Relevance and Feasibility of a Personalized Dietary Intervention in Older People with Meals-On-Wheels: A Randomized Controlled Pilot Trial.

Objective: The present study aimed at assessing the feasibility and the effectiveness of a personalized dietary intervention in a meals-on-wheels service through a randomized controlled pilot trial. Design: Sixty recipients of home-delivered meals (75% of women; 70-97 years old) were recruited and randomly assigned to a control and an experimental group and followed over a period of 4 months. In the experimental group, the nutritional status (Mini-Nutritional Assessment - MNA questionnaire), the food intake and the food preferences were measured for each participant. Based on this screening, participants were provided with dietary guidance and follow-up. Those at risk of malnutrition were proposed enriched home-delivered meals. Enrichment was set up considering food preferences of the participants. Results: Looking at the whole sample at baseline, 80% (n=48/60) were at risk of malnutrition. Furthermore, 55% (n=33/60) ate less than 2/3 of their calorie and/or protein recommended allowances. In the experimental group, the intervention led to an increase of protein intakes and to a lower extent of calorie intake. In the control group, no significant changes were observed. Conclusion: To conclude, this study suggests that providing dietary guidance and adding nutrient-dense food to meals while considering food preferences is feasible and may help older beneficiaries of meals-on-wheels to increase calorie and protein intake and improve their nutritional status. However, there is a need to develop products or recipes to enrich the meals of the elderly more efficiently to achieve the recommended allowance.

Frailty and nutrition: searching for evidence.

Frailty is a geriatric syndrome that predicts disability, morbidity and mortality in the elderly. Poor nutritional status is one of the main risk factors for frailty. Macronutrients and micronutrients deficiencies are associated with frailty. Recent studies suggest that improving nutritional status for macronutrients and micronutrients may reduce the risk of frailty. Specific diets such as the Mediterranean diet rich in anti-oxidants, is currently investigated in the prevention of frailty. The aim of this paper is to summarize the current body of knowledge on the relations between nutrition and frailty, and provide recommendations for future nutritional research on the field of frailty.

Vitamin D supplementation in older adults: searching for specific guidelines in nursing homes.

BACKGROUND: The prevalence of vitamin D insufficiency is very high in the nursing home (NH) population. Paradoxically, vitamin D insufficiency is rarely treated despite of strong clinical evidence and recommendations for supplementation. This review aims at reporting the current knowledge of vitamin D supplementation in NH and proposing recommendations adapted to the specificities of this institutional setting. DESIGN: Current literature on vitamin D supplementation for NH residents was narratively presented and discussed by the French Group of Geriatrics and Nutrition. RESULT: Vitamin D supplementation is a safe and well-tolerated treatment. Most residents in NH have vitamin D insufficiency, and would benefit from vitamin D supplement. However, only few residents are actually treated. Current specific and personalized protocols for vitamin D supplementation may not be practical for use in NH settings (e.g., assessment of serum vitamin D concentrations before and after supplementation). Therefore, our group proposes a model of intervention based on the systematic supplementation of vitamin D (1,000 IU/day) since the patient's admission to the NH and throughout his/her stay without the need of a preliminary evaluation of the baseline levels. Calcium should be prescribed only in case of poor dietary calcium intake. CONCLUSION: A population-based rather than individual-based approach may probably improve the management of vitamin D insufficiency in the older population living in NH, without increasing the risks of adverse health problems. The clinical relevance and cost effectiveness of this proposal should be assessed under NH real-world conditions to establish its feasibility.

Nutrition in care homes and home care: how to implement adequate strategies (report of the Brussels Forum (22-23 November 2007)).

BACKGROUND & AIMS: Undernutrition in home care and care home settings is an unrecognized problem with significant consequences. The present work was edited after a forum concerning nutrition in these settings was held in Brussels in order to tackle the problem. METHODS: Various aspects of the question were addressed with the participation of scientific experts. The proceedings of the forum were edited and completed by a review of previously published material. RESULTS: Prevalence of undernutrition in home care and care home settings varies between 15% and 65%. Causes of undernutrition are various: medical, social, environmental, organizational and financial. Lack of alertness of individuals, their relatives and health-care professionals play an important role. Undernutrition enhances the risk of infection, hospitalization, mortality and alter the quality of life. Moreover, undernutrition related-disease is an economic burden in most countries. Nutritional assessment should be part of routine global management. Nutritional support combined with physical training and an improved ambiance during meals is mandatory. Awareness, information and collaboration with all the stakeholders should facilitate implementation of nutritional strategies. CONCLUSIONS: Undernutrition in home care and care home settings is a considerable problem and measures should be taken to prevent and treat it.

