Energy and Protein Intake, Anthropometrics, and Disease Burden in Elderly Home-care Receivers--A Cross-sectional Study in Germany (ErnSIPP Study).

OBJECTIVE: To date, no study has examined the nutritional status and disease burden of elderly home-care receivers living in Germany. Aim of this cross-sectional study was, first, to assess disease burden and nutritional status, denoted in anthropometrics, and, second, to investigate associations between anthropometrics and disease burden. DESIGN: Cross-sectional multi-centre study. SETTING: Home-care receivers living in three urban areas of Germany in 2010. PARTICIPANTS: 353 elderly (>64 years) in home care (128 males aged 79.1 ±7.8 years, 225 females aged 82.0 ±7.5 years). MEASUREMENTS: Nutritional status was assessed by body mass index (BMI), mid upper arm circumference (MUAC) and calf circumference (CC). Medical conditions were assessed in personal interviews. A 3-day prospective nutrition diary was kept. Metric data are reported as mean±SD or median (interquartile range), p<0.05 was considered significant. RESULTS: Most participants were substantially (59%), and 11% severest in need of care. The seniors suffered from 5 (4-7) chronic diseases; dementia, depression, stroke, and respiratory illness were most prevalent (each 20-40%). More than one-third of participants had only moderate or poor appetite, nearly half were unable to eat independently. Chewing problems were reported for 52% of study participants, and more than one quarter of elderly had swallowing problems. Daily mean energy intake was 2017±528 kcal in men (n=123) and 1731±451 kcal in women (n=216; p<0.001). Mean protein intake amounted to 1.0 g/kg body weight. Mean BMI was 28.2±6.2 kg/m² (n=341), 14% of seniors had a BMI <22 kg/m² (including 4% with BMI <20 kg/m²). Critical MUAC (<22 cm) was indicated in 6% of subjects; and CC <31 cm in 11% of men, 21% of women (p<0.05). After adjusting for sex and age, BMI, MUAC and CC were negatively associated with high care level, hospitalization in the previous year, nausea/vomiting, prevalence of dementia, poor appetite, and eating difficulties like dependency, chewing and swallowing problems. CONCLUSION: We recommend to pay special attention to the nutritional status of elderly persons in home-care exhibiting named disease burden.

Revised reference values for selenium intake.

The German, Austrian and Swiss nutrition societies are the joint editors of the 'reference values for nutrient intake'. They have revised the reference values for the intake of selenium and published them in February 2015. The saturation of selenoprotein P (SePP) in plasma is used as a criterion for the derivation of reference values for selenium intake in adults. For persons from selenium-deficient regions (China) SePP saturation was achieved with a daily intake of 49µg of selenium. When using the reference body weights the D-A-CH reference values are based upon, the resulting estimated value for selenium intake is 70µg/day for men and 60µg/day for women. The estimated value for selenium intake for children and adolescents is extrapolated using the estimated value for adults in relation to body weight. For infants aged 0 to under 4 months the estimated value of 10µg/day was derived from the basis of selenium intake via breast milk. For infants aged 4 to under 12 months this estimated value was used and taking into account the differences regarding body weight an estimated value of 15µg/day was derived. For lactating women compared to non-lactating women a higher reference value of 75µg/day is indicated due to the release of selenium with breast milk. The additional selenium requirement for pregnant women is negligible, so that no increased reference value is indicated.

Revised D-A-CH intake recommendations for folate: how much is needed?

The D-A-CH reference value (D-A-CH arises from the initial letters of the common country identification for the countries Germany (D), Austria (A) and Switzerland (CH)) for folate equivalents had been set at 400 µg/d for adults in the year 2000. By that time, the prevention of cardiovascular diseases through reduction of homocysteine was considered an important target of the reference value. Since that time a number of research papers revealed that in spite of an inverse association between folate-rich diet and chronic diseases, a preventive effect of folic acid intake on cardiovascular events was not supported by randomized controlled trials, and the reduction of plasma homocysteine levels to around 10-12 µmol/l did not reduce the risk for thromboembolic and cardiovascular diseases in persons already affected by these diseases. These results together with the observation that folate intakes below 400 µg/d result in a sufficient folate status justified a review of the current literature and-consequently-a reduction of the reference value to 300 µg/d for adults. This reference value is expressed as dietary folate equivalents that take into account the difference in bioavailability between folic acid and all types of folates in food. The recommendation to take a daily supplement of 400 µg of synthetic folic acid for women who intend to get pregnant and until the end of the first trimester of pregnancy is maintained.

