Nutri-Senex: State of the art report – task 2.1

SIXTH FRAMEWORK PROGRAMME

PRIORITY 5

FOOD QUALITY AND SAFETY

Co-ordination Action

WP2 Task 2.1 – “State of the art report” Second update to Literature Survey D 29

Project acronym: NUTRI-SENEX

Project full title: Improving the quality of life of elderly people by co-ordinating research into malnutrition of the elderly

Proposal/Contract no.: 506382 2004

This report has been prepard within work package 2 by the following members of the Nutri-Senex consortium:

Elmadfa I & Freisling H (Wien), Bähr A. & Matullat I (TTZ), Rummel C, Drachner S, Wittekind C (SAM ASAP), Rouby C, Bensafi M, Barkat S (UCB), Köhler J, Leonhäuser U, Walter C (JLU), Gilbert C, Allen D, Papandopoulou A (CCFRA), Cooper-Smith D. (Chalex)

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1 Nutrition of the elderly...... 4

1.1 Physiologic changes influence nutritional requirements ...... 4 1.2 Nutritional requirements of the elderly ...... 6 1.3 Assessment of the nutritional status ...... 9 1.4 Malnutrition in the elderly...... 11 1.5 The challenge of a sex-differential imbalance...... 14 1.6 Physical activity ...... 15 1.7 Literatur ...... 15 2 Effects of ageing on chemosensory sensitivity, sensory preference and nutritional status...... 39

2.1 Introduction...... 39 2.2 Taste losses ...... 40 2.3 Olfactory losses ...... 43 2.4 Recent research on chemosensory sensitivity and nutritional status in the elderly...... 53 2.4.1 Cell death and renewal in the olfactory system ...... 53 2.4.2 Consequences on understanding human aging in chemical senses………………………………………………………………………… 55 2.4.3 Prediction of weight loss in the elderly by questionnaires...... 55 2.5 Literature ...... 58 3 Social and cultural reasons for food preferences and food selections...... 65

3.1 Introduction...... 65 3.2 Definition...... 65 3.3 State of the art ...... 66 3.4 Methods...... 66 3.5 Lifelong eating habits...... 67 3.5.1 Religion ...... 73 3.5.2 Tradition ...... 73 3.5.3 Factors influencing Obesity ...... 75 3.5.4 Sedentary Lifestyle...... 75

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3.5.5 Living-eating environment ...... 77 3.6 Psycho-social determinants of nutrition behaviour ...... 78 3.6.1 Motives ...... 78 3.6.2 Attitudes ...... 79 3.6.3 Emotions ...... 80 3.7 Literature ...... 82 4 Preventive nutrition strategies...... 93

4.1 Functional food based preventive nutrition strategies...... 93 4.2 Food targeting the elderly...... 94 4.3 Food designed for the altered perception of the ageing ...... 95 4.4 Designed food for catering homes or institutionalised elderly...... 96 4.5 Literature ...... 98 5 Study of dietetics- The institutionalised elderly...... 100

5.1 Introduction...... 100 5.2 Key Government Documents – UK / England...... 102 5.3 Key Government Documents – Scotland...... 105 5.4 Other Key Publications ...... 107 5.5 Other Key Websites...... 108 5.6 Primary Papers...... 109 5.7 Primary Papers...... 152 6 Patent Search ...... 243

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1 Nutrition of the elderly 1.1 Physiologic changes influence nutritional requirements Ageing produces physiologic changes that affect the need for several essential nutrients. While the impact of age-related alterations in physiology and metabolism has been extensively assessed in pharmacological studies, it has only been within the last two decades that much research has been conducted to define the influence of these changes on human nutritional requirements. The normal ageing process is accompanied by several physiologic changes that alter the older adult’s nutritional requirements:

1. Changes in taste and smell

Losses of taste and smell are common in the elderly and result from normal aging, certain disease states (especially Alzheimer disease), medications, surgical interventions, and environmental exposure. Deficits in these chemical senses cannot only reduce the pleasure and comfort from food, but represent risk factors for nutritional and immune deficiencies as well as adherence to specific dietary regimens. Chemosensory decrements can lead to food poisoning or overexposure to environmentally hazardous chemicals that are otherwise detectable by taste and smell. The reduced taste sensitivity has several causes. Saliva production is reduced, and taste buds decrease in size and number. The anterior taste buds, which are for sweet and salty, are affected first, whereas the posterior taste buds, for bitter and sour, are affected later. Therefore, older adults become more sensitive to bitter or sour flavours and less sensitive to sweet and salty flavours. These changes in the taste buds start at about age 70 on the average. Olfactory acuity also declines with age, whereas the sense of smell is more impaired by aging compared with the sense of taste. By this, smell disorders result from degeneration of the olfactory cells and a minor ventilation by the nose formation.

2. Changes of the digestive system

Decrease in gastrointestinal (GI) motility— It is fairly common for older people to have less frequent bowel movements and to suffer from constipation and GI distress. Because gastric emptying times are slower, the patient may eat less due to a feeling of fullness. Nutrient absorption is decreased and the stomach produces less hydrochloric acid to aid in digestion. Decreased hydrochloric acid secretion reduces the absorption of iron and calcium. Decreased intrinsic factor

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limits vitamin B12 absorption. Decreased gastric and pancreatic secretion inhibits fat and protein digestion. The common decrease in glucose tolerance results also from the decreased secretion of insulin by the pancreas. Dysphagia is a common problem in older patients and is becoming a larger health care problem as the populations of the United States and other developed countries rapidly age. Changes in physiology with aging are also seen in the upper esophageal sphincter and pharyngeal region in both symptomatic and asymptomatic older individuals. Age related changes in the esophageal body and lower esophageal sphincter are more difficult to identify, while esophageal sensation certainly is blunted with age. Stroke, Parkinson's disease, amyotrophic lateral sclerosis, Zenker's diverticula, and several other motility and structural disorders may cause oropharyngeal dysphagia in an older patient.

3. Changes of the muscles and the skeleton

Aging is associated with remarkable changes in body composition. Loss of skeletal muscle, a process called sarcopenia, is a prominent feature of these changes. In addition, gains in total body fat and visceral fat content continue into late life. The cause of sarcopenia is likely a result of a number of changes that also occur with aging. These include reduced levels of physical activity, changing endocrine function (reduced testosterone, growth hormone, and estrogen levels), insulin resistance, and increased dietary protein needs. Decrease in lean body mass Lean body mass (muscles, organs, and skeletal tissue) and muscle cell metabolism decrease with age. Such changes can be accelerated because older adults utilise dietary protein less efficiently and may actually need a greater than recommended amount of high quality protein in their diet to maintain lean tissue mass. As body protein decreases, body fat increases. This results in a lower basal energy expenditure (BEE). Bone mass decreases – about 3% to 5% for each decade beginning at age 40. With this decrease there is an increase in bone fractures.

4. Changes in the mineral and water balance

Decrease in the ability to concentrate urine—With this decrease comes decreased thirst. The hormonal changes associated with ageing, the occurrence of other medical conditions and the use of medications increases the likelihood of disturbances such as hyper- and hypo-natremia. There is reduced renal function

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with age and the kidneys' ability to produce a concentrated urine declines. Similarly, the excretion of a water load becomes impaired. Fluid and electrolyte homeostasis depend on a balance between the intake and output of water. Aging is characterized by reduced homeostatic capacity. Changes in the control of both water intake and excretion accompany aging and may predispose the elderly to disturbances in sodium and water balance. Reduced thirst and water intake in response to water deprivation and thermal dehydration have been observed in healthy elderly persons. This reduction, combined with reduced renal water- conservation capacity, may predispose the elderly to dangerous dehydration when illness increases water losses or physical incapacity prevents access to water. The reasons for the thirst deficit are not clear. The elderly have a reduced capacity to excrete a water load, which means they are predisposed to water overload and hyponatremia

1.2 Nutritional requirements of the elderly Many factors affect our nutritional behaviour: individual needs and wants, daily moods, social environment, physical activity, current selection of available foods, advertising, etc. In addition, each person has individual nutritional requirements. With advancing age, the older elderly are more likely to develop chronic illness - probably coupled with the need for more support. This age group is the fastest growing sector in society and has specific nutritional needs. However, nutrition advice should be based on individual needs rather than chronological age. A recent Government report, 'The Diet and Nutritional Survey of People aged 65 years and over', showed that older people in the UK are generally adequately nourished. However, on further investigation, the results show a mixed pattern of nutritional status. While 60% of men and women living in the community were overweight, those living in residential or nursing homes were more likely to be underweight (one in six), deficient in folate or anaemic. The requirement for energy declines with increasing age, particularly if physical activity is restricted. However, requirements for protein, vitamins and minerals remain the same, so it's imperative that food choices are nutritionally dense - supplying a rich supply of nutrients in a small volume. RDA stands for ‘recommended daily amount’. RDAs were originally set by the Department of Health in 1979 to say how much of a certain nutrient was needed by different groups of the population. But RDAs were often used wrongly to assess an individual person’s diet. The Department of Health replaced them with DRVs (dietary reference values) in 1991. DRVs are benchmark intakes of energy and nutrients – they can be used for

6 Nutri-Senex: State of the art report – task 2.1 guidance, but shouldn’t be seen as exact recommendations. They show the amount of energy or an individual nutrient that a group of people of a certain age range (and sometimes sex) needs for good health. Although DRVs are given as daily intakes, people often eat quite different foods from one day to the next, and their appetite can change, so in practice the intakes of energy and nutrients need to be averaged over several days. DRVs apply to healthy people only and don’t apply to children under five years old.

DRV is a general term used to cover: • Estimated average requirement (EAR): This is the average amount of energy or a nutrient needed by a group of people. • Reference nutrient intake (RNI): The amount of a nutrient that is enough to meet the dietary needs of about 97% of a group of people. • Lower reference nutrient intake (LRNI): The amount of a nutrient that is enough for a small number of people in a group with the smallest needs. Most people will need more than this. • Safe intake: This is used when there isn’t enough evidence to set an EAR, RNI or LRNI. The safe intake is the amount judged to be enough for almost everyone, but below a level that could have undesirable effects.

A full list of DRVs can be found in the ‘Dietary Reference Values for Food Energy and Nutrients for the UK’, Department of Health, 1991: Report of the Panel on DRVs of the Committee on the Medical Aspects of Food Policy (COMA). The Scientific Advisory Committee on Nutrition (SACN) is a UK-wide Advisory Committee set up to replace COMA. It advises the UK health departments as well as the Food Standards Agency. SACN discussed DRVs at their recent horizon scanning meeting.

General recommendations for the elderly:

Protein is essential for building and maintaining body tissues. It is a source of amino acids that function in muscles, organs, hormones, the nervous system, and the immune system. If the body is not receiving enough calories it will burn protein for its energy needs. Protein needs increase when the body is stressed by injury, infection, surgery, or illness. Protein needs: .8 - 1.0 g Pro /kg body weight for healthy elderly, about 12-14% of total calories.

A certain amount of fat is necessary for life. Fats are highly concentrated sources of energy. They transport fat-soluble vitamins (A, D, K, E), add flavour to food, and enhance its satiety value. The digestion of fat is inhibited with ageing. The fat needs

7 Nutri-Senex: State of the art report – task 2.1 are no more than 30% of total calories. Only 10% of calories should come from saturated fat. Dietary cholesterol should be limited to 300 mg or less per day.

Minimum recommended daily intake of carbohydrates is 50-100 g/day. At least 50% of total calories should come from complex carbohydrate sources.

The daily recommended fibre intake is 20-35 grams. Energy needs decrease with age because the lean body mass (LBM) decreases and the overall level of activity usually decreases. Calorie needs are dependent on activity level, as well as on body composition. Therefore, caloric requirements for a person who is bedridden are less than those for one who is mobile and active. The higher the LBM, the more a person can eat without gaining weight and the more likely he or she will obtain an adequate supply of all nutrients. The body needs about 1.5 times the basal energy expenditure (BEE). There is a 10% reduction of caloric need between ages 51-75 with an additional 10-15% reduction after age 75 depending on individual activity. Compared with the recommendations for young adults, the nutritional requirements in the elderly remain about the same, but their energy needs decrease. This means that older people should consciously select foods with a high nutritional value. These are foods that are high in vitamins, minerals, secondary plant materials, and fibre. Just as in younger years, attention must also be given in old age to maintaining a healthy body weight. According to the German/Austrian/Swiss Reference List 2000 for food intake, the average daily energy requirement for people 65 and older with a normal body mass index (BMI) should be: • Men: 2,300 calories • Women: 1,800 calories Although older adults need fewer total calories, they have an increased need for certain vitamins and minerals. This increased need must therefore be satisfied with a lower overall intake of food. Thus, it is especially important for the elderly to eat foods rich in nutrients: fruits, vegetables, whole grains, lean meat, fish, poultry, low- fat milk and dairy products. Nutrient-poor foods like sweets and alcohol should be limited.

- Vitamin A needs: decrease; supplements containing vitamin A should be avoided.

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- Vitamin D needs: Increase; the exposure to sunlight when possible is recommended and vitamin D-rich foods, such as fish and vitamin D fortified skim milk, should be part of the diet.

- Vitamin B12 needs: Increase; vitamin B12-rich foods, such as lean red meat, chicken, and skim milk are recommended.

- Folate needs: no increased needs for the elderly; commonly found in green vegetables, liver and yeast.

- Chromium needs: Increase; the increased intake of foods high in chromium, such as brewer's yeast and whole grain is recommended.

- Zinc needs: Increase; foods rich in zinc, such as lean red meat, oysters, wheat germ. and whole grains are recommended.

- Water is an important nutrient that is frequently overlooked. The thirst response decreases with age so the elderly should be encouraged to make a habit of drinking water and other fluids throughout the day. At least 6 to 8 cups daily are recommended. Nutrition advise for older adults should be designed to respond to the changing physiological, psychological, social and economic capabilities of the individual while assuring that the overall nutritional needs are met with the freedom to keep meals and eating an important aspect to the quality of life during the later years.

1.3 Assessment of the nutritional status The nutrition status of the elderly is also dependent on social conditions and is influenced by the long-term effects of chronic disease and the intake of medication, which can sometimes generate undesired interactions with nutrients. The physiologic changes of aging, including perceptual, endocrine, gastrointestinal, renal, and muscular changes, may affect nutrition needs. The nutritional status of elderly persons is determined by their nutrient requirements and intake, which are themselves influenced by other factors, such as physical activity, lifestyle, family and social networks, mental and intellectual activity, disease states, and socio-economic constraints. Any meaningful evaluation of the nutritional status must therefore include information on these factors to help in understanding the aetiology of possible deficiencies, designing corrective interventions, and evaluating their effectiveness. Unrecognised undernutrition is a frequent Achilles' heel among the elderly that can cause the condition known as failure to thrive and can trigger a domino effect to further decrease physical health and psychological function in the elderly. Global evaluation of physical, mental, and social states before treatment and re-adaptation

9 Nutri-Senex: State of the art report – task 2.1 is fundamental to the care of the elderly to assess health problems and restore their autonomy. Management after geriatric assessment is helping to improve the survival and functional status of the elderly. Thus, one critical issue is whether nutritional requirements should be adjusted on the basis of observed age-associated changes in body composition and physiologic function or whether optimal body composition and levels of function should be determined for different age groups and nutrient intakes designed to achieve them. The assessment of nutritional status has several components: an evaluation of dietary intake and symptoms that might be related to dietary deficiencies, a physical examination including anthropometric measurements, and blood studies. Nutritional problems in the elderly are as follows: • Usual body weight that is 20% above or below the ideal, recent significant weight gain or loss; any conditions that might increase metabolic needs, such as fever, trauma, burns, infection, or hyperthyroidism • Increased losses of nutrients through draining fistulas, open wounds, chronic blood loss, recent major surgery or illness; chronic diseases: diabetes, hypertension, coronary artery disease, carcinoma, gastrointestinal tract diseases • Social history: inadequate income, inability to buy own food, living alone, eating meals alone, disability, drug addiction, alcoholism, inadequate refrigeration or cooking facilities, smoking • Diet history: meals inadequate for needs, poor appetite, ill-fitting dentures, limited diet, lack of meal appeal, impaired sense of taste, impaired sense of smell, anorexia, problems chewing or swallowing, cultural or religious limitations on diet, frequent meals away from home The purpose of the dietary assessment is to identify a person's eating habits and to estimate the average daily nutrient intake. Through a variety of methods, information should be obtained on the amount and type of food eaten. The validity of the information obtained is affected by the older person's ability to communicate, hear, and remember the recent past. One method of assessing diet is to have the older adult keep a record of daily dietary intake. However, the food record may not be accurate because it relies on the person's memory. Caloric intake may be underestimated because of day to day variation.

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Nutritional Assessment Indicators Assessing nutritional status is an important first step in designing a successful nutrition care plan and providing for optimal wound healing in this population. There is no gold standard with which to assess nutritional status, so biochemical, anthropometric, and dietary intake indicators and the clinical judgment of the evaluator are used to classify nutritional status.

- Body Weight: Current body weight as percent ideal weight evidence of unintentional weight loss

- Anthropometry Triceps and subscapular skinfold thickness

Skinfold measurement is frequently used as a measure of nutritional status. An indirect estimate of body fatness or calorie stores, it correlates well with other measures of body fat. Mid-arm muscle circumference

- Blood Studies

Serum proteins: albumin, prealbumin, transferrin, retinol-binding protein

Creatinine-height index

- Immune Status

- Geriatric Nutritional Risk Index (GNRI)

1.4 Malnutrition in the elderly

The fastest growing segment of the population in most industrialised countries is the elderly; and too often this is also a group most susceptible to many health risks from a nutrient poor diet. Older persons are particularly vulnerable to malnutrition; one- third of people over age 65 suffer from nutritional deficiencies. Evidence from numerous sources indicates that a significant number of elderly fail to get the amounts and types of food necessary to meet essential energy and nutrient needs. Moreover, attempts to provide them with adequate nutrition pose many practical problems. First, their nutritional requirements are not well defined. Since both lean body mass and basal metabolic rate decline with age, an older person’s energy requirement per kilogram of body weight is also reduced. The process of ageing also affects other nutrient needs. For example, while requirements for some nutrients may be reduced, some data suggest that requirements for other essential nutrients may in fact rise in later life. Physiological, psychological and economical changes in the later

11 Nutri-Senex: State of the art report – task 2.1 years can all contribute to poor nutrition among the elderly, and accordingly establishment of healthy nutritional habits often requires a multifaceted intervention approach to address the wide range of factors contributing to suboptimal nutrient intakes.

There is an increasing demand for guidelines which competent national authorities can use to address the nutritional needs of their growing elderly populations. There are a wide range of reasons why older individuals might not be eating the most nutritious diet which is all the more reason why health professionals and care providers need to be constantly aware of the necessity for maintaining an optimal nutritional health status in the elderly.

The incidence of protein-calorie malnutrition (PCM) is higher among the elderly than any other segment of the population. Poor Nutrition may result when a person is not eating a wide variety of foods, is eating too little of the wrong kinds of food, is mishandling food storage or preparation or is not eating enough high fibre foods. Factors that contribute to malnutrition in the elderly are inadequate ingestion: social isolation, loss of spouse, depression, nutritional ignorance, economic adversity, gastrointestinal diseases (motility disorders, mechanical obstruction, nausea, vomiting), decreased physical mobility (stroke, Parkinson's disease, arthritis, cardiac insufficiency), dementia, organ failure, anorexia of disease (cancer, cirrhosis, emphysema), anorexia from medications, poor dentition, sensory abnormalities (taste, smell, vision), lack of nutritional support, pain, deficiencies of enteral or parenteral formula feedings; inadequate absorption and utilization: achlorhydria, drug-nutrient interactions, gastrointestinal diseases, alcoholism, disease-induced metabolic alterations; increased nutrient requirements: fever and inflammatory diseases, injury, surgery, burn losses; increased excretion: drugs, diseases.

Decreased visual acuity limits food shopping, preparation, and menu reading. Diminished hearing reduces enjoyment of the meal and of meal-time conversation. Decreased taste and smell acuity decreases the enjoyment of food. Poor dentition inhibits chewing.

Food and Drug Interactions: Nutrient absorption can be affected by alcohol abuse and drug therapy. Physiologic changes affect appetite and food intake. Drugs affect

12 Nutri-Senex: State of the art report – task 2.1 how the body handles nutrients. Conversely, nutrients can enhance or impede the effect of drugs on the body.

Effects of medications on nutrition: Elderly people who take several medications or who are on long-term drug therapy are at increased nutritional risk. Some drugs suppress appetite. Pain medications can cause constipation. Antibiotics can produce diarrhoea. Nausea, vomiting or dry mouth are side effects of some drugs. Other drugs irritate the stomach lining and cause discomfort. Chemotherapy can alter taste sensation so that food seems bitter or totally bland. Chronic laxative abuse and overuse of vitamin/mineral supplements can be harmful. Headaches, nausea, diarrhea, and eventually liver and bone damage can be caused by ingesting too much vitamin A. High doses of vitamin D can cause kidney damage and even death. Excessive amounts of supplemental iron can build up to harmful levels in the liver and other body organs.

Effects of food on medications: Food can enhance or impair the absorption of a drug and alter the way it is metabolised in the body.

Since energy requirements decrease in old age, special care must be taken to reduce our energy sources accordingly, to prevent a positive energy balance which will result in a slow but steady weight gain. In this situation, energy balance depends not only on caloric intake from food, but also physical activity. In the long term, weight increase can become a risk factor for the "diseases of civilization", such as diabetes, cardiovascular disease, and degenerative joint disease (osteoarthritis).

Older people are more susceptible to certain digestive disorders as well as constipation, diarrhoea, bloating, feelings of fullness, or loss of appetite, because the capacity of the digestive organs decreases in old age. Other causes lie in the way individuals eat: too little fibre-rich foods, lack of fluids, habitually eating too large a meal, or eating too fast. The causes may also be related to medications or diseases, as well as to personal circumstances involving stress, mental tension, or depression. These problems can be dealt with by balanced nutrition, eating fibre-rich foods such as whole-grain products and fruits and vegetables, and by drinking at least 1.5 litres of liquids. Proper chewing promotes digestion. The digestive tract is less burdened if several small meals a day are consumed, while digestive disorders such as bloating and feelings of fullness will occur less often. Exercise and abdominal massage keep the intestines moving. Causes of stress should be decreased.

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1.5 The challenge of a sex-differential imbalance As many societies have undergone economic and industrial development, a variety of social and cultural factors have combined to allow women's inherent biological advantage to emerge. The hazards of infectious diseases and the perils of childbearing have been reduced in industrialised countries while certain risks associated with male gender have increased, giving women longer, but not necessarily healthier, lives than men. These processes continue to be evident today but progress towards improved life expectancy for women differs markedly between societies. In some of the richest countries in the world the gap between female and male life expectancy is now extremely wide. Indeed, it may even be starting to narrow again as the consequences of increased female smoking rates become apparent. However, in other countries the picture is very different with gender discrimination continuing to prevent women from realising their potential for greater longevity. Women comprise the majority of the older population in virtually all countries, largely because women live longer than men. By 2025, both the proportion and number of older women are expected to soar from 107 to 373 million in Asia, and from 13 to 46 million in Africa. This pattern involves its own special nutritional needs, emphases and patterns of malnutrition, including for example the incidence of osteoporosis in older women. Osteoporosis and associated fractures, which are a major cause of illness, disability and death, are a huge medical expense. It is estimated that the annual number of hip fractures worldwide will rise from 1.7 million in 1990 to around 6.3 million by 2050. Women suffer 80% of hip fractures; their lifetime risk for osteoporotic fractures is at least 30%, and probably closer to 40%. In contrast, the risk is only 13% for men. Women are at greater risk because their bone loss accelerates after menopause. Lifestyle factors – especially diet, but also physical activity and smoking – are also associated with osteoporosis, which opens the way for primary prevention. The main aim is to prevent fractures; this can be achieved by increasing bone mass at maturity, by preventing subsequent bone loss, or by restoring bone mineral. Particularly important are adequate calcium intake and physical activity, especially in adolescence and young adulthood.

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1.6 Physical activity Regular physical activity can play a major role in ameliorating many age-related declines in the musculoskeletal and cardiovascular systems. Furthermore, physical activity often can prevent the need for medical treatment, or it can serve as an important adjuvant to medical treatment. Regular physical activity exerts beneficial effects on the functioning of the cardio-respiratory, vascular, metabolic, endocrine and immune systems. In so doing, it greatly reduces risk factors for coronary artery disease, the nation's leading cause of death, and may also prevent the development of, or effectively treat, diseases such as non-insulin dependent diabetes mellitus, osteoarthritis, osteoporosis, obesity, colon cancer, peripheral vascular occlusive arterial disease, arthritis and hypertension. Regular exercise reduces body fat stores, increases muscle strength and endurance, strengthens bones, and, importantly, improves mental health. Although the biochemical and physiological processes associated with aging are poorly understood, both research findings and extensive clinical experience strongly suggest that regular exercise may attenuate the aging process. For example, two common features of aging are decreased muscular strength and reduced functional capacity. The resulting weakness and frailty are associated with accidental falls, a major cause of morbidity in the aged, often leading to institutionalisation and even death. However, the deterioration of muscle strength and functional capacity is not entirely a result of aging. Instead, in many cases, it stems largely from disuse. Clearly, regular exercise and other forms of physical training can help extend the time that older individuals can continue living independently.

1.7 Literatur A New Efficacious Nutrition Education Tool for Seniors (50+years). Journal of Nutrition for the Elderly, 21 (3) 2002: 55 – 63,

Ahluwalia Nt, Sun J, Krause D, Mastro A, Handte G (2004): Immune function is impaired in iron-deficient, homebound, older women. Am. J. Clinical Nutrition, 79: 516 - 521.

Albanese A. A.:Nutrition for the Elderly, by Anthony A. Albanese Journal of Nutrition for the Elderly, 2 (1): 1:84 – 86

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Andersson J. C., Gustafsson K., Fjellström C., Sidenvall B., Nydahl M. (2001): Meals and energy intake among elderly women - an analysis of qualitative and quantitative dietary assessment methods. Journal of Human Nutrition and Dietetics, 14 (6): 467-476,

Arnal M-A, Mosoni Lt, Boirie Y, Houlier M-L, Morin L, Verdier E, Ritz P, Antoine J-M, Prugnaud J, Beaufrère B, Mirand P P (1996):Protein pulse feeding improves protein retention in elderly women. Am. J. Clinical Nutrition, 69: 1202 - 1208.

Ashmead J C, Bocksnick J G. Home-Based Circuit Training for Elderly Women: An Exploratory Investigation . Activities, Adaptation & Aging 26 (4): 47 – 60

Bales C W (2001): What does it mean to be "at nutritional risk"? Seeking clarity on behalf of the elderly. Am. J. Clinical Nutrition, 74: 155 - 156.

Bales C W.,. Ritchie C S (2002) : Elderly Women Need Dietary Protein to Maintain Bone Mass Source: Nutrition Reviews 60 (10) : 337-341

Balsam A, Poe D M, Bottum C L (1993):Food Habits and Nutritional Knowledge of Portuguese Participants in an Elderly Nutrition Program . Journal of Nutrition for the Elderly 12 (1):33 - 42

Bandini L G, Lew J M (1985): Nutrition and the Institutionalized Mentally Retarded Elderly . Journal of Nutrition for the Elderly 4 (4): 53 - 58

Bartali B., Salvini S., Turrini A., Lauretani F., Russo C. R., Corsi A. M., Bandinelli S., D’Amicis A., Palli D., Guralnik J.M., Ferrucci L. (2003): Age and Disability Affect Dietary Intake. Journal of Nutrition.133: 2868-2873.

Bates C J, Mansoor M A, van der Pols J, Prentice A, Cole T J, Finch S (1997): Plasma total homocysteine in a representative sample of 972 British men and women aged 65 and over. European Journal of Clinical Nutrition 51, 691 - 697

Bates C J, Prentice A, Finch S (1999): Gender differences in food and nutrient intakes and status indices from the National Diet and Nutrition Survey of People Aged 65&emsp4;Years and Over. European Journal of Clinical Nutrition 53, 694 - 699

Bates C J, Prentice A, van der Pols J C, Walmsley C, Pentieva K D, Finch S, Smithers G, Clarke P C (1998): Estimation of the use of dietary supplements in the National Diet and Nutrition Survey: People Aged 65 Years and Over. An observed paradox and a recommendation. European Journal of Clinical Nutrition 52, 917 - 923

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Beard J. (2001): Iron status of free-living elderly individuals. Am. J. Clinical Nutrition, 73: 503 - 504.

Beaufrère B, Castaneda C, de Groot L, Kurpad A, Roberts S, Tessari P (2000): Report of the IDECG Working Group on energy and macronutrient metabolism and requirements of the elderly. European Journal of Clinical Nutrition 54, S162 - S163

Beaufrère B, Morio B (2000):Fat and protein redistribution with ageing: metabolic considerations . European Journal of Clinical Nutrition 54, S48 - S53

Beck A M, Ovesen L (1999):Modification of the nutrition questionnaire for elderly to increase its ability to detect elderly people with inadequate intake of energy, calcium, vitamin C and vitamin D . European Journal of Clinical Nutrition 53, 560 - 569

Beck A M, Ovesen L, Schroll M (2001): A six months' prospective follow-up of 65+-y-old patients from general practice classified according to nutritional risk by the Mini Nutritional Assessment. European Journal of Clinical Nutrition 55, 1028 - 1033

Bedell B. A, Shackleton P. A (1989): The Relationship Between a Nutrition Education Program and Nutrition Knowledge and Eating Behaviors of the Elderly .Journal of Nutrition for the Elderly 0163 8 (3/4): 35 – 46

Bergstrom N, Wilson S. E.. Smith Laurel J.L (1988): Nutritional Status of Healthy Middle Class Elderly Women . Journal of Nutrition for the Elderly 7 (1): 3-21

Betts N M, Vivian V M (1984): The Dietary Intake of Noninstitutionalized Elderly. Journal of Nutrition for the Elderly 3 (4): 3 - 12

Blades M (2002): Nutrition and the elderly in residential care Nutrition & Food Science; 32 (5)

Blanc S, Schoeller D A, Bauer D, Danielson M E, Tylavsky F, Simonsick E M, Harris T B, Kritchevsky S B, Everhart J E (2004): Energy requirements in the eighth decade of life, Am. J. Clinical Nutrition, 79: 303 - 310.

Body mass index, physical inactivity and low level of physical fitness as determinants of all- cause and cardiovascular disease mortality—16&emsp4;y follow-up of middle-aged and elderly men and women. International Journal of Obesity 24, 1465 - 1474

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Boirie Y, Beaufrère B, Ritz P (2001) : Energetic cost of protein turnover in healthy elderly humans International Journal of Obesity 25, 601 - 605

Booth S L, Tucker K L, Chen H, Hannan M T, Gagnon D R, Cupples L A, Wilson P WF, Ordovas J, Schaefer E J, Dawson-Hughes B, Kiel DP (2000): Dietary vitamin K intakes are associated with hip fracture but not with bone mineral density in elderly men and women. Am. J. Clinical Nutrition, 71: 1201 - 1208.

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21 Nutri-Senex: State of the art report – task 2.1 mortality and cognitive or functional decline. European Journal of Clinical Nutrition 56, 305 - 312

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27 Nutri-Senex: State of the art report – task 2.1

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2 Effects of ageing on chemosensory sensitivity, sensory preference and nutritional status 2.1 Introduction The sensory properties of foods have a major effect on food choice and food intake (Rozin et al.). People choose and eat those foods that they like, and avoid foods that they do not like. The liking for foods depends to a large extent on the perception of the sensory properties of the foods (Stafleu et al, 2001). Within the population of elderly, weight loss and a low food intake is associated with a higher morbidity and mortality (Morley). The lower food intake of a particular group of elderly subjects, called anorexia of aging (Morley, ), is highly prevalent in elderly residing in nursing homes. For example, van der Wielen et al found in 1995 that in the Netherlands more than 50% of the nursing home residents has an intake of below the RDA of at least one micronutrient. This low micronutrient intake is not caused by unhealthy eating habits, but due to a low food intake. Elderly may perceive the sensory properties of foods different from young subjects, and this may in the end have an effect on nutritional status, through the effect of food intake. The different perception of foods may also be related to the use of medications, which can have an effect on taste and/or smell perception. The cascade of events of how changes in chemosensory sensitivity with ageing may have an effect on nutrition and health of elderly with a low food intake is given in Figure 1 (de Graaf et al, 1996).

Ageing/ medication Æ Decline in chemosensory sensitivity Æ Preferences for higher levels of taste/smell substances in foods/flavour enhancement Æ Beneficial effects of flavour enhancement on food intake in elderly with a low food intake Æ Better nutritional status on the long term

Figure 1. Presumed cascade of event how ageing leads to preferences for higher optimal taste and smell substances in foods, and how this may affect food intake and nutritional status.

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This chapter summarizes the present state of scientific knowledge with regard to chemosensory sensitivity in elderly and its effect on nutrition and health. Figure 1 provides the framework for the division of paragraphs in this chapter. First, we summarize the effects of ageing and medication on chemosensory sensitivity. Then we discuss the studies that have been done in the area of food preferences in the elderly. The overview is continued with a discussion of the results of studies that investigated the effects on food intake and nutritional status.

Losses of taste and smell are common in the elderly. We will review the losses due to “normal ageing”, then the diseases, medications and environmental exposures that may add their toll on sensory decline.

2.2 Taste losses

Normal aging

Detection thresholds and recognition thresholds are elevated in older persons; this means reduced sensitivity for sweet, sour, salty, bitter, amino acids such as glutamate salts (Schiffman, 1993; Stevens et al, 1995). However, decrements are modest for elderly individuals who take a moderate number of medications but otherwise have a normal and active life. “Compared with a young cohort, the average detection threshold for elderly with 1 or more medical condition taking an average of 3.4 medications were 11.6 times higher for sodium salts, 4.3 times higher for acids, 7.0 times higher for bitter compounds, 2.5 times higher for amino acids, 5.0 times higher for glutamate salts and 2.7 times higher for sweeteners”. However, thresholds may reflect poorly the real life impairment; some tastes remain relatively robust over the human life span (Davenport, 2004): despite elevated thresholds, elderly seem to respond to higher concentrations of sugar like younger people, whereas salt sensation declines and bitter response drops profoundly.

Causes of taste losses:

The cause of taste changes in normal aging in the absence of disease or medication is not fully understood. Some studies have found reduced number of papillae and/or taste buds, while others conclude that losses are rather due to altered functioning of cell membranes. The trigeminal sensory network also present in the mouth, responds to touch and pain. It is connected with taste nerves and these interactions probably change with age. A recent study (Boucher et al, submitted) establishes a relationship between

40 Nutri-Senex: State of the art report – task 2.1 dental deafferentation and electrogustometry: the greater the number of dental deafferentations, the higher the electrogustometric thresholds for all recording sites on the tongue. No significant increase related to age was measured when matching subgroups for age and dental deafferentation. This means that age itself might be of lesser importance in gustatory losses than interventions on teeth. Oral health also can impair gustatory and olfactory functions (Ship, 1999).

Medications

Over 250 drugs have been reported to affect the sense of taste. The site of action of these compounds is not known, but they may act at several levels, namely peripheral receptors, taste pathways and the brain itself. Drugs are present in the saliva where they can modify taste transduction or produce a taste of their own. Moreover, many drugs alter the production of saliva, and many old people complain from dry mouth symptoms. (A large number of european citizens were tested during the HealthSense study, and questionnaires could be crossed with measures on chewing capacity, trigeminal performance in recognising food, and other measures of preferences and quality of life. There is a strong potential for epidemiological research in these unpublished data.)

Lipid-Lowering drugs cholestyramine, clofibrate, fluvastatin sodium, gemfibrozil, lovastatin, pravastatin sodium Antihistamines Chlorpheniramine maleate, loratadine, terfenadine and pseudoephedrine Antimicrobials Ampicillin, ciprofloxacin, clarithromycin, ofloxacin, streptomycin, tetracyclines Antineoplastics Cisplatin, doxorubicin, and methotrexate, vincristine sulfate Anti-inflammatories Auranofin, colchicine, dexamethasone, diclofenac potassium/diclofenac sodium, dimethyl sulfoxide, gold, hydrocortisone, D-penicillamine and penicillamine Bronchodilators and Other Asthma Medications Albuterol sulfate, cromolyn sodium, flunisolide, metaproterenol sulfate, terbutaline sulfate Antihypertensives and Cardiac Medications Acetazolamide, adenosine, amiloride, benazepril hydrochloride and hydrochlorothiazide, betaxolol hydrochloride, captopril, clonidine, diltiazem, enalapril, ethacrynic acid,

41 Nutri-Senex: State of the art report – task 2.1 nifedipine, propanolol, spironolactone Muscle Relaxants and Drugs for the treatment of Parkinson Disease Baclofen, dantrolene sodium, levodopa Antidepressant and Anticonvulsants Amitriptyline hydrochloride, carbamazepine, clomipramine hydrochloride, clozapine, desipramine hydrochloride, doxepin hydrochloride, fluoxetine hydrochloride, imipramine , lithium carbonate, phenytoin, trifluoperazine Radiation Therapy Radiation to head Vasodilators Dipyridamole, nitroglycerin patch Schiffman S.S., Taste and smell losses in normal aging and disease, JAMA, 1997, 278 : 1357-1362

Diseases

A number of diseases, including Alzheimer’s disease and Parkinson’s disease, environmental exposures and surgical interventions, alter the sense of taste, resulting in reduction and /or distortion of taste.

Nervous Alzheimer disease Bell paisy Damage to chorda tympani Epilepsy Head trauma Korsakoff syndrome Multiple sclerosis Parkinson disease Tumors and lesions Nutritional Cancer Chronic renal failure Liver disease including cirrhosis Niacin (Vitamin B2) deficiency Zinc deficiency Endocrine Cushing syndrome

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Schiffman S.S., Taste and smell losses in normal aging and disease, JAMA, 1997, 278 : 1357-1362 2.3 Olfactory losses

Normal aging

Significant elevation of detection and recognition thresholds (Schiffman,1979; Schiffman and Warwick, 1991; Cain and Stevens, 1989) exists for a large range of substances: for most odours, the thresholds in a normal elderly cohort are 2 to 15 times higher than in a young cohort (Schiffman, 1997). Suprathreshold perception is also diminished: elderly have a reduced ability to discriminate intensity differences, and to discriminate between qualities (de Wijk and Cain, 1994). However, the identification tasks are the most difficult for the elderly (Murphy et al., 1991), despite of the large variance evidenced after 60 years (Doty, 1984); although Doty’s data could let us expect that elderly over 80 are anosmic, studies on centenarians (Elsner, 2001) show that it is not the case: the relative good health (a very small number took medication) and cognitive status of these “expert survivors” allows to suppose that illnesses and injuries are responsible for a large part of olfactory losses of “ordinary” elderly.

As a result of both reduced sensitivity, and discrimination and identification difficulties, impaired old people are twice more exposed to hazardous events like ingesting spoiled food, ignoring gas leaks, etc..( Santos et al, 2004). According to a recent study (Murphy, 2002), the incidence of smell impairment is about 25% of the american population of 80-97 years olds, and only 9,5% of this population reports an olfactory impairment: thus the olfactory loss seems largely underestimated. Men are more impaired than women at any age.

The trigeminal sensitivity in the nose is also decreased with age (Stevens, 1982). Because taste itself, smell and trigeminal sensitivity integrate into flavour perception, and because sensations of food in the mouth are attributed to taste, many old people complain from taste losses which are in fact due to reduced retronasal odour input. As trigeminal perception also plays the role in intensity perception, the flat flavour of foods is also partly dependent on reduction of this input.

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Causes of olfactory losses

Medications and diseases see tables 1 and 2 A recent review (Norès et al., 2000) points out that for the large number of drugs apparently responsible of olfactory disorders, the adverse side effect has only been observed in animal studies, and no clinical report has been made on the subject. The real toxicity to man is therefore hypothetical, and in a report on 150,000 cases recorded in pharmacovigilance centers in France only 0,05 have reported olfactory complications. The cardiovascular drugs are mainly implicated in these disorders (see Doty , 2003, for a recent review on anti-hypertensive drugs). Thus systematic studies are needed to measure the epidemiological effects of all the drugs listed as adverse for olfactory function.

Anatomical changes

Olfactory mucosa There are alterations in the olfactory mucosa in healthy adults (Hummel, 2002) and biopsies show that patches in the olfactory epithelium tend to be replaced by respiratory mucosa. These changes are also observed in rats (Hinds and McNeely, 1981). As olfactory neurons are renewed throughout life, alterations in the neurogenesis or increased cell death could be responsible. However, recent studies “indicate that not only are biopsies from older subjects equally likely to produce olfactory receptor neurons as younger subject's biopsies, but the olfactory receptor neurons from older subjects were even more likely to respond to odour stimuli. This suggests that age-associated olfactory loss is more likely to be due to a change in the signal-to-noise ratio in the bulbs, or to chronic adaptation due to the loss of selectivity, rather than to a simple reduction in the number of receptor cells." (Rawson, 2002) The expression of genes coding for receptor sites on these cells could also be altered by age.

Olfactory nerve and olfactory bulb

The decrease in the volume of olfactory tract and bulb is well documented (Yousem, 1998) The size of foramina (“holes”) of the cribriform plate also decreases with age, and might be partly responsible for impaired function (Kalmey et al., 1998). Central structures From a physiological point of view, it is now possible to figure out the changes in central processing of odours in the elderly: Evoked potentials show that the processing speed of olfactory stimulations decreases at a constant rate over decades, and also the amplitudes of the

44 Nutri-Senex: State of the art report – task 2.1 responses: thus the central processing efficiency weakens over decades. As it is known that adaptation increases in the elderly, one can conceive that the shorter the interval between stimulations, the greater the effect on perception. The study by Murphy, (2000) provides normative data of this evolution, and the method does not depend strongly on cognitive capacities of subject. Cerebral functional imagery also shows a greater cerebral activation of olfactory central regions in young subjects than in elderly (Yousem, 1999). Using a rather ecological mode of stimulation (flavoured aqueous solutions presented to the mouth), Cerf-Ducastel and Murphy (2003) showed that similar areas are activated in young and elderly subjects, but the degree of activation was significantly lower in piriform cortex, entorhinal cortex and amygdala, the regions receiving primary olfactory projections; this supports the hypothesis of dysfunction and /or degeneration in areas critical for olfactory processing that would be a major cause of deficits. This also raises the question of compensatory strategies used by elderly when the sensory input declines: "The increased activation shown in lobule VI among the elderly in this study may reflect the possibility that elderly adults respond to olfactory tasks by employing a compensatory strategy, such as eliciting more effort or more attention, in response to sensory decline." (Ferdon and Murphy, 2003 ; see also Kareken et al., 2003).

Hormonal changes

Hughes. et al (2002) hypothesized that the well-known age-related decline in olfaction in women might be associated with the decline of circulating estrogens that occurs during the menopause. Logically, appropriate hormone replacement therapy (HRT) or treatment with estrogen alternatives could improve age-related olfactory function. The authors were unable to detect any differences in any of the five measures between those receiving HRT and those not receiving HRT. However they found, like in other studies, a significant change in olfactory threshold sensitivity as a function of age. A gradual decrease in ability to detect odours occurs from the 4th to the 6th decade, greater decrease between the 6th and 7th decade.

Neurodegenerative diseases

As can be seen from table 2, Parkinson’s disease, Alzheimer’s disease and other dementias strongly alter olfaction. In Parkinson’s disease, it is one of the earliest symptom of the illness. The smell system seems particularly susceptible to degeneration and accumulates plaques that characterize Alzheimer’s disease earlier than the other cerebral regions (see Kovacs, 2004, for a recent review)

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Dental and oral health

Dental state also affects olfaction: according to Griep et al (1997) "Complete denture wearers and those with partial dentures had significantly lower values for odour perception than those with only natural teeth. Odour perception correlated significantly with measures of body fat and muscle mass, indicating that a poor sense or smell is associated with low body fat and muscle area." In a study by Thomas Danguin et al. (2003) on 340 subjects from 20 to 97 years of age, the authors observed about 25% (88) subjects with lower olfactory performances. The answers of this lower performance group were compared with the answers of the remainig “normal” group to a questionnaire on quality of life and food habits. More subjects in the impaired group declared difficulties in chewing, and dry mouth problems. (They also declared more often cardiac problems, diabetes and insomnia).

Rhinitis, Sinusitis and head trauma

In the nose, normal physiological changes of aging include loss of nasal tip support, atrophy of mucus-producing mucosal glands, and decreased olfaction. These changes contribute to geriatric rhinitis, and add to the effects of chronic rhinitis or sinusitis that are present at any time of the lifespan (Jordan and Mabry, 1998 ; Doty, 1997).

Smoking

Frye et al (1990) studied 638 subjects for whom detailed smoking history was available, and found that smoking was adversely associated with odour identification ability in a dose-related manner in both current and previous smokers. Among previous smokers, improvement in olfactory function was related to the time elapsed since the cessation of smoking. These implies long-term but reversible effects on olfaction; the authors underline that the magnitude of the adverse effect is not large compared with the effects of age and sex.

Environmental exposure

There is much work to do concerning the effects of the chemical environment on olfaction. Systematic studies are needed, mainly because most people are not aware of the type of chemicals they were exposed to. According to Gobba (2003), a review of the studies on the effect of industrial chemicals on smell is problematic, due to the lack of agreement on testing procedures (UPSIT in US, Sniffin'Sticks in Europe).

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Cadmium, chromium, nickel, solvent mixture, wood dust are reported to induce hyposmia or anosmia in workers

Effects of aging on sensory preferences

Whereas there are more than 50 studies showing that ageing has an effect on chemosensory sensitivity, there are about 15 studies on the effect of age on sensory preferences in elderly. A number of studies have shown that, on average, elderly have higher optimal preferred concentrations of taste and odorant substances in foods than young subjects (Murphy & Withee, 1986, 1987; Zallen et al, 1990; de Graaf et al, 1993; de Graaf et al, 1996; de Jong et al 1996). These studies referred to salt and sugar in beverages (Murphy & Withee, 1986), casein hydrolisate concentration in a beverage (Murphy & Withee, 1987), salt in mashed poptatoes (Zallen, et al, 1990), bouillon flavour, tomato juice flavour, orange juice flavour, and strawberry flavour in yogurt (de Graaf et al, 1993), and for bouillon, tomato soup, chocolate custard and orange juice flavours (de Graaf et al, 1996). De Jong et al (1996) found similar results for the optimal sugar concentration in breakfast products such as jam and porridge, and a recent study of Kozlowska et al found that elderly have higher optimal sugar concentrations in apple juice compared to young subjects. In line with these results, Schiffman et al found that elderly preferred foods with the flavour enhancer MSG compared to foods without the flavour enhancer . It should be acknowledged though, that not all studies have obtained similar results. For example in a recent study of Mojet et al (2004), the higher optimal preferred concentration for the elderly was confirmed for sweet tasting substances in drinks, but not for salt, sour, bitter and umami tastes. Koskinen et al, studied the effects of the addition of a red currant aroma in a yoghurt like product on the perceived intensity and pleasantness in a group of 50 elderly, and 58 young subjects. Increasing the black-currant aroma led to a decline in acceptability for the young subjects, but had little effect on the pleasantness in the elderly (Koskinen et al 2003). In the study of Koskinen et al ( ), there was also no relationship between optimal (preferred) flavour level and the sensitivity as measured by sensory performance tests. A recent study of Forde and Delahunty (2004) adds an interesting perspective to this discussion. They studied the sensory profile of orange juices that varied in pulp content (texture variable), sweetener concentration (taste) and the addition of capsaicin (trigeminal stimulation). On average elderly tended to prefer stimuli with elicited a higher sensory stimulation compared to the young subjects. However, the

47 Nutri-Senex: State of the art report – task 2.1 group of elderly subjects could be divided into three groups with different preferences. One group of elderly had similar preferences than the young subject, one group of elderly was indifferent to the sensory properties of the foods, and one group of elderly had a preference for stimuli with a higher sensory intensity. This latter group scored lower on several sensitivity measures. Summarizing the literature on this area, it is clear that on average elderly have higher optimal concentrations of taste and odour substances. The change in optimal concentration may be different for different type of tastants or odorants, and is also different for different types of subjects.

Effect of age on sensory specific satiety and monotony

Sensory specific satiety is the decline in the reward value of a particular food during its consumption. It is determined by measuring the decline of liking of an eaten food compared to the decline of liking of uneaten foods (Rolls et al). Sensory specific satiety is conceived to be instrumental for the drive of variety within a meal. People ingest more energy within a meal when there is more variety than when there is less variety (Rolls). Sensory specific satiety contributes to within meal variety. Variety also plays a role across meals over days. Research from the US Army in the 1950’s showed that the consumption of a limited number of meals across a period of 22-37 days leads to a decline in liking and a decline in consumption of the meals (Siegel & Pilgrim, 1958; Schutz & Pilgrim, 1958) In a recent study, Meiselman et al (2000) showed that consuming the same lunch across five days led to a decline of the liking of the vegetable part of the meal, but not for the mashed potato (staple) and meat part of the meal. With respect to the effects of aging on sensory specific satiety and monotony, three studies have been done. Rolls et al (1991) investigated the effect of age on sensory- specific satiety in adolescents (12- 15 y), young adults (22-35 y), older adults (45-60 y), and elderly subjects (65 – 82 y) (n =24/group). Subjects rated the pleasantness and the desire to eat five foods (tuna salad, celery and mayonnaise, sesame cracker, strawberry yoghurt, and a pretzel), then ate one of the five foods (strawberry yoghurt), and subsequently rerated the five foods. Compared to the other age groups, elderly subjects did not show a decrease in the pleasantness of the taste/desire to eat the eaten foods. Sensory specific satiety was pronounced in the adolescents, and diminished in the elderly people. With respect to the effect of ageing on the desire across meal variety, Pelchat & Schaefer (2000) did a study in which they exposed a group of 16 elderly (ave. age :

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73 y) and a group of 18 young subjects (ave. age: 24 y) to a nutritionally adequate, but sensory monotonous diet of sweet vanilla flavoured drinks for a period of 5 days. Young adults reported significantly more cravings per day during the monotony period than during a baseline period. The increase was due primarily to a greater number of craving for entrees. Elderly subjects were not responsive to the monotony condition. Recently, Essed and co-workers studied the effects of repeated exposure on intake and pleasantness of three different types of fruit juice. Young and elderly subjects received 1 litre of fruit juice each day over a total period of twelve days. Monotony was observed with the young subjects, but not in elderly subjects, i.e. in the young subjects, Essed et al observed a decline in pleasantness and in ad libitum consumption over the twelve days, whereas for the elderly subjects, pleasantness and consumption were stable. Taken together, these three studies suggest that elderly are less responsive to sensory specific satiety and/or monotony than young subjects. More work is necessary to determine whether or not this insensitivity leads to any adverse nutritional consequences. One could speculate that the lower drive for sensory variety leads to a diet lower in nutritional variety, which may lead to an increased risk for nutritional deficiencies. However, this idea was not confirmed in a study of Drewnowski et al (1997) with 24 young and 24 older subjects on dietary variety. In this study, the elderly had a more varied diet than the young subjects.

