The Active Female: Health Issues Throughout the Lifespan 2008th Edition

32. Nutritional Guidelines, Energy Balance, and Weight Control: Issues for the Aging Active Female

Jacalyn J. Robert-McComb Natalia E. Bustamante-Ara  and José E. Almaraz Marroquin 


Department of Health, Exercise, and Sports Sciences, Texas Tech University, Lubbock, TX, USA


Physical Activity and Sport, Department of Physical Activity and Health, Nengn Company, Maipú, Santiago, Chile


Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Gran Canaria, Spain

Jacalyn J. Robert-McComb (Corresponding author)


Natalia E. Bustamante-Ara


José E. Almaraz Marroquin



During aging total energy expenditure (TEE) decreases by 6 % per decade in women, parallel to the reduction in physical activity. Resting metabolic rate (RMR) decreases 1–2 % per decade and increases from 50 years (3 % per decade). There is a change in body composition not associated with the reduction in RMR or loss of fat-free mass (FFM). This change in body composition produces an increase in fat mass, and it is higher in women than in men. The change in body composition does not always imply a change in body weight (or body mass index). As the caloric intake requirements decrease with aging, the right quality of food and adequate portions become more important. Energy imbalances complicate health and quality of life in both malnutrition and overweight. The 7th edition of the Dietary Guidelines for the USA published in 2010 and incorporating MyPlate in 2011 are available resources to advise people and help improve nutrition, serving as a guide for adults and older active women also. Adequate calorie intakes should be matched to physical activity level in each, providing the required amount of macronutrients, vitamins, and minerals, and possible food supplements for active women to achieve proper weight control, energy balance, and heath.


Total energy expenditurePhysical activityWomenCaloric intake

32.1 Learning Objectives

After completing this chapter, you should have an understanding of:

·               Energy balance and weight control.

·               Dietary guidelines for the mature woman.

·               Important nutrients, vitamins, and minerals for physically active women;

32.2 Introduction

The nutritional needs of an aging population require special attention. Energy expenditure declines with age; thus, to achieve energy balance, less energy needs to be consumed. The reduction in energy intake can have adverse effects on the nutritional status of older people unless high nutritional quality foods are eaten [1]. Worldwide, micronutrient status of women is inadequate for several micronutrients. The rationale for micronutrient adequacy in the individual woman has been well defined for many micronutrients such as iron, calcium, iodine, folate, and vitamins A and D. However, for older women, especially those living beyond their eighties, more research about nutritional requirements is needed. Important micronutrients for the aging are discussed in this chapter as well as the dietary guidelines for the mature woman.

The decline in energy intake associated with aging also increases risk frailty and mortality [2] in people with low body mass index (BMI). However, obesity is now common in older women. Obesity is also associated with an increase in the prevalence of disability. Conversely, weight loss in overweight older women has been associated with increases in quality of life. Issues in energy balance and weight control are also highlighted in this chapter.

The Food and Nutrition Information Center (FNIC) is a leader in online global nutrition information. It is located at the National Agricultural Library (NAL) of the United States Department of Agricultural (USDA). The FNIC Web site contains over 2,500 links to current and reliable nutrition information. The FNIC provides links to the Dietary Reference Intakes (DRI) tables and reports discussed in this chapter. These tables and reports have been developed by the Institute of Medicine’s Food and Nutrition Board. Appendices 1 and 2 contain a list of the valuable information that you can assess at http://​fnic.​nal.​usda.​gov/​dietary-guidance.

32.3 Research Findings

32.3.1 Energy Balance and Weight Control

Generally, positive energy balance leads to weight gain and negative balance to weight loss. Changes in body composition are due to alterations in energy balance; however, this is not as simple as it seems. The aging process brings about many changes in body composition, often without concomitant changes in body weight and BMI. In the aging, body fat percentage (BF%) increases and leans body mass (LBM) and bone mineral density (BMD) decrease. The increase in fat mass (FM) is distributed more specifically in the abdominal region, an area associated with cardiovascular disease and diabetes [3]. Additionally, there is a difference in FM and body fat distribution between the sexes. Women are more efficient in conserving and storing energy as fat. It is also known that postmenopausal women experience an increase in the waist-to-hip ratio [4]. Women lose less fat-free mass (FFM) compared with men with similar weight loss (27.3 % vs. 25.4 % men and women respectively). Supporting this notion is the recognition that women must reduce their dietary intake by a higher proportion to achieve the same degree of weight loss as men [4].

Following the age of 40 years, total energy expenditure (TEE) begins to decline quite dramatically. Women 75 years old or more experience TEE levels similar to a 7–11 year old, despite having greater body mass. In order to fully understand TEE, some definitions need to be clarified using a single authoritative source [5]. In the research literature, terms are sometimes expressed with slight variations.

·               The basal metabolic rate (BMR) describes the rate of energy expenditure that occurs in the postabsorptive state

·               The BMR is commonly extrapolated to 24 h to be more meaningful, and it is then referred to as basal energy expenditure (BEE), expressed as kcal/24 h.

·               Resting metabolic rate (RMR), energy expenditure under resting conditions, tends to be somewhat higher (10–20 %) than under basal conditions due to increases in energy expenditure caused by recent food intake (i.e., by the “thermic effect of food”) or by the delayed effect of recently completed physical activity.

·               Resting energy expenditure (REE) is RMR extrapolated to 24 h.

