Renuka Visvanathan

Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group

New evidence shows that older adults need more dietary protein than do younger adults to support good health, promote recovery from illness, and maintain functionality. Older people need to make up for age-related changes in protein metabolism, such as high splanchnic extraction and declining anabolic responses to ingested protein. They also need more protein to offset inflammatory and catabolic conditions associated with chronic and acute diseases that occur commonly with aging. With the goal of developing updated, evidence-based recommendations for optimal protein intake by older people, the European Union Geriatric Medicine Society (EUGMS), in cooperation with other scientific organizations, appointed an international study group to review dietary protein needs with aging (PROT-AGE Study Group). To help older people (>65 years) maintain and regain lean body mass and function, the PROT-AGE study group recommends average daily intake at least in the range of 1.0 to 1.2 g protein per kilogram of body weight per day. Both endurance- and resistance-type exercises are recommended at individualized levels that are safe and tolerated, and higher protein intake (ie, ≥ 1.2 g/kg body weight/d) is advised for those who are exercising and otherwise active. Most older adults who have acute or chronic diseases need even more dietary protein (ie, 1.2-1.5 g/kg body weight/d). Older people with severe kidney disease (ie, estimated GFR <30 mL/min/1.73 m(2)), but who are not on dialysis, are an exception to this rule; these individuals may need to limit protein intake. Protein quality, timing of ingestion, and intake of other nutritional supplements may be relevant, but evidence is not yet sufficient to support specific recommendations. Older people are vulnerable to losses in physical function capacity, and such losses predict loss of independence, falls, and even mortality. Thus, future studies aimed at pinpointing optimal protein intake in specific populations of older people need to include measures of physical function.

Diabetes and Cardiovascular Disease Outcomes in the Metabolically Healthy Obese Phenotype: A cohort study

OBJECTIVE To determine the correlates of the “metabolically healthy obese” (MHO) phenotype and the longitudinal risks of diabetes and cardiovascular disease (CVD)/stroke associated with this phenotype. RESEARCH DESIGN AND METHODS The North West Adelaide Health Study is a prospective cohort study of 4,056 randomly selected adults aged ≥18 years. Participants free of CVD/stroke and not underweight (n = 3,743) were stratified by BMI categories and metabolic risk, defined as having two or more International Diabetes Federation metabolic syndrome criteria, excluding waist circumference. RESULTS Correlates of the MHO (n = 454 [12.1%]) included smoking, socioeconomic disadvantage, and physical inactivity. Compared with metabolically healthy normal-weight subjects (n = 1,172 [31.3%]), the MHO were more likely to develop metabolic risk (15.5 vs. 33.1%, P < 0.001) and incident diabetes (odds ratio 2.09 [95% CI 0.87–5.03]) but not CVD/stroke (1.16 [0.58–2.29]) during 5.5–10.3 years of follow-up. These risks were not seen in MHO subjects maintaining metabolic health (n = 188 [67%]). Sustained metabolic health in obese participants was associated with age ≤40 years and lower waist circumference. Compared with the metabolically at-risk obese, MHO women demonstrated a significantly higher (mean [SE]) percentage of leg fat (49.9 [0.5] vs. 53.2 [0.7]) and lower waist circumference (104 [0.6] vs. 101 cm [0.8]), despite no significant differences in overall adiposity. CONCLUSIONS “Healthy” obesity was a transient state for one-third of subjects. Persistence of a MHO phenotype, which was associated with favorable outcomes, was related to younger age and a more peripheral fat distribution. The MHO phenotype may be sustained by promoting lower waist circumferences.

The nutritional status of 250 older Australian recipients of domiciliary care services and its association with outcomes at 12 months.

OBJECTIVES: To identify predictors and consequences of nutritional risk, as determined by the Mini Nutritional Assessment (MNA), in older recipients of domiciliary care services living at home.

Effect of testosterone and a nutritional supplement, alone and in combination, on hospital admissions in undernourished older men and women