Institutional factors associated with the nutritional status of residents from 10 German nursing homes (ErnSTES study).

OBJECTIVES: In nursing homes malnutrition among residents is widespread. Because residents place part of their personal freedom of choice into institutional hands, institution-specific factors may influence nutritional status of residents. DESIGN: Multi-centre cross-sectional study. SETTING: 10 nation-wide German nursing homes. PARTICIPANTS: 714 exclusively orally fed residents (aged 65 years and older, not in final weeks of life). MEASUREMENTS: Participants' characteristics (e. g. gender, age, level of care, dementia diagnosis), body mass index (BMI), mini nutritional assessment (MNA), energy intake (3-day dietary record, BLS II.3), and selected institution-specific factors (size of institution, daily rate for food supply, number of residents per care staff member). Metric data are given as median (P25, P75). RESULTS: 11 % of residents (81 % female, 85 (81, 91) years) had a BMI <20 kg/m2 (n=658). According to MNA, 10 % of the residents were malnourished (n=650). Capacity of institutions was 116 (56, 139) beds, care staff ratio was 4.1 (3.5, 4.2) residents per care person (mean over all care levels), and daily food budget was 4.45 (4.10, 4.71) Euro/d. Low daily food budget was associated with a higher risk for a BMI <20 kg/m2 (OR 3.30 [95 %CI 1.70-6.42]). Higher food budget also decreased malnutrition risk (OR 0.66 [0.46-0.95]) according to MNA. Residents' mean energy intake was 6.1 (5.2, 7.1; n=565) MJ/day in women and 7.1 (6.2, 8.2; n=132) MJ/day in men. Intake was higher with small facility size, higher food budget, and lower care staff ratio (P <0.05). CONCLUSION: The institutional environment affects the nutritional status of nursing home residents as an independent risk factor. The results suggest promotion of small facilities and the provision of more care staff and more financial resources for food in the structural design of residential homes.

Malnutrition is related to functional impairment in older adults receiving home care.

OBJECTIVES: The aims of this work were (a) to provide a detailed description of the association between nutritional (Mini Nutritional Assessment; MNA®) and functional status in a sample of older adults receiving home care, using both questionnaire- and performance-based functional methods, and (b) to investigate the impact of different MNA subscales on this association. DESIGN: Multi-centre, cross-sectional. SETTING: Home care. PARTICIPANTS: 296 persons ≥65 years in need of care (80.7±7.7 y). MEASUREMENTS: Nutritional status was determined by the MNA and functional status by two questionnaires (Instrumental and Basic Activities of Daily Living; IADL, ADL) and three performance tests (handgrip strength, HGS; Short Physical Performance Battery, SPPB; Timed 'Up and Go' Test, TUG). A categorical and a covariance analytical approach were used to test for differences in functional status between MNA groups (well nourished, risk of malnutrition, malnourished). In addition, functional parameters were correlated with total MNA, a modified MNA version (modMNA), where functional items were excluded, and MNA subscales ('functionality', 'general assessment', 'anthropometry', 'dietary assessment', and 'subjective assessment'). RESULTS: 57% of the participants were at risk of malnutrition and 12% malnourished. 35% reported severe limitations in IADL, 18% in ADL. 40%, 39% and 35% had severe limitations in HGS, SPPB and TUG; 9%, 28% and 34% were not able to perform the tests. Functional status deteriorated significantly from the well nourished to the malnourished group in all functional measures. The modMNA was weak but still significantly related to all functional parameters except TUG. The subscale 'functionality' revealed strongest correlations with functional measures. All other MNA subscales showed only weak or no associations. CONCLUSION: More than one half of the seniors receiving home care were at nutritional risk and poor functional level, respectively. Malnutrition according to MNA was significantly associated to both questionnaire- and performance-based functional measures even after exclusion of functional MNA items.

[Dietary supplement use among adolescents in Germany. Results of EsKiMo]. / Supplementenkonsum bei Jugendlichen in Deutschland. Ergebnisse aus EsKiMo.

