Abstract
The present article aimed to compile information on the nutritional management for geriatric people. Popular textbooks of Persian medicine from 10th to 18th century were studied to derive relative viewpoints and considerations. The temperament, which is defined as the combination of 4 main elements (fire, air, water, and soil) and 4 humors made subsequently (black bile, yellow bile, phlegm, and blood), changes during age periods. Imbalance in proportional amounts of humors in elderly should be corrected with food and medicaments having opposite nature to the current condition. Traditional foods included mostly well-cooked soups, pottages, and porridges containing fresh sheep or chicken meat. Mono-ingredient foods were also administered according to their medical properties. Nutritional recommendations were also concerned with geriatrics’ physiological conditions such as constipation, sleep disorders, and memory deficits. Many of traditional geriatric nutritional requirements are relevant in the present day. However, there are still notes that may be beneficial for consideration.
It is well accepted that the elderly population as a demographic group of people are susceptible to malnutrition. 1 Many physiological and physical functions diminish during the aging process and thus affect the nutritional conditions. Furthermore, large group of old persons have medications, hospitalizations, and associated complications that are often viewed as other contributors to malnutrition. 2,3 Numerous efforts have been made to outline a framework for the nutritional management of the elderly and to confine the underlying factors of malnutrition. 4 Perioral weight evaluations as well as dietary interviews and education are of worthwhile factors to prevent the malnutrition. 5
On the other side, investigations have reported that nearly 85% of noninstitutional geriatric population has chronic conditions that can be controlled by nutritional modification. 6 Findings revealed that adequate nutrients intake such as carbohydrates, fat, and proteins as well as essential element improve the cognitional function and maintenance. 7
Therefore, focusing on nutritional therapy and tracking the risks for malnutrition in the geriatric population is important for medical and health providers throughout the world. It is known that the use of herbal and elemental supplements as alternative and complementary therapies among older adults is prevalent. 8,9
Concept of alternative and complementary medicine from ancient practitioners’ standpoints is based almost entirely on prevention approaches. 10 Along with the Chinese, Ayurveda, and Unani systems of medicine, traditional Persian medicine (TPM) with a backbone of more than 1000 years of medical knowledge can serve numerous aspects of health protections, maintenance, and medicinal management for elderly people. 11,12 This system of medicine has not only collected all findings of other medical system but has also improved that with practices and experiences of its own scholars such as Rhazes and Avicenna, who were the most outstanding medical practitioners and thinkers of the Islamic golden age. 12 Rhazes wrote more than 200 textbooks and treatises on a variety of subjects. On the other hand, the Canon of Medicine authored by Avicenna became a crucial reference work for medicine in the Western countries until late 16th century. 13 Accordingly, the current work aimed to compile all the information related to the nutritional management and daily nutrients for geriatric people.
Materials and Methods
Predominant medical and pharmaceutical textbooks of Persian medicine authored from 10th to 18th century were studied to derive all reported facts and viewpoints on geriatric nutrition and related considerations. These sources were Firdous al-Hikmah (Paradise of Wisdom) by Ali ibn Sahl Rabban al-Tabari (848/2008), Kitab Kamil al-sina‘ah al-tibbiyah (The Complete Book of the Medical Art or the Royal Book) by Ali ibn al-‘Abbas al-Majusi (980/2005), al-Qānūn fi al-tibb (Canon of Medicine) by Avicenna (1025/1998), Zakhireh-ye Kharazmshahi (Treasure of Kharazm Shah) by Jorjani (1131/2009), Kholasat-al-Hekmat (Summary of Wisdom), and Makhzan-ol-advieh (The Storehouse of Medicaments) by Aghili Shirazi (1771/1992). Table 1 presents the bibliographic descriptions of the medieval and traditional manuscripts. These manuscripts are known among main references for the education of traditional medicine and pharmacy in Iran.
Bibliographic Description of the Medieval and Traditional Manuscripts Used in the Study.
Additionally, we tried to find similarity between medieval approaches of those foods and medicinal foods recommended by early Persian scholars with current findings. Thus, an additional search was performed using databases such as Google Scholar, PubMed, and Scopus.