·               The thermic effect of food (TEF) was originally known as the Specific

Dynamic Action (SDA) of food. The intensity and duration of meal-induced TEF is determined primarily by the amount and composition of the foods consumed and the associated metabolic costs.

·               The physical activity level of index (PAL) is a way to express a person’s daily physical activity as a number, and is used to estimate a person’s TEE. The PAL is defined for a nonpregnant, non-lactatingadult as that person’s TEE in a 24-h period, divided by his or her BEE or PAL = TEE/BEE.

·               The physical activity coefficient (PA) is used in the formula found in Table 32.3 to determine estimated energy requirements (EER)where PA for girls 3–18 years old is as follows:

·                                   PA = 1.00 if PAL is estimated to be ≥1.0 < 1.4 (sedentary);

·                                   PA = 1.16 if PAL is estimated to be ≥1.4 < 1.6 (low active);

·                                   PA = 1.31 if PAL is estimated to be ≥1.6 < 1.9 (active);

·                                   PA = 1.56 if PAL is estimated to be ≥1.9 < 2.5 (very active).

·               The physical activity coefficient (PA) is used in the formula found in Table 32.3 to determine estimated energy requirements (EER)where PA for women 19+ years is as follows:

·                                   PA = 1.00 if PAL is estimated to be ≥1.0 < 1.4 (sedentary)

·                                   PA = 1.12 if PAL is estimated to be ≥1.4 < 1.6 (low active)

·                                   PA = 1.27 if PAL is estimated to be ≥1.6 < 1.9 (active)

·                                   PA = 1.45 if PAL is estimated to be ≥1.9 < 2.5 (very active)

·               TEE is the sum of BEE, which includes a small component associated with arousal, as compared to sleeping, the TEF, physical activity, thermoregulation, and the energy expended in depositing new tissues and in producing milk.

·               The estimated energy requirement (EER) is the average dietary energy intake that is predicted to maintain energy balance in a healthy adult of a defined age, gender, weight, height, and level of physical activity consistent with good health. In children and pregnant and lactating women, the EER is taken to include the needs associated with the deposition of tissues or the secretion of milk at rates consistent with good health.

Thus, it is important to distinguish between BMR and RMR. Because RMR is much easier to measure than BMR, RMR is frequently seen in the literature as a component of TEE. TEE is thus comprised of RMR, the TEF, and activity energy expenditure (AEE) [6]. Activity energy expenditure (AEE) is the modifiable component of TEE derived from all activities, both volitional and nonvolitional. Thus, TEE (kcal/day) =RMR + AEE + TEF [7].

With increasing age, TEE decreases for both RMR and AEE. This decrease in TEE with age is associated with reductions in body mass and FFM [6]. TEE decreases 6 % per decade for women, as a result of decreases in physical activity energy expenditure [8]. TEE remains higher for men than for women. However, when adjusted for FMM, TEE is higher for women than for men [9].

RMR is one of the largest components of TEE, comprising 50–80 %, and it has previously been estimated to decline 1–2 % per decade after 20 year. This decline in RMR with age may not be linear, breakpoint decline quickly becomes apparent around 50 years in women; this may be due to an accelerated loss of FFM during menopause [1011]. Recently, longitudinal studies indicated 3 % reductions in RMR per decade in women respectively, and the rate of decline in RMR was faster at age 70–80 years than at age 40–50 years [8].

Aging is associated with a decrease in almost all components of the equation: ↓RMR (change in FM and FFM), AEE (change in activity level), as well as energy intake. Yet, it remains unclear what factor initiates the change. The TEF contributes <10 % to TEE and does not decline with aging per se [11]. In many circumstances, aging and diseases might contribute to a decrease or increase in RMR [6]. The lower RMR of older adults may be due in part to slowed organ metabolic rates, and this may contribute to changes in FM, FFM, and fat distribution [12]. This could also be due, for example, to morphological changes like infiltration of the organs with fat, edema, or cystic structures [13] and change in fat oxidation. However, the decline in RMR is not entirely due to changes in body composition [3].

Older women maintain lower levels of AEE than men (576 kcal/day vs. 769 kcal/day) until the seventh decade of their life (seventies). During their seventies older women have similar physical activity levels (PAL) as men [14]. Older women may ameliorate the age related decrease in RMR, through increased physical activity to preserve body composition. There is a strong association [10] between physical activity levels and FFM [67].

The use of a measure or an estimate of TEE to validate instruments that measure food intake is dependent on the principle of energy balance. That is, in weight-stable adults, energy intake must equal TEE. In a balanced state, TEE corresponds to EER.

Recommendations for caloric intake to maintain weight will vary depending on a person’s age, sex, size, and level of physical activity. Specific equations for estimating caloric needs are provided in the Dietary Reference Intakes for Energy Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids [5]. These reports can be found in the USDA’s NAL and can be downloaded free of charge in a PDF file (http://​fnic.​nal.​usda.​gov/​dietary-guidance/​dietary-reference-intakes/​dri-reports). Web pages change with time, if the page is no longer available, type in DRI reports in the search box at http://​fnic.​nal.​usda.​gov/​.

The most accurate way to assess TEE is through the doubly labeled water technique (DLW). The DLW technique is considered the gold standard measure of free-living activity expenditure in conjunction with direct calorimetric for measurement of RMR. However, this method is expensive and impractical in many healthcare settings, and therefore predictive equations are used to estimate RMR in most clinical and inpatient care practices.

