The New Face of 60: 60 is Young Now

1
The New Face of 6060 is Young Now

• Optimizing Nutrition for Older Adults
• Joan G. Fischer, PhD, RD, LD

2
Why do Some Nutrient Needs Change with Age?

• Changes in body composition (energy)
• Changes in nutrient absorption (Ca, B12)
• Changes in nutrient metabolism (Vitamin D)

3
Energy Needs Decrease

• Lower energy expenditure due to
• Reductions in lean body mass
• Reductions in physical activity
• What are the challenges?
• Obtaining adequate protein, vitamins, minerals
  with fewer calories
• Preventing unintentional weight gain, overweight
  and obesity

• Focus on
• Nutrient dense foods
• Smaller portions
• Adequate physical activity

Kennedy AJCN 200683(supp)410S Image from
visualsonline.cancer.gov
4
Calcium Requirement is Increased

• Calcium absorption efficiency decreases with age
• Increased calcium intake needed to achieve
  calcium balance and prevent bone loss

mg/d
Age
Institute of Medicine, Dietary Reference Intakes
(IOM, DRI), 1997
5
How do we Achieve Adequate Intake?

• Challenges
• Communicate sources of calcium
• Dairy products
• Calcium fortified foods
• Supplements
• Communicate how to combine food and supplements
  to meet 1200 mg Ca/day

What we Eat in America Calcium NHANES, 2003-2004
(in mg)a
aMean calcium intakes from food
USDA, ARS. 2007 www.ars.usda.gov/ba/bhnrc/fsrg.
6
Vitamin D

• Sun exposure of skin is major source of vitamin D
  
• 7-dehydrocholesterol cholecalciferol
• Food sources
• Ergocalciferol (D2) in plant foods
• Cholecalciferol (D3) in fish
• Best biomarker of vitamin D status is serum 25
  (OH) vitamin D
• Reflects skin production food or supplement
  intake
• Frank D deficiency is lt25 nmol/L
• Optimal may be at least 80 nmol/L

UVB
Johnson Kimlin Nutr Rev 2006 64410 Nieves
AJCN 200581(supp)1232S
7
Adequate Calcium and Vitamin D Intakes are
Critical for Bone Health
8
Calcium,Vitamin D and Bone Health

• Higher calcium intakes and vitamin D status
  positively associated with bone mineral density

Optimal Ca and D Status
Increased intestinal Ca absorption
Increased circulating ionized Ca Decreased
serum PTH
Decreased bone resorption Increased bone
density Reduced fracture risk
Nieves AJCN 200581(supp)1232S
9
Calcium,Vitamin D and Bone Health

• Higher calcium intakes and vitamin D status
  positively associated with bone mass
• Calcium supplementation of post-menopausal women
  slows bone loss, particularly
• When initial calcium is low
• In cortical bone
• In late rather than early menopause
• Vitamin D supplementation reduces rate of bone
  loss in older adults

IOM, DRI, 1997 Bischoff-Ferrari et al. JAMA
20052932257 Nieves AJCN 200581(supp)1232S Bi
schoff-Ferrari et al. AJCN 20068418
Dawson-Hughes Bischoff-Ferrari J Bone Min Res
200722S2V59 Bischoff-Ferrari et al. AJCN
2007861780 Boonen et al. J Clin Endocrine
Metab 2007921415
10
Does this result in lower fracture risk?

• Consistent reduction in fracture risk not seen
  with calcium intake or supplementation alone
• Vitamin D supplementation of 700-800 IU/d plus
  calcium reduces risk of non-vertebral fracture
• Reduction in fracture risk may result from
• Enhanced bone mass
• Enhanced muscle function and reduced risk of
  falls

IOM, DRI, 1997 Bischoff-Ferrari et al. JAMA
20052932257 Nieves AJCN 200581(supp)1232S Bi
schoff-Ferrari et al. AJCN 20068418
Dawson-Hughes Bischoff-Ferrari J Bone Min Res
200722S2V59 Bischoff-Ferrari et al. AJCN
2007861780 Boonen et al. J Clin Endocrine
Metab 2007921415

11
Other Possible Benefits of Vitamin D

• Enhanced muscle function
• Reduced risk of falls
• Improved oral health
• Reduced risk for some cancers, including
  colorectal cancer
• Some evidence for possible benefit
• Osteoarthritis
• Hypertension
• Insulin resistance
• Multiple sclerosis

