Nutritional concerns, health and survival in old age.

The ageing process is-apart from chance or good luck-not only influenced by factors intrinsic to the individual, but also by extrinsic factors that include environmental and lifestyle variables. This paper deals with the epidemiological evidence for the role of dietary patterns and key nutritional concerns in relation to survival and ageing related disorders that present themselves in later life. Dietary patterns, such as the Mediterranean diet, characterized by mainly plant foods including protective factors e.g. vegetables, nuts and monounsaturated fatty acids and excluding harmful factors e.g. trans-fatty acids and foods with a high glycemic factor, appear to be relevant even in old age. Specific nutritional concerns focus on general undernutrition, vitamin D and vitamin B(12). Prevalence of nutritional inadequacies, diagnostic criteria, causes and health consequences are described. The paper ends with recommendations for guidance on healthy diets for elderly people. An important challenge should be research to further expand the knowledge base, acknowledging the complexity of the ageing process and integrating different dimensions of research into human healthy ageing in properly designed studies. In the mean time reversing poor adherence to existing guidelines for a healthy diet remains a first challenge in public health nutritional practices.

The effect of a nutrient dense drink on mental and physical function in institutionalized elderly people.

OBJECTIVES: To determine whether in the current study the supply of a nutrient dense drink has a positive effect on mental and physical function of institutionalized elderly people. DESIGN: A 24-week, randomized, double-blind, placebo-controlled, parallel-group, intervention trial. SETTING: Homes for the elderly and nursing homes in the Netherlands. PARTICIPANTS: Institutionalized elderly people older than 60 years, with a BMI < or = 30 kg/m2, and a Mini-Mental State Examination score of at least 10 points. INTERVENTION: In addition to their usual diet the participants (n=176) received either a nutrient dense drink or a placebo drink twice a day during 24 weeks. MEASUREMENTS: The functionality measures included cognitive function, mood, physical performance and the ability to perform activities of daily living. RESULTS: In the supplement group a favorable effect of the intervention drink on body weight (1.6 kg difference in change; P = .035), calf circumference (0.9 cm difference in change; P = .048), and blood values (e.g. Hcy decreased from 16.8 to 11.2 mumol/L in the supplement group) was found. In the total group no significant effect was found on functionality outcomes. However, a subgroup of participants with BMI at baseline below 24.4 kg/m2 performed better on the cognitive subscale of Alzheimer's Disease Assessment Scale (P = .09), and its language sub score (P = .01) after 24 weeks of intervention. CONCLUSION: The results in the total group of this trial suggest that the nutritional supplement used in this study improves nutritional status. Furthermore, the results of this trial suggest that it is effective as treatment for decreasing function in a subgroup of institutionalized elderly people with low BMI.

Optimal preferred MSG concentration in potatoes, spinach and beef and their effect on intake in institutionalized elderly people.

BACKGROUND: Elderly people may benefit from sensory stimulation to increase food intake since anorexia of ageing is prevalent among them. An optimal MSG concentration may increase the palatability of foods but this depends on the food and chemosensory status of the taster. Currently, the results on taste enhancing to increase intake are inconsistent. OBJECTIVE: To find an optimal preferred MSG concentration in mashed potatoes, spinach and ground beef and to determine whether this concentration increases consumption of these foods among institutionalized elderly people. DESIGN: Single blind within subject cross-over study performed at the laboratory and in the residents' own apartments. PARTICIPANTS: 33 elderly and 29 young people in the sensory study and 53 elderly people in the intake study. MEASUREMENTS: Pleasantness of the foods was rated of the foods each with 0, 0.5, 0.8, 1.3 and 2.0 g of MSG/100g. Intake was measured by weighing back leftovers of 2 meals with MSG (0.5% in mashed potatoes, 2% in spinach and ground meat) and without MSG. RESULTS: 0.5% MSG (p < 0.05) was preferred in mashed potatoes but no optimal preferred concentration was found for spinach and ground beef, possibly because of their complex taste. Intake was not different between the foods with and without MSG or the total meal (all p > 0.68). CONCLUSION: MSG (0.5% and 2%) does not guarantee a higher intake among elderly. The chemosensory heterogeneity of the elderly population requires more individual flavor enhancement to improve the dietary intake and sensory experience.