The Mifflin–St Jeor equation is more likely than other equations to estimate RMR within 10 % of the measured [15] and is estimated from weight, height, and age. Multiple-regression analyses were employed to drive relationships between RMR and weight, height, and age for both sexes (R 2 = 0.71) but separation by sex did not affect its predictive value.

RMR = 9.99 × weight (kg) + 6.25 × height (cm) − 4.92 × age (year) + 166 × sex (males, 1; females, 0) − 161 [16]. This equation has also been validated in obese population [17]. Table 32.1 details the process to estimate total caloric needs depending on activity level using the Mifflin–St Jeor multiple regression equation to estimate RMR. For example, if a person’s RMR was 1,000 and they were doing heavy activity, you would multiply 1,000 times the percentage above rest 100 % or 1.00 and add that value to their estimated RMR, 1,000 (RMR) + 1,000(1,000 × 1 for additional calories above rest) = 2,000. This value would be their estimated energy expenditure in kcal/day using the method presented in Table 32.1.

Table 32.1

An estimated energy expenditure prediction equation using the Mifflin–St Jeor equation to determine resting metabolic rate

Step 1Estimate resting metabolic rate (RMRusing the Mifflin–St Jeor equation

RMR = 9.99 × weight (kg) + 6.25 × height (cm) − 4.92 × age (year) + 166 × sex (males, 1; females, 0) − 161.

Step 2Determine additional caloric requirements based on level of activity

Physical activity level

Percentage above resting level

Bed rest


Quiet rest


Light activity


Moderate activity


Heavy activity


Additional caloric requirements = RMR × Percentage above resting level

Step 3Determine predicted total energy expenditure (TEE)

TEE = RMR + Additional caloric requirements based on activity

TEE = predicted energy expenditure in kcal/day

Adapted from Physiology of Fitness (3rd ed.) (p. 359) by B. J. Sharkey, 1990, Champaign, IL: Human Kinetics

The PAL can be used as an indirect index of physical activity and is useful in recommending energy intakes based on RMR and a PAL value [18]. In this instance, PAL is calculated as TEE/RMR [14] The PAL value establishes the difference between a sedentary and a very active person (the greater the value, the greater level of activity) [14]. The PAL value establishes categories for PA coefficient defined as: sedentary = 1.0; low active = 1.12; active = 1.27; and 1.45 very active for adult women >19 years and older [519].

The EER of mature persons using their PAL (as multiples of RMR), provides a convenient and practical way of controlling for age, sex, body weight and body composition, and the energy intake needs of a wide range of people in a quick way [20].

A Report of the Panel on Macronutrients, Subcommittees on Upper Reference Levels of Nutrients and Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference [5] provides equations for calculating EER based on sex, age, height, weight, and PA coefficient. The equation for adult women >19 years and older is as follows:

EER = 354 − (6.91 × AGE) + PA × (9.36 × WT + 726 × HT).

TEE measured from DLW and the equations in the referenced report [5] were highly correlated.

Tables 32.2 and 32.3 contain the information to calculate EER using PA coefficient, weight, sex, age, and height for female infants, girls and women. The equations were validated in terms of their intended use to estimate EER for healthy individuals but the equations were not validated for use in nutritional epidemiology or surveillance studies [9].

Table 32.2

Physical activity level index (PAL) and physical activity coefficient (PA) used to derive estimated energy requirements (EER) for women



Low active


Very active






Typical daily living activities (e.g., household tasks, walking to the bus)

Typical daily living activities PLUS 30–60 min of daily moderate activities (e.g., walking at 5–7 km/h)

Typical daily living activities PLUS at least 60 min of daily moderate activities

Typical daily living activities PLUS at least 60 min of daily moderate activities an additional 60 min of vigorous activity or 120 min of moderate activity


PA (level 1)

PA (level 2)

PA (level 3)

PA (level 4)

Girls 3–18 year





Women 19 year+





Adapted from A Report of the Panel on Macronutrients, Subcommittees on Upper Reference Levels of Nutrients and Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes for energy carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington DC: National Academy Press; 2005

Complete report can be viewed and downloaded at http://​fnic.​nal.​usda.​gov/​dietary-guidance/​dietary-reference-intakes/​dri-reports

PAL = Physical activity level or physical activity index

PA = Physical activity coefficient

Table 32.3

Equations to estimate energy requirement

Infants and young children

Estimated energy requirement (kcal/day) = Total energy expenditure + Energy deposition

0–3 months

EER = (89 × weight [kg] − 100) + 175

4–6 months

EER = (89 × weight [kg] − 100) + 56

7–12 months

EER = (89 × weight [kg] − 100) + 22

13–35 months

EER = (89 × weight [kg] − 100) + 20

Children and adolescents 3–18 years

Estimated energy requirement (kcal/day) = Total energy expenditure + Energy deposition


  3–8 years

EER = 135.3 − (30.8 × age [year]) + PA × [(10.0 × weight [kg]) + (934 × height [m])] + 20

  9–18 years

EER = 135.3 − (30.8 × age [year]) + PA × [(10.0 × weight [kg]) + (934 × height [m])] + 25

Adults 19 years and older

Estimated energy requirement (kcal/day) = Total energy expenditure


EER = 354 − (6.91 × age [year]) + PA × [(9.36 × weight [kg]) + (726 × height [m])]


