Nutritional Issues in the Nutritional Issues in the Elderly: 2007Elderly: 2007

Joel Mason, M.D.Joel Mason, M.D.Associate Professor of Medicine and Associate Professor of Medicine and

Nutrition, Tufts UniversityNutrition, Tufts University

Nutritional Needs Change with AgingNutritional Needs Change with Aging

Increased requirements:Increased requirements: calciumcalcium

vitamin Dvitamin Dvitamin B12 vitamin B12 vitamin B6vitamin B6(protein)(protein)

Decreased requirements:Decreased requirements:caloriescalories

(vitamin A)(vitamin A)

Sarcopenia of AgingSarcopenia of Aging

sarcopeniasarcopenia a “poverty of flesh” a “poverty of flesh” defined as the decrease in lean body mass defined as the decrease in lean body mass

often associated with a concomitant often associated with a concomitant increase in fat massincrease in fat mass

total body weight may not changetotal body weight may not change

body composition in the adultbody composition in the adult

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

Change in appendicular muscle mass as a function of ageChange in appendicular muscle mass as a function of age

From Starling et al. 1999. Am J Clin NutrAm J Clin Nutr 70: 70: 91-96. .

Consequences of SarcopeniaConsequences of Sarcopenia

Decreased resting energy expenditureDecreased resting energy expenditure Decreased insulin sensitivityDecreased insulin sensitivity Diminished muscle strengthDiminished muscle strength Increased risk of physical disabilityIncreased risk of physical disability

greater reliance on canes & walkersgreater reliance on canes & walkers several-fold increased risk of serious fallsseveral-fold increased risk of serious falls inability to conduct activities of independent inability to conduct activities of independent

living, eg: shopping, dressing, meal preparationliving, eg: shopping, dressing, meal preparation Increased risk of mortality Increased risk of mortality

Sarcopenia is a Multifactorial DisorderSarcopenia is a Multifactorial Disorder

Decreased levels of sex hormones Decreased levels of sex hormones (testosterone and DHEA)(testosterone and DHEA)

Decreased levels of growth hormone and Decreased levels of growth hormone and insulin-like growth factor 1 (IGF-1) insulin-like growth factor 1 (IGF-1)

Increased cytokine productionIncreased cytokine production Neuromuscular changesNeuromuscular changes Physical inactivityPhysical inactivity Malnutrition, especially protein deficiencyMalnutrition, especially protein deficiency Smoking Smoking

Treatment of SarcopeniaTreatment of Sarcopenia

•Hormonal therapyHormonal therapy• TestosteroneTestosterone• DHEADHEA• EstrogenEstrogen• Growth hormoneGrowth hormone

•Exercise interventionsExercise interventions•Nutritional supplementationNutritional supplementation

Elder adults can realize greatbenefits from exercise

Quadriceps strength in frail nonagenarians: Quadriceps strength in frail nonagenarians: improvement with strength trainingimprovement 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

The Boston FICSIT Trial 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

Exercise Training And Nutritional Supplementation For Physical Exercise Training And Nutritional Supplementation For Physical Frailty In Very Elderly People Frailty In Very Elderly People

(Fiatarone, NEJM, 1994)(Fiatarone, NEJM, 1994)

-4-2

0

2

46

8

10

12

R leg press(kg)

gait speed(m/min)

stair climbingpower (W)

thigh musclearea (cm2)

Exercise group Control group

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

A Randomized Controlled Trial of Resistance Exercise Training to A Randomized Controlled Trial of Resistance Exercise Training to

Improve Glycemic Control in Older Adults With Type 2 DiabetesImprove Glycemic Control in Older Adults With Type 2 Diabetes (Castaneda, Diabetes Care 2002)(Castaneda, Diabetes Care 2002)

Change inTG (mmol/L) Change in

SBP (mmHg)

-25-20-15-10-505

1015

Exercise group Control group

A Randomized Controlled Trial of Resistance Exercise Training to A Randomized Controlled Trial of Resistance Exercise Training to

Improve Glycemic Control in Older Adults With Type 2 DiabetesImprove Glycemic Control in Older Adults With Type 2 Diabetes (Castaneda, Diabetes Care 2002)(Castaneda, Diabetes Care 2002)

Change in HgbA1c (%)

77.27.47.67.8

88.28.48.68.8

Baseline Final

Exercise groupControl group

Progressive weight resistance training in OA of the knee: changes Progressive weight resistance training in OA of the knee: changes occuring over 12 weeks in a randomized controlled trialoccuring over 12 weeks in a randomized controlled trial

control group, n=23 exercise group, n=23 p-valueaffected knee -0.6 +5.9 0.001extension str., kgsaffected knee -2.5 +4.1 0.001flexion str.

WOMAC pain score -12% -43% 0.01WOMAC 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

Elderly individuals are at Elderly individuals are at increased risk of both increased risk of both

malnutrition and obesitymalnutrition and obesity

Prevalence of Malnutrition in Elderly Prevalence of Malnutrition in Elderly PopulationsPopulations

Community-dwelling:Community-dwelling:3 to 11% 3 to 11%

Nursing home residents:Nursing home residents:17 to 65% 17 to 65%

Hospital inpatients:Hospital inpatients:15 to 40% 15 to 40%

Prevalence of Obesity Increases with AgePrevalence of Obesity Increases with Age

01020304050

Percent with BMI > 30

20-39 40-59 60-74

Age in years

MenWomen

Data from Flegal et al. JAMA. 2002;288:1723–7. Data from Flegal et al. JAMA. 2002;288:1723–7.