Effect of higher taste/odour concentrations/flavour enhancement on food intake in elderly

From a nutrition and health perspective, it is not so much of interest, that elderly have higher optimal preferred concentrations in foods compared to young subjects. The important nutrition question is, whether or not higher taste/odorant concentrations lead to different nutrition/intake behaviour, which in the long term may eventually have a positive effect on nutritional status and health. In this paragraph we first deal with the short-term intake studies, and in the next paragraph we discuss the longer term observational and nutrition intervention studies. In a study on optimal sugar concentrations in breakfast foods, de Jong et al (1999) observed that elderly had higher optimal concentrations than young adults. These optimal preferred sucrose levels (one lower level for the young and a higher level for the elderly) were applied in the food items orangeade, strawberry and blueberry jam, and strawberry and blueberry yoghurt. A group of 33 young people and 25 elderly subjects participated in a cross-over study of 2 time 5 day breakfast treatments. The

49 Nutri-Senex: State of the art report – task 2.1 results showed that the sucrose concentrations had no effect on the amount consumed. So, in this study elderly reported higher optimal sucrose levels in foods, but this did not result in different intake behaviour. In a later study, Griep et al (1997) used three foods: tomato soup, quorn and skimmed yoghurt, in which he applied a low and a high concentration of appropriate odorants. These two conditions were served in an naturalistic setting in which a group of 16 young and 20 elderly subjects consumed ad libitum from the soup, quorn and yoghurt. The results showed the elderly ate more of the flavour enhanced products, while the young ate relatively more of the low-odorant level products. The results of this study confirm the usefulness of flavour enhancement in foods for the elderly. In a recently published study, Kozlowska (2003 ) studied optimal sweetener levels in apple juice in a group of 33 young and 35 elderly subjects. They also registered ad libitum consumption of apple juices with different sweetener levels. The sweetener level that resulted in the highest consumption level in the elderly was higher than the sweetener level that led to a higher consumption level in the young. In a study of Koskinen et al (2003), increasing the flavour levels in a yoghurt like product in an in- home test, resulted in a decrease in intake in a group of 57 elderly and 62 young subjects. Taken together, there is some, but not much evidence that increasing flavour levels in foods lead to a higher food intake in the elderly. There is much more work to be done in this area, on how taste and odorant concentration affect ad libitum food intake in young and elderly people.

Effects of flavour enhancement on long term food and nutritional status

As far as we know there are two published studies on the effects of flavour enhancement on long term food intake and nutritional status in the elderly. Schiffman & Warwick (1993) studied the effects of flavour enhancement in warm meals for three weeks in a nursing home setting with 39 elderly. For three weeks subjects ate an institutional diet (unenhanced), and during another three weeks period, the same subjects ate identical foods to which intense flavours were added. There were 30 different flavours used in vegetables, gravies and sauces, breakfast foods and other food products. Food intake was measured every weekday throughout the study and the nutritional composition of the diet was analysed. The results showed that elderly ate more of the flavour enhanced foods, but there was no effect of flavour enhancement on total energy intake or body weight.

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In a longer term 16-weeks study, Mathey et al, sprinkled flavour enhancers (chicken, beef bouillon, turkey, lemon butter, + MSG for each flavour) over the warm meal in a nursing home setting. In this parallel study, the control group encompassed 31 and the experimental group 36 subjects. One of the most important results of this study was that the body weight in the experimental group increased on average by 1.1 kg, while it remained stable in the control group. Dietary intake increased in the experimental group compared to the control group. The results of these two studies clearly indicate possible positive effects of flavour enhancement on food intake in nursing home residents.

Relationship between sensory performance and nutritional status: data from two cross-sectional studies

If sensory impairment has a strong effect on food enjoyment and consequently on food intake, it could be hypothesized that sensory impairment in elderly could have an effect on nutritional status. A lower chemosensory sensitivity would then lead to a worse nutritional status. A few cross-sectional observational studies have investigated the relationship between sensory performance and nutritional status. In a study by Duffy et al (19 ), several measures of 80 elderly subjects were collected: an olfactory test, food frequency questionnaire, body weight, height, waist and hip measurement. There was no relationship between the outcome of the olfactory test and body weight. However, a lower olfactory performance was associated with a lower interest in food related activities, and higher intake of sweet, and in general a nutrient intake profile indicative of a higher risk for cardiac disease. In 1999, de Jong et al compared 89 independently living elderly to 67 living in nursing homes for their taste and smell performance, dental state, illnesses, saliva excretion and composition, energy and food intake as assessed by a food frequency questionnaire, and body weight. Just as in the Duffy study, de Jong et al found no clear correlation between any sensory outcome measure and body weight and/or food intake measures.

Discussion and conclusion

This paper reviewed the current state of knowledge on the issue on how changes in chemosensory sensitivity during aging may have an effect on food preferences, food intake and nutritional status. Special attention was given to the usefulness of flavour enhancement in the elderly. It is clear that on average, elderly have a lower sensitivity with respect to the sense of smell and the sense of taste than young subjects. The sense of smell is more

51 Nutri-Senex: State of the art report – task 2.1 affected than the sense of taste. Changes in sensitivity are highly variable between subjects. There are elderly subjects with an age of 90 who can have a higher performance score than a middle aged person of 35-40 years of age. It is also clear that the decline in performance is quality specific, i.e. the decline is not necessarily the same for each taste or smell quality. On average, elderly seem to have higher optimal concentration of taste and smell substances than young adults. This result has been found in several studies from various groups of researchers. The change in optimal concentration with age is also quality specific. It should be noted though, that not all studies have confirmed this finding. It seems probably, that just as is the case for sensitivity, the groups of elderly form a heterogeneous group, with some elderly having similar preferences as young subjects, whereas others have a preference for higher sensory intensities. Much more larger scale work seems necessary to get more detailed information on how preferences change with age. Another issue in this respect is that the effects of ageing per se are difficult to separate from confounders in this respect such as medications, diseases, and other changes in lifestyle, environmental exposures, cohort effects etc… Carefully designed precise studies are necessary to answer the fundamental questions in this area. With respect to the consequences of changes of flavour enhancement for actual short term food intake, there have been just a few studies. Two trials confirmed that elderly consumed ad libitum more from flavour enhanced foods than from unenhanced foods. Two other studies could not confirm this. As food intake is highly variable within and between subjects, studies in this field should be carried out with large samples in order to be able to determine subtle effects of different flavour formulations in foods. Cross-sectional observational studies show no clear relationship between taste and smell performance and nutritional status. This is not surprising as there are many intervening variables that could modify the possible relationship between these variables. Moreover, as Mattes has already shown in the early 1990, subject who have taste and smell disorders, or those who do not taste and smell at all, do not necessarily eat less. It is clear that humans have the drive to eat, even without the enjoyment of the sense of taste and smell.

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2.4 Recent research on chemosensory sensitivity and nutritional status in the elderly

2.4.1 Cell death and renewal in the olfactory system

Two types of cells are continuously generated in the olfactory system: neuroreceptors in the nasal olfactory epithelium, and neurons generated from stem cells in the forebrain subventricular zone. Mature olfactory sensory neurons have only a limited life span (90 days in rodents) and their death or survival depend tightly on environmental factors (Lledo, Gheusi, & Vincent, 2005). Neural stem cells born in the basal forebrain subventricular zone (SVZ) are the precursors of new neurons (both granule and periglomerular cells) in the adult olfactory bulb in a process of neurogenesis that continues throughout the life of most adult mammals; however, the existence of the rostral migratory stream between the SVZ and the bulb is still debated in humans, and most of the research has been led in mice. Therefore, recent and promising animal work on cell death and survival in the olfactory system can only be considered as a model for what happens in the aging human.

Integration of new neurons in the olfactory bulb

In the olfactory bulb, the periglomerular cells surround the glomeruli, which are circular bundles of neuropil present in the periphery of the bulb. Granule cells are present in large numbers in the deepest layer of the olfactory bulb, known as the granule cell layer. Olfactory receptor neurons, which convey primary olfactory information from the olfactory epithelium in the nose, form excitatory synapses with periglomerular cells but not with granule cells. The majority of interneurons in the olfactory bulb are produced postnatally, such that their numbers increase steadily with age. Only 50% of these new neurons do not survive more than several days after maturation, and their survival depends on sensory input. Because sensory neurons as well as bulbar interneurons are generated throughout life, it is thus tempting to propose that bulbar neurogenesis represents a mechanism by which processing of sensory information in the brain could be adjusted in response to ever-changing sensory inputs (Lledo & Saghatelyan, 2005). Whether these two levels of neurogenesis are correlated, and whether the generation of new olfactory sensory neurons influences changes in bulbar circuits is the topic of active research in neuroscience, not only for olfaction itself, but also because this is a substrate for experience-dependent plasticity.

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Role of the bulbar neurogenesis in olfactory discrimination in the aging mice

Previous studies (Gheusi et al., 2000) showed that mice with reduced neurogenesis exhibit impaired discrimination between discrete odours. In humans, olfactory discrimination abilities also decline with age (Kaneda et al., 2000). Because mice show a similar age dependent decline in olfactory discrimination, and because a markedly decreased SVZ proliferation is seen in aging animals, Enwere and collaborators (Enwere et al., 2004) studied the total number of interneurons and of new interneurons in the olfactory bulb of young adult (2 months of age) mice and of aged mice (24 months of age) after testing their olfactory discrimination abilities. They showed that olfactory neurogenesis, rather than the total number of interneurons, was responsible for fine olfactory discrimination. This olfactory neurogenesis depends on the epidermal growth factor which is reduced in the aged forebrain.

Plasticity in the olfactory system

As regards olfactory cell death and renewal, it is known that there is some plasticity in the adult olfactory system; a study in females with Alzheimer’s disease evidenced that the women who had an estrogen replacement therapy (ERT) were less impaired in an olfactory memory task than women who never used ERT. This suggests that ERT could ameliorate the earliest symptoms of Alzheimer’s disease: olfactory dysfunction and memory impairment (Sundermann, Gilbert and Murphy, 2006) In the animal research field, recent research also indicates that the olfactory environment influences the neural network in the olfactory system: olfactory deprivation reduces the survival of neurons in the olfactory bulb (Mandairon, Sacquet et al. 2006), whereas olfactory enrichment (raising rats in an environment where pairs of odours are presented daily over 20 days) improves discrimination capacities (Mandairon, Stack et al. 2006). Thus it is reasonable to think that in aging humans also, the variety of olfactory stimulation could maintain the olfactory system in a good state, whereas the lack of environmental stimulation could have opposing effects.

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2.4.2 Consequences on understanding human aging in chemical senses

The slowing of cell proliferation and renewal in the olfactory system might be correlated to the impairments in discrimination and sensitivity observed in aging humans and also in primates (Aujard & Nemoz-Bertholet, 2004).

Aging and odour identification: importance of discrimination processes

A study by Larsson et al (2005) was aimed at determining correlates of odour identification in old age. One hundred and thirty-two men and women (60-91 years) were assessed in a number of tasks tapping sensory acuity (i.e., odour sensitivity, intensity discrimination, quality discrimination) and different cognitive abilities (i.e., perceptual speed, executive functioning, verbal fluency). The variance in odour identification was most related to deficits in odour sensitivity, quality discrimination, and perceptual speed. This supports the above cited animal studies which stressed the decrease of fine discrimination abilities with age.

Role of dietary intake on taste and smell dysfunction

A recent study (Henkin & Hoetker, 2003) in humans correlated taste and smell dysfunction in 250 patients with their Vitamin E intake. They found that their intake was 36% of the recommended daily allowance, although their other dietary intake criteria were normal. They discuss the non-antioxydant roles of vitamin E that may act as a co-factor of growth factors implied in the regeneration of the taste buds and olfactory epithelium. To test this hypothesis, they treated a group of seven patients with severe taste and smell problems with Vitamin E , but obtained no improvement after 6 to 8 months of treatment. Thus the role of vitamin E as a cofactor in cellular growth remains to be investigated.

2.4.3 Prediction of weight loss in the elderly by questionnaires

Recently, the Council for Nutritional Strategies in Long Term Care validated a tool for detection of anorexia risk and the prevention of weight loss in the elderly (Wilson et al., 2005). They designed an 8-item questionnaire, the Council of Nutrition Appetite Questionnaire (CNAQ). This questionnaire was evaluated according to its correlations with a longer 29-item questionnaire that was already validated on the

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Dutch population (Mathey, 2001). A long time care group of 247 people and a group of 1100 community-dwelling adults over 60 filled both questionnaires, and 4 questions of the CNAQ were shown most reliable, thus leading to a shorter version, the Simplified Nutritional Appetite Questionnaire (SNAQ). The sensitivity and specificity of these short questionnaires was established from their ability to predict unvoluntary weight loss over a 6 mo. period. Thus these tools can facilitate prompt nutritional intervention. Two recent papers review the changes in nutritional regulation in the elderly (Roberts and Rosenberg 2006) and the causes of anorexia of aging (Hays and Roberts 2006). The increased susceptibility to energy imbalance (both positive and negative) is analysed. According to (Hays and Roberts 2006), the anorexia of aging results from both physiological and psychosocial factors. The non physiological causes of anorexia may be: • Social (poverty, isolation- 30% lower energy intake in men eating alone) • Psychological (depression, dementia) • Medical (edentulism, dysphagia) • Pharmacological (medications) • Changes in the pattern of energy intake. The physiological factors are : • Changes in taste and smell • Reduction of sensory specific satiety • Delayed gastric emptying • Altered digestion hormones secretion and hormonal responsiveness, • Food intake regulatory impairments of unknown origin. For example, healthy elderly men who consume a diet over several weeks with either too many or too few calories do not compensate for the deficit or surplus when they return to an ad libitum diet, as young men do. They also are less hungry at meal initiation and more rapidly satiated. The use of a simple hunger questionnaire predicts unintentional weight loss in a sample of healthy older women and such a clinical tool is useful to identify individuals at risk of anorexia. The authors propose the following mixed model for the onset of anorexia: the social and medical changes may act on body weight directly, but also indirectly by interacting with the reduction of the internal signals regulating food intake.

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This underlines that the social environment has to compensate for the lack of this regulations in order to maintain body weight in the elderly. A Swedish study was led to compare frail, self-managing elderly living at home with elderly people living in nursing homes (Engelheart, Lames and Akner, 2006); the study showed that there were 4-5 daily eating episodes in both groups, but they were more widespread over the day in the self-managing elderly, whose length of fasting at night was reduced; however, the energy intake was similar in both groups. There was no correlation between energy intake and subjective assessments of appetite, or self-estimations of taste and smell.

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Murphy, C., W. S. Cain, Gilmore M.M., Skinner R.B., Sensory and semantic factors in recognition memory for odors and graphic stimuli : Ederly versus young persons, American Journal of Psychology, 1991, 104(2): 161-192

Nores J.M., Biacabe B., Bonfils P., Troubles olfactifs d’origine médicamenteuse : analyse et revue de la littérature [Olfactory disorders due to medications: analysis and review of the literature], Rev Med Interne. 2000 Nov;21(11):972-7

Pelchat M.L, Schaefer S. Dietary monotony and food cravings in young and elderly adults, Physiol Behav. 2000 Jan;68(3):353-9.

Proceedings from the 2005 Meeting of the Society for the Study of Ingestive Behavior 88(3): 257-266.

Rawson N.E., Gomez G., Cell and molecular biology of human olfaction, Microsc Res Tech., 2002, 58(3):142-51

Roberts, S. B. and I. Rosenberg (2006). "Nutrition and Aging: Changes in the Regulation of Energy Metabolism With Aging." Physiol. Rev. 86(2): 651-667.

Rolls B.J, McDermott T.M. Effects of age on sensory-specific satiety. Am J Clin Nutr. 1991, 54(6):988-96.

Rozin P. The socio-cultural context of eating and choice. In Muselman H.L, MacFie H.J. Food choice acceptance and consumption. Black Academic & Professional 1996, pp. 83-104.

Santos D.V., Reiter E.R., DiNardo L.J., Costanzo R.M., Hazardous events associated with impaired olfactory function, Arch Otolaryngol Head Neck Surg., 2004 Mar;130(3):317-9

Schiffman S., Changes in taste and smell with age: psychophysical aspects. In: Ordy JM, Brizzee K, eds. Sensory Systems and Communication in the Elderly: Aging, Volume 10. New York, NY: Raven Press; 1979:227-246

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Schiffman S.S, Graham B.G. Taste and smell perception affect appetite and immunity in The elderly. Eur J Clin Nutr. 2000 Jun;54 Suppl 3:S54-63.

Schiffman S.S, Warwick Z.S. Effect of flavor enhancement of foods for the elderly on Nutritional status: Food intake, biochemical indices and anthropometric measures, Physiology & Behavior. Vol. 53, pp. 395-402, 1993.

Schiffman S.S., Perception of taste and smell in elderly persons, Crit Rev Food Sci Nutr., 1993;33:17-26

Schiffman S.S., Taste and smell losses in normal aging and disease, JAMA, 1997, 278 : 1357-1362

Schiffman S.S., Warwick Z.S., Changes in taste and smell over the lifespan. In: Friedman MI, Tordoff MG, Kare MR, eds. Chemical Senses: Appetite and Nutrition, Volume 4. New York, NY: Marcel Dekker; 1991:341-365

Schutz H.G, Pilgrim F.J. A field study of food monotony. Psychol. Rep 1958;4:559-661.

Ship, J. A. ,The influence of aging on oral health and consequences for taste and smell, Physiol Behav, 1999, 66(2): 209-15.

Siegel P.S, Pilgrim F.J. The effects of monotony on the acceptance of food, Am J Psychol 1958;71:756-759.

Stafleu A, de Graaf C, van Staveren WA, Burema J. Affective and cognitive determinants Of intention to consume twenty foods that contribute to fat intake. Ecology of Food and Nutrition 2001,40,193-214.

Stevens J.C., Cruz L.A., Hoffman J.M., Patterson M.Q. ,Taste sensitivity and aging, Chem Senses. 1995;20:451-459

Stevens J.C., Plantinga A., Cain W.S., Reduction of odor and nasal pungency associated with aging, Neurobiol Aging, 1982;3(2):125-132

Sundermann E, Gilbert PE, Murphy C. (2006) “Estrogen and performance in recognition memory for olfactory and visual stimuli in females diagnosed with Alzheimer's disease”.

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Thomas-Danguin, T., C. Rouby, et al., Sensory analysis and olfactory perception : some sources of variation. Handbook of flavor characterization : Sensory analysis and physiology. K. L. Deibler and J. Delwich. 2003.New York, Marcel Dekker: 65-81.

Van der Wielen R.P, de Wild G.M, de Groot L.C, Hoefnagels W.H, van Staveren W.A., Dietary intakes of energy and water-soluble vitamins in different categories of aging. J. Gerontol A Biol Sci Med Sci. 1996 Jan;51(1):B100-7.

Wilson, M.-M. G., Thomas, D. R., Rubenstein, L. Z., Chibnall, J. T., Anderson, S., Baxi, A., et al. (2005). Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr, 82(5), 1074-1081.

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Yousem D.M., Maldjian J.A., Hummel T., Alsop D.C., Geckle R.J., Kraut M.A., Doty R.L. , The effect of age on odor-stimulated functional MR imaging, AJNR, 1999, 20(4): 600-608

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3 Social and cultural reasons for food preferences and food selections 3.1 Introduction Food patterns refer to a particular way in which food supply, food choice, food preparation, and eating practices are usually carried out or organised. As a part of food or nutritional behaviour it assembles various phenomena from everyday life, defines and arranges them according to the natural and technical sphere […] and to the human sphere, especially to the sphere of individual and social action (people’s- role and position with the corresponding social status, patterns of action in purchasing, handling, preparing, serving, consuming foodstuff; psycho-physical states such as fatigue, stress, humour) (Leonhaeuser 2002). The “Theory of Planned Behaviour” (Ajzen 1991) is a successful method in predicting human behaviour over a period of time. It has been demonstrated that intention can predict behaviour and therefore maintenance of health behaviour. The stability of health cognition may predict long-term effects on health behaviour. Findings suggest for example, that fruit and vegetable intake, as well as the percentage of fat consumption, are more under control of healthy eating intentions than fibre intake. Thus, to increase fibre intake, interventions may also need to increase knowledge about the sources of fibre in the diet (Bell et al, 2002). This theory clarifies the importance of past eating habits and knowledge of nutrition to overall healthy nutrition. This literature review was based on publications dealing with nutrition behaviour of the elderly from 14 EU member states mainly, but some publications of research articles originating from the 10 new EU country member states related to elderly dietary habits have also been found.

3.2 Definition The term ‘elderly’ normally refers to those older than 65 years. However, in this review, studies dealing with women aged 50 years and older were also included (e.g. The Norwegian Women and Cancer Study). This is because nutritional needs and habits change during the menopause.

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3.3 State of the art In the context of cultural reasons for food preferences and food selection, research into eating behaviours and attitudes towards food is often derived from larger epidemiological studies e.g. SENECA “Study on Nutrition of the elderly in Europe”. It is apparent that many epidemiological studies have been carried out in Scandinavia such as the Norwegian Women and Cancer Study and the North Karelian Project (Finland). World-wide, few publications dealing explicitly with eating behaviour of the elderly exist and many of these studies were carried out in the USA (see Oversea’s Literature). Studies often deal with food patterns and eating behaviour of adults in general. This usually considers those older than 15, or older than 18 years of age. Data from these studies can be applied to the elderly if age groups are defined, which is unfortunately not always performed. There were few studies found for the target group (the elderly) dealing specifically with nutrition behaviour/ habits in Europe. In addition, few publications deal with sociological and psychological determinants of meal patterns and food consumption. Findings from these investigations suggest that nutrition behaviour of the elderly is influenced by nutrition education and health behaviours established during childhood (Brombach 2000).

3.4 Methods A lot of the available food consumption data is based on questionnaires rather than the most internationally recognised method ’the 24h recall’. The 24h recall method should be conducted at least twice in order to be significantly valid. This method also allows for the estimation of mean intakes by a modelling technique that separates intra and inter individual intake. The standardisation of fieldwork and work procedures have been examined by Brussaard et al (2002) and Henauw et al. (2002). Focus groups with elderly people have been carried out to evaluate nutrition education wants and needs (Duerr 2003), and nutritional beliefs and practices of low income older women. Other methods that have been used to obtain food consumption information are the recording and weighing of the food that elderly consume in a canteen (hospital, nursing home) or other monitored environment, over a period of time (Gibbons and Henry 2005; Sydner and Fjellstrom, 2005). Using computerised diet history interviews is suggested as it reduces interviewer bias and is of otherwise similar quality to the face-to-face interview method (Kemper et al. 2003).

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3.5 Lifelong eating habits Eating habits manifest during childhood e.g. through nutrition education and behaviours of parents, and often they are retained for a lifetime (Brombach 2000). It seems that older women eat more frequently than men, usually 3 main dishes per day. Lunch is identified as the most important meal to this population group and often consists of vegetables, potatoes and meat. This meal is usually eaten around 12.00 h, takes approximately 30 minutes to prepare and another 30 minutes to consume, although regional differences have been identified within the EU. (Rurik 2004, Brombach 2000). The energy content of meals consumed by the elderly changes with age. This modification can be shown by a decreased contribution of the main dish, and an increased role of desserts to total energy intakes of both sexes. The shift in pattern is due to a change in nutrient composition, which can be characterised by fewer lipids and more carbohydrates in the diet. However, the reasons behind this change, like loss of appetite and a more pronounced taste for sweet foods, requires further study (Vincent et al. 1998). Home-made dishes are generally preferred by the elderly (Brombach 2000, Rurik 2004). Social support and delivery services like “Meals on Wheels” are rarely used by the elderly. Less than 10% of a study population aged over 65 years in Hungary (n=250) were supported by delivery services. These services are used in cases of illnesses, disabilities and handicaps, loneliness, or after the death of a partner (Rurik 2004). In the same study, the consumption of milk, dairy products, fish, fresh fruits and vegetables was found to be very low, while intakes of energy and protein were sufficient. However, high fat foods (including lard) and foods with a low carbohydrate content often contributed excessively to these energy intakes. This study also found that vitamins and mineral supplements were consumed by 33% of elderly Hungarians and that daily salt intakes were far above recommended levels. In terms of attitudes to diet, many elderly Hungarians believed that their nutritional habits were healthy. However, most of them would like to buy still healthier and more expensive food, if they could afford it (Rurik and Antal 2003) ). A more recent study of men (over 65 years) and women (over 60 years) (n=266) in Budapest revealed that meal frequency increased with aging (Rurik, 2006). Alcohol was consumed more frequently by men while women consumed more dairy products, fresh fruit, bread, biscuits, coffee, chocolate and vitamin supplements. In accordance with previous studies, fat represented a higher ratio (39%) than recommended. Although womens' eating

67 Nutri-Senex: State of the art report – task 2.1 habits and food choices were generally closer to healthy eating recommendations, weight gain was higher due to metabolic reasons and lower energy expenditure. The IEFS Pan-EU survey on consumer attitudes to food nutrition and health found that 71% of EU citizens above 15 years of age believe their diet to be healthy and so do not see the need to change their eating habits. In addition, this study found that 11% of retired EU citizens perceived ‘lack of time’ to be a barrier to changing their diet to a healthier one, compared to 44% of the younger employed population (Kearney and McElhone, 1999). The HealthSense study, a follow-up of the IEFS adult survey, examined specifically the attitudes to diet and health of adults aged 55 years and over within the EU. This study found that resistance to change appeared to increase with age, as those selecting ‘don’t need to change, or ‘don’t want to change’ were most likely to be in the oldest (51%) rather than youngest (36%) age group of older adults (Allen and Newsholme, 2003). The HealthSense study also investigated reasons for, and barriers to, change among older adults. The main reason for change in this group was ‘medical reasons’ (54%) suggesting that much change among the elderly is reactive (to an existing medical problem) rather than pro-active (to prevent the occurrence of a medical problem). In terms of barriers to change, the most striking barrier was the belief that their diet is already healthy enough (42%). Like the elderly adults in Hungary, and in line with the above Pan-EU results, the majority of retired women living in Sweden aged 65 to 88 years considered their food habits to be healthy. However, trying to follow health recommendations when cooking was frustrating for some of them mainly due to a ’fear of fat’. As long as these women were healthy, they saw no need to change their diet as they believed that one cannot prolong life by changing food habits in old age (Gustafsson and Sidenvall 2002). Similar results were obtained in Germany by the EVA study, where ’eating types’ and ‘habits’ were only changed in the event of illnesses Brombach (2000). The elderly population in Finland are following dietary guidelines more closely now than they did in the 1980’s (Sulander et al 2003). While this improvement was seen among all occupational groups, the healthiest diet was achieved by the youngest recently retired women who were married. Changes in product availability have had an influence on healthy diet. Today a wider variety of vegetables, fruits and low-fat products are on offer. Similar changes were obtained in Poland where eating patterns remain very traditional except for the significant decrease in consumption of dairy products and increase in vegetable oils (Kowrygo et al 1999). As in Finland, these differences are due to external changes in the food supply, organisation of shopping, and the possibilities of preparing meals.

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In Finland, Italy and the Netherlands food intake and its association with the cognitive function of elderly men was investigated (Huijbregts et al 1998). A diet close to the WHO guidelines was associated with better mental achievements. Due to the different diets recorded, no single food or specific nutrient could be held responsible for a better cognitive function. So it was concluded that the overall dietary pattern close to WHO guidelines is responsible for better cognitive functions. Within the group of women participating in the Norwegian Women and Cancer Study, dietary habits seem to vary only slightly with age, however, older women tended to have a healthier diet than younger women. Dietary habits also varied slightly with socio- economic status and lifestyle. Women with a higher socio-economic status reported the healthiest diet with regard to fat, dietary fibre, fruits, vegetables and potatoes. In other European countries similar results were obtained. Physically active women reported a diet in line with recommendations (Hjartåker and Lund,1998). Cluster analysis identified three large diet groups among men and three groups among women within a representative national British sample aged over 65 years. According to these clusters, 48% of British men follow a ’mixed diet’ (incorporating elements of a traditional diet with some elements of a healthy diet), 21% follow a ‘healthy diet’ and 17% follow a diet characterised as ‘traditional’ and high in alcohol content. The prevalent diet among the female population is a ’sweet traditional diet’ (33%), followed by a ‘healthy’ diet (32%) and 18% of the British elderly women consume a ’mixed diet’ (with traditional and healthy elements). Important differences in nutrient intakes, socio-demographic and behavioural characteristics can be identified across the clusters mentioned above (Pryer et al 2001). A study of German women aged over 65 years identified four different eating types (Brombach, 2000). These eating types were only changed in the event of marriage to a partner with another eating type, or in the case of illness or fear of adverse health implications. The eating types identified were characterised as ‘open’, ’closed’, ’authoritarian’ or ‘liberal’. However these eating types were based on childhood socialisation, which was for all participants either conservative/authoritarian or liberal. A national survey among the adult Spanish population concluded that older people had less difficulty in trying to eat healthy than younger people (Martínez et al 1999). While younger people accredited irregular working hours and too little willpower as the main barriers to healthy eating, older people saw several benefits in consuming healthy food in order to prevent disease, stay healthy and achieve a better overall quality of life. Over half of the elderly in Ireland and Northern Ireland are not willing to change their eating behaviour as they consider their own diet to be healthy enough (Kearney et al

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2001). Over 60% of the same sample make efforts to eat healthy. There was a positive association between attitudes and healthy eating behaviour with respect to fruit and vegetable consumption. Diet composition of 190 Italians aged 50-75 years participating in the EURONUT- SENECA study was assessed. As a conclusion, characteristics of the typical Mediterranean diet were identified by analysing the diets’ composition and the nutritional status of the individual. The typical Mediterranean diet is usually high in fruit and vegetable consumption as well as high in carbohydrate content and in the content of native olive oil. The specific meal patterns of the studied population are not mentioned in this context (Inelmen et al 2000). Dietary patterns of people over 65 years old living in 9 European countries and participating in the European Prospective Investigation into Cancer and Nutrition (EPIC) study were identified using Principal Component Analysis (Bamia et al., 2005). Two principal components were identified as reflecting ‘vegetable-based’ diets (PC1) and ‘sweet and fat dominated’ diet (PC2). PC2 was linked with several factors including older age and lower levels of physical activity whereas PC1 was associated with younger age and higher levels of physical activity. Elderly individuals in southern Europe scored positively on PC1 and close to zero on PC2, whereas elderly in northern Europe scored negatively on PC1 and varied along PC2. Cluster analysis also indicated similar dietary patterns and the identification of a north–south gradient regarding dietary choices. Volkert (2005) discussed the great variation in nutrition and lifestyle across Europe and the different food patterns between Northern and Southern European countries determined from the SENECA (Survey Europe on Nutrition in the Elderly: a Concerted Action) study. Food patterns in southern countries were characterised by high intakes of grains, vegetables, fruit and lean meat and olive oil whereas elderly people in northern countries consumed more milk products and more often reported the use of nutritional supplements. In accordance with these findngs the HealthSense study showed that regular fruit intake was highest in Spain and Italy and lowest in the northern European countries of Denmark, Ireland and Finland (Allen & Newsholme, 2003). Eating habits and alcohol consumption of middle-aged, highly educated French women were investigated by Kesse et al (2001). A positive correlation between the consumption of cheese, processed meat, seafood, vegetable oil, poultry, coffee, potatoes, eggs, lamb and the consumption of alcoholic beverages was found. The intakes of soup, yoghurts, vegetables and fruits on the other hand, declined with increasing alcohol consumption. Based on these findings it was concluded that some

70 Nutri-Senex: State of the art report – task 2.1 of the negative side effects of regular alcohol intake on health may be due to coinciding unhealthy dietary patterns of drinkers. As a consequence, the hypothesis of the beneficial effects of moderate alcohol consumption has to be dismissed (Kesse et al 2001). Presumably, these middle-aged women will not change their eating habits and their alcohol consumption, so they are very likely to show the same habits in old age. In general, alcohol use disorders in elderly people are common and associated with considerable morbidity. The ageing of populations worldwide means that the absolute number of older people with alcohol use disorders is on the increase ( O’Conell H, et al 2003). In a Seneca follow-up study the snack pattern of 807 European citizens aged 74 to 79 has been examined. In general, older people from the various European towns consumed the same snack types. Five distinct snack patterns emerged from the analyses. The large group of light snackers had a low snack use and low energy and micronutrient intakes. Alcohol drinkers and dairy snackers had a high snack use and high intakes of energy and several vitamins and minerals. Fruit and vegetable snackers and sweet drinkers often had intake values between the other three groups. The study indicates the existence of identifiable snack patterns that coincide with different intakes of energy and micronutrients. Especially in countries in which people derive high percentages of energy through snacking, the identification of snack patterns can improve dietary advice (Haveman-Nies et al 1998). A study conducted in the United states also examined the snacking habits of non- institutionalised Americans aged 55 years and older. The majority of seniors snacked at least once daily. When selecting snacks, taste outranks nutrition as selection criteria. Fruits were popular but were chosen less often then other snacks. Findings suggest that snacking should be targeted with specific nutrition education messages that address the influences of time of day, location and qualities of foods upon choices made when snacking (Cross et al 1995). Nutritional awareness and concerns about meat were examined in elderly and young adult populations in France in the light of rises in BSE and foot-and-mouth disease (FMD). Standardised telephone interviews using a 26-point questionnaire were conducted between March and April 2001 with 93 young adults (20-30 years of age) and 99 elderly individuals (65-75 years of age). The questions focused on nutritional knowledge and beliefs about meat, concerns regarding food safety linked to BSE and FMD, and information on meat consumption. Data indicated that both groups were aware that meat contains protein but were unaware of the physiological role of proteins. Even though the elderly participants knew that vitamins and iron (mineral) are present in meat, there was little awareness of the importance of meat

71 Nutri-Senex: State of the art report – task 2.1 consumption. Elderly individuals were more knowledgeable than young persons about animal diseases and less concerned about mad cow disease. Overall, the elderly participants recognised the nutritional properties of meat and were confident of its safety, but they did not think of it as being an essential part of the diet (Chatard et al 2004). In a recent study by Knoops et al (2004), single and combined effects of Mediterranean diet, physical activity, moderate alcohol use, and non-smoking on all- cause and cause-specific mortality were investigated in European elderly individuals. A cohort study was conducted between 1988 and 2000 with the study population comprising individuals enrolled in the SENECA (Survey in Europe on Nutrition and the Elderly: a Concerned Action) and FINE (Finland, Italy, the Netherlands, Elderly) studies, including 1507 apparently healthy men and 832 women, aged 70-90 yr. in 11 European countries. It was concluded that among individuals aged 70-90 yr., adherence to a Mediterranean diet and healthful lifestyle is associated with a >50% lower rate of all-causes and cause-specific mortality. The proportion of regular consumers of fish, raw fruit, raw vegetables and cooked fruit or vegetables and the quantity of alcohol consumed increased with educational level. Subjects living alone were less regular consumers of almost all foods (Larrieu et al 2004). Consequently, vulnerable groups of elderly people can be identified by questioning the number of meals per day, food group intake and assessment of weight change (Schroll M 2003). Additionally poor cooking skills and low motivation to change eating habits may constitute barriers to improving energy intake, healthy eating and appetite in older men (Hughes G, Bennett KM, Hetherington MM 2004). A cross-cultural study 'Food Habits in Later Life' (FHILL) was undertaken to determine to what extent health, social and lifestyle variables, especially food intake, collectively predict survival amongst long-lived cultures. A total of 818 participants aged 70 years and over were recruited from Sweden, Greece, Australia (Greeks and Anglo-Celts) and Japan. It was found that being an elderly Greek in Australia conferred the lowest mortality risk and being an elderly Greek in Greece presented the highest mortality risk. Mediterranean diet, Activities of Daily Living (ADL) and general health status showed the greatest effects in significantly reducing mortality hazard ratios. Diet, particularly the Mediterranean diet, was seen to be a significant contributor to survival, equivalent to or greater than all other measured variables.

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3.5.1 Religion

Little is known about whether religion influences a healthy lifestyle or eating patterns. An investigation of 250 participants aged 20-65 years (of whom 70 (28%) were aged over 50 years) showed that the Greek Christian Orthodox Ecclesiastical lifestyle involves dietary habits which reinforce the Mediterranean diet. In combination with special hygiene practices, it supports health through dietary practices (Chliaoutakis et al 2002). The general assumption that Christianity influences healthful behaviour including healthy eating patterns (such as the consumption of fish on Fridays and avoiding sweets and meat during the Lent period) and therefore includes more fruits and vegetables, could not be proven by this literature review of the elderly living in the EU due to a lack of related research.

3.5.2 Tradition

As the EU is a multi-cultural community, traditions differ from country to country. However, few studies deal with tradition and nutrition behaviour differences among these countries. The majority of people living in Scandinavia and Denmark traditionally eat one hot meal per day. However, two hot meals are frequently consumed in Finland and Sweden. One of the hot meals is eaten around noon and a second one in the evening. In Norway and Denmark a hot meal in the evening is more common. The main meal usually centres around fish in Norway, vegetables in Finland and meat in Denmark and Sweden (and in Norway when fish is not available). The Finns often eat bread together with their hot meal, whereas potatoes are served in the other countries (Mäkelä et al, 1999). Food intakes of population groups in Italy were studied to assess how close or far they were from a reference dietary pattern. Computation of an index, called the Mediterranean Adequacy Index (MAI), was carried out by dividing the sum of the percentage of total energy from typical Mediterranean food groups by the sum of the percentage of total energy from non- typical Mediterranean food groups. The reference Italian-Mediterranean diet utilised was that of subjects from Nicotera in S. Italy in 1960. Men aged 45-65 years at the start of the study from rural areas of Italy in the Seven Countries Study were followed for 26 years (in Crevalcore and Montegiorgio), elderly men and women from Perugia were followed for 11 years, men and women from Pollica (Salerno) were followed for 32 years, and families from Rofrano (Salerno) were followed for 41 years. Results indicated that the diet of these Italian population groups has changed over the last 4

73 Nutri-Senex: State of the art report – task 2.1 decades, progressively abandoning the nutritional characteristics of the reference Italian-Mediterranean diet (Alberti-Fidanza and Fidanza 2004). Laureati et al. (2006) investigated 60 institutionalised elderly aged 57-98 years to determine the most important aspects related to food selection. Focus groups identified simple cooking, tradition and sensory aspects as basic criteria for food choice. Evaluation of 11 first courses using a hedonic scale showed preference for those classified as traditional Italian preparations, whereas those least liked were classified as simple cooked/unfamiliar and complicated cooked/unfamiliar dishes.

Dietary practices among different birth cohorts of 70-years-old Swedes, who were examined between 1971 and 2000, were compared (Eiben at al 2004). Four population-based samples of 70-years-olds (1360), born in 1901, 1911, 1922 and 1930, were used, who had undergone health examinations and dietary assessments over a period of almost 3 decades. Diet history interviews were conducted in 1971, 1981, 1992 and 2000 with a total of 758 women and 602 men. The formats and contents of the dietary examinations were similar over the years. Statistical analysis of linear trends was conducted, using year of examination as the independent variable, to detect secular trends in food and nutrient intakes across cohorts. At the 2000 examination, the majority of 70-years-olds consumed nutritionally adequate diets. Later-born cohorts consumed more yoghurt, breakfast cereals, fruit, vegetables, chicken, rice and pasta than earlier-born cohorts. Consumption of low-fat spread and milk also increased, along with that of wine, light beer and candy. In contrast, potatoes, cakes and sugar were consumed less in 2000 than in 1971. The ratio of reported energy intake to estimated basal metabolic rate did not show any systematic trend over time in women, but showed a significant upward trend in men. It was concluded that the diet history method has captured changes in food selections in the elderly without changing in general format over 3 decades. Dietary quality has improved in a number of ways, and these findings in the elderly are consistent with national food consumption trends in the general population. The number of men living on their own in the UK has been growing in the past few years, now representing 36% of the male population with ~3.4% of all households being single men over 65 years of age (IGD, 2003). This includes men who have never married, who are widowed, divorced or separated. A single man is most likely to be over 45 years old and this trend is expected to intensify in the future as the UK population ages. In 2004, seniors (55+) accounted for 26 per cent of the European £11.1bn (€16.1 bn) ready meal market, according to a new report from Datamonitor (2005). The numbers show that with an outlay of £847million, French seniors are

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Europe’s biggest spenders on ready meals, followed by the British (£778 million), Germans (£677 million), Swedes (£220 million), and Dutch (£130 million). Prepared meal consumption is also an urban and male phenomenon. The UK (with 92 per cent) tops the ready meal markets in Europe, followed by Germany, with 91 per cent, and France with 80 per cent. In these same three countries male consumption accounts for 57 per cent of market value, suggesting that males are slightly more in need of a little help in the kitchen (Datamonitor 2005). The intake of energy, nutrients and food items in a ten-year cohort comparison and in a six-year longitudinal perspective have been examined in a population study of 70- and 76-year-old Swedish people. The result of the analysis demonstrated that there is no reason to believe that elderly people are more conservative regarding their food choices than the rest of the population – at least not at the relatively young ages studied. (Sjörgen 1994)

3.5.3 Factors influencing Obesity

Eriksson et al (2003) investigated in a group of 56 to 66 years old Finns, their size at birth, childhood growth pattern, in addition to socio-economic status in both childhood and adult life. The aim was to examine the relationship between obesity in adult life and growth and health conditions during childhood. A higher socio-economic status and better educational attainment were associated with a lower prevalence of obesity. Self-reported past food habit change was reported to be linked with obesity in a study carried out on a sub-sample (15282 women and 9867 men) within the Malmo Diet and Cancer (MDC) study in Malmo Sweden (Sonestedt et al., 2005). Individuals with body mass index (BMI) greater than 30 kg/m2 had an increased risk of having reported past food habit change compared with individuals with BMI less than 25 kg/m2. Those who had changed their diet were more likely to be highly educated, to live alone, to be retired, to be ex-smokers and to be non-drinkers at baseline. This study highlighted the importance of collecting information on past food habit change as this could influence relationships between diet and disease.

3.5.4 Sedentary Lifestyle

Martínez-González et al (2003), carried out the first European-wide evaluation of the distribution and determinants of sedentary lifestyles in Europe. Nationally representative samples of n~1000 participants in each country completed a questionnaire concerning attitudes to physical activity, body weight and health. In

75 Nutri-Senex: State of the art report – task 2.1 total, information was gathered on 15,239 subjects aged over 15 years, including 1914 participants over 65 years of age. Obese, less educated people and smokers show a high prevalence of sedentary lifestyle in all age groups. Cultural and demographic differences are high between Northern and Southern countries. The highest prevalence of a sedentary lifestyle was observed in Portugal, Belgium, Spain, Germany and Greece. Similarly, findings from the HealthSense study support the wide variation in attitudes to physical activity between Northern and Southern EU states (Allen and Newsholme, 2003). Adults in Northern states (Sweden, Finland, Netherlands and Denmark) were more likely to recognise the importance of physical activity to long term good health than did older adults in Southern regions (France, Italy, Portugal and Greece). Likewise, the percentage of adults reporting to participate in physical activity at least weekly was greater in Northern regions of the EU. However, it is also suggested that confusion may exist regarding what exactly is considered to be ‘physical activity’. For example, some may not be aware that every day activities such as gardening or walking to the shops, etc confers benefits similar to organised exercise and is therefore considered a form of ‘physical activity’. Nooyens et al. (2005) undertook a study investigating changes in lifestyle in relation to changes in body weight and waist circumference associated with occupational retirement in men aged 50-65 (n=288) from Doetinchem in The Netherlands. Men who retired from active jobs were more likely to show an increase in body weight and waist circumference than those retired from sedentary jobs. Weight gain and increase in waist circumference were associated with a decrease in fruit consumption and fibre density of the diet, with an increase in frequency of eating breakfast, and with a decrease in several physical activities, such as household activities, bicycling, walking and doing odd jobs. Ortega et al. (1996) investigated the energy and nutrient intake of 29 non- institutionalised active Spanish males between 65 and 79 years of age who practised sport (usually tennis) daily. Their high income classified them as belonging to a high socio-economic group. The subjects consumed more fruits, fish and non-alcoholic beverages than results reported for the sedentary elderly. However, more than 50% of the population showed intakes of vitamin D, zinc and magnesium lower than 80% of the recommended intakes (RI). It was concluded that the risk of suffering deficits of these micronutrients must be considered, even when taking into account the observed underreporting.

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3.5.5 Living-eating environment

In the UK a lot of the elderly (74.3 ± 7.7 years) may be living in a nursing home. A study was carried out to investigate the effect of eating environment on food intake in the elderly (Gibbons and Henry 2005). Two environments were considered; the improved environment was a state of the art training restaurant and the standard environment was a staff canteen. Each subject was served an identical meal in both environments. The energy intake was determined using the weighed intake method. Results showed that there was a significant difference in the energy intake in the elderly between the improved (4894 ± 613 KJ) and standard (4536 ± 620 KJ) eating environments, suggesting that changes to eating environment may improve energy intake in the elderly. Nutritional problems concerning older people in care can be affected both by their illness and by the standard procedures surrounding food provision, for example rigid routines of food supply and ritualised mealtime situations. A study carried out by Sydner and Fjellstrom (2005) sought to examine how organisational structure and staff members' routines and actions influence activities related to food and meals in different caring contexts in Sweden. Participant observation was the qualitative methodology adopted. Care recipients were given different opportunities concerning what, how, when and with whom to eat, depending on where their meals were served. In restaurants, older people could choose from several foods and they could also choose the time of and company for the meal. At care units with 'part-of-day' care or 'around-the-clock' care, food choices, time and company were limited, especially at the units with 'around-the-clock' care, where the most ailing older people lived. It was concluded that food provision and the mealtime situation for the elderly were shaped by the individual's living arrangements and the social organisation surrounding it, but are not determined by the individual's needs and wishes, including social and cultural meanings of food and meals, which could, thereby, affect nutritional intake. Another study sought to develop a survey tool for assessing the satisfaction of elderly long-term care (LTC) residents with the meals and food services they receive and to assess quality of life issues related to eating (Lengyel et al 2004). The questionnaire was administered as face-to-face interviews with 205 residents (greater than or equal to 65 years of age) of 13 LTC facilities in Saskatoon, Saskatchewan, Canada (participation rate = 67%). Residents expressed some concern with food variety, quality, taste and appearance, as well as with the posting of menus. Quality of life

77 Nutri-Senex: State of the art report – task 2.1 issues were mostly positive. However, residents were less satisfied with areas related to their autonomy such as food choice and snack availability.

3.6 Psycho-social determinants of nutrition behaviour

3.6.1 Motives

Eating behaviour is strongly influenced by cultural motives, for example, drinking coffee and eating cakes is a Swedish tradition, which is generally continued into old age (Gustafsson and Sidenvall 2002). Social factors strongly influence eating behaviour, for example, 79% of the French population believed that the elderly needed less food than younger people, and 20% of the elderly felt that they should live on a vegetarian diet. That’s why people in France aged over 65 years eat less volume of food and in particular less meat, which might be a risk factor for protein deficiency. The average protein intake of men was lower in the older age group while elderly women seem to consume more protein. The elderly usually consume most protein at lunch time which is related to meat- product consumption (Rousset et al 2003). Quality of food, personal habits and trying to eat healthy are the main factors that influence the food choice of the retired Irish (Kearney et al 2000). A US study showed that the elderly population stated that maintaining health, remaining independent and fearing illness provided the motivation needed to adhere to healthier eating behaviours. The strategies or the behavioural processes used to adopt or maintain these behaviours included counter-conditioning, helping relationships, stimulus control and self-liberation (Greaney et al 2004). Although a high prevalence of overweight is present in elderly people, the main concern is the reported decline in food intake and the loss of the motivation to eat in the target group. Poverty, loneliness, and social isolation are the predominant social factors that contribute to decreased food intake in the elderly. Depression, often associated with loss or deterioration of social networks, is a common psychological problem in the elderly and a significant cause of loss of appetite. There is now good evidence that, although age-related reduction in energy intake is largely a physiologic effect of healthy aging, it may predispose to the harmful anorectic effects of psychological, social, and physical problems that become increasingly frequent with aging. Poor nutritional status has been implicated in the development and progression of chronic diseases commonly affecting the elderly. Protein-energy malnutrition is associated with impaired muscle function, decreased bone mass,

78 Nutri-Senex: State of the art report – task 2.1 immune dysfunction, anemia, reduced cognitive function, poor wound healing, delayed recovery from surgery, and ultimately increased morbidity and mortality

(Donini et al 2003). A Scottish study showed that the diets of the elderly appear to differ little from the Scottish population as a whole. In all groups there was an under- consumption of fruits and vegetables reported. Findings from the interviews demonstrated that dietary beliefs were found to be firmly rooted in childhood and lifetime experiences (McKie 2000).

3.6.2 Attitudes

Meals are a daily pleasure and visually pleasing food can enhance the pleasure of eating (Gustafsson and Sidenvall 2002). Minor differences in health, taste attitudes and reported behaviour have been found among Finnish (n = 467), Dutch (n = 477) and British (n = 361) consumers aged 18-75 years. There were no significant differences in the level of interest in general health among Finnish, British and Dutch respondents, suggesting that eating healthily is equally important in all three countries. Finnish participants showed the most positive attitudes to ‘light’ (low fat, low density etc) products compared to Dutch and British consumers suggesting they were more health-orientated. This might be due to nutrition education campaigns in Finland. Though females in all three countries were more interested in health and natural products than were males, they consumed more sweets than males in Finland and in the UK (but not in the Netherlands). It is suggested that women get more pleasure from sweets (Roininen et al 2001). However the results of the study are cited for adults aged 18 to 75 years combined. A questionnaire in Germany about maintaining health and well being in the elderly population (76.2 ± 7.5 years) showed that 87% of the participants considered a balanced diet to be important to ensure health at old age (Volkert 2002). Two thirds agree that an adequate nutrition behaviour is necessary to feel good; a similar percentage were interested in obtaining information about optimal diet. Women and younger seniors where more interested in nutritional questions than men and older seniors. However, in older as well as young adults, the size of a meal is closely related to the rated appetite just before the meal (Parker BA, 2004). Different psycho-social influences on food choice exist in Southern France and central England. Pleasurable and social aspects of eating, certain food quality issues, as well as health as a value were regarded as priorities by French respondents. On the other hand, English respondents reported that organic and ethical issues and

79 Nutri-Senex: State of the art report – task 2.1 convenience were important factors influencing their food choices (Pettinger C, Holdsworth M, Gerber M, 2004).