Estimated Energy Requirement (kcal/day) = Nonpregnant EER + Pregnancy Energy Deposition

  First trimester

EER = Nonpregnant EER + 0

  Second trimester

EER = Nonpregnant EER + 340

  Third trimester

EER = Nonpregnant EER + 452


Estimated energy requirement (kcal/day) = Nonpregnant EER + Milk energy output − Weight loss

  0–6 months postpartum

EER = Nonpregnant EER + 500 − 170

  7–12 months postpartum

EER = Nonpregnant EER + 400 − 0

Note: These equations provide an estimate of energy requirement. Relative body weight (i.e., loss, stable, gain) is the preferred indicator of energy adequacy

Note: See Table 32.2 to find the appropriate PA value to use in these equations

Adapted from: A Report of the Panel on Macronutrients, Subcommittees on Upper Reference Levels of Nutrients and Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes for energy carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids (macronutrients). Washington DC: National Academy Press; 2005

Complete report can be viewed and downloaded at http://​fnic.​nal.​usda.​gov/​dietary-guidance/​dietary-reference-intakes/​dri-reports

EER = Estimated Energy Requirement

PA = Physical Activity Coefficient

32.4 Contemporary Understanding of the Issues

32.4.1 Dietary Guidelines for the Mature Woman

The aim of food-based dietary guidelines is to reduce chronic malnutrition, micronutrient malnutrition, and diet-related communicable and non-communicable diseases. Food-based dietary guidelines allow the principles of nutrition education to be expressed, qualitatively and quantitatively [1]. The Dietary Guidelines of Americans is published jointly every 5 years by the Department of Health and Human Services (HHS) and the USDA. The 2010 Dietary Guidelines for Americans, 2010 [21] was released January 31, 2011 and can be downloaded at:


The Dietary Guidelines for Americans, 2010 focuses on three major goals for Americans.

·               Balance your intake of calories with physical activity to manage weight.

·               Increase your intake of certain foods and nutrients such as fruits, vegetables, whole grains, fat-free and low-fat dairy products, and seafood.

·               Decrease your intake of foods with sodium (salt), saturated fats, trans fats, cholesterol, added sugars, and refined grains.

Furthermore, the Dietary Guidelines for Americans, 2010 include 23 key recommendations for the general population and six additional key recommendations for specific population groups [21]. According to research, the diet quality of Americans age 65 and older did not significantly improve in the past decade. To improve diet quality, the USDA suggests that older Americans need to increase their intakes of whole grains, dark green and orange vegetables, legumes, and milk. They also need to choose more nutrient-dense forms of foods. These changes, if made, would provide substantial health benefits [22]. The intention of the new dietary recommendations is to stimulate people to make more thoughtful choices: Choices that will reflect healthier foods and portion sizes that are appropriate for their caloric needs. It is also hoped that the physical activity of Americans is increased along with the healthier food choices, thereby reducing the risk of developing diet-related chronic disease [23].

The nutrition information found in the seventh edition of the Dietary Guidelines for Americans, 2010 (http://​www.​cnpp.​usda.​gov/​)will help the aging woman choose nutrient dense foods for an adequate diet [21]. Appendix 3displays the USDA food groups and recommended sub-groups to select in your diet. Appendix 4 outlines the USDA’s healthy choices for a desired caloric intake. The patterns of behaviors correlated with a healthy body weight are as follows:

·               focus on the total number of calories consumed;

·               monitor food intake;

·               when eating out, choose smaller portions or lower-caloric options;

·               prepare, serve, and consume smaller portions of foods and beverages, especially those high in calories;

·               eat a nutrient-dense breakfast; and

·               limit screen time

The total numbers of calories a person needs each day varies depending on a number of factors. These factors include: age, weight, gender, height, and level of physical activity. Generally one of the significant age-associated changes is that the need for energy decreases [24]. In order to maintain, lose or gain weight, the caloric needs of an individual should be known. However, even when caloric needs are known, many women find it impossible to lose weight or maintain a healthy weight after weight loss. A growing body of research has begun to describe overall eating patterns that help promote caloric balance and weight management. One researched aspect of these eating patterns is the concept of energy density, or the amount of calories provided per unit of food weight [25].

Energy density (ED) is the amount of energy per weight of food or beverage (kilojoules/g [kJ/g] or kilocalories/gram [kcal/g]). Foods high in water and/or fiber are lower in ED, while foods high in fat are higher in ED, increasing calorie intakes. The 2010 Dietary Guidelines Advisory Committee (DGAC) indicated that there is strong and consistent evidence in adults that a decrease in dietary ED improves weight loss and weight maintenance. Choosing foods that have a lower ED may also be associated with a lower risk of type 2 diabetes in adults [25].

Weight gains following menopause may be an indicator of relapses in weight reduction. More than 50 % of women in the menopausal period attempt to restrict their calories in an attempt to lose weight; however, they are unsuccessful at weight loss maintenance. Peak body weight gain is observed around age 50 [26].

From a clinical point of view, this fact is of great interest. Diets that are reduced in calories must also have macronutrient proportions that are within the ranges recommended in the Dietary References Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Proteins, and Amino Acids (protein: 10–35 %; carbohydrate: 45–65 %; fat: 20–35 %) [5]. Furthermore ED is also an important component of choosing the right food combinations that helps you lose weight and maintain the weight loss [25]. Nutritional goals for female 31–50 and +50 years based on dietary reference intakes and dietary guidelines recommendations are presented in Table 32.4.