BACKGROUND In older people, undernutrition is associated with increased hospitalization rates and mortality. Because weight loss in older people often reflects a disproportionate reduction of skeletal muscle, anabolic treatments may be beneficial. OBJECTIVE Our aim was to evaluate the hypothesis that testosterone treatment and a nutritional supplement have additive benefits. DESIGN Oral testosterone undecanoate (40 mg daily for women, 80 mg twice daily for men) and an oral nutritional supplement (475 kcal/d) were administered, alone or combined, for 1 y to 49 community-dwelling, undernourished people [Mini Nutritional Assessment score <24 and low body weight (body mass index, in kg/m(2): <22) or recent weight loss (>7.5% over 3 mo)] aged >65 y (mean age: 77 y; 26 women and 23 men). Hospital admissions and other variables were assessed. RESULTS In subjects receiving combined testosterone and nutritional supplements (n = 11), there were no hospital admissions, whereas there were 9 admissions (2 elective) in 13 subjects in the no-treatment group, 4 in the testosterone-treated group (n = 12), and 5 in the supplement-treated group (n = 13); P = 0.06 with no-treatment compared with combined treatment. When compared with the no-treatment group, the combined-treatment group had significantly fewer subjects admitted to hospital (0 compared with 5, P = 0.03), fewer days in hospital (0 compared with 74, P = 0.041), and a longer time to hospital admission (P = 0.017). CONCLUSIONS In undernourished older people, combined treatment with testosterone and nutritional supplementation reduced the number of people hospitalized and the duration of hospital admissions, which are important endpoints in this group. Larger, confirmatory studies are now needed. This trial was registered before commencement at clinical trials.gov as NCT00117000.

Preventing sarcopaenia in older people

With increasing age, there is a loss of appetite. Decline in food intake exceeds the decline in physical activity resulting in weight loss. With the ensuing weight loss, there is disproportionate loss of muscle mass. Even if weight is regained, there is a net loss of muscle mass. Sarcopaenia refers to a lack of muscle mass which leads to adverse health outcomes such as falls and reduced physical function. With sarcopaenia, there is change not only to muscle mass but also to muscle quality and function. As with other diseases, prevention is better than cure. With increasing age, there should be adequate protein intake and there is recommendation that the total protein intake is spread equally across three main meals. Sustained participation in resistance exercise programs also benefit muscle anabolism, an effect that may be enhanced if exercise is followed soon after by a high-protein meal. Attention to Vitamin D is not only likely to benefit muscle strength but would also reduce fracture risk with falls. Older people should focus on weight maintenance given that weight loss may result in undesirable loss of muscle mass. Those who are morbidly obese who need to lose weight should be advised to maintain protein intake and exercise to preserve muscle mass. Sarcopaenia, if unmanaged, is likely to result in significant health care costs. Preventing sarcopaenia will most likely not only result in significant health cost savings but will also contribute to better health in older age.

Undernutrition and Anorexia in the Older Person

Minimizing frailty in older age is important to individuals and society, as the increasing prevalence of chronic disease is leading to greater disability and health care costs. Nutritional frailty can be defined as the disability that occurs in old age due to rapid, unintentional loss of body weight and sarcopenia (lack of lean mass). This article provides a brief overview of the prevalence and consequences of undernutrition, age-related changes to appetite, food intake, and body composition, the factors contributing to the development of anorexia and undernutrition, and recommended management strategies.

Nutritional Screening Tools as Predictors of Mortality, Functional Decline, and Move to Higher Level Care in Older People: A Systematic Review

This systematic review assessed whether nutritional screening tools (NSTs) predict mortality, functional decline, and move to higher level care in older adults residing in the community or in institutions. In total, 37 prospective studies published between 1999 and 2012 met inclusion criteria and were included in this review. The most commonly used NST in these studies was the Mini Nutritional Assessment (MNA). Comparison of NSTs was limited by variation in follow-up time, lack of uniform definition of functional decline, and biases in many studies. Results of MNA, MNA-Short Form (MNA-SF), and Geriatric Nutrition Risk Index (GNRI) assessments were significantly associated with subsequent mortality, with good negative predictive power (∼0.83), but only modest positive predictive power (PPV∼0.32). MNA-SF and MNA results had a low to moderate association with functional decline (PPV∼0.34). Move to higher level care was less strongly associated with NST scores (PPV∼0.25). Overall, there is evidence that NSTs can predict those at low risk of mortality, functional decline, and, to a lesser extent, move to higher level care in older people.