In 2006, 20 % of adolescents aged 12-17 years used dietary supplements. Persons with high physical activity levels as well as those with high education levels consumed dietary supplements more often than others. Many supplement users used only one single-nutrient supplement. A similarly large proportion of users consumed one supplement with multiple nutrients. Most often supplements containing vitamin C, magnesium, B-vitamins, vitamin E and calcium were used.

[EsKiMo - the nutrition module in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. / EsKiMo - Das Ernährungsmodul im Kinder- und Jugendgesundheitssurvey (KiGGS).

In a module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), the dietary behaviour of 6-17-year-olds was assessed from January to December 2006. The study, named EsKiMo (Eating Study as a KiGGS Module), was performed by the Robert Koch Institute together with the division of nutrition and consumer education at the University of Paderborn. It was funded by the Federal Ministry of Food, Agriculture and Consumer Protection. Parents of participants younger than 12 years were asked to conduct a 3-day dietary record. Participants of 12 years and older were personally interviewed about their eating behaviour during the last four weeks using DISHES (Dietary Interview Software for Health Examination Studies). In addition, they were asked to fill in the KiGGS food frequency questionnaire a second time. Furthermore, all participants were asked about their socio-demographic background, leisure time activities, supplement use, meals at school, body weight and height. The study will provide up-to-date, representative data on the nutrition of children and adolescents in Germany. The analyses will include the amounts of foods and food groups consumed as well as the nutrient intake. By connecting these nutrition data with other health data from KiGGS, comprehensive analyses of relationships between nutrition and health are possible.

[Estimation of the dietary intake of pesticide residues based on new consumption data for children]. / Abschätzung der Aufnahme von Pflanzenschutzmittel-Rückständen in der Nahrung mit neuen. Verzehrsmengen für Kinder.

The risk assessment of pesticide residues is based on the estimation of their dietary intake. Models based on a new national consumption survey were developed to estimate the short- and long-term dietary intake of pesticide residues for children from 2 to under 5 years, allowing a realistic risk assessment to be made. The recommended methods are described. At the national level, the new models shall replace the previous methods for evaluating dietary intake.

[School nutrition and nutrition lessons]. / Ernährung und ernährungsbezogener Unterricht in der Schule.

Nutrition behavior usually becomes manifest during childhood and once learned food patterns and eating habits are often maintained for the rest of life. Therefore, imparting knowledge early about food composition, food habits, nutritional physiology, and connections between health and nutrition as well as instilling competence in dealing with food are of particular importance. In the EiS project, it was recently shown that fewer students than ever obtain less and less nutrition education in German schools. Promoting healthy eating is not only a matter of nutritional knowledge. It is also very much about creating a healthy environment and providing proper food, drinks, and meal service in schools. Therefore, both aspects will be discussed in the following article.

Energy and nutrient intake of young-old, old-old and very-old elderly in Germany.

BACKGROUND: Reliable information about the nutritional status of elderly people in Germany is lacking. OBJECTIVE: To describe energy and nutrient intake of elderly people living in private households in Germany with special focus on age-related differences in the elderly. DESIGN: Descriptive nationwide cross-sectional study. SETTING: Germany, 1998. SUBJECTS: : A random sample of 4020 elderly men and women living independently in private households stratified in three age groups (65-74, 75-84, 85+ y), of which 1550 participated and 1372 (789 female subjects) provided reliable 3-day estimated dietary records. RESULTS: The median daily energy intake was 2207 kcal (9.2 MJ) in men and 1994 kcal (8.3 MJ) in women without difference between the age groups. Protein intake amounted to 91 and 81 g/day, respectively, corresponding to 1.2 g/kg body weight per day. The median intake was well above the recommended amount for all nutrients except dietary fibre, calcium, vitamin D and folate, where 38, 35, 75 and 37% did not reach two-thirds of the recommended amount. An age-related decline was observed for calcium intake in male and for dietary fibre, water, calcium, magnesium, iron, vitamins A, E, C and thiamin intake in female participants; however, the overall picture was unaffected by these differences. CONCLUSIONS: Dietary intake in these independently living elderly, including the very-old, is adequate for most of the evaluated nutrients. Increased intake of foods rich in dietary fibre, calcium, vitamin D and folate as well as regular sunlight exposure is recommended in order to optimize nutrient supply in this population group. SPONSORSHIP: German Ministry of Health.