Table 32.4

Nutritional goals for female groups and age, based on dietary reference intakes and dietary guidelines recommendations

Nutrient (units)

Female 31–50

Female 51+

Source of goala




46 g

46 g



10–35 %

10–35 %



130 g

130 g



45–65 %

45–65 %


Total fiber

25 g

22 g


Total fat (calories)

20–35 %

20–35 %


 Saturated fat (calories)

<10 %

<10 %


 Linoleic acid

12 g

11 g



5–10 %

5–10 %


 Alpha-Linolenic acid

1.1 g

1.1 g



0.6–1.2 %

0.6–1.2 %



<300 mg

<300 mg


Sources: Britten P, Marcoe K, Yamini S, Davis C. Development of food intake patterns for the MyPyramid Food Guidance System. J Nutr Educ Behav 2006;38(6Suppl):S78–S92

 IOM. Dietary Reference Intakes: The essential guide to nutrient requirements. Washington (DC): The National Academies Press; 2006

 IOM. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): The National Academies Press; 2010. Revised Page 76, 77 pdf found at http://​www.​cnpp.​usda.​gov/​Publications/​DietaryGuideline​s/​2010/​PolicyDoc/​PolicyDoc.​pdf

 Complete report can be viewed and downloaded at http://​www.​cnpp.​usda.​gov

aDietary guidelines recommendations are used when no quantitative Dietary Reference Intake value is available; apply to ages 2 years and older

bRecommended dietary allowance, IOM

cAcceptable macronutrient distribution range, IOM

d14 g per 1,000 cal, IOM

eDietary guidelines recommendation

fAdequate intake, IOM

Recently, in June 2011, MyPlate replaced MyPyramid, a new initiative designed to make healthy food choices more attractive to the consumer. MyPlate illustrates five food groups in their design with bold colors [2327]. The USDA provides a Web site in which a food plan can be customized, at (http://​www.​ChooseMyPlate.​gov/​). This Web site helps consumers choose a healthy personal eating plan. Physical activity is also emphasized based on the recommendations of the American College of Sports Medicine (ACSM) [28].

Topics such as what is physical activitywhy is physical activity importanthow much physical activity do I need can be answered on this site.

Solid fats are abundant in the diets of Americans and contribute significantly to excess caloric intake and weight gain. A fat intake recommendation for older women is: 20–35 % of total daily calories. These ranges are associated with reduced risk of chronic diseases, such as cardiovascular disease, while providing for adequate intake of essential nutrients. The recommendation is to keep trans fatty acid consumption as low as possible, especially by limiting foods that contain synthetic sources of trans fats, such as partially hydrogenated oils, and by limiting other solid fats. All individuals, not just older women, should consume less than 10 % of their daily calories from saturated fatty acids. Saturated fatty acids should be replaced with monounsaturated and polyunsaturated fatty acids [21].

Among the significant age-associated changes in nutrient requirements is that the need for protein increases with age [24]. Protein requirements of older adults may be higher than the current recommended level of 0.8 g/kg/day. Despite an estimated increase in mean protein requirements for older adults, a recent study indicated that there is no difference between the young and old when the protein requirements are expressed per kilogram FFM. The recommended level is now 0.85 g/kg/day for both the young and old adult [29].

There are a wide variety of recommendations about the specific value of protein requirements; however, the data is non-conclusive with regard to the best recommendation. Nevertheless, dairy products digest quickly and have high biological levels of protein that contain essential amino acids (meaning that the human body cannot synthesize it, and it therefore must be ingested) such as leucine. Milk, a good source of high biological value protein, is particularly rich in essential and branched-chain amino acids. Protein metabolites, such as small peptides, have been shown to have bioactive properties [30]. Bioactive describes something that can have an effect on living tissue, such as the effect of the sun rays on the skin.

In the USA, total consumption of sugar has increased substantially in recent decades [31]. The obesity epidemic has focused attention on the relationship of sugars and sugar-sweetened beverages (SSB)—particularly glucose, sucrose, and fructose, e.g., as high-fructose corn syrup [32]. Higher consumption of carbohydrates have been associated with dyslipidemia, a lipid profile known to increase cardiovascular disease risk including lower HDL-C levels, higher triglyceride levels, and higher ratios of triglycerides to HDL-C. The consumption of large amounts of added sugars, a prominent source of low-nutrient calories, is a relatively new phenomenon. For mature women it is advised to limit their added sugars to fewer than 100 cal daily (approximately 5 % of total energy intake) [31].

Daily sodium intake should be reduced to less than 2,300 mg. Adults 51 years of age or more should further reduce their intake to 1,500 mg. Adults of any age who are African American or have hypertension, diabetes, or chronic kidney disease should also reduce their intake of sodium to 1,500 mg. The 1,500 mg recommendation applies to about half of the US population [21].

Since hypertension is a major public health problem affecting millions of adult women, the Dietary Approach to Stop Hypertension (DASH) diet has been created. This diet plan, DASH, is designed to: reduce the intake of saturated fat, total fat, sodium, and cholesterol; to increase the intake of fruits and vegetables; and to increase the consumption of potassium, calcium, magnesium, fiber, and protein. Adherence to DASH is a key component to controlling blood pressure [33]. Table 32.5 compares the usual US intake, the recommended DASH intake, and the USDA food patterns adjusted to a 2,000 cal level. Table 32.6 presents three different caloric intakes according to the DASH eating plan.