3.6.3 Emotions

Feelings of guilt were reported in several studies of elderly women after consuming foods high in fat, as they felt they were going against healthy eating recommendations. However widows are often at risk of poor nutrition because they simplify their meals due to the unfamiliar eating alone situation. In addition, a low-fat diet might increase the risk of malnutrition (Gustafsson and Sidenvall 2002). A study relating to diets and nutrient intakes of elderly Italian individuals showed that difficulties in nutrition-related activities were associated with inadequate intake of selected nutrients (Bartali et al 2003). Older persons tended to adapt their diets in response to individual functional difficulties, often leading to monotonous food consumption and, as a consequence, to inadequate nutrient intakes. Reporting difficulties in at least 3 nutrition-related activities (chewing, self-feeding, shopping for basic necessities, carrying a shopping bag, cooking a warm meal, using fingers to grasp or handle) significantly increased the risk of inadequate intake of energy. The study concluded that more attention to functional problems in the elderly population and the provision of formal or informal help to those who have difficulty in purchasing, processing and eating food may reduce, at least in part, the percentage of older persons with poor nutrition. 54 edentate people aged 60-93 have been interviewed in their own homes in London to evaluate difficulty chewing and consequent food choice. Most subjects (69%) expressed difficulty eating at least one type of food, half were unwilling to eat the foods they found difficult, others were conscious of cooking longer or cutting smaller in order to manage these foods, although no one accepted that they overcooked food (Millwood and Heath 2000). Eating difficulties of edentate patients in dental clinics have also been the issue of a Greek study, which has come to similar results, that most patients express difficulty eating at least one type of food and especially raw vegetables were rated difficult. Apples and oranges were also food of particular interest (Anastassiadou and Heath 2002). A study carried out by Hughes and colleagues (2004), showed that when elderly live on their own, poor cooking skills and low motivation to modify eating habits may act in older men as barriers to increasing energy intake, healthy eating and appetite. Larrieu et al. (2004) identified that people living alone and those with low education

80 Nutri-Senex: State of the art report – task 2.1 were particularly at risk of poor dietary habits. This study of French people aged 65 years and over living in the community found that older subjects ate less meat, fish, cereals, raw vegetables and pulses less regularly and subjects living alone were less regular consumers of all foods. In a review of nutrition and older people in England, Gabriella (2004) identified factors that hinder food preparation and eating. Emotional factors including isolation with an inability to go out shopping, decreased mobility, loss of spouse and depression were cited as risk factors for malnutrition in the elderly. Similar results have been shown by Westenhoefer (2005). When growing older changes in the chemosensory perceptual systems play an important role in food choice. The decline of gustatory and olfactory function may lead to a decrease of the pleasantness of food, thus limiting the reinforcing properties of food intake which eventually results in a decrease of appetite, often reported in elderly people. In addition, there are some indications that sensory-specific satiety diminishes with age. Sensory-specific satiety is the reduction in the pleasantness of food while consuming. This decrease of pleasantness usually motivates the choice of different foods and therefore, a varied diet. Therefore, the decrease of sensory-specific satiety may in part explain the limited variety of diets sometimes seen in older people. However, lifestyle, socio-economic situation and other variables may limit the influence of such physiological changes and help to maintain an adequate food intake despite these age-related processes (Westenhoefer 2005).

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3.7 Literature Ajzen I. (1991): The Theory of Planned Behavior Organisational Behavior and Human Decision Processes 50, 179-211

Alberti-Fidanza A., Fidanza,F (2004) Mediterranean adequacy index of Italian diets. Public Health Nutrition, 7 (7): 937-941

Allen D, Newsholme HC (2003) Attitudes of Older EU Adults to Diet, Food and Health: A Pan- EU Survey. CCFRA R&D Report 174

Almeida de, M. D. et al. (2001) Healthy Eating in European elderly: consepts, barriers and benefits Journal of Nutrition Health Aging 5(4); S217-S219

Bamia, C., Orfanos, P., Ferrari, P., Overvad K., Hundborg, H.H., Tjønneland, A., Olsen, A., Trichopoulou, A. (2005) British Journal of Nutrition, 94 (1), 100-113.

Bartali, B.; Salvini, S.; Turrini, A.; Lauretani, F.; Russo, C.R.; Corsi, A.M.; Bandinelli, S.; D’Amicis, A.; Palli, D.; Guralnik, J.M.; Ferrucci, L. (2003). Age and disability affect dietary intake. Journal of Nutrition, 133(9): 2868-2873.

Bell, R., Conner, M., Norman, P. (2002) The Theory of Planned Behavior and Healthy Eating Health Psychology 21(2), S194-S201

Bisogni, C. A. et al. (2002) Who We Are and How We Eat: A Qualitative Study of Identities in Food Choice Journal of Nutrition Education and Behavior 34, S128-S139

Blane D, et al (2003) Background influences on dietary choice in early old age. J-R-Soc- Health 123(4): 204-9

Brombach C (2001): The EVA-Study: Nutrition Behaviour in the Life Course of Elderly Women. Journal of Nutrition, Health and Aging 5: 261-263

Brombach C (2001a): The EVA-Study: Meal Patterns of Women over 65 Years. Journal of Nutrition, Health and Aging 5: 263-265

Brombach, C. (2000): Ernährungsverhalten im Lebensverlauf von Frauen über 65 Jahren: eine qualitativ biographische Untersuchung [Nutrition Behaviour in the Life Course of Elderly Women] Gießen: Köhler

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Brussaard, J.H. et al. (2002) A European food consumption survey method – conclusions and recommendations European Journal of Clinical Nutrition 56(2), S89-94

Chatard-Pannetier, A.; Russet, S.; Bonin, D.; Guillaume, S.; Droit-Volet, S.; (2004). Nutritional knowledge and concerns about meat of elderly French people in the aftermath of the crisis over BSE and foot-and-mouth. Appetite, 42(2): 175-183.

Chliaoutakis El, J. et al. (2002) Greek Christian Orthodox Ecclesiastical Lifestyle: could It Become a Pattern of Health-Related Behaviour? Preventive Medicine 34, S428-S435 (7 Oct 1998).

Datamonitor (2005) Evolution of Global Consumer Trends (July 2005) www.datamonitor.com

Dibsdall LA, et al (2003) Low-income consumers’ attitudes and behaviour towards access, availability and motivation to eat fruit and vegetables. Public Health Nutrition 6(2): 159-168

Donini LM, Savina C, Cannella C (2003) Eating habits and appetite control in the elderly: the anorexia of aging. Int-Psychogeriatr. 15(1): 73-87

Duerr, L. (2003) Assessing nutrition education wants and needs of older adults through focus groups. Journal of Nutrition for the Elderly, 23(2): 77-91.

Eiben, G.; Andersson, C.S.; Rothenberg, E.; Sundh, V.; Steen, B.; Lissner, L. (2004) Secular trends in diet amond elderly Swedes – cohort comparisons over three decades. Public Health Nutrition, 7(5): 637-644.

Eriksson, E. et al. (2003) Obesity from cradle to grave. International Journal of Obesity 27, S722-S727 (07 Jan 2003)

Fischer-Cyrulies, A. (2000) Wohnen im mittleren und höheren Alter – Eine Analyse der Leipziger Stichprobe [Living in middle and old age – An analysis of Leipzig’s spot-check]. In: Martin, P. et al. (Eds.) (2000) Aspekte der Entwicklung im mittleren und höheren Lebensalter. Ergebnisse der Interdisziplinären Längsschnittstudie des Erwachsenenalters (ILSE) [Aspects of the development in middle and old age. Results of the interdisciplinary longitudinal study of adults ]. Darmstadt: Steinkopf Verlag, S185-S200

Francis, S.L.; Taylor, M.L.; Strickland, A.W. (2004) Needs and preference assessment for an in-home nutrition education program using social marketing theory. Journal of Nutrition fo the Elderly, 24 (2); 73-92

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Gabriella, S. (2004) Nutrition and older people: Special considerations relating to nutrition and ageing. Clinical medicine, Journal of the Royal College of Physicians of London, 4 (5), 411- 416.

Gibbons, M.R.D., Henry, C.J.K. (2005) Does eating environment have an effect on food intake in the elderly? Journal of Nutrition Helath and Aging, 9 (1): 25-29

Greaney ML, et al (2004) What older adults find useful for maintaining healthy eating and exercise habits. Journal of Nutr-Elder 24(2): 19-35

Greaney, M.L.; Lees, F.D.; Greene, G.W.; clark, P.G. (2004) What older adults find useful for maintaining healthy eating and exercise habits. Journal of Nutrition for the Elderly, 24(2), 19- 35

Greenwood CE, et al (2005) Behavioral disturbances, not cognitive deterioration, are associated with altered food selection in seniors with Alzheimer's disease. Journal of Gerontol-A-Biol-Sci-Med-Sci. 60(4): 499-505

Gustafsson, K., Sidenvall, B. (2002) Food-related health perceptions and food habits among older women Journal of Advanced Nursing 39 (2), S164-S173

Guthrie, J. F., Lin, B-H. (2002) Overview of the Diets of Lower- and Higher-Income Elderly and Their Food Assistance Options Journal of Nutrition Education and Behavior 34, S31-S41 Henauw, S.D. et al. (2002) Operationalization of food consumption surveys in Europe: recommendations from the European Food Consumption Survey Methods (EFCOSUM) Project European Journal of Clinical Nutrition 56 (2), S75-S88

Hjartåker, A., Lund, E. (1998) Relationship between dietary habits, age, lifestyle and socio- economic status among adult Norwegian women. The Norwegian women and Cancer Study European Journal of Clinical Nutrition 52, S565-S572

Howler E (2004) Nahrungsverweigerung älterer Menschen in stationären Ein-richtungen: Der Unterschied zwischen Nicht-Wollen und Nicht-Können. [Food refusal in elderly inpatients: the difference between unwillingness and incapacity] Pflege-Zeitschrift 57(12): 845-9

Hughes G, Bennett KM, Hetherington MM (2004) Old and alone: barriers to healthy eating in older men living on their own. Appetite (43): 269-276

Hughes, G.; Bennett, K.M.; Hetherington, M.m. (2004) Old and alone: barriers to healthy eating in older men living on their own. Appetite, 43 (3): 269-276.

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Huijbregts, P.P.C.W. et al. (1998) Dietary patterns and cognitive function in elderly men in Finland, Italy and the Netherlands European Journal of Clinical Nutrition 52, S826-S831

IGD. Report Series. Consumer Watch 2003. www.igd.com/consumer Inelmen, E. M. et al (2000) Dietary intake and nutritional status in Italian elderly subjects Journal of Nutrition Health Aging 4(2), S91-S101

Jonsson, I. M. (2002) Choice of food and food traditions in pre-war Bosnia-Herzegovina: focus group interviews with immigrant women in Sweden Ethnic Health 7 (3), S149-S161

Jungjohann SM, et al (2005) Eight-year trends in food, energy and macronutrient intake in a sample of elderly German subjects. British Journal of Nutrition 93(3): 361-78

Kearney, J.M. et al. (2001) Attitudes towards and beliefs about nutrition and health among a random sample of adults in the Republic of Ireland and Northern Ireland Public Health Nutrition 4 (5A), S1117-S1126

Kearney, J.M., Hulshof, K.F.A.M., Gibney, M.J. (2001) eating patterns – temporal distribution, converging and diverging foods, meals eaten inside and outside of the home – implications for developing FBDG Public Health Nutrition 4 (2B), S693-S698

Kearney, J.M., McElhone, S. (1999) Perceived barriers in trying to eat healthier – results of a pan-EU consumer attitudinal survey British Journal of Nutrition 81 (2), S133-S137

Kearney, M. et al. (2000) Sociodemographic determinants of perceived influences on food choice in a nationally representative sample of Irish adults Public Health Nutrition 3 (2), S219- S226

Kemper, H.C.G. et al. (2003) Computerization of a dietary history interview in a running cohort; evaluation within the Amsterdam Growth and Health Longitudinal Study European Journal of Clinical Nutrition 57, S394-S404

Kesse, E. et al. (2001) Do eating habits differ according to alcohol consumption? Results of a study of the French cohort of the European Perspective Investigation into cancer and Nutrition (E3N-EPIC) American Journal of Clinical Nutrition 74, S322-S327

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Knoops, K.T.B.; Groot, L.C.P.G.M. de; Kromhout, D.; Perrin, A.E.; Moreiras-Varela, O.; Menotti, A.; Staveren, W.A. van (2004). Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women. Journal of the American Medical Association, 292(12): 1433-1439

Kowrygo, B., Groska-warsewicz, H., Berger, S. (1999) Evaluation of eating patterns with different methods: the Polish experience Appetite 32 (1), S86-S92 Larrieu S, et al (2004) Sociodemographic differences in dietary habits in a population-based sample of elderly subjects: the 3C study. Journal of Nutr Health-Aging 8(6): 497-502

Lasheras, L., Fernandez, S., Patterson, A. M. (2000) Mediterranean diet and age with respect to overall survival in institutionalized, nonsmoking elderly people American Journal of Clinical Nutrition 71, S987-S982

Laureati, M., Pagliarini, E., Calcinoni, O., Bidoglio,M. (2006) Sensory acceptability of traditional food preparations by the elderly. Food Quality and Preference,17 (1-2), 43-52.

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Leino-Kilpi, H. et al. (2003) Perceptions of Autonomy, Privacy and Informed consent in the Care of Elderly People in Five European Countries: general overview Nursing Ethics 10 (1), S18-S27

Leino-Kilpi, H. et al. (2003) Perceptions of Autonomy, Privacy and Informed consent in the Care of Elderly People in Five European Countries: comparison and implications for the future Nursing Ethics 10 (1), S58-S66

Lengyel, C.O.; Smith, J.T.; Whiting, S.J.; Zello, G.A. (2004). A questionnaire to examine food service satisfaction of elderly residents in long term care facilities. Journal of Nutrition for the Elderly, 24 (2): 5-18

Leonhaeuser, I.-U. (2002) Concerning food patterns in a comparative way in: Butijn, C. A. A. et al. (Eds) (2002): Changes at the other end of the chain. Everyday consumption in a multidisciplinary perspective. Shaker Publishing, Maastricht, The Netherlands, S19-S31

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Lindeman, M., Stark, K. (1999) Pleasure, Pursuit of Health or Negotiation of Identity? Personality Correlates of Food Choice Motives Among Young and Middle-aged Women Appetite 33, S141-S161 (15 Mar 1999)

Mäkelä, J., et al. (1999) Nordic Meals: Methodological Notes on a Comparative Survey Appetite 32, S73-S79

Martin, P. et al. (Eds.) (2000) Aspekte der Entwicklung im mittleren und höheren Lebensalter. Ergebnisse der Interdisziplinären Längsschnittstudie des Erwachsenenalters (ILSE) [Aspects of the development in middle and old age. Results of the interdisciplinary longitudinal study of adults ]. Darmstadt: Steinkopf Verlag

Martínez, J. A. et al. (1999) Perceived barriers of, and benefits to, healthy eating reported by a Spanish national sample Public Health Nutrition 2 (2), S209-S215

Martínez-González, M.A. et al. (2003) Distribution and determinants of sedentary lifestyles in the European Union International Journal of epidemiology 32, S138-S146 Mensink, G. et al. (2000) Lebensmittelkonsum in Deutschland [Food Consumption in Germany] Ernährungs-Umschau 47, S328-S332

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Morley, J. E. (2004) The Top 10 Hot Topics in Aging Journal of Gerontology 59A, S24-S33 n.n. (2000) Eurest Catering: Offering of ambulant services, example “Meals on Wheels” (summary) In: Kettschau, I., Methfessel, B., Piorkowsky, M-B. (Eds.): Familie 2000. Bildung für Familienhaushalte. Europäische Perspektiven. Hohen-gehren: Schneider Verlag, S227- S228 n.n. (2002) Eating Habits – Pan- European Overview, Consumer Goods Intelligence, Mintel (Eds.) www.mintel.com, London

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O’Conell H, Chin AV, Cunnighm C, Lawlor B (2003) Alcohol use disorders in elderly people – redefining an age old problem in old age. British Medical Journal (327): 664-7

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Ortega R. M., Lopez-Sobaler A. M., Zomora M. J, Redondo R, Gonzalez-Gross M, Andres P. (1996) Dietary intake of a physically active elderly Spanish male group of high socioeconomic status. International Journal of Food Science and Nutrition, 47(4), 307-313.

Oswald, F. et al. (2000) Wohnen als Entwicklungskontext: Objektive Wohn-bedingungen, Wohnzufriedenheit und Formen der Auseinandersetzung mit dem Wohnen in Ost- und Westdeutschland [Living in the context of development: Objective Living-conditions, Living- satisfaction and ways of life in East- and West-Germany ]. In: Martin, P. et al. (Eds.) (2000) Aspekte der Entwicklung im mittleren und höheren Lebensalter. Ergebnisse der Interdisziplinären Längsschnittstudie des Erwachsenenalters (ILSE) [Aspects of the development in middle and old age. Results of the interdisciplinary longitudinal study of adults ]. Darmstadt: Steinkopf Verlag, S201-S219

Paris-Riberio, J.L. (2004) Quality of life is a primary end-point in clinical settings Clinical Nutrition 23, S121-S130

Parker BA, et al (2004) Relationships of ratings of appetite to food intake in healthy older men and women. Appetite (43): 227-233

Pekka, P., Pirjo, P., Ulla, U. (2002) Part III. Can we turn back the clock or modify the adverse dynamics? Programme and policy issues. Influencing public nutrition for non-communicable disease prevention: from community intervention to national programme – experience from Finland Public Health Nutrition 5 (1A), S245-S251

Pettinger C, Holdsworth M, Gerber M (2004) Psycho-social influences on food choice in Southern France and Central England. Appetite (42): 307-316

Pfau, C., Piekarski, J. (2001) Speisenzubereitung in Haushalten älterer Menschen, Mahlzeitenstrukturen, Nahrungsergänzung, Lebensmittelauswahl und Geräte-ausstattung [Preparing meals in private households of the elderly, Structure of meals, Supplements, Food choice and Kitchen equipments] Ernährungs-Umschau 48, S356-S361

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Roether, D. et al. (2000) Ernährungsverhalten im mittleren und höheren Lebensalter [nutrition behaviour in middle and old age]. In: Martin, P. et al. (Eds.) (2000) Aspekte der Entwicklung im mittleren und höheren Lebensalter. Ergebnisse der Interdisziplinären Längsschnittstudie des Erwachsenenalters (ILSE) [Aspects of the development in middle and old age. Results of the interdisciplinary longitudinal study of adults ]. Darmstadt: Steinkopf Verlag, S273-S288

Roininen, K. et al. (2001) Differences in health and taste attitudes and reported behaviour among Finnish, Dutch and British consumers: a cross-national validation of the health and Taste Attitude Scales (HTAS) Appetite 37, S33-45

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Schlettwein-Gsell, D., Prins de, L. Ferry, M. (1991) Life-style: marital status, education, living situation, social contacts, personal habits (smoking, drinking). Euronut SENECA investigators. European Journal of Clinical Nutrition 45(3), S153-S168

Schmid A, Weiss M, Heseker H (2003) Recording the nutrient intake of nursing home residents by food weighing method and measuring the physical activity. Journal of Nutr- Health-Aging 7(5): 294-5

Schöb, A. (2002) Lebenssituation von Älteren [Life’s situation of the elderly]. In: Statistisches Bundesamt (Eds.): Datenreport 2002. Bonn, S551-S559

Schroll M (2003): Aging, food patterns and disability. Forum-Nutrition (56): 256-8 Schroll, K. et al (1996) Food patterns of the elderly Europeans. SENECA Investigators. European Journal of Clinical Nutrition 50 (2), S86-S100

Slimani, N. et al. (2002) Diversity of dietary patterns observed in the European Prospective Investigation into Cancer and Nutrition (EPIC) project Public Health Nutrition 5(6B), S1311- S1328

Sonestadt E., Wirfalt E., Gullberg B, Berglund G. (2005) Past food habit change is related to obesity, lifestyle and socio-economic factors in the Malmo Diet and Cancer Cohort. Public Health Nutrition, 8 (7), 876-885.

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Stehle, P. (2000) Ernährung aelterer Menschen [Nutrition of the elderly]. In: Deutsche Gesellschaft für Ernährung e.V. (DGE) (Eds.) (1996): Ernährungsbericht 2000. Frankfurt am Main, S147-S178.

Sulander T, et al (2005) Associations of functional ability with health-related behavior and body mass index among the elderly. Arch-Gerontol-Geriatr 40(2): 185-99

Sulander, T. et al. (2003) Changes and associations in healthy diet among the Finnish elderly, 1985-2001 Age and Ageing 32, S394-S400

Sydner, Y.M.; Fjellstrom,C. (2005) Food provision and the meal situation in elderly care – outcomes in different social contexts. Journal of Human Nutrition and Dietetics. 18(1): 45-52.

Tijhuis, M. A. R. et al. (1999) Changes in and factors related to loneliness in older men. The Zutphen Elderly Study Age and Ageing 28, S491-S495

Trichopoulou, A. et al. (1999) Are the advantages of the Mediterranean diet transferable to other populations? A cohort study in Melbourne, Australia British Journal of Nutrition 82, S57- S61

Trichopoulou, A. et al. (2003) Tracing the Mediterranean diet through principal components and cluster analyses in the Greek population European Journal of Clinical Nutrition 57, S1378-S1385

Turrini, A. et al. (2001) Food consumption patterns in Italy: the INN-CA Study 1994-1996 European Journal of Clinical Nutrition 55, S571-S588

Verbraucherzentrale Bundesverband e.V. (vzbv) (Eds.) (2004) Essen im Alter. Zu wenig? Zu viel? Das Falsche? Dossier zu Seniorenernährung in Deutschland [Food in old age. Too much? Too little? The false? Dossier for the nutrition of senior citizens in Germany] Berlin.

Vincent, D. et al. (1998) Changes in dietary intakes with age Journal Nutrition Health Aging 2(1), S45-S48

Volkert, D. (2005) Nutrition and lifestyle of the elderly in Europe. Journal of Public Health, 13 (2), 56-61.

Volkert, D., Oster, P., Schlierf, G. (1996) Mangelernährung geriatrischer Patienten [Malnutrition of geriatric elderly]. In: Deutsche Gesellschaft für Ernährung e.V. (DGE) (Eds.) (1996): Ernährungsbericht 2000. Frankfurt am Main, S233-S250

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Volkert, D.; Kreuel, K.; Stehle, P. (2002). Nutrition beyond 65 – Part 1: Attitudes of the elderly towards health and nutrition. Ernaehrungs-Umschau, 49 (22): 428-434

Wahlgyist M. L., Darmadi-Blackberry I., Kouris-Blazos A., Jolley D., Steen B., Lukito W., Horie Y. (2005) Asia Pacific Journal of Clinical Nutrition, 14 (1), 2-6.

Westenhoefer J (2005) Age and gender dependent profile of food choice. Forum-Nutrition (57): 44-51

Winter Falk, L., Bisogni, C. A., Sobal, J. (1996) Food Choice Processes of Older Adults: A Qualitative Investigation Journal of Nutrition Education and Behavior 28, S257-S265

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4 Preventive nutrition strategies 4.1 Functional food based preventive nutrition strategies During the last years more and more functional ingredients have been identified targeting the prevention of common diseases. Currently, the most important functional foods on the market are probiotic dairy products. In the same way there are ACE-, Wellness-Drinks, and dairy-, meat- or drinking products, which are enriched with phytosterines (Schmidt 2005). None of these products are marked as “Senior-products”, although it could be a potential market. “Not only will this group be large, it will, in many countries, also be wealthier, more active and more experimental than previous generations, and thus will represent an excellent target for functional foods.” (Jacklin 2006) Due to this fact a big part of the functional food, especially the blood cholesterol-lowering spreads and dairy products are apparently targeted at elderly people but without a specific marketing for this target group because integration of elderly people in existing marketing strategies seems to be more successful (Potroz 1999; Laubscher 2004). Zammer reports about functional ingredients targeting osteoarthritis like glucosamine or chondroitin that could be used for formulating healthful and good-tasting foods for elderly people. There is no information in her report if such products are already on the market but a clinic which treats arthritis patients has already developed a juice beverage containing 1500mg of glucosamine called “Joint Juice” (Zammer 2003). Von Ribbeck reports about functional food products for elderly people in Japan. There are products with dietary fibres (syrup and soft drinks with fructo-oligosaccharide), sugar substitution and probiotic components (products made of soy-protein like grilled tofu or soy- balls for frying) on the market (v. Ribbeck 2005). In a recent study by Brian Biusse he examined the healthy effects of cacao. He found out, that persons with a high consumption of cacao (mean 4g/day) have a 50 % reduction of cardiovascular diseases. The benefits of cacao could be ascribed to the high content of flavonoids (cacao contains more flavonoids than red wine or green tea), but it is too early for specific recommends for the daily consumption (Buisse et al. 2006). Much focus had been on the vitamin D and calcium combination for bone health in women since elderly females are four times more likely to develop osteoporosis than their male counterparts. A new study reports that elderly men, particularly those over 62, benefit from daily supplements of fortified milk. Some countries like Canada already fortify their milk and a 250 ml cup provides about 90 IU of vitamin D. In the UK for example, where milk is not fortified, a 250 ml cup contains only a trace of the vitamin.

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The 1999 USDA survey on food intakes by individuals reported that less than 15 % of over- sixty year-old men were meeting their recommended daily intake of calcium. 1

4.2 Food targeting the elderly There is also very few literature to be found about specific food targeting the elderly population that is already on the market. However, the necessities of such products or preventive nutritional strategies are discussed. Leatherhead reports about a limited range of starch-based meals, pre-thickened liquids and food products for the elderly population in UK (Leatherhead Food International, 2003). It would be interesting to know if the latter are indeed marketed as “senior-products”. Since market research shows that elderly people don’t want to be addressed as such, food industry and retailers are still reluctant in developing and marketing of “senior-style” products. Despite this, Nestlé Nutrition is presently developing special products for elderly people like yoghurts, nutrient bars and juices (Meyer-Hentschel, 2004). Endres et al.(2000) developed and tested products made of or enriched with soy that were served in form of traditional menus in a long term care facility in the US. Some of the products were specifically developed for this study, some products were provided by manufacturers. Protein intake was significantly higher with consumption of the soy products as compared to the control period with traditional food service. Prior to including these products into the meal plan, they were tested for sensory acceptance among seniors. Only the acceptable products were included in the study. In addition to heightened protein consumption, soy foods tend to hold more moisture in foods which might make the products easier to eat by the elderly and even increase fluid intake. This study shows an interesting way to increase protein intake among the elderly, although it would have been helpful to know how much the plasma protein level did actually increase. Soy products or soy enriched products such as oatmeal and pasta could also be included in more European style diets and seem to be a promising way to increase the protein content of a diet. A single product was developed by Vera et al.(1995) who enriched a dessert powder with vitamins. The final product contained 30% of the daily required vitamins and was sensory acceptable. The powder was designed to be prepared with skimmed milk which is probably aimed at the more overweight population. If these kinds of products are developed for the market there should be low fat as well as high fat versions to serve all needs of the elderly. This study shows that the idea of functional foods transferred to products eaten

1 Nutra www.nutraingredients.com/news/printNewsBis.asp?id=67988 (2006) Elderly men may benefit from vitamin D, calcium too

94 Nutri-Senex: State of the art report – task 2.1 regularly could be an effective tool to prevent malnutrition. A huge problem that companies encounter with these kinds of products is the marketing or branding of the products. “Senior- style” products marketed as such are less accepted and might damage the image of the existing brand (Biester, 1998). Literature about acceptance of existing liquid food products was not to be found. However, Wouters-Wesseling et al.(2002) studied the effect of using liquid food as a supplement between main meals in a psycho-geriatric nursing home. Bodyweight and plasma values for several vitamins were significantly improved. Stiftung Warentest in Germany compared six providers of meals on wheels for sensory acceptance and nutritional content. One of the six providers received the rating “good”; the others received the rating “satisfactory”. Since there are about 2000 providers of meals on wheels in Germany alone, it is to be expected that the sensory quality differs, as well as the nutritional quality. Overall, the food was higher in fat and salt than recommended.2

4.3 Food designed for the altered perception of the ageing Although the altered perception of the ageing is widely discussed in literature, there is very few literature to be found about specific food designed for this altered perception. Many studies about the food choice of the elderly, their food intake and the modification of flavour and taste perception were carried out in the last years. Many of these studies (Schiffman and Warwick, 1993 / Schiffman et. al 1997 / D Jong et. al 1996) suggest that higher liking for stronger flavour and taste stimuli is an age-related feature. Other studies by Philipsen et. al (1995), Koskinen et. al (2003) and a recent study by Mojet et. al (2005) didn’t support the assumption that age-related loss of the taste sensitivity will lead to a preference for taste-enhanced foods. The interest in sensory modifications and relationships with foods of the elderly may be explained by a steady increase in elderly population. In many European countries, in Japan and the USA the elderly population already presents over 15 % of the total population (Mojet 2004). Laureati et. al (2005) examined the sensory acceptability of traditional food preparations by elderly people. The elderly showed the tendency to confine food preference evolution to childhood, a life period when people probably form their preferences. It may also be assumed that the most important aspects related to food for the elderly were simple- cooking, tradition and sensory aspects (the results should be treated with caution, because the number of tests in that study didn’t allow a generalisation to the older population). In some research projects at universities in Chile and Mexico specific products were developed to meet taste and nutritional requirements for aged people. Witting de Penna et al

2 Anonymus (2004) Essen auf Rädern test (Stiftung Warentest, publisher) 5, S92-S95.Food designed for the altered perception of the ageing – Designed food for catering homes or institutionalized elderly

95 Nutri-Senex: State of the art report – task 2.1 for instance optimised a spaghetti formula enriched with dietary fibre and micronutrients to increase the dietary fibre intake in elderly people. They used sweet lupin bran (Vitafibre) as fibre source and gluten was used as improving additive. A trained sensory panel evaluated the sensory quality parameters to make sure to achieve the desired taste (Witting de Penna et al. 2002). In a second project Witting de Penna et al. (2002) developed individual cakes enriched with dietary fibre (lupin and oat fiber), vitamins and minerals. To improve flavour and texture they added polydextrose and sorbitol. Overall sensory quality was very good and also good quality and nutritive value could be achieved. In an acceptance test they obtained 100% acceptability (Witting de Penna et al. 2002). Morales de Leon et al. (1997) developed a soup paste based on the taste and nutritional requirements for aged people. The soup paste was based on a cereal /leguminous mixture of wheat semolina, beans and amaranth. The manufactured paste supplied 20% of the nutritional requirements of the elderly people of protein, carbohydrates, calcium, irons and vitamins A, B1 and C and it was highly accepted (95%) by the target group. In his study on chemical senses and nutrition in aging, Mattes (2002) highlights the difficulty in determining the optimal level and type of flavour, as age- related chemosensory losses deficits may be quality-specific and can vary largely in magnitude between individuals. Koskinen et al. (2003) and Issanchou et al. (2004) demonstrate in their studies on flavour enhancement as a tool for increasing the hedonic value of foods in the elderly population that flavour enhancement has only a limited effect on increasing food liking and especially on food intakes at a nutritionally relevant level. And Mojet (2004) reasons that compensation strategies through added sensory stimulation in food will only be successful if they are targeted at specific subgroups of elderly. 4.4 Designed food for catering homes or institutionalised elderly For hospitalised and institutionalised elderly some industries have marketed special formulas with increased energy density and high concentrations of macro – as well as micronutrients. Apart from these mainly medicine-like products nutritional strategies in catering or institutional homes for elderly people apparently often include the use of conventional food or ingredients in specific combinations or modifications to meet the diet requirements of their elderly patients. So Hankey et al (1993) achieved recommendations for the daily NSP (non- starch polysaccharide) with menu modification. They used “fibre rich” cakes including bran cereal from Kellogg’s Co. UK. To improve results they suggest to adjust not only one dietary component but more menu components by using different flour types, cereals or breads (Hankey et al., 1993). Also Ödlund Olin et al achieved additional energy intake in frail elderly by addition of natural energy-dense ingredients to regular meals. They increased energy density through adding fat in form of butter, cream, cheese etc (Ödlund et al., 2003) De Jong et al. (2001) also analysed appraisal and acceptance of micronutrient-dense foods among elderly by using regular milkshakes, yoghurt, custard, curd, juice and compote enriched with

96 Nutri-Senex: State of the art report – task 2.1 vitamins and minerals. They emphasize the development and evaluation of customary natural-seeming foods in contrast to the medicine type often used as an intervention supplement in care facilities (De Jong et al., 2001). One cook developed several concepts for institutionalized elderly. “Fingerfood” is developed for elderly persons, who cannot eat with cutlery anymore. Preparing food this way leaves the residents more choice of what they want to eat. “Eat by walking” is a concept aimed at elderly with dementia who cannot sit at a table for a longer time and are offered small pieces of fruit and vegetables to eat when walking by (Biedermann 2003; Engel 2004). The company “Apetito” creates menus for different facilities, for example nursery, hospitals, staff canteens and also for nursing homes or meals on wheels. Apetito offers special age- based menus for elderly people, especially for those who need mashed menus. In the mashed components of the dishes they add vitamins to satisfy the requirements of elderly people3.

3 [email protected], 20.06.06

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4.5 Literature Anonymus (2004) Essen auf Rädern test (Stiftung Warentest, publisher) 5, S92-S95.

Biedermann M Erste Deutsche Heimkochtagung: Gastfreundschaft im Heim – Esskultur als integratives Konzept in der Begleitung alter Menschen, conference proceedings 28-29.10.2003

Biester S (1998) Erste Hilfe Lebensmittel Zeitung Spezial 1, S28-S29.

De Jong, N. et al (2001) Appraisal of 4 month’s consumption of nutrient-dense foods within the daily feeding pattern of frail elderly Journal of Aging Health 13, S200-216

Endres, J. et al. (2000) Acceptance of Soy Foods by the Elderly in a Long-Term Care Facility Journal of Nutrition for the Elderly 19, S6-S22

Engel M (2004) Essen im Alter, Dossier zur Seniorenernährung in Deutschland (Publisher) Verbraucherzentrale Bundesverband e.V.

Hankey, C.R. et al (1993) Non-starch polysaccharide/dietary fibre supplementation using small meals in long-stay frail elderly patients European Journal of Clinical Nutrition 47, S521-3

Issanchou, S. (2004) Changing food liking with ageing. Workshop summary: How do age-related changes in sensory physiology influence food liking and food intake? Food Quality and Preference 15, S907-911.

Koskinen, S. (2005) Influence of chemosensory performance on flavor perception and food acceptance of the elderly, Department of Food Technology, University of Helsinki

Koskinen, S. et al (2003) Flavor enhancement as a tool for increasing pleasantness and intake of a snack product among the elderly Appetite 41, S87-96

Laubscher, C. (2004) Der Markt der Grauen wird farbig. KTI Innovation for Successful Ageing Handelszeitung 22, S10-11

Leatherhead Food International (2003) Research on food for the elderly Food news 37 (5) Mattes, R.D. (2002) The chemical senses and nutrition in aging: Challenging old assumptions. Journal of the American Dietetic Association 102, S192-196

Meyer-Hentschel, G, Meyer-Hentschel, H. (2004) Seniorenmarketing - Generationsgerechte Entwicklung und Vermarktung von Produkten und Dienstleistungen, BusinessVillage

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Mojet, J. (2004) Interactions between the senses and opportunities for compensation. Workshop summary: How do age-related changes in sensory physiology influence food liking and food intake? Food Quality and Preference 15, S907-911

Morales de Leon, J. et al (1997) Development of a soup paste based on the taste and nutritional requirements for aged people. Archivos Latinomeriacanos de Nutrici 47, S152-156

Ödlund Olin, A. (2004) Nutritional and functional effects of energy-dense food in the frail elderly, Karolinska Institutet Stockholm

Ödlund Olin, A. et al (1996) Energy-enriched hospital food to improve energy intake in elderly patients Journal of parenteral and enteral nutrition 20, S93-7

Ödlund Olin, A. et al (2003) Energy-dense meals improve energy intake in elderly residents in a nursing home Journal of Clinical Nutrition 22, S125-131

Potratz, B., Wildner, S. (1999) Functional Foods – Eine Frage des Alters? In Verbrauchereinstellungen zu Functional Food - Arbeitsbericht des Lehrstuhls für Agrarmarketing Kiel 16

Schiffman, S. (2000) The Use and Utility of Glutamates as Flavoring Agents in Foods. Intensification of Sensory Properties of Foods for the Elderly American Society for Nutritional Sciences, S927-930 v. Ribbeck (2005) Verbrauchereinstellung und Nachfrage aus der Sicht der Hersteller und des Handels, in: Functional Food – Forschung, Entwicklung und Verbraucherakzeptanz, Bericht der Bundesforschungsanstalt für Ernährung und Lebensmittel 1, S19-34

Vera M.S. et al. (1995) Development of products for the elderly population: vitamin enriched pudding Archivos Latinomeriacanos de Nutrici 45, S63-S66

Witting de Penna, E. et al (2002) Optimization of a spaghetti formula enriched with dietary fibre and micronutrients for elderly people Archivos Latinomeriacanos de Nutrici 52, S91-100

Witting de Penna, E. et al (2003) Chemical and sensory characterization of cakes enriched with dietary fibre and micronutrient for the elderly Archivos Latinomeriacanos de Nutrici 53, S74-83

Wouters-Wesseling W. et al. (2002) Study of the effect of a liquid nutrition supplement on the nutritional status of psycho-geriatric nursing home patients European Journal of Clinical Nutrition 56, S545-S251.

Zammer, C. (2003) How to keep boomers booming Wellness Foods Europe, June 2003, S18-21

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5 Study of dietetics- The institutionalised elderly 5.1 Introduction The following is a review of recent literature, dating back as far as 1993, concerning the study of dietetics specifically relating to the elderly, especially those in residential care institutions & hospitals. The purpose of this review is to prevent the repetition of work, consolidating scientific research efforts to optimise the rate of development in the field. It is widely accepted that the American Journal of Dietetics has been responsible for the vast majority of publications in this area across the reviewing period; however, many other sources are highlighted in this review, having contributed some valuable work. The main advances in the discipline concerned have been: 1) the identification of factors other than diet, which affect the nutritional intake of older members of the community; 2) the identification of specific nutritional requirements of the elderly and how these evolve with time and differ with lifestyle; and 3) an increased understanding of the physical impairment of the senses, which affect nutrient intake, leading to the onset of dementia. These factors are heavily themed across the papers in this review. 1) The success of development policy depends on the ability to successfully anticipate the response of individuals to changing incentives. Often, however, actual responses differ from anticipated responses. One important reason for this divergence is a poor understanding of how rights, responsibilities, and resources are allocated within institutions such as the household. The insights derived from intra-household research between the late 1970s and the mid-1980s on the determinants of food and nutritional status served as an important catalyst for the general development of the intra-household approach to development policy analysis. Despite serving as a building block for the wider study of intra-household resource allocation, there has not been an in-depth review of sex and gender differences in the food consumption and nutrition literature in the past 10 years. One of the papers in this review seeks to fill this gap. In addition, the paper undertakes a review of the gender and poverty literature, because economic access to food is so fundamental to food security and nutrition, (Haddad, L. et. al. 1996). 2) Another review included considered here, (Beaty, E.R.A, et. al. 2004), illustrates the selection of current research and resources in geriatrics, listing conferences, websites, journals, books, multimedia CD-ROM’s and governmental institutes associated with nutrition of the elderly over the last decade. This, along with selected papers from this review, identifies a research focus in identifying, more specifically, how nutritional requirements differ with age. 3) The deterioration of sight, taste, olfactory senses and tactility have been shown to reduce nutrient intake in patients as young as 50, as has been linked with malnutrition and,

100 Nutri-Senex: State of the art report – task 2.1 more recently, dementia, (Pelchat 1996; Haddad et. al. 1996; Wells et. al. 2003; Shenkin 2004; Russel & Cox 2003; Kendal 2003). The aim, here is to provide an essential guide to the research literature of the past decade.

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5.2 Key Government Documents – UK / England

National Service Framework for Older People. Department of Health. (2001) Crown copyright

This document sets out how the NHS and social care aims to ensure that older people gain the maximum benefit from their medication to maintain or increase their quality and duration of life and do not suffer unnecessarily from illness caused by excessive, inappropriate, or inadequate consumption of medicines

National Minimum Care Standards - Care Homes for Older People. Department of Health (2000) Crown copyright

LASSL (99) 20: National standards for residential and nursing homes for the elderly: consultation document Department of Health (1999). A statement of national minimum standards published by the Secretary of State for Health under section 23(1) of the Care Standards Act 2000. February 2003 This document contains a statement of national minimum standards published by the Secretary of State under section 23(1) of the Care Standards Act 2000. The statement is applicable to care homes (as defined by section 3 of that Act), which provide accommodation, together with nursing or personal care, for older people. The statement is accompanied, for explanatory purposes only, by an introduction to the statement as a whole, and a further introduction to each group of standards. Each individual standard is numbered and consists of the numbered heading and numbered paragraphs. Each standard is, for explanatory purposes only, preceded by a title and an indication of the intended outcome in relation to that standard. http://www.dh.gov.uk/assetRoot/04/03/43/68/04034368.pdf

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Seeking consent – working with older people. Department of Health, (2001). Crown Copyright.

Aimed at those involved in the treatment or care of older people, this DH booklet provides legal and best practice guidance on seeking consent from those in their care. Part one focuses on the appropriate procedures for seeking consent from those who are able to give it. It examines the nature of consent and the concept of 'capacity'. It also details the type of information people are likely to require in order to make an informed consent decision. Part two considers what should be done when a person is incapable of giving or refusing consent. It explains the use of 'advance directives' and how a person's 'best interests' can be determined. As in the previous section, a brief practical example is used to illustrate a typical scenario. Section three covers consent to involvement in research. The final section deals with decisions concerning withdrawing or withholding life-prolonging treatment.

National diet and nutrition survey. People aged 65 years and over. Volumes 1 & 2 Department of Health, (1998). Crown copyright. Stationery Office Publication.

National diet and nutrition survey people aged 65 years and over - Vol 1Author: Survey on behalf of the Ministry of Agriculture, Fisheries and Food and the Departments of Health Crown Copyright. The survey was designed to meet the aims of the NDNS program in providing detailed information on the current dietary behavior and nutritional status of people aged 65 years and over (older adults) in Great Britain, both living in the community and in institutions. Each group was designed to contain equal numbers of men and women when divided into age groups 65 years and 75-84 years. For the 85+ group there were more women. Amongst the facts collected are a four-day dietary record, socio-economic status and background health with tests to establish physical condition and mental states. Oral health was recorded and reported separately. The purpose and methodology of this survey are described in details before the consumption of feed and drink is examined as energy intake, protein, carbohydrates, alcohol, fats, vitamins and minerals. The anthropometric ratios, socio-economic patterns and regional differences are studied. Each chapter presents the results in text, cites references then provides tabulated and /or graphical statistics. Twenty appendices give additional information.

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National Service Framework for Coronary Heart Disease. Ann. Clin. Biochem. (2001); 38: 159-161 Department of Health (2001) Guidelines for the diagnosis & treatment of Coronary Heart Disease.

NHS Cancer Plan. Department of Health. (2000). A plan for reform of cancer diagnosis & treatment. http://image.guardian.co.uk/sys-files/Society/documents/2003/08/26/cancerplan.pdf

National Service Framework for Diabetes. Department of Health (2001) www.doh.gov.uk/nsf/diabetes

Better Hospital Food. Department of Health. (2001) Proceedings of 3 national conferences entitled `Better Hospital Food`. www.betterhospitalfood.com

NICE guidelines on pressure ulcer risk management and prevention. Royal College of Nursing (2003) Guidance for the prevention of pressure sores. www.doh.gov.uk

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5.3 Key Government Documents – Scotland

Expert group on health of older people report: Adding life to years. The nutrition of elderly people & nutritional aspects of their care in long term care settings The British Dietetic Association. Nutrition Advisory Group for Elderly People (2003)

The NAGE reference list has been updated in 2003. It contains key references to research and publications in nutritional issues affecting the older person. In the past the NAGE reference list has included details of research papers relating to different clinical areas. As research is constantly being published and undertaken it is very difficult to keep this information up to date. Therefore, useful sources of obtaining research information have been included in this document, rather than research literature itself. http://www.bda.uk.com/Downloads/nagereferencelist.pdf

The Scottish Health Plan “Our national health: A plan for action, a plan for change” Royal Pharmaceutical Society (2001) http://www.rpsgb.org.uk/scotland/pdfs/scotrespplan.pdf

Promoting nutrition for older adult in-patients in NHS hospitals in Scotland. British Dietetic Association - National Nursing, Midwifery and Health Visiting Advisory Committee. (2002). http://www.bda.uk.com/Downloads/nagereferencelist.pdf

Nutrition for physically frail older people. Nursing and Midwifery practice development unit. (2002) The Nursing and Midwifery Practice Development Unit (NMPDU) was established in January 2000 to support the identification, dissemination and implementation of best practice across Scotland. http://www.nmpdu.org/projects/bpstatements/ELD.PDF

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Nursing home Scotland core standards for nutritional care. Scottish Executive(1999). The White Paper "Designed to Care" set out a new vision for the National Health Service in Scotland based on co-operation rather than competition. This applies not only within the NHS in Scotland, but across the boundaries between health and the other agencies, which affect people's lives. Providing care in the community is one of the areas where the collaborative approach pays dividends in terms of improved care, as NHS and local authorities work closely together in the interests of providing, responsive, comprehensive and high quality packages of care for individuals. Modernising Community Care: An Action Plan published on 26 October 1998 developed this concept further and underlined the commitment to encourage and improve more effective joint working between agencies at the strategic, service organisation and service delivery levels. The Action Plan also sets out ways in which agencies can work on an integrated basis to secure better results for those who use community care services by focusing on better, quicker decision making, partnership working, and helping more people get care at home. http://www.scotland.gov.uk/library2/doc07/nhsar-07.htm

NHS Quality Improvement Scotland,

Food, Fluid and Nutritional Care in Hospitals Standards (2003) http://www.nhshealthquality.org/nhsqis/

The Nursing and Midwifery Practice Development Unit

Standing Nursing and Midwifery Advisory Committee (SNMAC) (2001)

This report by the Standing Nursing and Midwifery Advisory Committee (SNMAC) examines major deficits in the standards of nursing care given to older patients in acute hospitals, with some of their most fundamental needs remaining unmet and highlights areas of practice, leadership and education that need attention. This document is in PDF, which requires Adobe Acrobat Reader. Published and made available on the Web by the Department of Health. http://www.nmpdu.org/nmpdutemplate.pdf

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5.4 Other Key Publications

(2001). Withdrawing and withholding life-prolonging medical treatment. BMJ books. 2nd Edition.

Thomas, B (2001) Manual of Dietetic Practice. 3rd Edition. Blackwell Science.

(2000). Food for Thought. Alzheimers’ Society.

(1999). Guidelines of Practice for residents with diabetes. Care Homes. The British Diabetic Association.

(1995). Eating well for older people. Caroline Walker Trust.

(1998). Eating well for older people with dementia. VOICES.

Bond, S (1997). Eating Matters. University of Newcastle.

Mengham, H; Thomas, S (2002). Eating for health in care homes – A practice nutrition handbook. The Royal Institute of Public Health.

Copeman, J (1999) Nutritional care for older people. Age Concern.

Crawley, H (2002). Food, drink and dementia.

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5.5 Other Key Websites For other key websites, please see the NAGE links on the BDA website. (www.bda.uk.com). These include:

Age Concern www.ace.org.uk

Alzheimer’s Society www.alzheimers.org.uk

Alzheimer’s Research Society www.alzforum.org

American Dietetic Association www.eatright.org

British Geriatrics Society www.bgs.org.uk

Dietbetes UK www.diabetes.org.uk

Help the Aged www.helptheaged.org.uk

Scottish Nutrition and Diet Resources Initiative www.sndri.gcal.ac.uk

Stroke Centre www.strokecenter.com

Dysphagia www.dysphagiaonline.com

British medical journal www.bmj.com

Caroline Walker Trust www.cwt.org.uk

Health and Age www.healthandage.com

European stroke initiative www.eusi_stroke.com

Department of Health www.doh.gov.uk

Dementia Services Development Centre www.stir.ac.uk/dsdc

108 Nutri-Senex: State of the art report – task 2.1

5.6 Primary Papers

Nutritional status of older people in long term care settings: current status and future directions

Cowana, D.T. et. al. (2004) International Journal of Nursing Studies 41 (2004) 225–237 Ageing and Health Section, Florence Nightingale School of Nursing and Midwifery, King’s College London.

Despite being preventable and treatable, in the 21st Century, malnutrition remains a problem in the developed world and the nutritional needs of many older people in long-term care settings are not met. The UK government has pledged to provide high-quality care for this sector of the population, including minimum standards to ensure adequate nutrition. However, research is still needed into the detection, prevalence, cause and effects of malnutrition and maintenance of optimum nutrition; and to address the lack of training and education among those caring for older peoples. In the interim, simple measures such as monitoring older people’s weight regularly need to be implemented as a surveillance measure of nutritional status. r 2003 Elsevier Ltd. All rights reserved.

Continued Need for Increased Emphasis on Aging in Dietetics Education

Rhee, L.Q. et. al. (2004), Journal of the American Dietetics Association. 2004;104:645-649.

This study examined the content on aging in dietetics curricula via the Internet and a follow- up questionnaire. Only 14% to 15% of programs were not online. The 203 undergraduate and 88 graduate program Web sites listed 44 (22%) undergraduate and 39 (44%) graduate courses in aging. However, more maternal and child courses were listed. The number of undergraduate aging courses was similar to the 20% reported in 1989, although methodologies differed among the studies. Life cycle and community nutrition courses had the most aging content. More than half of program directors were not satisfied with the aging curriculum content. Integrating aging material into existing courses was the most acceptable way of increasing aging content. The common barriers were “curriculum already full” and “lack of faculty expertise.” As the nation’s changing demographics are reshaping the dietetics marketplace, a greater emphasis on aging would enable students to be more effective in serving this booming population.

109 Nutri-Senex: State of the art report – task 2.1

Continued Concern About Nutritional Supplements and Cognitive Function in the Elderly

Shenkin, S.D. et. al. (2004) Nutrition 20:336, 2004 ©Elsevier Inc., 2004. Printed in the United States. All rights reserved. Department of Psychology, University of Edinburgh, Edinburgh, UK

We were interested to see the continued debate on Dr. Chandra’s article concerning supplementation and cognitive function. We agree with the concerns raised by Roberts and Sternberg. We did not reply to Dr. Chandra’s response to our letter as it is a convention that readers draw their own conclusions from a letter and the author’s reply to it. However, having been prompted to respond, we are still not satisfied that Dr. Chandra has answered our main point regarding the MMSE score.

2004 Call for Abstracts from the ADA

2004 the American Dietetic Association

You are invited to submit an abstract for review and presentation at the American Dietetic Association (ADA) Food & Nutrition Conference & Expo (FNCE) in Anaheim, California on October 2-5, 2004.

The Resources for Enhancing Alzheimer's Caregiver Health (REACH): Project Design and Baseline Characteristics*1

Wisniewski, S.R. et. al. (2003) Psychology and Aging Volume 18, Issue 3 , September 2003, Pages 375-384 Copyright © 2003 American Psychological Association.

