and Identity Theft—Identity Theft Purpose: The US Federal Trade Commission operates IdentityTheft.gov to help prevent deceptive, fraudulent and/or unfair business practices to provide information to help consumers avoid, identify and prevent them from occurring. Value: Consumer information includes how to protect against unfounded information on cures, fitness, healthy living, treatments and weight loss. Consumer issues that include credit, debit, identity theft, loans and savings are other available free resources [229]. US Food and Drug Administration (FDA)—Food and Drug Protection Purpose: The US Food and Drug Administration is responsible for the protection of public health by assuring the efficacy, safety and security of biological products, cosmetics, drugs, the food supply, medical devices and products that emit radiation. Value: The US Food and Drug Administration (FDA) strives to provide accurate, science-based health information to the US public. Many ongoing and updated guidelines are used to create health, nutrition and physical fitness directives and programs for the US population. Market withdrawals, recalls and safety alerts provide archival and current references [230]. US Food Safety and Inspection Service (FSIS)—Food Safety Purpose: The US Food Safety and Inspection Service protects the health of the US public by ensuring the safety of meats, poultry and processed egg products. Value: The Food Safety and Inspection Service (FSIS) endeavors to assure that everyone in America has safe food by lowering the incidence of pathogens that cause foodborne illnesses, and limiting the occurrences of outbreaks of foodborne illnesses in regulated food products [231]. US Health Resources and Services Administration (HRSA)—Health Care Purpose: The US Health Resources and Services Administration is an agency of the US Department of Health and Human Services (USDHHS) and the primary federal agency for improving health care through access to quality services, innovative programs and a skilled health workforce for people who are economically or medically vulnerable and/or geographically isolated.

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489

Value: The Health Resources and Services Administration (HRSA) programs helps those in need of highquality primary health care, and supports the distribution of providers to areas where they are most needed, improvements in healthcare delivery, and training of health professionals. It also oversees bone marrow, cord blood and organ donations [232]. V Vestibular Disorders Association (VEDA)—Inner Ear Purpose: Though community outreach, the nonprofit Vestibular Disorders Association connects vestibular patients and their families with medical specialists to help to prevent and manage chronic vestibular disorders. Value: The Vestibular Disorders Association (VEDA) advocates on behalf of patients who are impacted by vestibular disorders, as supported by individual and membership contributions. A variety of specialists that include audiologists, physical therapists, physicians and others provide input for vestibular patients, family members and friends to help cope with balance and/or inner ear problems [233]. Visiting Nurse Association of America (VNAA)—Nursing Purpose: The nonprofit Visiting Nurse Association of America functions as a catalyst to ensure the advancement, innovation, quality and value of home-based healthcare as a preferred solution for first-rate and valued health care. Value: The Visiting Nurse Association of America (VNAA) advocates on behalf of community-based, nonprofit home health and hospice providers that offer comprehensive health care for Medicaid, Medicare and uninsured and under-insured patients, regardless of ability to pay or complexity of conditions. A Blueprint for Excellence provides a comprehensive quality improvement and workforce training resource for care providers, payers, policymakers and researchers and others who are involved in improving patient care throughout transitions and end-of-life [234]. W Well Spouse Foundation (WSF)—Spousal Support Purpose: The Well Spouse Association is a nonprofit organization that advocates for and addresses the needs of people who care for the chronically ill and/or disabled spouses and partners. Value: The Well Spouse Foundation (WSF) offers peer-to-peer support and educates healthcare professionals and the public about special challenges and unique issues that spouses and partners face daily through a mentor program, newsletter, regional and national conferences, support groups and website. The Well Spouse Foundation (WSF) advocates on behalf of spousal and partner caregivers, and seeks out new initiatives to alieve emotional and financial stresses that are associated with chronic illnesses and/or disabilities [235]. X No listing Y No listing Z No listing

DIGEST Many of the “prime time” resources that are provided in this chapter have existed for years while others are relatively newer. This may be due to the fact that aging has been growing throughout the decades from when some of these resources were first conceived. No doubt, other resources will develop as this text comes into fruition, and medical interventions and overall improved standards of living facilitate longer lives. Not having enough food and not having enough energy (calories) that are absorbed to maintain basic metabolism remain paramount to the growing US and global aging populations. Nutrition frailty and on the other extreme, nutrition-related obesity may prompt their own specialized resources. Still, new product launches that feature aging claims have been low worldwide. Although Asia appears to be ahead of other areas regarding marketing to the aging, the use of the word “senior” tends to be rare. Activity, positivity and even longevity may be viewed more positively than a senior mindset [236]. Supplements with specific health benefits, such as cognition, circulation and/or muscle health, may be perceived as more beneficial than a “mega” supplement for aging. Likewise, programs and/or services with specific advantages might be more favorably sensed than organizations with a more “umbrella-like” approach.

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A solution-forward mindset versus a problematic one may also garner positivity and interest by aging people. Resources that are listed in this chapter may thus consider subtle changes in names and/or focus to appeal to this more positive approach. While some of the resources that are listed in this chapter as well as those that are described in Chapter 11, Cooking Aids, Tableware Tips and Dining Advice, are considered basic to the aging process, others may be more progressive. These include drinkable and swallowable supplements, products with easy-to-open packaging and larger print labels, and those that address mobility constraints for food shopping, lifting and/or meal preparation and clean up [236]. More personalized approaches to optimal health and life will be on the horizon and concurrently, more individualized resources will be of demand. This is why this chapter should be considered as a “work in progress” as the rapidly expanding demographic of aging people in the United States and worldwide continues to strap future ingenuity, implementation, improvements and life itself.

MANNER OF SPEAKING Alopecia Areata Ankylosing Spondylitis Aphasia Benign Essential Blepharospasm Biosimilars Continent Diversions Endodontics Hospice Huntington’s Disease Hyperacusis Keratoconus Lupus Osteogenesis Imperfect Ostomies Paget’s disease of bone Retinitis Pigmentosa Sjo¨gren’s Syndrome Stargardt Disease Vestibular Schwannoma

autoimmune skin disease that typically causes hair loss and emotional pain form of arthritis that primarily affects the spine and/or other joints; causes inflammation; may lead to chronic pain and/or discomfort language impairment; loss of ability to understand or express speech neurological condition that is characterized by the forcible closure of the eyelids; caused by brain damage less costly imitations of drugs known as biologics internal urinary reservoirs that are created by surgeons from a section of the bowel study and treatment of dental pulp (the soft inner tissue of the teeth) philosophy and type of care that focuses on the palliation of chronically, terminally or seriously ill people inherited condition in which the nerve cells of the brain break down over time increased sensitivity to certain frequencies and volume ranges of sound condition whereby the clear tissue on the front of the eye (cornea) bulges outward chronic autoimmune inflammatory disease that affects many different body systems; causes damage, inflammation, pain and/or swelling group of inherited disorders characterized by fragile, breakable bones artificial openings created during operations disease that disrupts the replacement of old bone with new bone tissue damage of cells of the back wall of the eye (retina); causes vision loss systemic autoimmune disease that affects the entire human body; characterized by dry eyes and dry mouth juvenile macular degeneration; progressive damage or degeneration of the macula in the center of the retina that is responsible for sharp, straight vision noncancerous (benign) tumor on the main nerve that leads from the inner ear to the brain

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Index

Note: Page numbers followed by “f” and “t” refer to figures and tables, respectively.

A AA. See Alcoholics Anonymous (AA); Alzheimer’s Association (AA) AAAI. See American Academy of Allergy, Asthma & Immunology (AAAI) AAD. See American Academy of Dermatology (AAD) AADE. See American Association of Diabetes Educators (AADE) AAE. See American Association of Endodontists (AAE) AAFA. See Asthma and Allergy Foundation of America (AAFA) AAKP. See American Association of Kidney Patients (AAKP) AANS. See American Association of Neurological Surgeons (AANS) AAO-HNSF. See American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) AAOMS. See American Association of Oral and Maxillofacial Surgeons (AAOMS) AAOS. See American Academy of Orthopedic Surgeons (AAOS) AAP. See American Academy of Periodontology (AAP) AARP. See American Association of Retired Persons (AARP) AASM. See American Academy of Sleep Medicine (AASM) ABF. See American Brain Foundation (ABF) ABTA. See American Brain Tumor Association (ABTA) AC. See Adenylyl cyclase (AC) Academy of Nutrition and Dietetics (AND), 457 Academy of Nutrition and Dietetics Evidence Analysis Library, 457 ACB. See American Council of the Blind (ACB) Acceptable Macronutrient Distribution Range (ADMR), 35, 54 62 ACD. See Anemia of chronic disease or disorder (ACD) ACE inhibitors. See Angiotensin-converting enzyme inhibitors (ACE inhibitors) Aceto balsamico. See Balsamic vinegar Acetylcholine (ACh), 94 102, 165 169 ACG. See American College of Gastroenterology (ACG) ACHE. See American Council for Headache Education (ACHE)

Acid(ic) aromas, 179 180 in flavor enhancement, 178 180 ingredient, 300, 309, 331 332 taste, 94 102, 134 139 Acidifying, 134 139, 178, 228 229, 242 245 complementing, 179 heightening, 179 reducing or mask, 179 ACL. See Administration for Community Living (ACL) Acoustic neuroma, 457, 490 Acoustic Neuroma Association (ANA), 457 ACP. See American College of Prosthodontists (ACP) ACPA. See American Chronic Pain Association (ACPA) Acquired immunodeficiency syndrome (AIDS), 146, 271 272, 288 293, 436 ACR. See American College of Radiology (ACR) Acridity, 134 139 ACS. See American Cancer Society (ACS); American College of Surgeons (ACS) Active Choices, 53 Active lifestyle, 30, 54 62 Active Living Every Day, 53 Acute inflammation, 274, 288 293 Acute kidney disease, 263, 288 293 Acute olfaction, 83, 94 102 ADA. See American Dental Association (ADA) ADC. See Alzheimer’s Disease Research Center (ADC) Added sugars, 34, 54 62, 330, 334 337 Adenosine triphosphate (ATP), 38, 54 62, 144, 165 169 Adenylyl cyclase (AC), 144, 165 169 Adequate hydration, 332 Adequate intake (AI), 34, 41 42, 54 62 Adjusting, 229, 242 245 Administration for Community Living (ACL), 458, 483 Administration on Aging (AOA), 457 458, 469, 483, 487 488 ADMR. See Acceptable Macronutrient Distribution Range (ADMR) ADRCs. See Aging and Disability Resource Centers (ADRCs) Adult rickets. See Osteomalacia Adult-onset diabetes. See Type 2 diabetes Adulthood, 148 149

495

affecting nutritional status, 92 93 body composition reconfigurations, 92 brain function variations, 92 dehydration irregularities, 92 digestive system changes, 92 93 malnutrition, 93 sensory alterations, 93 Aerobic, 54 62 AF. See Aquafaba (AF) AFB. See American Foundation for Blind (AFB) African Americans, 19 23 AG Bell. See Alexander Graham Bell Association for Deaf and Hard of Hearing (AG Bell) AGA. See American Gastroenterological Association (AGA) Agar-Agar, 334 337 Age-related eye diseases (AREDs), 210, 242 245 Age-related macular degeneration (AMD), 35, 47, 54 62, 210, 242 245 Age/aging, 2, 19 23, 67, 67t, 191, 201 205, 250, 254t, 287, 456. See also Kitchen for aging people aged cheeses, 194 aged garlic extract, 201 205 anorexia of, 30, 47, 54 62, 73, 332, 334 337 aromas and, 151 152 aromatics in foods and beverages for, 75t baby boomers, 340 and balance, 72 behavioral, environmental, physical and social factors during, 68 challenging assumptions about chemosensory changes with, 164 conditions and diseases, 254 287 dependency ratio, 6, 19 23 diets minerals for, 37 43 quality, 68 vitamins for, 44 49 digest, 288 general considerations for meeting nutritional needs in, 254 global, 2 8 global coalition, 10 healthy eating for, 251 hearing and, 69 hearing loss and, 213 214 issues, 209

496 Age/aging (Continued) and kinesthesia, 73 minerals, 253 nutrients, 252 253 and pain, 73 and physical activity, 51 52 in place, 4, 19 23, 431, 451 452 populations worldwide, 3 saltiness and, 78 79 sight and, 70 smell and, 71 sourness and, 79 sweetness and, 80 taste and, 71 tastes, 131 and temperature, 73 touch and, 72 umami and, 81 US, 10 17 vision and, 210 vitamins, 253 water, 254 Ageusia, 84, 91, 94 102, 130, 134 139, 175, 201 205 Aggregation pheromones, 155, 165 169 Aging and Disability Resource Centers (ADRCs), 458 Aging Life Care Association (ALCA), 458 Aging with Dignity (AWD), 458 AGS. See American Geriatrics Society (AGS) AHA. See American Heart Association (AHA); American Hospital Association (AHA) AHF. See American Health Foundation (AHF) AHRF. See American Hearing Research Foundation (AHRF) AI. See Adequate intake (AI) AICR. See American Institute for Cancer Research (AICR) AIDS. See Acquired immunodeficiency syndrome (AIDS) Air frying technique, 326, 334 337 AJFCA. See Association of Jewish Family & Children’s Agencies (AJFCA) AKF. See American Kidney Fund (AKF) Al-Anon, 458 ALA. See Alpha-linolenic acid (ALA); American Lung Association (ALA) Alarm pheromones, 155, 165 169 ALCA. See Aging Life Care Association (ALCA) Alcohol, 229, 242 245 Alcohol-related dementia, 255, 288 293 Alcoholics Anonymous (AA), 255, 288 293, 458 Alcoholism, 254 255 dietary considerations, 255 interrelated conditions, 255 256 support systems, 255 Alexander Graham Bell Association for Deaf and Hard of Hearing (AG Bell), 458 ALF. See American Liver Foundation (ALF) Alkalinity, 229, 242 245 Alkalizing, 229, 242 245