Recording the nutrient intake of nursing home residents by food weighing method and measuring the physical activity.

The nutrient intake of 47 female nursing home residents, able to eat without help, and of 20 eating-dependent seniors was measured by weighing method. Hand grip strength was examined by a dynamometer. Furthermore the level of physical activity of the seniors able to eat without help was determined by means of a questionnaire. The results showed that the median energy intake of self-feeding elderly women was 1620 kcal (850-4450 kcal). More than one third of the seniors consumed less than 1700 kcal / d. The intake of vitamins and minerals remained below 40-90% of the recommended level. One important cause for the inadequate micronutrient intake was that 30% of the total energy intake is met by foods of a low nutrient density (cakes, cookies, spreadable fats, soups). The eating-dependent seniors were at high risk for protein-calorie malnutrition, consuming an average of 1130 kcal / d and 34 g protein / d. The level of physical activity was very low. Only 34% of the seniors were active for more than 2 hours per week (walking, gymnastics). 30% of the residents were largely inactive although they were able to walk. It is often ignored that immobility is a major risk factor for the development of malnutrition. Firstly inactivity accelerates the loss of muscle mass. This loss of metabolically active tissue decreases the energy requirements thus leading to a loss of appetite and reduced food intake.

[Epidemiology of obesity]. / Epidemiologie der Adipositas.

Obesity is a well-recognized health hazard in affluent societies. The prevalence of overweight and obesity are high and still increasing consistently in industrialized countries. The body mass index (BMI) is an internationally accepted index to estimate body weight. The recent published WHO-classification of body weight allows the worldwide comparison of obesity prevalences. The WHO-MONICA study revealed different obesity prevalences in several European countries. The lowest prevalence of obesity was found in Sweden and Northern France (7-14%) whereas the highest prevalence (40%) was reported from East-European countries. The results of the DHP-survey suggest that 50% of the adult German population are overweight and 20% are obese. Data from the MONICA-study show lower prevalences for Switzerland, where 38% of the adult population are considered to have overweight and 11% are obese. By the way the prevalence of obesity is still increasing with a renewed acceleration during the last two decades. Obesity is starting to get the status of a main health problem not only in western countries but also in less developed countries of Middle- and South-America. In Germany obesity and the obesity-related morbidity and mortality caused costs of nearly 20.7 Mrd. DM in 1995. Therefore obesity is a major economic burden for the society. Like in other developed countries the costs attributable to obesity correspond to 2-8% of total health care expenditure.

Low body mass indices in adolescents with obsessive-compulsive disorder.

The aim of this study was to evaluate the growth of adolescents with obsessive-compulsive disorder (OCD). Body heights and body mass indices (BMIs; expressed in kg m(-2)) of 51 adolescent patients with OCD were compared with the corresponding anthropometric variables in age- and sex-matched psychiatric controls and in a general population sample, respectively. In accordance with a previous epidemiologically based investigation, body heights and weights were found to be reduced, especially in male patients with OCD. The body mass indices of the patients with OCD were significantly lower than those of age-matched control patients and population controls. However, some of the parameters were also reduced in male psychiatric controls, indicating that the reductions are not entirely specific for adolescent OCD. The results suggest a neuroendocrine dysfunction in adolescent OCD. The low body mass index indicates that psychiatric disorders other than anorexia nervosa are associated with underweight during adolescence.

[Carotenoid intake in the German National Food Consumption Survey]. / Die Carotinoidzufuhr in der Nationalen Verzehrsstudie.