Nutrition: a major factor influencing immunity in the elderly.

This paper reviews recent findings on immune ageing. Ageing per se affects mainly cell-mediated immunity: decreases in mature T-cells (CD3+) partly compensated with increases in less mature T-cells (CD2+CD3-) are observed. In addition antigen pressure throughout life induces increases in memory T-cells (CD45R0+) and borderline decreases in CD8+ subsets. Those changes lead to lower proliferative ability. In contrast B-cell subsets and innate immunity are less affected with ageing. These changes are mainly related to health status and are less important in very healthy elderly. Such changes are more important in undernourished elderly, and in elderly who exhibit decreases in micronutrient status. They are even stronger in elderly patients with protein energy malnutrition (PEM). In seniors with PEM, decreased immune functions, for all aspects of immunity, i.e. T-cell, B-cell subsets and functions and innate immunity, are strongly related to protein nutritional status. Refeeding can boost immune response but at a lower speed in patients exhibiting inflammatory process. The disequilibrium between normal macrophage functions and decreased T-cell functions is partly responsible for long-lasting inflammatory process in stressed patients. Therefore acute phase responses are more detrimental on nutritional status and nutrient reserves in aged patients than in adults. Such disequilibrium, stress after stress, pushes the elderly to frailty state.

IGF-I, IGF-I-binding proteins and GH-binding protein in malnourished elderly patients with inflammation receiving refeeding therapy.

OBJECTIVE: To investigate the mechanisms determining the success or failure of refeeding therapy in malnourished elderly patients with inflammation by studying changes in plasma IGF-I, GH-binding protein (GHBP) and IGF-binding protein (IGFBP) levels and IGFBP-3 proteolysis. DESIGN AND METHODS: We studied 15 severely malnourished hospitalized elderly patients. Weight, food intake, plasma albumin, transthyretin, C-reactive protein (CRP), orosomucoid, interleukin-6 (IL-6), IGF-I, intact and proteolytically degraded IGFBP-3 and GHBP levels were determined on admission and during refeeding therapy designed to increase food intake to 40 kcal/kg body weight per day (15% protein). RESULTS: Plasma IGF-I, IGFBP-3 and GHBP levels were significantly low for age on admission in all malnourished elderly patients. They increased in nine patients as nutritional status improved (albuminemia >30 g/l; transthyretinemia >200 mg/l or weight gain >5% of initial body weight) and levels of inflammation markers decreased (group 1). In contrast, plasma IGF-I, IGFBP-3 and GHBP levels remained low in six patients in whom nutritional status failed to improve and levels of inflammation markers increased (group 2). IGF-I showed greater variations than IGFBP-3 or GHBP with respect to nutritional status. High plasma CRP and IL-6 levels were associated with high levels of IGFBP-3 proteolysis. CONCLUSION: Efficient refeeding therapy was associated with a significant increase in IGF-I plasma levels. In patients with severe and persistent inflammation, high levels of proteolysis of IGFBP-3 may have contributed to the low plasma IGF-I levels, persistence of hypercatabolism and lack of improvement in nutritional status.

[Malnutrition in the elderly. Clinical consequences]. / Dénutrition du sujet âgé. Conséquences cliniques.

UNLABELLED: A COMMON PROBLEM: Undernutrition occurs when nutrient intake does not meet nutritional needs. Selective food intake induced micronutrient deficits (moderate undernutrition) and can later lead to protein calorie malnutrition (PCM). PCM is often discovered during acute illness (increased nutritional needs). PCM is observed in 30 to 50% of the institutionalized population and in 2-4% of the elderly living at home. Micronutrient deficits are far more frequent and concern 4 million elderly persons in France. AGE-RELATED CHANGES: Decreased smell and taste capacities and the inability to modify eating habits in stress conditions are mainly responsible for low food intake. Low intake leads to immunodeficiency, and subsequent frailty. Any intercurrent illness aggravates both undernutrition and immunodeficiency, creating a disease-to-disease spiral (undernutrition-immunodeficiency) that is difficult to inverse. SIGNS OF PCM: Early signs of protein-calorie malnutrition are nonspecific: fatigue, apathy, decline in muscle strength. It is important to diagnose undernutrition at this stage before more specific symptoms develop: anorexia, weight loss, infection. Metabolic disorders occur at a later stage, generally during an acute illness, leading to overt PCM with perturbed glucose metabolism, recurrent infection, dehydration, impaired wound healing and calcium bone loss. The length of refeeding therapy depends on the intensity of the clinical signs, weight loss, dehydration, glucose metabolism disorder and/or on the severity of clinical complications such as infection or bone fractures. PRACTICAL ATTITUDE: Under nutrition must be recognized early at the stage of nonspecific clinical expression. Practitioners must be constantly aware of the risk of undernutrition and search for nonspecific signs in the elderly.