Table 32.5

Pattern comparison: Usual US intake, DASH, and USDA food Patterns, average daily intake at or adjusted to a 2,000 cal level


Usual US intake adultsa


USDA food pattern

Food groups



1.6 cups

2.1 cups

2.5 cups

Fruit and juices

1.0 cups

2.5 cups

2.0 cups


6.4 oz

7.3 oz

6.0 oz

 Whole grains

0.6 oz

3.9 oz

≥ 3.0 oz

Milk and milk products (dairy products)

1.5 cups

2.6 cups

3.0 cups

Protein foods



2.5 oz

1.4 oz

1.8 oz


1.2 oz

1.7 oz

1.5 oz


0.5 oz

1.4 oz

1.2 oz

Nuts, seeds, and soy products

0.5 oz

0.9 oz

0.6 oz


18 g

25 g

27 g

Solid fats

43 g


16 gc

Added sugars

79 g

12 g

32 gc


9.9 g



Complete report can be viewed and downloaded at http://​www.​cnpp.​usda.​gov/​

a Source: US Department of Agriculture, Agricultural Research Service and US Department of Health and Human Services, Centers for Disease Control and Prevention. What We Eat In America, NHANES 2001–2004, 1 day mean intakes for adult males and females, adjusted to 2,000 cal and averaged

bSee the DGAC report for additional information and references at www.​dietaryguideline​s.​gov

cAmounts of solid fats and added sugars are examples only of how calories from solid fats and added sugars in the USDA Food Patterns could be divided

dnd = Not determined

eIn the USDA Food Patterns, some of the calories assigned to limits for solid fats and added sugars may be used for alcohol consumption instead

Table 32.6

The DASH eating plan at various calorie levels. The number of daily servings in a food group varies depending on caloric needsa





Serving sizes

Food groupsb






1 cup raw leafy vegetable, ½ cup cut-up raw or cooked vegetable, ½ cup vegetable juice

Fruit and juices




1 medium fruit, ¼ cup dried fruit ½ cup fresh, frozen, or canned fruit, ½ cup fruit juice





1 slice bread 1 oz dry cerealc ½ cup cooked rice, pasta, or cerealc

Fat-free or low-fat milk and milk products




1 cup milk or yogurt, 1½ oz cheese

Lean meats, poultry, and fish

3–4 or less

6 or less

6 or less

1 oz cooked meats, poultry, or fish, 1 egg

Nuts, seeds, and legumes

3–4 per week

4 per week

4–5 per week

1/3 cup or 1½ oz nuts, 2 Tbsp peanut butter, 2 Tbsp or ½ oz seeds, ½ cup cooked legumes (dried beans, peas)

Fats and oils




1 tsp soft margarine, 1 tsp vegetable oil, 1 Tbsp mayonnaise, 1 Tbsp salad dressing

Sweets and added sugars

3 or less per week

5 or less per week

5 or less per week

1 Tbsp sugar, 1 Tbsp jelly or jam, ½ cup sorbet, gelatin dessert,1 cup lemonade

Maximum sodium limite

2,300 mg/day

2,300 mg/day

2,300 mg/day


Source: USDA and HHS, US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington, DC: Complete report can be viewed and downloaded at http://​www.​cnpp.​usda.​gov/​

aThe DASH eating Patterns from 1,600 to 3,100 cal meet the nutritional needs of children 9 years and older and adults

bSignificance to DASH Eating Plan, selection notes, and examples of foods in each food group

Grains: Major sources of energy and fiber. Whole grains are recommended for most grain servings as a good source of fiber and nutrients. Examples: Whole-wheat bread and rolls; whole-wheat pasta, English muffin, pita bread, bagel, cereals; grits, oatmeal, brown rice; unsalted pretzels and popcorn

Vegetables: Rich sources of potassium, magnesium, and fiber. Examples: Broccoli, carrots, collards, green beans, green peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes

Fruits: Important sources of potassium, magnesium, and fiber. Examples: Apples, apricots, bananas, dates, grapes, oranges, grapefruit, grapefruit juice, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines

Fat-free or low-fat milk and milk products: Major sources of calcium and protein. Examples: Fat-free milk or buttermilk; fat-free, low-fat, or reduced-fat cheese; fat-free/low-fat regular or frozen yogurt

Lean meatspoultryand fish: Rich sources of protein and magnesium. Select only lean; trim away visible fats; broil, roast, or poach; remove skin from poultry. Since eggs are high in cholesterol, limit egg yolk intake to no more than 4 per week; 2 egg whites have the same protein content as 1 oz meat

Nuts, seeds, and legumes: Rich sources of energy, magnesium, protein, and fiber. Examples: Almonds, filberts, mixed nuts, peanuts, walnuts, sunflower seeds, peanut butter, kidney beans, lentils, split peas

Fats and oils: DASH study had 27 % of calories as fat, including fat in or added to foods. Fat content changes serving amount for fats and oils. For example, 1 Tbsp regular salad dressing = one serving; 2 Tbsp low-fat dressing = one serving; 1 Tbsp fat-free dressing = zero servings. Examples: Soft margarine, vegetable oil (canola, corn, olive, safflower), low-fat mayonnaise, light salad dressing

