Nutrition and Ageing by HC111123064846

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									Nutrition and Ageing
        EAMA VI/2
    Hannes B Staehelin
 Geriatric University Clinic
            Basel
                   Content
•   Nutrition modifies the ageing process
•   Nutrition and age associated diseases
•   Nutritional requirements in the old
•   Malnutrition in geriatric patients
•   Conclusions
        Biological and Cultural Co-Evolution
The difference between the lower turquoise line (contribution by genetic evolution) and
the red line (additional contribution by cultural co-evolution) indicates the contribution
of environmental, nutritional, and social factors by selective optimization and compensation

  Effect on Phenotype

                                                           Culture



                Genetics




         0                                 50                                  100
                                          AGE
                           Successful Ageing
Biomedical Science                                                 Social Science
   Ageing Mechanism                                            Life-Style
   Gene-Nutrient/Environment                                   Social Condition and
   Chronic Diseases:                                            Mental Disease
   CNS, Metabolic Disorders, Cardiovascular
   Disease, Muscle and Bone Disorders                          Role in Society
   Oral Health                                                 Gender Issues
                                                By             Health Services
                                      Selective Optimisation   Coping / Education
                                                And
   Information Technology                 Compensation         Income
   Prostheses                                                  Health Services
   Transportation                                              Public Service
   Household Support                                           Employment


  Technology                                                         Economy
  Effect of Caloric Restriction on Life-Span

• Affects many age-sensitive changes
• Reduces O2 consumption
• Reduces oxidative stress mostly in brain, heart,
  and muscle
• Relation between intra- and interspecies variations
  in life-span and oxidative stress
Extension of life-span with superoxide dismutase/catalase
                        mimetics
               Melov S Science 2000 Sep 1;289(5484):1567-9


 Boosting the natural antioxidant
   systems of C. elegans with small
   synthetic superoxide
   dismutase/catalase mimetics.
   Treatment of wild-type worms
   increased their mean life-span by
   a mean of 44 %, and treatment
   of prematurely aging worms
   resulted in normalization of their
   life-span (a 67 % increase).
   Oxidative stress appears to be a
   major determinant of life-span
   accessible to pharmacological
   intervention.
Change in nutritional requirements
• Change in body composition
   Energy requirements
   Sarcopenia
   Osteopenia
• Change in energy expenditure
• Disease related alterations
  •   Immune disorders
  •   Inflammation
  •   Metabolic disorders
  •   Malignant diseases
  •   Cardiovascular Diseases
        Change in Body Composition with Age
      Lipschitz DA Oxford Textbook of Geriatric Medicine p. 144

Lower basal energy metabolism  proportion of body fat ++
Living Conditions Determine Energy
 Requirements and Access to Food




      Thrifty genes are advantageous in situations with
      scarcity and high energy requirements but convey risks
      in long periods of affluence.
  Reduced Perception of Thirst in Healthy Elderly
                Phillips PA, NEJM 1984;311:753

• Body Composition
   – body water decreased
   – Intracellular fluid decreased
• Reduced thirst perception
                                                    young
• Hormonal system changes
       • ADH,
• Renal function changes
   – GFR, concentration,                             old
     dilution, response to
     hormones

                                                 120 min
                                     20 h
             Decline in nutrient intake
Roberts, S. et al. (1994) “Control of food intake in older men.”
                     Jama 272(20): 1601-6.




                   Time in days after underfeeding
  Sarcopenia           diminished muscle
       strength Basel -IDA Study (n =380)
Watt
 90
 80
 70
 60                                     R- m
 50                                     L- m
 40                                     R- f
 30                                     L- f
 20
 10
  0
  65-69     70-74         75-79   80+

                    Age
           Balance and muscle strength
            diminish:One Leg Stand
Seconds        Basel -IDA Study (n=380)
 20
 18
 16
 14
 12                                           R-m
 10                                           L-m
  8                                           R-f
  6                                           L-f
  4
  2
  0
          65-69   70-74         75-79   80+

                          Age
  Do chemosensory changes influence food
           intake in the elderly
        Rolls BJ. Physiol Behav 1999;66(2):193-7