Nutrition and immunity in the elderly.

Immune function declines with age, leading to increased infection and cancer rates in aged individuals. In fact, recent progress in the study of immune ageing has introduced the idea that rather than a general decline in the functions of the immune system with age, immune ageing is mainly characterized by a progressive appearance of immune dysregulation throughout life. Changes appear earlier in life for cell-mediated immunity than for humoral immunity. Thus, age-related modifications in cell-mediated immunity, i.e. changes in naive : memory T-cells, mature : immature T-cells, T-helper 1 : T-helper 2 cells are more important in the elderly than changes in humoral immunity, i.e. CD5 : CD5+ cells or length of antibody responses. Such evolution of the immune system has been linked to declining thymus function and to accumulative antigenic influence over the lifespan. In contrast, innate immunity (macrophage functions) is preserved or even increased during the ageing process. This finding shows that the 'primitive' immune system is less affected by the ageing process than the sophisticated specific immune system. The present review focuses on innate and cell-mediated immune changes with ageing. It provides evidence that primary changes (intrinsic modifications in the immune system) and secondary changes (resulting from environmental influences during the lifespan) exert different influences on the immune system. Primary changes, occurring in healthy individuals, seem less important nowadays than they were considered to be previously. For example, interleukin 2 secretion in some very healthy aged individuals is comparable with that in younger adults. Primary immune changes may not explain the increased incidence and severity of infections observed in the elderly population. Secondary immunological changes are far more frequent and are certainly responsible for most of the immune modifications observed in the elderly population. Environmental factors leading to secondary immune dysfunctions include not only antigenic influence, which is a reflection of diseases experienced over the lifespan, but also many other factors such as drug intake, physical activity and diet; factors for which important changes occur in the elderly population. Nutritional factors play a major role in the immune responses of aged individuals and the present review shows that nutritional influences on immune responses are of great consequence in aged individuals, even in the very healthy elderly.

Pregnancies modulate B lymphopoiesis and myelopoiesis during murine ageing.

We recently reported that pregnancy affects age-related changes in the distribution of lymphoid and macrophage populations in the spleen of C57Bl/6 mice. In the present study, we examined the influence of pregnancies on the generation of various developmental B-cell subsets and granulocyte/macrophage lineage cells during murine ageing. Using flow cytometry, changes in lymphoid (mature and early B-cell precursors: B220high, B220low, surface immunoglobulin M (sIgM) mu chain +/-) and myeloid (monocyte/macrophage Mac-1/CD11b, granulocyte Gr-1/Ly-6G) compartments were monitored in the bone marrow of young (2 months) and 15- and 23-month-old mice including male, multiparous and virgin female mice. Pregnancies delayed the age-related decline in murine B lymphopoiesis and maintained B-cell reserve capacity during ageing. We also found an increased production of myeloid cells induced by pregnancies at middle (15 months) and advanced (23 months) ages. This comparative study provides new information on changes in marrow lymphopoiesis and myelopoiesis with age. Our data emphasizes that the onset, magnitude and kinetics of age-related changes in the haematopoietic marrow are parity dependent. These changes could influence the incidence of age-related diseases and may account for the greater longevity of females.

[Aging and the immune system. Experimental aspects]. / Vieillissement et système immunitaire. Quelques aspects expérimentaux.