The effects of drinks made from simple sugars on blood pressure in healthy older people

The objective of the research was to determine the blood pressure (BP) lowering effects in older people of 50 g carbohydrate drinks with varying carbohydrate content using a randomised, cross-over study with ten (six females) healthy older subjects (mean age 72.20 (sem 1.50) years). BP, heart rate and glucometer-derived blood glucose levels were determined at baseline and following the ingestion of equal volumes (300 ml) of water and carbohydrate drinks with varying nutrient content (glucose, sucrose and fructose). A significant decline in BP over the first 60 min was seen following glucose (systolic BP (SBP) P<0.01, diastolic BP (DBP) P<0.01, mean arterial BP (MAP) P=0.03) and sucrose (SBP P<0.01, DBP P<0.01, MAP P<0.01) ingestion, although the decrease occurred earlier after glucose than sucrose ingestion (SBP 7.33 (sem 2.19) v. 21.00 (sem 4.30) min (P=0.03) and MAP 11.22 (sem 3.10) v. 17.00 (sem 3.78) min (P=0.03)). BP increased after water ingestion (SBP P=0.04, DBP P=0.18, MAP P=0.02) but did not change after fructose ingestion (SBP P=0.36, DBP P=0.81, MAP P=0.34). Post hoc analyses revealed that the BP (SBP, DBP and MAP) decrease following glucose and sucrose ingestion were similar but significantly greater than following fructose or water ingestion. Sucrose, which is used widely (table sugar), reduces BP as much as glucose. In contrast to this, fructose ingestion causes no change in BP. Further studies are required to determine if the substitution of glucose or sucrose with fructose may be beneficial in the medical management of older people with severe symptomatic postprandial hypotension.

Use of the Mini Nutritional assessment to detect frailty in hospitalised older people

ObjectivesThe aims of this study were to: (1) determine the prevalence of undemutrition and frailty in hospitalised elderly patients and (2) evaluate the efficacy of both the Mini-Nutritional Assessment (MNA) screening tool and the MNA short form (MNA-SF) in identifying frailty.Setting and ParticipantsA convenient sample of 100 consecutive patients (75.0 % female) admitted to the Geriatric Evaluation and Management Unit (GEMU) at The Queen Elizabeth Hospital in South Australia.MeasurementsFrailty status was determined using Fried’s frailty criteria and nutritional status by the MNA and MNA-SF. Optimal cut-off scores to predict frailty were determined by Youden’s Index, Receiver Operator Curves (ROC) and area under curve (AUC).ResultsUndernutrition was common. Using the MNA, 40.0% of patients were malnourished and 44.0% were at risk of malnutrition. By Fried’s classification, 66.0 % were frail, 30.0 % were pre-frail and 4.0 % robust. The MNA had a specificity of 0.912 and a sensitivity of 0.516 in predicting frailty using the recommended cut-off for malnourishment (< 17). The optimal MNA cut-off for frailty screening was <17.5 with a specificity of 0.912 and sensitivity of 0.591. The MNA-SF predicted frailty with specificity and sensitivity values of 0.794 and 0.636 respectively, using the standard cut-off of < 8. The optimal MNA-SF cut-off score for frailty was < 9, with specificity and sensitivity values of 0.765 and 0.803 respectively and was better than the optimum MNA cut-off in predicting frailty (Youden Index 0.568 vs. 0.503).ConclusionThe quickly and easily administered MNA-SF appears to be a good tool for predicting both under-nutrition and frailty in elderly hospitalised people. Further studies would show whether the MNA-SF could also detect frailty in other populations of older people.

Blood pressure responses in healthy older people to 50 g carbohydrate drinks with differing glycaemic effects

The aim of the present study was to determine the effects on blood pressure response of 50 g carbohydrate drinks with differing glycaemic effects in ten healthy elderly subjects (age > 65 years; randomized crossover design). Systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressure, heart rate and plasma glucose levels were determined following ingestion of equal volumes (379 ml) of water and 50 g carbohydrate drinks with differing reported glycaemic indices (GI) (surrogate marker for glycaemic effect): (1) low-GI: Apple & Cherry Juice; (2) intermediate-GI: Fanta Orange; (3) high-glucose. Glucose (SBP and DBP P < 0.001; MAP P = 0.005) and Fanta Orange (SBP P = 0.005; DBP and MAP P < 0.001) ingestion caused a significant decrease in BP whilst blood pressure increased (SBP P = 0.008; MAP P = 0.005) from baseline following Apple & Cherry Juice ingestion. Water had no significant effect on postprandial blood pressure. Fanta Orange and Apple & Cherry Juice caused similar (P = 0.679) glycaemic effects, which were significantly greater than water, but lower than glucose (P < 0.001). There was no significant correlation between the glycaemic effect of the carbohydrate drinks and there was no change in blood pressure from baseline (SBP r - 0.123, P = 0.509; DBP r - 0.051, P = 0.784; MAP r - 0.069, P = 0.712). Apple & Cherry Juice and Fanta Orange had similar glycaemic effects, but differing effects on blood pressure. Therefore, it is unlikely that the glycaemic effect of a drink can be used to predict the subsequent cardiovascular response.