Transcript Document

Nutritional Issues in the
Elderly: 2007
Joel Mason, M.D.
Associate Professor of Medicine and
Nutrition, Tufts University
Nutritional Needs Change with Aging
Increased requirements:
calcium
vitamin D
vitamin B12
vitamin B6
(protein)
Decreased requirements:
calories
(vitamin A)
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
body composition in the adult
from Evans, W. & Rosenberg, I. (1991) Biomarkers. Simon & Schuster,
New York, NY.
Change in appendicular muscle mass as a function of age
From Starling et al. 1999. Am J Clin Nutr 70: 91-96.
Consequences of Sarcopenia
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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
Sarcopenia is a Multifactorial Disorder
 Decreased levels of sex hormones
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(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
Treatment of Sarcopenia
• Hormonal therapy
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•
•
•
Testosterone
DHEA
Estrogen
Growth hormone
• Exercise interventions
• Nutritional supplementation
Elder adults can realize great
benefits from exercise
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
The Boston FICSIT Trial
Prospective, randomized, controlled ten-week trial of
progressive strength training and/or nutritional
supplementation in 100 elderly, frail, institutionalized adults:
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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
Frailty In Very Elderly People
(Fiatarone, NEJM, 1994)
Exercise group
Control group
12
10
8
6
4
2
0
-2
-4
R leg press
(kg)
gait speed
(m/min)
stair climbing
powe r (W)
thigh muscle
area (cm2)
FICSIT trial: mean increase in strength in all muscle
groups trained. Effect of nutritional supplement
A Randomized Controlled Trial of Resistance Exercise Training to
Improve Glycemic Control in Older Adults With Type 2 Diabetes
(Castaneda, Diabetes Care 2002)
Exercise group
Control group
15
10
5
0
-5
-10
-15
-20
-25
Change in
TG (mmol/L)
Change in
SBP (mmHg)
A Randomized Controlled Trial of Resistance Exercise Training to
Improve Glycemic Control in Older Adults With Type 2 Diabetes
(Castaneda, Diabetes Care 2002)
Change in HgbA1c (%)
8.8
8.6
8.4
8.2
8
7.8
7.6
7.4
7.2
7
Exe rcise group
Control group
Baseline
Final
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
extension str., kgs
affected knee
flexion str.
-0.6
+5.9
0.001
-2.5
+4.1
0.001
WOMAC pain score
WOMAC physical fxn
-12%
-23%
-43%
-44%
0.01
0.01
Quality of life (self-report)
physical capabilities
socialization
mental functioning
4.2
-5.9
-3.2
16.6
12.5
8.2
0.01
0.01
0.001
J Rheumatol 2001;28: 1655
Elderly individuals are at
increased risk of both
malnutrition and obesity
Prevalence of Malnutrition in Elderly
Populations
Community-dwelling:
3 to 11%
Nursing home residents:
17 to 65%
Hospital inpatients:
15 to 40%
Prevalence of Obesity Increases with Age
50
40
Percent with 30
BMI > 30 20
10
0
20-39 40-59 60-74
Age in years
Data from Flegal et al. JAMA. 2002;288:1723–7.
Men
Women
5 Leading Causes of Death
Data for Americans Over Age 40, Year 2000
1.
2.
3.
4.
5.
Heart disease
Cancer
Cerebrovascular disease
Chronic lung disease
Diabetes mellitus
From: National Center for Health Statistics (www.cdc.gov)
4 of the 5 Leading Causes of Death Are
Associated With Obesity
1.
2.
3.
4.
5.
Heart disease
Cancer
Cerebrovascular disease
Chronic lung disease
Diabetes mellitus
From: National Center for Health Statistics (www.cdc.gov)
The Nutrition Screening Initiative
Micronutrient issues in the
elderly
Prevalence of Atrophic Gastritis by Age
Percent of
Individuals
40
30
20
10
0
60-69
70-79
80+
Age
Data from Krasinksi et al. J Am Geriatr Soc. 1986;34:800-6.
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
‘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
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
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
Vitamin D levels diminish with age
and disability
Causes of diminished D levels in the elderly
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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.
Agnusdei et al, 1998. Calcif Tissue Int. 63;197-201.
500 mgs of calcium+700 I.U. of D reduces
osteoporotic fractures in elder men and women
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
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
Vitamin D supplementation reduces falls: a metaanalysis 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
We cannot live the afternoon of life
according to the program of life’s morning:
For what was great in the morning
will be little at evening,
and what in the morning was true
will at evening have become a lie.
Carl Jung