In nutritional epidemiological studies high consumption of fruits and vegetables was shown to be an important preventive measure to reduce the risk of cancer, coronary heart disease, and cataracts. These effects cannot be explained completely and in a sufficient way by the intake of beta-carotene and vitamin C. Other carotenoids differing in their antioxidative and biological properties are also provided with fruits and vegetables in significant amounts. Because data for other carotenoids than beta-carotene are not considered in computerized German food database and food composition tables, representative carotenoid intake calculations for the German population are missing. Therefore a carotenoid database, containing alpha- and beta-carotene, lycopene, lutein/zeaxanthin, and cryptoxanthin values for different fruits, vegetables, and other carotenoid-containing foods, was developed. With this database the carotenoid intake of the German population--stratified by sex and age--was evaluated on the basis of the German National Food Consumption Survey (NVS). The mean total carotenoid intake amounts to 5.33 mg/day. The average intake lutein was 1.91 mg/day, beta-carotene intake amounts to 1.81 mg/day, lycopene intake was 1.28 mg/day, alpha-carotene intake was 0.29 mg/day, and cryptoxanthin intake was 0.05 mg/day. Tomatoes and tomato products provide most of the lycopene. Green salads and vegetables are the most important contributors of lutein in Germany. Zeaxanthin is mainly consumed with maize but also with spinach and other vegetables like cabbage; alpha- and beta-carotene are mainly consumed with carrots. Peppers, oranges, and orange-juice are the most important cryptoxanthin sources.

Body weight in acute anorexia nervosa and at follow-up assessed with percentiles for the body mass index: implications of a low body weight at referral.

OBJECTIVE: A systematic epidemiological comparison of body weights of patients with anorexia nervosa can be enhanced by the use of age percentiles for the body mass index. METHOD: To demonstrate the feasibility of this approach, body mass indices of 81 female adolescents with anorexia nervosa were calculated from anthropometric data upon admission for inpatient treatment and at follow-up and set into relationship to the age-dependent distribution of the body mass index in a large and representative sample of the German population. The percentiles were used to visualize the weight increase over time of each former patient by aligning the body mass index at referral with the respective body mass index at follow-up. RESULTS: Upon admission most adolescents had body mass indices below the third age centile. The distribution of body mass indices at outcome suggests a continuum between death of complications related to starvation, chronic anorexia, residual anorexia, and a low body weight Patients with very low body weights at referral had a poor prognosis, because their body weights tended to remain below the minimal normal weight for height. These conditions were statistically best described by categorical analysis, because they were nonlinear to a certain extent. DISCUSSION: The results indicate that the body mass index at referral influences the amount of weight that an individual patient gains in the future.

Use of percentiles for the body mass index in anorexia nervosa: diagnostic, epidemiological, and therapeutic considerations.

OBJECTIVE: Percentiles for the body mass index (BMI) offer a possibility to epidemiologically assess the linear weight criterion of 85% average body weight commonly used for the diagnosis of anorexia nervosa. METHOD: BMI values corresponding to 85% average body weight were calculated and assessed with percentiles derived from epidemiological studies in both the United States and Germany. The underweight range was characterized epidemiologically. RESULTS: The weight criterion used for the diagnosis of anorexia nervosa corresponds to BMI values between the 5th and 10th centiles in both populations. In epidemiological terms the lowest BMI values in individuals aged 10 years and older occur during adolescence. In the general population BMI values <16 kg/m2 are rarely observed. Upon the use of higher BMI cutoffs in the underweight range females clearly predominate. The BMI increase associated with the 5th or 10th centile in the age range between 18 and 30 years is quite low suggesting that many underweight females in the general population gain only minimal weight during this age span. DISCUSSION: The diagnostic, epidemiological, and therapeutic implications for anorexia nervosa are discussed.

[Antioxidative vitamins and cataracts in the elderly]. / Antioxidative Vitamine und Katarakte im Alter.

Senile cataract indicates the opacity of ocular lenses occurring in old and especially in very old people. Lens proteins are extremely long-living and often show oxidative damages. Aging and smoking appear to be the greatest risk factors for the development of lens opacities. The sufficient antioxidant protection of young lenses decreases with the aging process. Consequently, the importance of other protective factors increases. Nutritional factors, particularly vitamins with antioxidant properties, may influence the development of senile cataracts in the ocular lens. Meanwhile an association between the supply with vitamin C, E and beta-carotene and the risk of cataract development was demonstrated in animal studies and also in an increasing number of epidemiological studies. These epidemiological studies mainly support the hypothesis that higher vitamin intakes reduce the risk of developing cataracts in old age. The antioxidant properties of the named nutrients give a plausible explanation for the mechanism of cataractogenesis. On the basis of the present data definitive recommendation, necessary for cataract prevention can not yet be established. Some results seem to support higher recommendations. At the moment several large human intervention trials are carried out. Form these studies a further confirmation of the antioxidant hypothesis and of a dose-response-relationship are expected.