The Resources for Enhancing Alzheimer's Caregiver Health (REACH) project was designed to test promising interventions for enhancing family care giving for persons with dementia. The purpose of this article is to describe the research design, interventions, and outcome measures used in REACH and to characterize the sample recruited for the study. Nine interventions and 2 control conditions were implemented at 6 sites; 1,222 dyads were randomly assigned to an intervention or a control condition. The caregiver sample was 18.6% male with an average age of 62.3 years (56% Caucasian, 24% Black, and 19% Hispanic). Caregivers reported high levels of depressive symptoms and moderate burden. Care recipients were older, with a mean age of 79, and were moderately to severely impaired with mean Mini-Mental State Exam scores of 13/30.

110 Nutri-Senex: State of the art report – task 2.1

Effects of two models of nutritional intervention on homebound older adults at nutritional risk

Kretser A.J. et. al. (2003) Journal of the American Dietetic Association. 2003;103:329-336.

To test the feasibility of two models of home meal delivery with Meals-on-Wheels (MOW) applicants who were identified as being malnourished or “at-risk” as determined by the validated Mini Nutritional Assessment (MNA). A 6-month, prospective comparative study of two nutrition intervention models with data collection at baseline, 3 months, and 6 months. Randomized treatment assignment was followed, with a few exceptions linked to particular client circumstances. A total of 203 older adults (age range_60 to 90 years) newly applying for homebound meal service were enrolled. At baseline, the body mass index (BMI) was 26.3_7.2 (mean_SD) in the “Traditional” MOW model (101 subjects including 30 malnourished), and the BMI was 27.6_9.0 in the “New” MOW model (102 subjects including 26 malnourished) (P_ns). Study participants received either the Traditional MOW program of five hot meals per week, meeting 33% of the Daily Reference Intake (DRI) or the restorative, comprehensive New MOW program of three meals and two snacks per day, 7 days a week, meeting 100% of the DRI. Assessments were conducted in the home of the participants. The MNA was used to evaluate nutritional risk and status of participants at baseline, 3 months, and 6 months. Standardized functional impairment scales, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL) evaluated limitations in activities of daily living and life management skills. Comparisons between treatment groups were calculated with t tests or Wilcoxon rank-sum tests when appropriate. Comparisons among time periods between treatment groups were conducted with repeated measures analysis of variance. A general linear model was used to evaluate the relationship between change in functional status and BMI, controlling for sex. The New MOW group gained significantly more weight between baseline and 3 months than did the Traditional MOW group (2.78 lb vs _1.46 lb, respectively, P_.0120) and again between baseline and 6 months (4.30 lb vs _1.72 lb, respectively, P_.0004). MNA improved faster in the New MOW group. Functional change appeared to be related more to BMI and age than to treatment intervention. The malnourished participants in both groups took longer to affect positive change in nutrition measurements, with the New MOW group showing the most improvement over the 6-month measurement period. Both delivery models were well accepted. Applicants for home meal delivery have varying nutrition needs. By addressing nutritional risk, interventions can be targeted to meet these needs. A new, restorative, comprehensive meal program improved nutritional status and decreased nutritional risk and can possibly impact independence and functionality.

111 Nutri-Senex: State of the art report – task 2.1

Review Article: State of the Art in Geriatric Rehabilitation. Part II: Clinical Challenges

Wells, J.L. et. al. (2003) American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 2003;84:898-903.

To examine common clinical problems in geriatric rehabilitation and to make recommendations for current practice based on evidence from the literature. A CINAHL database and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search was completed by using the Cochrane database. One author reviewed the references for relevance and another for quality. A total of 336 articles were considered relevant. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports on a small number of patients. The following areas were the major geriatric rehabilitation subtopics identified in the search: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. This article focuses on the latter 5 subtopics. The literature was reviewed by using a level-of-evidence framework. Level 1 evidence was a randomized controlled trial (RCT) or meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts, descriptive studies, or reports of expert committees. Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic according to the level of evidence in the specific area. In cases in which several articles were written on a topic with similar conclusions, we selected the articles with the strongest level of evidence, thereby reducing the total number of references. Frail older patients with hip fracture should receive geriatric rehabilitation. They should also be screened for nutrition, cognition, and depression. Older persons should receive nutritional supplementation when malnourished. If severe dysphagia occurs in stroke patients, gastrostomy tube feeding is superior to nasogastric tube feeding.

112 Nutri-Senex: State of the art report – task 2.1

Nutritional Supplements and the Quest to Improve Human Performance—the Need for the Strictest Standards and Rigor When Reporting Clinical Trials

Meguid, M.M et. al. (2003). Nutrition 19:955–956, 200 Elsevier Inc., 2003. All rights reserved.

Inherent in the concept of nutrient supplementation is that a deficiency exists. The addition of the specific nutrient, or combination of nutrients, addresses a deficiency so that human performance is normalized or even enhanced. The quest to improve mental and physical performance, even in the absence of a recognizable or diagnosable deficiency, is as old as mankind. In the hieroglyphic records of the Ptolemaic Dynasty, evidence exists of a pharaoh specifically eating grapes in the belief that this would enhance his performance.1 Similar evidence comes from the Greeks who ate a variety of different foods to enhance their performance during the early Olympics. A glance at the shelves of present-day drugstores, chemists, convenience stores, and supermarkets attests to the strong societal acceptance of nutritional supplements of every type. The thriving health food industry and the constant subliminal or overt reinforcement of this message by the media further underscore the conventional wisdom that supplementing one’s diet with compounds, ranging from vitamins to herbs to single macronutrients, provides the consumer with a performance advantage, in addition to generating a billion dollar market. However, because the oral ingestion of these products is classified as a “food” and not a drug, the U.S. Food and Drug Administration does not require efficacy data to supplement the manufacturers’ often exaggerated claims. The implications are discussed.

Can Nutrient Supplements Improve Functional Outcome in the Elderly?

Chandra et. al. (2003). Nutrition Volume 19, Numbers 11/12, 2003 doi:10.1016/S0899- 9007(03)00025-X

It is surprising that Roberts and Sternberg find no merit at all in our studies; they have no positive comments to make, none whatsoever. They “doubt everything in it [the Nutrition paper]” and extend their paintbrush approach to the Lancet paper. The two papers were reviewed by a number of referees and statisticians before the journals accepted and published them. Their statements by themselves question the scientific objectivity of Roberts and Sternberg and point to an obvious bias on their part; there may well be a conflict of interest involved.

National Institutes of Health Conference: Dietary Supplement Use in the Elderly. Bethesda, Maryland, USA January 14 – 15, 2003

113 Nutri-Senex: State of the art report – task 2.1

Glade, M.J. (2003). Nutrition Volume 19, Numbers 11/12, 19:981–987, 2003

The National Institutes of Health (NIH) convened a conference on “Dietary Supplement Use in the Elderly” to consider the social, political, and scientific issues associated with the recognition that the frequency of consumption of dietary supplements among the elderly is high when compared with the general population. According to results from the Third National Health and Nutrition Examination Survey (NHANES III) conducted between 1988 and 1994, 56% of middle-age and older adults consume at least one supplement on a daily basis. The amount of scientific evidence supporting the safety and benefits of dietary supplements among the elderly differs according to the nature and form of the supplement. Not all supplements are safe, and the inappropriate consumption of some supplements can result in adverse health consequences. Inconsistencies in the safety and effectiveness of dietary supplements have arisen in some cases as a result of a lack of manufacturing standards. Scientific evidence demonstrating the safety and benefits of dietary supplements can be weak. As a consequence, concerns exist regarding supplement consumption in the elderly population: 1) prescription drugs may interact with dietary supplements (although the NIH is satisfied that there are few, if any, interactions with non-prescription medications); 2) a few platelet-inhibiting dietary supplements may produce perisurgical complications; 3) there have been reports of contamination of preparations; and 4) some manufacturers have been guilty of mislabeling their products. The goal of this conference was the development of a research program that will focus on dietary supplements and the elderly. Critical issues examined during the conference included:

• The stimulus of the physiologic changes that result from aging to increase dietary supplement consumption. • Data on dietary supplement consumption: Which segments of the elderly population are consuming which supplements? Under what circumstances are the supplements being consumed and what are the attitudes and beliefs influencing supplement consumption? • Age-related changes in physiology and their effect on the bioavailability of nutrients and other bioactive substances. • Identifying data gaps related to dietary supplement consumption in the elderly in relation to safety, efficacy, and various types of interactions. • Evaluation of current justifications for use, including: ƒ The roles of diet and dietary supplements in meeting the national health goals for the elderly. ƒ The need for supplements in the maintenance of health and wellness.

114 Nutri-Senex: State of the art report – task 2.1

ƒ Effects of dietary supplement consumption in the elderly on risk factors for chronic diseases.

Meals and snacks among elderly self-managing and disabled women

Anderssona, J, et. al. (2003). Appetite 41 (2003) 149–160. Elsevier Ltd. All rights reserved.

The aim of this study was to describe the frequency and distribution of self-managing and disabled elderly women’s eating events, as well as to investigate which definition/names the women had given their different eating events and to categorise these into meals and snacks. An additional aim was to study the composition of meals and snacks, and analyse the nutritional significance of these eating events in terms of energy and macronutrients. Elderly women, both self-managing ðn ¼ 139Þ and disabled (n ¼ 63; with Parkinson’s disease, rheumatoid arthritis or stroke), aged 64–88 years, and living at home participated. A repeated 24 h recall and an estimated food diary for three consecutive days were used. The eating events defined by the women that were categorised as meals contributed 74% of the total daily energy intake, while snacks contributed 22–23%. The meals that the women had defined as dinner, was the most energy dense meal. The frequency of eating events not defined by the women, was 30–34%, but contributed only 3–4% of the total daily energy intake. The disabled women had a significantly lower energy content in meals and most snacks, compared to the self-managing women. The main conclusion was that elderly women still living at home had their meals distributed during the day and that these meals were characterised by individuality and flexibility.

115 Nutri-Senex: State of the art report – task 2.1

Hedonic tests in different locations as predictors of apple juice consumption at home in elderly and young subjects

Kozlowskaa, K, et. al. (2003). Food Quality and Preference 14 (2003) 653–661. 2003 Elsevier Ltd. All rights reserved.

The objective of this study was to evaluate the predictive value of hedonic tests on apple juice carried out in a sensory laboratory, University common room and at home (post- consumption test) on ad libitum home consumption measured over 5 consecutive days. Thirty-five elderly volunteers (59–88 years old) and 33 young subjects (20–30 years old) assessed the degree of liking five apple juices varying in sweetness (0, 2, 4, 7 and 10% w/w sucrose added) on a nine-point hedonic scale. Both age groups judged similarly the juice with the lowest sugar concentrations, whereas the juice with 2% sugar added received lower scores from the elderly compared to the young participants. Those samples with higher sweetness (4, 7 and 10%) received higher scores from the elderly compared to the young people. The sample with no sugar added had higher mean score (all the subjects) in the home test (6.92 1.78) compared to both laboratory (5.51 2.15) and common room (5.92 2.08). No such differences were observed for the juices with the other sugar contents. In the elderly group, 1-day intake of apple juice remained on a similar level, regardless of sweetness liking, while among young adults the intake varied, and was highest for juices that were liked most (with 0 and 2% sucrose added). The results showed that hedonic ratings have a limited value as predictors of fruit juice consumption at home. The correlation between rated degree of liking and intake was low, especially for the elderly (r=0.39), indicating that factors other than pleasantness may affect intake. Among three test conditions, the lowest correlation of juice intake was obtained with laboratory test results (r=0.38), relatively higher—when hedonic tests were conducted in common room setting (r=0.49), or as the post-consumption test at home (r=0.73). Further research is required on sensory procedures relevant for the elderly, which together with some other non-sensory factors, would give a better prediction of consumption.

116 Nutri-Senex: State of the art report – task 2.1

Position of the American Dietetic Association and Dieticians of Canada: Vegetarian diets

Journal of the American Dietetic Association, (2003) 2003;103:748-765.

It is the position of the American Dietetic Association and Dieticians of Canada that appropriately planned vegetarian diets are healthful, nutritionally adequate, and provide health benefits in the prevention and treatment of certain diseases. Approximately 2.5% of adults in the United States and 4% of adults in Canada follow vegetarian diets. A vegetarian diet is defined as one that does not include meat, fish, or fowl. Interest in vegetarianism appears to be increasing, with many restaurants and college foodservices offering vegetarian meals routinely. Substantial growth in sales of foods attractive to vegetarians has occurred, and these foods appear in many supermarkets. This position paper reviews the current scientific data related to key nutrients for vegetarians, including protein, iron, zinc, calcium, vitamin D, riboflavin, vitamin B-12, vitamin A, n-3 fatty acids, and iodine. A vegetarian, including vegan, diet can meet current recommendations for all of these nutrients. In some cases, use of fortified foods or supplements can be helpful in meeting recommendations for individual nutrients. Well-planned vegan and other types of vegetarian diets are appropriate for all stages of the life cycle, including during pregnancy, lactation, infancy, childhood, and adolescence. Vegetarian diets offer a number of nutritional benefits, including lower levels of saturated fat, cholesterol, and animal protein as well as higher levels of carbohydrates, fibre, magnesium, potassium, folate, and antioxidants such as vitamins C and E and phytochemicals. Vegetarians have been reported to have lower body mass indices than non- vegetarians, as well as lower rates of death from ischemic heart disease; vegetarians also show lower blood cholesterol levels; lower blood pressure; and lower rates of hypertension, type 2 diabetes, and prostate and colon cancer. Although a number of federally funded and institutional feeding programs can accommodate vegetarians, few have foods suitable for vegans at this time. Because of the variability of dietary practices among vegetarians, individual assessment of dietary intakes of vegetarians is required. Dietetics professionals have a responsibility to support and encourage those who express an interest in consuming a vegetarian diet. They can play key roles in educating vegetarian clients about food sources of specific nutrients, food purchase and preparation, and any dietary modifications that may be necessary to meet individual needs. Menu planning for vegetarians can be simplified by use of a food guide that specifies food groups and serving sizes.

117 Nutri-Senex: State of the art report – task 2.1

A computerised adaptation of the repertory grid methodology as a useful tool to elicit older consumers’ perceptions of foods

Russell, C.G., Cox, D.N, (2003). Food Quality and Preference 14 (2003) 681–691 Elsevier Ltd. All rights reserved. CSIRO Health Sciences and Nutrition, PO Box 10041 Adelaide BC, SA 5000, Australia

With an ageing population in industrialised countries, there is a need to understand older consumers’ perceptions of foods in order to improve marketing and maintain nutritional status. Individual interviews may be a preferred elicitation method but are time-consuming to administer and analyse. A computerised adaptation of the repertory grid methodology (RGM) was utilised to elicit older consumers (65–75 years, n=48) perceptions of 14 meat and fish products. Generalised Procrustes and w2 analysis found some differences in perceptions (P<0.01) by gender. Consequently two product maps were produced characterising perceptions, with two explainable dimensions on each map characterised, generally, as ‘processed’–‘good quality’ and ‘light’/‘healthy’–‘heavy’/ ‘fatty’. A cross-modality task and further analysis found no evidence of differences in responses according to computer mouse inexperience (52%). Hence, with meaningful results obtained, a computerised adaptation of RGM was considered an appropriate method to use with older consumers.

Strengthening the role of nutrition and improving the health of the elderly population

Thorpe, M, (2003). Journal of the American Dietetics Association doi: 10.1053/jada.2003.50077

By providing opportunities for social contact and improved nutritional intake, the Elderly Nutrition Program is designed to delay the premature institutionalization of the elderly. Home- delivered meal programs, such as Meals on Wheels, greatly contribute to maintaining quality of life in the elderly population and also in delaying costly institutionalization. As a consultant dietician and president and owner of Steffen and Associates, Inc, a company that provides dietary and nutritional consultation to long-term care facilities, psychiatric facilities, group homes, and congregate feeding programs, Marolyn Steffen, RD, has a great deal of experience with the elderly patients. The preceding study, “The effects of two models of nutritional intervention on homebound older adults at nutritional risk,” tests the feasibility of a Traditional Meals on Wheels program (5 hot meals/week meeting 33% of the Daily Reference Intake) and a restorative, comprehensive new Meals on Wheels program (3 meals and 2 snacks/day, 7 days/week meeting 100% of the Daily Reference Intake). Steffen finds

118 Nutri-Senex: State of the art report – task 2.1 this study to confirm “that providing adequate nutrition to a homebound elderly population will improve their health and functional status.”

Effectiveness of Service Learning and Learning through Service in Dietetics Education.

Kim, et. al. (2003). Journal of Allied Health; 32, 4. p275-278 (4)

Positive assessments of service learning as a teaching methodology have stimulated colleges and universities to adopt service learning in their curricula. This study was undertaken to determine whether service learning could be implemented effectively as a teaching methodology in dietetics education. A total of 49 undergraduate students who were enrolled in Nutrition for the Aging course participated in a service-learning project. During 5 weeks of the service-learning project, students interacted with and assisted clients of the federal Elderly Nutrition Program (Title IIIc). Orientation to the project, reflection on the experience, and evaluation were important components of this project. Evaluation indicated that service learning was an effective teaching method in the dietetics curriculum. Students reported that they were able to integrate the classroom content with real-life experience and learned more while doing so. Service learning had a positive effect on learning by bringing additional personal, professional, and spiritual context to the subject content taught in the classroom and on an understanding of community resources and needs.

Document Type: Research article ISSN: 0090-7421 SICI (online): 0090-7421(20031201)32:4L.275;1- Publisher: Association of Schools of Allied Health Professions

Food handling behaviours of special importance for pregnant women, infants and young children, the elderly, and immune-compromised people.

Kendall et. al. (2003). Journal of the American Dietetic Association 103, 12. p1646 – 1649 (4)

This study used a Web-based Delphi process with a group of nationally recognized food safety experts to identify food-handling behaviours of special importance in reducing the risk of food-borne illness among pregnant women, infants and young children, elderly people, and people with compromised immune systems because of disease or pharmacologic therapy. Behaviours were related to 13 pathogens. Top-rated behaviours for pregnant women were associated with Listeria monocytogenes, Toxoplasma gondii, and Salmonella

119 Nutri-Senex: State of the art report – task 2.1 species. Top-rated behaviours for infants and young children, elderly people, and immune- compromised people were associated with a number of different pathogens. The results should help dietetics professionals and community health educators focus their efforts on those behaviours of special importance to the population being targeted.

Language: English Document Type: Research article ISSN: 0002-8223 DOI (article): 10.1016/j.jada.2003.09.027 SICI (online): 0002-82231031216461649 Publisher: Elsevier Science Copyright 2001 Elsevier Science B.V., Amsterdam.

Preliminary experience of allied health assessments delivered face to face and by videoconference to a residential facility for elderly people.

Guilfoyle et. al. (2003). Journal of Telemedicine and Telecare 1 August 2003, vol. 9, no. 4, pp. 230-233(4). Blue Care, Brisbane, Australia, Centre for Online Health, University of Queensland, Brisbane, Australia

We investigated whether allied health assessments carried out via videoconferencing were comparable to assessments carried out face to face. Five allied health therapists (in dietetics, occupational therapy, physiotherapy, podiatry and speech pathology) conducted an assessment of 12 high-dependency residents both face to face and by videoconferencing. On a five-point Likert scale, the therapists' mean ratings for the efficiency and suitability of videoconferencing for assessment were significantly lower than for face to face. Their mean rating for the adequacy of their care plans was also significantly lower for videoconferencing than for face to face. However, in each case the dietician's assessments did not differ significantly between the two modalities. In 35 cases out of 60, two independent raters agreed that the therapists' care plans after the videoconferencing and face-to-face assessments were the same. However, the level of agreement between raters was only moderate (kappa=0.31). Despite the therapists' (natural) preference for face-to-face working, care plans formulated via videoconferencing were reasonably similar to those formulated in face-to-face assessment. Allied health assessments carried out by videoconferencing would therefore seem to be feasible.

DOI (article): 10.1258/135763303322225571 SICI (online): 1357- 633X(20030801)9:4L.230;1- Publisher: Royal Society of Medicine Press

120 Nutri-Senex: State of the art report – task 2.1

Screening of nutritional status in The Netherlands

Kruizenga et. al. (2003) Clinical Nutrition, Volume 22, Issue 2, April 2003, Pages 147-152

In 2001, the Dutch Dietetic Association conducted a national screening on malnutrition. The goal of this screening was to determine the prevalence of disease-related malnutrition in The Netherlands in all fields of medical care and to investigate the involvement of the dietician in the treatment of malnutrition. Eight thousand five hundred and twenty nine patients were screened of which data of 7606 patients could be analysed. Eighty one per cent (6150) of the patients were hospital patients. Eleven per cent (808) of the patients lived in a nursing home. Seven per cent (533) of the patients were home-care patients, who were measured at home or at the general practitioner's office. The origin of 115 patients (2%) was not registered. Age, height, weight, unintentional weight loss, kind of illness and intervention by a dietician were registered. Malnutrition was defined as >10% unintentional weight loss during the past 6 months and risk of malnutrition was defined as 5–10% unintentional weight loss during the past 6 months. Twelve per cent (884) of all patients appeared to be malnourished. Thirteen per cent (962) were at risk of malnutrition and 75% (5760) were well nourished. Fifty four per cent of the malnourished patients were referred to a dietician. Oncological disease was more associated with malnutrition than non-oncological disease (in particular in the head and neck, lung and intestinal areas). Also, non-oncological gastro- intestinal and lung disease patients were often categorised as malnourished. Elderly patients (>75 years) were more at risk of malnutrition. BMI and unintentional weight loss did not correlate well. In this national survey conducted by dieticians, including a convenience sample of mainly institutionalised patients, approximately 25% of patients in all medical fields were categorised as moderately or severely malnourished. About half of these patients were seen by a dietician.

121 Nutri-Senex: State of the art report – task 2.1

The Elderly Nutrition Program - An effective national framework for preventive nutrition interventions.

Millen, et. al. (2002). Journal of the American Dietetic Association. February 2002, vol. 102, no. 2, pp. 234-240(7)

B. E. Millen is a professor at the Boston University School of Public Health and School of Medicine, Boston, Mass, USA. To guide national policy, Congress mandated the 1992 research evaluation of the Elderly Nutrition Program (ENP), the nation's oldest framework for providing community- and home- based preventive nutrition and health-related services to older persons. This article summarizes key findings on the program's influence on nutritional health, the targeting and costs of its nutrition services, and the study's policy implications. The research included a nationally representative sample of ambulatory and homebound ENP participants And a matched sample of non-participants drawn from the US Health Care Financing Administration's Medicare beneficiary listings. Interviews conducted in respondents' homes considered demographic and health characteristics and assessed anthropometry and physical functioning, nutrient intake and socialization patterns, and utilization of ENP program services (participants only). Administrative and service delivery data were gathered from all levels of the ENP infrastructure. The ENP program currently provides congregate and home-delivered meals and other nutrition- and health-related services to about 7% of the older population overall, including an estimated 20% of the nation's poor elders. Compared with non-participants, ambulatory and homebound ENP participants are better nourished (4% to 31% higher mean daily nutrient intakes; P<.001) and achieve higher levels of socialization (17% higher average monthly social contacts; P<.001). Federal spending on ENP nutrition services are efficiently leveraged by funding from other public and private sources, allowing ENP to more than double the nutrition services it provides to program participants. ENP is a well-targeted, effective, and efficient federal program available to dietetics and other professionals for providing elderly persons with community-based and home- delivered nutrition and related services. The ENP infrastructure offers a potential model for preventive nutrition intervention programs in ambulatory and homebound at-risk older populations. J Am Diet Assoc. 2002; 102:234-240. Language: English Document Type: Research article ISSN: 0002-8223 DOI (article): 10.1016/S0002-8223(02)90055-6 SICI (online): 0002-82231022234240 Publisher: Elsevier Science Copyright 2001 Elsevier Science B.V., Amsterdam. All rights reserved.

122 Nutri-Senex: State of the art report – task 2.1

Inadequate Nutrient Intakes Are Common and Are Associated with Low Diet Variety in Rural, Community-Dwelling Elderly

Teresa A. et. al. (2001). Journal of Nutrition. 2001;131:2192-2196. © 2001 The American Society for Nutritional Sciences

Poor dietary habits and inadequate nutrient intakes are of concern in the elderly. The nutritional characteristics of those who survive to become the oldest are not well defined. Our goal was to describe dietary habits, nutrient intakes and nutritional risk of community- dwelling, rural Iowans, 79 y of age and older. Subjects were interviewed (n = 420) using a standardized format on one occasion in their homes and instructed to complete 3-d diet records (n = 261) after the in-home interview. Standardized interviews assessed demographic information, cognitive function and dietary habits (Nutrition Screening Initiative Checklist). Adequate nutrient intake was defined as consumption of the nutrient’s estimated average requirement, 67% adequate intake or 67% recommended dietary allowance. Mean age was 85.2 y, 57% lived alone and 58% were widowed. Subjects completing 3-d diet records were younger, more cognitively intact and less likely to be at nutritional risk than subjects not completing diet records. The percentage of subjects with inadequate intakes of selected nutrients was 75% for folate, 83% for vitamin D and 63% for calcium. Eighty percent of subjects reported inadequate intakes of four or more nutrients. Diet variety was positively associated with the number of nutrients consumed at adequate intakes (r = 0.498), total energy (r = 0.522) and dietary fibre (r = 0.421). Our results suggest that rural, community- dwelling old have inadequate intakes of several nutrients. Recommendations to increase diet variety and consume a nutrient supplement may be necessary for elderly people to achieve adequate nutrient intakes.

123 Nutri-Senex: State of the art report – task 2.1

What does it mean to be “at nutritional risk”? Seeking clarity on behalf of the elderly

Bales, C (2001). American Journal of Clinical Nutrition 2001;74:155–6. © 2001 American Society for Clinical Nutrition

Most clinical nutritionists would agree that in the care of sick or frail elderly patients, nutritional and hydration concerns often rank far too low on the list of evaluation and treatment priorities. In hospitals and nursing homes and in the community, elderly patients may receive a variety of costly and complex medical interventions, eg, extensive drug therapy and mechanical ventilation support, while the routine availability of adequate food and fluids is neglected.

Nutrition and Health Promotion in Older Adults

Chernoff, R, (2001). The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:47-53 (2001) © 2001 The Gerontological Society of America. Geriatric Research Education and Clinical Centre, Central Arkansas Veterans Healthcare System, Little Rock, and Department of Nutrition and Dietetics, University of Arkansas for Medical Sciences, Little Rock During recent decades, the concept of health promotion has become a legitimate part of health care because of the aging of the post-war baby boom generation. As this population ages, the potential strain on health care systems will increase because the greatest use of health care services occurs during the last years of life. In older adults there are many correctable health factors that can be assessed through screening protocols. Hypertension, cholesterol, hearing, vision, diabetes, and cancer screening are well integrated into health promotion programs; nutrition promotion programs are not as well integrated. Reluctance to develop health promotion programs for older adults exists because of a perception that they would not follow such plans or change their lifestyles. However, longitudinal studies have shown that health promotion activities extend the number of years of health in older people although the relationship weakens in older age. Changes in diet and exercise patterns are most effective in the prevention of nutrition-related conditions when they are instituted early in life, but positive effects can occur at any age. If nutritional interventions are instituted early, a substantial reduction in health care expenditures may result from a decrease in the incidence or the delayed onset of these conditions. Changes in behaviours (reducing salt and fat intake) were positively associated with a belief that consuming a healthful diet would contribute to better health. The use of a variety of adult education theories and models will enhance behaviour changes that lead to more healthful habits and enable a health educator to be successful in effecting change.

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The reported use of dietary supplements (sip feeds) in hospitals in Wessex, UK,

Clinical Nutrition, Volume 20, Issue 5, October 2001, Pages 445-449 Brosnan et. al. (2001) on behalf of the Wessex dietetic managers

Aims: To assess the prevalence of the use of supplements (sip feeds) in district general, psychiatric and community hospitals in the former Wessex health region. Method: Cross sectional study of prevalence and determinants of supplement use in 10 district general hospitals (covering medical, surgical, orthopaedic, and elderly specialities), 4 psychiatric hospitals and 3 community hospitals. Results: Overall 14% of patients were being supplemented although the variation across hospitals and specialities was wide (0%–35%); elderly care patients within district hospitals were most likely to be supplemented (20%; range 12–35%). In 34% of patients there was no documented reason as to why supplements were given. 60% of patients were not weighed on admission; 70% did not have a weight history recorded and 83% did not have a current weight recorded. Documentation regarding supplement use appeared to be recorded in an unsystematic manner. Many patients were not being weighed on admission and appeared to have no documentation as to why supplements were given. Given the importance of malnutrition in hospital patients a more evidence based, objective approach to assessing nutritional requirements, intake and support may be beneficial.

Total antioxidant levels, gender, and age as risk factors for DNA damage in lymphocytes of the elderly,

Mendoza-Núñez, et. al. (2001). Mechanisms of Ageing and Development, Volume 122, Issue 8, June 2001, Pages 835-847

During past years, the association of oxidative stress with DNA damage and its possible clinical translation into chronic degenerative illnesses, such as atherosclerosis, cancer, diabetes mellitus and Alzheimer's disease, has been demonstrated. In addition, it has been pointed out that age and gender are factors that influence the generation of DNA damage; however, this is still controversial. We have previously reported the results of a study of 88 subjects older than 60 years of age in whom DNA damage is related with serum levels of total antioxidants. The results of this study demonstrate a greater frequency of DNA damage in elderly persons with normal levels of antioxidants, in addition to males, and in the younger group of subjects, i.e., 60–69 years. In this work, we enlarged our study sample to 160 elderly subjects; in this way, we were able to evaluate the consistency of the influence of

125 Nutri-Senex: State of the art report – task 2.1 total antioxidants, age, and gender on the magnitude and grade of DNA damage in lymphocytes of the elderly. The results demonstrated that 45% of the subjects showed DNA damage, measured by an alkaline unicellular electrophoresis technique (comet assay). Similarly, 62% of the subjects presented low levels of total antioxidant levels measured by a colorimetric method (Randox Kit). A greater percentage of DNA damage was observed in subjects with normal levels of antioxidants (48%) compared with subjects with low levels (43%), although the difference was not statistically significant. The group of subjects 70 years of age or older showed a greater percentage of DNA damage (50%) than the group of subjects of 60–69 years of age (41%). However, the difference was again not statistically significant (P>0.05). With respect to gender, 64% of males and 38% of females had DNA damage with an odds ratio (OR) of 2.86 and a 95% confidence interval (CI) of 1.31–6.32 (P<0.05). In the logistic regression analysis, the interaction of the male sex variables with low antioxidants had an OR of 2.5 (CI 95%, 1.33–4.68; P<0.01). We conclude that the interaction of male sex factors–low levels of antioxidants would justify the indication of antioxidant dietetic supplements.

Screening for Under-nutrition in Geriatric Practice Developing the Short-Form Mini- Nutritional Assessment (MNA-SF)

Rubenstein, et. al. (2001). The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M366-M372 (2001) © 2001 The Gerontological Society of America

The Mini-Nutritional Assessment (MNA) is a validated assessment instrument for nutritional problems, but its length limits its usefulness for screening. We sought to develop a screening version of this instrument, the MNA-SF, that retains good diagnostic accuracy. We reanalyzed data from France that were used to develop the original MNA and combined these with data collected in Spain and New Mexico. Of the 881 subjects with complete MNA data, 151 were from France, 400 were from Spain, and 330 were from New Mexico. Independent ratings of clinical nutritional status were available for 142 of the French subjects. Overall, 73.8% were community dwelling, and mean age was 76.4 years. Items were chosen for the MNA-SF on the basis of item correlation with the total MNA score and with clinical nutritional status, internal consistency, reliability, completeness, and ease of administration. After testing multiple versions, we identified an optimal six-item MNA-SF total score ranging from 0 to 14. The cut-point score for MNA-SF was calculated using clinical nutritional status as the gold standard (n = 142) and using the total MNA score (n = 881). The MNA-SF was strongly correlated with the total MNA score (r = .945). Using an MNA-SF score of 11 as

126 Nutri-Senex: State of the art report – task 2.1 normal, sensitivity was 97.9%, specificity was 100%, and diagnostic accuracy was 98.7% for predicting under-nutrition. The MNA-SF can identify persons with under-nutrition and can be used in a two-step screening process in which persons, identified as "at risk" on the MNA-SF, would receive additional assessment to confirm the diagnosis and plan interventions.

Flavour enhancement of food improves dietary intake and nutritional status of elderly nursing home residents.

Mathey et. al. (2001) Journal Gerontology A Biological Science, Medical Science. Apr;56(4):M200-5.

Taste and smell losses occur with aging. These changes may decrease the enjoyment of food and may subsequently reduce food consumption and negatively influence the nutritional status of elderly persons, especially those who are frail. The objective of this study was to determine if the addition of flavour enhancers to the cooked meals for elderly residents of a nursing home promotes food consumption and provides nutritional benefits. We performed a 16-week parallel group intervention consisting of sprinkling flavour enhancers over the cooked meals of the "flavour" group (n = 36) and not over the meals of the control group (n = 31). Measurements of intake of the cooked meals were taken before and after 8 and 16 weeks of intervention. Appetite, daily dietary intake, and anthropometry were assessed before and after the intervention. On average, the body weight of the flavour group increased (+1.1 +/- 1.3 kg; p <.05) compared with that of the control group (-0.3 +/- 1.6 kg; p <.05). Daily dietary intake decreased in the control group (-485 +/- 1245 kJ; p <.05) but not in the flavour group (-208 +/- 1115 kJ; p =.28). Intake of the cooked meal increased in the flavour group (133 +/- 367 kJ; p <.05) but not in the control group (85 +/- 392 kJ). A similar trend was observed for hunger feelings, which increased only in the flavour group. Adding flavour enhancers to the cooked meals was an effective way to improve dietary intake and body weight in elderly nursing home residents. PMID: 11283191 [PubMed]

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Understanding Needs Is Important for Assessing the Impact of Food Assistance Program Participation on Nutritional and Health Status in U.S. Elderly Persons

Lee, J.S. & Frongillo, E.A. Jr. (2001). Journal of Nutrition. 2001;131:765-773 Division of Nutritional Sciences, Cornell University, Ithaca, New York 14853.) © 2001 The American Society for Nutritional Sciences

This study aimed to assess the impact of food assistance programs on nutritional and health status of nutritionally needy elderly persons. Two cross-sectional and one longitudinal data sets were used: Third National Health and Nutrition Examination Survey (1988–94), Nutrition Survey of the Elderly in New York State (1994) and Longitudinal Study of Aging (1984–1990). Multiple logistic and linear regression analyses were used to examine whether food assistance participants among food insecure elderly (i.e., those whose needs for food assistance programs are met) have better nutrient intake, skin fold thickness and self- reported health status and less nutritional risk, hospitalization and mortality than non- participants (i.e., those whose needs are unmet) and whether the benefit is larger than that among food secure elderly persons. Across three data sets, food insecure elderly persons had poorer nutritional and health status than food secure elderly persons. Contrary to the hypotheses, among food insecure elderly persons, food assistance participants had similar or poorer nutrient intakes, skin fold thickness, nutritional risk, self-reported health status, hospitalization and mortality than non-participants. Food secure participants had similar nutritional and health status as food secure non-participants. Lack of information on the dynamic nature and changes in needs with program participation in the three data sets likely did not allow accurate estimation of the impact of food assistance participation. Different study designs, as well as theory and knowledge of needs that clarifies need status and its change within each older individual across an appropriate time interval, are necessary to accurately assess impacts of food assistance programs.

Guest Editorial, Bitter-Sweet Memories: Truth & Fiction

Wilson, M.M.G, (2001). Journal of Gerontology, Medical Sciences. Vol. 56A, No. 4, M169- M199

Changing trends in the attitudes of health professionals toward geriatric medicine can be attributed in part to the painstaking repetition of basic, yet frequently ignored, geriatric principles. Nevertheless, as gerontology evolves and advances into the new millennium, clinical and academic geriatrics must move beyond the realms of mere syndrome definition. The syndromes of under-nutrition and “anorexia of ageing” are now firmly entrenched as

128 Nutri-Senex: State of the art report – task 2.1 bone fide geriatric problems. The current challenge lies in the precise identification of the pathogenesis of these conditions. Critical appraisal of nutritional therapeutic modalities, utilising objective outcome measures, is a crucial component of this process. This paper addresses some of the issues concerning theories of the satiety in the elderly population.

Ethically Responsible Research

Elsner et. al. (2001). Food Technology. March 2001. Vol. 55, No. 3

As food is the largest industry in most Western nations, the lack of clearly articulated ethical guidelines for all types of food research – not only research related to food safety – is of particular concern. Information for food researchers to ensure appropriate forethought into the systems and control of ethical assurance is needed to assure quality and validity of research, as well as avoid legal difficulties stemming from unethical procedures or results. Although the public opinion of these needs may focus only on specific issues, such as genetically modified foods or nutraceuticals, a broad set of guidelines is necessary.

Language: English Document Type: Research article

Interactive Diffusion of Knowledge about Nutrition to Consumers on the WWW : The Experience of NutriWeb Magazine

Andra et. al. (2001)

The number of consumers who look for information about diets, nutrition and fitness on the Internet is growing steadily. However, according to the American Dietetic Association (ADA)1, TV and magazines are still the main sources of information in this area, with 48% and 47%, respectively; while the Internet represents only 6%. This and other surveys have demonstrated the importance of consumer oriented health publications for defining the behavior in relation to nutrition as one of the factors, which improve their health. www.amia.orgzSzpubszSzsymposiazSzD200357.PDF/interactive-diffusion-of-knowledge.pdf

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Intake and Food Sources of Macronutrients Among Older Hispanic Adults: Association With Ethnicity Acculturation, and Length of Residence in The United States,

Odilia, et. al. (2000). Journal of the American Dietetic Association, Volume 100, Issue 6, June 2000, Pages 665-673

To describe the food intake and food sources of macronutrients in diets of older Hispanic adults in the North-eastern United States and to explore relationships between acculturation, years in the United States, and macronutrient intake. Cross-sectional study using a representative sample of older Hispanic adults and a comparison group of non-Hispanic whites. Subjects/setting Hispanic (n=711) and non-Hispanic white (n=226) persons, aged 60 years and older, residing in Massachusetts. Macronutrient intakes, collected by 24-hour dietary recall, were compared across ethnic groups by means of the general linear models procedure (with Bonferroni adjustments). Associations between macronutrient intake and predictor variables were tested with Pearson correlations and linear regression. The contribution of foods to total intake of macronutrients was determined by use of a rank procedure. Hispanic elderly subjects consumed significantly less saturated fat and simple sugars and more complex carbohydrates than did non-Hispanic whites. Hispanics residing in the United States for a longer time tended to have macronutrient profiles more similar to those of the non-Hispanic whites. Rice for Hispanic and bread for non-Hispanics were the major contributors of energy. More acculturated Hispanic elders consumed fewer ethnic foods and more foods related to the non-Hispanic-white eating patterns than those less acculturated. Efforts to promote better diets among Hispanic elders need to emphasize maintenance or adoption of healthful dietary patterns based on ethnic and modern foods that will satisfy their biological, emotional, and social needs. Dieticians and other dietetics practitioners can use the information presented here in studying nutrition-related chronic diseases, in public health planning, and in nutrition education and promotion efforts directed to ethnic-specific, elderly Hispanic groups. J Am Diet Assoc. 2000;100:665-673.

The food consumption patterns and perceptions of dietary advice of older people.

McKie L. et. al. (2000) Journal of Human Nutrition & Dietetics June 2000, vol. 13, no. 3, pp. 173-183(11)

Prevention policies do not have an upper age limit, and as the overwhelming majority of older people continue to reside in the community there is a growing role for community dietetics and primary care team members in the promotion of healthy eating.

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Method The multi-method project ascertained the dietary beliefs and practices of older people residing in high-income, low-income and rural localities of Scotland. One hundred and fifty-two people aged 75 years and over were interviewed using a semi-structured interview schedule and 24-h food recall questionnaire. An analysis of the food recall questionnaire demonstrated that the diets of the elderly appear to differ little from the Scottish population as a whole. In all groups there was an under consumption of fruits and vegetables reported. Findings from the interviews demonstrated that dietary beliefs were found to be firmly rooted in childhood and lifetime experiences. Participants defined healthy eating as ‘proper meals’, ‘proper foods’, and a variety of foods eaten in moderation. These definitions were based upon the consumption of fresh foods, which would be considered healthy. Changing and conflicting advice on health and nutrition was contrasted with personal experiences. Few knew of the role of the dietician or community dietician. This study demonstrates a contrast between stated beliefs and actual consumption patterns. Access to food, and the cost and quality of foods impacted upon food practices. The role of the community dietician should be promoted. Advice on healthy eating must work with contemporary practices and beliefs building upon positive aspects of diet and eating and involving the food industry, retail sector and health services.

Language: English Document Type: Research article Publisher: Blackwell Publishing. SICI (online): 0952-3871133173183 ISSN: 0952-3871

Food-based dietary guidelines – the Austrian perspective

Koenig, J & Elmadfa, I, (1999). British Journal of Nutrition (1999), 81, Suppl. 2, S31–S35 Institute of Nutritional Sciences, University of Vienna, Althanstrasse 14, A-1090 Vienna, Austria

Presently, no national dietary guidelines – neither food- nor nutrient-based – exist for Austria. Usually, the recommendations of the German Society of Nutrition are used instead. The determination of national characteristics of nutritional behavior and food consumption can reveal starting-points for the improvement of nutritional status in Austria. Seven-day weighed records (children and adolescents, n¼2 173) and 24-h-recalls (adults, n¼2 488) were used for the evaluation of nutrient intake and food consumption. For a sub-sample of children and adolescents, results from laboratory assessment of biomarkers were also available (n¼1 400). Based on fat intake, the age groups were divided into low fat intake (less than 25th percentile¼ 28–34% fat energy) and high-fat eaters (greater than 75th percentile¼38– 45% fat energy). Approximately 75% of the Austrian population has fat intakes above 30% of

131 Nutri-Senex: State of the art report – task 2.1 energy intake, older age groups having a higher prevalence of high fat intakes. Intakes of saturated fatty acids reach 40–46% of total fat. The usual intake of dietary fiber in the Austrian population is between 17–21 g/d; some individuals are able to achieve the recommended intakes for dietary fiber, but do not represent a significant majority of the population. The mean intakes of fruits are clearly higher in children and adolescents (10% of total food intake) than in adults (2–6 %). Differences in the intake of selected nutrients in foods between low and high fat consumers, unexpectedly, did not result in different plasma concentrations of cholesterol, nor did it result in differences in fat-soluble vitamins. Therefore, one of the primary dietary guidelines for Austria should be the reduction of fat consumption, which is also associated with increasing intakes of fruits and vegetables, increasing intakes of dietary fiber and decreasing intakes of cholesterol.

Mini Nutritional Assessment (MNA): Research and Practice in the Elderly

Vellas, et. al. (1999). Nestlé Nutrition Workshop Series Clinical & Performance Programme, Volume 1. Nestec Ltd., 55 Avenue Nestlé, CH–1800 Vevey (Switzerland) S. Karger AG, P.O. Box, CH–4009 Basel (Switzerland)

The prevalence of malnutrition is high in elderly people in hospital, living in nursing homes, or involved in home care programs. Development of malnutrition in the elderly is usually a continuum, starting with inadequate food intakes, followed by changes in body composition and biochemical variables. Consequences of malnutrition often go unrecognized owing to lack of specific validated instruments to assess nutritional status in frail elderly persons. The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a single, rapid assessment of nutritional status in the elderly. The MNA provides primary care physicians with a tool for rapid screening of patients who may subsequently need a more extensive nutritional assessment.

Subjectively Healthy Elderly Consuming a Liquid Nutrition Supplement Maintained Body Mass Index and Improved Some Nutritional Parameters and Perceived Well- Being,

Krondl, et. al. (1999). Journal of the American Dietetic Association, Volume 99, Issue 12, December 1999, Pages 1542-1548

To evaluate regular use of a liquid nutrition supplement by subjectively healthy elderly persons in terms of body mass index, nutrient intake, selected biochemical parameters, and perceived quality-of-life changes, and to identify advantages and limitations of use. A 16-week intervention study in which subjects were assigned randomly to either a supplemented group or a control group and compared in terms of inter-group and intra-group

132 Nutri-Senex: State of the art report – task 2.1 differences in weight, food intake, blood values, and quality-of-life indexes. Adherence to protocol was monitored by monthly visits with an interviewer and food intake records. Seventy-one independent living, older Canadian adults (mean AGE=70±7 years) consuming on average less than 4 servings of fruit and vegetables daily and a supplement-free diet before the study. Subjects were without functional limitations and did not require therapeutic diets or medical treatments that affect nutritional status. Data were collected in home interviews. Blood for analysis was obtained from a sub-sample of 36 subjects. Intervention Inclusion of six 235-mL cans of liquid nutrition supplement weekly into the self- selected dietary patterns of the supplemented group. Results were analyzed by Student t tests or Wilcoxon rank sum test, analysis of variance, and multiple stepwise regression. Body mass index, energy intake, and consumption of fruit and vegetables did not change throughout the study. In the supplemented group, statistically significant increases occurred from baseline to termination of the study in these nutrients: protein, calcium, iron, magnesium, and folate. Serum albumin, folate, ferritin, hemoglobin, and zinc values were within the normal range for the supplemented and control groups. Scores for the Medical Outcomes Study 36-Item Short-Form Health Status scales increased for the supplemented group from baseline to termination for vitality and general health perception. Values for the General Well-Being Questionnaire improved for anxiety and general well-being. Of the dietary predictors, folate intake explained the most variance for vitality and for general well being, 8.6% and 14.2%, respectively. A liquid nutrition supplement could be recommended to the elderly when energy maintenance and increases in nutrient intake are necessary and convenience is an important consideration. Dietetics professionals should address the issues of affordability of the supplement, the role of food in achieving nutritional adequacy, and overall quality of life of clients. Folate intake as a predictor of perceived general well being and vitality requires further investigation. J Am Diet Assoc. 1999;99:1542–1548.

Dieticians' Educational Levels and Beliefs Related to Intentions to Recommend Calcium and Vitamin D Supplements for Osteoporosis Prevention and Treatment,

Folk, et. al. (1999). Journal of the American Dietetic Association, Volume 99, Issue 9, Supplement 1, September 1999, Page A77

The objective of this research was to examine whether registered dieticians' educational levels or beliefs concerning calcium and vitamin D supplementation are related to their intended behaviour in recommending calcium and/or vitamin D supplements to patients for osteoporosis prevention and treatment. A mail questionnaire was used to survey the participants. Three hundred twenty registered dieticians were randomly selected from the

133 Nutri-Senex: State of the art report – task 2.1

American Dietetic Association practice group, Dieticians in General Clinical Practice. One hundred seventy-one surveys (53%) were returned. Composite scores of Likert-type responses were used in the data analysis. Frequencies and percentages were used to examine demographic characteristics of the respondents. Pearson's correlation and one-way analysis of variance were used to assess the relationships between the variables. Most of the respondents (76.6%) agreed or strongly agreed that it is the registered dietician’s responsibility to recommend calcium and vitamin D supplements when indicated. The respondents were more likely to recommend supplements to women than men, less likely to recommend calcium supplements to elderly women than younger women, and more likely to recommend calcium supplements than vitamin D supplements. A significant but moderate correlation (r = 0.57) was found between respondents' beliefs about calcium and vitamin D supplementation and intention to recommend the supplements to patients. No significant correlation was found between educational levels and intended behaviour. Further research to examine additional factors that might influence dieticians' intent to recommend calcium and vitamin D supplements would benefit dieticians, educators and, ultimately, persons with or at risk for osteoporosis.

Preparing Dietetic Interns for the Future: Building a practice Foundation in Geriatric Nutrition

C. Stein & J. Moreschi-Mason, (1999). Journal of the American Dietetic Association, Volume 99, Issue 9, Supplement 1, September 1999, Page A83

The US Census Bureau predicts a dramatic increase of the population aged 65 and older to 20% of the population by 2030. These projections bring concerns about the elderly to the forefront of public health issues. Although the Elderly Nutrition Program (ENP) is a highly successful program, the Administration on Aging identifies future challenges, including addressing the 64% of congregate and 88% of home-delivered meals participants who remain at high or moderate nutritional risk, as assessed by the Nutrition Screening Initiative (NSI). According to the NSI, health care professionals also need education and training in identifying, evaluating, and providing feeding assistance. Consequently, we implemented dietetic internship rotations that assess, provide, monitor, and research nutrition services, including education, to seniors and ENP personnel - in long-term care settings, ENP dining centres, homes for those receiving delivered meals, and through a campus-based Nutrition Education Centre. Evaluative feedback demonstrates improved comprehension of nutrition issues by those served. Interns gain practice in developing and implementing educational models, materials, and evaluation instruments for group education. Individualized counselling experience is gained in varied community-based settings. Interns articulate a broader and deeper understanding of issues influencing the health and nutrition status of the elderly,

134 Nutri-Senex: State of the art report – task 2.1 including psychosocial aspects. Further, feedback indicates that interns are empowered by sense of independence required during these rotations. As a bonus, the utilization of these more diverse sites reduces the need of site usage in traditional health care settings (e.g., hospitals) while meeting vital community needs, an important consideration when several practice programs are located in a similar geographic region. Full access to the curriculum outlining objectives, experiences, and evaluation will be provided.

Nutrition Education and Counselling in Community Settings by Clinical Dieticians as Part of National Nutrition Month Activities

V. Cruz, (1997). Journal of the American Dietetic Association, Volume 97, Issue 9, Supplement 1, September 1997, Page A112

The participant will be able to identify the impact of a community nutrition education program by clinical dieticians. Dade County, FL is a multiethnic, multilingual community with a high percentage of elderly, poor children and recent immigrants. As part of the National Nutrition Month activities, the dieticians of a publicly funded teaching facility serving Dade County were asked to provide nutrition education and counselling in a variety of community settings and agencies. The purpose of this program was to provide services to traditionally underserved sectors of the community and to promote dieticians as nutrition experts. Arrangements were made with community organizations to include churches, battered women's shelters, schools and congregate meal sites, and dieticians were asked to sign up for an activity of their choice. Some of the activities were joint efforts in partnership with the Miami Dietetic Association. Twelve dieticians conducted presentations that reached 633 participants, provided counselling at two sites and participated in one health fair. The dieticians reported feelings of satisfaction with the activities and a good reception by the participants. This program allowed the clinical dieticians to utilize educational skills not frequently called for in clinical settings and enhanced the reputation of the facility in the communities it serves.