So far no comparative studies have been conducted to know whether physiological influences related to sex hormonal differences affect the age-related changes of the immune system. The aim of this study was to investigate whether pregnancies and sex influence the age-related changes in the peripheral lymphoid compartment and functions of T cells in mice. Using flow cytometry, we examined changes in (Thy1.2+) T cells, (B220+) B cells and (CD11b/Mac-1+) macrophages in the spleen of multiparous and virgin females and males at 2, 8, 15 and 23 months of age. The development of naive (CD44low) and memory (CD44high) cells were investigated in CD4+ and CD8+ T cell subsets. To analyze the age-related changes in functions of T cells, we examined the secretion of some T cell immunoregulatory cytokines (IL-2, IL-4, gamma-interferon and GM-CSF) of in vitro Concanavalin A-activated spleen cells of C57BL/6 mice. Both short term (8 months) and long term (15-23 months) effects of pregnancies were obvious in the age-related changes of the immune system. Short term effect included delayed appearance of memory CD4+ cells and the preserved IL-2 production. At eight months, shortly after pregnancies, both parameters were higher in multiparous females. Later effects of pregnancies were evidenced by a higher level of macrophages (Mac-1+) than in other groups throughout life. The increased gamma-interferon, IL-4 and GM-CSF productions appeared earlier, at 15 months, IL-4 and GM-CSF levels remained higher in multiparous females than in virgin females and males in late adulthood. Sex differences were also noticed: males exhibited lower macrophage levels after one year and gamma-interferon secretion capacity than females in late life. This study underlines that the onset, magnitude and kinetics of the age-related changes in the distribution of immune cells and T cell functions are parity- and sex-dependent. These changes may influence the incidence of age-related diseases and may explain the greater longevity of women, especially the multiparous ones.

[An unusual variant of urothelial carcinoma: the "nested variant of urothelial carcinoma." Report of two cases]. / Une variante particulière de carcinome urothélial: le "nested variant of urothelial carcinoma". A propos de deux cas.

We report two cases of a poorly known variant of transitional cell carcinoma, the "nested variant of urothelial carcinoma". This tumor is composed of small islands or nests of transitional cells, presenting little atypia and mimicking von Brünn's nests. This low grade tumoral variant seems to behave as a high grade tumor of the same stage. Deep biopsies are necessary to display tumoral invasion, which allows the diagnosis. Importance of the knowledge of this entity is highlighted in order to avoid misdiagnoses that could delay appropriate therapy.

Immune response during disease and recovery in the elderly.

The present article reviews immune ageing and its relationship with nutritional ageing, with a particular insight into the influences of disease on both ageing processes. Immune ageing can be described primarily as the progressive appearance of immune dysregulations, mainly acquired immunity (mature: immature, naive: memory T lymphocyte subset decreases) leading to gradual increases in T-helper 2: T-helper 1 cells. This change is due initially to decreased thymic function, and later to accumulative antigen pressure over the lifespan. In contrast, innate immunity (macrophage functions) is preserved during the ageing process and in the elderly this leads to macrophage-lymphocyte dysequilibrium, which is particularly critical during on-going disease. Indeed, any disease induces long-lasting acute-phase reactions in aged patients and leads to body nutritional reserve (mainly protein) losses. Episodes of disease in the aged patient progressively deplete body nutritional reserves and lead to protein-energy malnutrition, undernutrition-associated immunodeficiency, and finally cachexia. Undernutrition is a common symptom in the elderly; protein-energy malnutrition is found in more than 50% of hospitalized elderly patients and in most elderly diseased subjects. In addition, micronutrient deficit or low levels are common in home-living self-sufficient apparently-healthy elderly subjects. All these nutritional deficits induce decreased immune responses, and micronutrient deficits are now thought to be partly responsible for the decreased immune responses (immune ageing?) observed in the apparently-healthy elderly. Indeed, several studies have shown that micronutrient supplements induce increased immune responses in the healthy elderly. The progression of infectious diseases depends on immune responses and on nutritional status before the onset of illness in aged subjects. In addition, recovery depends on the intensity of acute-phase responses in the undernourished elderly. In fact, chronic acute-phase responses, commonly associated with diseases in aged patients, lead to progressive lowering of metabolic responses in the undernourished elderly. This can be quantified by increased production of free radicals during treatment and these increases may explain the difficulty in successfully treating aged patients. Nutritive therapy in order to improve metabolic processes and also to maintain body reserves should be considered as a necessary adjuvant therapy in the treatment of elderly patients.

Nutritional influences on immune response in healthy aged persons.