Effect of a nutrient-enriched drink on dietary intake and nutritional status in institutionalised elderly.

OBJECTIVE: (1) To determine whether nutritional supplementation (energy and micronutrients) in institutionalised elderly has a positive effect on dietary intake and nutritional status. (2) To investigate whether individuals tend to compensate for the energy content of the intervention product by decreasing their habitual food consumption. METHODS: A 24-week, randomised, double-blind, placebo-controlled, intervention trial in homes for the elderly (n=3), in nursing homes (n=3) and 'mixed' homes (n=3) in The Netherlands. Institutionalised elderly people (n=176) older than 60 years of age, with a body mass index < or =30 kg/m(2) and a Mini-Mental State Examination score of 10 points or higher, randomly received a nutrient-enriched drink or a placebo drink twice a day during 24 weeks in addition to their usual diet. Allocation to treatment took into account of sex, the Mini-Mental State Examination score and the plasma homocysteine level. Body weight and several nutrition-related analyses in fasting blood samples were measured in all participants. Data on dietary intake were collected in a subsample (n=66). RESULTS: A significantly favourable effect (P<0.001) of the intervention drink was observed on vitamin intake, mineral intake and vitamin status in blood (for example, homocysteine decreased from 14.7 to 9.5 micromol/l in the intervention group as compared with that in the placebo group (17.2-15.9)). The difference in change in total energy intake between the two treatment groups was 0.8 MJ/day (P=0.166). Energy intake from food decreased in both groups to the same extent (-0.5 MJ/day). Therefore, this decrease cannot be considered as compensation for the energy content of the product. CONCLUSIONS: This group of institutionalised elderly people does not compensate for the energy content of a concentrated nutritional supplement. Therefore, this supplement is effective for counteracting the development of malnutrition in this population.

Dietary assessment in elderly people: experiences gained from studies in the Netherlands.

BACKGROUND/OBJECTIVES: In selecting a dietary assessment method, several aspects such as the aim of the study and the characteristics of the target population should be taken into account. In elderly people, diminished functionality and cognitive decline may hamper dietary assessment and require tailored approaches to assess dietary intake. The objective of this paper is to summarize our experience in dietary assessment in a number of different studies in population groups over 65 years of age in the Netherlands, and to discuss this experience in the perspective of other nutrition surveys in the elderly. METHODS: In longitudinal studies, we applied a modified dietary history; in clinical nursing home studies, trained staff observed and recorded food consumption; and in a controlled trial in healthy elderly men, we used a food frequency questionnaire (FFQ). RESULTS: For all methods applied in the community-dwelling elderly people, validation studies showed a similar underestimation of intake of 10-15% compared with the reference value. In the care-depending elderly, the underestimation was less: 5% according to an observational method. The methods varied widely in the resources required, including burden to the participants, field staff and finances. CONCLUSIONS: For effective dietary assessment in older adults, the major challenge will be to distinguish between those elderly who are able to respond correctly to the less intensive methods, such as 24-h recalls or FFQ, and those who are not able to respond to these methods and require adapted techniques, for example, observational records.

Dietary intake and status of folate and vitamin B12 and their association with homocysteine and cardiovascular disease in European populations.