Food Security And Nutrition Implications Of Intra-household Bias: A Review Of Literature Haddad et. al. (1996)

The success of development policy depends on the ability to successfully anticipate the response of individuals to changing incentives. Often, however, actual responses differ from anticipated responses. One important reason for this divergence is a poor understanding of how rights, responsibilities, and resources are allocated within institutions such as the household. The insights derived from intra-household research between the late 1970s and

135 Nutri-Senex: State of the art report – task 2.1 the mid-1980s on the determinants of food and nutritional status served as an important catalyst for the general development of the intra-household approach to development policy analysis. Despite serving as a building block for the wider study of intra-household resource allocation, there has not been an in-depth review of sex and gender differences in the food consumption and nutrition literature in the past 10 years. This paper seeks to fill this gap. In addition, the paper undertakes a review of the gender and poverty literature, because economic access to food is so fundamental to food security and nutrition. Why is this an important gap to fill? First, the availability of a series of new food consumption and nutrition studies from the past 10 years affords us an opportunity to get a clearer picture of where intra-household and sex differences in food and nutrition occur. Second, the availability of a number of intra-household studies from outside the food and nutrition community may have some important lessons for food and nutrition programming. Finally, a number of important measurement issues have emerged in the past 10 years and their importance can be illustrated well in a review of studies such as this. These three considerations, then, form the basis for formulating the objectives of the paper. Specifically, the paper aims to critically review the existing literature and studies on the distribution of food and other proximate factors within the household (with an emphasis on boy-girl differences), critically review the existing literature and studies in the areas of poverty and gender, gender and income earning, drawing out implications for food and nutrition programs, and highlight some important methodological concerns related to poverty, income, and food consumption measurement. http://www.ifpri.org/divs/fcnd/dp/papers/dp19.pdf

Incentives Perceived by Management Dieticians Which Minimized Absenteeism of Foodservice Personnel

Liu, et. al. (1996). Journal of the American Dietetic Association, Volume 96, Issue 9, Supplement 1, September 1996, Page A42

To investigate incentives which minimized absenteeism of foodservice. Questionnaires were sent to 987 randomly selected dieticians in the practice group: Management in Health Care Systems of the American Dietetic Association (ADA), and the response rate was 32% (N=317). Frequencies, percentages, and Chi-square were used in data analysis. Management dieticians were mostly female. 41 to 60 years of age, with BS or MS degrees in foods/ nutrition or dietetics; and completed a dietetic internship. They had 16 to 25 years experience in the dietetic profession, and 1 to 10 years as directors of a unit. Most of the respondents worked in small urban facilities, supervising 30 or less, ethnically diverse, married, female employees, 41 to 60 years of age, with no dependents at home.

136 Nutri-Senex: State of the art report – task 2.1

Major reasons for absence were health-related and rarely job-related. Absenteeism which was below 5% in 1/3 of the facilities was significantly associated (p0.05) with gender and ethnic background, while turnover which was 1 to 10% in 1994 was significantly associated (p0.05) with age, marital status, young children at home and miles travelled to work. Incentives perceived by management dieticians, which effectively minimized absenteeism, were fairness, training and education with tuition break, health promotions, flexitime, job content improvement, and team building. Availability of transportation and health promotions was significantly associated (p0.05) with most of the demographic and institutional variables. Further studies need to explore job-related causes of absence, and verify if incentives such child/elderly care services, monetary/non-monetary compensation, job sharing and employment of an ombudsman would significantly minimize absenteeism among foodservice personnel.

Gerontology Training needs for Nutrition/Dietetics Students: Results of a needs Assessment,

B. J. Knutson & E. M. Gehling (1996). Journal of the American Dietetic Association, Volume 96, Issue 9, Supplement 1, September 1996, Page A82

To identify learning needs for use in the design of gerontology/geriatric nutrition training curriculum for nutrition/dietetics programs. A needs assessment utilizing three surveys (one telephone and two mailed) was used to collect data between 1994-1995.

Three target populations were sampled to obtain a broad perspective of perceived educational needs: dietetic internship program directors (N=94); recent dietetic internship program alumni (N=24); non-nutrition professionals who interface with older adults (N=250). Descriptive statistics using frequency and ranking of the of the most frequently cited responses; categorized and summarized in narrative format.

Response rates of the internship directors, alumni, and non-nutrition professionals were 75%, 67%, and 45% respectively. The following perceived training needs were consistently cited among the three samples respectively: Knowledge of community resources available for the elderly (21%, 11%, 12%); knowledge of financial concerns facing older adults (14%, 13%, 17%); and recognition of the heterogeneity in the older adult population (8%, 5%, 12%). Consistently recommended learning activities included: exposure to long-term care settings (43%, 33%, 28%); home visits to older adults (23%, 8%, 30%); and involvement with community programs (10%, 8%, 13%). Non-nutrition professionals stressed the need to train

137 Nutri-Senex: State of the art report – task 2.1 students in communication skills (verbal and non-verbal) and use of adaptive teaching methods to promote enhanced interactions with older adults. Results of the needs assessment can be used in designing a gerontology curriculum for students. Planning positive and relevant learning activities for students to learn educational objectives is paramount for students to acquire positive perceptions of aging adults, thus the facilitation of effective care giving.

Home and Community Nutrition Care for Elders: A Practicum Module for Dietetic Student

M. Luis & D. O. Weddle, (1996). Journal of the American Dietetic Association, Volume 96, Issue 9, Supplement 1, September 1996, Page A85

To develop a module enabling dietetic students to apply nutrition care principles and skills for elders in home and community based settings. Delivery of health, supportive and nutrition services is shifting from institutional to home and community settings. Dietetic students must be able to translate didactic knowledge into practical solutions that elders and caregivers can use in home settings. This module is designed to facilitate this translation for our coordinated and didactic internship students who elect to participate in an optional community based elderly nutritional practicum. Initially, students complete a self-assessment on eider nutrition practices and identity their rotation objectives. The module includes nutrition screening, comprehensive assessment, interdisciplinary interventions, nutrition case management, community resources, outcomes and prevention interventions. Each topic provides students with a variety of interactive assignments including case studies, short answers, and short projects. Assessment forms are included to provide orientation to available and/or commonly used nutrition assessment tools. Students use books, newsletters, videos, and journal references for completeness, accuracy and consistency of information. Module completion varies based on previous knowledge and experience. Most assignments are completed during the first week, before the field practice begins. The module begins as a learning tool and later becomes a reference. Ongoing practice application discussions with practicum supervisors are held. Students evaluate the efficacy of the module and identify additional information needed. The module, updated regularly with students' suggestions and new clinical information, helps students make practical nutrition care plans for frail homebound elders.

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Model Geriatric Clinical Education in Dietetics

Siler, (1995) Journal of the American Dietetic Association, Volume 95, Issue 9, Supplement 1, September 1995, Page A52

Through research supplemented by interviews with professionals working in geriatrics and dietetic educators, a survey was developed with sixty-one objectives in six domains to determine their relative importance in entry-level dietetic practice and if they were covered in the curriculum. The six domains were cognitive knowledge, affective, clinical skills, professional practice, foodservice administration, and public policy. The objectives in these domains were identified as being important to develop dietetic professionals who are competent to work with the elderly in a variety of settings. The survey was then administered to alumni who graduated between 1990–1994 whose mail was deliverable. There were a total of 56 available alumni with 21 returning the surveys or a return rate of 37.5%.

Of the original 61 survey objectives, 52 were categorized as being important to essential for dietetic practice by alumni. Their responses also identified that the coordinated program did provide minimal exposure up to adequate coverage and competency in an average of 88% of the 52 objectives. Assessment of coverage in the curriculum of the individual objectives ranged from 41–100%. It is possible to cover a multitude of objectives, which deal with knowledge and practice in six domains in a variety of classroom and clinical settings to adequately prepare graduates to work with geriatric clients in the field of dietetics. (This research was supported the U.S. Department of Health and Human Services grant #1- 376000511A-7.)

Nutrition and health risks in the elderly: the nutrition screening initiative

Posner, et. al. (1993) American Journal of Public Health, (1993) Vol 83, Issue 7 972-978, by American Public Health Association Office of the Director, Boston University School of Public Health, MA 02118.

The Nutrition Screening Initiative is a national collaborative effort committed to the identification and treatment of nutritional problems in older persons. A 14-item checklist of characteristics associated with nutritional status was administered to a random sample of Medicare beneficiaries, aged 70 years and older, in New England. Regression analysis was used to derive item weights that would predict poor nutrient intakes and low perceived health status. Sensitivity and specificity values were reviewed to define low, moderate, and high nutritional risk scores. A revised checklist containing 10 yes/no items was adopted. Scores of 6 or more points defined persons at high nutritional risk. Twenty-four percent of the Medicare

139 Nutri-Senex: State of the art report – task 2.1 population was estimated to be at high nutritional risk according to the checklist. Among those in the high-risk group, 56% perceived their health to be "fair" or "poor" and 38% had dietary intakes below 75% of the recommended dietary allowances for three or more nutrients. The Nutrition Screening Initiative Checklist is a brief, easily scored instrument that can accurately identify non-institutionalized older persons at risk for low nutrient intake and health problems.

Beyond nutrition screening: A systems approach to nutrition intervention: Challenges and opportunities for dietetics professionals

White, et al. (1993). Journal of the American Dietetic Association, (1993) Volume 93, Issue 4, April, Pages 405-407 [no .pdf file available]

Malnutrition in older Americans involves many disparate and complex causes. Dietetics professionals need to broaden their scope of practice in dealing with nutrition screening and intervention themselves and in providing expert consultation to others. Health and social services generalists such as physicians, nurses, and social workers must become more aware of the presence and risk of nutrition-related problems in the elderly and must adopt a systematic, collaborative approach to their solution. Nutrition screening, intervention, appropriate referral, and consultation must be built into daily practice. The NSI is a challenge and a call to action for all dietetics professionals. Registered dieticians must become active participants on interdisciplinary teams. They must assume a leadership role in areas of nutrition screening, assessment, and intervention. Their knowledge, skills, and expertise must continue to keep pace not only with advances in the science and technology of nutrition but also with relevant areas of related fields.

The relationship between oral health and nutrition in older people

A.W.G. Walls and J.G. Steele. Mechanisms of Ageing and Development Volume (2004) 125, Issue 12 , December, Pages 853-857 The oral health of older people is changing with reducing numbers of people relying on complete dentures for function, and retaining some natural teeth. Despite this there are substantial numbers of older people whose ability to chew foods is compromised by their oral health status, either because they have few or no natural teeth. This alteration results in individuals selecting a diet that they can chew in comfort. Such diets are low in fruits and vegetables intake with associated reduction in both non-starch polysaccharide and micronutrient intakes. There is also a trend for reduced dietary intake overall. Salivary flow and function may have an impact in relation to the ability to chew and swallow. Whilst there are few differences in salivary function in fit healthy unmedicated subjects, disease resulting in reduced salivary flow and particularly polypharmacy, with xerostomia as a side effect, are

140 Nutri-Senex: State of the art report – task 2.1 likely to have a role in older people. This paper explores the relationships between oral health status and food's choice and discusses the potential consequences for the individual of such dietary change.

Nutritional status of older people in long term care settings: current status and future directions

David T. Cowan, et al., International Journal of Nursing Studies Volume 41, Issue 3, (2004) March, Pages 225-237

Despite being preventable and treatable, in the 21st Century, malnutrition remains a problem in the developed world and the nutritional needs of many older people in long-term care settings are not met. The UK government has pledged to provide high-quality care for this sector of the population, including minimum standards to ensure adequate nutrition. However, research is still needed into the detection, prevalence, cause and effects of malnutrition and maintenance of optimum nutrition; and to address the lack of training and education among those caring for older peoples. In the interim, simple measures such as monitoring older people's weight regularly need to be implemented as a surveillance measure of nutritional status.

Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet

Wright L, et al., Journal of human nutrition and dietetics. (2005) Jun;18 (3):213-9 There are very few studies looking at the energy and protein requirements of patients requiring texture modified diets. Dysphagia is the main indication for people to be recommended texture-modified diets. Older people post-stroke are the key group in the hospital setting who consume this type of diet. The diets can be of several consistencies ranging from pureed to soft textures. OBJECTIVE: To compare the 24-hour dietary intake of older people consuming a texture modified diet in a clinical setting to older people consuming a normal hospital diet. METHOD: Weighed food intakes and food record charts were used to quantify the patients' intakes, which were compared to their individual requirements. RESULTS: The oral intake of 55 patients was measured. Twenty-five of the patients surveyed were eating a normal diet and acted as controls for 30 patients who were prescribed a texture-modified diet. The results showed that the texture-modified group had significantly lower intakes of energy (3877 versus 6115 kJ, P < 0.0001) and protein (40 versus 60 g, P < 0.003) compared to consumption of the normal diet. The energy and protein deficit from estimated requirements was significantly greater in the texture-modified group (2549 versus 357 kJ, P < 0.0001; 6 versus 22 g, P = 0.013; respectively). CONCLUSION:

141 Nutri-Senex: State of the art report – task 2.1

These statistically significant results indicate that older people on texture-modified diets have a lower intake of energy and protein than those consuming a normal hospital diet and it is likely that other nutrients will be inadequate. All patients on texture-modified diets should be assessed by the dietitian for nutritional support. Evidence based strategies for improving overall nutrient intake should be identified.

Stakeholder views of the training needs of an interprofessional practitioner who works with older people

Fiona Shield et al., Nurse Education Today Volume 26, Issue 5 July 2006, Pages 367-376

This paper, reports on United Kingdom research to examine the education and training requirements of an interprofessional practitioner for older people. The research was part of a larger study, funded by a local Workforce Development Confederation to identify whether there is a need for an interprofessional practitioner, and if so, determine their role and training requirements. Views of clients, carers and service providers were elicited using multiple methods including interviews, focus groups and questionnaires. The majority of service providers identified the need for an interprofessional practitioner and confirmed that these staff already exist within many multi-disciplinary community teams. The range of educational needs identified reflects the understanding that rehabilitation for older people requires a broad spectrum of knowledge and skills that cover both ‘health’ and ‘social’ needs. It was felt that education and training should be established and accredited at a national level, with a career structure and appropriate recognition of the interprofessional role. Clients and carers identified unmet needs and want a ‘Jack of all trades’ who will complement the existing workforce. They recommended that recognised qualifications would provide interprofessional workers with ‘status’ and therefore acceptance by other professionals. This paper, discusses the implications of the stakeholder views on interprofessional education and training.

Nutritional status of older people in long term care settings: current status and future directions. Cowan DT, et al. International journal of nursing studies (2004) Mar;41(3):225-37. Despite being preventable and treatable, in the 21st Century, malnutrition remains a problem in the developed world and the nutritional needs of many older people in long-term care settings are not met. The UK government has pledged to provide high-quality care for this sector of the population, including minimum standards to ensure adequate nutrition. However, research is still needed into the detection, prevalence, cause and effects of malnutrition and maintenance of optimum nutrition; and to address the lack of training and education among those caring for older peoples. In the interim, simple measures such as

142 Nutri-Senex: State of the art report – task 2.1 monitoring older people's weight regularly need to be implemented as a surveillance measure of nutritional status.

Nutrition in the Elderly McGee M, et al. Journal of clinical gastroenterology. (2000) Jun;30 (4):372-80. Older people are growing in prevalence and their nutrition-related concerns adversely impact upon health, function, and life quality. Changes in body composition and organ system function alter nutrient requirements. The purpose of this review is to examine changes in nutritional requirements with aging and to highlight practical approaches to nutritional screening, assessment, and intervention. A multidisciplinary approach with individualized care is recommended. Health care providers who work with older people must be attentive to nutrition, because appreciable comorbidity and unfavorable outcomes may accompany either under- or overnutrition.

Detecting and managing undernutrition of older people in the community. Todourovic V. British journal of community nursing. (2001) Feb;6(2):54-60 Undernutrition is an important public health issue which is frequently undetected and untreated. Disease and illness are the major causes of undernutrition in this country, and older people are a particularly vulnerable group. Effective screening is needed to reduce the prevalence of malnutrition in older people and when this is established, action can then be taken to address the problem. Community nurses and the primary care team have a key role to play in making this happen. The recently developed Malnutrition Advisory Group (MAG) nutrition screening tool, for adults will help community staff and primary care staff to identify those older patients most at risk of malnutrition in the community. Routine nutrition screening of vulnerable individuals is the first stage in raising standards of nutrition care. Further improvements can be made through the development of appropriate nutritional guidelines, clinical risk management strategies provides opportunities to highlight the importance of nutrition care of older people.

Under-nutrition in older people: a serious and growing global problem! Visvanathan R. Journal of postgraduate medicine. (2003) Oct-Dec;49(4):352-60. Everyone agrees that adequate nutrient intake is important to all living things. Without food or water, life on earth would cease to exist. In the field of medical health, some gains have been made in meeting maternal and child nutritional needs. There is great community awareness regarding the importance of meeting the nutritional needs of the developing foetus and child. Malnutrition secondary to decreased intake in older people and weight loss is also a serious problem with unfortunately, very little notice from the community at large. As one ages,

143 Nutri-Senex: State of the art report – task 2.1 several physiological processes may contribute towards the development of protein energy malnutrition. Under-nutrition in older people is sadly far too common, even in developed countries. It is very likely that the same concerted effort used to address child malnutrition is required to combat under-nutrition in our elders. Protein energy malnutrition in older people comes at a significant cost to the individual, families, communities and the healthcare system. Failure to address this syndrome is not only unethical and unhealthy, but also costly. Vigilance and community awareness is important in ensuring that this important syndrome is detected and managed appropriately. This review mainly attempts to describe the pathophysiology, prevalence and consequences of under-nutrition and aims to highlight the importance of this clinical syndrome and the recent growth in our understanding of the processes behind its development. Some management strategies are also briefly described.

Promoting nutrition in older people in nursing and residential homes. Copeman J. British journal of community nursing. (2000) Jun;5(6):277-8, 280-84.

Malnutrition and dehydration are serious and common problems among older people in nursing and residential care homes. The situation is exacerbated because staff may not be trained to recognize the signs and symptoms of malnutrition and dehydration and hence opportunities for early intervention are missed. A nutrition assessment should form part of the admission process to identify whether an individual has, or is at risk of developing, malnutrition and dehydration. This article suggests key questions that should be asked to assist this process. The individual and organizational risk factors that affect nutrition and health status are discussed, and practical suggestions given to help address any problems recognized. The causes and consequences of dehydration are explained and practices that place an individual at risk of dehydration considered. Suggestions are given to help identify when a person is not drinking sufficiently so that early rapid intervention can be initiated. Helping an older person to eat and drink independently is a practical activity that is often undervalued. Its importance needs to be recognized in all nursing and residential care settings.

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The relationship between oral health and nutrition in older people. Walls AW, and Steele JG. Mechanisms of ageing and development. (2004) Dec;125(12):853-7. The oral health of older people is changing with reducing numbers of people relying on complete dentures for function, and retaining some natural teeth. Despite this there are substantial numbers of older people whose ability to chew foods is compromised by their oral health status, either because they have few or no natural teeth. This alteration results in individuals selecting a diet that they can chew in comfort. Such diets are low in fruits and vegetables intake with associated reduction in both non-starch polysaccharide and micronutrient intakes. There is also a trend for reduced dietary intake overall. Salivary flow and function may have an impact in relation to the ability to chew and swallow. Whilst there are few differences in salivary function in fit healthy unmedicated subjects, disease resulting in reduced salivary flow and particularly polypharmacy, with xerostomia as a side effect, are likely to have a role in older people. This paper explores the relationships between oral health status and food's choice and discusses the potential consequences for the individual of such dietary change.

What do we know about... nutrition and older people? Holmes S. The journal of family health care. (2004)14(6):153-5. Nutrition is important to the health and functioning of elderly people. This paper summarises the evidence that many old people suffer from undernutrition and outlines the insidious effects of this form of malnutrition. It discusses the physiological and practical difficulties elderly people face in achieving good nutrition, and the challenge this poses to health workers. Given the UK's ageing population, undernutrition in older people is a significant public health issue as well as one that should concern all health professionals involved in individual or group contacts with elderly clients.

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Nutrition and cognitive impairment in the elderly. Gonzalez-Gross M, et al., The British journal of nutrition (2001) Sep;86 (3):313-21. As the number of older people is growing rapidly worldwide and the fact that elderly people are also apparently living longer, dementia, the most common cause of cognitive impairment is getting to be a greater public health problem. Nutrition plays a role in the ageing process, but there is still a lack of knowledge about nutrition-related risk factors in cognitive impairment. Research in this area has been intensive during the last decade, and results indicate that subclinical deficiency in essential nutrients (antioxidants such as vitamins C, E and beta-carotene, vitamin B(12), vitamin B(6), folate) and nutrition-related disorders, as hypercholesterolaemia, hypertriacylglycerolaemia, hypertension, and diabetes could be some of the nutrition-related risk factors, which can be present for a long time before cognitive impairment becomes evident. Large-scale clinical trials in high-risk populations are needed to determine whether lowering blood homocysteine levels reduces the risk of cognitive impairment and may delay the clinical onset of dementia and perhaps of Alzheimer's disease. A curative treatment of cognitive impairment, especially Alzheimer's disease, is currently impossible. Actual drug therapy, if started early enough, may slow down the progression of the disease. Longitudinal studies are required in order to establish the possible link of nutrient intake--nutritional status with cognitive impairment, and if it is possible, in fact, to inhibit or delay the onset of dementia.

Oral Condition and Its Relationship to Nutritional Status in the Institutionalized Elderly Population

Michelle Soares Rauen Journal of the American Dietetic Association Volume 106, Issue 7 , July (2006), Pages 1112-1114

The objective of this study was to identify the relationship between the oral condition and nutritional status of all institutionalized elderly people in Florianópolis, Brazil. Of the population of 232 institutionalized individuals, the sample consisted of 187 elderly people. In the oral evaluation, the criteria used was the number of functional units present in the oral cavity, classifying the participants as those with highly compromised dentition (48%) and those with less-compromised dentition (52%). Diagnosis of nutritional status was carried out according to body mass index, observing a prevalence of 14% thin, 45% eutrophic, 28% overweight, and 13% obese. Statistical analysis of the variables studied was carried out by means of χ2 association tests. There was a statistically significant association between highly compromised dentition and thinness (P=0.007) and among those who presented less- compromised dentition and the nutritional status of overweight, including obesity (P=0.014). It was concluded that compromising of the teeth could contribute to a tendency toward inadequate nutritional status.

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Eating habits and appetite control in the elderly: the anorexia of aging. Donini LM, Savina C, Cannella C. International psychogeriatrics / IPA (2003) Mar;15(1):73- 87.

Although a high prevalence of overweight is present in elderly people, the main concern in the elderly is the reported decline in food intake and the loss of the motivation to eat. This suggests the presence of problems associated with the regulation of energy balance and the control of food intake. A reduced energy intake causing body weight loss may be caused by social or physiological factors, or a combination of both. Poverty, loneliness, and social isolation are the predominant social factors that contribute to decreased food intake in the elderly. Depression, often associated with loss or deterioration of social networks, is a common psychological problem in the elderly and a significant cause of loss of appetite. The reduction in food intake may be due to the reduced drive to eat (hunger) resulting from a lower need state, or it arises because of more rapidly acting or more potent inhibitory (satiety) signals. The early satiation appears to be predominantly due to a decrease in adaptive relaxation of the stomach fundus resulting in early antral filling, while increased levels and effectiveness of cholecystokinin play a role in the anorexia of aging. The central feeding drive (both the opioid and the neuropeptide Y effects) appears to decline with age. Physical factors such as poor dentition and ill-fitting dentures or age-associated changes in taste and smell may influence food choice and limit the type and quantity of food eaten in older people. Common medical conditions in the elderly such as gastrointestinal disease, malabsorption syndromes, acute and chronic infections, and hypermetabolism often cause anorexia, micronutrient deficiencies, and increased energy and protein requirements. Furthermore, the elderly are major users of prescription medications, a number of which can cause malabsorption of nutrients, gastrointestinal symptoms, and loss of appetite. There is now good evidence that, although age-related reduction in energy intake is largely a physiologic effect of healthy aging, it may predispose to the harmful anorectic effects of psychological, social, and physical problems that become increasingly frequent with aging. Poor nutritional status has been implicated in the development and progression of chronic diseases commonly affecting the elderly. Protein-energy malnutrition is associated with impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, poor wound healing, delayed recovery from surgery, and ultimately increased morbidity and mortality. An increasing understanding of the factors that contribute to poor nutrition in the elderly should enable the development of appropriate preventive and treatment strategies and improve the health of older people.

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Nutrition and dietary recommendations for the elderly "Public Health" Working Group of the Spanish Nutrition Society Arbones G, et al., Nutrición hospitalaria : organo oficial de la Sociedad Española de Nutrición Parenteral y Enteral. (2003) May-Jun;18(3):109-37.

With the increase of life expectancy, the desire to maintain good health, functionality and maximum quality of life at advanced ages, for which nutrition plays a critical role, is a priority for the elderly. Though genetic factors are a determinant of life expectancy, there are several extrinsic factors which have a great influence on the quality of life of the elderly. Diet and nutritional status have a great influence, especially in the prevention and treatment of several diseases, which affect this heterogeneous and vulnerable age group. The nutritional status and needs of elderly people are associated with age-related biological, psychological and often socio-economic changes. All of these changes can increase the risk of developing a number of age-related diseases. In developed countries the elderly are the most affected by malnutrition, either because of a deficiency (energy and several nutrients) or an excess, leading to obesity and related diseases. This review highlights the most important factors affecting nutritional status in elderly people and focus on the need to maintain adequate physical activity level and an optimal physic, psychic and social functional capacity. It discusses dietary reference intakes and guidelines to improve and/or maintain adequate nutritional status in older people in order to reduce susceptibility to some illness and disease.

References www.sciencedirect.com http://www.ingenta.com/ http://www.the-scientist.com/ http://hkrt.wok.mimas.ac.uk http://www.blackwell-synergy.com/servlet/useragent?func=showHome http://www.google.com/search?q=site:citeseer.nj.nec.com http://www.metacrawler.com/ http://citeseer.ist.psu.edu/ http://www.ncbi.nlm.nih.gov http://www.scirus.com

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Introduction

The following is a review of recent literature, dating back as far as 1995, concerning the study of the prevention of malnutrition specifically relating to the elderly, especially those in residential care institutions & hospitals. The purpose of this review is to prevent the repetition of work, consolidating scientific research efforts to optimise the rate of development in the field. It is widely accepted that the American Journal of Dietetics, Nutrition and Nutrition Research, have been responsible for the vast majority of publications in this area across the reviewing period; however, many other sources are highlighted in this review, having contributed some valuable work. The main advances in the discipline concerned have been: 1) assessment of the viability of current guidelines for care homes and institutions; 2) the nutritional value of foods and food supplements and optimal application of these foods; and, 3) an increased understanding of the nutritional requirements of the elderly. These factors are heavily themed across the papers in this review. 1) A recent example of guideline viability assessment comes from the World Health Organisation (WHO). Their case-management guidelines for severe malnutrition aim to improve the quality of hospital care and reduce mortality, aiming to assess whether these guidelines are feasible and effective in under-resourced hospitals, (Ashworth 2004). Others have considered guidelines for nutrition risk screening applicable to different settings (community, hospital, elderly) based on published and validated evidence. These guidelines deliberately make reference to the year 2002 in their title to indicate that this version is based on the evidence available until 2002 and that they need to be updated (Kondrup 2003). Guidelines specific to those sections of the elderly population who are ill, infirm or suffering from long-term illness have also been reviewed here. Stroke patients experience multiple impairments, which impair ability to eat and render them vulnerable to the deleterious sequel of malnutrition. This study, (Perry & McLaren 2002),aimed to develop, implement and evaluate evidence-based guidelines for nutrition support following acute stroke using a multifaceted change management strategy. Some important implications for the way data are organised on food and nutrient databases have been considered. New Dietary Reference Intakes (DRIs) have been set for 17 nutrients, and in several cases the units for these recommendations do not match those traditionally carried on nutrient databases. Furthermore, some of the tolerable Upper Intake Levels (ULs) are specified only for supplemental and fortification forms of nutrients, which necessitates calculating separate intake values for nutrients from foods and nutrients that are added to foods or taken as supplements, (Murphy 2001).

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2) The nutritional value of foods, food supplements and the timing and application of these has been widely debated across the reporting period. Some findings have been controversial – providing much debate, for example, surrounding the economic benefits of nutritional supplement use. Food plans, with and without nutritional supplements, are developed by maximising a quadratic food utility function subject to nutrient and budget constraints. The quadratic programming solutions, which include both the marginal utilities and marginal costs of nutrients, are then presented. The results demonstrate the economic optimality of partial supplementation, (Lancaster 2003). Golden Rice has been genetically modified to produce beta-carotene in the endosperm of grain. It could improve the vitamin A status of deficient food consumers, especially women and children in developing countries. A recent paper analyses potential impacts in a Philippine context. Since the technology is still at the stage of R&D, benefits are simulated with a scenario approach, (Zimmermann & Qaim 2004). In another recent study, Chen and Huang have presented a comprehensive study on dietary fibre intake in Taiwanese elderly with respect to their health status. Dietary fibre intake of these elderly was only half the recommended value (12 g/Mcal). Dietary fibre affects morbidity. However, health disorders also affect dietary fibre intake. About 80% of the subjects had chewing difficulties and more than 60% of those had gut disorders, (Dror 2003). Over half of U.S. adults use vitamin or mineral supplements, and some are likely using supplements to treat chronic diseases or risk factors for disease. Information on the relationship between supplement use and medical conditions is useful to health professionals to understand the self-medication behaviour of their patients, and important for researchers because medical conditions may be potential confounding factors in observational studies of supplement use and disease risk, (Satia-Abouta 2003). Sarcopenia is a common feature in the healthy elderly. However, little is known on age- related modifications of body composition in malnourished patients. The aims of another cross-sectional study were to evaluate the effects of aging per se on body composition and resting energy expenditure in malnourished patients (Schneider 2002). 3) It is widely accepted that external factors such as cost, decreases in motor-control, isolation and the impairment of senses significantly contribute to reduced nutrient intake in elderly populations. However, increasing debate surrounding changes to the ability of older people to uptake nutrients and means to avoid any subsequent malnutrition has been documented over this reviewing period. In old age, the complex relationship between food consumption with energy and nutrient requirements finds expression in both single and multiple nutritional problems. Addressing conditions affecting intake –– either from foods or from supplements –– endogenous

150 Nutri-Senex: State of the art report – task 2.1 production, bioefficacy and/or requirements can benefit nutritional health in old age through balancing requirements and supply (de Groot 2001). To define which feeding enhancement strategies are used and considered effective for increasing food intake among institutionalised elderly in long-term-care, the extent of use and perceived effectiveness of food intake enhancement strategies have been investigated. Operational obstacles to the use of strategies and training used to prepare staff in using feeding strategies were also studied, the results are discussed (Kim & Cluskey, 2003). The focus of another study was on the affects of long-term injury or sickness aimed to describe eating difficulties and especially swallowing in patients with dysphagia, types of nursing intervention, and the development of complications over 3 months. The aim was also to explore common characteristics of eating difficulties that influenced the ability to finish meals (Westergren 2001). The aim, here is to provide an essential guide to the research literature of the past decade.

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5.7 Primary Papers

The nutritional fortification of cereals

Poletti et.al, (2004) Current Opinion in Biotechnology Journal volume 15, issue 2 pages 162-

The low micronutrient content of cereals requires the fortification of food and bio fortification of plants. Many laboratories are currently pursuing bio fortification using breeding and genetic modification, but progress is challenged by technical hurdles and our understanding of physiological processes. Recent studies have largely been confined to the improvement of levels of iron, zinc, some vitamins and a variety of essential amino acids. Progress has been made in the accumulation of iron, zinc, and vitamins A and E in genetically modified plants. For future success in this area, many more studies will be required on the physiology of ion uptake and on the transport of vitamin precursors. Publisher: Elsevier Ltd. All rights reserved. Doi 10.1016/j.copbio.2004.03.002

WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors

Ashworth PhD et.al (2004) The Lancet volume 363, issue 9415 pages 1110-1115

Background WHO case-management guidelines for severe malnutrition aim to improve the quality of hospital care and reduce mortality. We aimed to assess whether these guidelines are feasible and effective in under-resourced hospitals. All children admitted with a diagnosis of severe malnutrition to two rural hospitals in Eastern Cape Province from April 2000 to April 2001, were studied and their case-fatality rates were compared with the rates in a period before guidelines were implemented (March, 1997 to February, 1998). Quality of care was assessed by observation of medical and nursing practices, review of medical records, and interviews with carers and staff. A mortality audit was used to identify cause of death and avoidable contributory factors. Findings At Mary Theresa Hospital, case-fatality rates fell from 46% before implementation to 21% after implementation. At Sipetu Hospital, the rates fell from 25% preimplementation to 18% during 2000, but then rose to 38% during 2001, when inexperienced doctors who were not trained in the treatment of malnutrition were deployed. This rise coincided with less frequent prescribing of potassium (13% vs. 77%, p<0·0001), antibiotics with gram-negative cover (15% vs. 46%, P=0·0003), and vitamin A (76% vs. 91%, P=0·018). Most deaths were attributed to sepsis. For the two hospitals combined, 50% of deaths in 2000–01 were due to doctor error and 28% to nurse error. Weaknesses within the health system––especially doctor training, and nurse supervision and support––

152 Nutri-Senex: State of the art report – task 2.1 compromised quality of care. Interpretation Quality of care improved with implementation of the WHO guidelines and case-fatality rates fell. Although major changes in medical and nursing practice were achieved in these under-resourced hospitals, not all tasks were done with adequate care and errors led to unnecessary deaths. Publisher: Elsevier Ltd. Doi 10.1016/S0140-6736 (04)15894-7

Potential health benefits of Golden Rice: a Philippine case study

Zimmermann & Qaim (2004). Food Policy Journal

Golden Rice has been genetically modified to produce beta-carotene in the endosperm of grain. It could improve the vitamin A status of deficient food consumers, especially women and children in developing countries. This paper analyses potential impacts in a Philippine context. Since the technology is still at the stage of R&D, benefits are simulated with a scenario approach. Health effects are quantified using the methodology of disability-adjusted life years (DALYs). Golden Rice will not completely eliminate the problems of vitamin A deficiency, such as blindness or increased mortality. Therefore, it should be seen as a complement rather than a substitute for alternative micronutrient interventions. Yet the technology could bring about significant benefits. Depending on the underlying assumptions, annual health improvements are worth between US$ 16 and 88 million, and rates of return on R&D investments range between 66% and 133%. Due to the uncertainty related to key parameters, these results should be treated as preliminary. Publisher: Elsevier Science Ltd. All rights reserved. Do10.1016/j.foodpol.2004.03.001

Nutraceutical and functional food industries: aspects on safety and regulatory requirements

Bagchi (2004) Toxicology Letters volume 150 issue 1 pages 1-2

The need, scope and importance of this special issue are clearly evident due to the recent surge in growth in the nutraceutical and functional food industries. Nutraceutical ingredients and functional foods, legally defined as natural substances that may be used individually, in combination, or even added to food or beverage for a particular technologic purpose or health benefits, must have an adequate safety profile demonstrating the safety for consumption by humans. Risk of toxicity or adverse effects of medical drugs led us to consider safer nutraceutical and functional food based approaches for health management. This resulted in a world-wide nutraceutical revolution. The option of health and disease management by natural means has been embraced by a large fraction of the world population. Striking growth in research on nutraceuticals and functional foods is an integral and vital component of the revolution. Proof of efficacy and safety are two key sets of

153 Nutri-Senex: State of the art report – task 2.1 information that underlie the successful use of nutraceuticals and functional foods for the management of human health and well-being. The inventory of modern and sophisticated technologies available to derive such information is rapidly expanding in this age of technology driven health care. The time is ripe to revisit nutraceuticals and functional food research in light of these emerging technologies. The current issue has been undertaken to address that objective with support from eminent world-experts. Publisher: Elsevier Ireland Ltd. All rights reserved Doi 10.1016/j.toxlet.2004.01.011

Adverse events associated with dietary supplements: an observational study

Palmer, (2003). The Lancet volume 361, issue 9352 pages101-106

Background Adverse events associated with dietary supplements are difficult to monitor in the USA, because such products are not registered before sale, and there is little information about their content and safety. Methods In 1998, 11 poison control centres in the USA recorded details of 2332 telephone calls about 1466 ingestions of dietary supplements, in 784 of which patients had symptoms. We used a multitiered review process (kappa 0·42) to select 489 cases for whom we were at least 50% certain that their negative events were associated with dietary supplements. We aimed to assess the effects of multiple ingredients and long-term use, and collated data for patterns of use and information resources. Findings A third of events were of greater than mild severity. We noted both new and previously reported associations that included myocardial infarction, liver failure, bleeding, seizures, and death. Increased symptom severity was associated with use of several ingredients, long-term use, and age. Paediatric exposures were more often unintentional than were adult ingestions, and treatment of disease was the reason for supplement use in at least 28% of reports. Most products and ingredients were not identified in the information database (Poisindex) used by poison control centres, and specific adverse events were reported variably among five additional sources. Interpretation Dietary supplements are associated with adverse events that include all levels of severity, organ systems, and age groups. Associations between adverse events and ingredients are difficult to verify if a product has more than one ingredient, and because of incomplete information systems. Research into hazards and risks of dietary supplements should be a priority. Publisher: Elsevier Science Ltd. All rights reserved Doi 10.1016/S0140-6736(03)12227-1

154 Nutri-Senex: State of the art report – task 2.1

Dietary supplement use and medical conditions

Satia-Abouta, et.al (2003). American Journal of Preventive Medicine volume 24, issue 1 pages 43-51

Over half of U.S. adults use vitamin or mineral supplements, and some are likely using supplements to treat chronic diseases or risk factors for disease. Information on the relationship between supplement use and medical conditions is useful to health professionals to understand the self-medication behaviour of their patients, and important for researchers because medical conditions may be potential confounding factors in observational studies of supplement use and disease risk. The cross-sectional data in this report are from 45,748 participants, aged 50 to 75 years, who completed a self-administered, mailed questionnaire on current dietary supplement use (multivitamins plus 16 individual vitamins or minerals), medical history (cancer, cardiovascular-related diseases, and other self-reported medical conditions), and demographic characteristics. Supplement use (mean number used at least once a week) was higher among respondents who were older, female, highly educated, Caucasian, and of normal body mass index (all p<0.001). After controlling for these covariates, supplement use was higher among those with the condition for 13 of the 21 conditions examined (p<0.01); only having diabetes or high stress was associated with using fewer supplements. For specific supplements, the strongest associations were for cardiovascular disease and its risk factors with vitamin E, niacin, and folate, and for calcium with indigestion and acid reflux disease. For several conditions, the relative odds of using specific supplements were consistently higher for men than for women. Supplement use was associated with many medical conditions in this cohort. However, these cross-sectional data do not permit inferences about the temporal sequence. Some associations appeared to be based on evidence for efficacy (e.g., folate with coronary artery disease), and others could be based on misinformation (e.g., selenium with benign prostatic hyperplasia). Publisher; Elsevier Science Inc. All rights reserved. Doi 10.1016/S0749-3797(02)00571-8

Does additional feeding support provided by health care assistants improve nutritional status and outcome in acutely ill older in-patients?––a randomised control trial

Hickson, et.al (2003) Clinical nutrition journal volume 23, issue 1 pages 69-77

Malnutrition is common in the elderly and increases morbidity and mortality. Most attempts to reverse malnutrition have used liquid supplements, but the findings are inconsistent. This study tests a new approach using a randomised-controlled design. The aim was to examine whether health care assistants, trained to provide additional support with feeding, can

155 Nutri-Senex: State of the art report – task 2.1 improve acutely ill elderly in-patients' clinical outcomes. The study was carried out on three acute medicines for the elderly wards at Hammersmith Hospitals NHS Trust, London. In all, 592 patients, all over 65 years old, were recruited. The results showed that the median time patients received feeding support was 16 days, and the assisted group was given less intravenous antibiotics (P=0.007). However, the groups did not differ in markers of nutritional status, Barthel score, grip strength, length of stay or mortality. It was concluded that the use of health care assistants in this specialised role, in an acute setting, without change to the food provision or without targeting higher risk patients, reduced the need for intravenous antibiotics. However, the intervention did not improve nutritional status or have an effect on length of stay in the time span studied. The results highlight the difficulties of improving the intake of acutely ill elderly patients during a hospital stay. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0261-5614(03)00090-6

A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes

Edington et.al (2003) Clinical Nutrition Journal volume 23, issue 2 pages 195-204

Malnutrition is common in sick elderly people on admission to hospital and in the community. We conducted a randomised controlled trial to determine if nutritional supplementation after discharge from hospital improved nutritional status and functional outcomes, or reduced health-care costs. Elderly malnourished subjects were randomised to 8 weeks of supplementation or no supplementation post discharge, and followed up for 24 weeks. Weight, body mass index, anthropometrics, handgrip strength, quality of life and requirements for health-care professionals' services and social services were measured throughout the study. Nutritional status improved significantly from baseline to week 24 in the intervention group (P<0.05), but not in the control group. There was no significant difference in nutritional status between groups at week 24. Handgrip strength improved significantly in the intervention group during supplementation, and was significantly different from that of the control group at week 8, but decreased thereafter. There was no significant difference in quality of life or health economic outcomes between groups at week 24. In already malnourished elderly subjects, it may be too late to expect to improve function or quality of life or to reduce health-care costs simply by providing nutritional supplements after hospitalisation. Prevention is key. All elderly patients should be nutritionally assessed as part of their routine care, and appropriate intervention initiated early. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0261-5614(03)00107

156 Nutri-Senex: State of the art report – task 2.1

A blueprint-based case study analysis of nutrition services provided in a midterm care facility for the elderly

Paquet, (2003) Journal of American Dietetic Association volume 103, issue 3, pages 363-368

Ensuring nutritionally adequate food intake in institutions is a complex and important challenge for dieticians. To tackle this problem, we argue that dieticians need to adopt a systematic, integrative, and patient-centred approach to identify and manage more effectively organizational determinants of the quality of food intake under their control. In this study, we introduce such an approach, the blueprint-based case study that we applied in the context of a midterm care facility for elderly patients. Data gathered through interviews and field observations were used to develop, from the perspective of key patient encounters, detailed representations of the food, nutrition, and nursing activities necessary to ensure adequate food intake. These service ″blueprints" were developed to illustrate all activities that might potentially impact on the nutritional, sensory, functional, and social quality of patients' meals. They were also used as roadmaps to develop a case study analysis in which critical areas were identified and opportunities for improvement put forth, while considering services' resources and priorities. By providing a precise, objective, yet comprehensive mapping of the service operations and management, the blueprint-based case study approach represents a valuable tool to determine the optimal allocation of resources to insure nutritionally adequate food intake to patients. Copyright 2003 American Dietetic Association All rights reserved. Doi 10.1053/jada.2003.50047

Effects of two models of nutritional intervention on homebound older adults at nutritional risk

Kretser, et.al (2003) Journal of American Dietetic Association volume 103 issue 3 pages 329- 336

To test the feasibility of two models of home meal delivery with Meals-on-Wheels (MOW) applicants who were identified as being malnourished or ″at-risk" as determined by the validated Mini Nutritional Assessment (MNA). A 6-month, prospective comparative study of two nutrition intervention models with data collection at baseline, 3 months, and 6 months. Randomised treatment assignment was followed, with a few exceptions linked to particular client circumstances. A total of 203 older adults (age RANGE = 60 to 90 years) newly applying for homebound meal service were enrolled. At baseline, the body mass index (BMI) was 26.3±7.2 (mean±SD) in the ″Traditional" MOW model (101 subjects including 30 malnourished), and

157 Nutri-Senex: State of the art report – task 2.1 the BMI was 27.6±9.0 in the ″New" MOW model (102 subjects including 26 malnourished) (P = ns). Intervention Study participants received either the Traditional MOW program of five hot meals per week, meeting 33% of the Daily Reference Intake (DRI) or the restorative, comprehensive New MOW program of three meals and two snacks per day, 7 days a week, meeting 100% of the DRI. Assessments were conducted in the home of the participants. Main outcome measures The MNA was used to evaluate nutritional risk and status of participants at baseline, 3 months, and 6 months. Standardized functional impairment scales, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL) evaluated limitations in activities of daily living and life management skills. Statistical analysis Comparisons between treatment groups were calculated with t tests or Wilcoxon rank-sum tests when appropriate. Comparisons among time periods between treatment groups were conducted with repeated measures analysis of variance. A general linear model was used to evaluate the relationship between change in functional status and BMI, controlling for sex. The New MOW group gained significantly more weight between baseline and 3 months than did the Traditional MOW group (2.78 lb vs. −1.46 lb, respectively, P = .0120) and again between baseline and 6 months (4.30 lb vs. −1.72 lb, respectively, P = .0004). MNA improved faster in the New MOW group. Functional change appeared to be related more to BMI and age than to treatment intervention. The malnourished participants in both groups took longer to affect positive change in nutrition measurements, with the New MOW group showing the most improvement over the 6-month measurement period. Both delivery models were well accepted. Conclusions Applicants for home meal delivery have varying nutrition needs. By addressing nutritional risk, interventions can be targeted to meet these needs. A new, restorative, comprehensive meal program improved nutritional status and decreased nutritional risk and can possibly impact. Copyright 2003 American Dietetic Association All rights reserved. Doi 10.1053/jada.2003.50052

Nutritional status of older people in long term care settings: current status and future directions

Cowan et.al (2003) International Journal of Nursing Studies volume 41, issue 3 pages 225-237

Despite being preventable and treatable, in the 21st Century, malnutrition remains a problem in the developed world and the nutritional needs of many older people in long-term care settings are not met. The UK government has pledged to provide high-quality care for this sector of the population, including minimum standards to ensure adequate nutrition. However, research is still needed into the detection, prevalence, cause and effects of

158 Nutri-Senex: State of the art report – task 2.1 malnutrition and maintenance of optimum nutrition; and to address the lack of training and education among those caring for older peoples. In the interim, simple measures such as monitoring older people's weight regularly need to be implemented as a surveillance measure of nutritional status Publisher: Elsevier Ltd. All rights reserved. Doi 10.1016/S0020-7489(03)00131-7

Strategies for Enhancing Food Intake Among the Elderly in Long-Term Care Facilities

Kim & Cluskey, (2003) Journal of American Dietetic Association volume 99 issue 9 supplement 1 page A15

To define which feeding enhancement strategies are used and considered effective for increasing food intake among institutionalised elderly in long-term-care. The extent of use and perceived effectiveness of food intake enhancement strategies were studied using a mailed survey instrument. Operational obstacles to the use of strategies and training used to prepare staff in using feeding strategies were also studied. A total of 311 questionnaires listing seventeen strategies for enhancing food intake among the elderly were mailed to two target populations: (I) Directors of Nursing Service (DONs) and (2) Consultant Registered Dieticians (RDs) in the Pacific region. DONs most frequently use improving the dining room environment, optimal positioning of resident and providing liquid supplements to enhance intake among the elderly in long-term care. Registered Dieticians more frequently use offering snacks, adding nutrients to food and the use of liquid supplements for enhancing intake and less often focus on strategies related to actual feeding. The results revealed that the frequency of use of feeding strategies does not necessarily mean that they are perceived to be effective DONs and RDs frequently use or recommend most strategies, but doubt the effectiveness of many. Significant differences in the use and perceived effectiveness of strategies between DONs and RDs were also found. DONs more frequently use liquid supplements, specialized feeding utensils, and simple verbal prompts to eat (p<0.01). RDs had a more positive perception of the effectiveness of tube feeding for enhancing intake among elders than did DONs (p=0.0006). The need for additional food-service/dietary labour cost and/or product costs were considered obstacles to implementing some of the strategies. Most staff training was related to offering liquid supplements, less often was staff trained in actual tableside feeding strategies. Further research is needed to determine why DONs and RDs have different opinions about feeding strategies and their effectiveness. It would be beneficial to measure the actual effectiveness of the use feeding strategies in enhancing intake among the elderly. Copyright 1999 American Dietetic Association. Publisher: Elsevier Science U.S.A Doi 10.1016/S0002-8223(99)00452-6

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Frail elderly, nutritional status and drugs

Pickering, (2003) Archives of Gerontology and Geriatrics volume 38 issue 2 pages 174-180

This review focuses on the interactions between nutritional status and drugs in frail elderly persons. Impairment of nutritional status, a component of clinical presentation in the frail elderly, has a major impact on the pharmacology of many drugs devolving from the physiological alterations it generates. Food itself plays a central role in nutritional status and in possible interactions with drugs. Conversely, drugs have often, directly and indirectly, a deleterious effect on the nutritional state of the elderly. However, research in this domain is scarce, and future clinical studies will need to include more elderly and frail elderly individuals, to help clinicians to better understand these interactions. Publisher: Elsevier Ireland Ltd all rights reserved. Doi 10.101/j.archger.2003.09.004

A Medical Nutrition Therapy Tool to Effect Positive Weight Outcomes in the Elderly

Jackobs (2003) Journal of American Dietetic Association volume 99 issue 9 supplement 1 page A119

To state the efficacy of megestrol acetate therapy upon positive weight change in the elderly. Many elderly individuals in long-term care facilities are at risk for weight loss. Sometimes this is due to a specific disease process. Other times, weight loss is due to loneliness, lack of interest in life and elderly forms of anorexia, in the long term care facility, unexplained weight loss can be a precursor to further physical decline including pressure ulcers and mood changes. When a significant weight loss is noted, interventions are begun. These may take the form of special food preferences or a supplement given with or between meals. Sometimes none of these interventions work. The resident is just not hungry. This study focused on a prescription medication, megestrol acetate, as an adjunct that might pique an appetite in the elderly population. Data gathered included age, gender, diet, weight before and after drug initiation as well as ideal and usual body weight. Elderly residents monitored included 27 residents, 19% male with an age range of 75 to 85 years and 81% female with an age range of 76 to 100 years. AH of these residents had lost weight and were under their usual body weight. Weight increase was seen in 74% of these residents. All five of the men gained weight in one month with a mean percentage increase of 2.08±.57, mean±SD. Of the 22 women, 68% gained weight with a mean percentage increase of 3.73±2.06, mean±SD. Thus, megestrol acetate can be a useful adjunct to help the elderly resident gain weight This intervention is cost effective with a usual daily dose of 40 mg tid. It is important for the

160 Nutri-Senex: State of the art report – task 2.1

Registered Dietician to be aware of this adjunct treatment and to discuss it with the physician when appropriate so that the elderly resident may enjoy optimum health. Copyright 1999 American Dietetic Association. Publisher Elsevier Science U.S.A. Doi 10.1016/S0002-8223(99)00810-X

Dietary fibre intake for the elderly

Dror (2003). Journal of Nutrition volume 19, issue 4 pages 388-389

In this issue, Chen and Huang have presented a comprehensive study on dietary fibre intake in Taiwanese elderly with respect to their health status. Dietary fibre intake of these elderly was only half (6.1 g/Mcal) the recommended value (12 g/Mcal). Its distribution among nine foods, in percentages, groups was 55 in vegetables, 20 in fruits, 15 in grains, 5 in soybean and other legumes, and 2.5 in snacks. Dietary fibre affects morbidity. However, health disorders also affect dietary fibre intake. About 80% of the subjects had chewing difficulties and more than 60% of those had gut disorders. About 50% of the subjects also had chronic diseases Publisher: Elsevier Science Inc. All right reserved. Doi 10.1016/S0899-9007(02)00981-4

The effect of fortified breakfast cereal on plasma homocyst(e)ine concentrations in healthy older men already consuming a folate fortified diet Holmes, and Gates (2003) Nutrition Research volume 23, issue 4 pages 435-449

High plasma homocysteine (hcy) concentrations may be an independent risk factor for cardiovascular disease. Folic acid supplementation reduces plasma hcy, however no studies used fortified foods and nutrition education to promote a sustained diet change. The effects of nutrition education and fortified cereal consumption on plasma hcy were studied in 41 men 58 years old. Subjects randomised into the experimental group (n=21) received super- fortified ready-to-eat cereal (400 g folic acid) for 8 weeks, and nutrition education based on the Social Cognitive Theory. Control group subjects (n=20) received general nutrition education only. Folate intake at baseline was similar to recommended levels (436±204 g/day). Experimental subjects increased folic acid intake, and serum folate was significantly higher at follow up. Plasma hcy did not differ significantly over time between groups. Subjects with moderate hcy concentrations who are already eating fortified foods regularly may not benefit from consuming folate above recommended levels. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0271-5317(02)00547-X

161 Nutri-Senex: State of the art report – task 2.1

Value of body mass index in the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters

Campillo, et.al (May 2003) Clinical Nutrition Journal

We have estimated the prevalence of severe malnutrition in groups of patients hospitalised for different medical causes and assessed the sensitivity of BMI in the diagnosis of severe malnutrition. A prospective study enrolled 1052 patients: 396 patients with liver cirrhosis including 165 non-ascitic patients (NAP), 124 patients with mild ascites (MAP), 107 patients with tense ascites (TAP), 251 patients after cardiac surgery (SCP), 81 patients with cardiac diseases (MCP), 85 patients with stroke (SP), 36 patients with degenerative neurological diseases (DNP), 68 patients after surgery of a hip fracture (HFP), 91 patients with palliative care for cancer (CP) and 44 elderly patients with medical affections (EP). BMI, mid-arm muscular circumference (MAMC) and triceps skinfold thickness (TST) were measured within 48 h after admission. Patients with MAMC and TST below the 5th percentile of a reference population when aged 74 or the 10th percentile when aged 75 were defined as severely malnourished. Sensitivity of BMI<20 to detect malnutrition was assessed. The prevalence of severe malnutrition was the highest in TAP (39.1%) HFP (25.6%) and MAP (24.3%) and the lowest in SCP (4%), SP (4.8%), DNP (5.7%) and MCP (7.4%) (P<10-4). In multivariate analysis, low TST was associated with female gender (P<10-4) mild and tense ascites (P=0.038, P=0.0004), low MAMC with male gender (P<10-4), low BMI with female gender (P=0.0082), hip fracture (P=0.0407) and cancer (P=0.0059). The sensitivity of BMI to detect severe malnutrition was the highest in HFP, CP and EP (100%, 80% and 100% respectively) and the lowest in TAP, MCP and SP (40%, 33.3% and 50% respectively). After exclusion of TAP, sensitivity of BMI to detect malnutrition correlated significantly with the coefficient of correlation between MAMC and TST observed in each group (r=0.821, P=0.0066). Conclusion: Ascitic cirrhotic patients and elderly patients after surgery of hip fracture had the highest prevalence of severe malnutrition. BMI had the highest sensitivity when both TST and MAMC were damaged to the same extent. BMI<20 has a high sensitivity in the diagnosis of severe malnutrition in elderly and cancer patients but not in cirrhotic patients with tense ascites, cardiovascular and neurological patients. Publisher: Elsevier Ltd. All rights reserved. Doi 10.1016/j.clnu.2003.10.003

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Nutrition considerations in the development and review of food standards, with particular emphasis on food composition

Lewis et.al, (2003) s.i.c Food Control Journal volume 14, issue 6 pages 399-407

Although Australia and New Zealand have nutritious and abundant food supplies, nutrition policies continue to be important in guiding food regulation in these countries. This paper documents the regulatory nutritional principles that serve to meet the Australia New Zealand Food Authority's key objectives, in particular the protection of public health and safety, and their implementation in the development and recent review of food regulation in Australia and New Zealand. These principles, based on a cautionary approach to risk, have been applied particularly to the compositional aspects of the food regulation. These aspects include the regulatory control of voluntary and mandatory addition of nutritive substances such as vitamins and minerals to foods; particular standards that regulate foods for general consumption; and standards for special purpose foods. Labelling controls on nutrient information are also discussed Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016/S0956-7153(03)00038-06

Micronutrient supplementation: when is best and why?