Healthy elderly (80+/-5 years) with different nutritional status were compared to young healthy adults (25+/-5 years) to quantify the relative influences of aging and nutrition on immune response. Aged persons, without alteration of their nutritional status, had lower CD3+, CD8+, and CD45RA+ as well as higher CD2+CD3-, CD2+CD4-CD8-, and CD45RO+ T cell subsets and IL-6 release than their younger counterparts. T cell proliferation and IL-2 production were comparable in the two healthiest groups. Aged subjects with low nutritional status expressed similar but more marked changes in immune response while nutritional status did not influence the immune response in young subjects. Furthermore, lower nutritional status was associated with lower CD4+ counts and lower T cell functions in aged persons. These results indicate that the influences of aging and undernutrition in humans are cumulative and suggest that some changes in immune response that have been attributed to aging may, in fact, be related to nutrition and not aging.

[Discovery of a renal chromophobe cell carcinoma in a pregnant woman. Apropos of a case]. / Découverte d'un carcinome rénal à cellules chromophobes chez une femme enceinte. A propos d'un cas.

We report the case of a young pregnant woman with a malignant tumour of the kidney suggestive of oncocytoma. Because of the pregnancy, preoperative staging consisted of abdominal ultrasound and magnetic resonance imaging. Caesarean section was performed. Several days later, surgical exploration of the kidney was performed with tumourectomy and frozen section analysis: radical nephrectomy was finally performed. The definitive histology was chromophobe renal cell carcinoma. This is a rare tumour of the kidney, with its own characteristics allowing histopathological diagnosis and with a better prognosis than renal cell carcinoma. In the literature, pregnancy, a situation of immune depression, does not increase the prevalence of malignant neoplasms.

Sex and parity modulate cytokine production during murine ageing.

We have previously shown that physiological hormone differences related to pregnancy or sex affect the age-related distribution of mononuclear cell populations during murine ageing. To determine whether such changes are involved in the age-related changes in functions of T cells, we examined the secretion of major T cell immunoregulatory cytokines (IL-2, IL-4, interferon-gamma (IFN-gamma), IL-3, IL-6 and granulocyte-macrophage colony-stimulating factor (GM-CSF)) of in vitro concanavalin A-activated spleen cells of C57B1/6 mice. The study included multiparous and virgin females and males at 2, 8, 15 and 23 months of age. Short-term effects of parity (8 months) were evidenced by the decrease of IFN-gamma and the preserved IL-2 production in multiparous females (8 months), while IFN-gamma was unchanged and IL-2 decreased in virgin mice. The increase in IL-4 production appeared earlier in multiparous females (15 months) than in virgin mice (23 months). The increase in IL-4/IFN-gamma and IL-4/IL-2 ratios at 8 and 15 months, respectively, in multiparous females, suggests that pregnancy modifies the Th1/Th2 equilibrium. In late adulthood (15 months), IL-6 and GM-CSF production was higher in multiparous females than in virgin males or females. Sex differences were also noticed: IFN-gamma secretion capacity was lower in males than in females during ageing. This study underlines that the onset, magnitude and kinetics of the age-related changes in cytokine production are parity- and sex-dependent. These changes probably influence the incidence of age-related diseases and may explain the greater longevity of females.

Nutrition and immunity in the elderly: modification of immune responses with nutritional treatments.

Nutrition has a strong influence on the immune system of the elderly. Aging induces dysregulation of the immune system, mainly as a result of changes in cell-mediated immunity. Aging is associated with changes to the equilibrium of peripheral T and B lymphocyte subsets, such as decreases in the ratios of mature to immature, naive to memory, T helper 1 subset (TH1) to TH2, and CD5- to CD5+ cells. As a consequence, cell-mediated immune responses are weaker and neither cell-mediated nor humoral responses are as well adapted to the antigen stimulus. Undernutrition, common in aged populations, also induces lower immune responses, particularly in cell-mediated immunity. Protein-energy malnutrition is associated with decreased lymphocyte proliferation, reduced cytokine release, and lower antibody response to vaccines. Micronutrient deficits, namely of zinc, selenium, and vitamin B-6, all of which are prevalent in aged populations, have the same influence on immune responses. Because aging and malnutrition exert cumulative influences on immune responses, many elderly people have poor cell-mediated immune responses and are therefore at a high risk of infection. Nutritional therapy may improve immune responses of elderly patients with protein-energy malnutrition. Supplementation with high pharmacologic doses of a single nutrient (zinc or vitamin E) may be useful for improving immune responses of self-sufficient elderly people living at home. Therefore, nutritional deficiency must be treated in the elderly to reduce infectious risk and possibly slow the aging process.