Nutritional Issues in the Elderly: 2007

1. Nutritional Issues in the Elderly: 2007 Joel Mason, M.D. Associate Professor of Medicine and Nutrition, Tufts University

3. Nutritional Needs Change with Aging Increased requirements: calcium vitamin D vitamin B12 vitamin B6 (protein) Decreased requirements: calories (vitamin A)

4. Sarcopenia of Aging • sarcopenia • a “poverty of flesh” • defined as the decrease in lean body mass • often associated with a concomitant increase in fat mass • total body weight may not change

5. body composition in the adult

6. from Evans, W. & Rosenberg, I. (1991) Biomarkers. Simon & Schuster, New York, NY.

7. Change in appendicular muscle mass as a function of age From Starling et al. 1999.Am J Clin Nutr 70: 91-96.

8. Consequences of Sarcopenia • Decreased resting energy expenditure • Decreased insulin sensitivity • Diminished muscle strength • Increased risk of physical disability • greater reliance on canes & walkers • several-fold increased risk of serious falls • inability to conduct activities of independent living, eg: shopping, dressing, meal preparation • Increased risk of mortality

9. Sarcopenia is a Multifactorial Disorder • Decreased levels of sex hormones (testosterone and DHEA) • Decreased levels of growth hormone and insulin-like growth factor 1 (IGF-1) • Increased cytokine production • Neuromuscular changes • Physical inactivity • Malnutrition, especially protein deficiency • Smoking

10. Treatment of Sarcopenia • Hormonal therapy • Testosterone • DHEA • Estrogen • Growth hormone • Exercise interventions • Nutritional supplementation

11. Elder adults can realize great benefits from exercise

12. Quadriceps strength in frail nonagenarians: improvement with strength training • Strength gains averaged 174% + 31% • Midthigh muscle area increased 9.0% + 4.5%. • Mean tandem gait speed improved 48% JAMA 1990;263:3029

13. The Boston FICSIT Trial • Prospective, randomized, controlled ten-week trial of progressive strength training and/or nutritional supplementation in 100 elderly, frail, institutionalized adults: • age: 87 (72-98) • cognitive impairment: 51% • depression: 42% • diagnoses of chronic disease: 5/person • regular medications: 5.5/person

14. Exercise Training And Nutritional Supplementation For Physical Frailty In Very Elderly People (Fiatarone, NEJM, 1994)

15. FICSIT trial: mean increase in strength in all muscle groups trained. Effect of nutritional supplement

16. A Randomized Controlled Trial of Resistance Exercise Training to Improve Glycemic Control in Older Adults With Type 2 Diabetes(Castaneda, Diabetes Care 2002)

17. A Randomized Controlled Trial of Resistance Exercise Training to Improve Glycemic Control in Older Adults With Type 2 Diabetes(Castaneda, Diabetes Care 2002)

18. Progressive weight resistance training in OA of the knee: changes occuring over 12 weeks in a randomized controlled trial control group, n=23 exercise group, n=23 p-value affected knee -0.6 +5.9 0.001 extension str., kgs affected knee -2.5 +4.1 0.001 flexion str. WOMAC pain score -12% -43% 0.01 WOMAC physical fxn -23% -44% 0.01 Quality of life (self-report) physical capabilities 4.2 16.6 0.01 socialization -5.9 12.5 0.01 mental functioning -3.2 8.2 0.001 J Rheumatol 2001;28: 1655

19. Elderly individuals are at increased risk of both malnutrition and obesity

20. Prevalence of Malnutrition in Elderly Populations Community-dwelling: 3 to 11% Nursing home residents: 17 to 65% Hospital inpatients: 15 to 40%

21. Prevalence of Obesity Increases with Age Data from Flegal et al. JAMA. 2002;288:1723–7.

22. 5 Leading Causes of Death Data for Americans Over Age 40, Year 2000 • Heart disease • Cancer • Cerebrovascular disease • Chronic lung disease • Diabetes mellitus From: National Center for Health Statistics (www.cdc.gov)