L’Abbé (2003) Proceedings of The Nutrition Society volume 62, issue. 2, page. 413-420. [PDF Not available]

For many nutrients, a systematic determination of the effects of high intakes over extended periods of time has not been conducted. Governments and scientific bodies have just begun to establish the methodology for, and to conduct, nutrient risk assessments for setting ‘tolerable upper levels of intake’ (UL) for nutrients. Nutrient risk assessment provides the framework for using available information to evaluate the safety of nutrients when added to foods or when consumed as supplements, in order to minimize the risks from over- consumption. When intakes are inadequate, food fortification may be the appropriate choice for some nutrients, while in other situations, when requirements are markedly higher for some population subgroups than for the general population, supplements may be the most appropriate intervention. The present paper will present some examples of how to use the UL along with food consumption data to assess the appropriateness of food fortification v. supplementation strategies and to assess their impact on nutrient intakes of the population. The important steps to be followed when evaluating which approach is best are: (a) establishing need, i.e. assessing the gap between current and desired intakes; (b) assessing safety, i.e. consider the margin of safety between requirement and UL as well as the severity and reversibility of the adverse effect that was used to establish the UL; (c) estimating

163 Nutri-Senex: State of the art report – task 2.1 exposure through statistical modelling, in which population-based estimates of intakes before and after the intervention are compared; (d) monitoring the impact of the intervention to ensure that the desired benefits are achieved and that excessive intakes are minimized. This approach can optimise the public health benefits of food fortification or supplement use while minimizing the risks due to excessive intakes. Publisher: CABI publishing on behalf of the Nutrition Society. Doi: 10.1079/PNS2003263

Persistence of vitamin B12 insufficiency among elderly women after folic acid food fortification

Ray, et.al (2003) Clinical biochemistry Journal volume 35, issue 5 pages 387-391.

To estimate the associated risk of folate and vitamin B12 (B12) insufficiency, as well as vitamin repletion, following folic acid food fortification. Design Retrospective cross-sectional study over a 5-year period. Setting Two large laboratory databases in the provinces of Ontario and British Columbia, Canada. Participants Canadian women aged 65 years and over who underwent concomitant clinical testing of serum folate and B12 during the pre- fortification period of January 1996 to December 1997 in Ontario (n = 733) and British Columbia (n = 3839), and in the near-complete post-fortification period of January 1998 to December 2000 in Ontario (n = 4415) and British Columbia (n = 6677). Geometric mean concentrations of serum folate and B12 before and after folate fortification. Prevalence ratios (PR) were used to separately compare the post- and pre-fortification period rates of folate deficiency (below 6.0 nmol/L); B12 insufficiency (below 150 pmol/L); and B12 insufficiency in combination with supraphysiological concentrations of serum folate (above 45 nmol/L). The mean baseline folate and B12 concentrations were similar between provinces. Using the combined provincial data, the mean serum folate concentration increased by 64% after fortification, from 14.8 to 24.2 nmol/L (p < 0.001). The average B12 concentration increased from 280 to 300 pmol/L, which was more pronounced in BC (p < 0.001) than in Ontario (p = 0.16). The prevalence of folate deficiency declined from 6.3% to 0.88% after fortification (PR 0.14, 95% confidence interval [CI] 0.11-0.18), while the decline in B12 deficiency was less pronounced (PR 0.78, 95% CI 0.71-0.86). The prevalence of combined B12 insufficiency with supraphysiological concentrations of serum folate increased from 0.09% pre-fortification to 0.61% post (PR 7.0, 95% CI 2.6-19.2). The introduction of folic acid food fortification was associated with a substantial improvement in the folate status of Canadian women aged 65 years and older, paralleled by a large decline in the rate of folate deficiency. Improvement in the B12 status of these women was far less pronounced. Because the prevalence of combined B12 insufficiency and supraphysiological concentrations of serum folate may have

164 Nutri-Senex: State of the art report – task 2.1 increased with folic acid food fortification, consideration should be given to confirming this finding, and possibly, to the addition of B12 to folate fortified foods. SponsorshipPublic Health Branch, Ontario Ministry of Health and Long Term Care.Potential conflict of interest, none Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0009- 9120(03)00061-4

Multiple sources of dietary calcium––some aspects of its essentiality

Fishbein (2003). Regulatory, Toxicology and Pharmacology volume 39, issue 2 pages 67-80

The increasing recognition of the important role of calcium in the myriad regulation of cellular processes in the health and well being throughout one's lifetime has focused on the need to ensure a sufficiency of its intake for nutritional, physiological, and medical reasons. Additionally, the recognition of the dynamic dietary changes and preferences of various populations in terms of their consumption of calcium-containing products coupled with large variations of food patterns and availability of calcium, highlights the need to consider and evaluate multiple sources of calcium (dairy, non-dairy, fortified foods, and supplemental). Aspects of the essentiality of calcium are thus considered via an initial consideration of: the salient aspects of absorption and bioavailability, changes in individual and societal dietary habits and preferences and the evaluation of various RDAs, AIs, and DRIs for calcium. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/j.yrtph.2003.11.002

Impact of nutritional status and nutrient supplements on immune responses and incidence of infection in older individuals

Chandra, (2003) Ageing Research Reviews volume 3, issue 1 pages 91-104

With advancing age there is a progressive decline in immune responses although this is not inevitable. The impairment in immuno competence is noticeable as early as 35–40 years in many individuals. At the same time, some persons even in the 80s may show a vigorous immune system comparable with that of the young adult. Nutrient deficiencies are frequent in older populations. A variety of nutrients are affected: zinc, iron, beta-carotene, Vitamins B6, B12, C, D and E, ad folic acid. The causal interaction between nutritional deficiencies and impaired immunity has been known in children; a similar relationship has been postulated in the elderly. In the last 25 years, many studies employing different designs have examined the role of diet, nutritional status, and nutrient supplements in the immune responses of older individuals. Some nutrients, for example zinc and Vitamin E, have been shown to increase selected immune responses but have not been beneficial in terms of reduction in infectious morbidity. A growing consensus indicates that the use of a multinutrient containing optimum

165 Nutri-Senex: State of the art report – task 2.1 amounts of essential trace elements and vitamins is likely to result in enhanced immune responses and reduction in the occurrence of common infections. These findings have considerable fundamental, clinical and public health significance. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/j.arr.2003.08.004

Oral supplements differing in fat and carbohydrate content: effect on the appetite and food intake of undernourished elderly patients

Ryan et.al, (2003) Clinical nutrition Journal

Since fat, relative to other macronutrients, has low satiety and high energy density, it may have therapeutic application for supplementing energy intake. This study compared the effect of isoenergetic (1050 kJ) high fat or high carbohydrate oral supplements, given at breakfast, on the short-term appetite and energy intake in undernourished elderly subjects. Sixteen hospitalised, undernourished (body mass index: 20±3 kg/m2), elderly (77±8 yr) people were randomly allocated to a control or 1 of 2 supplement groups [fat: carbohydrate: protein (% energy) was 70:25:5 or 25:70:5]. In each group, energy intake (24-h food consumption) and appetite (visual analogue scales) were assessed over 3 consecutive days. Mean energy intake significantly (P=0.0035) increased following supplementation: high fat 6973 kJ/d, high carbohydrate 6906 kJ/d vs. control 6079 kJ/d but mean voluntary 24-h energy intake remained unaffected. Compared to controls, supplemented subjects experienced reduced hunger (P=0.07) between breakfast and lunch, but showed no difference over the whole day (P=0.55). Under these study conditions a 1050 kJ oral supplement, irrespective of macronutrient composition, does not cause voluntary short-term energy intake compensation in undernourished elderly people. Publisher: Elsevier Science Inc. Doi 10.1016/j.clnu.2003.11.003

166 Nutri-Senex: State of the art report – task 2.1

ESPEN Guidelines for Nutrition Screening 2002

Kondrup, et.al (2003) Clinical Nutrition volume 22, issue 4 pages 415-421

To provide guidelines for nutrition risk screening applicable to different settings (community, hospital, elderly) based on published and validated evidence available until June 2002. Note: These guidelines deliberately make reference to the year 2002 in their title to indicate that this version is based on the evidence available until 2002 and that they need to be updated and adapted to current state of knowledge in the future. In order to reach this goal the Education and Clinical Practice Committee invites and welcomes all criticism and suggestions (button for mail to ECPC chairman). Publisher: Elsevier Ltd. All rights reserved. Doi 10.1016/S0261-5614(03)00098-0

Short-term effect of a protein load on appetite and food intake in diseased mildly undernourished elderly people

Irvine et.al, (August 2003). Clinical Nutrition Journal

Malnutrition is a risk factor for mortality and various morbidities in the elderly. A low-energy intake often prevails and therapeutic interventions include the administration of dietary supplements, sometimes rich in proteins. We have tested the hypothesis that a protein-rich supplement inhibits appetite and decreases voluntary food intake. Twelve mildly undernourished (BMI 21.3±2.4 kg/m2) elderly (84±7.8 yr) diseased persons were each studied under 3 conditions, in which they were given in random order at breakfast, and on consecutive days: either no supplement, a 250 kcal, 20 g protein supplement or a 250 kcal, 3.5 g protein supplement. Hunger, fullness, and desire to eat sensations were monitored half-hourly from before breakfast until lunch, and hourly from lunch until dinner. Food intake was assessed by weighing food before and after meals. Total energy and macronutrient intakes were calculated over 24 h. Both supplements increased energy intake (+185 kcal protein supplement, +176 kcal). Protein supplementation induced a net 17 g increase in protein intake (P0.0003). Neither supplement affected spontaneous food intake at lunch, dinner, or over the 24 h. Protein supplementation significantly depressed appetite in the breakfast to lunch period. A 250 kcal, 20 g protein supplement depresses hunger without affecting food intake in elderly diseased mildly undernourished persons. Publisher: Elsevier Science Inc. All rights reserved Doi 10.1016/j.clnu.2004.02.011

167 Nutri-Senex: State of the art report – task 2.1

Predicting malnutrition in nursing home residents using the minimum data set

Crogan, (2003). Geriatric Nursing Journal volume 23, issue 4 pages 224-226

This article describes the prevalence of protein/calorie malnutrition among newly admitted elderly nursing home residents and identifies the most significant predictors using Minimum Data Set (MDS) variables. This random selection, cross-sectional study included 266 residents, 65 and older, from three nursing homes. Malnutrition risk factors, indicators, and prevalence variables in the MDS were measured for each resident on admission to the nursing home. MDS data provide an opportunity for early identification of residents at risk for malnutrition and accompanying morbidity. Treating residents who are malnourished or at high risk for weight loss on admission could dramatically improve their quality of life. (Geriatric Nurse 2002;23:224-6) Publisher: Mosby Inc. All rights reserved Doi 10.1067/mgn.2002.126972

Use of oral supplements in malnourished elderly patients living in the community: a pharmaco-economic study

Arnaud-Battandier et.al (2003) Clinical Nutrition Journal.

Background & aims: Inadequate nutritional support in elderly patients is likely to be responsible for increased morbidity and increased associated costs. Conversely prescribing oral supplements to ensure sufficient protein and energy intake should be beneficial. Even though this claim makes sense there is a lack of objective data to support the evidence. The objective of the present study was to assess the cost of malnutrition and related co morbidities among elderly patients living in the community and to determine the impact of nutritional support practice on these outcomes. Observational, prospective, longitudinal, cohort study with a 12 months follow-up conducted with 90 general practitioners in France. Two groups of physicians were selected based on historical prescribing practice: group 1 with rare and group 2 with frequent prescription of oral nutrition supplements. The resulting study population was 378 elderly malnourished patients aged over 70, living in the community, either at home or in institutions. Nutritional status at baseline was determined using the Mini Nutritional Assessment (MNA) scale. Main outcome measures were nutritional status; malnutrition-related co morbidities and medical care consumption. Populations in the two groups of patients were balanced for age, gender, weight and body mass index but differed significantly in terms of housing status (P<0.005) and nutritional status (P<0.001). After adjustment for baseline characteristics, MNA improved within both

168 Nutri-Senex: State of the art report – task 2.1 groups over time but improvement was significantly higher in group 2 than in group 1 (P<0.01). The adjusted cost per patient of hospital care (EUR -551), nursing care (EUR -145) and other medical care was significantly reduced in group 2 as compared to group 1, with cost savings of EUR -723 per patient (90% CI: EUR -1.444 to EUR -43). Including the costs related to nutritional products, the total cost savings per patient attributable to nutrition support were EUR -195 (90% CI: EUR -929 to EUR +478). Appropriate nutrition support can address the problem of malnutrition among elderly individuals living in the community and may contribute to reduce the costs of health care Publisher: Elsevier Science Ltd. Doi 10.1016/j.clnu.2004.02.007

The development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN)

Weekes et.al (2003) Clinical Nutrition volume 14 issue 4 page 269

Nutrition screening tools (NST) identify individuals who are malnourished or at risk of becoming malnourished and who may benefit from nutritional support. The aims of this study were to design, pilot and evaluate a NST based on four nutritional parameters (weight, height, recent unintentional weight loss and appetite) recommended by the British Association for Parenteral and Enteral Nutrition as the minimum required to identify patients with nutritional problems. A dietician assessed the nutritional status of 100 patients admitted to the general medical wards. Results from the study were used to design a NST. The concurrent validity of the screening tool was then assessed, by comparing it with a nutritional assessment by an experienced dietician in 100 patients admitted to acute medical and elderly care wards. The inter-rater reliability of the screening tool was also assessed using three nurses and 26 acute medical patients. All four nutritional parameters were required to identify all at-risk patients. There was good agreement between the screening tool and the dietician’s assessment (=0.717) and inter- rater reliability was reasonable (mean =0.66).The screening tool was valid and reliable in identifying medical patients at risk of malnutrition and was quick and simple to use. Publisher: Elsevier Science Ltd. Doi 10.1016/j.clnu.2004.02.003

169 Nutri-Senex: State of the art report – task 2.1

A role for supplements in optimising health: the metabolic tune-up

Ames (2003) Archives of Biochemistry and Biophysics volume 423, issue 2 pages 227- 234

An optimum intake of micronutrients and metabolites, which varies with age and genetic constitution, would tune up metabolism and give a marked increase in health, particularly for the poor, young, obese, and elderly, at little cost. (1) DNA damage. Deficiency of vitamins B- 12, folic acid, B-6, C or E, or iron or zinc appears to mimic radiation in damaging DNA by causing single- and double-strand breaks, oxidative lesions or both. Half of the population may be deficient in at least one of these micronutrients. (2) The Km concept. Approximately 50 different human genetic diseases that are due to a poorer binding affinity (Km) of the mutant enzyme for its coenzyme can be remedied by feeding high-dose B vitamins, which raise levels of the corresponding coenzyme. Many polymorphisms also result in a lowered affinity of enzyme for coenzyme. (3) Mitochondrial oxidative decay. This decay, which is a major contributor to aging, can be ameliorated by feeding old rats the normal mitochondrial metabolites acetyl carnitine and lipoic acid at high levels. Many common micronutrient deficiencies, such as iron or biotin, cause mitochondrial decay with oxidant leakage leading to accelerated aging and neural decay. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/j.abb.2003.11.002

Modelling the supplementing of human diets

Lancaster et.al (2003) Socio-Economic Planning Sciences Journal

This paper looks at the economic benefits of nutritional supplement use. Food plans, with and without nutritional supplements, are developed by maximizing a quadratic food utility function subject to nutrient and budget constraints. The quadratic programming solutions, which include both the marginal utilities and marginal costs of nutrients, are then presented. The results demonstrate the economic optimality of partial supplementation. Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016/j.seps.2003.10.0001

170 Nutri-Senex: State of the art report – task 2.1

The potential benefits of dietary and/or supplemental calcium and vitamin D

Moyad (2003). Urologica Oncology: Seminars and original investigations volume 21, issue 5, pages 384-391

Osteoporosis is a significant problem in women and men. In addition, as osteoporosis has garnered more attention there should be more attention than ever placed on the potential benefits of calcium and vitamin D. Clinicians need to inform patients that there are numerous healthy dietary sources of calcium and vitamin D. Calcium and vitamin D supplements seem to act synergistically to reduce fracture risk in men and women; therefore, they need to be taken together to impact fracture risk. In addition, almost every randomised trial of an effective osteoporosis drug therapy has utilized calcium and vitamin D to enhance the efficacy of the drug itself. Several forms of calcium supplements are commercially available today and clinicians need to understand the similarities and differences between them. Calcium and vitamin D in moderation also have a good safety profile and may actually have benefits far beyond osteoporosis therapy. For example, calcium may increase high-density lipoprotein (HDL), prevent colon polyps, reduce blood pressure, reduce kidney stone recurrence, and may promote weight loss. Vitamin D may reduce the risk of some cancers, provide an enhanced response to some chemotherapeutic agents, prevent type I diabetes, and may reduce tooth loss along with calcium. Clinicians need to encourage individuals to receive the recommended daily allowance of these two agents because they seem to have an impact on numerous health conditions besides osteoporosis. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S1078-1439(03)00108-X

Demographic and health-related correlates of herbal and specialty supplement use

Gunther, et.al (2003). Journal of the American Dietetic Association Volume 104 Issue 1 pages 27-34

By broadening the definition of a dietary supplement, the 1994 Dietary Supplements Health and Education Act opened the market to many herbals, botanicals, and other food ingredients that would have otherwise needed safety testing before being sold. Information regarding patterns and correlates of herbal and specialty supplement use can help nutritionists understand which compounds are most commonly used, who are likely to use these supplements, and whether the choice of herbal supplements appears motivated by specific health concerns. Data are from 61,587 participants, aged 50 to 76 years, who completed a self-administered mailed questionnaire in 2000–2002 on current dietary supplement use (20 herbal/specialty

171 Nutri-Senex: State of the art report – task 2.1 supplements, multivitamins, and 17 individual vitamins or minerals), demographic and lifestyle characteristics, and medical history. When compared with no supplement use, herbal/specialty supplement use was significantly higher among respondents who were older, female, educated, had a normal body mass index, were non-smokers, engaged in exercise, and ate a diet lower in fat and higher in fruits and vegetables (all P<.001). Similar trends were observed when herbal/specialty supplement users were compared with vitamin/mineral users. For specific supplements and medical conditions, the strongest associations were cranberry pills and multiple bladder infections (odds ratio [OR], 4.66; 95% confidence interval [CI], 4.03–5.38), acidophilus pills and lactose intolerance (OR, 3.37; 95% CI, 2.96–3.84), and saw palmetto and enlarged prostate (OR, 3.33; 95% CI, 3.00–3.72). Odds of supplement use are high for certain demographic and lifestyle characteristics. Additionally, persons with specific medical conditions are using supplements promoted to reduce risk for their particular conditions. Copyright 2004 The American Dietetic Association Publisher: Elsevier Science USA Doi 10.1016/j.jada.2003.10.009

Effect of age on substrate oxidation during total parenteral nutrition

Al-Jaouni et.al (2002.) Nutrition Journal volume 18 issue1, pages20-25

Parenteral nutrition is increasingly used in the elderly. Aging is accompanied by metabolic changes that can modify substrate use. We compared substrate oxidation during cyclic total parenteral nutrition (TPN) in elderly and middle-aged patients: Twelve elderly patients (eight women, four men; 72 ± 5 y) and 12 middle-aged patients (nine women, three men; 39 ± 13 y) who were on cyclic TPN for intestinal failure were investigated while in stable condition after at least 15 d of TPN. No patient was diabetic. Indirect calorimetry was performed during fasting and every 30 min during the 3 h of TPN infusion and 3 h after infusion, allowing the measurement of nutrient oxidation. Blood samples were obtained every hour for the measurement of glucose, insulin, triacylglycerols, and free fatty acids. In the fasting state, resting energy expenditure was significantly higher in the elderly patients than in the middle- aged patients (39.3 ± 8.1 versus 31.9 ± 4.3 kcal/kg of fat-free mass per day, P = 0.008). During TPN, lipid oxidation was significantly higher in the elderly patients than in the middle- aged patients (1.09 ± 0.17 versus 0.84 ± 0.27 mg · kg-1 · min-1, P = 0.011); glucose oxidation was significantly lower in the elderly patients than in the middle-aged patients (2.19 ± 0.93 versus 3.22 ± 1.54 mg · kg-1 · min-1, P = 0.038). Areas under the curves of glycaemia and free fatty acids were significantly higher in the elderly patients. In the elderly, TPN was

172 Nutri-Senex: State of the art report – task 2.1 associated with significantly higher lipid oxidation and lower glucose oxidation than in younger patients. TPN formulas and flow rates should therefore be adapted in the elderly. Publisher: Elsevier Science Inc. Doi 10.1016/S0899-9007(02)00794- 9

Usefulness of soluble dietary fibre for the treatment of diarrhoea during enteral nutrition in elderly patients

Nakao et.al (2002) Nutrition Journal volume 18 issue 1 pages 35-39

We investigated the clinical usefulness of soluble dietary fibre (SDF) for the treatment of diarrhoea during enteral nutrition in elderly patients. This study included 10 men and 10 women (mean age ± standard deviation: 79.3 ± 5.1 y) who had diarrhoea during long-term nutrition management. When administering SDF, the initial dose was 7 g and thereafter gradually increased at 1-wk intervals. After 4 wk, the administration was discontinued for 2 wk to confirm the effects of SDF. After the administration of SDF, serum diamine oxidase activity significantly increased (P < 0.001): The water content of the faeces decreased significantly after the administration of fibre (P < 0.01). The frequency of daily bowel movements also decreased significantly (P < 0.05). Simultaneously, the faecal features improved. Concerning intestinal flora, there were no significant changes in the total number of bacteria or the number of anaerobic bacteria. The faecal pH decreased significantly 4 wk after the administration of fibre (P < 0.05). The total level of short-chain fatty acids increased significantly 4 wk after the administration of fibre (P < 0.05). There were no significant changes in the various nutritional indices. The administration of SDF is useful for controlling spontaneous, favourable bowel movement by improving symptoms of small intestinal mucosal atrophy and normalizing the intestinal flora. Publisher: Elsevier Science Inc. Doi 10.1016/S0899-9007(01)00715-8

Dietary flavonols: chemistry, food content, and metabolism

Aherne (2002) Nutrition Journal volume 18 issue 1 pages 75-81

The flavonols belong to a large group of compounds called flavonoids, which are diverse in their chemical structure and characteristics. Fruits, vegetables, and beverages such as tea and red wine are major sources of flavonols in the human diet. The daily consumption of flavonols is difficult to estimate because values depend on accurate assessment of feeding habits and flavonol content in foods. Food sources, dietary intakes, and bioavailability of flavonols are strongly influenced by variations in plant type and growth, season, light, degree

173 Nutri-Senex: State of the art report – task 2.1 of ripeness, food preparation, and processing, all of which are discussed. In the past few years, a number of studies on the absorption and metabolism of flavonols in humans have been published and the findings from these studies are reviewed. We do not discuss the health effects of flavonols.

Forum on therapeutic nutrition: 2000 clinical practice update. September 9, 2000, Palisades, New York, USA

Kendler (2002) Nutrition Journal volume 18, issue 1 pages115-117

A "Forum on Therapeutic Nutrition: 2000 Clinical Practice Update" was held on September 9, 2000 at the Palisades Executive Convention Centre in Palisades, New York. The conference was sponsored by Thorne Research, Inc., a formulator and distributor of nutritional supplements. Presentations by the five speakers were summarized. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(01)00733-X

Effects of caffeine, vitamin D, and other nutrients on quantitative phalangeal bone ultrasound in postmenopausal women

Rico, et.al, (February 2002) Journal of Nutrition volume18 issue 2 pages 189-193

We investigated the controversial effects of coffee and other nutrients on bone mass. A study of 93 healthy postmenopausal women (mean ± standard deviation: 57.3 ± 7.1 y old and 8.9 ± 7.5 y since menopause) selected on the basis of not having changed their eating habits since premenopause, not smoking, not exercising, not receiving hormone-replacement therapy, and having a weight in the range of 70% to 130% of their ideal weights, amplitude-dependent speed of sound (Ad-SOS) was determined by quantitative bone ultrasound, and a prospective 7-d diet survey evaluated the intake of caffeine and nutrients involved in calcium metabolism. Women were stratified according to their caffeine, calcium, and vitamin D intakes and ratios of calcium to phosphorus and to protein. Ad-SOS differed only with vitamin D intake and was greater in the group taking at least 400 IU/d (P < 0.0001). In simple and multiple regression analyses, the only significant variable that affected Ad-SOS and nutrient intake was vitamin D (P < 0.0001). Phalangeal bone Ad-SOS was influenced only by the intake of vitamin D, not of caffeine or other nutrients. This lack of effect of caffeine and protein may be related to good nutritional intake or the low levels of caffeine consumed Publisher: Elsevier Science Inc. Doi 10.1016/S0899-9007(02)00794

174 Nutri-Senex: State of the art report – task 2.1

Nutrition in the elderly

Pirlich & Lochs, (2002) The Best Practice and Research Clinical Gastroenterology volume 15, issue 6 pages 869-884

Malnutrition is more common in elderly persons than in younger adults. Ageing itself, however, neither leads to malabsorption nor to malnutrition with the exception of a higher frequency of atrophic gastritis in older persons. Malnutrition in elderly people is therefore a consequence of somatic, psychic or social problems. Typical causes are chewing or swallowing disorders, cardiac insufficiency, depression, social deprivation and loneliness. Under nutrition is associated with a worse prognosis and is an independent risk factor for morbidity and mortality. Awareness of this problem is therefore important. For the evaluation of nutritional status, it must be remembered that most normal values are derived from younger adults and may not necessarily be suitable for elderly persons. Suitable tools for evaluating the nutritional status of elderly persons are e.g. the body mass index, weight loss within the last 6 months, the Mini Nutritional Assessment (MNA) or the Subjective Global Assessment (SGA). An improvement in the nutritional status can be achieved by simple methods such as the preparation of an adequate diet, hand feeding, additional sip feeding or enteral nutrition. Publisher: Harcourt Publishers Ltd. Doi 10.1053/bega.2001.0246.

Effect of treatment with folic acid and vitamin B6 on lipid and homocysteine concentrations in patients with coronary artery disease

Mark, et.al (2002) Journal of Nutrition volume 18 issue 5 pages 428-429

It has become clear in recent years that in addition to the traditional cardiovascular disease risk factors, high plasma homocysteine concentrations increase the risk of atherosclerotic diseases. A meta-analysis of 27 studies found that 10% of a population's coronary risk is attributable to homocysteine and that a 5- M/L increase in the plasma homocysteine concentration elevates coronary risk by as much as a 0.5-mM/L increase in cholesterol. Recent studies showed an inverse relation between plasma concentrations of homocysteine and of folic acid, vitamin B6, and vitamin B12, which are cofactors and substrates in homocysteine and methionine metabolism. The methylenetetrahydrofolate reductase (MTHFR) enzyme plays an important role in homocysteine metabolism. Homozygosity for the C-to-T substitution at nucleotide 677 (C677T mutation) in the MTHFR gene can elevate the homocysteine concentration, although there is no clear evidence that the mutation itself influences the incidence of coronary artery disease (CAD). In the present prospective study, we measured concentrations of lipids, homocysteine, and folic acid and assessed the C677T

175 Nutri-Senex: State of the art report – task 2.1 mutation status of CAD patients to evaluate the effect of supplementation with folic acid and vitamin B6 on these variables. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(02) 00772-4

Nutritional support in acute stroke: the impact of evidence-based guidelines

Perry, & McLaren (2002) the Clinical Journal volume 22, issues 3 pages 283-293

Stroke patients experience multiple impairments, which impair ability to eat and render them vulnerable to the deleterious sequelae of malnutrition. This study aimed to develop, implement and evaluate evidence-based guidelines for nutrition support following acute stroke using a multifaceted change management strategy. Prospective quasi-experimental design. Documentation of two groups of 200 acute stroke patients admitted to medical and care of the elderly wards of an acute NHS Trust in South London was surveyed using a checklist before and after implementation of 24 guidelines for nutritional screening, assessment and support. Guidelines were based on systematic literature review and developed by consensus in a nurse-led multiprofessional group; implemented via a context- specific, multifaceted strategy including opinion leaders and educational programmes linked to audit and feedback. Staff outcomes: Compliance with guidelines by doctors, nurses, and therapists. Patient outcomes: Changes in Barthel Index scores and Body Mass Index in hospital, infective complications, length of stay, discharge destination. Results: Statistically significant improvements in compliance with 15 guidelines occurred in the post-test group. Infective episodes showed a significant reduction in the post-test group but other patient outcomes were unaffected. Implementation of evidence-based guidelines for nutritional support following acute stroke using a multifaceted strategy was associated with improvements in documented practice and selected patient outcomes. Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016/S0261-5614(02)00213-3

The effect of a liquid nutrition supplement on body composition and physical functioning in elderly people

Wouters-Wesseling, (2002) Clinical Nutrition Journal Volume 22, Issue 4 pages 371-377

The elderly are at an increased risk of poor nutritional status, which is mutually interacting with functional status. We evaluated the effects of a liquid nutrition supplement on anthropometric and functional indices in elderly people. Subjects (n=68; mean AGE=82±7 years) with body mass index 25 kg/m2 received either a supplement or a placebo for 6

176 Nutri-Senex: State of the art report – task 2.1 months. Anthropometric (body weight, bioelectrical impedance, calf circumference), biochemical (albumin, prealbumin), functional parameters (handgrip strength, timed `up and go' test) and dietary intake were measured. Activities of daily living and Nottingham Health Profile (NHP) were assessed. No compensation of energy intake occurred. After 6 months, the supplement group had gained more weight (+1.6 kg) than the placebo group (+0.3 kg) (P=0.03). No other significant changes in anthropometric, functional or blood parameters were seen. There was a significant improvement on the section `sleep' of the NHP (mean change±SE=-0.38±0.19 for supplement vs. 0.24±0.19 for placebo, P=0.03). Dietary supplementation led to an increase in body weight and had a positive influence on sleep in elderly persons. Supplementation did not affect energy intake from regular meals and thus resulted in additional energy intake. Publisher: Elsevier Science Inc. All rights reserved Doi10.1016/S0261/5614(03)00034-7

Preventive nutrition: the comprehensive guide for health professionals, 2nd ed.

Kendler (2002) Journal of nutrition volume 18, Issue 6 pages 540-542.

In the Preface the editors set out their objectives for this second edition of Preventive Nutrition: The Comprehensive Guide for Health Professionals. They hope to provide health professionals of all disciplines with the latest research supporting the thesis that simple nutritional modifications of the diet can prevent or delay many chronic degenerative diseases. Such diseases include cardiovascular disease and cancer, the leading killers in industrialized countries. It can be estimated that the application of preventive nutrition to the prevention of cardiovascular disease and cancer could result in annual health care savings of more than 20 billion dollars. Other diseases amenable to nutritional prevention and discussed in detail in this book include macular degeneration (the primary cause of incurable blindness in the United States); osteoporosis (the leading cause of bone fractures); birth defects and their consequences, low birth weight and impairments in childhood vision and intellectual capacity; and disorders of the immune system. ISBN: 0-89603-911-0 Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(02)00794-3

177 Nutri-Senex: State of the art report – task 2.1

Improving iron, zinc and vitamin A nutrition through plant biotechnology

Zimmermann, & Hurrell (2002) Current Opinion in Biotechnology Volume 13 issue 2 pages 142-145

Recent understanding of plant metabolism has made it possible to increase the iron, zinc and -carotene (pro-vitamin A) content in staple foods by both conventional plant breeding and genetic engineering. Improving the micronutrient composition of plant foods may become a sustainable strategy to combat deficiencies in human populations, replacing or complementing other strategies such as food fortification or nutrient supplementation. Improving the micronutrient composition of plant foods may help to combat deficiencies in human populations. Recent understanding of plant metabolism has made it possible to increase the iron, zinc and pro-vitamin content in staple foods. Publisher: Elsevier Science Ltd. All rights reserved Doi 10.1016/S0958-1669(02)00304-X

Lack of adaptation to severe malnutrition in elderly patients

Schneider et.al (2002) Journal of Clinical Nutrition volume 21, issue 6 pages 499-504

Sarcopenia is a common feature in the healthy elderly. However, little is known on age- related modifications of body composition in malnourished patients. The aims of this cross- sectional study were to evaluate the effects of aging per se on body composition and resting energy expenditure (REE) in malnourished patients. Ninety-seven non-stressed patients referred for chronic malnutrition (C-reactive protein <5 mg/l) were separated into two groups: middle-aged (26 female, 19 male, 48±15 yr), and elderly (26 female, 26 male, 79±6 yr). Body composition was assessed by bioelectrical impedance analysis and REE by indirect calorimetry. In middle-aged patients, body composition remained stable between moderate (body-mass index [BMI; in kg/m2] 16–18.5) and severe (BMI < 16) malnutrition, with similar values of fat-free mass (FFM), body cell mass (BCM) and fat mass (FM) as percentages of body weight, whereas in elderly patients malnutrition occurred at the expense of FFM and BCM, with unchanged FM absolute values. REE/FFM values remained stable in middle-aged patients at every stage of malnutrition, whereas they increased in elderly patients along with their degree of malnutrition. In multivariate analysis, both body composition and REE/FFM were influenced by sex, age, BMI and mid-arm circumference. Compared to younger patients, weight loss in the elderly leads to cachexia, with a preferential loss of FFM and BCM that may participate in the more severe outcomes observed in these patients. They also show elevated REE/FFM values that induce higher energy needs. Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1054/clnu.2002.0584

178 Nutri-Senex: State of the art report – task 2.1

Supplement use: Is there any nutritional benefit?

Troppmann et.al, (2002) Journal of American Dietetic Association volume 102 issue 6 pages 818-825

To examine the role of dietary supplements in improving total nutrient intakes in adults. Dietician-administered 24-hour recalls (of intake including supplements) were conducted in 1997 and 1998. Supplement users were categorized into groups based on the types of supplements used and nutrient intake was examined. Subjects Using a multistage, stratified random sampling, 1,530 Canadian adults aged 19 to 65 years were surveyed. Statistical analyses performed Intakes from diet, supplements, and diet plus supplements were examined by age/gender stratification. Supplement users had dietary intakes, from food alone, similar to nonusers with mean intakes in some age/sex groups below the Recommended Daily Allowance (RDA)/Adequate Intake (AI) for iron, calcium, and folate. Multivitamin users had mean intakes (from diet plus supplement) of folate above the RDA and iron intakes also increased to RDA levels among women aged 19 to 50 years. Calcium supplement users had lower calcium and vitamin D intakes than nonusers from diet alone in some age/sex groups. Calcium tablets increased mean calcium intakes to AI levels among all age/sex groups. Many supplement users exceeded the new Upper Limits of safe intake; 47% in the case of niacin. Supplements are commonly used and can help some persons adhere to Dietary Reference Intake recommendations concerning intake of folate, calcium, vitamin D, and iron. We found multivitamin users to have higher total intakes of folic acid, iron, calcium, and vitamin D. Also, targeted use of calcium supplements effectively enhanced intakes. However, concurrent vitamin D supplementation is important and awareness of product composition with respect to Upper Limits is essential. Copyright 2002 American Dietetic Association. Publisher: Elsevier Science U.S.A Doi 10.1016/S0002-8223(02)90183-5

Adjunctive therapies in nutritional support

Ziegler et.al (2002) Nutrition Journal volume 13, Issue 9 Supplement 1 pages 64-72

The need for new therapeutic approaches to improve the metabolic and clinical efficacy of nutritional therapy has been increasingly emphasized. The field of nutrition support of catabolic, malnourished, or hospitalised patients is rapidly evolving in response to the beneficial effects observed with adjunctive therapies in animal models and in emerging clinical investigations. Enteral nutrition is being increasingly administered, and enteral diets are being tested to improve gut structure and function. Adjunctive therapies in enteral and parenteral nutrition are being actively investigated. These include administration of

179 Nutri-Senex: State of the art report – task 2.1 recombinant growth factors and anabolic steroid hormones (e.g., growth hormone, oxandrolone); conditionally essential amino acids (e.g., arginine, glutamine); novel lipid products (e.g., structured lipids, fish oils); nutrient antioxidants (e.g., vitamins C and E); and combinations of these approaches. It is likely that current methods of enteral and parenteral nutrition support will evolve in response to the results of these research studies. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1001/S0899-9007(97)83046-8

Vitamin C in Inuit Traditional Food and Women's Diets

Fediuka et.al (2002). Journal of Food composition and Analysis Volume 15, Issue 3 pages 221-235

Vitamin C values for 37 traditional foods (TFs) of the Inuit of the Canadian Arctic and women's intakes from TF and market food (MF) are reported. This is the first report on vitamin C values in several traditional food samples. There are a variety of rich sources of vitamin C from animal and plant food with the most notable among items with multiple samples being raw fish (Coregonus spp.) eggs (49.6±12.3 mg/100 g, mean± S.D.), raw whale (Delphinapterus leucas and Monodon monoceros) skin, locally termed "mattak", (36.0±8.7 and 31.5±7.0 mg/10 g), caribou liver (Rangifer tarandus) (23.8±4.9 mg/100 g), ringed seal liver (Phoca hispida) (23.8±3.8 mg/100 g), and blueberries (Vaccinium uliginosum) (26.2±4.9 mg/100 g). Dietary analysis of 20–40-year-old women's 24-h recalls for vitamin C as TF and MF revealed total mean intake of 60±8 mg/day (mean± S.E.). TF contributed only 20% of total intake, although there was significant seasonal variation (P<0.02). While rich sources of vitamin C are present as TF, the primary contemporary dietary sources of this nutrient are fortified MF. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1006/jfca.2002.1053

Benefits of Nutritional Supplementation in Free-living, Frail, Undernourished Elderly People A Prospective Randomised Community Trial

Hélène Payette, (2002). Journal of American Dietetics Association volume 102 issue 8 pages 1088-1095

To evaluate the impact of nutritional supplementation on nutritional status, muscle strength, perceived health, and functional status in a population of community-living, frail, undernourished elderly people. Design a 16-week intervention study in which subjects were randomised to an experimental or a control group and visited in their home on a monthly

180 Nutri-Senex: State of the art report – task 2.1 basis. Outcome variables were measured at the start and end of the study at subjects' homes by a dietician blinded to treatment assignment. Subjects/setting 83 elderly people (experimental group: N=42; control group: N=41; mean AGE=80±7 years) receiving community home-care services and at high risk for under nutrition. Intervention Provision of a nutrient-dense protein-energy liquid supplement and encouragement to improve intake from other foods. Outcome measures Anthropometric indexes, handgrip strength, isometric elbow flexion and leg extension strength, lower extremity function, perceived health, and functional status. Statistical analyses Study groups were compared on an "intention to treat" basis using analysis of variance for repeated measures and unpaired and paired t tests and their nonparametric equivalents where appropriate. Total energy intake (1,772 vs. 1,440 kcal; P<.001) and weight gain (1.62 vs. 0.04 kg; P<.001) were higher in the supplemented group. No significant changes were observed with respect to other anthropometric indexes, muscle strength, or functional variables; however, beneficial effects were observed in emotional role functioning (P<0.01) and number of days spent in bed (P=.04). Nutrition intervention is feasible in free-living, frail, undernourished elderly people and results in significant improvement of nutritional status with respect to energy and nutrient intake and weight gain. Weight loss can be stopped and in some cases reversed; however, increased physical activity may also be required to improve health and functional status. Copyright 2002 American Dietetic Association. Publisher: Elsevier Science Ltd U.S.A All rights reserved. Doi 10.1016/S0002-8223(02)90245-2

Efficacy of a complex multivitamin supplement

Earnest et.al (2002) Journal of Nutrition Volume 18, Issue 9 pages 738-742

Multivitamin supplements are often sold to consumers with the claim that supplements modify risk factors associated with disease. Because few products are validated scientifically, we examined the effects of a 24-ingredient multivitamin formula in an open-label pilot investigation. We examined 150 subjects for specific endpoints including blood concentrations of selected vitamins, homocysteine, lipids, and low-density lipoprotein (LDL) oxidation indices at baseline and at 12 and 24 wk. One hundred forty-one subjects were successfully assayed for and showed significant time effects for homocysteine and vitamin B6 (as pyridoxal-5'-phosphate), B12, and folic acid concentrations during treatment (P < 0.0001). Vitamin B6, B12, and folic acid concentrations were significantly elevated at weeks 12 and 24 (P < 0.05). Homocysteine concentration decreased significantly during the same periods (7.9 ± 2.4 versus 6.7 ± 1.7 versus 6.7 ± 1.9 mM/mL; P < 0.05). There were

181 Nutri-Senex: State of the art report – task 2.1 correlations relating homocysteine to vitamins B6 (P = 0.001, r2 = 0.03), B12 (P < 0.001, r2 = 0.09), and folic acid (P = 0.001, r2 = 0.10). Significant time effects were noted for 121 subjects successfully assayed for vitamin C, E, -carotene, LDL oxidation rate, and LDL lag time (P < 0.0001). Post hoc assessment showed elevations in vitamin C, E, and -carotene concentrations at 12 and 24 wk (P < 0.05). LDL oxidation lag time at baseline (57.5 ± 13.9 min) increased by 12 wk (63.5 ± 19.0 min; P < 0.05) and 24 wk (63.8 ± 16.3 min; P < 0.05). LDL oxidation rate at baseline (9.7 ± 3.0 M · min-1 · g-1) was reduced at 12 wk (7.1 ± 2.5 M · min-1 · g-1; P < 0.05) and 24 wk (6.0 ± 2.0 M · min-1 · g-1; P < 0.05). Only vitamin C was significantly correlated with LDL oxidation rate (P = 0.05, r2 = 0.003). A multi-ingredient vitamin formula with antioxidant properties has measurable effects on homocysteine and LDL oxidation indices. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(2)00808-0

A surgeon's guide to herbal supplements

Tessier & Bash (2002) Journal of Surgical Research Volume 114, Issue 1 p30-36

The use of herbal supplements has steadily increased in the United States over the last decade. Despite the increased awareness of alternative therapies by the government and lay public, many physicians do not ask their patients about their use of these alternative medications. In addition, many physicians are unaware of the possible side effects that may occur when a patient consumes these substances. Considering a number of these supplements have been associated with adverse reactions in the perioperative period, it is important for a surgeon to understand all of the herbs a patient may be taking. The purpose of this article is to discuss the growing trend of herbal use among surgical patients and give the reader some background on the most commonly used herbs. Publisher: Elsevier Science Inc. All rights reserved Doi 10.1016/S0022-4804(03)00130-6

Fermented grain products, production, properties and benefits to health

Minamiyama, et.al (2002) Pathophsiology Journal Volume 9 Issue 4 pages 221-227

Fermented foods such as Japanese traditional food "miso (fermented soy bean paste)" have been shown to be rich source of micronutrients with the potential to prevent various human diseases. We have introduced effects of a new dietary supplement of fermented grain foods mixture containing extracts from wheat germ, soybeans, rice bran, tear grass, sesame, wheat, citrus lemon, green tea, green leaf extract and malted rice under the trade name of

182 Nutri-Senex: State of the art report – task 2.1 antioxidant biofactor (AOB). Chemical analysis of AOB shows the presence of various phenolic compounds (catechins, rutin, genistin, daidzin, etc.). AOB has strong antioxidant properties and additional biological effects, which might be of importance in context with the prevention of degenerative diseases. This paper focuses on the effect of supplementing AOB in various animal models and humans. Publisher: Elsevier Science Ireland Ltd. All rights reserved. Doi 10.1016/S0928- 4680(03)00022-1

Plants and Human health in the Twenty-first Century

Raskin, et.al (2002) Trends in Biotechnology Journal volume 20 issue 12 pages 522-531

The concept of growing crops for health rather than for food or fibre is slowly changing plant biotechnology and medicine. Rediscovery of the connection between plants and health is responsible for launching a new generation of botanical therapeutics that include plant- derived pharmaceuticals, multicomponent botanical drugs, dietary supplements, functional foods and plant-produced recombinant proteins. Many of these products will soon complement conventional pharmaceuticals in the treatment, prevention and diagnosis of diseases, while at the same time adding value to agriculture. Such complementation can be accelerated by developing better tools for the efficient exploration of diverse and mutually interacting arrays of phytochemicals and for the manipulation of the plant's ability to synthesize natural products and complex proteins. This review discusses the history, future, scientific background and regulatory issues related to botanical therapeutics. Publisher: Elsevier Science Ltd. All rights reserved Doi 10.1016/S0167-7799(02)02080-2

Meeting expanding needs for nutrient specificity: the NASA case study Van Heel et. al (2002) Journal of Food Composition and Analysis Volume 16, Issue 3 pages 299-303

Food and nutrient databases are populated with data obtained from a variety of sources including USDA Reference Tables, scientific journals, food manufacturers and foreign food tables. The food and nutrient database maintained by the Nutrition Coordinating Centre (NCC) at the University of Minnesota is continually updated with current nutrient data that are carefully evaluated for reliability and relevance before incorporation into the database; however, some values are obtained from calculations or from similar foods rather than from direct chemical analysis of specific foods. Precise nutrient values for specific foods are essential to the nutrition program at the National Aeronautics and Space Administration

183 Nutri-Senex: State of the art report – task 2.1

(NASA). Specific foods to be included in the menus of astronauts are chemically analysed at the Johnson Space Centre for selected nutrients. A request from NASA for a method to permit NASA nutritionists to enter chemically analysed nutrient values for space flight food items into the Nutrition Data System for Research (NDS-R) software resulted in modifications of the database and interview system. The database was expanded by entering the nutrients of interest to NASA as though they were individual foods, thereby allowing entry of a "recipe" of nutrients that exactly match the Johnson Space Centre chemical analysis of each specific flight food. Subsequent work by NCC resulted in further modifications to extend the method for related uses by other research studies. Publisher: Elsevier Science ltd. All rights reserved. Doi 10.1016/S0889-1575(03)00047-4

Use of ornithine -ketoglutarate in clinical nutrition of elderly patients

Blonde-Cynober et. al (2002) Journal of Nutrition Volume 19, Issue 1 pages 73-75

OKG is a salt formed of two molecules of ornithine and one of -ketoglutarate (10 g of OKG contains 1.30 g of nitrogen). The effects of OKG on nutrition status were demonstrated 15y ago. Results showed that OKG is a potent nutritional modulator characterized by an anticatabolic activity, anabolic activity, or both, according to the tissue considered and the pathologic situation, and is an efficient immunomodulator and a key promoter of wound healing and tissue repair. The mechanisms underlying the improved nutritional status resulting from OKG administration are not completely understood. OKG action is probably multifactorial, linked to the stimulation of the secretion of anabolic hormones (insulin and growth factor), to the production of OKG metabolites, or both, such as glutamine, arginine, proline, and polyamines. All of these act in the control of protein anabolism and modulation of cell multiplication and differentiation and thus play a major role in the viability and function of the proximal intestine. All these effects result largely from the specific interaction between the two components of the molecule. Publisher: Elsevier Science Inc. All right reserved.Doi1016/S08999007(02)00849-3

184 Nutri-Senex: State of the art report – task 2.1

Safety evaluation of functional ingredients

Kruger, & Mann (2002) Food and Chemical Toxicology volume 41 issue 6 pages 793- 805

Functional ingredients are a diverse group of compounds that are intended to produce a positive effect on the health of the consumer. The term "functional" is not meant to differentiate these ingredients from other ingredients historically consumed as part of the food supply that are indeed biologically active constituents, for example, nutrients. Indeed, all foods should be considered "functional". The term functional ingredient is meant to convey the function of these new ingredients, which is to produce a positive health outcome via physiological activity in the body. Functional ingredients encompass elements of drugs, nutrients and food additives. A framework for evaluation of the safety of functional ingredients utilizes an understanding of both the current regulatory frameworks in place as well as the characteristics that define these particular ingredients. The types of studies conducted and the data generated to support safety of functional ingredients is product- specific and can include compositional analysis, structure/toxicity analysis, and evaluation of historical and intended exposure, animal studies, clinical/epidemiologic studies, and evaluation of special considerations such as potential for adverse food or drug interactions. Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016/S0278-6915(03)00018-8

Research science, regulatory science, and nutrient databases: achieving an optimal convergence Capstone Lecture

Ershow, (2002) Journal of Food composition and analysis volume 16 issue 3 pages 255-268 26th International Nutrient Database Conference.