Results and Discussion
According to the principles of TPM, growth and development of a human being is divided into 4 main stages. These stages are as growth or pediatric period (from the time of birth to the age 30 years), youth stage (30-40 years), midlife period (40-60 years), and finally, the senescence (60 years until death), which was called sheikhukhiat. 14 Like for the Unani medicine, all managements and consideration in TPM are based on the temperament (mizaj) or nature and homeostasis (tabiat). The temperament, which was defined a combination of 4 main elements and 4 subsequently made humors (black bile, yellow bile, phlegm, and blood) 15,16 changes during those ages mentioned earlier. Cold and dry temperament with different proportion of the humors, compared with previous growth stages, was defined for the elderly people. 12,14 It was believed that during the lifetime, the body temperament would changes from hot and wet (growth period) to hot and dry (youth stage), cold and dry (midlife period), and finally to cold and more dry or wet in old age. It was also remarked that the temperament and subsequently the homeostasis in geriatrics are profoundly affected by all internal and external conditions. 17
As a fact in basics of TPM, the imbalance in the proportional amounts of humors in an old and aged person should be corrected with food and medicaments having opposite nature to the current condition. 18 Therefore, all foods and medicinal foods, according to their degree of potency in TPM basics, 19 were administered in line with the elderly temperament. As mentioned by early Persian physicians, foods and beverages for geriatrics were usually confined to those having warm and wet nature for thin elderly individuals. On the other hand, they prefer warm and dry foods for fat elderly people. 20,21 Table 2 presents the reported mono- and multi-ingredient foods or medicinal foods that have been recommended by traditional practitioners. One of the most recommended meals for these people was cooked milk with honey or rock candy. 14 On the contrary, some foods, fruits, and vegetables were reported as harmful. Excessive or unchecked indulgence in the consumption of eggplant (Solanum melongena L.), lentil (Lens culinaris Medik.) and watermelon (Citrullus lanatus Thunb.) were not permitted for the geriatric population. Vinegar, as a cooking ingredient and marinades were also reported harmful for nerve system in old people. 20,22
Mono- and Multi-Ingredients Foods or Medicinal foods Recommended in Traditional Persian Medicine.
Persian physicians did know about the physiological complications during old ages. The most abundant prescribed foods and medicinal foods for geriatric were based on the gastrointestinal performance and general health improvement. There are reports on the recommendation of special foods as memory enhancers in Persian manuscripts. Examples of these foods are Vitis vinifera L. and Juglans regia L. Based on the theory of the change in the temperament during aging, daily recommended food exhibited laxative and gastrointestinal tonic properties to improve the weak intestinal movement in the elderly. 23,24 Moreover, early Persian physicians have noted that food for the elderly should be served in low amounts, but be of high quality, and meals be served more number of times. The elderly have complications in chewing concerned with impaired teeth or presence of dentures. Thus, traditional multi-ingredients foods were mostly well-cooked soups, pottages, and porridges. Persian physicians believed that daily food for the elderly should be light, but they can have a full dinner meal. They reminded that no limited nutritional regimen or starving should be considered for old people. 14,20
Constipation is known as a common complication during old age. 25 Persian scholars recommended fresh fig in daily food for the geriatric population during summer. A fresh maceration of dry fig was also suggested during winter. They have strongly forbidden overnight starving in old age. Precautions were also noted for wine consumption. But if necessary, they recommended old wine with added pepper. 21
Today, it is proved that geriatric people need special scheme on nutrition. 26 Many of the early nutritional instruction remarked by Persian scholars are in line with present-day knowledge. Vinegar and marinades can reduce body weight and body fat mass. 27 Therefore, consumption of these nutritional substances in old people should be supervised. On the other hand, hen’s egg yolk, which contains numerous nutraceuticals such as lipids, lipoprotein, phosvitin, and antibodies, 28 has been traditionally recommended in geriatric nutritional regimen. Palm wine was a tonic drink in TPM. Today, the nutritional properties of this drink have been evaluated and presence of nicotinic acid and vitamin C in this alcoholic drink has been proved. Another investigation has also reported that palm wine could be a rich source of protein, thiamin, and riboflavin. 29 Apart from common foods such as meat, milk, and fresh low-salt bread, many of the mono-ingredient foods were recommended to correct and modify a specific complication in old people. Persian scholars administered some vegetables such as cabbage, beetroot, and common fig to keep the bowel habit of geriatrics regular and comfortable. 14 They also recommended vegetables as tonic foods in geriatric nutrition. It is now accepted that these herbs possess antioxidant and radical scavenging activities. 30 –32 The memory-enhancing effects of some traditional nutraceuticals such as Vitis vinifera L. and Juglans regia L. are proved via evaluation of acetyl cholinesterase inhibitory and antioxidant properties. 33,34 These nutrients have being administered for the same purposes. Early Persian physicians were aware of probability of sleep disruption in the elderly. Hence, they administered foods possessing hypnotic effects (Table 2). 35
Conclusion
Taken as a whole, Persian medieval practitioners considered herbs, spices, and other rich nutritious substances as food or medicinal food in geriatric nutritional regimen. They observed elderly physiological conditions and the temperament to define a specific nutritional regimen. The consideration of nutritional regimen for patients in each period of life outlines that Persian physicians did know about the impact of nutrition on health conditions. Although many of the TPM geriatric nutritional needs and requirements are relevant in the present day, there are still notes that may be beneficial for consideration.
Footnotes
Acknowledgments
Authors of this article wish to express their thanks to the Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences (Project number: 91-0-64-4793-64-01-91).
Author Contributions
ME wrote the draft and contributed in data gathering and writing the final version of the manuscript. MAZ rewrote the draft and contributed in the revision of the final manuscript. MMZ rewrote the first version of the manuscript and contributed in data gathering and writing the final version of the manuscript. HR contributed in the guidance, revision, and correction of the draft and final manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
This is a review article and needs no ethical approval. The study was done in the Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences.