National Diet and Nutrition Survey: people aged 65 years and over. Published 1995 HMSO London

National Diet and Nutrition Survey: people aged 65 years and over.

Published 1995 HMSO London

An analysis by

Dr Alan Stewart MRCP

www.stewartnutrition.co.uk

http://www.stewartnutrition.co.uk/

Purpose of the Study

“This provides a sound basis for the development of future food and heath policies for this increasingly important group in our society“

Tessa Jowell Minister for Public health DoHJeff Rooker Minister of State MAFF

The NDNS are undertaken by the Department of Healthand Ministry of Agriculture Fisheries and Food with the support of outside agencies

Important Note from Dr Alan Stewart

• Dr Stewart took no part in the study and reports here as an independent physician with an interest in nutrition

• The findings of this survey are not well-known and are not currently available at the Department of Health website nor the Office of National Statistics despite being listed on the latter site as available. The printed report can be purchased from The Stationery Office www.tsoshop.co.uk

• The findings of this survey will be superseded by the NDNS Rolling Programme, which includes those aged over 65 yrs and is due to finish reporting years 1 and 2 of the three year programme toward the end of 2012

NDNS65+: Background

• Part of a rolling programme of national nutritional surveys of different sectors of the British population

• Previous study of a non-representative sample of 365 elderly >70 years showed:- malnutrition in 7%, anaemia in 12.5%- vitamin B12 deficiency 2.5%, folate deficiency 5.4%- vitamin B1 deficiency 8%, vitamin B12 deficiency 30%(DHSS 1979)

• Risk of deficiency rose with increasing age, prevalence of chronic illness and socio-economic deprivation

• Link between poor nutrition and common diseases; cardiovascular, poor immunity, osteoporosis and possibly mental illness and early dementia

• A study of acutely ill geriatric patients in Leeds revealed a high incidence of nutritional deficiencies (next two slides)

Nutritional Deficiencies in Acutely ill Geriatric Patients: Prevalence of Haematological Deficiencies 1973/75

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Anaemia RBC Folate Vitamin B12 % Low Iron Sat

Age 65-70yrs (n=16)

70-79yrs (n=53)

80+yrs (n=24)

• 93 acutely ill patients >65yrs: male = 35, female = 58 in Yorkshire• Folate and vitamin B12 were measured using micobiological assays• 9/93 = plasma albumin ,<28g/l, 29/93 = plasma albumin 28-34g/l• Morgan AG et al. Int J Vit and Nut Res. 1973:43;46-471 & 1975:45:448-462

Vitamin Deficiencies in Acutely ill Geriatric PatientsPrevalence of various vitamin deficiencies 1973/75

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Vit A PTT TPP Vit B2 Vit B3 WBC Vit C

Age 65-70yrs (n=16)

70-79yrs (n=53)80+yrs (n=24)

• 93 acutely ill patients >65yrs: male = 35, female = 58• PTT = prothrombin time (Vit K), TPP = thiamin pyrophosphate effect (vit B1)

Vit B2 = whole blood riboflavin, Vit B3 = urine n-methyl nicotinamide level• Morgan AG et al. Int J Vit and Nut Res. 1975:45:448-462

NDNS65+: Methodology• Two nationally representative samples:

- free-living- institutionalised

• Individuals were identified by their postal addresses• Men equalled women except those aged 85+ (more women)• In each co-operating institution three residents were selected• Initial assessment by interview• Consent or proxy-consent obtained for participation and

permission to flag the NHS Central Register of Births and Deaths to give future notice of death or cancer development

• Payment of £10 on completion of dietary record• Survey completed between October 1994 to September 1995

• Acutely ill elderly are unlikely to have participated in NDNS 65+; prevalence of poor nutrition is thus likely to be at least as great in ill patients in the care of medical staff

NDNS 65+: data collected

• Interviewer-administered questionnaire about dietary habits, medication use, nutritional supplements, physical activity and health

• Four-day weighed dietary record of all food and drink consumed in and out of the home

• Seven-day record of bowel movements

• Memory and depression questionnaires

• Physical measurements: height, weight, mid-arm circumference, hand grip strength and visual acuity

• Blood and urine (not 24 hours) tests

• Dental examination (see separate report)

NDNS65+: Response to the Survey - Free-living

• 30, 546 sample addresses

• 23, 486 positive responders

• 6,445 eligible households

• 2172 initially selected Eligible sample 100%

• 1632 completed interview Responding sample 75%

• 1275 completed dietary record Diary sample 59%

• 986 provided blood sample 45%

• 1115 provided urine sample 51%

NDNS65+: Response to the Survey-Institutions

• 454 initially identified Eligible sample 100%

• 428 completed interview Responding sample 94%

• 412 completed diet record Diary sample 91%

• 290 provided blood sample 64%

• 310 provided a urine sample 68%

Some weighting for disproportionate sampling of sex, age,over-representation of people living alone and regionalvariations

Defining Nutritional Deficiency

• Nutritional deficiency can develop as a result of an inadequate intake, poor absorption, illness, alcohol excess & other factors

• In the UK nutrient intake requirements are given in:Dietary Reference Values for Food Energy and Nutrients for the United Kingdom (1991 – TSO)

• The report defines The Lower Reference Nutrient Intake, LRNI, for protein or a vitamin or mineral as “an amount of the nutrient that is enough for only a few people in a group who have low needs”.

• In practice this means that if the percentage of a population with an intake below the LRNI for a particular nutrient exceeds 3% then it is likely that a percentage of the population will be deficient in the nutrient

• Also deficiency is likely, but not certain, if, on testing its blood level is below the lower end of an accepted normal range.

Distribution of Nutrient RequirementsAssumes a Gaussian (normal) distribution

Dietary Reference Values: Dept of Health 1991

• LRNI “An amount enough for only the few people in a group who have low needs”

• EAR “About half will usually need more than the EAR and half less”

• RNI “An amount of the nutrient that is enough, or more than enough, for about 97% of people in a group”

What can Nutritional Surveys Tell Us?

• Two main types of data:- dietary habits and intake of nutrients- test information on nutrient levels in blood and urine

• Assess the prevalence of both types of malnutrition:- undernutrition- overnutrition

• Data about social circumstances, alcohol and smoking that allows identification of those at risk of malnutrition

• Data about the health of the survey group may examine the possible health consequences of malnutrition

How Do Nutritional Deficiencies Develop?

Develop over days to years in a logical and recognizable sequence

• State of Adequacy

• State of Negative Balance

• Decline in Tissue Stores

• Loss of Function:1. Symptoms 2. Physical Signs3. Organ Failure

• Death

What Components were Surveyed in NDNS?NDNS = National Diet and Nutrition Survey

Stage NDNS 65+ Component


• State of Negative Balance 1. Poor intake Diet + Supplements 2. Reduced absorption 3. Increased losses 4. Increased requirement 5. Altered metabolism Alcohol, drugs, liver and renal

• Decline in Tissue Stores Tests – blood and urine

• Loss of Function:1. Symptoms Depression2. Physical Signs BMI 3. Organ Failure Renal and Liver Function Tests

• Death Collected 17 yrs later

NDNS: Prevalence of Deficiency - Low IntakeTotal Intakes (Food and Supplements) below LRNI for males and females

0%

3%

6%

9%

12%

15%

18%

21%

24%

27%

30%

33%

36%

39%

Free-living Elderly Institution Elderly

Calcium

Potassium

Magnesium

Iron

Zinc

Vitamin A

Vitamin B12

Folate

Vitamin C

• “Lower Reference Nutrient Intake – an amount of the nutrient that is enough for only the few people in a group who have low needs” = 3% of the population

• Prevalence rates >3% suggest that a significant % of the population could be deficient

Use of Nutritional Supplements – NDNS 65+

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Adults F-L Elderly

Total

Multi Vit+Mins

Multivitamins

Vits A,C+D

Multivits+Iron

Vitamin C

Iron only

Minerals

CLO +Fish Oil

EPO

• Supplement categories have slight differences between the surveys• Females are usually larger consumers of supplements than males

Prevalence of low Potassium Intake <LRNI

0%

10%

20%

30%

40%

50%

60%

65-74yr 75-84yr 85+yr Institution65-84yr

Institution85+yr

Male

Female

• Potassium content of the body is related to its water content and muscle bulk• There are no differences in LRNI between the sexes despite physical differences• The high LRNI for women results in a high percentage appearing deficient• Plasma or serum potassium levels were not measured as part of any of the NDNS

Prevalence of a low Body Mass Index - NDNS

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

65-74yrs 75-84yrs 85+yrs Inst 65-84yrs

Inst 85+yrs

Men <18.5kg/m2

Men 18.5-20.0kg/m2

Women <18.5kg/m2

Women 18.5-20.0kg/m2

• Percentages for age >65 years are the author’s estimates from presented data• Underweight + ill individuals are likely to have been under-represented in NDNS

Nutrition Support in Adults NICE Feb. 2006 www.nice.org.uk/cg032

Based on Malnutrition Universal Screening Tool - MUST

• UnderweightBMI >18.5kg/m2

• Unintentional weight lossLoss >10% within the last 3 – 6 months

• Underweight + Unintentional Weight LossBMI 18.5 - 20kg/m2 and Wt Loss >5% within the last 3 – 6 mo.

• Others Risk FactorsEaten little or nothing or unlikely to for >5 daysPoor absorptive capacity, high nutrient losses or increased needs

http://www.nice.org.uk/cg032

Nutritional Assessment - Risk FactorsNICE guidelines www.nice.org.uk/cg032 (2006) and others

• Fragile skin• Poor wound healing• Apathy• Wasted muscles• Poor appetite• Altered taste sensation• Impaired swallowing• Altered bowel habit• Loose fitting clothes• Prolonged illness:

chronic infection, chest disease, cardiac failure, cancer etc.



• Fragile skin• Poor wound healing• Apathy• Wasted muscles• Poor appetite• Altered taste sensation• Impaired swallowing• Altered bowel habit• Loose fitting clothes• Prolonged illness:


• Life Stage:- extremes of age- infants, adolesence, pregnancy

• Social Circumstances:- in receipt of benefits- living alone – especially men

• Medical History:- loss: bleed, vomiting, diarrhoea- chronic illness/organ failure

• Family History/Genetic Factors• Medical Drug Use• Poor mobility/lack of sun • Smoking• Symptoms and Physical Signs


Influence of Household Income on Average Intake of Nutrients in Elderly Men [NDNS 1998]

0%

20%

40%

60%

80%

100%

120%

140%

160%

Energy Protein Vitamin C VitaminB12

Folate

<4K/yr

4-6K/yr

6-10K/yr

>10K/yr

• Annual income in £000s; upper income bands are compared with lowest <4k/year• Increasing income is associated with higher intake of protein and many nutrients

Daily Alcohol Intake and Nutritional Status: NDNS 65+% difference in status compared with non/low drinkers

-30.00%

-20.00%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

PlasmaVitamin C

PlasmaVitamin D

Red CellFolate

SerumVitamin B12

Males <10g

Males 10-20g

Males =/>20g

Females <10g

Females =/>10g

• Intake determined from 4 day diary • Caution, no adjustment for age, health, diet or supplements was made• Non-drinkers were more likely to be older and have abnormal liver test

Diagnosing Malnutrition: Under and Overnutrition

1. History Intake: diet + supplements Risk Factors for

deficiency/XSSymptoms of

deficiency/XS

2. Physical Anthropometric MeasuresExamination (Body Mass Index - kg/m2)

Signs of Deficiency Signs of Underlying

Disease

3. Laboratory Blood and Urine TestsInvestigation Bone Mineral Density X-Ray

Making a Diagnosis: History is Paramount

Nottingham 1975 W. Virginia 1992

History 82.5% 76%

Examination 8.75% 12%

Investigation 8.75% 11%

• Both studies assessed new patients, with no clear diagnosis who were referred to a medical outpatient clinic

• The percentages relate to the information that was required to reach the final diagnosis

• References:Hampton JR et al. BMJ. 1975;2:486-9Peterson MC et al. West Med J. 1992;156(2):163-5

NDNS65+: Prevalence of Anaemia

0%

5%

10%

15%

20%

25%

30%


Institution85+yr

Male

Female

• World Health Organisation Normal Ranges were used; women >12.0g/dl, men >13.0g/dl. British laboratories often use a normal range of >11.5g/dl for women

• Levels of 11.5-11.9g/dl in women can result in symptomatic iron deficiency• In the elderly anaemia results from: poor nutrient intake + bleeding, chronic

illness and unknown factors in equal frequency

NDNS65+: Prevalence of Iron Deficiency Low Plasma Ferritin: Range < 10-20ug/l

0%

5%

10%

15%

20%

25%

30%


Institution85+yr

Male

Female

• Normal ranges: females > 15.0ug/l, males > 20.0ug/l • Plasma ferritin can be elevated by acute or chronic

inflammation, infection or liver disease and may not be a reliable measure of iron status in ill and elderly people

NDNS65+: Prevalence of Vitamin B12 Deficiency Plasma vitamin B12 <118 pmol/l (154pg/ml)

0%

5%

10%

15%

20%

25%

30%


Institution85+yr

Male

Female

• Macrocytosis (MCV >101fl) was seen in: 2% of free-living elderly and 3% of elderly in institutions.

• Macrocytosis can be due to vit B12/folate deficiency or alcohol excess• Only a minority of those with vitamin B12 deficiency also had macrocytosis

NDNS65+: Prevalence of low Red Cell Folate

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%


Institution85+yr

Male

Female

• The normal ranges for red cell folate and method of analysis varied from other NDNS

• Folate status is influenced by dietary intake, illness, alcohol excess and altered metabolism

NDNS 65+: Prevalence of Vitamin D DeficiencyPlasma 25-hydroxyvitamin D <25nmol/l

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%


Institution85+yr

Male

Female

• Plasma 25-OHD levels show considerable seasonal variation with low levels being commonplace in late winter and spring.

• Dietary sources provide approximately 10% of intake of the vitamin. • Preferred level for those with osteoporosis is >75 nmol/l

NDNS65+: Prevalence of Vitamin C Deficiencyplasma Vit. C<11.0umol/l - NDNS data

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%


Institution85+yr

Male

Female

• Vitamin C status is adversely affected by smoking, use of aspirin and NSAIDS• Approximately 12% of the elderly took supplements likely to contain vitamin C• Approximately 28% of British adults smoke and less after the age of 65 years• Aspirin was taken by 20% of free-living elderly and 24% of institutionalised

NDNS65+: Prevalence of Vitamin A DeficiencyPercentage of Population with a plasma Retinol < 0.7mmol/l

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%


Institution85+yr

Male

Female

• WHO lower end of normality, plasma level < 0.7 mmol/ • Plasma retinol levels may be temporarily lowered as a result of infection and the

acute phase response• Severe deficiency, plasma <0.35 mmol/l, is very rare

Nutritional Supplements and the Elderly

“Many would agree that iron, vitamin C, vitamin D and B complex vitamins should be given for three to four weeks to elderly patients recovering from a severe illness of any type ...”

Editorial British Medical Journal. Nutrition in the Elderly 1974:1;212-3.

Correlations between intake and blood levels

• NDNS 65+ and other surveys calculated the correlation coefficients between the intake of many nutrients and it’s level in the blood

• The degree of correlation between these two was often less than 50% and is usually best for the more water-soluble and better absorbed nutrients

• The reason for low correlation are many and include: level of intake, limited or poor absorption, smoking and alcohol, and differences in metabolism/transport of the nutrient

• In practice this means that clinicians should not rely too heavily on dietary assessment but consider many other risk factors for under and overnutrition

Correlation Coefficients: Vitamin CPlasma Ascorbate and Total Intake

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1.5-4.5 yrs 4-18 yrs 19-64 yrs 65+ yrs

Male

Female

Correlation Coefficients: Folate Red Cell Folate and Total Intake

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1.5-4.5 yrs 4-18 yrs 19-64 yrs 65+ yrs

Male

Female

Correlation Coefficients: RetinolPlasma Retinol and Intake (Retinol Equivalents)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1.5-4.5 yrs 4-18 yrs 19-64 yrs 65+ yrs

Male

Female

Correlation Coefficients IronHaemoglobin and Total Intake of Iron

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1

1.5-4.5 yrs 4-18 yrs 19-64 yrs 65+ yrs

Male

Female

Correlation Coefficients B Vitamins in ElderlyNDNS 65+ Free-Living only

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Vitamin B2 Folate Vitamin B1 Vitamin B12

Male

Female

• Tests – red cell folate, serum vitamin B12; vitamins B1 & 2 by enzyme activation, which increase with increasing deficiency

• CCs for vitamins B1 & 2 are -ve but are presented as +ve

• All CCS are significant (p<0.01) except vitamin B12 in men

NDNS 65+: What Have we Learnt so Far?

• This important survey, though conducted 20 years ago reveals that:- poor intake of micronutrients is common- low BMI, anaemia and micronutrient deficiencies are common

• Risk factors for undernutrition include:- low income – or being in receipt of benefits- increasing age- smoking- alcohol excess but not moderate intake- illness especially chronic illness- multiple drug therapy

• Risk Factors for undernutriiton detailed by NICE are presented next


NICE Listed• Fragile skin• Poor wound healing• Apathy• Wasted muscles• Poor appetite• Altered taste sensation• Impaired swallowing• Altered bowel habit• Loose fitting clothes• Prolonged intercurrent illness:



NDNS 65+: Prevalence of Overnutritionfigures are for free-living

• Obesity BMI >30 kg/m2 M - 17%, F – 23%• Alcohol excess >21/14 units/week ~ 10%• Dietary Salt Intake >6g/day estimated at ~80%

risk of:hypertension, stroke, osteoporosis and heart failure

• Retinol - elevated plasma level ~10%risk of:osteoporosis, hypercalcaemia (cc%)

• Iron excess - haemochromatosis ~1.5%iron saturation >55%

• Trace element excess - reduced excretion due to:renal disease (?<5%) – vitamin A and potassiumliver disease (10-20%) – iron, manganese and copper

• Excessive intake of nutrients from supplementsretinol (5-10%) and possibly manganese (not assessed)

Safety of Vitamin A: SACN Sept 2005

• Total Safe Intake, TSI 1500 ug/day

• Diet provides average 700 ug/day

• Supplements limited to 800 ug/day

• % NDNS 65+ intakes >TSI- F-L Males 11%, Females 10%- Inst. Males 7%, Females 6%

• High intakes from: - food – liver, very high dairy - supplements high intake & overages

• Acute Toxicity: – rare >50,000ug/day- liver failure, death

• Chronic Toxicity:- osteoporosis (vit D antagonist)- hair loss, dry skin- hypercalcaemia (PTH excess)

• Risk increased by: renal impairment, alcohol excess and obesity

Retinol Status of the British Population (estimates)Plasma Retinol Levels NDNS 65+ Data

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Free-Living Institutionalised

Deficient <0.7/0.75 umol/lBorderline 0.75-1.0 umol/lAdequate 1.0-2.8 umol/lMild Excess 2.8-3.5 umol/lSevere Excess >3.5 umol/l

Renal Function and Plasma Retinol: NDNS 65+Correlation between deteriorating renal function and plasma retinol

UK Supplements – Retinol ContentFSA (2003) and SACN (2005) - Safe Upper Level of 800 ug/day

• Cod Liver Oil 10 mls 1,800ug

• Holford Multivitamin 1,200ug

• HealthSpan Multi 50+ 1,000 ug• H and B ABC Plus Senior 1,050 ug• Solgar Solovit 750 ug• Biocare Adult Multi 600

ug

• According to industry overages are commonly 20% to 30% more than the label claim

NDNS 65+ The Spread of Malnutrition

• The following slides detail the spread and extremes of nutrient intake and laboratory findings from the free-living NDNS 65+ population

• These show the means, 95% limits and highest and lowest values for a number of measures of nutrients

• These findings make the point that both under and over nutrition occur

• They help the practitioner put into perspective the results that they might obtain when assessing their own patients

• Such data is unique and is unlikely to be reported in future survey

The Spread of Malnutrition: Energy & BMINDNS 65 + Free-living M = 538, F = 516

Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053

Parameter Lowest 2.5 pc

Mean 97.5 pc

Highest

Age years M 65 75.8 96

F 65 77.3 99

Energy Intake Kcal/day

M 819 2101 1892 2838 4117

F 455 756 1416 2101 2325

Height m M 1.49 156.5 1.69 185.6 1.98

F 1.2 142.3 1.55 168.2 1.75

Weight kg M 38.7 53.6 75.2 101 121

F 32.5 42.6 64 90.5 112.9

Body Mass Index kg/m2

M 16.3 19.6 26.3 34.3 43.2

F 14.4 18.3 26.6 36.7 44.46

The Spread of Malnutrition: Iron and AnaemiaNDNS 65 + Free-living M = 538, F = 516


Parameter

and norm

Lowest 2.5 pc

Mean 97.5 pc

Highest

Total Iron Intake

non-haem mg/day M 1.7 11.4 174.2

F 2.3 10.9 201.2

Iron Intake -haem

mg/day

M 0 0.72 4.83

F 0 0.53 4.8

Iron Saturation 15% - 55%

M 4.1 11.6 28.1 53.4 91.2

F 4.0 7.0 24.2 46.9 82.7

Serum Ferritin ug/l

M 20-300, F 15-150

M 4.0 120.9 420.5

F 9.0 90.2 376.4

Haemoglobin g/dl M 13-18, F 12-16.5

M 11.5 14.5 16.7

F 11 13.5 15.5

The Spread of Malnutrition: Retinol & CarotenoidsNDNS 65 + Free-living M = 538, F = 516


Parameter and Normal Range

Lowest 2.5 pc

Mean 97.5 pc

Highest

Retinol Intake

ug/day 300 – 1,500

M 10 161 940 5996 20,400

F 60 121 850 6068 18.800

Plasma retinol

1.0 – 2.8 umol/l

M 0.85 1.25 2.21 3.54 5.55

F 0.42 1.17 2.18 3.56 6.8

Total carotenoids Intake mg/day

M 0.1 222 1.97 5760 12,000

F 60 196 1.62 5367 9,970

Plasma beta-carotene nmol/l

M 8.0 54 323 828 1,674

F 37 79 405 1011 1,960

Renal Function and Plasma Retinol: NDNS 65+Correlation between deteriorating renal function and plasma retinol

The Spread of Malnutrition: Vitamins C and ENDNS 65 + Free-living M = 538, F = 516


Parameter

Normal Range

Lowest 2.5 pc

Mean 97.5 pc

Highest

Total Intake Vitamin C mg/day

M 4.9 12.1 71.1 196.1 1,023

F 1.0 12.4 65.4 223 601

Plasma vitamin C umol/l (>11.0)

M <3 3.0 38.2 80.4 101.5

F <3 2.3 45.8 96 116.5

Total Intake

Vitamin E mg/day

M 0.8 2.7 9.51 24.4 114

F [0.06] 1.8 10.69 28.1 [18.8]

Plasma alpha-tocopherol umol/l

M [0.45] 18.9 35 57.3 [7.49]

F 10.3 19.1 39.1 66.8 128

Plasma gamma-tocopherol umol/l

M 0.45 0.82 2.24 5.02 7.49

F 0.57 0.78 2.53 5.53 8.65

The Spread of Malnutrition: Homocysteine NutrientsNDNS 65 + Free-living M = 538, F = 516


Parameter

(norm or RNI)

Lowest 2.5 pc

Mean 97.5 pc

Highest

Pl. Homocysteine

<12 umol/l

M 5.8 16.3 95.6

F 4.4 15.2 54.9

Total Folate Intake

ug/day (200)M 75 116 263.4 455 728

F 27 86 204 385 535

Red Cell Folate nmol/l (>350)

M 60 155 496 1170 2216

F 78 139 507 1238 2357

Total Vitamin B12 Intake ug/day (1 )

M 0.55 1.8 5.9 19.5 87.2

F 0.66 1.2 4.3 17.9 42.8

Serum Vit. B12 pmol/l (>118)

M 49 90 226 436 737

F 48 103 238 [728] [737]

Folate/Folic Acid and Cancer Risk Ulrich CM. Editorial Am J Clin Nutr 2007;86:271-3

• Low intakes of folate increase the risk of alcohol-associated breast cancer

• Moderate intakes have no effect on risk

• High intakes of folic acid from supplements may increase the growth of an existing tumor

• The effect of folate/folic acid may be influenced by other nutrients and genetic factors

http://www.ajcn.org/content/vol86/issue2/images/large/znu0080746490001.jpeg

Problems with Folate and Vit. B12 in UK Elderly • Deficiencies of both are common in NDNS 65+

• Supplement use is associated with better folate status but only slightly better vit B12 status Dangour A et al J. Nutr. 2008 138;1121-1128

• US NHANES III: those with a serum B12 <148 pmol/l (~35% of UK elderly) increasing serum folate was associated with increased HCys and MMA levelsSelhub J et al Am J Clin Nutr 2009;89(2):702S-706S

• European EPIC no overall association of prostate cancer risk and the status of these nutrientsHowever in those with a high vitamin B12 level there was an increased risk of more advanced disease.Johansson M et al Cancer Epidemiol Biomarkers Prev 2008;17(2):279-85See also Hultdin J et al Int J Cancer 2004;113:819-24

Plasma Homocysteine and Mortality in UK Older PeopleDangour A et al J. Nutr. 2008 138;1121-1128

853 UK M + F >75 yrs. Median follow-up 7.6 yr. 50.3% died. Death rate 1000 per/year

0

20

40

60

80

100

120

Pl. Folate Pl. Vit B12 Pl. Hcys

Lowest 1/3

Middle 1/3

Highest 1/3

Plasma Homocysteine and Mortality: CharacteristicsDangour A et al J. Nutr. 2008 138;1121-1128

Measure Plasma HCys concentration P-trendLowest 1/3 Middle 1/3 Highest 1/3

Age yrs 78.2 78.4 79.7 <0.001

Men % 35.5% 45.9% 50.1% <0.001

HDL Cholesterol mmol/l 1.23 1.27 1.17 0.026

Pl. Vit B12 pmol/l 290.1 264.4 238.3 <0.001

Pl. Folate nmol/l 27.9 21.9 17.4 <0.001

Chronic Kidney Dis. 3 or 4 2.6 9.5 25.3 <0.001

History of Cancer 13.7 5.2 5.4 0.007

Current Smoker % 5.1 7.7 17.2 <0.001

Activity Units/week 3.2 3.5 2.0 0.001

Supplement Use 52.9 45.2 28.6 <0.001

Green Veget. >1 portion/wk 56.4 50.5 42.6 <0.001

The Spread of Malnutrition: Zinc and CopperNDNS 65 + Free-living M = 538, F = 516


Parameter

(and norm/RNI)

Lowest 2.5 pc

Mean 97.5 pc

Highest

Total Zinc Intake

4.5-40 mg/day

M 1.86 4.2 8.81 14.7 27.1

F 1.65 3.4 6.96 11.8 23.3

Plasma zincFasting >10.71 umol/l

Non-fast 9.95 – 20 umol/l

M 7.2 9.9 14.2 19.0 20.5

F 8.2 10.0 14.2 19.1 24.2

Total Copper Intake

1.0-10 mg/day

M 0.29 0.46 1.1 3.37 6.72

F 0.19 0.35 0.88 2.3 5.87

Plasma copper umol/l

M 10.4 17.4 31.5

F 8.4 19.5 38

Dietary Copper and Fats and Cognitive DeclineMorris MC et al Arch Neurol. 2006;63(8):1085-8

• Dietary intake and cognitive function were assessed in 3,718 community-dwelling participants age 65 years and older living in Chicago over 6 years

• Those with a high dietary intake of saturated or trans fats and a high copper intake had a greater rate of cognitive decline

• Comparing the highest quintile 2.75 mg/day vs lowest quintile 0.88 mg/day the difference in decline was -6.14 units/yr or the equivalent of more than 19 yrs of age

• There was a strong dose-response association with higher dose copper in supplements.

• There was no association in those whose diets were not high in these fats.

Iowa Women’s Health Study: Supplements & MortalityMursu J et al. Arch Intern Med 2011;171(18):1625-33

• 38,772 women mean 61.6 yr in 1986; 40.2% died by end 2008• Supplement use in 1986, 1997 and 2004 was associated with an

increased mortality, which may have been due to pre-existing illness• Particular concerns about use of copper-containing products

Nutrient(s) Provided by Supplement

Hazard Ratio

Confidence Intervals

Absolute Risk

Calcium 0.91 0.8 to 0.94 - 3.8%

Multivitamins 1.06 1.02 to 1.1 + 2.4%

Vit B6 1.1 1.01 to 1.21 + 4.1%

Folic acid 1.15 1.00 to 1.32 + 5.9%

Iron 1.1 1.03 to 1.17 + 3.9%

Magnesium 1.08 1.01 to 1.15 + 3.6%

Zinc 1.08 1.01 to 1.15 + 3.0%

Copper 1.45 1.20 to 1.7 + 18%

The Spread of Malnutrition: SeleniumNDNS 65 + Free-living M = 538, F = 516


Parameter

Normal Range

Lowest 2.5 pc

Mean 97.5 pc

Highest

Plasma selenium 1.0 – 1.8 umol/l

M 0.375 0.95 2.376

F 0.461 0.924 1.786

Blood glutathione peroxidase nmol NADPH/mg Hb per min

M 59 89 140 223 359

F 85 93 145 245 353

Serum Selenium and Mortality among US AdultsBleys J et al. Arch Intern Med 2008;188(4):404-410

• Serum Selenium was measured in 13,887 US adults

• Follow-up mortality data over 12 years

• Serum Selenium levels <130 ng/ml (1.6 umol/l)Associated with an inverse association between serum selenium and all-cause and cancer mortalities

• Serum Selenium levels >150 ng/ml (1.9 umol/l)Associated with a modest increase in all-cause mortality

• No association between serum Se and cardiovascular mortality

• Normal Range:Serum or Plasma Selenium 80 -150 ng/ml 1.0 -1.85 umol/l

NDNS 65+ Abnormal Liver Function TestsPrevalence of: Plasma Alkaline Phosphatase >110 IU/L

Plasma Gamma-Glutamyl Transferase >50/32 IU/L

• Abnormal LFTs in 10% - 30% of all UK adults

• Elevated Alk. Phosphatase - cholestatic liver disease - reduced excretion of:Copper and Manganese and increased mortality

• Elevated Gamma GT- often alcohol excess - obesity – NAFLD, hepatitis and drug-induced

• Chronic Liver Disease:- elevated plasma retinol- deficiencies of : vitamins D, B, - later vitamins A and K - zinc- iron accumulation

0%

10%

20%

30%

40%

50%

65-74 yrs 75-84 yrs 85+yrs 65-84 yrsInst

85+ yrsInst

Alk P MenAlk P Women

0%

10%

20%

30%

40%

50%

65-74 yrs 75-84 yrs 85+yrs 65-84 yrsInst

85+ yrsInst

GGT Men

GGT Women

Liver Disease: Brain Manganese Accumulation• Primary Biliary Cirrhosis is a not uncommon cause of chronic

liver disease especially in women• Presents with fatigue and skin itching without jaundice • Tests reveal raised alkaline phosphatase• Studied 18 PBC patients 14 with early pre-cirrhotic • Blood manganese elevated - reduced ability to excrete excess• Accumulation of mineral in the brain (reduced magnetisation

transfer ratio in the globus pallidus) similar to industrial manganese excess, which causes Parkinsonism

• Similar changes may occur in infants with biliary atresia• Manganese accumulation can easily occur in those

with cholestasis or raised alkaline phosphatase level• Reference: Fotron DM et al. Gut 2004;53:587-592.

Fatigue and primary biliary cirrhosis: association of globus pallidus magnestisation transfer ratio measurements with fatigue severity and blood manganese levels.

Manganese: UK Position

Daily provision:

Multivitamin mineral 0.5 mg

Glucosamine +

Chondroitin* 3.5 mg

*2010 Tesco have agreed to

reduce the Mn content to 0.5 mg

• Adult intakes average 2.77 – 3.42 [95% CI 1.05-8.11] mg/day• Food sources: grains (50%), tea, beans, supplements 3%• Deficiency rare but may occur in those fed parenterally• 1.03% to 4.86% of dietary manganese is absorbed• Absorption is increased in iron deficiency or by low intake• Excess is excreted via the bile, if liver function is normal• Safe Upper Level 4 mg but 0.5 mg/day for those aged >50 yrs• Many UK preparations contain 1mg to 10 mg/day often with Glucosamine

but up to 60 mg/day in US imports

Definitions of Safe Levels

• UK Safe Upper Levels (SULs) Guidance Levels (GLs) “are the doses of vitamins and minerals that susceptible individuals could take daily on a life-long basis, without medical supervision.”Single figure, applies to adults only, based on 60 kg femaleTotal Safe Intakes (TSIs) are set for retinol and some trace elements

• US Tolerable Upper Intake Levels (ULs)Range of figures depending upon age and sex“is the highest average daily nutrient intake level likely to pose no risk of adverse effects for nearly all people in a particular group”Based on total intake from food, water and supplements

• EU Tolerable Upper Intake Level (UL)“the maximum level of total chronic daily intake of a nutrient (from all sources) judged to be unlikely to pose a risk of adverse effects”.ULs vary with age and sex and exclude “those under medical supervision and certain disease states” but includes “sensitive individuals”

NDNS 65+ The Final AnalysisWhat was surveyed in NDNS?

Stage NDNS 65+ Component


• State of Negative Balance 1. Poor intake Diet + Supplements 2. Reduced absorption 3. Increased losses 4. Increased requirement 5. Altered metabolism Alcohol, drugs, liver and renal

• Decline in Tissue Stores Tests – blood and urine

• Loss of Function:1. Symptoms Depression2. Physical Signs BMI 3. Organ Failure Renal and Liver Function Tests

• Death Data Collected after 14yrs

NDNS 65+: Determinants of Longevity• During 14 yrs of follow-up the causes of death were recorded

for free-living people; 74% of men and 62% of women died• Mortality was predicted by baseline measures of:

- poor grip strength (men)- low intakes of food and protein - poor renal function - raised plasma creatinine and homocysteine- raised Hb A1c - prediabetes/diabetes

• Mortality also predicted by plasma levels of nutrients:- raised copper - infection, cancer, liver or inflammatory disease- raised plasma retinol – high intake, renal impairment, alcohol XS- low vitamin C- low alpha-carotene - low vitamin B6- low vitamin D (men)- low zinc and selenium

• Mortality was not predicted by:- dietary intakes of folate and vitamin B12- haemoglobin, serum/plasma vitamin B12, folate and beta-carotene- serum cholesterol

Physical Health: All-cause mortality NDN 65+ [Hazard Ratio <1.0 = Increased Survival with increased level]

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

Grip Strength Mid-Arm Circumf. BMI

Men and Women

Bates CJ et al Br. J Nutr. 104:893-9 & 105: and Osteop Int 2011

Nutrient Intake: All-Cause Mortality NDNS 65+ [Hazard Ratio <1.0 = Increased Survival with increased level]

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

Energy Protein Vit. C Phosph. Calcium Vit. D Non-HaemIron

Men and Women


Plasma Mineral Level: All-cause mortality NDN 65+[Hazard Ratio <1.0 = Increased Survival with increased level]

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

Selenium Zinc Iron Iron Sat Copper

Men and Women


Vitamin Test Status: All-cause mortality NDN 65+ Plasma Levels [Hazard Ratio <1.0 = Increased Survival]

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

Vit. D Vit. B6P5P

Alpha-Carot

Lut. + Zx S. Folate S. Vit.B12

RBC Fol

Men and Women


Laboratory Tests: All-Cause Mortality NDNS 65+ Plasma [Hazard Ratio <1.0 = Increased Survival with increased level]

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

Albumen T. Chol. Phos. Fibrinog. T. Hcys A1 Anti-T Hb A1C Creatin.