BACKGROUND/OBJECTIVES: Folate and vitamin B12 have been suggested to play a role in chronic diseases like cardiovascular diseases. The objectives are to give an overview of the actual intake and status of folate and vitamin B12 in general populations in Europe, and to evaluate these in view of the current vitamin recommendations and the homocysteine concentration. METHODS: Searches in Medline with 'folic acid', 'folate' and 'vitamin B12', 'B12' or 'cobalamin' as key words were combined with the names of the European countries. Populations between 18 and 65 years were included. RESULTS: Sixty-three articles reporting on studies from 15 European countries were selected. Low folate intakes were observed in Norway, Sweden, Denmark and the Netherlands. Low intakes of vitamin B12 were not common and only seen in one small Greek study. In the countries with a low intake of folate, the recommended levels were generally not achieved, which was also reflected in the folate status. Vitamin B12 intake was not strongly associated with the vitamin B12 status, which can explain why in the Netherlands and Germany the vitamin B12 status was inadequate, despite sufficient intake levels. In countries with a low folate intake in particular, the Hcy concentration was higher than ideal. CONCLUSIONS: Populations from the Nordic countries, the Netherlands, Germany and Greece may need to improve their intakes of folic acid, B12 or both to either meet the recommendations or to optimize their statuses. This could be achieved via a food-based approach, food fortification or supplements.

Effect of fish oil on cognitive performance in older subjects: a randomized, controlled trial.

BACKGROUND: High intake of n-3 polyunsaturated fatty acids may protect against age-related cognitive decline. However, results from epidemiologic studies are inconclusive, and results from randomized trials in elderly subjects without dementia are lacking. OBJECTIVE: To investigate the effect of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) supplementation on cognitive performance. METHODS: Double-blind, placebo-controlled trial involving 302 cognitively healthy (Mini-Mental State Examination score > 21) individuals aged 65 years or older. Participants were randomly assigned to 1,800 mg/d EPA-DHA, 400 mg/d EPA-DHA, or placebo capsules for 26 weeks. Cognitive performance was assessed using an extensive neuropsychological test battery that included the cognitive domains of attention, sensorimotor speed, memory, and executive function. RESULTS: The mean age of the participants was 70 years, and 55% were male. Plasma concentrations of EPA-DHA increased by 238% in the high-dose and 51% in the low-dose fish oil group compared with placebo, reflecting excellent compliance. Baseline scores on the cognitive tests were comparable in the three groups. Overall, there were no significant differential changes in any of the cognitive domains for either low-dose or high-dose fish oil supplementation compared with placebo. CONCLUSIONS: In this randomized, double-blind, placebo-controlled trial, we observed no overall effect of 26 weeks of eicosapentaenoic acid and docosahexaenoic acid supplementation on cognitive performance.

Changes in markers of cobalamin status after cessation of oral B-vitamin supplements in elderly people with mild cobalamin deficiency.

Mildly cobalamin-deficient elderly were supplemented with 1000 microg cobalamin (group C, n=34), 1000 microg cobalamin with 400 microg folic acid (group CF, n=31) or a placebo (n=30) for 6 months. Participants provided one single blood sample 3, 5 or 7 months after cessation of supplementation to monitor early changes in plasma concentrations of cobalamin, holotranscobalamin (holoTC) and methylmalonic acid (MMA). At the end of supplementation (groups C+CF), one participant met our criteria for mild cobalamin deficiency, as did 13, 14 and 43% of the participants assessed at respectively 3, 5 and 7 months post-supplementation. Cobalamin and holoTC declined on average with 47 and 56% relative to concentrations at the end of supplementation for the group assessed at 7 months post-supplementation. Essentially similar declines were observed for those participants assessed at 3 and 5 months post-supplementation. Mean MMA concentrations increased by 15% (P=0.07) in those participants assessed at 3 and 5 months post-supplementation, and increased by 50% (P=0.002) in those participants assessed at 7 months post-supplementation. Considering MMA as a sensitive tissue marker for cobalamin status, oral supplementation may afford adequate cobalamin status for a period of up to 5 months after cessation in the majority of participants.

Comparison of three different dietary scores in relation to 10-year mortality in elderly European subjects: the HALE project.

