Diet and nutrition and how it affects the CVS in older people

Dr Khalid AliSenior Lecturer in Geriatrics

Brighton & Sussex Medical School

Ageing, diet and health

From Scurvy to Gout,

the story goes on

Older people and diet

Elizabeth Taylor

Elvis Presley

To Ghandi

To Hannibal Lecter

Contents of the talk

Malnutrition Under nutrition Obesity and the Metabolic syndromeAssessment of nutritional statusRelation to CVS healthIntervention trialsMediterranean diet Current evidence

Introduction

Increased longevity worldwide

EU 2 years rise in life expectancy

Heterogeneity

Research bias

Food, health and age

“when you don’t have any money, the problem is food. When you have money, it is sex, when you have both, it is health”

(The Ginger Man, 1955, J. P. Donleavy, Irish American novelist).

Ageing and nutrition Factors affecting food intake in the elderly: • Physical disabilities Chewing problems Dysphagia Problems cutting food Impaired mobility• Mental impairment Loss of memory Confusion Dementia• Psychological factors Depression• Social Loneliness• Economic Poverty• Health problems Gastro-intestinal diseases• Chronic conditions Pain• Iatrogenic Medications

Impact on disease

Every organ system is affectedCVS, CNS, Endocrine (cholecystokinin, leptin,

cytokines, reduced testosterone)Bone health and Osteoporosis Acute illness Dehydration PEM and relation to outcome in H. patients (Morley 1998)

Ageing

Reduced physical activity

Reduced muscle mass

Reduced muscle strength

Poor performance

Poor QOL

Poor mood

Anorexia of ageing

Decline in resting BMRLess physical activity Decline in smell and tasteDeterioration in dental statusDecrease in opioid feeding driveIncrease in early satiety Slowing of gastric emptying

BODY COMPOSITION IN THE ELDERLY

0

20

40

60

80

25 70

AGE (years)

Kg

BONE MINERAL

LEAN BODY MASS

H

H

BONE MINERAL

BODY FATBODY FAT

H2OH2O

LEAN BODY MASSLEAN BODY MASS

40 year-old 70 year-old sarcopenic

66 year-old runner 76 year-old farmer

Is weight loss and body composition change an aging process?

Young vs deconditioned vs leisure exercise vs high usual daily activity

Age-related decreases in thigh muscle area, knee extensor strenght, and aerobic capacity

in 78 healthy persons

Nair KS, Am J Clin Nutr 2005

Age-Related Changes in Physiologyc Functions Age-Related Changes in Physiologyc Functions That Influence Nutrient NeedsThat Influence Nutrient Needs

Peripheral tissues take up fat-soluble vitamins at slower rates

Efficency absorption of calcium declines

Skin synthesis of vitamin D declines

Utilization of Vitamin B 6 is less efficient

One third of individuals older than 70 y lose entirely or have significant diminished capacity to secrete stomach acid (Vit B12, calcium, iron, foilc acid, zinc)Rosemberg IH, 1996

Age-Related Changes in Physiologyc Functions Age-Related Changes in Physiologyc Functions That Influence Nutrient NeedsThat Influence Nutrient Needs

Peripheral tissues take up fat-soluble vitamins at slower rates

Efficency absorption of calcium declines

Skin synthesis of vitamin D declines

Utilization of Vitamin B 6 is less efficient

One third of individuals older than 70 y lose entirely or have significant diminished capacity to secrete stomac acid (Vit B12, calcium, iron, foilc acid, zinc)Rosemberg IH, 1996 (modificata)

Nair KS, 2005

Ageing and mortality

“Young men may die,

but old men must die”

Malnutrition??

Excess intake

Unbalanced diet

Undernourishment

Specific dietary deficiencies

Malnutrition and older people

Global phenomenonEuropean scale Early diagnosis is crucialPrevalence is 15% in community 5-44% in homebound ind. 20-65% in hosp. pts. 23-85% in nursing home res.But it can be reversible

Evaluation

History, examination Blood tests: albumin, Cholesterol, TLCBMI does not work in older people Screening tools: INA SGA DETERMINE SCALES MNA

Sarcopenia

Definition

““Sarcopenia is a term that denotes the Sarcopenia is a term that denotes the

decline in muscle mass and strength decline in muscle mass and strength

that occurs with healthy aging.”that occurs with healthy aging.”