NHANES III
        Median daily energy intake declines with age, risk of
          inadequate intake of micronutrients rises
Decline in olfactory functions and taste with age
        Impact on food intake low
Flavor enhancer influence food choice but not quantity
In subjects with chemosensory impairments combined with
   changes in food intake regulatory mechanisms, the risk for
   nutritional deficiencies may be high
    Age Related Change in Food intake and GI
                   Function
Lower activity level  maintains energy balance
Age related esophageal dysfunction usually
  asymptomatic
Basal and max. gastric acid output decreases with aging,
  risk for atrophic gastritis increases
      Omeprazol may induce malabsorption of Vit B12
       (Marcuard SP Ann Int Med 1994)
Liver flow decreases 1% /y, serum albumin declines
  0.6g/decade
      Nutrient intake and chronic disease:
     Body Weight and Atherogenic Lipoproteins
                     Hartmann G 1966

• Body weight correlates
  with b-lipoproteins
• BMI correlates with
  insulin level  diabetes
  mellitus
• Gender difference during
  adult life
• Example of gene –
  nutrient –environment
  interaction
       The age associated decline in homeostatic resilience
         increases the vulnerability by an allostatic load
The incresing prevalence of obesity leads to an higher prevalence of diabetes mellitus



        Allostatic Load and Loss of Homeostatic
             Control: Metabolic Syndrome
         Loss of
         Metabolic Control



                              Glucose                Retinopathy
                              140-200                Nephropathy
                              2h pp                  CVD / Stroke

                                         Hb A1c
                                         > 7%
                                                                    t
           Obesity         IGT         Type II    Organ
                           Hyper-      Diabetes   Damage
                        Insulinismus
Diabetes and Gestational Diabetes Trends
Among Adults in the U.S., BRFSS 1990-1998
1990                               1991-92                             1993-94




            1995-96                                          1997-98




       4%             4-6%                 6%                 n/a

               Source: Mokdad et al., Diabetes Care 2000;23:1278-83
Favorable dieatary habits diminish the incidence of chronic diseases



  Impact of Diet on Coronary Heart Disease

  Risk Ratio
   1,2

     1
           High
   0,8
           Trans fatty acids
   0,6     Glycemic index
   0,4     Low
           N-3 fatty acids             High
   0,2     Folate                      Low
     0     Cereal fibers
               Lowest Quintile             Higest Quintile

                                 Hu FB et al NEJM 2000;343:530
      Poor subjective health indicates malnutrition

           Subjective Health and Nutritional Intake
           SENECA Results (2586 Europeans aged 70-75)

Health                      poor         good           p(D)

Cal / day                   1540         1800           <.0001
Fat g/day                    54            79           <.0001
Calcium mg/ay                691          906           <.0001
Vit. B1 mg/day               0.83         0.98          <.0001
Vit. C mg/day               84            110           <.001

Low budget                  29.4%         7%            <.0001
All meals at home           91%          75%            <.001
  Malnutrition an Important Co-morbidity
                   Factor
                 Sullivan DH JAMA 1999;281:2013

• Malnourished patients vs adequately nourished
  total n= 395


  – Energy                  < 50% n=102 vs.       rest
    Albumin on admission g/l       36.6           36.6
  – Albumin end of stay g/l        29.1           33.2
  – Assistance after discharge %   27.5           16
  – Death within 90 days %         15.7           5.8
   Increased Annual Death Rates in
Malnourished Patients in Nursing Homes
                 in %
% 90
  80
  70
  60
  50
  40                                        Cholesterol < 4 mmol
  30                                        Cholesterol > 4mmol
  20
  10
   0
       Age >70   BMI < 90% Albumin <
                   ideal      39

       Chen LH Int J Nutr Vit Res 1981;51:232
         Anorexie in the old
               Alpha – MSH
                Neuropeptide
                                     Hypothalamus

Leptin
          Melanocortin 4 Receptor


   Appetite                    Energy balance

                 Kachexie

 Marks, D. L. Recent Prog Horm Res 2001;56:359
                  Stress
                                 Fasting
Hypothalamus
           CRH                  NPY


               Glucocortico-                    Hunger
                  steroids
                               Insulin Leptin
                  Energy
    Sympathetic
      outflow
           Thermogenesis          Eating
Anorexie:many factors contribute
                                Cytokines                Muscle
        N - loss                Hormones                 wasting
             Lipolysis                        Low albumin

• Social factors                         • Modulators / mediators
• Mechanical barrages                       – Serotonin, NE
• Sensory changes                           – Leptin, NPY, CRF
   – Taste, smell, texture, appearance      – IL-1, IL-6l, TNF-alpha
                                             a– MSH
• Illness (Cancer, Infectious               – CCK, GRP, Amylin,
  diseases, COPD, gastrointestinal
  diseases, heart failure, pressure         – Glucagon, GLP
  sores)                                      Somatostatin
                                            – Ghrelin
• Psychiatric illnesses
     Protein Turnover during Fasting and PEM
     PEM leads to muscle wasting, fasting spares muscle and
                           proteins