Men and Women


Mortality, Homocysteine and Related Nutrients: NDNS 65+Bates CJ et al Br J Nutr. 2010;104:893-899

• n =1100, 50.2% Female. Baseline 1994/5; follow-up Sept 2008

• Mortality data and cause were collected – related to baseline data

• Mortality predictable by; plasma tHcys, pyridoxal PO4, creatinine, Glyc Hb, alpha1-antichymotrypsin, fibrinogen, diet, but not folate/vit B12 intake/status

Biochemical Measure or

Dietary Factor

All-cause Mortalitydied =749, alive =351

Vascular Disease Mortalitydied =199, alive =351

Hazard Ratio 95% CI Hazard Ratio 95% CI

Pl. tHcys umol/l 1.19 1.11, 1.27 1.36 1.13, 1.63

Total Chol mmol/l 0.90 0.83, 0.99 0.89 0.73, 1.08

Blood HbAIc% 1.23 1.14, 1.32 1.32 1.11, 1.57

Pl. Creatinine 1.20 1.10, 1.31 1.25 1.05, 1.49

Energy KJ/day 0.87 0.8, 0.96 0.86 0.72, 1.02

Fat g/day 1.1 0.94, 1.29 0.92 0.79, 1.08

Protein g/day 0.86 0.77, 0.97 0.79 0.67, 0.94

Plasma Nutrient Levels and Specific Mortality: NDNS 65+ Age-and sex-adjusted ;l values outside of 0.9 to 1.1 are significant p<0.05

00.10.20.30.40.50.60.70.80.9

11.11.21.31.4

Vit C Alpa-carot

Se Zn Cu Fe

All Cause

Vascular

Cancer

Respiratory

Undernutrition: Prevalence and Likely Significancein NDNS65+ Free-Living Population

Nutrient % Pop. Clinical SignificanceEnergy 1 - 5% Underweight, fatigue, poor immunity, fracture

Protein 1 - 5% Fatigue, poor wound healing, infection

Fibre >50% Constipation, colon cancer, vascular disease

Water ? Dehydration

Anaemia Due to deficiency, bleeding, chronic illness

Folate 5 - 30% Depression, anaemia, vascular disease

Vitamin B 10 - 20% Fatigue, neurological and vascular disease

Vitamin D Osteoporosis, muscle pain/weak, infection

Iron 1 - 25% Anaemia, fatigue, heart failure

Calcium 10% Osteoporosis

Trace elements

1 - 25% Poor immunity and reduced longevity; Zn – taste, vision, wound healing; Cu - anaemia

Overnutrition: Prevalence and Likely Significancein NDNS65+ Free-Living Population

Nutrient % Pop. Clinical SignificanceEnergy 30% Obesity, vascular disease and cancer

Saturated Fats Vascular disease, inflammation

Protein animal 5% Obesity, osteoporosis ?renal impairment

Sugar NMES 50% Dental caries, obesity, T2D

Water Uncertain Hyponatraemia

Sodium 80% Hypertension, strokes, fluid retention, heart failure, osteoporosis and fatigue

Iron 0.6% Haemochromatosis – fatigue & arthritis

Vitamin A 10-20% Birth defects, osteoporosis, liver disease

Micronutrients from food water or supplements

Uncertain Possible due to excessive intake, liver or renal disease; concerns about copper and manganese.

Nutrition and Ageing: Conclusions from NDNS 65+

• Problems of nutritional deficiency and excess are common in ageing populations and frequently co-exist in patients

• The commonest cause of undernutrition is poor dietary intake but alcohol excess, illness and medical drugs are also factors

• Both types of problem are under-recognised

• Both under and overnutrition can be detected by careful history (diet, risk factors and symptoms), examination and investigation

• Many such problems are preventable & treatable but the value of treating and the best method of doing so are not clear

• Nutrition decline and excess can also be part of the ageing process and may develop in terminal situations

• Doctors, patients and society in general need to decide just how far they can go in assessing and managing these problems

NDNS 65+: What has happened in last 20 yrs?

• Current NDNS Rolling Programme includes >65 yrsdata for years 1 and 2 (of 3) have reported on:- methodology and nutrient intake- blood data will be reported on in late 2012

• UK Population changes include:- small increase in fruit and vegetable consumption- continuing decline in saturate and trans-fats- increase in alcohol and excessive alcohol consumption - continuing low levels of activity by many- increase in obesity- increased supplement use especially calcium and vit. D- increased use of medication

• Increased longevity and increased disease- longevity improved mainly in non-deprived but more;T2D, liver/renal disease, cancer, dementia and osteoporosis

Getting it right: what do patients need to know?Headstone 19th C St Andrews, Scotland - deaths at (M)76 & (F)93 yrs

• Achieve food-based targets for: protein, fish/oily fish, dairy, nutritious carbohydrates and fruit & vegetables

• Do not exceed limits for salt, sugar, alcohol and fats

• Avoid obesity and underweight

• Be active and get out of doors

• Socialise, eat and be active with others and maintain interests

• Have medical treatment when ill

• Make use of supplements when necessary and avoid excess

• Encourage others to do likewise

NDNS 65+: The Last Word

• Thank you for your attention

• More information is available in lecture form on:- Nutritional Assessment- Low Income Diet and Nutrition Survey- Safety of Nutritional Supplements

• I would welcome your feedback on this and other presentations [email protected]

• Dr Stewart is available to lecture on these topics

mailto:[email protected]

National Diet and Nutrition Survey: people aged 65 years and over. Published 1995 HMSO London

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Transcript of National Diet and Nutrition Survey: people aged 65 years and over. Published 1995 HMSO London