INDEX

Alkaloids, 109, 134 139 Allergic rhinitis, 94 102, 158 Allergies, 176 177, 288 293, 459 Alliance for Retired Americans (ARA), 459 Allicin, 201 205 Allspice, 374, 421 Allyl isothiocynate, 201 205 Almond butter, 393 Almond extract, 299 Alopecia areata, 490 Alpha-linolenic acid (ALA), 35, 36t, 54 62 Alpha-tocopherol, 54 62 ALS. See Amyotrophic lateral sclerosis (ALS) Alternative sweeteners, 330, 334 337 Alzheimer’s Association (AA), 459 Alzheimer’s disease, 11, 19 23, 94 102, 257 258, 459 dietary considerations, 257 258 supplements, 258 support systems, 258 Alzheimer’s Disease Research Center (ADC), 459 AMA. See American Medical Association (AMA) Ambient light, 446, 451 452 AMD. See Age-related macular degeneration (AMD) AMDF. See American Macular Degeneration Foundation (AMDF) American Academy of Allergy, Asthma & Immunology (AAAI), 459 American Academy of Dermatology (AAD), 459 American Academy of Orthopedic Surgeons (AAOS), 459 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF), 459 American Academy of Periodontology (AAP), 460 American Academy of Sleep Medicine (AASM), 460 American Association of Diabetes Educators (AADE), 460 American Association of Endodontists (AAE), 460 American Association of Kidney Patients (AAKP), 460 American Association of Neurological Surgeons (AANS), 460 American Association of Oral and Maxillofacial Surgeons (AAOMS), 460 American Association of Retired Persons (AARP), 427, 444, 460 American Brain Foundation (ABF), 460 American Brain Tumor Association (ABTA), 461 American Cancer Society (ACS), 461 American Chronic Pain Association (ACPA), 461 American College of Gastroenterology (ACG), 461 American College of Prosthodontists (ACP), 461 American College of Radiology (ACR), 461 American College of Surgeons (ACS), 461

American Council for Headache Education (ACHE), 461 American Council of the Blind (ACB), 462 American Dental Association (ADA), 462 American Foundation for Blind (AFB), 462 American Gastroenterological Association (AGA), 462 American Geriatrics Society (AGS), 18 23, 462 American Health Foundation (AHF), 462 American Hearing Research Foundation (AHRF), 463 American Heart Association (AHA), 462 American Hospital Association (AHA), 463 American Institute for Cancer Research (AICR), 463 American Kidney Fund (AKF), 463 American Liver Foundation (ALF), 463 American Lung Association (ALA), 463 American Macular Degeneration Foundation (AMDF), 466 American Medical Association (AMA), 463 American Mental Health Counselor Association (AMHCA), 463 American Music Therapy Association, Inc. (AMTA), 463 American Nurses Association (ANA), 464 American Occupational Therapy Association, Inc. (AOTA), 486 American Optometric Association (AOA), 464 American Parkinson’s Disease Association (APDA), 464 American Physical Therapy Association (APTA), 464 American Podiatric Medical Association (APMA), 464 American Psychiatric Association (APA), 464 American Red Cross (ARC), 465 American Sleep Apnea Association (ASAA), 465 American Society for Geriatric Dentistry (ASGD), 468 American Society of Anesthesiologists (ASA), 465 American Society of Colon and Rectal Surgeons (ASCRS), 465 American Society of Internal Medicine (ASIM), 465 American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), 465 American Society on Aging (ASA), 465 American Speech-Language Hearing Association (ASHA), 465 American Stroke Association (ASA), 466 American Tinnitus Association (ATA), 466 American Trauma Society (ATS), 466 American Urological Association (AUA), 466 AMHCA. See American Mental Health Counselor Association (AMHCA) Amino acids, 110, 134 139 AMP-activated protein kinase (AMPK), 33, 54 62 AMPK. See AMP-activated protein kinase (AMPK)

497

INDEX

AMTA. See American Music Therapy Association, Inc. (AMTA) Amygdala, 90, 94 102, 144, 165 169 Amyotrophic lateral sclerosis (ALS), 288 293 ANA. See Acoustic Neuroma Association (ANA); American Nurses Association (ANA) Anaerobic, 54 62 Anchovy paste, 190 AND. See Academy of Nutrition and Dietetics (AND) Androgen receptor modulators, 284, 288 293 Androstenone, 147, 165 169 Anemia of chronic disease or disorder (ACD), 288 293 Anemias, 258 259 Anesthesiology, 465 Angina, 12 Angiotensin system, 288 293 Angiotensin-converting enzyme inhibitors (ACE inhibitors), 71, 92, 132 139, 284, 288 293 Anhedonia, 132, 134 139 Ankylosing spondylitis, 486, 490 Anorexia, 30, 54 62 of aging, 30, 47, 54 62, 73, 332, 334 337 nervosa, 30 Anorexia nervosa. See Anorexia Anosmia, 91, 94 102, 156, 158, 165 169, 175, 201 205 ANS. See Autonomic nervous system (ANS) Anthocyanins, 54 62, 288 293 Anti-scald devices, 433 Antidiuretic hormone, 92, 94 102 Antioxidants, 28, 45, 54 62, 379 Antiretroviral therapy (ART), 271, 288 293 AOA. See Administration on Aging (AOA); American Optometric Association (AOA) Aorta, 261, 288 293 AOTA. See American Occupational Therapy Association, Inc. (AOTA) APA. See American Psychiatric Association (APA) APDA. See American Parkinson’s Disease Association (APDA) Aphasia, 475, 490 Apigenin, 193 194, 201 205 APMA. See American Podiatric Medical Association (APMA) Apocrine sweat glands, 156, 165 169 Apolipoprotein E (APOE), 47, 54 62, 162 Apoptosis, 288 293 Appearance and flavor perception, 74 Appetite/fullness, lack of, 332 333 Appetitive behavior responses, 112, 134 139 Appetitive taste, 78, 94 102 Apple cider vinegar, 365 Applesauce, 194 Apricots, 375, 384 APTA. See American Physical Therapy Association (APTA) Aquafaba (AF), 334 337 ARA. See Alliance for Retired Americans (ARA)

ARC. See American Red Cross (ARC) AREDs. See Age-related eye diseases (AREDs) Arginine, 288 293 Armoracia lapathifolia, 201 205 Armoracia lapathifolia Gilib (horseradish), 196t Armoracia rusticana. See Armoracia lapathifolia Aromas, 149 151, 165 169 and aging, 151 152 categorizations, 149 150 multidimensional aroma classifications, 150 151 Aromatherapy, 153, 154t, 165 169 Aromatic olive oil, 300 Aromatics, 193, 233 Arrhythmias, 261, 288 293 ART. See Antiretroviral therapy (ART) Arthritis, 19 23, 259 260, 288 293 foundation, 466 Artificial sweeteners, 176 ASA. See American Society of Anesthesiologists (ASA); American Society on Aging (ASA); American Stroke Association (ASA) ASAA. See American Sleep Apnea Association (ASAA) ASB. See Associated Services for Blind and Visually Impaired (ASB) Ascetic acid fermented or “pickled” vegetables with, 179 vinegars with, 179 Ascites, 269, 288 293 Ascorbate, 45 Ascorbic acid, 45, 46t, 178, 201 205 ASCRS. See American Society of Colon and Rectal Surgeons (ASCRS) ASGD. See American Society for Geriatric Dentistry (ASGD) ASHA. See American Speech-Language Hearing Association (ASHA) Asian fish sauce, 190 ASIM. See American Society of Internal Medicine (ASIM) ASOPRS. See American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) Aspartame, 177, 201 205 Aspirin, 39 Associated Services for Blind and Visually Impaired (ASB), 466 Association of Jewish Family & Children’s Agencies (AJFCA), 485 Asthma, 94 102, 459 Asthma and Allergy Foundation of America (AAFA), 466 A-streptococcus, 94 102 Astringent ingredients, 360 ATA. See American Tinnitus Association (ATA) ATP. See Adenosine triphosphate (ATP) Atrophic gastritis, 49, 54 62 Atrophy, 54 62, 286, 288 293

ATS. See American Trauma Society (ATS) Au jus, 334 337 AUA. See American Urological Association (AUA) Audition, 7, 69, 94 102, 213 216 background sounds, 215 enhancing auditory cues, 215 enhancing food intake through sounds, 214 food and beverage sounds, 215 216 food intake and hearing loss, 214 hearing loss and aging, 213 214 social ramifications of hearing loss, 214 Auditory perception, 69, 94 102 Augmented gustation, 134 139 Autoimmune disease, 288 293, 485 Autoimmune disorders, 424 Autolyzed yeast extracts, 199, 201 205 Autonomic nervous system (ANS), 90, 94 102 Aversive behavior responses, 112, 134 139 Aversive taste, 94 102 AVI/AVI, 109 Avocado, 401 AWD. See Aging with Dignity (AWD)

B B vitamins, 28, 48, 354 BA. See Bioavailability (BA) Baby boomers, 19 23 Baking, 229, 242 245 baked salmon with mustard sauce, 371 Balance, 52, 54 62, 94 102 sense, 72, 94 102 aging and, 72 taste combinations for, 121 122, 122t Balance sense, 94 102 Balsamic vinegar, 190, 347 Banana nut oat bran muffin, 399, 404 Basal metabolic rate (BMR), 29, 54 62 Basic vinaigrette salad dressing with herb and lemon blend, 421 Basting, 230, 242 245 Bay leaves, 418 BEBRF. See Benign Essential Blepharospasm Research Foundation (BEBRF) Be´chamel (White Sauce), 428 Bedsores. See Pressure ulcers (PU) Beef, 368 Beer, 303 304 Behavioral changes, 132 factor, 68 of aging, 94 102 and mental health, 463 Behavioral and Psychological Symptoms of Dementia (BPSD), 153, 165 169 Bell’s palsy, 94 102 Benign essential blepharospasm, 490 Benign Essential Blepharospasm Research Foundation (BEBRF), 467 Benign paroxysmal positional vertigo (BPPV), 72, 94 102 Benzoates, 177, 201 205 Berries, 187

498 Berry compote with lemon and ginger, 410 Beta-glucans, 19 23, 118, 134 139 Better broccoli, 379 Better Hearing Institute (BHI), 467 Beverages, 143, 341, 396 BHA. See Butylated hydroxyanisole (BHA) BHI. See Better Hearing Institute (BHI) BHT. See Butylated hydroxy toluene (BHT) Bifidobacterium, 34, 54 62 Bilirubin, 54 62 Bioavailability (BA), 201 205 Biogerontology, 18 Biosimilars, 490 Bite-sized food portions, constructing, 323, 323t Bitter taste, 71, 78, 94 102, 109 110, 134 139, 180 in depth, 110 111 methods to add bitter taste, 111 methods to combat bitter taste, 110 111, 110t PROP, 111 in flavor enhancement, 180 181 bitter aromas, 181 complementing, 181 heightening, 181 reducing or mask bitterness, 180 181 Bitterness. See Bitter taste Black pepper, 387 Blanching, 230, 242 245 Bleu cheese, 415 Blindness, 69 70, 94 102 Blood glucose, 54 62 pressure monitors, 444 sugar, 32 33, 54 62 Bloom(ing), 196t, 201 205, 334 337 Blueberry and fig crumble, 388 Blueberry jam or preserves, 194 BMI. See Body mass index (BMI) BMR. See Basal metabolic rate (BMR) BMS. See Burning mouth syndrome (BMS) Body composition reconfigurations, 92 Body mass index (BMI), 74 Body systems, 28, 28t, 54 62 Boiling, 307, 334 337 Bolding, 230, 242 245 Bone(s), 459 broth, 303 calcium for, 255 magnesium for, 255 mineralization, 54 62 nutrients, 28 vitamins A and D, calcium and magnesium for, 255 Bosc pears, 413 Botulism. See Clostridium botulinum Bouquet Garni, 304t, 334 337 BPPV. See Benign paroxysmal positional vertigo (BPPV) BPSD. See Behavioral and Psychological Symptoms of Dementia (BPSD) Brady Urological Institute (BUI), 467 Bradycardia, 54 62

INDEX

Brain, 460 function variations, 92 imaging research, 147 thiamine or vitamin B1 for, 255 tumors, 461 Braising, 230, 242 245, 308, 334 337 Brandy, 304 Brassicaceae, 111, 134 139 Breakfasts, 341, 404 “Brightening” flavor, 331 Brining, 184 Broiling, 230, 242 245 Bromelain, 334 337 Bronchial asthma, 94 102 Bronchitis, 94 102 Broths, 302 303, 334 337 Brown sugar, 371 Browning, 230 231, 242 245 Brunoise, 232 Brussels sprouts salad, 365 Buffalo wing-style pizza, 342 BUI. See Brady Urological Institute (BUI) Building, flavor, 231, 242 245 Burning mouth syndrome (BMS), 131, 134 139 Butter, 182, 194 Butylated hydroxy toluene (BHT), 176 177, 201 205 Butylated hydroxyanisole (BHA), 176 177, 201 205

C C-reactive protein (CRP), 288 293 Cacogeusia, 130, 134 139 CAD. See Coronary Artery Disease (CAD) Calcium, 37 38, 38t, 116 117 for bones, 255 citrate, 279 Calcium carbonate, 279, 288 293 Calcium channel blockers (CCBs), 134 139, 273, 288 293 Calcium-sensing receptor (CaSR), 117, 134 139 Calming pheromones, 155, 165 169 Calorie restriction (CR), 260 261, 288 293 Calories, 51, 54 62, 252 during aging, 29 by gender, 29 30 Camellia Sinensis, 201 205 cAMP. See Cyclic adenosine monophosphate (cAMP) Campylobacter, 436, 451 452 Cancer, 19 23, 260 261, 461, 463, 467 prostate, 484 sinonasal, 94 102 Cancer Research Institute (CRI), 467 CancerCare, 467 Candida spp., 132, 134 139 Canned selection, 327 331 Canola oil, 406 Capers, 346 Capsaicin, 111, 134 139 Caramelization, 229, 231, 242 245, 325 326, 334 337 Caramelizing, 231, 242 245