The compelling practical applications of nutrient databases, and the technical challenges in their development, often divert attention from their underlying research basis. Nutrient databases are, in fact, the publications of research projects that draw on the methodology of analytical chemistry, sampling statistics, and information technology in order to answer a core question: "What is the nutrient content of the food supply?" The responsibility for addressing this question, and for conducting the ensuing research, is typically assigned to governmental entities, especially for databases that are reflective of national food supplies. This responsibility reflects the key role of nutrient data in public health decision-making. At their best, nutrient databases can represent an optimal convergence of the characteristics of both "research science," which seeks to increase knowledge of natural phenomena and processes, and "regulatory science," which provides the knowledge base needed for policy- making and other government work. These two categories of research have many

185 Nutri-Senex: State of the art report – task 2.1 commonalities, such as their scientific methodology, even though they differ in their sites of performance and affiliated institutions, their operational procedures, and their standards of accountability. A good example of this convergence is found in the National Food and Nutrient Analysis Program and its various ancillary projects (databases on fluoride, choline, phytonutrients, Native American/Alaska Native foods, commodity foods, and dietary supplements). Confirmed validity of the findings, enhanced trust in the results, strengthened political and public support, and funding that underwrites the capacity for high scientific standards, are all potential benefits of acknowledging the simultaneous research and regulatory science aspects of nutrient databases. Publisher: Elsevier Science USA All rights reserved. Doi 10.1016/S0889-1575(03)00054-1

Patterns of prescribing of nutritional supplements in the United Kingdom

Gale et al (2001) Clinical Nutrition Volume 20, Issue 4 pages 333-337

A large number of prescriptions are issued for nutritional supplements under British National Formulary classifications 9.4.1 (foods for special diets) and 9.4.2 (enteral feeds), but little is known about the characteristics of the patients who receive them. We used the General Practice Research Database to examine patterns of prescribing of these supplements. Methods: We selected patients who had been prescribed supplements under classifications 9.4.1 and 9.4.2 during 1996–1997. Descriptive statistics were used to examine how prescribing varied. Results: 28644 patients received prescriptions during 1996–1997. Among the 27413 (96%) patients prescribed supplements for oral use, 14750 received supplements for enteral nutrition alone, 8122 received supplements for special diets alone and 4541 had both types of supplement. 51% of patients receiving supplements for special diets were <18 years. The commonest diagnoses among such children were milk intolerance (24%) and malnutrition (17%). 94% of patients receiving supplements for enteral nutrition were adult, 52% of whom had cancer or cardiovascular disease. Only 4% of patients had weight and height recorded prior to first prescription. Conclusions: The GPRD provides valuable information on the characteristics of patients prescribed nutritional supplements. But because only limited data are available on their nutritional status prior to supplementation, it is hard to assess whether general practitioners are prescribing these supplements appropriately. Publisher; Harcourt Publishers Ltd. All rights reserved. Doi 10.1054/clnu.2001.0396

186 Nutri-Senex: State of the art report – task 2.1

Position of the American Dietetic Association Food Fortification and Dietary Supplements

American Dietetic Association (Jan 2001) Volume 101 Issue 1 pages115–125

Wise food choices provide the necessary foundation for optimal nutrition. Science has not fully identified the specific chemical components that account for the benefits of healthy eating patterns. Selection of a variety of foods, using tools such as the USDA/HHS Dietary Guidelines for Americans and the USD A Food Guide Pyramid, is the best way to provide a desirable balance, without excessive intakes of macronutrients, micronutrients and other beneficial components of foods. Nevertheless, for certain nutrients and some individuals, fortification, supplementation, or both may also be desirable. Nutrient intakes from all these sources should be considered in dietary assessments, planning and recommendations. The recommendations of the National Academy of Sciences' Food and Nutrition Board provide a sound scientific basis for vitamin and mineral intakes. Intakes exceeding those recommendations have no demonstrated benefit for the normal, healthy population. Dietetics professionals should base recommendations for use of fortified foods or supplements on individualized assessment and sound scientific evidence of efficacy and safety. It is the position of the American Dietetic Association that the best nutritional strategy for promoting optimal health and reducing the risk of chronic disease is to wisely choose a wide variety of foods. Additional vitamins and minerals from fortified foods and/or supplements can help some people meet their nutritional needs as specified by science-based nutrition standards such as the Dietary Reference Intakes (DRI) Publisher: Elsevier Science USA ltd. All rights reserved. Doi 10.1016/S0002-8223(01)00026- 8

Eating difficulties, assisted eating and nutritional status in elderly (65 years) patients in hospital rehabilitation

Westergren, et.al (2001) International Journal of Nursing Studies volume 39, issue 3 pages 341-351

This study describes frequencies and associations between eating difficulties, assisted eating and nutritional status in 520 elderly patients in hospital rehabilitation. Eating difficulties were observed during a meal and nutritional status was assessed with Subjective Global Assessment form. Eighty-two percent of patients had one or more eating difficulties, 36% had assisted eating and 46% malnutrition. Three components of eating were focused upon ingestion, deglutition, and energy (eating and intake). Deglutition and ingestion difficulties and low energy were associated with assisted eating, and low energy associated with

187 Nutri-Senex: State of the art report – task 2.1 malnutrition. Underestimation of low energy puts patients at risk of having or developing malnutrition. Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016/S0020-7489(01)00025-6

Meeting nutrient and energy requirements in old age de Groot et.al (2001) Maturitas Journal volume 38 issue 1 pages 75- 81

In old age, the complex relation of food consumption with energy and nutrient requirements finds expression in both single and multiple nutritional problems. Addressing conditions affecting intake –– either from foods or from supplements –– endogenous production, bioefficacy and/or requirements can benefit nutritional health in old age through balancing requirements and supply. Publisher: Elsevier Science Ireland Ltd. All rights reserved Doi 10.1016/S0378- 5122(00)00193-6

Enteral versus parenteral nutrition: a pragmatic study

Woodcock, et.al, (2001) Nutrition Journal volume 17, issue 1 pages 1-12

Controversy persists as to the optimal means of providing adjuvant nutritional support. The aim of this study was to compare enteral nutrition (EN) and parenteral nutrition (TPN) in terms of adequacy of nutritional intake, septic and no septic morbidity, and mortality. This was a prospective pragmatic study, whereby the route of delivery of nutritional support was determined by the attending clinician's assessment of gastrointestinal function. Patients considered to have inadequate gastrointestinal function were given TPN (group 1), while those deemed to have a functioning gastrointestinal tract received EN (group 2). Patients in whom there was reasonable doubt as to the adequacy of intestinal function were randomised to receive either TPN (group 3) or EN (group 4). The trial setting was a large district general hospital with a dedicated nutrition team. A total of 562 patients were included in the study (331 males; median age 67 y). Gastrointestinal function on entry into the study was considered inadequate in 267 patients who were given TPN (group 1) and adequate in 231 whom received EN (group 2). There was clinical uncertainty about the adequacy of gut function in 64 patients (11.4%) who were randomised to receive either TPN (group 3, 32 patients) or EN (group 4, 32 patients). The incidence of inadequate nutritional intake was significantly higher in group 4 compared with group 3 (78.1% versus 25%, P < 0.001). Complications related to the delivery system and other feed-related morbidity were

188 Nutri-Senex: State of the art report – task 2.1 significantly more frequent in both EN groups compared with the respective TPN groups. EN was associated with a higher overall mortality in both nonrandomized and randomised patients. There were no significant differences observed in the incidences of septic morbidity between patients receiving TPN and those given EN. EN is associated with a higher incidence of inadequate nutritional intake, complications related to the delivery system, and other feed-related morbidity than TPN. There is no evidence from this study to support a difference between the two modalities in terms of septic morbidity. Patients in whom there is reasonable doubt as to the adequacy of gastrointestinal function should be fed by the parenteral route Publisher: Elsevier Science Inc. All rights Reserved. Doi 10.1016/S0899-9007(00)00576-1

Changes in Dietary Guidance: Implications for Food and Nutrient Databases

Murphy (2001) Journal of Food Composition and Analysis volume 14 issue 3 pages 269- 278

Two types of dietary guidance for Americans have recently been released, and both have important implications for the way data are organized on food and nutrient databases. New dietary reference intakes (DRIs) have been set for 17 nutrients, and in several cases the units for these recommendations do not match those traditionally carried on nutrient databases. Furthermore, some of the tolerable upper intake levels (ULs) are specified only for supplemental and fortification forms of nutrients, which necessitates calculating separate intake values for nutrients from foods and nutrients that are added to foods or taken as supplements. The year 2000 revision of the Dietary Guidelines for Americans also suggest new ways to evaluate dietary intakes: there is an increased emphasis on obtaining an appropriate number of servings from food groups such as fruits, vegetables, whole grains, and low fat dairy products. To allow users of nutrient databases to provide relevant evaluations of dietary data, developers will need to consider carrying a much larger array of variables in order to calculate intakes of folate in folate equivalents, vitamin E as alpha- tocopherol (not as alpha-tocopherol equivalents), nutrients occurring in foods versus added or supplemental nutrients, and the number of servings from a variety of food groups Publisher: Academic Press All right reserved Doi 10.1006/jfca.2001.0985

189 Nutri-Senex: State of the art report – task 2.1

Nutritional assessment in the elderly: facing up to the challenges of developing new tools for clinical assessment

Apovian (2001) Nutrition Journal volume17, issue 1 pages 62-63.

Malnutrition is an important predictor of morbidity and mortality in the elderly but is often overlooked. Therefore, it is imperative that assessment tools for measuring nutritional status in the elderly be easy to administer and well validated. Malnutrition can occur from under nutrition due to lack of calories, vitamins, or minerals, over nutrition due to excessive calories or excessive amounts of potentially toxic substances such as alcohol. The prevalence of under nutrition in the free-living elderly population is estimated to be between 5% and 10%. Under nutrition is present in 30% to 60% of institutionalised patients and in 35% to 65% of hospitalised patients. Publisher: Elsevier Science Inc. All rights reserved Doi 10.1016/S0899-9007(00)00479-2

Role of nutrition in preventing and treating breast and prostate cancers, American Institute for Cancer Research 10th Annual Research Conference, Washington, DC, August 31–September 1, 2000

Glade (2001) Nutrition Journal volume 17, issue 3 pages 277-279

More than 200 research scientists and interested health care professionals attended the 10th Annual Research Conference of the American Institute for Cancer Research, held in Washington, DC, between August 31 and September 1, 2000. Two- dozen podium presentations and three- dozen posters addressed the theme of the conference, The Role of Nutrition in Preventing and Treating Breast and Prostate Cancer. Highlights of the most compelling presentations are summarized. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00560-8

190 Nutri-Senex: State of the art report – task 2.1

The reported use of dietary supplements (sip feeds) in hospitals in Wessex, UK

Brosnan et.al (2001) Clinical Nutrition journal volume 20, issue 5 pages 445-449

To assess the prevalence of the use of supplements (sip feeds) in district general, psychiatric and community hospitals in the former Wessex health region. Method: Cross sectional study of prevalence and determinants of supplement use in 10 district general hospitals (covering medical, surgical, orthopaedic, and elderly specialities), 4 psychiatric hospitals and 3 community hospitals. Overall 14% of patients were being supplemented although the variation across hospitals and specialities was wide (0%–35%); elderly care patients within district hospitals were most likely to be supplemented (20%; range 12–35%). In 34% of patients there was no documented reason as to why supplements were given. 60% of patients were not weighed on admission; 70% did not have a weight history recorded and 83% did not have a current weight recorded. Documentation regarding supplement use appeared to be recorded in an unsystematic manner. Many patients were not being weighed on admission and appeared to have no documentation as to why supplements were given. Given the importance of malnutrition in hospital patients a more evidence based, objective approach to assessing nutritional requirements, intake and support may be beneficial. Publisher: Harcourt Publishers Ltd. All rights reserved. Doi 10.1054/clnu.2001.0468

Malnutrition in hospitalised elderly patients: when does it matter?

Gariballa (2001) Clinical Nutrition Journal volume 20, issue 6 pages 487- 491

Identifying the individual effects of acute illness and malnutrition on elderly patient outcome and the timing of nutritional support is still an important challenge for modern medicine. The aims of this study were to assess the practical significance of serum albumin concentrations following acute illness as a measure of nutritional status in ageing patients and also to review recently published studies related to this field. Consecutive stroke patients had their nutritional status assessed from anthropometric, haematological and biochemical data during the hospital stay. Predicted energy needs and daily in-hospital energy intake were also studied in a subgroup of 24 acute stroke patients and 24 age and sex-matched hospitalised non-stroke patients. A multivariate analysis was used to measure the amount of variance in serum albumin concentrations explained by nutritional and non-nutritional clinical variables. Serum albumin concentrations deteriorated steadily during the study period and there was an increase in the amount of variance in the serum albumin explained by nutritional variables between admission and week 4 of the hospital stay. Almost all patients

191 Nutri-Senex: State of the art report – task 2.1 studied were in negative energy balance during hospitalisation. Evidence is provided which links low serum albumin concentrations with clinical outcomes during the hospital stay and immediately following discharge. That nutritional supplementation started one week as opposed to immediately following acute illness, and continued during the convalescent period, can improve serum albumin concentrations during the hospital stay. Poor nutritional status following acute illness in ageing patients may be of more prognostic significance and amenable to therapy later on during the course of hospitalisation. Publisher: Harcourt Publishers Ltd. All rights reserved. Doi 10.1054/clnu.2001.0477

Clinical pictures of malnutrition in ill elderly subjects

Seiler (2001). Nutrition Journal volume 17, issue 6 pages 496-498

Malnutrition in ill elderly subjects is common in hospitals, nursing homes, and home care. Depending on the type and composition of the groups of patients under consideration, the prevalence of malnutrition is cited at up to 60%. With advancing age, the amounts of food- consumed daily diminish and become significantly smaller than the amounts consumed by the younger population. The elderly mostly eat food of low nutrient density. Especially at times of high-energy requirements such as acute or chronic illness, this results in an energy deficit and general malnutrition. Precise diagnosis of malnutrition can be facilitated by determination of a number of biochemical parameters. Knowledge of these permits individualized nutrition therapy. The most important deficits affecting ill elderly subjects are those relating to proteins, iron, zinc, selenium, and vitamins B12, B1, B6, and D. Malnutrition prolongs hospital stays, imposes enormous costs on health services, and causes considerable mortality. The present, very rapid increase in the size of the elderly population will exacerbate the problem of malnutrition. Therefore, more attention should be paid to malnutrition by treating it as a disease in its own right and including it in the training of doctors and nurses. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/So899-9007(01)00558-5 .

`Protective nutrients' and up-to-date dietary recommendations

Kromhout (2001) European Heart Journal Supplements volume 3 issue 4 pages D33-D36

In the past, dietary recommendations were focused on reductions in the consumption of foods and nutrients deemed bad for health, such as saturated fat, dietary cholesterol and salt. In more recent years, an increased consumption of foods and nutrients deemed good

192 Nutri-Senex: State of the art report – task 2.1 for health has also been emphasized, e.g., increased consumption of vegetables, fruits, legumes, fish, dietary fibre and polyunsaturated fatty acids. Another major development has been the change from dietary recommendations for specific diseases, such as coronary heart disease and diabetes, to integrated, comprehensive dietary recommendations for chronic diseases and health in general. A healthy diet forms an important component of a healthy lifestyle. This also includes advice not to smoke and to be physically active for at least 30 min each day. Such a lifestyle prevents coronary heart disease and is important for both primary and secondary prevention. Observational studies and clinical trials on n-3 polyunsaturated fatty acids suggest that besides a diet low in saturated and trans fatty acids and in cholesterol, a healthy diet also needs to contain adequate amounts of alpha-linolenic acid (2 g. day-1) and EPA and DHA (200 mg. day-1). Evidence that a diet rich in fruits and vegetables may protect against coronary heart disease is increasing. Fruits and vegetables are plentiful sources of antioxidants. Until recently, most research in this area was focused on the so-called nutritive antioxidants, vitamins with antioxidant properties such as tocopherol (vitamin E), carotenoids and vitamin C. Recently; there is an increasing interest in the so-called non-nutritive antioxidants. These are polyphenols present in plant foods and have strong antioxidant properties. Clinical trials with vitamin E supplements were mainly negative. High-dose pharmacological supplementation of diet with so-called `protective' nutrients, however, do not relate to the nutritional domain. In future trials a dose corresponding to a multiple of the recommended dietary allowance of 10-mg. day-1 should be used rather than the high, pharmacological doses used so far Publisher: Elsevier Ltd All rights reserved Doi 10.1016/S1520-765X(01)90116-6

Eating difficulties, complications and nursing interventions during a period of three months after a stroke

Westergren et.al , (2001) Journal of Advanced Nursing Volume 35 Issue 3 Page 416

Eating difficulties, complications and nursing interventions during a period of three months after a stroke. The aim of this study was to describe eating difficulties and especially swallowing in patients with dysphagia, types of nursing intervention, and the development of complications over 3 months. The aim was also to explore common characteristics of eating difficulties that influenced the ability to finish meals. Methods. Twenty-four consecutive patients admitted because of stroke and dysphagia were included. Nursing interventions, based on assessments, were individually designed. Results. Three subgroups could be identified: those (n=9) who were unable to complete a meal, despite assisted feeding, because of reduced alertness/energy and impaired swallowing function; those (n=5) who could complete a meal, despite suffering from reduced alertness/energy; and those (n=10)

193 Nutri-Senex: State of the art report – task 2.1 who could complete meals with minor difficulties. Patients in the first two groups developed complications such as respiratory infections and/or malnutrition. There was a tendency towards those complications in the third group were less frequent and the hospital stay was significantly shorter than in the other groups. Conclusion. The level of alertness/energy in patients with dysphagia after stroke was important for the ability to eat and swallow and the development of complications over time, and thus of great importance for the interventions applied. Publisher: Blackwell Publishing Inc. doi:10.1046/j.1365-2648.2001.01884x

Preventive nutrition: its changing context in Mesoamerica

Valdés-Ramos & Solomons (2001) Nutrition research Journal volume 22, issue 1-2 pages 145-152

The present article is an overview of the nutrition transition that is undergoing in Mesoamerica, where both sides of the malnutrition spectrum are present at very high rates. Although deaths due to the diseases of affluence are increasing at the same rate as in developed countries, under nutrition and its consequences (i.e. infectious diseases) are still taking a high toll among the youngest of the population. Preventive measures should include programs for promotion of sufficient nutrition while controlling for excesses leading to over nutrition. Nutrition recommendations should be able to promote both sides of the spectrum. The recommendation for an increased consumption of functional foods such as probiotics and prebiotics may become an appropriate measure as most studies indicate that they can be useful to decrease the incidence of infectious diseases while reducing some of the chronic ailments that affect the populations from developing countries. Publisher: Elsevier Science Inc. All rights Reserved. Doi 10.1016/S0271(01)00356-6

Folic acid: are current fortification levels adequate?

Neuhouser & Beresford (2001 Nutrition Journal volume 17 issue 10 pages 868-872.

Beginning on January 1, 1998, all cereal and grain products in the United States were fortified with folic acid to reduce the occurrence of the very common congenital malformations known as neural-tube defects. Three years have passed since the fortification program began, and it is time to evaluate whether the current fortification levels have met their intended objective. We offer an overview of folate and its potential role in the etiology of neural-tube defects, review some of the highlights of the deliberations that led to the decision

194 Nutri-Senex: State of the art report – task 2.1 by the Food and Drug Administration to fortify the food supply, and offer a perspective on how to measure whether current fortification levels are adequate. There is no national system in the United States that monitors neural tube and other birth defects over time, and no post marketing surveillance was mandated to monitor the safety of the fortification program. Therefore, we must evaluate the program in other ways. Blood biomarkers of folate status such as the levels of folate in red blood cells and homocysteine in plasma provided the best evidence of the effectiveness of the folic acid–fortification program because of their relatively high sensitivities in relation to their specificities as markers of folate status. In addition, these biomarkers might provide information about the risks of other diseases related to folate status such as vascular disease. Federal agencies should coordinate efforts to gather and evaluate markers of folate status at the population level. These measures can be used to evaluate the safety and efficacy of folic-acid fortification and whether changes are warranted in fortification levels. Publisher Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(01)00648-7

Vitamin K and bone health

Weber (2001) Journal of Nutrition volume 17 issue 10 pages 880-887

In the past decade it has become evident that vitamin K has a significant role to play in human health that is beyond its well-established function in blood clotting. There is a consistent line of evidence in human epidemiologic and intervention studies that clearly demonstrates that vitamin K can improve bone health. The human intervention studies have demonstrated that vitamin K can not only increase bone mineral density in osteoporotic people but also actually reduce fracture rates. Further, there is evidence in human intervention studies that vitamins K and D, a classic in bone metabolism, works synergistically on bone density. Most of these studies employed vitamin K2 at rather high doses, a fact that has been criticized as a shortcoming of these studies. However, there is emerging evidence in human intervention studies that vitamin K1 at a much lower dose may also benefit bone health, in particular when co administered with vitamin D. Several mechanisms are suggested by which vitamin K can modulate bone metabolism. Besides the -carboxylation of osteocalcin, a protein believed to be involved in bone mineralisation, there is increasing evidence that vitamin K also positively affects calcium balance, a key mineral in bone metabolism. The Institute of Medicine recently has increased the dietary reference intakes of vitamin K to 90 g/d for females and 120 g/d for males, which is an increase of approximately 50% from previous recommendations. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(01)00709-2

195 Nutri-Senex: State of the art report – task 2.1

Nutritional aspects of nitric oxide: human health implications and therapeutic opportunities

Janero (2001) Nutritional Journal volume 17 issues 10 pages 896-903

Nitric oxide (NO), the most potent natural vasorelaxant known, has close historical ties to cardiovascular physiology, despite NO's rich physiologic chemistry as an ubiquitous, signal- transducing radical. Aspects of NO biology critical to gastrointestinal health and, consequently, nutritional status are increasingly being recognized. Attempts are underway to exploit the gastrointestinal actions of NO for therapeutic gain. Cross talk between NO and micronutrients within and outside the gastrointestinal system affects the establishment or progression of several diseases with pressing medical needs. These concepts imply that NO biology can influence nutrition and be nutritionally modulated to affect mammalian (patho)physiology. At least four nutritional facets of NO biology are at the forefront of contemporary biomedical research: 1) NO as modulator of feeding behaviour and mediator of gastrointestinal homeostasis; 2) NO supplementation as a therapeutic modality for preserving gastrointestinal health; 3) interactions among elemental micronutrients (e.g., zinc), NO, and inflammation as potential contributors to diarrhoeal disease; and 4) vitamin micronutrients (e.g., vitamins E and C) as protectors of NO-dependent vascular function. Discussion of extant data on these topics prompts speculation that future research will broaden NO's nutritional role as an integrative signalling molecule supporting gastrointestinal and nutritional well-being. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(01)00647-5

Calcium fortification of vegetables by vacuum impregnation Interactions with cellular matrix

Gras, et.al (2001) Journal of Food Engineering Volume 56, Issue 2-3 Pages 279-284

Calcium fortification of vegetables by applying vacuum impregnation is an alternative in developing functional foods. Nevertheless, calcium ions can interact with the plant tissue, modifying its mechanical and vacuum impregnation responses. These effects were studied in eggplant, oyster mushroom and carrot samples. Sample VI was carried out with isotonic solutions containing sucrose and calcium lactate and sucrose. From the analysis of sample impregnation and deformation levels, the slight influence of Ca presence on the impregnation behaviour of these products could be concluded. Nevertheless, mechanical behaviour of eggplant and carrot were notably affected by calcium, although no significant effects were observed in oyster mushroom (without pectin in their cell architecture). Energy dispersive X-

196 Nutri-Senex: State of the art report – task 2.1 ray microanalysis (EDXMA) in impregnated products showed that calcium impregnation occurs in the intercellular spaces of eggplant and oyster mushroom and in xylem of carrot. Publisher: Elsevier Science Ltd. All rights Reserved Doi 10.1016/S0260-8774(02)00296-8

Does a liquid supplement improve energy and protein consumption in nursing home residents?

Remsburg, et.al (2001) Geriatric Nursing Journal volume 22 issue 6 pages 331-335

One popular strategy to improve the acceptance and efficacy of oral liquid supplements in long-term care is dispensing them during the medication pass, although few studies support its effectiveness. This study evaluated the impact of a supplement medication pass program on energy and nutrient consumption and weight in nursing home residents. Findings indicate that residents maintained their pre-study weight and had a 29% decrease in supplement energy intake, a 19% increase in food energy intake, and a 17% decrease in net energy intake (supplement plus food). Supplement and food protein intake remained stable. Over longer periods, this reduced energy consumption could lead to weight loss, so routine monitoring and periodic evaluations of resident intake (both food and supplement) are recommended to ensure residents are receiving and consuming adequate amounts of daily energy and nutrients. Publisher: Academic Press All rights reserved. Doi 10.1067/mgn.2001.121001

How to promote food intake in the elderly

Lesourd et. al. (2001). Nutrition Clinique et Metabolisme (Alimentation clinics and metabolisme) 2001, volume 15, issue. 3, page. 177-188 [No PDF available]

Insufficiency of the nutritional intakes is a common situation for aged persons. Anorexia, as defined by intakes below 1000kcal/d, leads to protein-energy malnutrition (MPE) and therefore initiates a vicious circle that accelerates the ageing process. Ageing is an important component of the decrease in intakes in the aged persons. In fact ageing leads to decreased smell and taste sensory perception, which progressively induces lower intakes. Such changes are particularly dangerous for the aged individuals since they appear very slowly and therefore are not consciously perceived by the elderly. In addition, deterioration in the dental status and slowing of the rate of gastric emptying also lead to lower intakes. The most important change is the inability of the aged persons to react appropriately to nutritional stress. The elderly must learn to consciously react to any nutritional stress. Guidelines have been established to help the aged individual to preserve sufficient and well-balanced food

197 Nutri-Senex: State of the art report – task 2.1 intake. In order to help aged persons and their aides to deal with this problem, those rules are presented at the end of this paper. In order to warrant sufficient intakes, food must be regular, well balanced, tasty, pleasant, and adapted to personal capacities. One must tend to very personalised meals. Publisher: Elsevier Science all rights reserved. Doi:10.1016/S0985-0562

A multi-centre trial of the effects of oral nutritional supplementation in critically ill older inpatients

Bourdel-Marchasson et.al (2000). Nutrition Journal volume 16, issue 1 pages 1-5

The purpose of this study was to assess the effect of nutritional supplementation on dietary intake and on pressure ulcer development in critically ill older patients. The multi-centre trial involved 19 wards stratified according to speciality and recruitment for critically ill older patients; 9 wards were randomly selected for nutritional intervention (nutritional intervention group), consisting of the daily distribution of two oral supplements, with each supplement containing 200 kcal, for 15 d. Pressure ulcer incidence was prospectively recorded for grades I (erythema), II (superficial broken skin), and III (subcutaneous lesion) for 15 d. Nutritional intake was monitored by using estimates in units of quarters validated by comparison with weight measurement. There were 672 subjects older than 65 y, and 295 were in the nutritional intervention group versus 377 in the control group. The patients were similar for age, sex ratio, and C-reactive protein. In comparison with the control group, the nutritional intervention group included more patients with stroke, heart failure, and dyspnea and fewer with antecedent falls, delirium, lower limb fractures, and digestive disease. The nutritional intervention group had a lower risk of pressure ulcers according to the Norton score but was less dependent (Kuntzman score) and had a lower serum albumin level. During the trial, energy and protein intakes were higher in the nutritional intervention group (day 2: 1081 ± 595 kcal versus 957 ± 530 kcal, P = 0.006; 45.9 ± 27.8 g protein versus 38.3 ± 23.8 g protein in the control group, P < 0.001). At 15 d, the cumulative incidence of pressure ulcers was 40.6% in the nutritional intervention group versus 47.2% in the control group. The proportion of grade I cases relative to the total number of cases was 90%. Multivariate analysis, taking into account all diagnoses, potential risk factors, and the intra-ward correlation, indicated that the independent risk factors of developing a pressure ulcer during this period were: serum albumin level at baseline, for 1 g/L decrease: 1.05 (95% confidence interval: 1.02 to 1.07, P < 0.001); Kuntzmann score at baseline, for 1-point increase: 1.22 (0.32 to 4.58, P = 0.003); lower limb fracture: 2.68 (1.75 to 4.11, P < 0.001); Norton score <10 versus >14: 1.28 (1.01 to 1.62, P = 0.04); and belonging to the control group: 1.57 (1.03 to 2.38, P = 0.04). In conclusion, it was possible to increase the dietary intake of critically ill elderly subjects by

198 Nutri-Senex: State of the art report – task 2.1 systematic use of oral supplements. This intervention was associated with a decreased risk of pressure ulcer incidence Publisher: Elsevier Science Inc. All rights reserved Doi 10.1016/S0899-9007(00)00227-0

Effects of supplementation with folic acid and antioxidant vitamins on homocysteine levels and LDL oxidation in coronary patients

Bunout et. .al (2000) Nutrition Journal volume 16, issue 2 pages 107-110.

Hyperhomocysteinemia is an important cardiovascular risk factor. Serum homocysteine levels are especially dependent on folate nutritional status. In addition, the oxidative modification of low-density lipoproteins (LDLs) in the endothelial microenvironment is a damaging factor that can be modified with fat-soluble antioxidant vitamins. The present study was done to assess the effect of a supplementation of folic acid and antioxidant vitamins on homocysteine levels and in vitro LDL oxidation in patients with coronary artery disease. Twenty-three patients with angiographically proven coronary artery disease were given supplements for 15 d consisting of one capsule twice a day of a multivitamin preparation containing 0.65 mg folic acid, 150 mg -tocopherol, 150 mg ascorbic acid, 12.5 mg - carotene, and 0.4 g vitamin B12. Serum lipids, vitamin and homocysteine levels, and in vitro LDL oxidation were measured before and after the supplementation period. During the supplementation period, serum folate levels increased from 5.0 ± 1.5 to 10.8 ± 3.8 ng/mL (P

< 0.001), vitamin B12 increased from 317.4 ± 130.4 to 334.5 ± 123.8 pg/mL (P < 0.05), and - tocopherol increased from 8.2 ± 5.1 to 13.7 ± 7.9 mg/L (P < 0.001). Serum homocysteine levels decreased from 8.7 ± 4.3 to 6.3 ± 2.2 mol/L (P < 0.001). In vitro LDL oxidation decreased from 2.6 ± 1.1 to 1.6 ± 1.1 nmol malondialdehyde/mg protein (P < 0.001). In comparing patients with healthy controls, basal levels of folate were lower in the patients, whereas vitamin B12, -tocopherol, and homocysteine levels were similar. No changes in serum lipid levels or body weight were observed. In conclusion, a short-term supplementation with folic acid and antioxidant vitamins can reduce serum homocysteine levels and in vitro LDL oxidation in patients with coronary artery disease. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00248-8

199 Nutri-Senex: State of the art report – task 2.1

Cognitive-behavioural treatment of food neophobia in adults

Marcontell, et, al (2000) Journal of Anxiety Disorders volume 17, issue 2 pages 243- 251

Food neophobia is an eating disturbance defined as the fear of trying new foods. In its extreme, the disorder can lead to malnutrition, limited social functioning, and psychological difficulties. Successful treatment of food neophobia in children has been reported, but if those children are not provided with treatment, it stands to reason that the disorder may follow them into adulthood. To date, adult cases have not been described in the literature and the prevalence in adults is unknown. Our paper will review the methods used to treat children with the disorder then delineate how the procedures were modified for an adult population, giving two case examples. Publisher: Elsevier Science Inc. All rights reserved Doi 10.1016/S0887-6185(01)00090-1

Pushing the envelope of nutrition support: complementary therapies

Bloch, (2000) Nutrition Journal 16, 3 p236-239

When the survey on unconventional medicine in the USA appeared in the New England Journal of Medicine in January 1993, most practitioners were surprised at the findings. One- third of those surveyed were using at least one unconventional therapy. However, in 1992, the National Institutes of Health (NIH) had already established an Office Alternative Medicine (OAM). An NIH workshop on alternative medicine was held in late 1992, from which a report on alternative medical systems and practices in the United States was later published. Six fields of alternative medicine were identified Publisher Elsevier Science Inc. All rights reserved Doi 10.1016/S0899-9007(00)00275- 0

Nutritional care in Indian hospitals: present and future role of dieticians

Tarvady, (2000). Nutrition Journal volume 16, issue 5 pages 395

In India, the terms dietetics and dietician have been domesticated since the career in dietetics began with the introduction of graduate programs in home sciences. To add to its greater degree of domesticity was the fact that the study of home science was purely a female prerogative. The baccalaureate degree in home science was encouraged because the family felt that the girl was educated without her domesticity being adversely affected, especially in the marriage market. The enterprising among the graduates of home science

200 Nutri-Senex: State of the art report – task 2.1 decided to convert their academic qualification into a specialization in the allied-health specialist category, and thus the profession of dietician was generated. Their ambit of interaction, however, was limited to the hospital kitchens, thus retaining the domestic character of the dietician, and this identification is best described by the following phrases: rotund; an official food taster; glorified cook; a sedentary clerk, calculating and maintaining calories and the weight of the food or nutrient; and maintaining and formulating unappetizing recipes for the helpless, hapless patient. Publisher Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00236-7

The validity and reproducibility of clinical assessment of nutritional status in the elderly

Duerksen et.al (2000) utrition Journal volume16, issue 9 pages 740-744

Malnutrition is an important predictor of morbidity and mortality. In the non-elderly, a subjective global assessment (SGA) has been developed. It has a high inter-rater agreement, correlates with other measures of nutritional status, and predicts subsequent morbidity. The purpose of this study was to determine the validity and reproducibility of the SGA in a group of patients older than 70 y of age. Consecutive patients from four geriatric/rehabilitation units were considered for the study. Each patient underwent independent nutritional assessments by a geriatrician and senior medical resident. At the completion of the assessment, skin fold caliper measurements were obtained and the patient reclassified according to the results, which were then compared with objective measures of nutritional status. Six-month follow-up was obtained on all patients. The agreement between the two clinicians was 0.48 ± 0.17 (un-weighted kappa), which represents moderate agreement and is less than the reported agreement in non-elderly subjects. Skin calipers improved the agreement between clinicians but did not improve the correlation with other nutritional markers or prediction of morbidity and mortality. There was a correlation between a patient's severely malnourished state and mortality. In addition, patients with a body mass index (BMI) of <75% or >150% age/sex standardized norms had an increased mortality. The SGA is a reproducible and valid tool for determining nutritional status in the elderly. The reproducibility is less than in the non-elderly, which may relate to changes in body composition or ability to obtain an accurate nutritional history. Publisher: Elsevier Science Inc. All rights reserved. Doi 101016/S0899-9007(00)00398-1

201 Nutri-Senex: State of the art report – task 2.1

Global outlook on nutrition and the environment: meeting the challenges of the next millennium

Iyengar & Air (2000). The Science of the total Environment journal volume 249, issue 1-3 pages 331- 346

As we enter the new millennium, nearly 800 million of the World's population will remain chronically malnourished. Nearly 200 million children are moderately to severely underweight, while 70 million are severely malnourished. And those who are yet to be born will be faced with the same set of circumstances that predispose them to malnutrition and its consequences. Eradication of nutritional deficiencies among women and children on a global scale are needed to ensure improved quality of life for the next generation of citizens. Primary deficiencies in vitamin A, iron, iodine, calcium, folic acid and trace elements such as zinc are compounded by pollutants caused by human activity. Environmental lead, arsenic, mercury, and other heavy metals that enter the food chain can seriously deplete body stores of iron, vitamin C and other essential nutrients leading to decreased immune defences, intrauterine growth retardation, impaired psychosocial faculties and other disabilities associated with malnutrition. Increased susceptibilities to communicable diseases, and those provoked by water or insect borne vectors are additional risks encountered by malnourished individuals. Migration of populations from rural to urban centres and the expansion of major metropolitan areas have had a significant and adverse impact on the quality of life of these citizens. In the next 20 years most of the growth in urban populations will be in Asia and Latin America. Urbanization and the resultant burden on limited national resources is a major contributory factor to malnutrition. There are many other lifestyle-associated disabilities such as use of tobacco (cancer) and alcoholism that require active intervention. Within the family unit, socio-economic factors and the status of women (literacy, economic independence) are major determinants of the quality of life. In the coming century, the World will have to meet these challenges by careful planning and international cooperation. Publisher: Elsevier Science B.V All rights reserved Doi 10.1016/S0048-9697(99)00529-X

202 Nutri-Senex: State of the art report – task 2.1

The anorexia of aging

MacIntosh et. .al , (2000) Nutrition Journal volume 16, issue10 pages 983-995

In the past 100 y, there has been a dramatic increase in the number and proportion of people living into old age in Western countries. The proportion of the population that is elderly continues to grow rapidly. In the United States, the elderly population is expected to increase by 8% over the next 20 y, so that in the year 2020 there will be 65 million people (24.6% of the population) older than 60 y.Similar predictions have been made in Australia, where more than 24% of the population will be older than 65 y the year 2051 versus 12% in the year 2000.The largest absolute growth in the numbers of older persons, however, will occur in the developing countries, e.g., China, Indonesia, the Indian subcontinent, and Mexico. In addition, there will be a marked increase in the number of persons living beyond the age of 85 y, i.e., the "old old." This dramatic demographic trend brings with it an enormous socio- economic burden, not only on the individual but also on governments because the use of health care increases with age. Poor nutritional status has been implicated in the development and progression of chronic diseases commonly affecting the elderly, including osteoporosis, cardiovascular disease, diabetes mellitus, and cancer. An increased understanding of the factors that contribute to poor nutrition in the elderly should enable the development of appropriate preventive and treatment strategies and improve the health of older people. Publisher : Elsevier Science Inc. All rights Reserved. Doi 10.1016/S0899- 9007(00)00405-6

The Knowledge, Attitudes, and Practices of Dieticians Licensed in Oregon Regarding Functional Foods, Nutrient Supplements, and Herbs as Complementary Medicine

Lee, et. .al (2000) Journal of American Dietetics Association volume 100 issue 5 pages 543- 548

To examine the perceived knowledge and attitudes of dieticians licensed in Oregon (LDs) regarding the effectiveness and safety of functional foods, nutrient supplements, and herbs as complementary medicine as well as their personal use, recommendations for the use of others, and training needs. A mailed survey was used to gather data. The questionnaire was developed and face-validated after a focus group discussion. A geographically stratified, random sample of 202 Oregon LDs was surveyed; usable data were collected from 162 LDs (80%). Descriptive statistics and 2 tests were used to analyse data. The data were weighted to take account of the sampling method and yield population estimates. LDs considered themselves to be knowledgeable of functional foods and nutrient supplements. More than

203 Nutri-Senex: State of the art report – task 2.1

80% were confident of the effectiveness of functional foods and nutrient supplements for prevention of illness and treatment of chronic illness, and at least 89% were confident of their safety for these uses. Fewer than 75% considered herbs to be safe and only about 50% were confident of the effectiveness of herbs. Only 10% or fewer LDs considered themselves to be knowledgeable about herbs for prevention and treatment of illness. Interest in training about each of these less-traditional nutrition therapies was high. Oregon LDs consider themselves to be actively practicing in the area of complementary medicine and have a strong desire for further training. The dietetics profession can capitalize on this interest by taking the lead in training dieticians about the role of functional foods, nutrient supplements, and herbs in health. Copyright 2000 American Dietetic Association. Publisher: Elsevier Science U.S.A Doi 10.1016/S0002-8223(00)00169-3

A recipe for improving food intakes in elderly hospitalised patients

Barton & Beigg et. .al (2000) Clinical Nutrition Journal volume 19 issue 6, pages 4511-454

Background & Aims: The aim of this study was to compare food wastage and intake between the normal hospital menu and one where more energy dense but smaller portions were provided. Methods: This study was carried out on an Elderly Rehabilitation ward in a University hospital. Patients were randomly allocated to receive either a normal or a reduced portion size fortified menu for a 14 day cycle and then swapped-over at the end of each cycle for the 56 day study. One group received a cooked breakfast and normal menus throughout the study. Results: All the menu combinations could meet the patients recommended intake. The fortified menu provided 14% more energy than the normal menu. Food wastage was highest in the cooked breakfast group (32%) and lowest in the Fortified group (27%). The total weight of wasted food was less than in the previous study. Nutritional intakes were 25% higher on the fortified menu compared with the normal menu. The mean protein intakes were still below that recommended. All patients had higher energy intakes on the Fortified menu compared with their intake on the normal menu despite being served a lower weight of food. Conclusions: We conclude from our own data and that of others that it is possible for elderly patients to achieve their nutritional targets using a combination of smaller portions of increased energy and protein density and between-meal snacks. The needs of other groups of patients also needs to be assessed in a similar way to make hospital food appropriate to the needs of the sick. Publisher: Harcourt Publishers Ltd all rights reserved. Doi 10.1054/clnu.2000.0149

204 Nutri-Senex: State of the art report – task 2.1

Nutrition and senescence: healthy aging for all in the new millennium? de Jong (2000) Nutrition Journal volume16, issue 7-8 pages 537-541

Community-dwelling, physically frail elders are a particularly vulnerable group who need special and more structured attention within the total health-care system. Early identification of deteriorating health with easily applied methods is a prerequisite for successfully implementing simple and enjoyable interventions aimed at autonomy and improved quality of life. Several issues play a role in the downward spiral of frailty and may be of particular interest in future research in the elderly and in future actions taken to prevent or slow the onset of frailty. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00317-8

Nutraceutical interventions may delay aging and the age-related diseases

Villeponteau, et. .al (2000) Experimental gerontology volume 35 issues 9-10 pages 1405- 1417

Largely due to better control of infectious diseases and to year-round access to a more nutritious diet, life expectancy in developed countries has increased dramatically in the twentieth century. However, as the average age of the population has risen, the incidence of chronic age-related diseases such as Alzheimer's, Parkinson's, cardiovascular disease, cancer, arthritis, osteoporosis, benign prostatic hyperplasia, late-onset diabetes, and macular degeneration have increased. To obtain further significant improvements in both lifespan and the quality of life in this century, treatments and nutritional changes that address the age- related diseases and the aging process itself need to be examined and validated. There are many reports suggesting that oxidative stress and certain nutritional deficiencies may contribute to the aging process and to many age-related diseases. In this article, we report on two human clinical trials using novel antioxidant supplements in which urinary oxidative stress is significantly reduced. We also discuss the conceptual basis and existing literature for several nutritional supplements that may have beneficial effects on aging and age-related diseases. Based on the available data, we suggest that human life expectancy can be significantly increased in the twenty-first century by optimising diet and using nutritional supplements. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0531- 5565(00)00182-0

205 Nutri-Senex: State of the art report – task 2.1

Malnutrition: causes, consequences, and solutions

Gopalan (2000) Nutrition Journal volume16 issue 7-8 pages 556-558

As we enter the 21st century and the new millennium, malnutrition, acting either directly or indirectly, remains the single most important factor impairing health and productivity of large human populations. The ongoing demographic and developmental transition has brought about a steady change in the profile of malnutrition, especially in the latter half of the previous century. This has been particularly noticeable in the developing countries. Until approximately 50 y ago, malnutrition was largely considered to be the problem of the poor. Famines, due to acute shortage of food, periodically devastated vast populations in Asia and Africa. Florid, classic nutritional deficiency diseases such as kwashiorkor, keratomalacia, pellagra, beriberi, and goitre took a heavy toll. Thanks to the timely advent of the "green revolution," gloomy Malthusian prophecies of near extinction of populations from famine were belied. Florid nutritional-deficiency diseases were largely brought under control. However, considerable under nutrition reflected in "mild" and "moderate" malnutrition, stunting in children, and anaemia’s in pregnancy associated with low–birth-weight deliveries are still widely prevalent in many parts of the Third World. Thus, nearly half of children younger than 5 y in South Asia are presently stunted and nearly one-third of infants born are of low birth weight (<2.5 kg). Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00315-4

Dietary considerations to prevent loss of bone and renal function

Calvo (2000) Nutrition Journal volume16 issue 6-7 pages564-566

At the beginning of the 20th century, the average life expectancy in the United States was less than 50 y, but after a century of technical and medical advances, the life expectancy of the average American has increased by more than 25 y. A longer life expectancy creates a compelling need to initiate early lifestyle changes that will maintain bone and renal health to ensure a good quality of life as we age. Two costly and debilitating diseases dramatically reduce the independence and quality of life of older Americans. These diseases are the brittle bone disease, osteoporosis, which is associated with an estimated 1.5 million bone fractures annually at costs in excess of $10 billion; and end stage renal disease, which requires more than 200 000 patients to undergo dialysis at an annual cost of $15.6 billion.

206 Nutri-Senex: State of the art report – task 2.1

Both diseases have different etiologies, and both are considered modifiable or their progression slowed through dietary intervention. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00313-0

Functional foods. Part 1: the development of a regulatory concept

Kwak & Jukes, (2000) Food control Journal volume 12 issue 2 pages 99-107

As a number of functional foods have been already introduced into the international market, their claims of health benefits may challenge the traditional border between food and medicine. As a result the position of functional foods within existing categories in the regulatory system is vague. The regulatory concept of functional foods on the basis of Japanese and international concepts has been examined in view of the approaches in other countries. From the examination, it is generally agreed that functional foods should provide health benefits over and above their normal nutritional values within daily dietary patterns. In order to clarify the scope of functional foods their relationship with food and drugs is also examined. Publisher Elsevier Science Ltd. All rights reserved. Doi 10.1016/S0956-7135(00)00028-1

Functional foods. Part 2: the impact on current regulatory terminology

Kwak, & Jukes (2000) Food Control Journal volume 12 issue 2 pages 109-117

In order to introduce the category of functional foods into the present regulatory system, it is necessary to review the relationships between functional foods and other existing legal or commercial terms, with the internationally agreed definitions. Functional foods may be distinguishable from medical foods and dietary supplements, whereas they overlap foods for special dietary uses and fortified foods. They are also regarded as nutraceuticals and health foods, and novel foods in a certain case. These complex relationships can be one of the reasons why functional foods should be controlled on the basis of horizontal approaches such as health claims Publisher: Elsevier Science Ltd. All rights reserved Doi 10.1016/S0956-7135(00)00029-3

207 Nutri-Senex: State of the art report – task 2.1

Pharmaceutical aspects of parenteral nutrition: from now to the future

Allwood, (2000) Nutrition Journal volume 16 issue 7-8 pages 615-618

The methods used to provide parenteral nutrition (PN) have changed rapidly in the past 20 y. It is still possible to recall daily feeding being accomplished by as many as six separate infusions, each containing protein, glucose, or fat emulsion, and intended to be infused over 6 to 8 h. This procedure required regular changes of bags and bottles by ward staff that were also required to add trace elements, electrolytes, and vitamins. Incompatibilities were inevitable and line infection rates greater than 25% have been reported. The entire method was hazardous in the extreme, spasmodic in nutrient provision, and, not surprisingly, regularly failed to contribute to improving nutrition status. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00337-3

Multiple approaches and partnerships in public-health nutrition interventions

Darnton-Hill, (2000). Nutrition Journal volume16 issue 7-8 pages 633-636

Why, at the beginning of the year 2000, are there still >150 million malnourished children in the world? Like most easy questions, there are no easy final answers. Nevertheless, we do have the answers to most of the underlying questions, certainly enough that we can already be addressing the main question. We know the consequences of malnutrition physiologically and on intellectual development, although the details may vary in some populations. We know how much food is needed by individuals by age and gender, and, broadly, what the nutrient composition of these diets should be. We know the individual and, less accurately, the societal costs of malnutrition. We even know how to prevent, control, and manage the problem. So, perhaps the question is really: why have we not eliminated the problem? Publisher: Elsevier Science Inc. All rights Reserved. Doi 10.1016/S0899-9007(00)00292-6.

Improving public awareness of nutrition issues

Clayton (2000) Nutrition Journal volume 16 issue 7-8 pages 637-639

This article is my personal view of the way forward in nutrition as it relates to the United Kingdom. For a long time, nutrition has been concerned with the prevention and treatment of disease. There is now increasing emphasis on its importance in the promotion and maintenance of optimal health. However, the role of physical activity has been much neglected, and I believe it is essential that we educate the public that nutrition and physical

208 Nutri-Senex: State of the art report – task 2.1 activity must be seen as a single entity. I had the privilege of chairing the Nutrition Task Force for England and Wales for the British Government between 1993 and 1996. After wide discussion, the Health Education Authority in association with the Ministry of Agriculture, Fisheries and Food and the Department of Health produced eight guidelines for a healthy diet that provide a good, simple, practical, and consistent basis for a healthy diet Publisher: Elsevier Science Inc. All rights Reserved. Doi 10.1016/S0899-9007(00)00238-0

Nutrition communication in the 21st century: what are the challenges and how can we meet them?