Rosenberg, Am J Clin Nutr 1989

““Sarcopenia is part of normal agingSarcopenia is part of normal aging

and does not require a disease to occur,and does not require a disease to occur,

although it is accellerated by chronic although it is accellerated by chronic diseases.”diseases.”

Roubenoff et al, J Gerontol 2000

The metabolic syndrome (1)

A bit of history

Albert Camus

The metabolic syndrome (2)

Growing now to epidemic proportions

In UK the 65-75 year old,25% women and 18% of men are obese

>75 years, 22% women, and 12% men

The metabolic syndrome (3)

IDF Definition

Components:

fasting blood glucose: >5.6 mmole/L

Hypertension

High Triglycerides> 1.7 mmole/L

HDL Chol.<1.03 mmole/L

Good old age starts early

Absence of CVS risk factors at 50 predicts less disease and longer life.

Framingham Heart Study participants at 50

Less CVS risk >39 vs 28 in men

>39 vs 31 in women

Lloyd-Jones D et al 2006, Circulation.

Risk factors for coronary artery disease and strokeHypothetical representation of relative importance of risk factors

Hypertension

Hypercholesterolemia

STROKECAD

VASCULARDISEASE

Delanty N et al. Stroke. 1997; 28: 2315-2320

?

Musclecatabolis

m

CytokinesIL-1 IL-6 IL-8 TNF- IFN- GDF-8 CNTF

Inhibition of protein synthesis

and muscle repair

ApoptosisSkeletal muscle

contractility

CVS and death in older people

553 men, 888 women

Above 60 years

Mortality at 5 and 5-9 years

Inflammatory markers & prediction of death

Biomarkers (CRP, AAG, low albumin and TTR)

These markers predict death

Major studies

SENECA

Our BRAVES study

Mediterranean diet

• Benefits

• On CVS disease

Medi. D also good for your brain

M diet can reduce the risk of MCI and progression to Alzheimer’s disease

Endothelial dysfunction and diet

Adherence to the Mediterranean diet attenuates inflammation and coagulation

The ATTICA Study (1,514 men, 1528 women)

(Chrysohoou C et al 2004. J Am Coll

Cardiol. 2004; 44:152-8)

The HALE Study

• Single and combined effect of Mediterranean diet, being• physically active, moderate alcohol use and non-smoking on

allcause• mortality (10-year follow-up of 2,339 participants of the• HALE study, aged 70 to 90 years at baseline; Knoops et al. 2004)• Hazard ratios (95% CI)• ·Mediterranean diet 0.77 (0.68 – 0.88)• ·Moderate alcohol use 0.78 (0.67 – 0.91)• ·Non-smoking 0.65 (0.57 – 0.75)• ·Physical activity 0.63 (0.55 – 0.72)• ·All four factors 0.35 (0.28 – 0.88)

EPIC Study

M. diet confer a health benefit and prolong life

(Trichopoulou et al BMJ 2005)

Cereals and CVS

Cereal fibre consumption results in less CVS events in old people

Mozaffarian et al 2003

Olive oil and the elderly

Olive oil and health in Italy

Fortes C 2000 et al

The CARDIA Study

The CARDIA study

3031 young adults

Pereira et al, 2005

The cardia study: 3031 young adults, 15-year prospective analysis

Body weight

“healthier lifestyle”

Physicalexercise

Health diet

Lifestyle changes work

Systematic review of 105 trials on BP

6805 subjects

Improved diet, aerobic exercise, alcohol and sodium restriction, fish oil supp.

Reductions in BP were: 5.0, 4.6, 3.8, 2.3 (also in DBP) mmHg

Dickinson H O et al 2006, J Hum Hyp

Does supplementation work?

Cochrane meta-analysis 2006

55 trials, 9187 subjects

Poor quality data

Supplements can improve n. status

But not robust enough to support routine supplementation

A more recent view

Protein and energy supplementation in elderly people at risk from malnutrition

Cochrane Database Syst Rev 2009

Supplementation results in a small consistent weight gain, mortality may be reduced in undernourished p, but no effect on functional ADL or LOS.

How much exercise

regular moderate-intensity physical exercise at least 30 min continuous or intermittent (preferable 60 min)

5 d/w (but preferable daily)

AHA/NHLBI Scientific Statement. Circulation, 2005

“30 min of low activity undertaken 5 or more times per week

is important to reduce morbidity and mortality associated with

cardiovasculardiseases” International Obesity Task Force, 2002