National Diet and Nutrition Survey: people aged 65 years and over. Published 1995 HMSO London

1. National Diet and Nutrition Survey: people aged 65 years and over.Published 1995 HMSO London An analysis by Dr Alan Stewart MRCP www.stewartnutrition.co.uk

2. Purpose of the Study “This provides a sound basis for the development of future food and heath policies for this increasingly important group in our society“ Tessa Jowell Minister for Public health DoH Jeff Rooker Minister of State MAFF The NDNS are undertaken by the Department of Health and Ministry of Agriculture Fisheries and Food with the support of outside agencies

3. Important Note from Dr Alan Stewart • Dr Stewart took no part in the study and reports here as an independent physician with an interest in nutrition • The findings of this survey are not well-known and are not currently available at the Department of Health website nor the Office of National Statistics despite being listed on the latter site as available. The printed report can be purchased from The Stationery Office www.tsoshop.co.uk • The findings of this survey will be superseded by the NDNS Rolling Programme, which includes those aged over 65 yrs and is due to finish reporting years 1 and 2 of the three year programme toward the end of 2012

4. NDNS65+: Background • Part of a rolling programme of national nutritional surveys of different sectors of the British population • Previous study of a non-representative sample of 365 elderly >70 years showed:- malnutrition in 7%, anaemia in 12.5%- vitamin B12 deficiency 2.5%, folate deficiency 5.4%- vitamin B1 deficiency 8%, vitamin B12 deficiency 30%(DHSS 1979) • Risk of deficiency rose with increasing age, prevalence of chronic illness and socio-economic deprivation • Link between poor nutrition and common diseases; cardiovascular, poor immunity, osteoporosis and possibly mental illness and early dementia • A study of acutely ill geriatric patients in Leeds revealed a high incidence of nutritional deficiencies (next two slides)

5. Nutritional Deficiencies in Acutely ill Geriatric Patients:Prevalence of Haematological Deficiencies 1973/75 • 93 acutely ill patients >65yrs: male = 35, female = 58 in Yorkshire • Folate and vitamin B12 were measured using micobiological assays • 9/93 = plasma albumin ,<28g/l, 29/93 = plasma albumin 28-34g/l • Morgan AG et al. Int J Vit and Nut Res. 1973:43;46-471 & 1975:45:448-462

6. Vitamin Deficiencies in Acutely ill Geriatric PatientsPrevalence of various vitamin deficiencies 1973/75 • 93 acutely ill patients >65yrs: male = 35, female = 58 • PTT = prothrombin time (Vit K), TPP = thiamin pyrophosphate effect (vit B1)Vit B2 = whole blood riboflavin, Vit B3 = urine n-methyl nicotinamide level • Morgan AG et al. Int J Vit and Nut Res. 1975:45:448-462

7. NDNS65+: Methodology • Two nationally representative samples:- free-living- institutionalised • Individuals were identified by their postal addresses • Men equalled women except those aged 85+ (more women) • In each co-operating institution three residents were selected • Initial assessment by interview • Consent or proxy-consent obtained for participation and permission to flag the NHS Central Register of Births and Deaths to give future notice of death or cancer development • Payment of £10 on completion of dietary record • Survey completed between October 1994 to September 1995 • Acutely ill elderly are unlikely to have participated in NDNS 65+; prevalence of poor nutrition is thus likely to be at least as great in ill patients in the care of medical staff

8. NDNS 65+: data collected • Interviewer-administered questionnaire about dietary habits, medication use, nutritional supplements, physical activity and health • Four-day weighed dietary record of all food and drink consumed in and out of the home • Seven-day record of bowel movements • Memory and depression questionnaires • Physical measurements: height, weight, mid-arm circumference, hand grip strength and visual acuity • Blood and urine (not 24 hours) tests • Dental examination (see separate report)

9. NDNS65+: Response to the Survey - Free-living • 30, 546 sample addresses • 23, 486 positive responders • 6,445 eligible households • 2172 initially selected Eligible sample 100% • 1632 completed interview Responding sample 75% • 1275 completed dietary record Diary sample 59% • 986 provided blood sample 45% • 1115 provided urine sample 51%

10. NDNS65+: Response to the Survey-Institutions • 454 initially identified Eligible sample 100% • 428 completed interview Responding sample 94% • 412 completed diet record Diary sample 91% • 290 provided blood sample 64% • 310 provided a urine sample 68% Some weighting for disproportionate sampling of sex, age, over-representation of people living alone and regional variations