Carbohydrates, 33, 33t, 253 Carbon dioxide (CO2), 117, 152 Carbonation, 117, 134 139 Carbonic acid (H2CO3), 117 Cardiac arrest, 54 62 Cardiac dysrhythmia. See Arrhythmias Cardiac output, 54 62 Cardiovascular disease, 19 23, 462 Cardiovascular health, 261 262 CARF. See Commission on Accreditation of Rehabilitation (CARF) Caribbean and Latin America aging populations, 3 Carotenoids, 19 23, 44, 54 62 CaSR. See Calcium-sensing receptor (CaSR) Cataracts, 19 23, 54 62, 70, 94 102, 210, 242 245 Catholic Health Association of United States (CHA), 467 Caucasians, 19 23 Cauliflower and white bean pate, 348 Caustic soda, 118, 134 139 CCBs. See Calcium channel blockers (CCBs) CCF. See Crohn’s & Colitis Foundation (CCF) CCK. See Cholecystokinin (CCK) CCLVI. See Council of Citizens with Low Vision International (CCLVI) CD36 (taste bud cells), 182, 201 205 CDC. See Centers for Disease Control and Prevention (CDC) Celiac disease, 262 263, 288 293 Celiac hepatitis, 262, 288 293 Cellular atrophy, 94 102 Cellular senescence, 260, 288 293 Centenarians, 19 23 Centers for Disease Control and Prevention (CDC), 32, 67, 467 Centers for Medicare & Medicaid Services (CMS), 468 Central nervous system (CNS), 94 102, 144 145, 147, 149, 165 169, 189, 460 Cerebellum, 71, 90, 94 102 Cerebral cortex, 70 71, 90, 94 102 Cerebrum, 90, 94 102 CHA. See Catholic Health Association of United States (CHA) CHAP. See Community Health Accreditation Partner (CHAP) Cheese, 194 Chelators, 288 293 Chemesthesis, 81, 94 102, 134 139, 227, 242 245 Chemical aromas, 150, 165 169 Chemical messengers, 155 Chemical senses, 163 164 Chemoreception, 94 102, 143 Chemoreceptive sensory interaction, 143, 165 169 Chemoreceptors. See Sensory receptors Chemosensory changes, 7, 15, 19 23 Chemosensory changes, strategies for addressing, 133 Chemosensory decline, 91 Chewing, 324 325 Chickpea salad with pita triangles, 366

INDEX

Chiffonade, 232, 242 245 Chili peppers, 369 Chilies, 192 “Chinese parsley”, 359 Chinese restaurant syndrome, 200 205 Chocolate yogurt and orange mousse, 394 Cholecalciferol, 46 Cholecystokinin (CCK), 333 337 Cholesterol, 19 23, 327 Chopping, 231, 242 245 Chorda tympani, 134 139 Christopher & Dana Reeve Foundation, 468 Chronic bronchitis, 282, 288 293 Chronic disease, 11 12, 33 Chronic inflammation (CI), 274, 288 293 Chronic kidney disease (CKD), 94 102, 263 264, 288 293 Chronic kidney failure. See Chronic kidney disease (CKD) Chronic metabolic diseases, 33, 54 62 Chronic obstructive pulmonary disease (COPD), 19 23, 282, 288 293 Chronic pain, 461 Chronic renal failure, 94 102 Chronic rhinosinusitis (CRS), 94 102 Chunky garlic salad dressing, 364, 414 Chutney, 334 337 CI. See Chronic inflammation (CI) Cilantro. See “Chinese parsley” Cilia, 144, 165 169 Circulatory system, 54 62 Circumvallate, 77, 94 102 Circumvallate papillae, 108, 134 139 Cirrhosis, 269, 288 293 Cirrhosis of liver (CL), 94 102 Citations, 457 Citrate. See Citric acid Citric acid, 178, 201 205, 288 293 Citrus, 192 193 fruits, 179 juice, 179, 300 zest, 332 CKD. See Chronic kidney disease (CKD) CL. See Cirrhosis of liver (CL) Clarified butter, 182, 201 205 Clean, Classify, Cook and Chill (four “Cs”), 425 for foodborne illness prevention, 425t Clinical Depression, 19 23 Clostridium botulinum, 436, 451 452 Clostridium perfringens, 436, 451 452 CMS. See Centers for Medicare & Medicaid Services (CMS) CN. See Cranial nerve (CN) CN V. See Fifth Cranial Nerve (CN V) CN X. See Tenth cranial nerve (CN X) CNS. See Central nervous system (CNS) COAH. See Johns Hopkins Center on Aging & Health (COAH) Cochlea, 69, 94 102, 214 Coconut fish chowder, 356 Coconut oil, 182, 201 205 Coconuts/coconut products, 193 Coenzyme Q10, 257, 288 293 Cognition, 146, 165 169

Collagen, 54 62 Colon and rectum, 465 Color Rendering Index (CRI), 446 Colorful fruits and vegetables, 257 Colors, 211, 211t enhancement, 211 Commission on Accreditation of Rehabilitation (CARF), 467 Commodity Supplemental Food Program (CSFP), 468 Common cold, 94 102 Community Health Accreditation Partner (CHAP), 468 Community services, 469 Compassion and choices, 468 Computed tomography scan (CT scan), 158, 165 169 Concentrated fruit purees, 193 194 Concentration, 231, 242 245 Concord grapes, 398 Conduction, 334 337 Conductive olfactory loss, 158, 165 169 Confiting, 232, 242 245 Congenital anosmia, 158, 165 169 Congestion, 94 102 Conjugated linoleic acid, 373, 428 Conjunctivitis, 45, 54 62, 70, 94 102 Conscious thoughts. See Cognition Consistency-altered diet, 264 265, 288 293 Consomme´s, 237 Consumer information, 471 Consumerism, 477 Continent diversions, 487, 490 Convection, 334 337 Cooking aids, 437 Cooktop adjustment for aging people, 433 434 fire suppressor, 434, 451 452 COPD. See Chronic obstructive pulmonary disease (COPD) Copra oil. See Coconut oil “Cork taint”, 151, 165 169 Cornea, 69, 94 102 Cornu ammonis, 94 102 Coronary arteries, 12 Coronary Artery Disease (CAD), 19 23 Cortisol, 94 102 Cottage cheese, 194, 407 Coulis, 334 337 Coumarins, 114, 134 139 Council for Geriatric Dentistry, 468 Council of Citizens with Low Vision International (CCLVI), 468 CR. See Calorie restriction (CR) Crackly, 214 Cranberries, 366 cranberry sauce, 194 Cranial nerve (CN), 81, 90 91 Cream, 187, 194 195 Cre´me, 201 205 Crepes, 393 CRI. See Cancer Research Institute (CRI); Color Rendering Index (CRI) Crime reduction, 469 Crohn’s & Colitis Foundation (CCF), 469

499 CRP. See C-reactive protein (CRP) CRS. See Chronic rhinosinusitis (CRS) Crushed red pepper. See Red pepper flakes Cryovac, 233, 242 245 CSFP. See Commodity Supplemental Food Program (CSFP) CT scan. See Computed tomography scan (CT scan) Cucumbers, 414 berry grape quencher, 402 cucumber pepper buttermilk soup, 355 Culinary arts, 2, 8, 15 16 Culinary considerations for aging. See also Age/aging digest, 333 334 strategies and uses for addressing changes in tastes and/or smells, 298 333 acidic ingredients prudently, 331 332 amplifying food flavors, 298 304 constructing bite-sized food portions, 323 creating “finger foods”, 316 creating healthy comfort foods, 309 315 creating visually appealing and ethnically correct garnished foods, 323 324 culinary herbs and spices, 304 306 dining experience, 333 focus on moist-heat cooking methods, 307 309 higher-fiber foods and beverages, 317 319 hydration, 332 lack of appetite/fullness, 332 333 lower fat and switch to other fats, oils, 319 320 lower sodium and replace salty foods and beverage, 320 321, 321t lower sugar and naturally sweetened foods and beverages, 322 maximizing aroma, color, taste and texture, 325 327 MTFs, 317 plan and prepare meals and snacks, 315 316 preparing foods for easy chewing, 324 325 selecting canned, frozen and packaged foods and beverages, 327 331 Culinary herbs, 304 306, 334 337 blends, 305, 305t general guidelines for cooking with culinary herbs, 304t Culinary perspectives, 7 8 Culinary spices, 306, 306t, 334 337 Culinary techniques, 209, 324 325 for flavor enhancement, 228 241 Cultured buttermilk, 195, 201 205 Cumin, 383 Curcumin, 196t, 201 205, 288 293 Curing, 191, 201 205, 232, 242 245 Curry rub, 301 Cushing’s syndrome, 94 102 Cutaneous receptor, 73, 94 102 Cutting, 232, 242 245

500 Cyanocobalamin, 48 49 Cyclic adenosine monophosphate (cAMP), 144, 165 169 Cyclical effects, 67 Cytokines, 288 293

D D-amino acids, 114, 134 139 Dairy foods/products, 242 245 Dairy milk, 195, 201 205 Dairy products, 194, 232 DASH diet, 288 293 Dates, 187 DDNC. See Digestive Disease National Coalition (DDNC) Deafness, 94 102 impairment, 69 Decayed aromas, 150, 165 169 Declarative memory. See Explicit memory Decubitus ulcers. See Pressure ulcers (PU) Deep-frying, 234, 242 245, 334 337 Defensive antioxidants, 378 Deficient contrast sensitivity, 211, 242 245 Degenerative neuropsychiatric disorders, 146, 165 169 Deglazing, 233, 242 245 Dehydration, 51, 54 62, 94 102, 265 irregularities, 92 Delirium, 19 23 Dementia, 19 23, 257 258 dietary considerations, 257 258 supplements, 258 support systems, 258 Dentistry, 460 Department of Health and Human Services (HHS), 483, 488 Depression, 19 23 Depression, Diarrhea, Delirium and Dementia (four D’s), 94 102 Dermatitis herpetiformis (DH), 262, 288 293 Desserts, 341, 387 Detection threshold, 84, 94 102, 130, 134 139 Deviated septum, 94 102 Devil’s claw. See Harpagophytum procumbens Dextrose, 54 62 DGAs. See Dietary Guidelines for Americans (DGAs) DH. See Dermatitis herpetiformis (DH) DHA. See Docosahexaenoic acid (DHA) DHDS. See Disability & Health Data System (DHDS) Diabetes. See Diabetes mellitus Diabetes mellitus, 19 23, 94 102, 266, 460, 462 Diabetic retinopathy, 210, 242 245 Diacetyl, 194, 201 205, 231, 242 245 Diallyl disulfide, 288 293 Dialysis, 263 dietary restriction, 288 293 Dice, 232 Diet(ary) carbohydrates, 32 33, 54 62 decline and aging, 27 28

INDEX

fats, 35, 54 62 fibers, 32 35, 54 62, 317, 331, 331t, 334 337 minerals, 54 62 protein, 36, 36t, 54 62, 270 271 quality during aging, 68 restrictions, 177, 261 sodas, 332 supplementation, 468 vitamins, 54 62 Dietary Guidelines for Americans (DGAs), 29 30, 32 33, 54 62 Dietary Reference Intake (DRI), 35 36, 54 62, 251, 251t, 262 Difficulty swallowing. See Dysphagia Digestive Disease National Coalition (DDNC), 469 Digestive health, 462 Digestive system, 54 62 changes, 92 93 Dihydrochalcones, 114, 134 139 Dijon mustard, 363 Dill, 350 Dining experience in aging, 333 and living considerations for aging people, 445 448 out, 427 rooms in assisted living facilities, 448, 448t Direct food additives, 176, 201 205 Disability & Health Data System (DHDS), 469 Disabled people, preparation, cooking and dining aids designed for, 437 442 Disinfectant by-products, 119, 134 139 Disodium guanylate (GMP), 119, 134 139, 190, 201 205 umami-rich combinations with Lglutamate and disodium inosinate and, 190 umami-rich ingredients with, 190 Disodium inosinate (IMP), 119, 134 139, 190, 201 205 umami-rich ingredients with, 190 Disodium phosphate, 329, 334 337 Distorted smells, 160 Diuretics, 273, 288 293 Diverticulosis, 268 Docosahexaenoic acid (DHA), 35, 54 62, 257, 270, 288 293 Dopamine, 94 102, 333 337 Double-handled kitchen equipment, 434 Double-sugar lactose, 79 Dressings, 413 DRI. See Dietary Reference Intake (DRI) Dried fruits, 187, 193 Dried mushrooms, 190 DRIs. See US Dietary Reference Intakes (DRIs) Dry aging, 233, 242 245 Dry eyes, 70, 94 102 Dry rubs, 195, 201 205, 301 Drying, 191, 201 205 Duhring’s disease. See Dermatitis herpetiformis (DH)

Dusting method, 326 Dysgeusia, 84, 91, 94 102, 134 139, 175, 201 205 Dysomia, 91, 175, 201 205 Dysosmia, 94 102, 158, 165 169 Dysphagia, 194, 201 205, 264, 288 293, 324, 334 337 Dyspnea, 288 293

E EA. See Emotions Anonymous (EA) Ear, nose and throat (ENT), 129, 133 139 Eardrum, 94 102, 214 EARs. See Estimated Average Requirements (EARs) EBAA. See Eye Bank Association of America (EBAA) Eccrine sweat glands, 156, 165 169 ECG. See Electrocardiogram (ECG) Economic growth, 6 Edema, 286, 288 293 Education, 4 5 US aging and, 13 Educational institutions, organizations and support groups, 457 489 A through Z resources, 457 489 citations, 457 EFA. See Epilepsy Foundation of America (EFA) EFAs. See Essential fatty acids (EFAs) Egg lemon soup, 352 Eicosapentaenoic acid (EPA), 35, 54 62 Eldercare Locator, 469 Elderly Nutrition Program, 469 ElderWatch, 469 Electrical taste, 117 118, 134 139 Electrocardiogram (ECG), 261, 288 293 Electrolytes, 40, 42, 54 62, 134 139, 288 293 Emergency services, 465 Emotion, 144 145 Emotions Anonymous (EA), 469 Emphysema, 282, 288 293 Employment, 5 6 US aging and, 13 En“lite”tened beef sandwiches, 368 Endocrine system, 54 62 Endodontics, 460, 490 Endorphins, 153 Endurance, 52, 54 62 EnhanceFitness, 53 Enriching, 233, 242 245 ENT. See Ear, nose and throat (ENT) Enteroendocrine cells, 80, 94 102 Entorhinal cortex, 94 102 Entre´es, 341, 368 Environmental decline in aging, 54 62 Environmental factor, 4, 7, 27, 68 of aging, 94 102 Enzymes, 134 139 EPA. See Eicosapentaenoic acid (EPA) Epideictic pheromones, 155, 165 169 Epigenetic factors, 288 293 Epiglottis, 71, 94 102 Epilepsy, 94 102 Epilepsy Foundation of America (EFA), 469

