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.

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.

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.

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.

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 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.

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.

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.

Reduced bone mass in Dutch adolescents fed a macrobiotic diet in early life.

This study investigated the effect of a macrobiotic (vegan-type) diet, low in calcium and vitamin D, consumed in early life, on bone mineral during adolescence. Bone mineral content (BMC) and bone area were measured in 195 adolescents (103 girls, 92 boys) aged 9-15 years, using dual-energy X-ray absorptiometry. Ninety-three adolescents (43 girls, 50 boys) had followed a macrobiotic diet in childhood, and 102 (60 girls, 42 boys) were control subjects. After adjustment for bone area, weight, height, percent body lean, age, and puberty, BMC was significantly lower in macrobiotic subjects, in boys and girls, respectively, at the whole body, -3.4% and -2.5%, spine, -8.5% and -5.0%, femoral neck, -8.0% and -8.2%, midshaft radius, -6.8% and -5.6%, and also in girls, at the trochanter, -5.8% (p < 0.05). No group differences were observed at the wrist. Group differences were not explained by current calcium adjusted bone mass at age 9-15 years, observations which may hold important implications for fracture risk in later life.

Food consumption, growth, and development of Dutch children fed on alternative diets.

A review of four studies examining food consumption growth and development of Dutch children fed on alternative diets is given. A literature study indicated that regarding child nutrition the three important movements in the Netherlands are the ecological movement, the anthroposophics, and the macrobiotics. A study on food consumption, height, and weight in preschool children fed these diets showed that the group of macrobiotic children were most at risk. Antropometric data collected in a cross-sectional study with 300 macrobiotic-fed children aged 0-8 y showed that the growth curves for boys and girls deviated from the Dutch standard curves after approximately 5 mo of age. There was no catch-up growth. In a selected sample of this latter group (43 children aged 4-6 y) mental development was measured by the Snijders-Oomen-Nonverbal intelligence test. The results of this test did not indicate an abnormal mental development for this age group of macrobiotic children.

Macrobiotic nutrition and child health: results of a population-based, mixed-longitudinal cohort study in The Netherlands.

A population-based study on the nutritional status of children consuming macrobiotic diets was carried out in The Netherlands. Participants followed a macrobiotic diet based mainly on whole-grain cereals, pulses, and vegetables. Studies in children aged 0-10 y suggested that growth was retarded mainly between 6 and 18 mo. This was confirmed in a subsequent mixed-longitudinal study (including data on diet, anthropometry, blood chemistry, and pediatric examination) in 4-18 mo-old macrobiotic infants and a matched omnivorous control group. Ubiquitous deficiencies of energy, protein, vitamin B-12, vitamin D, calcium, and riboflavin were detected in macrobiotic infants, leading to retarded growth, fat and muscle wasting, and slower psychomotor development. Breast milk from macrobiotic mothers contained less vitamin B-12, calcium, and magnesium. Supplementation of the macrobiotic diet with fat (minimum 20-25 g/d), fatty fish (minimum 100-150 g/wk), and dairy products (minimum 150-250 g/d) is recommended.

Resting metabolic rate and diet-induced thermogenesis in young and elderly subjects: relationship with body composition, fat distribution, and physical activity level.

To investigate the relationship between age and energy expenditure, resting metabolic rate (RMR) and diet-induced thermogenesis (DIT; for 180 min after a 1.3-MJ meal) were measured by indirect calorimetry in 56 young and 103 elderly subjects. In addition, the influence of body composition, body-fat distribution, and physical activity level on this relationship was studied. RMR was significantly lower in elderly (3.98 +/- 0.46 and 3.33 +/- 0.39 kJ/min for men and women, respectively) than in young (5.29 +/- 0.53 and 4.08 +/- 0.33 kJ/min for men and women, respectively) subjects, which persisted after adjustment for body composition. DIT was significantly lower in older than in younger men (126 +/- 27 vs 154 +/- 34 kJ/180 min) but not in women (111 +/- 26 vs 115 +/- 25 kJ/180 min). The difference in men disappeared after adjustment for body composition. No clear relation between physical activity level and RMR or DIT was observed. These results demonstrate a relationship of age per se with RMR but not with DIT.

Food consumption, habitual physical activity, and body fatness in young Dutch adults.

The relationship between body fatness and both food consumption and habitual physical activity, was studied in young adult males (n = 122) and females (n = 140) in three age groups (20 to 22, 25 to 27, and 30 to 32 yr) in a Dutch population. In males the average daily energy intake was rather high (about 3000 kcal) and average body weight increased by 1.2 kg in the preceding year. Both findings suggest the existence of a positive energy balance. In females the average daily energy intake was normal (about 2170 kcal) and average body weight remained constant. Physical activity at work and sport was not related to the percentage of body fat in either sex, but physical activity, such as walking and cycling during leisure time, was slightly lower in fatter males. The fatter subjects tended to eat less than the leaner subjects but this was only significant in females. However, after adjusting for lean body mass and physical activity in a multiple regression model, energy intake was inversely related to percentage of body fat in both sexes. Change in body weight in the period of 4 months preceding the food consumption study seemed to reflect energy balance at the time of the food consumption study in only leaner and fatter females. After adjusting also for change in body weight in these females energy intake of fatter females remained lower, suggesting a reduced need for energy among many fatter females.

Validity and reproducibility of a dietary history method estimating the usual food intake during one month.