11. Defining Nutritional Deficiency • Nutritional deficiency can develop as a result of an inadequate intake, poor absorption, illness, alcohol excess & other factors • In the UK nutrient intake requirements are given in:Dietary Reference Values for Food Energy and Nutrients for the United Kingdom (1991 – TSO) • The report defines The Lower Reference Nutrient Intake, LRNI, for protein or a vitamin or mineral as “an amount of the nutrient that is enough for only a few people in a group who have low needs”. • In practice this means that if the percentage of a population with an intake below the LRNI for a particular nutrient exceeds 3% then it is likely that a percentage of the population will be deficient in the nutrient • Also deficiency is likely, but not certain, if, on testing its blood level is below the lower end of an accepted normal range.

12. Distribution of Nutrient RequirementsAssumes a Gaussian (normal) distribution Dietary Reference Values: Dept of Health 1991 • LRNI “An amount enough for only the few people in a group who have low needs” • EAR “About half will usually need more than the EAR and half less” • RNI “An amount of the nutrient that is enough, or more than enough, for about 97% of people in a group”

13. What can Nutritional Surveys Tell Us? • Two main types of data:- dietary habits and intake of nutrients- test information on nutrient levels in blood and urine • Assess the prevalence of both types of malnutrition:- undernutrition- overnutrition • Data about social circumstances, alcohol and smoking that allows identification of those at risk of malnutrition • Data about the health of the survey group may examine the possible health consequences of malnutrition

14. How Do Nutritional Deficiencies Develop? Develop over days to years in a logical and recognizable sequence • State of Adequacy • State of Negative Balance • Decline in Tissue Stores • Loss of Function:1. Symptoms 2. Physical Signs 3. Organ Failure • Death

15. What Components were Surveyed in NDNS?NDNS = National Diet and Nutrition Survey Stage NDNS 65+ Component • State of Adequacy • State of Negative Balance 1. Poor intake Diet + Supplements 2. Reduced absorption 3. Increased losses 4. Increased requirement 5. Altered metabolism Alcohol, drugs, liver and renal • Decline in Tissue StoresTests – blood and urine • Loss of Function:1. Symptoms Depression 2. Physical Signs BMI 3. Organ Failure Renal and Liver Function Tests • DeathCollected 17 yrs later

16. NDNS: Prevalence of Deficiency - Low IntakeTotal Intakes (Food and Supplements) below LRNI for males and females • “Lower Reference Nutrient Intake – an amount of the nutrient that is enough for only the few people in a group who have low needs” = 3% of the population • Prevalence rates >3% suggest that a significant % of the population could be deficient

17. Use of Nutritional Supplements – NDNS 65+ • Supplement categories have slight differences between the surveys • Females are usually larger consumers of supplements than males

18. Prevalence of low Potassium Intake <LRNI • Potassium content of the body is related to its water content and muscle bulk • There are no differences in LRNI between the sexes despite physical differences • The high LRNI for women results in a high percentage appearing deficient • Plasma or serum potassium levels were not measured as part of any of the NDNS

19. Prevalence of a low Body Mass Index - NDNS • Percentages for age >65 years are the author’s estimates from presented data • Underweight + ill individuals are likely to have been under-represented in NDNS

20. Nutrition Support in Adults NICE Feb. 2006 www.nice.org.uk/cg032 Based on Malnutrition Universal Screening Tool - MUST • Underweight BMI >18.5kg/m2 • Unintentional weight lossLoss >10% within the last 3 – 6 months • Underweight + Unintentional Weight LossBMI 18.5 - 20kg/m2 and Wt Loss >5% within the last 3 – 6 mo. • Others Risk FactorsEaten little or nothing or unlikely to for >5 daysPoor absorptive capacity, high nutrient losses or increased needs

21. Nutritional Assessment - Risk FactorsNICE guidelines www.nice.org.uk/cg032 (2006) and others • Fragile skin • Poor wound healing • Apathy • Wasted muscles • Poor appetite • Altered taste sensation • Impaired swallowing • Altered bowel habit • Loose fitting clothes • Prolonged illness:chronic infection, chest disease, cardiac failure, cancer etc.