Sweets and added sugars: Sweets should be low in fat. Examples: Fruit-flavored gelatin, fruit punch, hard candy, jelly, maple syrup, sorbet and ices, sugar

cServing sizes vary between ½ cup and 1¼ cups, depending on cereal type. Check product’s Nutrition Facts label

eThe DASH Eating Plan consists of patterns with a sodium limit of 2,300 and 1,500 mg/day

Adverse Blood Pressure (BP)—prevalent worldwide—is an independent major risk factor for cardiovascular diseases (CVD). Established modifiable risk factors for elevated BP are high sodium intake, inadequate potassium intake, high body mass index (BMI), and excessive alcohol intake [32]. Sodium and potassium have opposing effects on arterial vasodilation [30].

32.4.2 Important Nutrients, Vitamins, and Minerals For Physically Active Women

The micronutrient and macronutrient needs of individuals, men and women alike, who are physically active, has always been a subject of debate. The intensity, duration, and frequency of the physical activity as well as the overall nutrient intake of the individual have an impact on whether or not micronutrients and macronutrients are required in greater amounts. The Dietary Reference Intakes (DRIs) for macronutrients, vitamins, and minerals for females of all ages, regardless of level of physical activity, as established by the Food and Nutrition Board, Institute of Medicine, and National Academies can be found in the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) [5]. The report is referenced in Appendix 2 and can be downloaded at http://​fnic.​nal.​usda.​gov/​dietary-guidance/​dietary-reference-intakes/​dri-reports. There is no charge for the PDF download.

Generally, the vitamin and minerals needs of active individuals are not greater than those who are not active, if the DRIs are being met. However, it has been shown that frequently women, of all ages, do not meet their nutrient needs through diet alone, and therefore supplementation may be necessary. Older adults are at even greater risk for nutritional deficiencies than are younger adults due to physiologic changes associated with aging. Therefore, it is recommended that individuals 50 years and older consume food fortified cereals, or dietary supplements [21]. Nonetheless, mega dosing with one vitamin and/or mineral can impair the functions of other vitamins and minerals.

The DRIs suggest dietary carbohydrate should be in the range of 45–65 % of total calories. Using the recommendations of 5–7 g/kg/day for general training needs, a 54.4 kg (120 lb) woman would need roughly 272–380 g of carbohydrate. The typical US diet provides 4–5 g/kg/day, and athletes who train daily and compete at high intensity need more carbohydrate [34]. Therefore, women who train daily would need more carbohydrates than the typical US diet would provide.

32.5 Future Directions

As individuals are living longer than the lifespan expectancies of their parents for the most part, supplementation may be needed for the aging woman who wants to be vital and competitive in recreational sports and activities. Among the micronutrients, the significant ones that may be associated with deficiencies in mature active women include vitamin B-12, vitamin A, vitamin C, vitamin D, calcium, iron, zinc, and other trace minerals [35]. Since essential fatty acids help in the absorption of the fat-soluble vitamins A, D, E, and K, it is important that women intake healthy levels of fats ranging from 20 to 35 % of total daily calories (<10 % saturated).

Taking antioxidants including carotenoids, vitamin C, flavonoids, and other polyphenols through vegetables is important because of an associated beneficial decrease in CVD risk. Natural antioxidants are present in the human diet in many different chemical forms [36]. The need for energy adjusted antioxidant intake from diet increases with age and exercise level (except for flavonoids). Furthermore, the need for antioxidant intake is higher in older very active woman (supplementation may be necessary). Interestingly, low total serum carotenoid concentrations are associated with low walking speed and greater decline of walking speed [37]. Thus, fortified foods and supplements may be needed in order to meet the DRIs of these micronutrients in the older women.

Multi-nutrient supplementation may improve indices of inflammation and help exercise recovery in active older women. In addition to improving energy, supplements may prolong functionality and physiological performance with age. Thus supplements may allow older women to maintain an active lifestyle and promoting a cycle of anti-inflammatory and anti aging activity [38].

With regard to the effects of exercise on vitamin and minerals needs, irrespective of age, thiamin, vitamin C, E, calcium, and iron are discussed in more detail in this chapter under the category, Future Directions, since research has shown that the DRI for these micronutrients may be greater in exercising individuals. Vitamin B12, folate, and vitamin A are also discussed in Future Directions because of the importance of these micronutrients from a health perspective for the older woman.

32.5.1 Vitamin B12 and Folate

The benefits of vitamin B12 and folic acid fortification/supplementation are not only applicable to women throughout the lifecycle but also to all sectors of the population due to vitamin B12’s ability to lower homocysteine level [39]. Folic acid is also emerging as important in lowering the risk of certain types of cancers [40].

On average, Americans 50 years and older consume adequate levels of vitamin B12. Nonetheless, a substantial proportion of individuals 50 years and older may have reduced ability to naturally absorb vitamin B12. They are encouraged to include foods fortified with vitamin B12, such as fortified cereals, or take dietary supplements [21]. Supplement B12 is easily available, adequately absorbed, and well tolerated in older adults.

Even if adequate supplementation raises the level to an acceptable range, a physician should assess the individual with the deficiency because the deficiency may be caused by disease. Vitamin B12 deficits are associated with impaired peripheral nerve function and the development of anemia. Nerve function impairment may lead to declines in physical function and disability in older adults [41].