      Muscle                                      Input
      75g/d                                       100g


Fasting
                +         Protein-pool
                             12 kg               AA-pool
 PEM
               +/-
            Other
           Proteins                               Output
           120g/d
Activation of the Ubiquitine Proteasome
  Pathway Leads to Muscle Wasting

Macrophage
                           Muscle         Glucocorticoids
            TNFa                          activate
           IL-1
           IL-6
                            Nutrient
                                          Insulin blocks
              T3
                               Blood supply
 Thyroid


   Mitch WE, NEJM 1996;335:1897
        Assessment of Malnutrition
     Most important: be aware of the problem!
• Screening by the Mini Nutritional Assessment MNA
       • Guigoz Y et al Facts and Res Gerontol 1994; Suppl 2:15
• Laboratory indicators of undernutrition
Undernutrition        mild moderate           severe              t1/2
Albumin g/l           32-35     28-32         <28                 21d
Transferrin g/l        2.5-3   1.5-2.5        <1.5                8d
Prealbumin mg/l       120-150 100-120         <100                2d
Retinol binding protein not defined, lower limit 26 mg/l          0.5d
Cholinesterase E/l depends on method                              2d
• Lymphocyte count 1500-1800           900-1200      <900
• Zinc, Cholesterol, Vitamin B12, Folate
          To supplement or not?
• Facts
     •   Energy requirements and intake diminish
     •   Less endogenous Vit. D
     •   Hyperhomocysteinemia
     •   Inadequate diet
     •   Chronic infections
     •   Consuming illnesses
     •   Access to adequate nutrition often not given
Nutrition Related Diseases May
Lead to Mobility Impairement

   OSTEOPOROSIS       CANCER
ARTHRITIS

OBESITY                          MOBILITY
               DISEASE         IMPAIREMENT
DIABETES

HYPERTENSION
            HYPERLIPIDEMIA
Vit-D Substitution over 3 Month in Geriatric Patients,
             Muscle Strength, and Falls
                  Bischoff et al submitted


 25-(OH) D           Knee extension          Falls
                        power




                             +D                      +D
Protein Supplements Enhances Recovery from Hip Fracture
                Tkatch et al J Amer Coll Nutr
  Some specific causes of malnutrition in the
                     old
• Polypharmacy often contributes to mal- compliance and
  iatrogenic anorexia
• Zinc deficiency impaires wound healing and recovery
• Vitamin D deficiency in geriatric patients prevalent
• Inadequate folate and B12 levels prevalent
       Failure to Thrive
            a Vicious Circle
Malnutrition        Loss
Self Neglect
                                Loneliness
Cognitive        Depression        Physical
Decline                            Impairment
                 Cognitive
Loss of           Decline          No Body
Independence      Frailty          Contacts
                               Life is Meaningless
        Social Isolation
                           No Thrive
The 10 Most Important Risk Factors
    for Malnutrition in the Old
•   Less than 8 main meals per week
•   Very little milk consumption
•   Negligible fruit and vegetable consumption
•   Rottening of food
•   Long periods during the day without food or beverages
•   Unintended weight changes
•   Depression and loneliness
•   Difficulties in shopping
•   Poverty
•   Physical and mental impairement (incl.alcoholism)
             Common Mistakes
•   Ignorance
•   Inattention
•   Diet inappropriate or not accepted by patient
•   Time for eating too short and ill chosen
•   No or inadequate assistance (e.g. cutting meat)
•   Circumstances of meal (body position, lieu)
•   Overlooking of deficiencies
                           Conclusions
• Nutrition affects the aging process
   – by slowing or accelerating basic aging phenomena
   – By contributing to, or protecting from chronic diseases
        • Atherosclerosis, cancer, metabolic syndrome, diabetes, dementia
• Obesity will become a major health challenge
• Changing requirements, illness in old age and socioeconomic conditions
  contribute to malnutrition and are an important co-factor in morbidity and
  mortality
• Supplements are useful to optimize the diet and to compensate for
  deficiencies
• A careful evaluation of the nutritional status and history is mandatory
  in geriatric medicine and as important as other clinical workups

								
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