INDEX

Epithelialization, 288 293 Equilibrioception sense. See Balance—sense Ergocalciferol, 46 Erythrocyte sedimentation rate (ESR), 262, 288 293 Escherichia coli (E. coli), 436, 451 452 Esophagus, 71, 94 102 ESR. See Erythrocyte sedimentation rate (ESR) Essence, 334 337 Essential fatty acids (EFAs), 35, 54 62, 327 Essential oils, 153 155, 153t Esters, 110, 134 139 Estimated Average Requirements (EARs), 38 40, 42, 44 45, 54 62 Ethnic and racial disparities, 4, 12 Excretory system, 54 62 Exercises, 51. See also Diabetes mellitus and physical activity, 471 programs for aging, 53 54 Active Choices, 53 Active Living Every Day, 53 EnhanceFitness, 53 Fit and Strong!, 53 Healthy Moves for Aging Well, 54 Walk With Ease, 54 Expectation assimilation, 147, 165 169 Explicit memory, 145, 165 169 External ear, 94 102 Exteroceptive senses, 69, 94 102 Extracts/extractions, 195 198, 201 205, 299, 334 337 Eye Bank Association of America (EBAA), 470 EyeCare America, 470 Eyes, 69 and neurology, 467 Eyesight, 462, 464, 466 and blindness, 466 relating to taste and smell, 70

F Facial nerve, 90 91 Facial structure, 461 Fasting, 261, 288 293. See also Diet(ary) mimetics, 261, 288 293 Fat(s), 253, 319 320. See also Diabetes mellitus deciphering, 328t decreasing, 327 328 in flavor enhancement, 181 183 fatty aromas, 183 fatty flavor enhancers, 182 183 and proposed tastes, 116 121 calcium, 116 117 carbonation, 117 electrical, 117 118 hydroxide, 118 kokumi, 118 lysine, 118 119 minerals, 119 polycose, 119 protein, 120 pyrophosphates, 120 soapy, 120 121 starchy, 121

Fattening, 233, 242 245 Fatty acids, 81 82 Fatty ingredients, 319 320 FBI. See US Federal Bureau of Investigation (FBI) FDA. See US Food and Drug Administration (FDA) Fermenting, 191, 201 205 fermented cheese products, 179 FFB. See Foundation Fighting Blindness (FFB) FGA. See Free glutamic acid (FGA) FHHC. See Foundation for Hospice and Home Care (FHHC) Fiber, 28 Fibrosis, 269, 288 293 Fifth Cranial Nerve (CN V), 94 102 Filiform, 77, 94 102 Financial assistance, 474 Fine herbs, 334 337 Finger foods, 316, 334 337 Fire alarms, 430 431 and smoke safety in kitchen, 435 Flat-leaf parsley, 359 Flavonoids, 54 62, 110, 134 139 Flavor(ed), 74 77, 94 102, 134 139, 174 175, 201 205. See also Food flavors appearance and flavor perception, 74 enhancement, 175, 201 205, 209, 324 aging issues, 209 of basic tastes, 178 192 combinations of savory and sweet extracts for, 196t culinary techniques for, 209, 228 241 digest, 200 201, 242 food ingredients, 176 ingredients, 175 176 sensory issues and, 209 228 enhancer regulations, 176 factors, 77 flavor-enhancing ingredients, 192 200 natural flavor derivatives, 192 198 sensory agents, 199 200 gestalt, 75, 94 102 layering, 231, 242 245 methods to heighten, 326 327 oils, 233 234, 242 245, 299 olive oils, 183 smell, 74 temperature, 76 texture, 76 touch, 76 77 vinegars, 303 Flavorants, 174, 201 205 Flavorful ingredients, 175 Flavorings, 195 198, 201 205 Flexibility, 52, 54 62 Floaters, 70, 94 102 Focal aware seizures, 94 102 Folacin, 44 Folate, 44, 44t Foliate, 77, 94 102 Foliate papillae, 108, 134 139

501 Folic acid, 44 Fond, 229, 242 245, 326, 334 337 Food and Nutrition Board (IOM-FNB), 470 Food flavors, 298 304. See also Flavor(ed) chutney, 299 coulis, 299 extracts and extractions, 299 infusions, 300 juices, 300 marinades, 300 oils, 299 300 powerful cheeses, 300 301 purees, 301 reductions, 301 relishes, 301 rubs, 301 302 salsas, 302 sauces, 302 stocks and broths, 302 303 vinegars, 303 wine, beer and spirits, 303 304 Food(s), 143 additives, 176, 201 205 adventurousness, 111, 134 139 arrangements, 212 and beverage to avoiding to preventing foodborne illnesses, 425, 425t smells, 216 217 sounds, 215 216 tastes, 221 222, 221t choices, 210 211 combinations, 212 enhancers, 176, 201 205 focus, 212 ingredients, 176 insecurity, 19 23 intake, 214 intolerances and sensitivities food allergies, 256 257. See also Allergies dietary considerations, 256 supplements, 257 support systems, 257 neophobia, 111, 134 139 pheromones, 155 portions, 213, 213t safety, 424, 428 tips for preventing foodborne illness, 425 426 science, 7 8, 15 16 shapes, 212 textures, 212 Foodborne illnesses food safety tips for preventing, 425 426 foods and beverages, 425, 425t prevention in kitchen, 436, 436t risks of, 424 425 Foot and ankle health, 464 Foundation Fighting Blindness (FFB), 470 Foundation for Digestive Health and Nutrition, 462 Foundation for Hospice and Home Care (FHHC), 470 Fragrant aromas, 150, 165 169 Free glutamic acid (FGA), 191

502 Fresh juices, 300 Frozen selection, 327 331 Fructose, 33, 54 62 Fruits, 41 coulis, 299 fruit-nut squash, 380 Fruity aromas, 150, 165 169 Frying, 234, 242 245 FSIS. See US Food Safety and Inspection Service (FSIS) FTO on Chromosome 16, 156, 165 169 Functional ability, 7, 19 23 Functional anosmia, 91, 94 102 Functional decline and aging, 27 Fungiform, 77, 94 102 Fungiform papillae, 108, 134 139 Furan molecules, 229, 231, 242 245

G G protein, 144, 165 169 gustducin, 134 139 G protein-coupled receptors (GPCRs), 78, 94 102, 108, 114, 134 139 G-protein-coupled receptor 120, 182, 201 205 Galactose, 79, 94 102 Gamma-glutamyl peptides, 118, 134 139 Gamma-tocopherol (γ-Tocopherol), 46 47 Garlic (Allium sativum), 196t, 349 Garnished foods, 323 324 Garnishes, 323 Gastriques, 237, 242 245 Gastroesophageal reflux disease (GERD), 79, 94 102, 267, 288 293 Gastrointestinal health, 267 268 Gastrointestinal tract, 424, 461 GCOA. See Global Coalition on Aging (GCOA) GEC. See Geriatrics and Extended Care (GEC) Gelato, 334 337 Generally Recognized as Safe (GRAS), 176, 201 205 Genetics, 83 Genotypes, 109, 134 139 GERD. See Gastroesophageal reflux disease (GERD) Geriatrics, 9 10, 18 23 Geriatrics and Extended Care (GEC), 488 Gerontological Society of America (GSA), 18 23, 470 Gerontology, 9 10, 18 23, 470 Ghee, 182, 201 205, 334 337 Ginger, 378 Gingiva/gingivitis, 83, 94 102 Gingivitis, 94 102 Glaucoma, 70, 94 102, 210, 242 245 Glaucoma Research Foundation (GRF), 470 Gliadin, 288 293 Global aging. See also Age/aging and chemosensory changes, 7 and disease, 4 and education, 4 5 and employment, 5 6 and ethnic and racial disparities, 4

INDEX

global aging by numbers, 2 3, 8t health, and health care, 6 impact, 8 on nutrition, food science, and culinary perspectives, 7 8 and life expectancy, 3 and nutrition, 6 7 and residence, 4 world population, 3 Global Coalition on Aging (GCOA), 19 23, 471 Global food industry, 8 Global gender gap, 5 Glomerular filtration rate, 263, 288 293 Glomeruli, 90, 94 102, 146, 165 169 Glossopharyngeal nerve, 90 91 Glucose, 32 33, 54 62, 94 102 monitoring system, 444 polymers, 119, 134 139 Glucose transporters (GLUTs), 186 187, 201 205 Glucosinolates, 54 62, 78, 110, 134 139, 181, 201 205 Glutamate. See Glutamic acid Glutamic acid, 80, 94 102, 115, 177, 189, 201 205 Glutathione (GSH), 118, 134 139 peroxidase, 54 62 Gluten, 288 293 ataxia, 262, 288 293 gluten-free diets, 262 263, 288 293 Glutenin, 288 293 GLUTs. See Glucose transporters (GLUTs) Glycosides, 109, 114, 134 139 GMP. See Disodium guanylate (GMP) Go4Life, 53, 471 Gout, 268 269, 288 293 GPCRs. See G protein-coupled receptors (GPCRs) Grain-based foods, 378 Grapes, 360 Grapple. See Harpagophytum procumbens GRAS. See Generally Recognized as Safe (GRAS) Gray divorce revolution, 12, 19 23 Great Depression, 5 Great Recession, 5 Greek yogurt, 195, 201 205, 386 Green onions. See Scallions Green pick-me-up, 400 Green tea, 257 GRF. See Glaucoma Research Foundation (GRF) Grilling, 234, 242 245 Ground ginger, 396 Growing aging populations, 3 GSA. See Gerontological Society of America (GSA) GSH. See Glutathione (GSH) Guanosine Monophosphate (GMP). See Guanylic acid Guanylic acid, 199, 201 205 Guiding Eyes for the Blind, Inc., 471 Gums, 460 inflammation, 94 102

Gustation. See Taste(s) Gustatory calyculi, 107, 134 139 Gustatory cortex, 94 102 Gustatory system, 94 102

H Habituation, 145, 165 169 Halal (Islamic dietary laws), 275, 288 293 dietaries, 275 276 Half-and-half, 194 195, 201 205 HAND. See HIV-associated neurocognitive disorders (HAND) Handgrip flexibility, 54 62 Haptic perception, 128, 134 139, 225, 242 245 Haram, 275 Hard water, 119, 134 139 Harpagophytum procumbens, 274, 288 293 Hay fever, 94 102 hCG. See Human chorionic gonadotropin (hCG) HDSA. See Huntington’s Disease Society of America (HDSA) Head trauma, 94 102 Headaches, 461 Health and well-being, 487 Health Care Financing Administration (FCFA). See Centers for Medicare & Medicaid Services (CMS) Health(y), 6, 129 ageing, 7, 340 care, 6, 467 and prevention, 67 comfort foods, creating, 309 315 for breakfast or brunch, 309t for dinner, 311t for lunch, 310t for snacks, 314t digestive, 462 eating for aging, 251 fats, 327 hazards, 11 and health care, 14 smell and, 156 Healthy Eating Index (HEI), 15, 19 23, 214 Healthy Moves for Aging Well, 54 Hearing, 69, 94 102, 457, 465, 467 and aging, 69 impairment, 94 102 loss, 19 23, 213 214 food intake and, 214 social ramifications, 214 Hearing Health Foundation (HHF), 471 Heat stroke, 94 102 HEI. See Healthy Eating Index (HEI) Hemiparesis, 451 452 Hemiplegia, 451 452 Hemochromatosis, 39, 54 62 Hemorrhagic stroke, 47, 54 62 Henry J. Kaiser Family Foundation (KFF), 471 Hepatic encephalopathy, 94 102 Hepatic liver disease, 269 270, 288 293 Herb blend culinary uses of, 196t

503

INDEX

for marinades, 419 ranch dressing, 423 Herbal infusions, 300 Herbing, 234, 242 245 Herbs, culinary uses of, 196t Heterocyclic amines, 234, 242 245 Heterodimer, 134 139 HFA. See Hospice Foundation of America (HFA) HFPTAs. See High frequency pure tone average (HFPTAs) HHF. See Hearing Health Foundation (HHF) HHS. See Department of Health and Human Services (HHS) High blood pressure, 255 High frequency pure tone average (HFPTAs), 214, 242 245 High glycemic indices, 33, 54 62 Higher-fiber foods and beverages, 317 319 methods to increasing fiber in baking, 319 methods to increasing fiber in cooking, 317 318 Hippocampus, 94 102, 144, 165 169 HIS. See International Hearing Society (HIS) Hispanic, 19 23 HIV. See Human immunodeficiency virus (HIV) HIV-associated neurocognitive disorders (HAND), 288 293 Hollandaise, 428 Home care agencies, 17, 19 23 Homocysteine, 48, 54 62, 288 293 Homodimer, 134 139 Honey, 187 honey-mustard sauce, 416 horseradish. See Armoracia lapathifolia Gilib (horseradish) Hospice, 468, 490 Hospice Foundation of America (HFA), 472 HPP. See Hydrolyzed plant proteins (HPP) HRSA. See US Health Resources and Services Administration (HRSA) Hub and motion sensors, 451 452 Huitlacoche, 118, 134 139 Human chorionic gonadotropin (hCG), 148, 165 169 Human immunodeficiency virus (HIV), 271 272, 288 293, 436 Human olfactory receptor genes, 148 Huntington’s disease, 490 Huntington’s Disease Society of America (HDSA), 472 HVP. See Hydrolyzed vegetable proteins (HVP) Hydration, 332 Hydrogenation, 34, 54 62 oils, 327 Hydrolyzed plant proteins (HPP), 199, 201 205 Hydrolyzed proteins, 199 Hydrolyzed vegetable proteins (HVP), 199, 201 205 Hydroxide, 118, 134 139 25-Hydroxyvitamin D (25(OH)), 284, 288 293

Hyperacusis, 466, 490 Hypercortisolism, 94 102 Hyperfiltration, 288 293 Hyperglycemia, 266, 288 293 Hypergusia, 91, 94 102 Hyperosmia, 83, 91, 94 102 Hyperphosphatemia, 263, 288 293 Hyperplasia, 260, 288 293 Hypertension, 19 23, 272 273, 288 293 Hypoalbuminemia, 262, 288 293 Hypocalcemia, 54 62 Hypogeusia, 91, 94 102, 130, 134 139, 175, 201 205 Hypokalemia, 54 62 Hyposmia, 91, 94 102, 156, 158, 165 169, 175, 201 205 Hypothalamus, 90, 94 102, 157, 165 169 Hypothyroidism, 94 102, 262, 288 293

I IAGG. See International Association of Gerontology and Geriatrics (IAGG) IBD. See Inflammatory bowel disease (IBD) ICAA. See International Council on Active Aging (ICAA) Idiopathic anosmia, 158, 165 169 IDRT. See Institute for Disabilities Research and Training (IDRT) IETF. See International Essential Tremor Foundation (IETF) IFA. See International Federation on Ageing (IFA) IFFGD. See International Foundation for Functional Gastrointestinal Disorders (IFFGD) IGF. See Insulin-like growth factor (IGF) IHD. See Ischemic heart disease (IHD) Immediate hypersensitivity, 256, 288 293 Immune function, 19 23, 273, 288 293 Immune system, 288 293 Immunology, 459 Immunosenescence, 288 293 IMP. See Disodium inosinate (IMP) Implicit memory, 145, 165 169 Indirect food additives, 176, 201 205 Individualized diets, 315 Indoor camera, 444 Industrial Revolution, 2 3 Infants, 148 Inflammation, 274 275, 288 293 Inflammatory bowel disease (IBD), 35, 54 62 Influenza virus, 158 Infused oils, 299, 334 337 Infusing/infusions, 234 235, 242 245, 300, 334 337 Insoluble fibers, 34 35, 54 62, 317, 334 337 foods with, 331 Institute for Disabilities Research and Training (IDRT), 472 Institutes of Medicine (IoM), 35, 54 62 Insulin-like growth factor (IGF), 54 62 IGF-1, 38 Integumentary system, 54 62 Intergenerational conflict, 19 23 Internal medicine, 465

International Association of Gerontology and Geriatrics (IAGG), 9, 19 23, 472 International Council on Active Aging (ICAA), 10, 472 International Essential Tremor Foundation (IETF), 472 International Federation on Ageing (IFA), 10, 19 23, 472 International Foundation for Functional Gastrointestinal Disorders (IFFGD), 473 International Hearing Society (HIS), 473 International Psychogeriatric Association (IPA), 10, 473 Interoceptive senses, 69, 94 102 Intraglomerular pressure, 288 293 Intrinsic capacity, 7, 19 23 Intrinsic factor, 48, 54 62 IoM. See Institutes of Medicine (IoM) IOM-FNB. See Food and Nutrition Board (IOM-FNB) IPA. See International Psychogeriatric Association (IPA) Iron, 38 39, 39t deficiency anemia, 38, 54 62 overload, 39 Ischemic heart disease (IHD), 12, 19 23 Isoflavonoids, 54 62

J Jacobson’s organ for sensing food and/or danger, 165 Jams, 193 194 Jaundice, 54 62 JDC. See Joslin Diabetes Center (JDC) Jellies, 193 194 Johns Hopkins Center on Aging & Health (COAH), 473 Joint Commission on Accreditation of Healthcare Organizations (JCAHO). See The Joint Commission (TJC) Joslin Diabetes Center (JDC), 473 Juices, 300, 334 337 Julienne, 232 Just Enough Bleu Salad Dressing, 415 Juvenile or insulin-dependent diabetes. See Type 1 diabetes Juxtaposed tastes, 126, 134 139

K Kallmann syndrome, 158, 165 169 Kashrut, 275, 288 293 Kefir, 195, 201 205, 288 293 Kelvin (K), 446 Keratoconus, 490 Ketoanalogs, 288 293 KFF. See Henry J. Kaiser Family Foundation (KFF) Kidney function, 54 62, 460 Kimchi, 242 245 Kinesthesia, 72, 94 102 Kinesthesis, 7, 72 aging and, 73 Kitchen for aging people

504 Kitchen for aging people (Continued) adapted kitchen layout, functionality and safety, 431 432 additional kitchen considerations, 434 kitchen guidelines for aging people with dementia, 435t adjustments of kitchen appliances, 433 434 cooktops, standard ranges and wall ovens, 433 434 dishwashers, 434 microwave ovens, 434 refrigerators and freezers, 434 digest, 451 dining and living considerations, 445 448 dining rooms in assisted living facilities, 448, 448t environmental factors, 445 light/illuminating factors, 445 446 preventing risks and injuries, 447 448 sound/acoustical factors, 446 447 touch/textural factors, 447 fire and smoke safety, 435 foodborne illnesses prevention in kitchen, 436 improving appetite within dining environments, 448 451 medical and personal care devices, 444 modified kitchen layout, 432 433 pots, pans and cooking equipment, 434 preparation, cooking and dining aids, 437 442 rational for kitchen modifications, 431 rationale for accommodated cooking aids, 437 tableware for accommodated or disabled consumers, 443 444 techniques to avoid visual overload, 444 445 Kodo, 242 245 Kokumi, 94 102, 118, 134 139 Korsakoff’s psychosis, 94 102 Kosher dietaries, 275 276 Kosher salt, 185, 392

L L-glutamate, 189, 201 205 umami-rich combinations with disodium guanylate and disodium inosinate and, 190 umami-rich ingredients with, 190 L-histidine, 118, 134 139 Labor force, 5, 19 23 Labyrinthitis, 72, 94 102 Lactase, 94 102 Lactic acid, 201 205 Lacto-ovo vegetarian diets, 285 286, 288 293 Lactobacillus, 34, 54 62 Lactones, 110, 134 139 Lactose, 33, 54 62, 94 102 intolerance, 276 277, 288 293 Lamiaceae, 201 205 Lard, 183, 201 205 LASIK surgery, 54 62

INDEX

Latrogenic, 158, 165 169 Layering, 235, 242 245 Lazy-susan type cabinet, 432 LBM. See Lean body mass (LBM) LDL. See Low-density lipoprotein (LDL) Leafy greens, 180 Lean body mass (LBM), 29, 54 62 Lecithin, 327 Leftovers concept, 424, 428 Lemon, 150, 323 324 aroma, 165 169 extract, 299 Lemon blend for marinades, 419 ranch dressing, 423 Leptin, 333 337 Leukemia & Lymphoma Society (LLS), 473 Lewy body, 94 102 LFA. See Lupus Foundation of America (LFA) LI. See Lighthouse International (LI) Life expectancy, 3, 19 23 Lifestyle factors, 27 Light/illuminating factors for aging people, 445 446 Lighthouse International (LI), 473 LIHEAP. See Low Income Home Energy Assistance Program (LIHEAP) Limberness, 54 62 Limbic system, 71, 90, 94 102, 144, 165 169 Limiting amino acids, 118, 134 139 Limonoids, 54 62 Listeria, 436, 451 452 Liver disease/damage, 256 LLS. See Leukemia & Lymphoma Society (LLS) Localized taste loss, 19 23 Low autoletics, 128, 134 139 Low frequency pure tone average, 214 Low Income Home Energy Assistance Program (LIHEAP), 474 Low or underactive thyroid. See Hypothyroidism Low vision, 210, 242 245 Low-density lipoprotein (LDL), 34, 41 Low-protein diet (LPD), 288 293 Lower esophageal sphincter, 79, 94 102 LPD. See Low-protein diet (LPD) LRA. See Lupus Research Alliance (LRA) Lungs, 90 Lupus, 474, 490 Lupus Foundation of America (LFA), 474 Lupus Research Alliance (LRA), 474 Lutein, 19 23, 28, 47, 54 62 Lymphatic system, 54 62 Lymphocytes, 43, 54 62 Lysine (Lys), 118 119, 134 139

M MAC. See UCSF Memory and Aging Center (MAC) Macerating, 235, 242 245 Macrominerals, 37 Magnesium, 39, 40t for bones, 255

Magnetic resonance scan (MRI scan), 158, 165 169 Maillard browning, 134 139 Maillard reactions, 134 139, 231, 237, 242 245, 325 326, 334 337 Male-producing sex attractants. See Aggregation pheromones Malnutrition, 93 102, 277 278, 288 293 Maltodextrin, 199, 201 205 Maltol, 229, 231 Maltooligosaccharides, 119, 134 139 Mandible, 83, 94 102 Mango salsa, 194 yogurt shake, 396 Manufactured flavor enhancers, 176, 201 205 Marinades, 300, 334 337, 413 Marinating, 235, 242 245 Mashgiach, 275, 288 293 Mastication, 134 139 Maxilla, 83, 94 102 Maximum heart rate (MHR), 54 62 Maximum oxygen uptake, 54 62 MCI. See Mild cognitive impairment (MCI) Meal delivery services (MDS), 17, 19 23 Meal(s) planning for aging, 315 316 on wheels, 16 17, 19 23 Meals on Wheels America (MWA), 474 Meat tenderizers, 334 337 Meatiness, 134 139 Mechanical smell disorders, 157 161 Mechanoreception, 71, 94 102 Mechanoreceptors, 94 102, 224 Medical alert systems/lifelines, 444 care, 27 conditions implicated with smell and taste decline, 85 88, 85t and personal care devices, 444 Medical nutrition therapy (MNT), 266, 288 293 Medicare, 19 23, 474 Medicare interactive (MI), 474 Medicare Rights Center (MRC), 474 Medication(s) implicated with decline in taste and/or smell, 89 minders, 444 use, 132 Medicinal herbs, 304, 334 337 Mediterranean-type diet, 257, 260, 288 293 Medium tasters, 109, 134 139 Medulla oblongata, 108, 134 139 Megaloblastic anemia, 44, 48 49, 54 62, 288 293 Memory, 145 Menaquinone, 47 Mended Hearts (MH), 475 Meniere’s disease, 72, 94 102 Mental health, 463, 485 Mercaptans, 159, 165 169 Metabolic smell disorders, 157 161 syndrome, 268 269

INDEX

Metabolism, 54 62 Methanethiol. See Mercaptans 1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPDP), 159, 165 169 Methylcobalamin, 48 49 Methylxanthines, 110, 134 139 Mexican rub, 301 MH. See Mended Hearts (MH) MHR. See Maximum heart rate (MHR) MI. See Medicare interactive (MI) Mild cognitive impairment (MCI), 94 102 Mince, 232 Minerals, 27, 119, 134 139, 253. See also Vitamin(s) for aging diets, 37 43 calcium, 37 38 iron, 38 39 magnesium, 39 phosphorus, 40 potassium, 40 41 selenium, 41 42 sodium, 42 zinc, 43 Mint, 196t, 201 205 minty/peppermint aroma, 150, 165 169 Mirepoix, 185, 201 205, 302 303, 334 337 Miso paste, 190 Mitochondrial decline, 288 293 Mixtures, 227 228 MNT. See Medical nutrition therapy (MNT) Mock sangria, 397 Moderate active lifestyle, 30, 54 62 Modified consistency diet, 264, 288 293 Modified kitchen layout, 432 433 cabinets, 432 hardware and design, 432 countertops, 432 flooring, 432 heating and cooling, 432 433 lighting, 433 seating, 433 sinks, 433 Modified sugars, 114, 134 139 Modified texture foods (MTFs), 317, 334 337 Moist-heat cooking methods, 334 337 taste and smell in aging to focus on, 307 309 boiling, 307 combined cooking methods, 308 poaching, 307 simmering, 307 slow cooking, 309 steaming, 307 308 Monopotassium glutamate (MPG), 200 205 Monosodium glutamate (MSG), 118, 120, 134 139, 176 177, 189 190, 200 205, 329, 334 337 Monounsaturated fatty acids, 327 Moroccan rub, 301 spices, 374 “Mother” sauces, 302, 334 337 Motivation, 145, 165 169 Motor neuron disease (MND). See Amyotrophic lateral sclerosis (ALS)

Mouthfeel, 116, 227, 242 245 MPDP. See 1-Methyl-4-phenyl-1,2,3,6tetrahydropyridine (MPDP) MPG. See Monopotassium glutamate (MPG) MRC. See Medicare Rights Center (MRC) MRI scan. See Magnetic resonance scan (MRI scan) MS. See Multiple sclerosis (MS) MSG. See Monosodium glutamate (MSG) MTFs. See Modified texture foods (MTFs) Multimorbidity, 4, 19 23 Multiple sclerosis (MS), 94 102, 481 Muscle(s), 459 mass, 54 62 Musculoskeletal system, 54 62 Mushroom barley soup, 353 and goat cheese omelet, 406 Mustard oil. See Allyl isothiocynate Mustards, 196t MWA. See Meals on Wheels America (MWA) My plate for older adults, 32 36 added sugars, 34 chronic disease and carbohydrates, 33 dietary carbohydrates, 32 33 dietary fats, 35 dietary fibers, 34 35 dietary protein, 36 insoluble fibers, 35 nutrients, 32 omega-3 fatty acids, 35 SoFAS, 34 solid fats, 34 soluble fibers, 35 Myelin, 77, 94 102, 134 139 Myelodysplastic syndrome, 288 293 MyPlate for Older Americans, 32, 54 62

N NAA. See National Aphasia Association (NAA) NAAF. See National Alopecia Areata Foundation (NAAF) NAAS. See National Academy on an Aging Society (NAAS) NAC. See National Alliance for Caregiving (NAC) NaCl. See Sodium chloride (NaCl) NAD. See National Association of the Deaf (NAD) NADSA. See National Adult Day Services Association (NADSA) NAELA. See National Academy of Elder Law Attorneys (NAELA) NAF. See National Ataxia Foundation (NAF) NAFC. See National Association for Continence (NAFC) NAFLD. See Nonalcoholic fatty liver disease (NAFLD) Nage, 334 337 NAHC. See National Association for Home Care & Hospice (NAHC) Nails, 459 NAM. See National Academy of Medicine (NAM)

505 NAMI. See National Alliance on Mental Illness (NAMI) NARIC. See National Rehabilitation Information Center (NARIC) Naringin, 111, 134 139 Nasal endoscopy, 158, 165 169 glands, 94 102 mucosa, 90, 94 102 polyps, 94 102 NASH. See Nonalcoholic steatohepatitis (NASH) NASUAD. See National Association of States United for Aging and Disabilities (NASUAD) NASW. See National Association of Social Workers (NASW) National Academy of Elder Law Attorneys (NAELA), 475 National Academy of Medicine (NAM), 35 National Academy on an Aging Society (NAAS), 18 23 National Adult Day Services Association (NADSA), 475 National Alliance for Caregiving (NAC), 475 National Alliance on Mental Illness (NAMI), 475 National Alopecia Areata Foundation (NAAF), 475 National Aphasia Association (NAA), 475 National Association for Continence (NAFC), 476 National Association for Home Care & Hospice (NAHC), 476 National Association for Visually Handicapped (NAVH), 476 National Association of Social Workers (NASW), 476 National Association of States United for Aging and Disabilities (NASUAD), 476 National Association of the Deaf (NAD), 476 National Ataxia Foundation (NAF), 477 National Brain Tumor Society (NBTS), 477 National Breast Cancer Foundation (NBCF), 477 National Cancer Institute (NCI), 477 National Coalition for Cancer Survivorship (NCCS), 477 National Comprehensive Cancer Network (NCCN), 477 National Consumer Voice for Quality LongTerm Care, 478 National Consumers League (NCL), 477 National Council on Aging (NCOA), 53, 478 National Council on Alcoholism and Drug Dependence (NCADD), 478 National Council on Disability (NCD), 478 National Council on Seniors Drug & Alcohol Rehab, 478 National Dairy Council (NDC), 478 National Diabetes Information Clearinghouse (NDIC), 478 National Digestive Diseases Information Clearinghouse (NDDIC), 479

506 National Elder Law Foundation (NELF), 479 National Eye Institute (NEI), 479 National Federation of Blind (NFB), 479 National Geographic Smell Survey, 159 160 National Guardianship Association (NGA), 479 National Headache Foundation (NHF), 479 National Health and Nutrition Examination Survey (NHANES), 214 National Heart, Lung and Blood Institute (NHLBI), 479 National Hospice and Palliative Care Organization (NHPCO), 480 National Institute of Allergy and Infectious Diseases (NIAID), 480 National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), 476 National Institute of Dental and Craniofacial Research (NIDCR), 480 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 480 National Institute of General Medical Sciences (NIGMS), 480 National Institute of Mental Health (NIMH), 480 National Institute of Neurological Disorders and Stroke (NINDS), 481 National Institute on Aging (NIA), 481 National Institute on Deafness and Other Communication Disorders (NIDCD), 69, 94 102, 480 National Institutes of Health (NIH), 469, 481 National Kidney Foundation (NKF), 481 National League for Nursing (NLN), 481 National Mental Health Consumers’ SelfHelp Clearinghouse (NMHCSHC), 481 National Multiple Sclerosis Society (NMSS), 481 National Organization for Rare Disorders (NORD), 482 National Osteoporosis Foundation (NOF), 482 National Psoriasis Foundation (NPF), 482 National Rehabilitation Information Center (NARIC), 482 National Sleep Foundation (NSF), 482 National Stroke Association (NSA), 482 National Women’s Health Network (NWHN), 482 Natto, 47, 54 62 Natural flavor derivatives, 192 198, 201 205 butter, 194 cheese and cottage cheese, 194 chilies and peppers, 192 citrus, 192 193 coconuts/coconut products, 193 concentrated fruit purees, jams, jellies and sauces, 193 194 cream, half-and-half and sour cream, 194 195 dairy milk and cultured buttermilk, 195 dairy products, 194 dry rubs, 195

INDEX

extracts and flavorings, 195 198 yogurt, Greek yogurt and kefir, 195 Naturally sweetened foods and beverages, 322 NAVH. See National Association for Visually Handicapped (NAVH) NBCF. See National Breast Cancer Foundation (NBCF) NBTS. See National Brain Tumor Society (NBTS) NCADD. See National Council on Alcoholism and Drug Dependence (NCADD) NCCN. See National Comprehensive Cancer Network (NCCN) NCCS. See National Coalition for Cancer Survivorship (NCCS) NCD. See National Council on Disability (NCD) NCI. See National Cancer Institute (NCI) NCL. See National Consumers League (NCL) NCOA. See National Council on Aging (NCOA) NDC. See National Dairy Council (NDC) NDDIC. See National Digestive Diseases Information Clearinghouse (NDDIC) NDIC. See National Diabetes Information Clearinghouse (NDIC) NE. See Norepinephrine (NE) Necromones, 155, 165 169 Negative emotions, 146 147 NEI. See National Eye Institute (NEI) NELF. See National Elder Law Foundation (NELF) Neo-cortex, 144, 165 169 Nervous system, 54 62 Neuro-vegetative areas, 142, 165 169 Neuromessengers, 153 Neurons, 94 102 Neuropsychiatric symptoms. See Behavioral and Psychological Symptoms of Dementia (BPSD) Neurotoxin MPP 1 , 159 “New Age” Potato Salad, 361 NFB. See National Federation of Blind (NFB) NGA. See National Guardianship Association (NGA) NHANES. See National Health and Nutrition Examination Survey (NHANES) NHF. See National Headache Foundation (NHF) NHLBI. See National Heart, Lung and Blood Institute (NHLBI) NHPCO. See National Hospice and Palliative Care Organization (NHPCO) NIA. See National Institute on Aging (NIA) NIAID. See National Institute of Allergy and Infectious Diseases (NIAID) NIAMS. See National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) NIDCD. See National Institute on Deafness and Other Communication Disorders (NIDCD)

NIDCR. See National Institute of Dental and Craniofacial Research (NIDCR) NIDDK. See National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Night-blindness, 45, 54 62 NIGMS. See National Institute of General Medical Sciences (NIGMS) NIH. See National Institutes of Health (NIH) NIMH. See National Institute of Mental Health (NIMH) NINDS. See National Institute of Neurological Disorders and Stroke (NINDS) Nitrates, 177, 201 205 Nitrites, 177, 201 205 Nixtamalization, 118, 134 139 NKF. See National Kidney Foundation (NKF) NLN. See National League for Nursing (NLN) NMHCSHC. See National Mental Health Consumers’ Self-Help Clearinghouse (NMHCSHC) NMSS. See National Multiple Sclerosis Society (NMSS) NNSs. See Nonnutritive sweeteners (NNSs) Nociception, 73, 94 102 Nociceptors, 224 NOF. See National Osteoporosis Foundation (NOF) Non-celiac gluten sensitivity, 262, 288 293 Non-hispanic blacks, 19 23 Non-hispanic whites, 19 23 Nonalcoholic fatty liver disease (NAFLD), 35, 54 62 Nonalcoholic steatohepatitis (NASH), 270, 288 293 Noncitrus aromas. See Fruity aromas Noncommunicable diseases, 4, 19 23 2-Nonenal, 156 Nonnutritive or alternative sweeteners. See Artificial sweeteners Nonnutritive sweeteners (NNSs), 330, 334 337 Nonsteroidal anti-inflammatory drugs (NSAIDS), 268 269, 288 293 “Nontasters”, 109, 134 139 Noradrenaline (NA). See Norepinephrine (NE) NORD. See National Organization for Rare Disorders (NORD) Norepinephrine (NE), 145, 154, 157, 165 169 Norovirus, 436, 451 452 Nostrils, 219 NPF. See National Psoriasis Foundation (NPF) NSA. See National Stroke Association (NSA) NSAIDS. See Nonsteroidal anti-inflammatory drugs (NSAIDS) NSF. See National Sleep Foundation (NSF) NSIP. See Nutrition Services Incentive Program (NSIP) NSP. See Nutrition Services Program (NSP) Nucleic acids, 115, 134 139 Nucleotides, 115, 134 139

507

INDEX

Nursing, 464 Nutmeg, 394 NutraSweet, 177, 201 205 Nutrients, 32, 252 253 calories, 252 carbohydrates, 253 fats, 253 needs for aging, 27 protein, 252 smaller nutrient dense meals and snacks, 325t Nutrition Services Incentive Program (NSIP), 483 Nutrition Services Program (NSP), 482 Nutrition(al), 2, 6 8, 15 16, 19, 457, 485 assistance, 486 and culinary arts partnerships for aging, 16 17 frailty, 14, 19 23 and physical concerns in aging, 26 27 aging and physical activity, 51 52 anorexia, 30 calories by gender, 29 30 calories during aging, 29 dietary decline and aging, 27 28 digest, 54 exercise programs for aging, 53 54 functional decline and aging, 27 minerals for aging diets, 37 43 nutrient needs for aging, 27 obesity, 31 32 physical activity needs, 53 physiological changes during aging, 28 plate for older adults, 32 36 vitamins for aging diets, 44 49 weight gain, 31 weight loss, 30 requirements, 6 screening, 19 23 supplements, 27 US aging and, 14 15 Nutritious breakfasts, 404 Nutritive sweeteners, 330, 334 337 Nuts, 182, 196t, 299 300 NWHN. See National Women’s Health Network (NWHN) Nyctalopia, 54 62

O OAA. See Older Americans Act (OAA) Oat bran, 405 topping, 389 waffles, 410 and berry compote with lemon and ginger, 409 Obesity, 19 23, 31 32, 31t, 54 62, 94 102 smell and, 156 157 Occupational therapists, 133 Occupational therapy, 486 ODEP. See Office of Disability Employment Policy (ODEP) Odor fatigue. See Smell—fatigue Odor(s), 74, 94 102, 149, 161, 165 169 Odorants, 144, 165 169

Odorprints, 156, 165 169 ODPHP. See Office of Disease Prevention and Health Promotion (ODPHP) OECD. See Organization for Economic Cooperation and Development (OECD) Office of Disability Employment Policy (ODEP), 483 Office of Disease Prevention and Health Promotion (ODPHP), 483 Office of Special Education and Rehabilitation Services (OSERS), 483 Office of Special Education Programs (OSEP), 483 Oil(s), 299 300, 319 320 deciphering, 328t decreasing, 327 328 infusions, 300 Older Americans Act (OAA), 457 458, 483 Oleic acid, 373, 428 Oleocanthal, 242 245, 288 293 Oleogustus, 81 82, 94 102 Olfactory/olfaction, 7, 70 71, 89, 94 102, 142 146, 165 169, 216 221 adaptation, 152, 165 169 affecting sense of taste, 126 127 blind spot, 151, 165 169 bulb, 70 71, 90, 94 102 cleft, 94 102 cognition, 146, 165 169 digest, 165 dysfunction affecting nutrition status, 91 92 emotion, 144 145 epithelium, 89, 94 102, 144, 165 169 fatigue. See Smell—fatigue food and beverage smells, 216 217 habituation, 145 hallucinations, 156, 165 169 improving, 161 162 steps to sustaining, 161t utilizing smell memory for improving smell sensations, 161 162 interactions with other senses, 162 164 loss, 90 91 memory, 145 modality, 149 motivation, 145 nerve, 94 102 pathways, 89 90 receptors, 90 smell training, 218 smell-enhancement techniques, 218 221 system, 70, 144 Olfactory receptor neurons (ORN), 90, 94 102, 146, 152, 165 169 Olfactory sensory neurons (OSN). See Olfactory receptor neurons (ORN) Olive oils, 183, 355 Omega-3 fatty acids (ω-3 fatty acids), 19 23, 28, 35, 54 62, 257, 288 293, 327 Omega-6 fatty acids (ω-6 fatty acids), 35, 54 62, 327 Onions, 196t Optic nerve, 69, 94 102

OR7D4 (smell receptor), 147, 165 169 Oral cavity, 71, 75, 83, 94 102 disease, 131 132, 134 139, 278 279, 288 293 health, 462 oral-somatosensory qualities, 309, 334 337 structure, 461 Orbito-frontal cortex, 90, 94 102 Organ of Corti, 69, 94 102 donation, 487 sharing, 487 Organization for Economic Cooperation and Development (OECD), 11, 19 23 ORN. See Olfactory receptor neurons (ORN) Oropharynx, 83, 94 102 Orthonasal perceiving odors, 164 169 route, 70 71, 89 90, 94 102 smell or olfaction, 165 169 Orthostatic hypotension, 261, 269, 288 293 Orzo, 353 OSEP. See Office of Special Education Programs (OSEP) OSERS. See Office of Special Education and Rehabilitation Services (OSERS) Osmosis, 232, 242 245 Ossicles, 94 102 Osteoarthritis, 19 23, 259, 279 280, 288 293 Osteogenesis imperfect, 490 Osteomalacia, 54 62, 279 280, 288 293 Osteopenia, 31, 54 62 Osteoporosis, 31, 37, 54 62, 279 280, 288 293 Ostomies, 487, 490 Otolaryngologist, 129, 134 139 Otoliths, 69, 94 102 Outer ear, 69, 94 102 Oval window, 94 102 Oven drying, 235 236, 242 245 Oven-frying, 234, 242 245 Overheating, 73, 94 102 Overnutrition, 288 293 Oxalic acid, 38, 54 62

P PAACT. See Patient Advocates for Advanced Cancer Treatment (PAACT) Packaged foods and beverage selection, 327 331 Paget’s disease of bone, 490 Pain, 73, 226, 242 245 aging and, 73 receptors, 73, 94 102 Palliative care, 280, 288 293 Pan-frying, 234, 236, 238, 242 245 Panko, 326, 334 337 Papain, 334 337 Papillae, 77, 94 102, 108, 134 139 Parabens, 177, 201 205 Parasympathetic nervous system, 90, 94 102 Parethesia, 71, 94 102 Parkinson’s disease, 94 102, 464 Parkinson’s Disease Foundation (PDF), 484

508 Parmesan cheese, 409 Parmigano-Reggiano cheese, 190 Parosmia, 156, 158 Parotid glands, 94 102 Parsley, 359 Part-time work, 5 Partial hydrolysis, 199 Partial seizures, simple, 94 102 Partially hydrogenated oils, 327 Pasta, 378 Pastes, 334 337 Patient Advocates for Advanced Cancer Treatment (PAACT), 484 PAV/AVI genotype, 109 PAV/PAV, 109 PBA. See Prevent Blindness America (PBA) PCEC. See Prostate Conditions Education Council (PCEC) PCSFN. See President’s Council on Sports, Fitness & Nutrition (PCSFN) PDF. See Parkinson’s Disease Foundation (PDF) Peanut butter, banana and coffee blend, 399 Peppercorn rub, 301 Peppering, 236, 242 245 Peppers, 192 Peptides, 110, 114, 134 139 Pericarp, 334 337 Periodontal disease, 94 102 Periodontitis, 278, 288 293 Peripheral nerve, 94 102 Pernicious anemia. See Megaloblastic anemia Personal emergency systems. See Medical alert systems/lifelines Personal fire promotion efforts, 435t Perspiration, 94 102 pH scale, 113, 134 139 Phantom taste sensations, 19 23, 134 139 Phantosmia, 156, 158, 165 169 Pharyngitis, 94 102 Pharynx, 71, 89 90, 94 102, 324, 334 337 Phenolic compounds, 180, 201 205 Phenols/polyphenols, 134 139 Phenylalanine, 177, 288 293 Phenylketonuria (PKU), 177, 201 205, 281, 288 293 Phenylthiocarbamide (PTC), 109 111, 134 139, 349, 428 Phenylthiocarbamide (PTC), 349, 428 Pheromones, 155 156, 165 169 Phospholipids, 327 Phosphorus, 40, 40t Phylloquinone, 47 Physical activity, 4, 27, 51 52, 54 62 vs. exercise, 51 52 needs, 53 Physical exercise, 51 52, 54 62 balance, 52 endurance, 52 flexibility, 52 strength, 52 Physical factor, 4, 68 of aging, 94 102 decline in, 68 Physical fire promotion efforts, 435t