22. Fragile skin Poor wound healing Apathy Wasted muscles Poor appetite Altered taste sensation Impaired swallowing Altered bowel habit Loose fitting clothes Prolonged illness:chronic infection, chest disease, cardiac failure, cancer etc. Life Stage:- extremes of age- infants, adolesence, pregnancy Social Circumstances:- in receipt of benefits- living alone – especially men Medical History:- loss: bleed, vomiting, diarrhoea- chronic illness/organ failure Family History/Genetic Factors Medical Drug Use Poor mobility/lack of sun Smoking Symptoms and Physical Signs Nutritional Assessment - Risk FactorsNICE guidelines www.nice.org.uk/cg032 (2006) and others

23. Influence of Household Income on Average Intake of Nutrients in Elderly Men [NDNS 1998] • Annual income in £000s; upper income bands are compared with lowest <4k/year • Increasing income is associated with higher intake of protein and many nutrients

24. Daily Alcohol Intake and Nutritional Status: NDNS 65+% difference in status compared with non/low drinkers • Intake determined from 4 day diary • Caution, no adjustment for age, health, diet or supplements was made • Non-drinkers were more likely to be older and have abnormal liver test

25. Diagnosing Malnutrition: Under and Overnutrition • HistoryIntake: diet + supplements Risk Factors for deficiency/XS Symptoms of deficiency/XS • Physical Anthropometric MeasuresExamination (Body Mass Index - kg/m2)Signs of Deficiency Signs of Underlying Disease • Laboratory Blood and Urine TestsInvestigation Bone Mineral Density X-Ray

26. Making a Diagnosis: History is Paramount • Both studies assessed new patients, with no clear diagnosis who were referred to a medical outpatient clinic • The percentages relate to the information that was required to reach the final diagnosis • References:Hampton JR et al. BMJ. 1975;2:486-9Peterson MC et al. West Med J. 1992;156(2):163-5

27. NDNS65+: Prevalence of Anaemia • World Health Organisation Normal Ranges were used; women >12.0g/dl, men >13.0g/dl. British laboratories often use a normal range of >11.5g/dl for women • Levels of 11.5-11.9g/dl in women can result in symptomatic iron deficiency • In the elderly anaemia results from: poor nutrient intake + bleeding, chronic illness and unknown factors in equal frequency

28. NDNS65+: Prevalence of Iron Deficiency Low Plasma Ferritin: Range < 10-20ug/l • Normal ranges: females > 15.0ug/l, males > 20.0ug/l • Plasma ferritin can be elevated by acute or chronic inflammation, infection or liver disease and may not be a reliable measure of iron status in ill and elderly people

29. NDNS65+: Prevalence of Vitamin B12 Deficiency Plasma vitamin B12 <118 pmol/l (154pg/ml) • Macrocytosis (MCV >101fl) was seen in: 2% of free-living elderly and 3% of elderly in institutions. • Macrocytosis can be due to vit B12/folate deficiency or alcohol excess • Only a minority of those with vitamin B12 deficiency also had macrocytosis

30. NDNS65+: Prevalence of low Red Cell Folate • The normal ranges for red cell folate and method of analysis varied from other NDNS • Folate status is influenced by dietary intake, illness, alcohol excess and altered metabolism

31. NDNS 65+: Prevalence of Vitamin D DeficiencyPlasma 25-hydroxyvitamin D <25nmol/l • Plasma 25-OHD levels show considerable seasonal variation with low levels being commonplace in late winter and spring. • Dietary sources provide approximately 10% of intake of the vitamin. • Preferred level for those with osteoporosis is >75 nmol/l

32. NDNS65+: Prevalence of Vitamin C Deficiencyplasma Vit. C<11.0umol/l - NDNS data • Vitamin C status is adversely affected by smoking, use of aspirin and NSAIDS • Approximately 12% of the elderly took supplements likely to contain vitamin C • Approximately 28% of British adults smoke and less after the age of 65 years • Aspirin was taken by 20% of free-living elderly and 24% of institutionalised

33. NDNS65+: Prevalence of Vitamin A DeficiencyPercentage of Population with a plasma Retinol < 0.7mmol/l • WHO lower end of normality, plasma level < 0.7 mmol/ • Plasma retinol levels may be temporarily lowered as a result of infection and the acute phase response • Severe deficiency, plasma <0.35 mmol/l, is very rare

34. Nutritional Supplements and the Elderly “Many would agree that iron, vitamin C, vitamin D and B complex vitamins should be given for three to four weeks to elderly patients recovering from a severe illness of any type ...” Editorial British Medical Journal. Nutrition in the Elderly 1974:1;212-3.

