1. Diet and nutrition and how it affects the CVS in older people Dr Khalid Ali Senior Lecturer in Geriatrics Brighton & Sussex Medical School

2. Ageing, diet and health From Scurvy to Gout, the story goes on

5. Older people and diet Elizabeth Taylor Elvis Presley To Ghandi To Hannibal Lecter

11. Contents of the talk Malnutrition Under nutrition Obesity and the Metabolic syndrome Assessment of nutritional status Relation to CVS health Intervention trials Mediterranean diet Current evidence

12. Introduction Increased longevity worldwide EU 2 years rise in life expectancy Heterogeneity Research bias

13. Food, health and age when you dont 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).

14. 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

15. Impact on disease Every organ system is affected CVS, CNS, Endocrine (cholecystokinin, leptin, cytokines, reduced testosterone) Bone health and Osteoporosis Acute illness Dehydration PEM and relation to outcome in H. patients (Morley 1998)

16. Ageing Reduced physical activity Reduced muscle mass Reduced muscle strength Poor performance Poor QOL Poor mood

17. Anorexia of ageing Decline in resting BMR Less physical activity Decline in smell and taste Deterioration in dental status Decrease in opioid feeding drive Increase in early satiety Slowing of gastric emptying

18. BODY COMPOSITION IN THE ELDERLY 0 20 40 60 80 2570 AGE (years) Kg BONE MINERAL LEAN BODY MASS H H BONE MINERAL BODY FAT H2OH2O H2OH2O LEAN BODY MASS

19. 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

20. Age-related decreases in thigh muscle area, knee extensor strenght, and aerobic capacity in 78 healthy persons Nair KS, Am J Clin Nutr 2005

21. Age-Related Changes in Physiologyc Functions That 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

22. Age-Related Changes in Physiologyc Functions That 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)

23. Nair KS, 2005

24. Ageing and mortality Young men may die, but old men must die

25. Malnutrition?? Excess intake Unbalanced diet Undernourishment Specific dietary deficiencies

26. Malnutrition and older people Global phenomenon European scale Early diagnosis is crucial Prevalence 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

28. Evaluation History, examination Blood tests: albumin, Cholesterol, TLC BMI does not work in older people Screening tools: INA SGA DETERMINE SCALES MNA

29. Sarcopenia Definition

30. Sarcopenia is a term that denotes the decline in muscle mass and strength that occurs with healthy aging. Rosenberg, Am J Clin Nutr 1989 Sarcopenia is part of normal aging and does not require a disease to occur, although it is accellerated by chronic diseases. Roubenoff et al, J Gerontol 2000

31. The metabolic syndrome (1) A bit of history Albert Camus

33. 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

34. 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

36. 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.

37. Risk factors for coronary artery disease and stroke Hypothetical representation of relative importance of risk factors Hypertension Hypercholesterolemia STROKECAD VASCULAR DISEASE Delanty N et al. Stroke. 1997; 28: 2315-2320 ?

38. Muscle catabolism Cytokines IL-1 IL-6 IL-8 TNF- IFN- GDF-8 CNTF Inhibition of protein synthesis and muscle repair Apoptosis Skeletal muscle contractility

39. 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

40. Major studies SENECA Our BRAVES study

41. Mediterranean diet Benefits On CVS disease

42. Medi. D also good for your brain M diet can reduce the risk of MCI and progression to Alzheimers disease

43. 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)

44. 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)

45. EPIC Study M. diet confer a health benefit and prolong life (Trichopoulou et al BMJ 2005)

46. Cereals and CVS Cereal fibre consumption results in less CVS events in old people Mozaffarian et al 2003

47. Olive oil and the elderly Olive oil and health in Italy Fortes C 2000 et al

48. The CARDIA Study The CARDIA study 3031 young adults

49. Pereira et al, 2005 The cardia study: 3031 young adults, 15-year prospective analysis

50. Body weight healthier lifestyle Physical exercise Health diet

51. 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

52. 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

53. 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.

54. 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