OBJECTIVE: To investigate and compare the associations between dietary patterns and mortality using different European indexes of overall dietary quality. DESIGN, SETTING AND PARTICIPANTS: The HALE (Healthy Ageing: a Longitudinal study in Europe) population includes 2,068 men and 1,049 women, aged between 70 and 90 years of 10 European countries. Subjects were followed for 10 years. This cohort study was conducted between 1988 and 2000. RESULTS: During the follow-up period, 1,382 people died. The Mediterranean Diet Score (MDS) (HR: 0.82 with 95% CI: 0.75-0.91), the Mediterranean Adequacy Index (MDI) (HR: 0.83 with 95% CI: 0.75-0.92) and the Healthy Diet Indicator (HDI)(HR: 0.89 with 95% CI: 0.81-0.98) were inversely associated with all-causes mortality. Adjustments were made for age, gender, alcohol consumption, physical activity, smoking, number of years of education, body mass index, chronic diseases at baseline and study centre. CONCLUSIONS: The MDS, the MDI and the HDI were significantly inversely related with mortality. SPONSORSHIP: This study is based on data of the HALE project and supported by a grant from the European Union (QLK6-CT-2000-00211) to D Kromhout.

Homocysteine and cognitive function in institutionalised elderly A cross-sectional analysis.

BACKGROUND: Several cross-sectional, case-control and prospective studies revealed a relation between homocysteine and cognitive function or dementia. These studies included either patient populations or healthy, community- dwelling elderly people. AIM OF THE STUDY: In this study we tested the hypothesis that homocysteine was inversely associated with cognitive function in a population of institutionalised elderly (aged >/= 60 y; n = 157). METHODS: For testing this hypothesis baseline data of a recently conducted intervention study in institutionalised elderly (median age 83 years) were used. Cognitive function was evaluated by the cognitive subscale of the Alzheimer's disease Assessment Scale (ADAS-cog). The association between fasting plasma homocysteine level and cognitive function was investigated by multiple linear regression analysis. RESULTS: In the crude model homocysteine concentration was not significantly related to ADAS-cog score (beta = 0.061; p = 0.45). Age was found to be related to ADAS-cog score (beta = 0.161; p < 0.05). Adjusting for age did however not result in a relation between homocysteine and cognitive function. CONCLUSIONS: In our study no association was found between homocysteine and cognitive function in a population of very old institutionalised subjects.

Effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review.

BACKGROUND: Guidelines for lifestyle and dietary modification in patients with coronary artery disease (CAD) are mainly supported by evidence from general population studies. CAD patients, however, differ from the general population in age (older) and treatment with preventive drugs. This review seeks to provide evidence for a prognostic benefit of lifestyle and dietary recommendations from studies in CAD patients. METHODS AND RESULTS: A literature search was performed on the effect of lifestyle and dietary changes on mortality in CAD patients. Prospective cohort studies and randomized controlled trials of patients with established CAD were included if they reported all-causes mortality and had at least 6 months of follow-up. The effect estimates of smoking cessation (relative risk [RR], 0.64; 95% CI, 0.58 to 0.71), increased physical activity (RR, 0.76; 95% CI, 0.59 to 0.98), and moderate alcohol use (RR, 0.80; 95% CI, 0.78 to 0.83) were studied most extensively. For the 6 dietary goals, data were too limited to provide reliable effect size estimates. Combinations of dietary changes were associated with reduced mortality (RR, 0.56; 95% CI, 0.42 to 0.74). CONCLUSIONS: Available studies show convincingly the health benefits of lifestyle changes in CAD patients. Effect estimates of combined dietary changes look promising. Future studies should confirm these findings and assess the contribution of the individual dietary factors.

Potentials and pitfalls for nutrition counselling in general practice.

This paper was based on collaborative research efforts from Wageningen University and the University Medical Centre St Radboud in The Netherlands and describes the rationale for web-based nutrition counselling applications in general practice as well as some of the frequently used models and theories (predominantly the Stages of Change Model). General practitioners can play an important role in cardiovascular risk reduction by giving nutrition counselling to patients at elevated cardiovascular risk. Unfortunately, general practitioners perceive barriers that may limit their nutrition counselling practices. Some of these barriers may be overcome using computer and Internet technologies. Computerized reminders for preventive services, and websites with reliable high-quality information may prove to be valuable additions to usual care. Cooperation with dietitians may also lead to improvements in nutrition counselling in general practice. For example, general practitioners could use their unique position to create awareness and motivation among patients. They could subsequently refer motivated patients to dietitians for detailed personal dietary advice.