5 Leading Causes of Death 5 Leading Causes of Death Data for Americans Over Age 40, Year 2000Data for Americans Over Age 40, Year 2000

1.1. Heart diseaseHeart disease2.2. CancerCancer3.3. Cerebrovascular diseaseCerebrovascular disease4.4. Chronic lung diseaseChronic lung disease5.5. Diabetes mellitusDiabetes mellitus

From: National Center for Health Statistics (www.cdc.gov)From: National Center for Health Statistics (www.cdc.gov)

4 of the 5 Leading Causes of Death Are 4 of the 5 Leading Causes of Death Are Associated With ObesityAssociated With Obesity

1.1. Heart diseaseHeart disease2.2. CancerCancer3.3. Cerebrovascular diseaseCerebrovascular disease4.4. Chronic lung diseaseChronic lung disease5.5. Diabetes mellitusDiabetes mellitus

From: National Center for Health Statistics (www.cdc.gov)From: National Center for Health Statistics (www.cdc.gov)

The Nutrition Screening InitiativeThe Nutrition Screening Initiative

Micronutrient issues in the Micronutrient issues in the elderlyelderly

Prevalence of Atrophic Gastritis byPrevalence of Atrophic Gastritis by Age Age

0

10

20

30

40

Perc

ent o

f In

divi

dual

s

60-69 70-79 80+Age

Data from Krasinksi et al. J Am Geriatr Soc. 1986;34:800-6. Data from Krasinksi et al. J Am Geriatr Soc. 1986;34:800-6.

Atrophic GastritisAtrophic Gastritis

An eminently age-related but silent conditionAn eminently age-related but silent condition chronic inflammatory disorder chronic inflammatory disorder associated with Helicobacter pylori associated with Helicobacter pylori

infection infection results in decreased secretion of results in decreased secretion of

hydrochloric acid, pepsin and to a modest hydrochloric acid, pepsin and to a modest degree, intrinsic factordegree, intrinsic factor

‘‘Marginal’ B12 deficiency can result in Marginal’ B12 deficiency can result in neurodegenerative diseasesneurodegenerative 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

Guidelines for the diagnosis of B12 Guidelines for the diagnosis of B12 deficiency in the elderlydeficiency in the elderly

• Plasma B12 remains the ‘first line’ testPlasma 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 Those individuals whose B12 is 150-250 and whose MMA is normal should be monitored occasionally for slow MMA is normal should be monitored occasionally for slow transition to a frank deficiencytransition to a frank deficiency

• Making a diagnosis is not entirely objective and still Making a diagnosis is not entirely objective and still requires some interpretation and judgement!requires some interpretation and judgement!

**renal insufficiency causes increases in MMA

Vitamin D and calcium availability in Vitamin D and calcium availability in the elderlythe 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

Vitamin D levels diminish with age Vitamin D levels diminish with age and disabilityand disability

Causes of diminished D levels in the elderlyCauses of diminished D levels in the elderly

Holick et al. Lancet;2:1104–1105,1989. Holick et al. Lancet;2:1104–1105,1989.

• habitually low dietary intake (120-200 I.U./d)• impaired synthesis in senile skin (see below)• little sun exposure in homebound and institutionalized elders

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

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

Recommendations: Expert Panel of the National Recommendations: Expert Panel of the National Osteoporosis Foundation, 2003Osteoporosis 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

Reducing tooth loss in the elderly with vitamin Reducing tooth loss in the elderly with vitamin D+calcium supplementationD+calcium supplementation

A randomized, controlled trial (described in the A randomized, controlled trial (described in the prior slide: 145 elder subjects, 3 yr. intervention prior slide: 145 elder subjects, 3 yr. intervention with D+calcium)with D+calcium)

Detailed dental exams were performedDetailed dental exams were performed Results:Results:

13% in the Ca/D group vs. 27% in placebo group lost 13% in the Ca/D group vs. 27% in placebo group lost one or more teeth over 36 mos.one or more teeth over 36 mos.

Odds of tooth loss=0.4 (C.I. 0.2-0.9)Odds of tooth loss=0.4 (C.I. 0.2-0.9) Effects did not differ by gender or by smoking statusEffects did not differ by gender or by smoking status

Am J Med 2001:111:452-456Am J Med 2001:111:452-456

Vitamin D supplementation reduces falls: a meta-Vitamin D supplementation reduces falls: a meta-analysis of 5 RCTs analysis of 5 RCTs ((JAMA 2004;291: 1999JAMA 2004;291: 1999))

Primary analysis was of 1237 subjects in 5 Primary analysis was of 1237 subjects in 5 RCTsRCTs

A RR of 0.78 (0.64-0.92) of falls occurred A RR of 0.78 (0.64-0.92) of falls occurred with vitamin D supplementation with vitamin D supplementation ++ calcium calcium compared to calcium supplementation compared to calcium supplementation alone or placeboalone or placebo

A sensitivity analysis with an additional 5 A sensitivity analysis with an additional 5 less rigorously conducted studies revealed less rigorously conducted studies revealed a somewhat less robust effect but one that a somewhat less robust effect but one that was still significantwas still significant

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