35. Correlations between intake and blood levels • NDNS 65+ and other surveys calculated the correlation coefficients between the intake of many nutrients and it’s level in the blood • The degree of correlation between these two was often less than 50% and is usually best for the more water-soluble and better absorbed nutrients • The reason for low correlation are many and include: level of intake, limited or poor absorption, smoking and alcohol, and differences in metabolism/transport of the nutrient • In practice this means that clinicians should not rely too heavily on dietary assessment but consider many other risk factors for under and overnutrition

36. Correlation Coefficients: Vitamin CPlasma Ascorbate and Total Intake

37. Correlation Coefficients: FolateRed Cell Folate and Total Intake

38. Correlation Coefficients: RetinolPlasma Retinol and Intake (Retinol Equivalents)

39. Correlation Coefficients IronHaemoglobin and Total Intake of Iron

40. Correlation Coefficients B Vitamins in ElderlyNDNS 65+ Free-Living only • Tests – red cell folate, serum vitamin B12; vitamins B1 & 2 by enzyme activation, which increase with increasing deficiency • CCs for vitamins B1 & 2 are -ve but are presented as +ve • All CCS are significant (p<0.01) except vitamin B12 in men

41. NDNS 65+: What Have we Learnt so Far? • This important survey, though conducted 20 years ago reveals that:- poor intake of micronutrients is common- low BMI, anaemia and micronutrient deficiencies are common • Risk factors for undernutrition include:- low income – or being in receipt of benefits- increasing age- smoking- alcohol excess but not moderate intake- illness especially chronic illness- multiple drug therapy • Risk Factors for undernutriiton detailed by NICE are presented next

42. NICE Listed Fragile skin Poor wound healing Apathy Wasted muscles Poor appetite Altered taste sensation Impaired swallowing Altered bowel habit Loose fitting clothes Prolonged intercurrent illness: chronic infection, chest disease, cardiac failure, cancer etc. Nutritional Assessment - Risk FactorsNICE guidelines www.nice.org.uk/cg032 (2006) and others

43. NDNS 65+: Prevalence of Overnutritionfigures are for free-living • Obesity BMI >30 kg/m2 M - 17%, F – 23% • Alcohol excess >21/14 units/week ~ 10% • Dietary Salt Intake >6g/day estimated at ~80%risk of:hypertension, stroke, osteoporosis and heart failure • Retinol - elevated plasma level ~10%risk of:osteoporosis, hypercalcaemia (cc%) • Iron excess - haemochromatosis ~1.5%iron saturation >55% • Trace element excess - reduced excretion due to:renal disease (?<5%) – vitamin A and potassiumliver disease (10-20%) – iron, manganese and copper • Excessive intake of nutrients from supplementsretinol (5-10%) and possibly manganese (not assessed)

44. Safety of Vitamin A: SACN Sept 2005 • Total Safe Intake, TSI 1500 ug/day • Diet provides average 700 ug/day • Supplements limited to 800 ug/day • % NDNS 65+ intakes >TSI- F-L Males 11%, Females 10%- Inst. Males 7%, Females 6% • High intakes from: - food – liver, very high dairy - supplements high intake & overages • Acute Toxicity: – rare >50,000ug/day- liver failure, death • Chronic Toxicity:- osteoporosis (vit D antagonist)- hair loss, dry skin- hypercalcaemia (PTH excess) • Risk increased by: renal impairment, alcohol excess and obesity

45. Retinol Status of the British Population (estimates)Plasma Retinol Levels NDNS 65+ Data

46. Renal Function and Plasma Retinol: NDNS 65+Correlation between deteriorating renal function and plasma retinol

47. UK Supplements – Retinol ContentFSA (2003) and SACN (2005) - Safe Upper Level of 800 ug/day • Cod Liver Oil 10 mls 1,800ug • Holford Multivitamin 1,200ug • HealthSpan Multi 50+ 1,000 ug • H and B ABC Plus Senior 1,050 ug • Solgar Solovit 750 ug • Biocare Adult Multi 600 ug • According to industry overages are commonly 20% to 30% more than the label claim

48. NDNS 65+ The Spread of Malnutrition • The following slides detail the spread and extremes of nutrient intake and laboratory findings from the free-living NDNS 65+ population • These show the means, 95% limits and highest and lowest values for a number of measures of nutrients • These findings make the point that both under and over nutrition occur • They help the practitioner put into perspective the results that they might obtain when assessing their own patients • Such data is unique and is unlikely to be reported in future survey

49. The Spread of Malnutrition: Energy & BMINDNS 65 + Free-living M = 538, F = 516Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053

50. The Spread of Malnutrition: Iron and AnaemiaNDNS 65 + Free-living M = 538, F = 516Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053