Role of social support in lifestyle-focused weight management interventions.

Social support is important to achieve beneficial changes in risk factors for disease, such as overweight and obesity. This paper presents the theoretical and practical framework for social support, and the mechanisms by which social support affects body weight. The theoretical and practical framework is supported with a literature review addressing studies involving a social support intervention for weight loss and weight loss maintenance. A major aspect in social support research and practice is the distinction between structural and functional support. Structural support refers to the availability of potential support-givers, while functional support refers to the perception of support. Interventions often affect structural support, for example, through peer groups, yet functional support shows a stronger correlation with health. Although positive correlations between social support and health have been shown, social support may also counteract health behaviour change. Most interventions discussed in this review showed positive health outcomes. Surprisingly, social support was clearly defined on a practical level in hardly any studies, and social support was assessed as an outcome variable in even fewer studies. Future social support intervention research would benefit from clear definitions of social support, a clear description of the intended mechanism of action and the actual intervention, and the inclusion of perceived social support as a study outcome.

Nutritional deficiency in Dutch primary care: data from general practice research and registration networks.

OBJECTIVE: To explore incidence and prevalence rates of nutritional deficiency in adults in general practice. METHODS: Six Dutch general practice research and registration networks supplied incidence and prevalence rates of nutritional deficiency by the International Classification of Primary Care (ICPC) or 'E-list' labels ('loss of appetite, feeding problem adult, iron, pernicious/folate deficiency anaemia, vitamin deficiencies and other nutritional disorders, weight loss'). In case of disease-related nutritional deficiency, we asked whether this was labelled separately ('co-registered') or included in the registration of the underlying disease. RESULTS: 'Iron deficiency anaemia' had highest incidence (0.3-8.5/1000 person years), and prevalence rates (2.8-8.9/1000 person years). Nutritional deficiency was mostly documented in the elderly. In two networks 'co-registration' was additional, two only documented the underlying disease and two did not specify 'co-registration'. No clear difference was found between networks considering the difference in 'co-registration'. CONCLUSION: Nutritional deficiency is little documented in general practice, and generally is not registered separately from the underlying disease.

Nutritional deficiency in general practice: a systematic review.

OBJECTIVE: Nutritional deficiency is an independent risk factor for mortality. Despite its clinical relevance, the prevalence in a primary care setting is poorly documented. We performed a systematic review of reported prevalence and clinical assessment of nutritional deficiency in general practice. METHODS: From MEDLINE, Current Contents and EMBASE, we derived articles and checked the initially included ones for references on prevalence data. Of the eligible articles, we assessed the quality of research and results. RESULTS: We finally included eight studies. The prevalence ranged from 0 to 13%. However, the study populations were heterogeneous and all studies contained methodological flaws, especially selection bias. In addition, the clinical assessment differed between studies. CONCLUSION: Literature on the prevalence of nutritional deficiency within general practice is rare and provides disputable prevalence assessments.

The effect of supplementation with an enriched drink on indices of immune function in frail elderly.

Ageing induces a change in immune responses. Besides this, impaired nutritional status is considered to have a critical influence on immune function, which may be reversed by nutritional supplementation. We evaluated the effect of an enriched drink on immune function in the elderly. 33 frail elderly subjects (aged > or = 65 years and body mass index < or = 25) received two 125 ml packages of either an enriched drink (n=20) or placebo (n=13) daily for 6 months. The enriched drink contained macro- and micronutrients. At baseline and after 6 months blood samples were drawn and PBMC's were isolated. ConA stimulated proliferation and IL-2 production of PBMC's were measured. There was a significant difference between groups in proliferation over the study period. The supplement group remained stable whereas the placebo group showed a reduction in proliferation over the 6-month period. There was no significant difference in IL-2 production between groups. Our study adds to the evidence that nutritional supplementation can affect immune function in the elderly.