INDEX

Physical therapy, 464 Physiological changes during aging, 28 decline in aging, 54 62 factors of dietary decline and aging, 28 pain, 73, 94 102 Phytates, 43, 54 62 Phytonutrients, 49 50, 50t, 54 62 Phytosterols, 54 62 Pickling, 236, 242 245 Pimenta. See Allspice Pineapple juice, 372 Pink eye, 94 102 Piperine, 200 205, 428 Piriform cortex, 94 102, 147, 165 169 PKU. See Phenylketonuria (PKU) Place-based interventions, 4 Plant oils, 183 Plaque, 12, 19 23 Plastic and reconstructive surgery, 465 Plate garnishes, 213 presentations, 212 Pneumogastric nerve, 94 102 Poaching, 236, 242 245, 307, 334 337 Polycose, 119, 134 139 Polyphenol oxidase, 178, 201 205 Polyphenol(s), 54 62, 110, 134 139, 288 293, 412 phytonutrients, 50 Polyunsaturated fatty acids (PUFAs), 34, 41, 328 Popcorn, 151 aroma, 165 169 Pork fat, 183, 201 205, 334 337 Postprandial hyperglycemia, 94 102 Pot watcher, 442, 451 452 Pot-roasting, 230, 242 245 Potassium, 40 41, 41t Powerful cheeses, 300 301 Prebiotics, 54 62, 268, 288 293 Pregnancy, 148 Presbycusis, 94 102, 214, 242 245 Presbyopia, 70, 94 102 Presbyosmia, 91 President’s Council on Sports, Fitness & Nutrition (PCSFN), 484 Pressure, 226, 242 245 Pressure injuries. See Pressure ulcers (PU) Pressure sores. See Pressure ulcers (PU) Pressure ulcers (PU), 19 23, 281 282, 288 293, 447, 451 452 Prevent Blindness America (PBA), 484 Primal pheromones, 155, 165 169 Primary aging, 18 23 Primary cilium, 144, 165 169 Primary olfactory cortex, 90, 94 102 Primary somatosensory cortex, 128, 134 139 Primer pheromones, 155 Probiotics, 34, 54 62, 268, 288 293 Procyanidins, 412 Progressive supranuclear palsy, 159, 165 169 PROP. See 6-n-Propylthiouracil (PROP) Proprioception, 225, 242 245

6-n-Propylthiouracil (PROP), 83 84, 94 102, 109 111, 134 139 Prosocial behavior, 153 Prostate cancer, 484 Prostate Conditions Education Council (PCEC), 484 Protamine, 134 139 Protein, 120, 252 dietary protein, 36, 36t, 54 62, 270 271 hydrolyzed, 199 nutrient, 252 PKD2L1, 113, 134 139 Pseudogenes, 148, 165 169 Psoriasis, 288 293 Psoriatic arthritis, 259, 288 293 Psychiatry, 464 Psychological/psychology, 464 decline in aging, 54 62 factors of dietary decline and aging, 28 PTAs. See Pure tone average (PTAs) PTC. See Phenylthiocarbamide (PTC) PU. See Pressure ulcers (PU) PUFAs. See Polyunsaturated fatty acids (PUFAs) Pulmonary disease, 282 283 Punctuating, 237, 242 245 Pungent aromas, 151, 165 169 Pupil, 69, 94 102 Pure tone average (PTAs), 214, 242 245 Pureed, 196t, 201 205 Purees, 201 205, 301, 334 337 Purines, 269, 288 293 Pyridoxine, 48 Pyriform cortex. See Piriform cortex Pyrophosphates, 120, 134 139

Q Quality-Adjusted Life Expectancy (QUAL), 19 23 Quinoa, 382 Qur’an (holy book of Islam), 288 293

R Radiological care, 461 Radionecrosis, 132, 134 139 Ranch dressing, 423 Raw crimini mushrooms, 354 Recall guide, 484 Recipes and menus to aging palates, 341 424 carrying in, 427 creative leftover concepts, 426, 426t digest, 427 428 dining out, 427 foodborne illnesses food safety tips for preventing, 425 426 foods and beverages to avoid to preventing, 425 risks of, 424 425 leftovers, 424 practical advice for eating out, 427t Recognition threshold, 84, 94 102, 130, 134 139 Recovery International (RI), 485 Red pepper

INDEX

flakes, 357 jelly, 194 Red wine, 304, 412 Refractive errors, 19 23 Rehabilitation, 467 Rehabilitation Services Administration (RSA), 483 Releaser pheromones, 155, 165 169 Relishes, 301, 334 337, 413 Renal function, 460 “Renewed” orange slices with berry sauce, 387 Renin-angiotensin-aldosterone system. See Angiotensin system Reproductive system, 54 62 Residence, 4 US aging and, 12 13 Resin, 428 Resistance training, 52, 54 62 Resistant starch (RS), 334 337 Respiratory infection, 94 102 system, 54 62 Resveratrol, 54 62, 398, 412 Retina, 69, 94 102 Retinal disorders, 44 45, 70, 94 102 Retinitis pigmentosa, 470, 490 Retinol, 44 45, 54 62 Retinyl ester, 44 45 Retirement, 19 23 plans and wealth, 5 Retromolar trigone, 83, 94 102 Retronasal rhinosinusitis, 164 169 route, 70 71, 89 90, 94 102 smell, 152, 165 169 Rheumatic diseases, 486 Rheumatoid arthritis, 259, 279 280, 288 293 Rhinosinusitis, 158 Rhodopsin, 45, 54 62 RI. See Recovery International (RI) Rice pudding with pears and almonds, 390 vinegar, 376 Ripe bananas, 187 Ripening, 191, 201 205 Risoni. See Orzo Roasting, 237, 242 245 cauliflower with shallots and raisins, 384 garlic, onions and other root vegetables, 190 Robert and Arlene Kogod Center on Aging, 485 Root vegetables, 188, 379 Rosemary, 384 Rough cut, 232 Roughage. See Diet(ary)—fiber RS. See Resistant starch (RS) RSA. See Rehabilitation Services Administration (RSA) Rubs, 301 302

S SAA. See Spondylitis Association of America (SAA)

Salad onions. See Scallions Salads, 341, 360 Salivary gland infections, 94 102 Salmon mash, 350 Salmonella, 436, 451 452 Salsa, 302, 334 337, 370 371, 380 Salt(ing), 110, 134 139, 237, 242 245, 320 deciphering, 330t decreasing, 329 330 salt/sodium in flavor enhancement, 183 186, 184t complementing, 185 heightening, 185 reducing or mask saltiness, 185 salty aromas, 185 186 taste, 71, 78 79, 112, 112t, 134 139 Saltiness, 78 79, 134 139 saltiness and aging, 78 79 Salts of Benzoic Acid. See Benzoates SAM. See Social Support, Attitude and Management (SAM) SAMHSA. See Substance Abuse and Mental Health Services Administration (SAMHSA) Sarcopenia, 14, 19 23, 54 62, 284 285, 288 293 Sarcopenic obesity, 19 23 Saturated fatty acids, 328 Sauces, 193 194, 302, 334 337, 413 Saute´ed tofu patties, 375 Saute´ing, 234, 237 238, 242 245 Savoriness, 80 81, 134 139 Savory deliciousness, 76 extracts, 299 oatmeal with eggs, 407 taste, 80 Savoy spinach, 363 Scallions, 423 SCDA. See Special Care Dentistry Association (SCDA) Scent signals, 147, 149, 165 169 SCF. See Skin Cancer Foundation (SCF) SCI/D. See Spinach cord injury or disease (SCI/D) Scleroderma Foundation (SF), 485 Scleroderma/autoimmune disease, 485 Sea salt, 185 Seafood, 188 Searing. See Pan-frying Seasonings, 238, 238t, 242 245 Sebum, 156, 165 169 Secondary aging, 18 23 Sed Rate. See Erythrocyte sedimentation rate (ESR) Sedentary lifestyle, 30, 54 62 Seed oils, 182 Seeds, 182, 196t, 299 300 Selenium, 41 42, 42t Selenosis, 54 62 Self-Help for Hard of Hearing People (SHHH), 485 Semicircular canals, 69, 94 102 Semisavoy spinach, 363 Senescence, 54 62

509 Senior Farmers’ Market Nutrition Program (SFMNP), 485 Senior Resource Connect (SRC), 485 Sensations. See Somesthetics Sense(s), 68 72, 68f, 94 102, 107 hearing, 69 sight, 69 70 of sight, sound and touch affect sense of taste, 127 128, 129f of smell. See Olfactory/olfaction taste, 71 of taste, 107, 132 touch, 71 72 Sensitive tasters, 84, 94 102 Sensory adaptation, 160 agents, 199 200 alterations, 93 102 considerations, 72 73 balance, 72 kinesthetic, 72 pain, 73 temperature, 73 disorders, 15 issues, 209 matters, 210 228 audition, 213 216 gustation, 221 224 olfaction, 216 221 somesthetics, 224 228 vision, 210 213 neurons, 144, 165 169 receptors, 144, 165 169 sensory-specific satiety, 91, 94 102 Sensory receptors, 89, 165 169, 224 Serotonin, 153 Sex pheromones, 155, 165 169 Sexually transmitted diseases (STDs). See Sexually transmitted infection (STI) Sexually transmitted infection (STI), 288 293 SF. See Scleroderma Foundation (SF) SFMNP. See Senior Farmers’ Market Nutrition Program (SFMNP) SGLT1. See Sodium-glucose cotransporters (SGLT1) Shallots, 385 Shallow-frying, 234, 242 245 Shellfish, 371 SHHH. See Self-Help for Hard of Hearing People (SHHH) Shortening, 334 337 Sides (recipes), 341 Sight, 69 70, 94 102, 127, 163 and aging, 70 eyesight relating to taste and smell, 70 Signal(ing) molecules, 32 33, 54 62 pheromones, 155, 165 169 Simmering, 239, 242 245, 307, 334 337 Sinigrin, 201 205, 417, 428 Sinonasal cancer, 94 102 Sinonasal undifferentiated carcinoma (SNUC), 94 102 Sinuses/sinusitis, 94 102

510 Sirtuins, 287 293 Sjogren’s syndrome, 94 102, 490 Sjo¨gren’s Syndrome Foundation (SSF), 485 Skin, 459 Skin Cancer Foundation (SCF), 486 Sleep, 460 apnea, 465 Slow browning, 231, 242 245 Slow cooking, 239, 242 245, 309, 334 337 Sluries, 334 337 Smart thermostat, 444 Smell-enhancement techniques, 218 221. See also Taste enhancement techniques alternate nostrils, 219 deeply smell foods and beverages, 219 “educated” noses, 220 exercise or keep active, 219 mucus production and/or congestion, 219 odors, 220 using or losing, 220 221 question pollutants and assertive smells, 220 smell sensations, 218 smells detecting in isolation, 220 vitamin B12 and zinc status, 219 Smell(s), 67, 70 71, 74, 75t, 94 102 adaptations, 160 161 and aging, 71 and behavior, 153 155 diagnosis of smell impairment, 158 disorders, 133, 157 161 treatments for, 160 fatigue, 160, 165 169 and health, 156 interactions and affects, 89 91 olfaction, 89 olfactory loss vs. taste loss, 90 91 olfactory pathways, 89 90 types of smell loss, 91 and obesity, 156 157 perceiving, 146 149 adulthood, 148 149 evolutions, 147 expectations, 147 genes, 147 148 infants, 148 interpretations, 147 pathological changes, 149t pregnancy, 148 receptors, 70 tests to detecting olfactory function, 159 160 training, 149, 165 169, 218, 242 245 and weight loss, 157 Smoke/smoking, 239, 242 245 detection, 430 431 points, 182 183, 201 205 smoked fish, 351 Snacks planning for aging, 315 316 SNAP. See Supplemental Nutrition Assistance Program (SNAP) SNS. See Sympathetic nervous system (SNS) SNUC. See Sinonasal undifferentiated carcinoma (SNUC)

INDEX

Soapy taste, 120 121, 134 139 Social factors, 4, 68 of aging, 94 102 Social gerontology, 18 23 Social security, 19 23 benefits, 13 Social Security Administration (SSA), 486 Social Support, Attitude and Management (SAM), 281, 288 293 Socioeconomic costs, US aging and, 13 14 Socioeconomic factors of dietary decline and aging, 28 Sociological decline in aging, 54 62 Sodium (Na), 42, 43t, 94 102, 320 deciphering, 330t saccharin, 329, 334 337 Sodium alginate, 329, 334 337 Sodium benzoate, 329, 334 337 Sodium caseinate, 329, 334 337 Sodium chloride (NaCl), 78, 94 102 Sodium citrate, 329, 334 337 Sodium hydroxide, 118, 134 139, 329, 334 337 Sodium nitrite, 329, 334 337 Sodium propionate, 329, 334 337 Sodium sulfite, 329, 334 337 Sodium-glucose cotransporters (SGLT1), 186 187, 201 205 Solid fats, 34, 54 62 Solid fats and added sugars (SoFAS), 34 Soluble fibers, 34 35, 54 62, 317, 334 337 foods with, 331 Somatic receptor, 94 102 Somatic senses, 73, 94 102, 225, 242 245 Somatosensation, 94 102 Somatosensory, 71, 94 102 cortex, 77, 94 102 system, 81, 94 102, 224, 242 245 Somesthesis, 164 169 Somesthetics, 67, 224 228, 242 245 mixtures, 227 228 movement of foods and beverages, 225 pain, 226 pressure, 226 tactile sensations, 226 228, 227t temperature of foods and beverages, 225 touch, 226 Sound(s), 67, 69, 94 102, 127 128, 163 sound/acoustical factors for aging people, 446 447 Soups, 340 Sour, 71 cream, 194 195, 201 205 or acidic taste, 79 taste, 94 102, 113 114, 113t Sourness, 79, 134 139 and aging, 79 Southwestern rub, 301 Soy sauce, 190, 373 Special Care Dentistry Association (SCDA), 468 Specialty nut and seed oils, 182 Specific anosmia, 91, 94 102, 151, 165 169 Spices, culinary uses of, 196t