32.5.2 Vitamin A

Vitamin A has many roles in the maintenance of health; it is important to maintain normal vision, for cell differentiation, efficient immune function, and genetic expression. Obtaining supplemental vitamin A in its precursor form β-carotene, appears to be considerably safer, more effective, and has not been associated with adverse or unanticipated side effects.

Physical activity and total serum carotenoids are strong and independent predictors of survival in older women [42]. It is important for active women to maintain high intakes of fruit and vegetables. Consuming a diet rich in fruits and vegetables is a reasonable way to meet vitamin A needs in older adults as well as providing a good source of dietary fiber [35].

Together with robust levels of physical activity, high total serum carotenoid concentration offers women some added health protection [41].

32.5.3 Thiamin

Thiamin, also known as vitamin B1 and aneurin (a less common name for thiamin), functions as a coenzyme in the metabolism of carbohydrates and branched-chain amino acids [43]. The DRI for women age 19–70 is 1.1 mg/day. For women who are pregnant or following birth of their child, during lactation, the requirement is higher, 1.4 mg/day. However, those who engage in physically demanding occupations or who spend much time training for active sports may require increased levels of thiamin intake [44].

32.5.4 Vitamin C

Women tend to have higher blood levels of vitamin C than men of the same age, even when intake levels are the same, making the requirements for women lower than for men. However, pregnant women who smoke, abuse drugs or alcohol, or regularly take aspirin may have increased requirements for vitamin C. If an individual has adequate C status, supplementation with vitamin C does not enhance performance. However, strenuous and prolonged exercise has been shown to increase the need for vitamin C, physical performance can be compromised with marginal vitamin C status or deficiency. Athletes who participate in habitual prolonged, strenuous exercise should consume 100–1,000 mg of vitamin C [45]. Both of these values are greater than the established DRIs [43].

The major food sources of dietary vitamin C in the USA are citrus fruit juice, citrus fruits, fruitades, potatoes, tomatoes, and other vegetables. The dietary intake of vitamin C in the USA is less than in Europe. The difference can be explained by the fact that fruit and vegetable intake in Europe on average is higher compared with in the USA [36].

32.5.5 Vitamin E

Because endurance exercise results in increased oxygen consumption and thus increased oxidative stress, it seems logical that vitamin E supplementation might be beneficial for people who exercise. Although vitamin E has been shown to sequester free radicals in exercising individuals (by decreasing membrane disruption) [46], there have been no reports that vitamin E actually improves exercise performance. Nonetheless, vitamin E’s role in the prevention of oxidative damage due to exercise may be noteworthy. However, more long-term research is needed to make solid claims about the role that vitamin E plays in decreasing oxidative stress.

32.5.6 Calcium

Presently, the DRIs for calcium for adult women is 1,200 mg/day calcium but there have been suggestions that daily intakes of 1,500 mg/day may by appropriate for postmenopausal women or women over age 65 [35].

Calcium recommendations may be achieved by consuming recommended levels of fat-free or low-fat milk and milk products and/or consuming alternative calcium sources [21].

Individuals should avoid calcium supplements containing bone meal, oyster shell, and shark cartilage due to the increased lead content in these supplements, which can result in toxic effects in the body.

Calcium supplements are best absorbed if taken in 500 mg or less between meals. For older women, calcium citrate is the best supplement [4047]. It is advisable for any calcium intake to be accompanied by Vitamin D supplementation in order to increase absorption rates [43], especially in postmenopausal women. Fortunately, Vitamin D levels can also be improved from moderate skin sun exposure, since it is produce from cholesterol molecules in skin cells.

32.5.7 Iron

Studies show that iron status is often marginal or inadequate in many individuals, particularly females, who engage in regular, intense physical activity. The requirement of these individuals may be as much as 30–70 % greater than those who do not participate in regular strenuous exercise.

There are two forms of dietary iron: heme and nonheme. Heme iron is derived from hemoglobin, the protein in red blood cells that delivers oxygen to cells. Heme iron is found in animal foods that originally contained hemoglobin, such as red meats, fish, and poultry. Iron in plant foods such as lentils and beans is arranged in a chemical structure called nonheme iron. This is the form of iron added to iron-enriched and iron-fortified foods. Heme iron is absorbed better than nonheme iron, but most dietary iron is nonheme iron.

Plant-based foods, such as vegetables, fruits, whole-grain breads, or whole-grain pasta contain 0.1–1.4 mg of nonheme iron per serving. Fortified products, including breads, cereals, and breakfast bars can contribute high amounts of nonheme iron to the diet [43]. Therefore, exercising women should consume high levels of food containing both heme and nonheme iron. Consuming iron-enriched and iron-fortified foods as well as supplementation may be necessary to achieve the level required for highly active individuals.

32.6 Concluding Remarks

A food-based approach is ideal for meeting macronutrient and micronutrients needs of women. However, with food-based approaches only, women are not attaining the intake level needed for optimal health and performance in the USA and worldwide [48]. Consideration must be given to fortified foods and/or supplements to meet the recommended daily allowances for optimal health and performance. Among the micronutrients, the significant ones that may be associated with deficiencies in the older women include vitamin B-12, vitamin A, vitamin C, calcium, iron, zinc, and other trace minerals [35].