23. 4 of the 5 Leading Causes of Death Are Associated With Obesity • Heart disease • Cancer • Cerebrovascular disease • Chronic lung disease • Diabetes mellitus From: National Center for Health Statistics (www.cdc.gov)

24. The Nutrition Screening Initiative

25. Micronutrient issues in the elderly

26. Prevalence of Atrophic Gastritis by Age Data from Krasinksi et al. J Am Geriatr Soc. 1986;34:800-6.

27. Atrophic Gastritis An eminently age-related but silent condition • chronic inflammatory disorder • associated with Helicobacter pylori infection • results in decreased secretion of hydrochloric acid, pepsin and to a modest degree, intrinsic factor

30. ‘Marginal’ B12 deficiency can result in neurodegenerative diseases • 141 subjects with a variety of neurodegenerative diseases whose disease significantly improved with administration of B12 but who had neither anemia or a high MCV • A significant minority of these subjects had ‘low-normal’ B12 levels of 200-350 pg/mL

33. Guidelines for the diagnosis of B12 deficiency in the elderly • Plasma B12 remains the ‘first line’ test • a level of >350 pg/mL (258 pmol/L) excludes deficiency • a level of <150 pg/mL (110 pmol/L) should be considered diagnostic of deficiency • levels between 150 and 350 should prompt a MMA level. If MMA is substantially elevated*, the the patient should be considered to have B12 deficiency • Those individuals whose B12 is 150-250 and whose MMA is normal should be monitored occasionally for slow transition to a frank deficiency • Making a diagnosis is not entirely objective and still requires some interpretation and judgement! *renal insufficiency causes increases in MMA

34. Vitamin D and calcium availability in the elderly • 20% of post-menopausal white women have osteoporosis • 1 of 2 white women will experience an osteoporotic fx in their lifetime • Only 40% of pts experiencing a femoral neck fx regain their pre-fx degree • of independence • Management of 1 hip fx costs $40,000 (in 2001 $$); est. annual cost to U.S. • health care system=$17 billion

35. Vitamin D levels diminish with age and disability

36. Causes of diminished D levels in the elderly • habitually low dietary intake (120-200 I.U./d) • impaired synthesis in senile skin (see below) • little sun exposure in homebound and institutionalized elders Holick et al. Lancet;2:1104–1105,1989.

37. Agnusdei et al, 1998. Calcif Tissue Int. 63;197-201.

38. 500 mgs of calcium+700 I.U. of D reduces osteoporotic fractures in elder men and women

39. Recommendations: Expert Panel of the National Osteoporosis Foundation, 2003 • all women over 50 should consume 1200 mgs elemental calcium/d (median intake of p/m women in U.S.=600, TUL=2500 mgs) • all women over 50 should consume at least 600 IU of vitamin D/d; 800 IU for those at risk of deficiency (elderly, chronically ill, housebound or institutionalized; TUL=2500 IU/d) • weight-bearing and muscle-strengthening exercise >3X/wk for all adults • pro-active strategies to prevent falls for at-risk individuals • avoidance of tobacco use and >2 alcoholic drinks/d

40. Reducing tooth loss in the elderly with vitamin D+calcium supplementation • A randomized, controlled trial (described in the prior slide: 145 elder subjects, 3 yr. intervention with D+calcium) • Detailed dental exams were performed • Results: • 13% in the Ca/D group vs. 27% in placebo group lost one or more teeth over 36 mos. • Odds of tooth loss=0.4 (C.I. 0.2-0.9) • Effects did not differ by gender or by smoking status Am J Med 2001:111:452-456

41. Vitamin D supplementation reduces falls: a meta-analysis of 5 RCTs (JAMA 2004;291: 1999) • Primary analysis was of 1237 subjects in 5 RCTs • A RR of 0.78 (0.64-0.92) of falls occurred with vitamin D supplementation + calcium compared to calcium supplementation alone or placebo • A sensitivity analysis with an additional 5 less rigorously conducted studies revealed a somewhat less robust effect but one that was still significant

42. We cannot live the afternoon of lifeaccording to the program of life’s morning:For what was great in the morningwill be little at evening,and what in the morning was truewill at evening have become a lie.Carl Jung