The validity and reproducibility of a dietary history method with a time of reference of one month was assessed with 44 young adults (aged 19-32 yr). The concurrent validity of the method was assessed by means of the 24-h urine nitrogen excretion. The mean difference between N-intake and N-excretion (24-h urine N-excretion plus 2 g for extra renal nitrogen losses) was 0.0 g with 95%-confidence limits of +/- 1.1 g. These limits for the mean difference between excretion and intake indicate a valid assessment of the protein intake of this group. The reproducibility was evaluated in the same group through a test-retest design. The intraclass correlation coefficients were high over a weighted average of weekdays and for an average workday with regard to the intakes of energy and selected nutrients. For the Saturday and Sunday intakes, the intraclass correlation coefficients were lower for the energy intakes and most of the nutrients (except alcohol), indicating a poorer reproducibility for weekend assessments.

Vitamin B-12 from algae appears not to be bioavailable.

The effect of algae (nori and spirulina) and fermented plant foods on the hematological status of vitamin B-12-deficient children was evaluated. Although rising plasma vitamin B-12 concentrations in children consuming only plant foods (0.1-2.7 micrograms vitamin B-12/d) indicated that the vitamin B-12 was absorbed, elevated baseline values of mean corpuscular volume (MCV) further deteriorated. In contrast, MCV improved in children receiving fish containing 0.15-0.5 microgram vitamin B-12/d or a vitamin B-12 supplement. Further studies on the specificity of current vitamin B-12 assays are warranted. It seems unjustified to advocate algae and other plant foods as a safe source of vitamin B-12 because its bioavailability is questionable.

Relative and biomarker-based validity of a food-frequency questionnaire estimating intake of fats and cholesterol.

The relative validity of a 104-item food-frequency method to assess intakes of fats and cholesterol was tested against the dietary history of 191 men and women. Pearson correlation coefficients ranged from 0.38 for linoleic acid (% of energy) to 0.83 for energy intake, with 0.78 and 0.75 for the intakes of total fat and saturated fatty acids, respectively. Mean intakes were overestimated by the food-frequency questionnaire relative to the dietary history by 5% for energy and monounsaturated fatty acids (% of energy) and up to 30% for linoleic acid intake. Linoleic acid concentrations in erythrocytes and adipose tissue were used as biomarkers of intake. The correlation of the linoleic acid intake according to the food-frequency questionnaire with linoleic acid in erythrocytes and adipose tissue was 0.44 and 0.28, respectively, and the dietary history gave similar values. The food-frequency questionnaire gives results similar to those from the dietary history and is thus considered appropriate for classifying subjects according to their fat intake.

Energy expenditure at rest and during standardized activities: a comparison between elderly and middle-aged women.

To estimate energy expenditure (EE) in elderly subjects, more age-specific data are required on energy costs of standardized activities. EE was assessed by using indirect calorimetry in 28 women aged 72 +/- 4 y (mean +/- SD) and in 29 middle-aged women (42 +/- 1 y) at rest (resting metabolic rate; RMR) and during sitting, sitting with standardized arm activity, and walking on a treadmill at 3 km/h. RMR and EE during sitting, and sitting with standardized arm activity did not differ significantly between the groups, although EE expressed as a ratio of arm activity to RMR (physical activity ratio, PAR) tended to be higher in the elderly subjects. Walking EE was significantly higher in the elderly women (16.4 +/- 4.0 kJ/min) than in the middle-aged women (12.7 +/- 2.3 kJ/min), also when expressed as PAR. It is suggested that elderly women walk less efficiently. Because PARs are frequently used to estimate daily EE, it is important to note that additional age-specific data might be required.

Assessing diets of elderly people: problems and approaches.

This paper deals with the question of whether dietary assessment methods developed and validated for younger adults can be used in surveys for elderly people. From the literature it is clear that a decline in short-term memory with age makes the 24-h recall method particularly unreliable. Better results have been obtained with other methods, especially when a combination of methods is used and equipment is adapted for use by older people. However, validity of these methods when applied in older people is dependent on the group of elderly people under study and the type of information required for the purpose of the study. As an example, the validity of the adapted dietary-history method used in the Survey in Europe on Nutrition and the Elderly a Concerted Action (SENECA) is discussed. This method showed good agreement with the weighed record and with other evaluation criteria.

Risk of persistent cobalamin deficiency in adolescents fed a macrobiotic diet in early life.

BACKGROUND: Cobalamin deficiency has been described in children consuming macrobiotic diets. OBJECTIVE: We investigated whether moderate consumption of animal products is sufficient for achieving normal cobalamin function in 73 adolescents who had received a macrobiotic diet until 6 y of age and had then switched to a lactovegetarian, lactoovovegetarian, or omnivorous diet (macrobiotic adolescents). DESIGN: Hematologic indexes and serum concentrations of methylmalonic acid (MMA), total homocysteine (tHcy), and folate were measured. Current consumption frequency of animal products and cobalamin intake from dairy products were assessed by questionnaire. Data from 94 age-matched adolescents who received an omnivorous diet from birth were used as a reference. RESULTS: Serum cobalamin concentrations were significantly lower and concentrations of MMA and folate and mean corpuscular volume (MCV) were significantly higher in macrobiotic adolescents than in control adolescents: of macrobiotic adolescents, 21% had abnormal MMA concentrations (>0.41 micromol/L), 37% had abnormal cobalamin concentrations (<218 pmol/L), 10% had abnormal tHcy concentrations (> 12.8 micromol/L), and 15% had abnormal MCV (> 89 fL). In macrobiotic adolescents, dairy products (200 g milk or yogurt and 22 g cheese/d) supplied on average 0.95 microg cobalamin/d; additionally, these adolescents consumed fish, meat, or chicken 2-3 times/wk. In girls, meat consumption contributed more to cobalamin status than the consumption of dairy products, whereas in boys these food groups were equally important. CONCLUSIONS: A substantial number of the formerly strict macrobiotic adolescents still had impaired cobalamin function. Thus, moderate consumption of animal products is not sufficient for restoring normal cobalamin status in subjects with inadequate cobalamin intake during the early years of life.