Dawson-Hughes Bischoff-Ferrari J Bone Min Res
200722V59 Bischoff-Ferrari et al. AJCN
200480752 Bischoff-Ferrari et al. JAMA
20042911999 Bischoff-Ferrari et al. AJCN
20068418 Lappe et al. AJCN 2007851586 Nieves
AJCN 200581(supp)1232S Johnson Kimlin Nutr
Rev 200664410
12
Vitamin D Requirement Increases for Older Adults

• With age gt50
• UVB-induced production of vitamin D3 in skin is
  decreased
• Decreased sun exposure
• More likely to cover skin outside
• More likely to use sunscreen
• Frail adults spend less time outdoors

Johnson Kimlin, Nutr Rev 200664410 Image from
NCI, visualsonline.cancer.gov
13
Vitamin D intake Recommendations
2005 Dietary Guidelines

• Optimal serum 25 (OH) D level is believed to be
  at least 75-80 nmol/L
• To achieve this level need 25 ug
  (1000 IU) per day

DRI AI, 1997
ug/d
25 ug 1000 IU
Bischoff-Ferrari et al. AJCN 20068418 DHHS,
USDA Dietary Guidelines for Americans, 2005
Nieves AJCN 200581(supp)1232S Figure adapted
from Johnson Kimlin, Nutr Rev 200664410
14
Vitamin D Intake and Status NHANES III
Adapted from Johnson Kimlin, Nutr Rev
200664410
15
Vitamin D Sources

• Fortified foods (D2 D3)
  
• Milk has100 IU/cup
• Fish (D3)
• 3 oz salmon has 400-650 IU
• Supplements (D2 D3)
• D3 more bioavailable than D2

• Challenges
• Communicate need for increased intakes
• Ways to combine food and supplements to meet needs

Johnson Kimlin, Nutr Rev 200664410. Images
from NCI, visualsonline.cancer.gov
16
Vitamin B12

• Critical nutrient for
• Red blood cell synthesis
• Deficiency results in megaloblastic anemia
• Neurological function
• Deficiency results in peripheral neuropathy,
  degeneration of spinal cord and cognitive
  impairment
• RDA is 2.4 ug/day
• Sources Foods of animal origin, fortified foods
  and supplements
• Low B12 status in 5-25 of older adults,
  depending on study (Johnson et al. 2003 Morris
  et al. 2007)

IOM DRI, 1998 Johnson et al. AJCN 200377211
Miller. AJCN 2006841259 Clarke et al. AJCN
2007861384 Morris et al. 200785193
17
Vitamin B12 A Change in Source for Older Adults

• Absorption of B12 from foods may be reduced in
  older adults
• 10-30 may have atrophic gastritis, with lower
  gastric acidity
• Result?
• B12 cleavage from protein foods is reduced
• Bacterial overgrowth may utilize available B12
• Crystalline form of B12 recommended for older
  adults
• This form can be absorbed in those with atrophic
  gastritis
• Sources are supplements and fortified foods, such
  as cereals

IOM, DRI, 1998
18
Vitamin B12 and Folate Interactions

• Both are important to normal hematological and
  cognitive function
• Concern that high serum folate will mask B12
  deficiency in older adults
• After mandatory folic acid fortification, the
  prevalence of high serum folate increased in
  older adults (Pfeiffer et al. 2007)
• B12 and folate interactions in older adults
  (Morris et al. 2007)
• Higher serum folate
• Reduced risk of anemia and cognitive impairment
  in those with normal B12 status, but
• with low vitamin B12 status, high serum folate
  increased risk of cognitive impairment and anemia
  

Pfeiffer et al. AJCN 200786718 Morris et al.
AJCN 200785193.
19
Vitamin B6

• Older adults are at risk for low B6 status
• Deficiency results in neurological changes and
  microcytic anemia
• Vitamin B6 status declines with age due to
• Lower dietary intake
• Changes in B6 metabolism
• Higher intakes needed to achieve adequate serum
  B6 in older adults
• RDA for those 50
• Men 1.7 mg/d
• Women 1.5 mg/d

IOM, DRI, 1998
20
Other Nutrients of Concern

• Protein
• Important role in maintaining muscle mass and
  preventing sarcopenia
• Impacts bone health
• In NHANES, 2003-2004
• 7.2-8.6 women aged 50 consumed lt .66 g
  protein/kg/d (EAR)

• Fluid
• Fiber
• Vitamin E, vitamin K and potassium

Paddon-Jones et al. AJCN 200887(supp)1562S
Houston et al. AJCN 200887150 Heaney Layman
AJCN 200887(supp)1567S Fulgoni
200887(supp)1554S Lichtenstein et al. J Nutr
20081385.