Spinach cord injury or disease (SCI/D), 487 Spinach salad, 363 with chunky garlic dressing, 363 Spiral organ, 94 102 Spirits, 303 304 Spondylitis Association of America (SAA), 486 Spring onions. See Scallions Squeezing, 239 240, 242 245 SRC. See Senior Resource Connect (SRC) SSA. See Social Security Administration (SSA) SSF. See Sjo¨gren’s Syndrome Foundation (SSF) Staph. See Staphylococcus aureus Staphylococcus aureus, 436, 451 452 Starchy taste, 82, 121, 134 139 Stargardt disease, 490 Starters, 340, 359 Steaming, 240, 242 245, 307 308, 334 337 Steatosis, 269, 288 293 Steele-Richardson-Olszewski Syndrome. See Progressive supranuclear palsy Stem cells, 83 Sterols, 328 Stewing, 308, 334 337 STI. See Sexually transmitted infection (STI) Stir-frying, 234, 240, 242 245 Stocks, 302 303, 334 337 Stomatitis, 134 139 Strawberry, banana and almond butter crepes, 392 Strep A bacteria, 94 102 Strep throat, 94 102 Stroke, 19 23, 466 Strong autotelics, 128, 134 139 Structural components, 54 62 Strychnine, 109, 134 139 Substance Abuse and Mental Health Services Administration (SAMHSA), 486 Substance use and abuse, 458 Substituted aromatic substances, 114, 134 139 Suet, 183, 201 205, 334 337 Sugar(ing), 188, 240, 242 245, 257 achieving sweet taste, 186 188 complementing, 188 deciphering, 331t decreasing, 330 in flavor enhancement, 186 189 heightening, 188 189 reducing or mask sweetness, 188 simple, 94 102 fructose, 79 sweet aromas, 189 Sulfhydryl groups, 134 139 Sulfimides, 110, 134 139 Sulfites, 177, 201 205 Sulforaphane, 288 293 Sun stroke, 94 102 Sunnah, 275, 288 293 Superfine sugar, 188 Supertasters, 83 84, 94 102, 109 110, 134 139

511

INDEX

Supplemental Nutrition Assistance Program (SNAP), 486 Suprathreshold concentrations, 175, 201 205 level, 146, 165 169 Surgery, 461 Sweating, 94 102, 241 245 Sweet/sweetening/sweetness, 71, 79 80, 134 139, 186, 240 245 and aging, 80 aromas, 151, 165 169 butter, 187 cream, 194 extracts, 299 in protein foods, 179 and spicy lamb, 373 taste, 79 80, 94 102, 114, 114t, 134 139 Sympathetic nervous system (SNS), 90, 94 102 Synesthesia, 128, 134 139, 163, 165 169 Systemic inflammation. See Chronic inflammation (CI)

T

T1R2 1 3 receptors, 114, 134 139 T1R3 receptors, 114, 134 139 Tableware for accommodated or disabled consumers, 443 444 Tactile cues, 225, 242 245 sensations, 226 228, 227t Tactition, 71, 94 102 Tai Chi, 54 62 Tallow, 183, 201 205, 334 337 Talmud, 275 Target Heart Rate Zone (THRZ), 54 62 Tartrazine, 177, 201 205 TAS1R1 receptors, 115, 134 139 TAS1R3 receptors, 115, 134 139 TAS2R38 gene, 83 84, 94 102 Task lighting, 446 Tastants, 94 102 Taste enhancement techniques, 121 124, 134 139, 223 224. See also Flavor enhancement; Smell-enhancement techniques ingredients, 123 124 taste balances, 123 taste combinations for balance, 121 122 Taste(s), 7, 67, 71, 74 81, 94 102, 134 139, 163 164, 221 224 acidic, 79 and aging, 71, 131 antagonism, 134 139 antagonists, 134 139 augmentation, 126, 134 139 balances, 123 behavioral changes, 132 bitter, 78, 109 taste in depth, 110 111 blindness, 110, 134 139 buds, 71, 75, 82 83, 94 102, 108, 134 139 debated, 81 82 fatty, 81 82

starchy, 82 decline and loss, 130 digest, 133 134 enhancement techniques, 223 224 exercises, 223t fat and proposed tastes, 116 121 and health, 129 highlights, 109, 109t food and beverage tastes, 221 222 juxtaposition, 126, 134 139 loss, 84, 90 91 opposition/antagonism, 125, 134 139 oral disease, 131 132 pathways, 77 78 perceptions across lifecycle, 82 83 pores, 82, 94 102 producing and perceiving, 107 108 receptors, 82, 94 102 cells, 75, 77 salty, 78 79, 112 sense, 107, 132 of sight, sound and touch affect sense of taste, 127 128 of smell affecting sense, 126 127 and smell interactions and affects, 89 91 olfaction, 89 olfactory loss vs. taste loss, 90 91 olfactory pathways, 89 90 types of taste loss, 91 sour, 79, 113 114 strategies for addressing chemosensory changes, 133 supertasters and bitter taste, 109 110 sweet, 79 80, 114 synopsis, 108 temperature and touch, 121 thresholds, 84 85, 94 102, 130, 134 139 training, 222 treatment of taste and smell disorders, 133 umami, 80 81, 115 use of medications, 132 TCA. See 2,4,6-Trichloroanisole (TCA) Tea(s), 196t, 334 337 extracts, 299 Tearing, 70, 94 102 Teeth, 460 461 TEFAP. See The Emergency Food Assistance Program (TEFAP) Temperature, 73, 76, 94 102, 121, 134 139 aging and, 73 of foods and beverages, 225 Tenth cranial nerve (CN X), 94 102 Terpenes, 110, 134 139 Terpenoids, 54 62, 120 Territorial pheromones, 155, 165 169 Tertiary aging, 18 23 Texture, 76, 94 102 modification, 16 olive oils, 183 and trigeminal sense, 7 Texturized soy protein (TSP), 334 337 Texturized vegetable protein (TVP), 334 337 Thalamus, 90, 94 102, 147, 165 169

The Emergency Food Assistance Program (TEFAP), 486 The Joint Commission (TJC), 487 The Living Bank (TLB), 487 “Thermal” tasters, 225 Thermoception, 73 Thermoreception receptors, 94 102 Thermoreceptors, 224 Thiamine, 255 THRZ. See Target Heart Rate Zone (THRZ) Thyme, 420 Tinnitus, 94 102, 214, 242 245, 466 TJC. See The Joint Commission (TJC) TLB. See The Living Bank (TLB) Toasting, 241 245 Tomatoes, 379 products, 190 tomato-carrot relish, 418 Tuscan salad with ricotta, 346 Torah (books for Jewish law and practice), 275, 288 293 Tortellini potage, 358 Touch, 71 72, 76 77, 94 102, 121, 128, 134 139, 164, 226 and aging, 72 touch/textural factors for aging people, 447 TP. See Transmembrane proteins (TP) Traditional and manipulative medicine, 464 Trail pheromones, 155, 165 169 Trans fats, 258, 288 293 Trans fatty acids, 328 Transmembrane proteins (TP), 144, 165 169 Trauma, 466 2,4,6-Trichloroanisole (TCA), 165 169 Trigeminal nerves, 81, 94 102, 134 139 Trigeminal senses, 74, 94 102 Triglycerides, 328 Tropical oils, 328, 334 337 TRPM5, 76, 94 102, 225, 242 245 TSP. See Texturized soy protein (TSP) Tuna, 345 and caper spread with cucumbers, 344 Turkey salad with grapes, 360 Turmeric, 196t, 201 205, 367 TVP. See Texturized vegetable protein (TVP) Tympanic membrane, 69, 94 102, 214 Type 1 diabetes, 266, 288 293 Type 2 diabetes, 266, 288 293

U Ubiquinone. See Coenzyme Q10 UCF. See Urology Care Foundation (UCF) UCSF Memory and Aging Center (MAC), 475 Umami, 71, 181 boosting, 241 in flavor enhancement, 189 192 aromas, 191 192 complementing, 190 191 heightening, 191 reducing or mask, 190 and salt reduction, 191 taste, 80 81, 94 102, 115, 115t, 134 139

512 Umami (Continued) and aging, 81 umami-ing, 242 245 Umaminess, 80 81 Unconscious memory. See Implicit memory Undernutrition, 288 293 Unemployment patterns, 5 Unilateral paresis. See Hemiparesis United Network for Organ Sharing (UNOS), 487 United Ostomy Association of America (UOAA), 487 United Spinal Association (USA), 487 United States (US), 2 aging, 10 17, 17t and chemosensory changes, 15 and chronic diseases, 11 12 and disease, 11 and education, 13 and employment, 13 and ethnic and racial disparities, 12 health, and health care, 14 impacts on nutrition, food science, and culinary perspectives, 15 16 life expectancy, 10 11 by numbers, 10 and nutrition, 14 15 nutrition and culinary arts partnerships for aging, 16 17 and residence, 12 13 and socioeconomic costs, 13 14 Department of Veterans Affairs Veterans Health Administration, 488 Dietary Guidelines for Americans, 54 62 Federal Trade Commission, 488 Great Recession, 19 23 life expectancy, 10 11 Medicare system, 10 United States Department of Agriculture (USDA), 15, 19 23, 32, 35, 54 62, 483, 486 United Way Worldwide (UWW), 487 University of Pennsylvania Smell Identification Test (UPSIT), 146, 159, 165 169 UNOS. See United Network for Organ Sharing (UNOS) Unsaturated fatty acids, 328 UOAA. See United Ostomy Association of America (UOAA) UPSIT. See University of Pennsylvania Smell Identification Test (UPSIT) Urea, 114, 134 139 Uric acid, 288 293 Urinary incontinence, 19 23 Urinary tract diseases, 487 Urology, 466 467 Urology Care Foundation (UCF), 487 US Department of Health and Human Services (US-DHHS), 32, 54 62, 67, 458, 469, 483, 486 487 US Dietary Reference Intakes (DRIs) US Dietary Reference Intakes (DRIs), 35 36, 38 42, 44 45, 54 62, 251, 251t, 262

INDEX

US Federal Bureau of Investigation (FBI), 488 Fraud Warnings for Seniors, 488 US Food and Drug Administration (FDA), 484, 488 FDA Food Code (3 603.11), 426, 428 US Food Safety and Inspection Service (FSIS), 488 US Health Resources and Services Administration (HRSA), 488 US-DHHS. See US Department of Health and Human Services (US-DHHS) USA. See United Spinal Association (USA) USDA. See United States Department of Agriculture (USDA) UWW. See United Way Worldwide (UWW)

V VA. See Volatile acidity (VA) Vagus nerve, 94 102, 157, 165 169 vagus nerve X, 90 91 Vanilla extract, 381 Vascular dementia, 94 102 VC. See Vital capacity (VC) VEDA. See Vestibular Disorders Association (VEDA) Vegan diets, 285 286, 288 293 Vegetable(s), 41 coulis, 299 oils, 328 in pea family, 187 188 purees, 196t vegetable-based oils, 299 300 Vegetarian diets, 285 286, 288 293 Verjuice, 233, 242 245 Vertigo, 72 Vestibular Disorders Association (VEDA), 489 Vestibular nerve, 94 102 Vestibular schwannoma. See Acoustic neuroma Vestibular sense. See Balance sense Vestibular system, 69, 94 102 Vibrio, 436, 451 452 Vinaigrette, 422 Vinegar(s), 196t, 303, 334 337 infusions, 300 Viral hepatitis, 94 102 Viral infections, 94 102 Visceral body organ, 73, 94 102 Visceral receptor, 94 102 Viscerosensor-sensory cues, 120, 134 139 Vision, 94 102, 210 213, 471 and aging, 210 colors, 211, 211t enhancement, 211 and food choices, 210 211 food arrangements, 212 combinations, 212 focus, 212 portions, 213, 213t shapes, 212 textures, 212 plate garnishes, 213

plate presentations, 212 visual appearance, 211 Visiting Nurse Association of America (VNAA), 489 Visual memory, 69 70, 94 102 Visual overload, techniques to avoiding, 444 445 Vital capacity (VC), 54 62 Vitamin C. See Ascorbic acid Vitamin(s), 27, 253. See also Minerals for aging diets, 44 49 25-hydroxy vitamin D, 279, 288 293 vitamin A, 28, 44 45, 45t, 54 62, 378 for bones, 255 precursors or provitamins, 54 62 vitamin B1 for brain, 255 vitamin B6, 48, 48t vitamin B12, 48 49, 49t vitamin D, 46, 46t for bones, 255 content of mushrooms, 354 vitamin D2, 46 vitamin D3, 46 vitamin E, 46 47, 47t, 255, 378 vitamin K, 47, 48t vitamin K1, 47 vitamin K2, 47 vitamins C, 28, 378 VNAA. See Visiting Nurse Association of America (VNAA) VO2 max, 54 62 Voice-activated devices, 444 Volatile acidity (VA), 179, 201 205 Volatizing, 229, 242 245

W Walk With Ease, 54 Walnuts, 382 Water, 50 51, 254 infusions, 300 Water pills. See Diuretics Weight gain, 31, 54 62, 286 287 Weight loss, 30, 54 62, 286 287 smell and, 157 Weill Institute for Neurosciences, 475 Well Spouse Foundation (WSF), 489 Well-balanced diet, 27, 255 Wernicke’s Encephalopathy. See Wernicke Korsakoff Syndrome (WKS) Wernicke Korsakoff Syndrome (WKS), 94 102, 255, 288 293 Wesson Wilson discovery of olfactoryauditory integration, 163 Wet aging, 233, 242 245 Wet rubs, 301 Wheat allergy, 262, 288 293 Whipped cream, 187 White pepper, 352 White stock, 302 303, 334 337 WHO. See World Health Organization (WHO) Whole-grain French toast with pears, 411 Wine, 179, 196t, 303 304, 360

513

INDEX

consumption, 258 Winter squash, 381 WKS. See Wernicke Korsakoff Syndrome (WKS) Wood spider. See Harpagophytum procumbens Woody/resinous aromas, 151, 165 169 Worcestershire sauce, 190 World Health Assembly, 7 World Health Organization (WHO), 6, 19 23

World population, 3 WSF. See Well Spouse Foundation (WSF)

X Xerophthalmia, 45, 54 62 Xerostomia, 130, 278, 288 293

Y Yoga, 54 62

Yogurt, 195, 201 205

Z Zeaxanthin, 28, 47, 54 62 Zinc, 28, 43, 43t Zinc acetate, 119, 134 139 Zingerone, 134 139 Zucchini with Yogurt Basil sauce, 385