Goldberg (2000) Nutrition Journal volume16 issue 7-8 pages 644-646

In the 1950s, future dieticians like me––food and nutrition majors––were usually found in departments of home economics. Along with biochemistry and physiology, we were required to take courses with titles like "Foods" or "Advanced Foods." There we learned such basic skills as how to extract the sections from an orange without wasting the tiniest morsel of flesh, how to poach the perfect egg, and how to bake muffins without tunnels (clear evidence that they had been over mixed). Today's students of nutrition balk at spending precious time and tuition dollars learning these mundane tasks given the enormous amount of science that must be mastered in an intensive academic program. Yet, the skills that we acquired in foods labs back then were critical to understanding what real people in the real world needed to know. We learned how to handle food, and in the process, we experienced some of the difficulties that our clients would encounter as they tried to implement our dietary recommendations at home Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00353-1

Role of nutrition in primary care

Feldman, (2000) Nutrition Journal 16, 7-8 page 649-651

This editorial opinion is written by an internist and focuses on adult medicine, with less information included on applications to children and to pregnant and lactating women. It reviews the role of nutrition in primary care in the immediate past, the present, and into the next millennium; attitudes of physicians toward using nutrition concepts in patient care; delivery of primary care; specifics of nutrition content, education, and training; sources of information; and predictions of the future. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00239-2

209 Nutri-Senex: State of the art report – task 2.1

Nutraceuticals and functional foods: introduction and meaning

Hardy, (2000). Nutrition Journal volume 16, issue 7-8 pages 688-689

As we enter the third millennium, with increased life expectancy and greater media coverage of health care issues, consumers are understandably more interested in the potential benefits of nutritional support for disease control or prevention. A recent survey in the UK, Germany, and France concluded that diet is rated more highly by consumers than exercise or hereditary factors for achieving good health. At the same time, advances in food/ingredient technologies, coupled with a better understanding of specific nutrient properties, have stimulated an explosion of innovative nutrition products by food manufacturers Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(00)00239-2

A European consensus of scientific concepts of functional foods

Roberfroid (2000) Nutrition Journal volume 16 issue 7-8 pages 689-691

To understand functional food it is first necessary to understand how the science of nutrition itself has changed. Nutrition has progressed from the prevention of dietary deficiencies and the establishment of the concept of balanced diet to the promotion of a state of well-being and health and the reduction of the risk of disease, as well as the development of the concept of optimum (optimised) nutrition. During the 20th century, nutrition has discovered the essential nutrients and it has established nutrient standards, dietary guidelines, and food guides, mainly if not exclusively with the aim of preventing deficiencies and of supporting body growth, maintenance, and development. More recently it has also made recommendations aiming to avoid excessive consumption of some of these nutrients after recognizing their potential role in the etiology of miscellaneous (mostly chronic) diseases. Through these developments, one of the major contributions of nutrition in the 20th century has been the concept of balanced diet, "an appropriate mixture of food items that provides, at least, the minimum requirements of nutrients and a few other food components needed to support growth and maintain body weight, to prevent the development of deficiency diseases and to reduce the risk of diseases associated with deleterious excesses." Publisher: Elsevier Science Inc. All rights reserved Doi 10.1016/S0899-9007(00)00329-4

210 Nutri-Senex: State of the art report – task 2.1

Functional food and contemporary nutrition-health paradigm: tempeh and its potential beneficial effects in disease prevention and treatment

Karyadi, & Lukito (2000). Nutrition journal, volume 16, issue 7-8 pages 697

The roles of tempeh, an Indonesian indigenous and traditional fermented soy food, in disease prevention and treatment have gained worldwide recognition. Many scientific meetings have been held, and published manuscripts on tempeh have added to the scientific vocabularies of functional foods. Several studies undertaken in Indonesia demonstrated that tempeh had anti diarrheal and hypolipidemic effects. It is yet to be ascertained whether the anti diarrhoeal property of tempeh is through its ant microbial activity or through gut immunity. It also remains to be seen whether tempeh has direct antiatherogenic effects without its hypolipidemic activity. Publisher: Elsevier Science Inc. All rights Reserved. Doi 10.1016/S0899-9007(00)00364-4

Enrichment of food staples through plant breeding: a new strategy for fighting micronutrient malnutrition

Bouis (2000) Nutrition journal volume 16, issue 7-8 pages 701-704 Can commonly eaten food-staple crops be developed that fortify their seeds with essential minerals and vitamins? Can farmers be induced to grow such varieties? If so, would this result in a significant improvement in human nutrition at a lower cost than existing nutrition interventions? Having concluded that the available scientific evidence indicates positive answers to all three of these questions, an interdisciplinary, international effort is underway to breed for mineral- and vitamin-dense varieties of rice, wheat, maize, beans, and cassava for release to farmers in developing countries. Not only does plant breeding hold great promise for making a significant, low-cost, and sustainable contribution to reducing micronutrient, particularly mineral, deficiencies in humans, it also may well have important spin-off effects for increasing farm productivity in developing countries in an environmentally beneficial way. Publisher: Elsevier Science Inc. All rights Reserved Doi 10.1016/S0899-9007(00)00266-6

211 Nutri-Senex: State of the art report – task 2.1

Implementing Calcium Fortification: An Industry Case Study

Tobelmann (2000) Journal of Food Consumption and Analysis Volume 14 Issue 3 Pages 241-244 Food manufacturers bear the responsibility of providing accurate nutritional information for the products they produce. Consumers and health professionals increasingly request more detailed information beyond what is supplied on the "Nutrition Facts" panel. Providing this information is a complex process due to confidential new product development and reformulation. Product reformulation regularly occurs for several reasons, including product improvement and flavour enhancement. This case study illustrates a major U.S. food manufacturer's experience with calcium fortification of children's cereals. Focus groups, modelling studies, and bioavailability tests were conducted prior to the products' introduction. Early dietary intake research determined that children's average daily calcium intake was declining and that no gender or age group over age nine met the new recommended daily intake of 1300 mg. Cereal was found to be an appropriate vehicle to fortify with calcium, in the form of calcium carbonate. Bioavailability of calcium in cereal was found to be equivalent to the bioavailability of calcium in milk. From this case study, one can observe the difficulty of providing detailed nutritional information when a product is in the reformulation stage of its life cycle. Publisher: Academic Press. All rights reserved. Doi 10.1006/ifca.2001.1001

Iron deficiency and iron fortified foods––a review

Martínez-Navarrete et. al, (2000) Food Research International Journal volume 35 Issue 2-3 Pages 225-231

Iron is a mineral that is necessary for producing red blood cells and for redox processes. Iron deficiency is considered to be the commonest worldwide nutritional deficiency and affects approximately 20% of the world population. Lack of iron may lead to unusual tiredness, shortness of breath, a decrease in physical performance, and learning problems in children and adults, and may increase your chance of getting an infection. This deficiency is partly induced by plant-based diets, containing low levels of poorly bio-available iron. The most effective technological approaches to combat iron deficiency in developing countries include supplementation targeted to high risk groups combined with a program of food fortification and dietary strategies designed to maximize the bio-availability of both the added and the intrinsic food iron. In this paper, different aspects related to iron-fortified foods is reviewed. These include used iron compounds, considering its bioavailability and organoleptic problems, food vehicles and possible interactions.

212 Nutri-Senex: State of the art report – task 2.1

Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016/S0963-9969(01)00189-2

Nutraceuticals: a piece of history, present status and outlook

Andlauer & Fürst (2000) journal of Food Research international volume 35 issue 2-3 pages 171-176

The term "nutraceutical" was coined in 1989 by the Foundation for Innovation in Medicine (New York, US), to provide a name for this rapidly growing area of biomedical research. A nutraceutical was defined as any substance that may be considered a food or part of a food and provides medical or health benefits including the prevention and treatment of disease. Nutraceuticals may range from isolated nutrients, dietary supplements and diets to genetically engineered "designer" foods, herbal products and processed products such as cereals, soups and beverages. Doubtlessly, many of these products possess pertinent physiological functions and valuable biological activities. The ongoing research will lead to a new generation of foods, which will certainly cause the interface between food and drug to become increasingly permeable. The present accumulated knowledge about nutraceuticals represents undoubtedly a great challenge for nutritionists, physicians, food technologists and food chemists. Public health authorities consider prevention and treatment with nutraceuticals as a powerful instrument in maintaining health and to act against nutritionally induced acute and chronic diseases, thereby promoting optimal health, longevity and quality of life. Publisher: Elsevier Science Ltd. All rights reserved Doi 10.1016/S0963-9969(01)00179-X

Prevalence of zinc deficiency and its clinical relevance among hospitalised elderly

Pepersack, (2000) Archives of Gerontology and Geriatrics volume 33 issue 3 pages 243-253

Zinc is an essential trace element, and constituent of many metallo-enzymes required for normal metabolism. Age may be associated with altered metallothionein metabolism related to changes in zinc metabolism. The objectives of this study were: (i) to assess the prevalence of zinc deficiency among hospitalised elderly patients; (ii) to define the social, functional, pathological and nutritional characteristics of zinc deficient elderly hospitalised patients; and (iii) to assess the relationship between the zinc status and humoral immune function among hospitalised elderly patients. Fifty consecutive patients underwent comprehensive geriatric assessments included evaluations of the medical (index of the severity of the disease(s)), psychiatric (Geriatric depression scale (GDS)), therapeutic,

213 Nutri-Senex: State of the art report – task 2.1 social, functional (Katz's scale), and nutritional problems (Mini Nutritional Assessment (MNA) and biochemical markers (zinc, albumin, prealbumin (PAB), cholesterol) before their discharge. Fourteen patients (28%) presented a zinc concentrations lower than 10.7 mol/l, this value is usually considered as the cut-off level below which a zinc deficient status is possible. Higher proportions of respiratory infections, cardiac failure, and depression were observed among zinc deficient patients as compared with the group of patients with normal zinc status. The other parameters of comprehensive geriatric assessment did not allow to discriminate the zinc deficient patients. The only slight differences (which remained insignificant) concerned the prealbumin levels which tended to be higher in the group of patients presenting normal zinc status than in the group with poor zinc status (0.208±0.062 versus 0.171±0.068 g/l respectively, P=0.06), and the IgG2 levels which tended to be lower in the group of patients with normal zinc status than in the group presenting poor zinc status (2.77±1.91 versus 4.06±2.56, respectively, P=0.057). A negative correlation was observed between the Zn concentrations and the IgG2 levels (Spearman R=-0.311, P=0.028). To the best of our knowledge, this is the first study presenting zinc status according to a comprehensive geriatric assessment among European hospitalised geriatric patients. We decided to perform this study to known who of our patients needed to be supplemented with zinc administration. Considering the low energy intake of hospitalised patients (confirmed here in regards of the nutritional assessment), and the insufficient trace element density in European foods, the relevance of providing medical supplements or enriched foods to this population has to be evaluated. Although most of the current diseases may be relevant to long-term interactions between nutrition and ageing, certain states observed in the elderly, like impaired immune and cognitive functions, could still benefit from an appropriate nutritional supplementation. Publisher: Elsevier Science Ireland Ltd. All rights reserved. Doi 10.1016/S0167- 4943(01)00186-8

Nutritional status after short-term dietary supplementation in hospitalised malnourished geriatric patients

Bos et.al (2000) Clinical Nutrition Journal volume 20, issue 3 pages 225-233

To examine the evolution of different parameters of the nutritional status after short-term oral protein-energy supplementation in moderately malnourished geriatric patients. Seventeen hospitalised malnourished elderly patients and 12 healthy adults received dietary supplements for 10 days. A group of six malnourished elderly subjects served as controls. Spontaneous oral intakes, biological and biophysical markers of the nutritional status were measured. Fat-free mass (FFM) was assessed using Dual energy X-ray absorptiometry

214 Nutri-Senex: State of the art report – task 2.1

(DXA), bio-impedance analysis (BIA) and anthropometry. In elderly subjects, the supplementation significantly increased both dietary intake (energy +32%, protein +65%) and FFM (+1.3 kg, P<0.001) as assessed using DXA. BIA and anthropometric data correlated with DXA measurements in the elderly (BIA: r=0.68–0.80, anthropometry:r =0.80–0.89), but failed to reflect accurately the changes measured in FFM. Supplementation had no notable effect on biological markers in any of the groups. IGF-I and handgrip strength were not significantly influenced by the supplementation despite trends towards an improvement. Monitoring short-term changes in nutritional status in malnourished elderly individuals is a problem in routine clinical management. Our data put in the limelight the changes in IGF-I values related to dietary supplementation, and, chiefly, suggest a prime role for the assessment of dietary intake and FFM, as assessed by DXA, as indicators of short-term efficacy of refeeding. Nevertheless larger studies are necessary to confirm the clinical and prognostic significance of the changes. Publishers: Harcourt Publishers Ltd. All rights reserved Doi 10.1054/clnu.0387

Dietary supplements

Nesheim (1999) Nutrition Journal volume 14, issue 9 pages 729-730

The use of dietary supplements by Americans is extensive. Recent surveys estimate that over 50% of the population of the US uses some type of dietary supplement. This is in spite of the general recommendation in most of our official dietary advice (Recommended Dietary Allowances [RDA], dietary guidelines) that we should be able to receive the nutrients we need by consuming a varied diet. Vitamin and mineral supplements represent the largest category of supplements used, but the use of herbal products, antioxidants, and amino acids and other products seems to be increasing. The sales of supplements in the US is estimated as being in excess of $8 billion. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(98)00096-3

Outcome From Nutritional Support Using Hospital Food

Kondrup et.al (1999) Nutrition Journal volume 14, issue 3 pages 319-321

It is beginning to be widely accepted that under nutrition in hospital patients is a common and important clinical problem that affects illness outcome. Although there are areas of disagreement, there are a growing number of studies showing that nutritional support by the oral, enteral, or parenteral route improves outcome in certain groups of patients. Although

215 Nutri-Senex: State of the art report – task 2.1 most studies have focused on artificial means of nutritional support, the majority of patients receive their nourishment from the hospital kitchen, which is currently organized, in most hospitals, on the hotel or institutional model, rather than being targeted to groups of sick patients with their own particular needs. At the Rigshospitalet in Copenhagen we have developed a seamless nutritional service in which most patients are screened nutritionally on admission and, if found to be at risk, referred to our nutrition department, which is staffed by dieticians who make a more detailed assessment of the patients and design a treatment plan, based mainly on the hospital menu but supported by oral supplements, enteral, or parenteral feeds as clinically indicated. Using weight as the main outcome measure, we collected data prospectively in different groups of hospital patients in order to assess their energy requirements from all sources. This has allowed us to design nutritionally appropriate menus in an attempt to avoid the continuing weight loss. We are a 1 200-bed university hospital with 50 000 annual admissions. In a 5-y period, 10 650 patients were referred to the nutrition unit. Of these, 5 112 patients were found to have an inadequate intake and/or were undernourished. In the majority of cases, the problems were managed by normal food and oral supplements as required, but 1 115 patients were judged to be at special risk, necessitating more intensive management. Publisher:Elsevier Science Inc. All rights reserved Doi 10.1016/S0899-9007(97)00481-4

The chemical composition of "Multimistura" as a food supplement

Madruga & Camara (1999) Food Chemistry Journal volume 68, issue 1 pages 41-44

The utilization of a "Multimistura" as a food supplement, in nutritional improvement programmes for low-income populations, represents a low cost, fast food preparation alternative which satisfies local taste preferences. This is based on the fact that the "Multimistura" is made up of non-conventional ingredients/foods and/or agroindustrial by- products rich in different nutrients. The present work has been designed to analyse the chemical composition of a "Multimistura" utilized as food supplement in institutional programmes to prevent malnutrition by means of the Department of Wealth and Social Affairs of the City of Natal-RN, Brazil. The product studied was elaborated by employing the following formulation: wheat bran 30%, wheat flour 30%, corn bran 30%, powder from cassava leaves 3%, pumpkinseeds powder 4% and egg shell powder 3%. The results from the chemical analysis made, showed that the product presented high levels of carbohydrates (67.0%) and proteins (12.7%), the total caloric value (TCV) corresponding to 377 kcal/100 g. The amino acids profile was deficient in only two essential amino acids, methionine and phenylalanine, when compared to a standard protein from FAO/WHO, which resulted from

216 Nutri-Senex: State of the art report – task 2.1 the biological nature of the product. The analysis of micronutrient minerals revealed the products as being a potential source of calcium, as well as a good source of phosphorus, magnesium, iron and zinc. The "Multimistura" presented a significant content of carotene, which favours the roll of vitamin A, although thiamine, riboflavin and niacin were detected. Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016/S0308-8146(99)00152-1

Dietary antioxidants modulation of aging and immune-endothelial cell interaction

Meydani (1999) Mechanisms and Aging and Development Journal volume 111 issue 2-3 pages 123-132 Oxidative damage by free radicals, which is the basis for the free radical theory of aging, has been well investigated within the context of oxidant/antioxidant balance. Age-associated disorders are believed to be associated with the time-dependent shift in the antioxidant/prooxidant balance in favour of oxidative stress. In this brief review, the importance of dietary antioxidant intervention on longevity and age-associated changes in bodily functions and diseases are discussed. Evidence has indicated that increasing the endogenous antioxidants defence system and modulation of free radical production by dietary restrictions contribute to increased longevity in animal models. Thus, increasing dietary intake of antioxidants is believed to increase longevity. Earlier studies have shown some increase in median life span in animal models. It was found that supplementing middle- aged (18 months) C57/BL mice with various antioxidants (vitamin E, glutathione, melatonin, and strawberry extract) had no effect on longevity as measured by the average age of death. Therefore, dietary antioxidant supplementation seems unlikely to increase longevity when begun in middle age; supplementation started in early life might be more effective. However, in middle-aged mice, vitamin E was effective in reducing lung viral titre when animals were exposed to influenza virus. Vitamin E supplementation improves cell-mediated immunity in mice and in humans. In addition to modulating the oxidation of low-density lipoproteins, vitamin E can modulate immune/endothelial cells interactions, thus reducing the risk of cardiovascular disease (CVD), a major cause of morbidity and mortality in elderly. Thus, antioxidants such as vitamin E from food sources or supplements appear to be promising for successful aging by improving immune function, and reducing the risk of several age- associated chronic diseases, such as CVD. Publisher: Elsevier Science Ireland Ltd. All rights reserved Doi 10.1016/S0047- 6374(99)00067-6

217 Nutri-Senex: State of the art report – task 2.1

Preparing dietetic professionals for practice in the 21st century: how can educational programs respond to changes in health care?

Touger-Decker (1999) Nutrition Journal volume 14, issue 6 pages 535-539 As health care gets ready for the new millennium, the roles and responsibilities of all health providers are undergoing a tremendous paradigm shift. The health care paradigm of the 20th century has been focused on treatment, with specialized care provided by individual practitioners in institutionalised settings. The "Emerging Paradigm" is supported by a shifting health care system with downsizing of acute-care facilities and upsizing of out-of-hospital care organizations and managed care sites, and shifts toward community-based patient care, provided by a multidisciplinary, cross-trained health care team. The focus is increasingly on disease prevention and management of chronic diseases. The impact of this paradigm shift is now on health care providers, as well as the educators responsible for training and retraining health professionals for practice. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(98)00043-4

The Impact of Nutritional Needs of Older Adults on Recommended Food Intakes

Russell, et. al. (1999) Nutrition in Clinical Care Volume 2 Issue 3 Page 164.

The elderly are at greater risk for nutrient deficiencies than are younger people. The complications of chronic disease states that are more common among older adults as well as the limitations that accompany the natural aging process can affect nutrient intake, absorption, and utilization. This paper reviews those nutrients for which research has been conducted among elderly populations to determine their specific needs. Based on the state of knowledge to date, recommendations are made. In addition, a modified food pyramid that takes into account the lower energy intakes and special nutrient needs of the elderly has been designed and is described here. Nutrient-dense foods, adequate fluid and fibre, and supplementation of calcium, vitamin D, and vitamin B12 are each emphasized in this narrower version of the Food Guide Pyramid for seniors over age 70. Specific food choices that will help elderly people meet their changing needs and avoid nutrient deficiencies, such as fortified cereals, brightly coloured vegetables and fruits, and low-fat dairy products, are highlighted as well. Publisher; Blackwell Publishing Inc. doi:10.1046/j.1523-5408.1999.00110.x

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Formulation of enteral diets

Silk (1999) Nutrition Journal volume 15, issue 7-8 pages 626-632 The number of enteral diets has increased from a handful in the 1970s to over 100 at present. These can be classified as polymeric, chemically defined, disease-specific, and specialized diets, as well as oral dietary supplements. The properties, indications, pros and cons for the use of these diets are outlined in an effort to assist clinicians in their selection. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/SO899-9007(99)00099-4

Retrospective Study Of The Effects Of Zinc Supplementation In An Elderly Institutionalised Population With Decubitus Ulcers

Haggard.et.al (1999) journal of American Dietetics Association volume 99 issue 1 supplement 1 pages A11 To identify positive and adverse effects of large doses of zinc supplements (440 mg zinc sulfate/day) in an institutionalised elderly population with decubitus ulcers. The present pilot study was a retrospective analysis of 70 institutionalised elderly (37F 33 M, mean age 81.7 + 8.3 years) with documented decubitus ulcers (stage II-IV). The study compared 26 patients who received 440 mg zinc sulphate/day (100 mg elemental zinc/day) for 30 days with 44 patients not receiving zinc sulphate. There were no significant differences between groups in age, sex, % ideal body weight, mobility, continence, or glucocorticoid use. Food intake was <30 kcal/kg in 68% of the non-supplemented, and 69% of zinc-supplemented subjects. The effects of the zinc sulphate on outcome measures of healing were inconclusive. There was a statistically greater decrease in surface area of the ulcers related to zinc supplementation when stage of the ulcer was considered. Days to heal were not affected by zinc supplementation. Adverse affects were observed related to the zinc supplementation. Patients receiving the large doses of zinc sulphate had 12.5 times greater odds of experiencing nausea/vomiting, and 7.8 times greater odds of an infection requiring antibiotic use compared to patients not receiving the zinc supplementation (p<0.05). Sufficient statistical power was demonstrated (l-=0.71, nausea/vomiting; and 0.76, infection rate) and the effect size for infection rate was moderate (w2=0.32). Some of the effects of the zinc sulphate supplement appeared to be modulated by multi-vitamin/mineral supplementation at RDA levels. CONCLUSIONS: This preliminary study suggests several adverse effects related to zinc sulphate supplementation in excess (6 times) of the RDA. Further study is needed to substantiate these Findings. The maximal safe dose of zinc supplementation is not known. Findings from the present study emphasize the importance of carefully evaluating zinc supplementation practices.

219 Nutri-Senex: State of the art report – task 2.1

Copyright 1999 American Dietetic Association. Publisher: Elsevier Science U.S.A Doi 10.1016/S0002-8223(99)00437

Preparing Dietetic Interns for the Future: Building a practice Foundation in Geriatric Nutrition

Stein & Moreschi-Mason (1999) Journal of American Dietetic Association volume 99 issue 9 supplement 1 page A83 The US Census Bureau predicts a dramatic increase of the population aged 65 and older to 20% of the population by 2030. These projections bring concerns about the elderly to the forefront of public health issues. Although the Elderly Nutrition Program (ENP) is a highly successful program, the Administration on Aging identifies future challenges, including addressing the 64% of congregate and 88% of home-delivered meals participants who remain at high or moderate nutritional risk, as assessed by the Nutrition Screening Initiative (NSI). According to the NSI, health care professionals also need education and training in identifying, evaluating, and providing feeding assistance. Consequently, we implemented dietetic internship rotations that assess, provide, monitor, and research nutrition services, including education, to seniors and ENP personnel - in long-term care settings, ENP dining centres, homes for those receiving delivered meals, and through a campus-based Nutrition Education Centre. Evaluative feedback demonstrates improved comprehension of nutrition issues by those served. Interns gain practice in developing and implementing educational models, materials, and evaluation instruments for group education. Individualized counselling experience is gained in varied community-based settings. Interns articulate a broader and deeper understanding of issues influencing the health and nutrition status of the elderly, including psychosocial aspects. Further, feedback indicates that interns are empowered by sense of independence required during these rotations. As a bonus, the utilization of these more diverse sites reduces the need of site usage in traditional health care settings (e.g., hospitals) while meeting vital community needs, an important consideration when several practice programs are located in a similar geographic region. Full access to the curriculum outlining objectives, experiences, and evaluation will be provided Copyright 1999 American Dietetic Association. Publisher: Elsevier Science U.S.A

220 Nutri-Senex: State of the art report – task 2.1

The Relationship Between Nutrition Knowledge and Nutritional Risk of Elderly Residing Independently in the Community

Angeiella et. al (1999) Journal of American Dietetics Association volume 99 issue 9 supplement 1 page A111 The study was a descriptive cross-sectional study that evaluated elderly sixty years and older (n=50) from four elderly high-rise apartment buildings in North-eastern Pennsylvania. Three instruments were used in the study. The Langan Nutrition Knowledge Survey tested subject's knowledge of basic nutrition; the Mini Nutritional Assessment and the DETERMINE Checklist identified the subjects’ nutrition risk. The mean score on the nutrition knowledge survey was 67.74% on a 100% scale. The DETERMINE Checklist identified fifty-six percent of the subjects at high nutritional risk. Whereas, the Mini Nutritional Assessment categorized two percent of the subjects as malnourished. Both the Mini Nutritional Assessment and the DETERMINE Checklist indicated that nutritional risk was inversely related to nutrition knowledge. Results of the study indicated that there was a significant correlation at the 0 05 level between nutritional risk as determined by the Mini Nutritional Assessment scores and nutrition knowledge. As nutrition knowledge increased, nutritional risk decreased. Similar results were also obtained using the Determine Checklist and nutrition knowledge. Registered Dieticians need to reach as many elderly as possible to screen them for malnutrition and educate them on proper nutrition. This will allow us to improve their quality of life. Copyright 1999 American Dietetic Association. Publisher: Elsevier Science U.S.A. Doi 10.1016/S0002-8223(99)00792-0

Does Geographic Targeting of Nutrition Interventions Make Sense in Cities? Evidence from Abidjan and Accra

Morris et.al (1999) World Development Journal volume 27, issue11 pages 2011-2019

Although most developing country cities are characterized by pockets of substandard housing and inadequate service provision, it is not known to what degree low incomes and malnutrition are confined to specific neighbourhoods. This analysis uses representative household surveys of Abidjan and Accra to quantify small-area clustering in service provision, demographic characteristics, consumption, and nutrition. Both cities showed significant clustering in housing conditions but not in nutrition, while income was clustered in Abidjan but less so in Accra. This suggests that neighbourhood targeting of poverty- alleviation or nutrition interventions in these and similar cities could lead to under coverage of the truly needy. Publisher: Elsevier Science Ltd. All rights reserved. Doi 10.1016.S0305-750X(99)00098-4

221 Nutri-Senex: State of the art report – task 2.1

Relationship of serum leptin levels and selected nutritional parameters in patients with protein-caloric malnutrition

Haluzík et.al (1999). Nutritional Journal volume 16, issue 11-12 pages 829-833 Leptin is a protein hormone produced by adipocytes that reflects the body fat content, i.e., its serum concentration in healthy individuals positively correlates with the body mass index and body fat content. Serum leptin levels are lower in both patients with anorexia nervosa and protein-caloric malnutrition caused by chronic non-malignant illnesses. The aim of the present study was to compare serum leptin levels and selected, routinely used nutritional parameters in women with anorexia nervosa (n = 17), severely malnourished patients with short bowel syndrome (n = 13), and control non-obese healthy women (n = 17) to clarify the relation between selected nutritional parameters and serum leptin levels. We found that serum leptin levels in the anorexia nervosa and short bowel syndrome groups were significantly lower than those in the control group (in ng/mL: 3.63 ± 1.64 and 2.59 ± 1.17 versus 12.06 ± 7.59, respectively). Protein malnutrition expressed by decrease in serum concentrations of total protein, albumin, and prealbumin was more pronounced in the short bowel syndrome group. Triceps skin fold, arm muscle circumference, and body mass index were significantly lower in the patient group than in the control group and did not significantly differ between the short bowel syndrome and anorexia nervosa groups. No significant difference in serum leptin concentration between the short bowel syndrome and anorexia nervosa groups was found. Serum leptin levels correlated positively with body mass index and triceps skin fold in the control and anorexia nervosa groups but not in the short bowel syndrome group. We conclude that serum leptin levels in patients with anorexia nervosa and short bowel syndrome are significantly lower than in healthy individuals and have no statistically significant relation to serum total protein, albumin, and prealbumin. Publisher Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(99)00177-X

Compliance of orthopaedic patients with postoperative oral nutritional supplementation

R. M. Lawson et.al (December 1999) Clinical Nutrition volume 19 issue 3 pages 171-175 Studies have shown clinical benefits of nutritional supplementation in orthopaedic and elderly patients in both under and well-nourished groups. However, patient compliance with the supplementation has not been reported. To assess level of patient compliance with nutritional supplementation when prescribed postoperatively to unselected orthopaedic patients as part of a large controlled trial researching the clinical benefits of non-targeted nutritional supplementation. Patients in the intervention group were prescribed two oral supplements each day of their hospital stay, in addition to usual meals. Information describing the supplements was given by the dietician. Supplements were issued on drug

222 Nutri-Senex: State of the art report – task 2.1 rounds and the proportion of each drink consumed was recorded and collated. Patients could choose to change the type of drink or to discontinue the supplements completely at any time. Twenty-four hour food intake was analysed for a random sub-sample of 48 patients. Eighty- four patients (27 men, 57 women; mean age, 72 years) were prescribed supplements. Median length of stay was 14.4 days. Supplements were taken for a mean of 6.7 days. Median compliance was 14.9%. Despite this, median energy intake in the study group was 1523 kcal/day and 1289 kcal/day in the control (P= 0.0214). Compliance with non-targeted, postoperative nutritional supplementation is poor in unselected orthopaedic patients but even low levels of supplementation significantly increase energy intake. Publisher: Harcourt Publishers Ltd. All rights reserved. Doi 10.1054/clnu.1999.0094

Subjectively Healthy Elderly Consuming a Liquid Nutrition Supplement Maintained Body Mass Index and Improved Some Nutritional Parameters and Perceived Well- Being

Krondl et.al (1999) Journal of American Dietetics Association volume 99 issue 12 pages 1542-1548

To evaluate regular use of a liquid nutrition supplement by subjectively healthy elderly persons in terms of body mass index, nutrient intake, selected biochemical parameters, and perceived quality-of-life changes, and to identify advantages and limitations of use. A 16- week intervention study in which subjects were assigned randomly to either a supplemented group or a control group and compared in terms of intergroup and intragroup differences in weight, food intake, blood values, and quality-of-life indexes. Adherence to protocol was monitored by monthly visits with an interviewer and food intake records. Seventy-one independent living, older Canadian adults (mean AGE=70±7 years) consuming on average less than 4 servings of fruit and vegetables daily and a supplement-free diet before the study. Subjects were without functional limitations and did not require therapeutic diets or medical treatments that affect nutritional status. Data were collected in home interviews. Blood for analysis was obtained from a sub sample of 36 subjects. Intervention Inclusion of six 235-mL cans of liquid nutrition supplement weekly into the self-selected dietary patterns of the supplemented group. Results were analysed by Student t tests or Wilcoxon rank sum test, analysis of variance, and multiple stepwise regression. Body mass index, energy intake, and consumption of fruit and vegetables did not change throughout the study. In the supplemented group, statistically significant increases occurred from baseline to termination of the study in these nutrients: protein, calcium, iron, magnesium, and folate. Serum albumin, folate, ferritin, haemoglobin, and zinc values were within the normal range for the supplemented and control groups. Scores for the Medical Outcomes Study 36-Item Short-

223 Nutri-Senex: State of the art report – task 2.1

Form Health Status scales increased for the supplemented group from baseline to termination for vitality and general health perception. Values for the General Well-Being Questionnaire improved for anxiety and general well-being. Of the dietary predictors, folate intake explained the most variance for vitality and for general well being, 8.6% and 14.2%, respectively. A liquid nutrition supplement could be recommended to the elderly when energy maintenance and increases in nutrient intake are necessary and convenience is an important consideration. Dietetics professionals should address the issues of affordability of the supplement, the role of food in achieving nutritional adequacy, and overall quality of life of clients. Folate intake as a predictor of perceived general well being and vitality requires further investigation. Copyright 1999 American Dietetic Association. Publisher: Elsevier Science U.S.A. Doi 10.1016/S0002-8223(99)00378-8

Micronutrients and outcome

Shenkin, (1998) Nutritional Journal volume 13, issue 9 pages 825-828

Micronutrient deficiency not only causes symptoms of severe deficiency, but may also cause more subtle effects on tissue function, including immune deficiency and oxidative damage. The duration of a deficiency state, which is necessary before such effects are clinically significant, is not known. Most biochemical tests are relatively insensitive in detecting changes in micronutrient status, although they do provide a crude index. Many tests are non- specific, being affected by the acute phase response as well as by nutritional status. Cellular tests are more sensitive and specific than tests in plasma. When interpreted carefully in association with the knowledge of the patient's clinical condition and nutritional intake, laboratory tests can be helpful in diagnosing deficiency states or conditions of excess provision, and in monitoring progress. Well-conducted clinical trials of micronutrients in nutritional support are beginning to appear in the literature. Further studies are urgently required that relate outcome to levels of provision and biochemical indices of nutrient status Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(97)002200-1

224 Nutri-Senex: State of the art report – task 2.1

The mini nutritional assessment (MNA) and its use in grading the nutritional state of elderly patients

Vellas et.al (1998) Nutrition Journal volume 15, issue 2 pages 116-122

The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a single, rapid assessment of nutritional status in elderly patients in outpatient clinics, hospitals, and nursing homes. It has been translated into several languages and validated in many clinics around the world. The MNA test is composed of simple measurements and brief questions that can be completed in about 10 min. Discriminant analysis was used to compare the findings of the MNA with the nutritional status determined by physicians, using the standard extensive nutritional assessment including complete anthropometric, clinical biochemistry, and dietary parameters. The sum of the MNA score distinguishes between elderly patients with: 1) adequate nutritional status, MNA 24; 2) protein-calorie malnutrition, MNA < 17; 3) at risk of malnutrition, MNA between 17 and 23.5. With this scoring, sensitivity was found to be 96%, specificity 98%, and predictive value 97%. The MNA scale was also found to be predictive of mortality and hospital cost. Most important it is possible to identify people at risk for malnutrition, scores between 17 and 23.5, before severe changes in weight or albumin levels occur. These individuals are more likely to have a decrease in caloric intake that can be easily corrected by nutritional intervention Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(98)00171-3

Using Resident Assessment Data to Improve Nutritional Care in Nursing Homes: The Power of Information

Zimmerman et.al (1998) Nutrition Journal volume 14, issue 4 pages 410-415

Nursing home residents are often at high risk for developing nutritional deficiencies and disorders that require appropriate and timely intervention. The ability to intervene can be enhanced through the use of information on which staff can base their quality improvement efforts in the nutritional care area. Tools that can assist the clinical team in early identification and intervention, along with monitoring progress and identifying potential nutritional care problems, are essential to the quality of care and quality of life for residents in the nursing facility. The Minimum Data Set (MDS) quality indicators (QIs) developed by the Centre for Health Systems Research and Analysis (CHSRA) at the University of Wisconsin-Madison can provide just such a tool. In this article, we discuss the potential use of four QIs that are either directly or indirectly related to nutritional care. They are 1) the prevalence of weight loss, 2) the prevalence of tube feeding, 3) the prevalence of dehydration, and 4) the prevalence of pressure ulcers.

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Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(97)00461-9

Outcomes From Nutritional Support in the Elderly

Allison, (1998) Nutrition Journal volume 14, issue 5 pages 479-480 The prevalence of malnutrition in the elderly is higher than among other sections of the population, both in the community and in hospital. Several studies have shown that the nutritional status of the elderly continues to deteriorate during hospital stay unless active intervention is undertaken. In a recent meta analysis of randomised trials of nutritional supplementation in the elderly, Potter et al. (unpublished observations) concluded that, although the evidence for benefit was strongly suggestive, the methodological limitations of some of the studies did not allow firm conclusions to be reached in some instances Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(98)00056-2

Nutrition and the immune system of the gut

Cunningham-Rundles & Ho Lin (1998) Nutrition Journal volume 14, issue 7-8 pages 573- 579

Studies suggest that the development and expression of the regional immune system in the gastrointestinal (GI) tract is relatively independent of systemic immunity. This is reflected in significant differences in functional response of T cells and B cells and affects cytokine patterns and activation pathways when regional immunity is compared to systemic immunity. Nutrients have fundamental and regulatory influences on the immune response of the GI tract and, therefore, on host defence. In addition to the effect of nutrition during development, the local impact of different dietary and antigenic elements on the regional immune system contributes to potential diversion of the two systems throughout life. The route of exposure during antigenic contact is known to affect host immune response, whether it be a normal process, happening in the context of normal environmental encounter with non-pathogenic microbes or planned immunization, or occurring as a result of resolution of a potentially pathologic process i.e., an infectious encounter. Interactions at the local level profoundly influence systemic immune response, in part because of intrinsic differences in these systems, and also because of different requirements for optimal function. Although inflammatory processes are central to host defence in the periphery, the protective blocking action of the secretary immunoglobulin A immune response is crucial to local host defence, and, therefore, to the integrity of GI tract immune function. For these reasons, interaction with normal bacteria of the GI tract may be seen as the model of how the system has evolved and provide clues to the restoration of balance in the immunocompromised host. Reduction of

226 Nutri-Senex: State of the art report – task 2.1 normal commensal bacteria in the context of infection or after antibiotic treatment may interfere with nutrient availability and impair beneficial stimulation of GI immune response. This impairment may be associated with continued colonization with opportunistic microbes and inflammatory immune response that could lead to malabsorption and malnutrition. Study of the impact of nutrient imbalance on the function of the GI tract has profound implications for clinical medicine and May in the future lead to the rational design of preventive approaches to support immune response and host defence. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(98)00029-X

The potential role of antioxidant vitamins in preventing cardiovascular diseases and cancers

Hercberg, et.al (1997) Nutrition Journal volume 14 , issue 6 pages 513-520

Cardiovascular diseases and cancers constitute major public health problems in all industrialized countries, where they are the main causes of premature mortality. There is a large body of evidence suggesting that free-radical production can directly or indirectly play a major role in cellular processes implicated in atherosclerosis and carcinogenesis. Here we present mechanistic data and results of epidemiologic studies on the relationship between antioxidant vitamin intake or biochemical status and the risk of cancer and cardiovascular diseases. Most epidemiologic data obtained on this topic were based on an observational approach, i.e., ecologic, case-control, or prospective studies. All these studies indicate that a high dietary intake or high blood concentrations of antioxidant vitamins are associated with a reduced risk of cardiovascular diseases and cancer at several common sites. Although the results of these studies are convergent, they merely suggest a relationship at the population and individual level but do not affirm a causality link. Only intervention studies (randomised trials), by specifically changing antioxidant vitamin intake, can provide conclusive answers. The apparent discrepancies between the results of four recently published trials may be explained by the type of population (general or high-risk subjects), the differing doses of supplementation (nutritional levels or higher), the number of antioxidants tested (one, two, or more), and the type of administration (alone or in balanced association). It thus appears that a low risk of pathologies may be related to multiple nutrients consumed at nutritional doses and in combination. Optimal effects may be expected with a combination of nutrients at levels similar to those found in a healthy diet. A single antioxidant vitamin given at high doses in subjects with high risk of pathologies (smokers, asbestos-exposed subjects) may not have substantial benefits and could even have negative consequences. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/S0899-9007(98)000404-9

227 Nutri-Senex: State of the art report – task 2.1

Do dietary antioxidants prevent postmenopausal bone loss?

Leveille et. al (1997) Nutrition Research Journal volume 17 issue 8 pages 1261-1269

The role of dietary antioxidants in osteoporosis has not been well explored. The objective of this study was to examine the relationship between the dietary antioxidants, vitamin E and beta-carotene, and hipbone mineral density (BMD) in postmenopausal women. Subjects were 1892 screened, aged 55–80 years, who were volunteers for a clinical trial. Bone densitometry and osteoporosis risk factor information was obtained during screening. Dietary and supplement information was obtained by mailed food frequency and vitamin supplement questionnaires. We found no evidence of an association between dietary and/or supplemental vitamin E and bone density of the femoral neck. Dietary beta-carotene, adjusted for age and weight was positively associated with hip BMD (=1.5×10−6 gm/cm2, P=0.05). Further adjustment for osteoporosis risk factors diminished the association (=0.7×10−6gm/cm2, P=0.38). Neither total nor supplemental beta-carotene intake was found to be associated with BMD. We did not find that vitamin E or beta-carotene was associated with femoral neck bone density in postmenopausal women, however, the potential role of antioxidants and other nutrients in postmenopausal bone loss warrants further study, including research of other bone sites. Publisher; Elsevier Science Inc. Doi 10.1016/S0271-5317(97)00109-7

The Use of Dietary Supplements in the Elderly Current Issues and Recommendations

Tripp (1997) Journal of American Dietetics Association volume 97 issue 10 supplement 1 pages S181-S183. [No PDF available]

Research on dietary intake in the elderly shows evidence of both adequate and inadequate nutrient consumption from food. More recent studies have documented inadequate mineral intake from food and confirmed the overall decline in nutrient intake from food as people age. Food is incontrovertibly the best vehicle for nutrient consumption. However, some authorities have found reason to recommend a daily multivitamin-mineral for the elderly as a reasonable way to assure adequate micronutrient intake. There appears to be no reason to recommend complete liquid supplements or modular macronutrient supplements to the active free-living elderly population. Copyright 1997 American Dietetics Association. Publisher: Elsevier Science U.S.A Doi 10.1016/S0002-8223(97)00759-1

228 Nutri-Senex: State of the art report – task 2.1

Nutritional aspects of hip fractures

Bonjour (1996) Journal of Bone. Volume 18 issue 3 supplement 1 Pages S139-S144

Prevalence of malnutrition, particularly under nutrition, increases with advancing age, and patients with hip fracture are often particularly malnourished and/or undernourished. Deficiency in both micronutrients and macronutrients appears to be strongly implicated in the pathogenesis and the consequences of hip fracture in osteoporotic elderly. Such deficiencies can accelerate age-dependent bone loss; increase the propensity to fall by impairing movement coordination, and affect protective mechanisms that reduce the impact of falling. With respect to micronutrients, the most documented information concerns calcium and vitamin D. Studies conducted in the elderly have shown that administration of calcium and vitamin D can reduce femoral bone loss and, in institutionalised patients, lower the incidence of hip fracture. Besides hypovitaminosis D, deficiency in vitamin K has been suggested to contribute to bone fragility in patients sustaining hip fracture. As far as macronutrients are concerned, low protein intake appears to play a distinct detrimental role in the causes and complications of hip fracture. In a recent survey in hospitalised elderly patients, reduced protein intake was associated with lower femoral neck bone mineral density (BMD) and poor physical performance. This observation is in keeping with several studies in which a state of energy-protein malnutrition was documented in elderly patients with hip fracture. In these patients, in whom we detected very low femoral neck bone mineral density at the level of the proximal femur, the self-selected intake of protein and energy was insufficient during their hospital stay. Interestingly, the clinical outcome after hip fracture was significantly improved by daily oral nutritional supplement normalizing the protein intake, documented as a reduction in both complication rate and median duration of hospital stay. Further studies showed that normalization of the protein intake, independently of that of energy, calcium, and vitamin D, was responsible for this more favourable outcome. Preliminary data suggest that protein supplementation may also reduce further bone loss in elderly patients having sustained hip fracture. Increasing the protein intake from low to normal could act through an increase in the plasma level of IGF-I, a growth factor that exerts a positive effect on bone mass and that has been found to decrease with aging. Publisher: Elsevier Science Inc. All rights reserved. Doi 10.1016/8756-3282(95)00494-7

229 Nutri-Senex: State of the art report – task 2.1

A comparison between oral and nasogastric nutritional supplements in malnourished patients

McWhirter & Pennington (1996) Nutrition Journal volume 12 issues 7-8 pages 502-506

There is a common perception that malnutrition is an inevitable manifestation of illness, that oral nutritional supplements are not taken or reduce the consumption of oral diet, and that nasogastric feeding is poorly tolerated. This study assessed the efficacy of supplemental enteral feeding on the nutritional status of malnourished patients, to compare oral supplements (OS) with overnight supplemental nasogastric feeding (NG) on nutritional status and to determine the effect of nutritional supplements on oral diet. Malnourished hospital patients were randomised to one of three groups: control (C), OS, or NG. All patients had access to hospital diet. Supplements were prescribed to meet estimated nutritional needs. Nutritional status was recorded at the start and the end of the feeding period. The total nutritional intake was recorded. Weight gain occurred in 64% of the supplemented patients, whereas 73% of the controls lost weight with mean weight changes of +2.9% OS, +3.3% NG, and −2.5% C. There was no difference in the mean energy intake from food in the three groups. There were no documented complications of OS and three minor complications of NG. Both methods of supplementation allow weight gain without significantly affecting spontaneous oral intake. Publisher Elsevier Science Inc. Doi 10.1016/S0899-9007(96)91727- X

Five-A-Day Meal Plan an Optimal Approach to Meeting Nutritional Needs of Alzheimer's Clients

Welch, (1996) Journal of American Dietetics Association volume 96 issue 9 supplement 1 page A32

LEARNING OUTCOME: Improve intake, overall nutritional status and feeding ability of residents in a long term care setting with Alzheimer's disease whose lack of attention span decreases meal consumption. Cognitively impaired residents who enjoy eating and are able to feed themselves often have difficulty focusing their attention on the eating process throughout the meal. As a result, inadequate intake and unplanned weight loss may occur, increasing the need for staff assistance. Frequently commercial supplements are given as a replacement for unconsumed meals. This takes away from pleasures and familiarity of eating a variety of common foods. A special program was designed by an interdisciplinary team comprised of nursing, activities, occupational therapy, the dietary manager and the registered dietician. This program was developed to optimise meal intakes, arrest weight loss, and decrease staff assistance with meals. A five-a-day meal plan made up of traditional

230 Nutri-Senex: State of the art report – task 2.1 foods was supplied. This plan decreased the quantities offered at standard meals while increasing total daily calories to 2450 without the use of commercial supplements. The addition of a midmorning and afternoon meals were incorporated into, the daily activities schedule as coffee hour and teatime activities. Nine residents participated in the program. Monthly team meetings were held to evaluate progress and modify the program as necessary. Average overall consumption increased by 612 calories daily. Weight loss was arrested for three residents and four residents showed weight gain. Supplement usage decreased by 45%. Using a multi skilled team of available staff, the nutritional needs of cognitively impaired residents in a long-term care setting were met in a simple, creative manner. Copyright 1996 American Dietetic Association. Publisher: Elsevier Science U.S.A Doi 10.1016/S0002-8223(96)00420-8

Self-reported use of Vitamin Mineral Supplements in a Pilot Study with Elderly Participants

Fox & Wish (1996) Journal of American Dietetics Association volume 96 issue 9 supplement 1 page A79

To identify the frequency of vitamin/mineral supplement use among elderly participants. As more studies are conducted regarding nutrient intake and dietary habits of the elderly, findings may reveal the need for modification of current recommendations. This pilot study was conducted to evaluate nutrient intake of elderly participants. The Block Food Frequency Questionnaire, Short Version, which addresses dietary intake and vitamin/mineral usage, was administered to thirty, free-living, urban elderly men(12) and women (18), ages 60-99; mean age 70.57. Of the 30 participants, 21 (70%) reported taking supplements. Nine of 12 males (75%) and 12 of 18 females (66.7%) reported using a supplement. Based on educational level, 20% of those with 17+years, 36.7% of those with 12-16 years, and 16.7% with 12 or less years of education took a supplement. The type of supplements taken were: One-a-day type-15(71%), of which 4 took only this; Calcium-11 (52.4%); Vitamin C-8(38.1%); Vitamin E -(33.3%):Zinc or Theragran-type vitamin-2(9.5%); Iron, Magnesium, Vitamin B69 Vitamin B120 Beta-carotene, Vitamin B19 or Vitamin A-1 (4.8%). To summarize, a greater percentage of the male then female participants took vitamins. Those with some college education were more likely to take supplements than those who did not go to college. The top four ingested supplements identified in this study agree with those reported in other studies. Further investigation with the elderly of the comparison of dietary analysis with supplement use, the reason(s) for taking the supplements, and the source of information

231 Nutri-Senex: State of the art report – task 2.1 about perceived need for supplements, would provide a more complete picture of supplementation by this population. Copyright 1996 American Dietetics Association. Publisher Elsevier Science U.S.A Doi 10.1016/S0002-8223(96)00591-3

Factors affecting Dietary Adequacy of Elderly Recipients of Home-delivered Meals

Vaughan, et.al (1996) Journal of the American Dietetics Association volume 96 issue 9 supplement 1 Page A95

The purpose of this study was to identify those factors associated with dietary adequacy in a multiethnic sample of homebound elderly receiving home-delivered meals. Demographic, environmental, and dietary data were obtained from 111 elderly (24 male, 77 female; mean AGE = 77 y; 65% Caucasian, 17% Hispanic, 16% Black, 2% Native American). Dietary adequacy (DA) was assessed by determining if the subjects’ typical intakes met or exceeded the recommended number of servings for each of the five food group classifications used in the Nutrition Screening Initiative Level I Screen: Bread/Cereal, Fruit, Vegetable, Milk/Dairy, and Meat/Meat Alternate. Subjects living with at least one other person (n=82) had a significantly (p=.002) better DA score than those living alone, although persons living alone who had visitors at least once/week had significantly (p=.002) better dietary profiles than those with infrequent (

232 Nutri-Senex: State of the art report – task 2.1

Does a Nutrition Handout cause Behaviour Changes on the Dietary Intake of Older Adults?

Leeds, & Gaudi (1996) Journal of American Dietetic Association volume 96, issue 9 supplement 1 page A97

The effects of a nutrition handout (with no dietary counselling provided) on dietary intake in older adults was studied. The research subjects included 18 older adults (14 females and 4 males) from rural western Pennsylvania, with a mean age of 74.1±6.4 years. Data collection included two 3-day food records and a questionnaire about personal information. Intervention included a written nutrition handout provided between food records, that was relevant to the subject's specific dietary concerns. No nutrition counselling was offered. The pre- and post- dietary records were analysed using the Nutritionist IV computer program. Data analysis methods included descriptive statistics and use of the dependent t-test. In terms of health- related habits, 55.6% of older adults used multivitamin/mineral supplements and 22.2% used individual supplements, 61.1% exercised at least 3 times per week on a regular basis and used prescription drugs, 38.9% lived alone, 27.8% participated in congregate nutrition programs, 11.1% consumed alcohol, and none smoked. In comparing pre- and post-records, there was no statistically significant difference found (p<.05) between the two 3-day food records when analysing for total kcalorie, carbohydrate, protein, fat, vitamin, and mineral intake. Overall, the mean intakes of the older adults’ diets were adequate for all nutrients except vitamin D (66.0% and 63.7% of the RDA for pre- and post-recalls, respectively). The results suggest that a nutrition handout alone is inadequate for helping older adults improve their eating habits. It appears that dieticians need to take a more active role in order for behaviour changes to occur in the dietary intakes of older adults. Copyright 1996 American Dietetic Association. Publisher Elsevier Science U.S.A. Doi 10.1016/S0002-8223(96)00646-3

An Effective Multidisciplinary Team Approach to Reducing Unexpected Weight Loss of Residents in a Long Term Care Facility

Berardi & Maher (1995) Journal of American Dietetics Association volume 95 issue 9 supplement 1, page A58

The objective for the development of a Weight Wellness Program was to create an effective multidisciplinary team approach to reducing unexpected weight loss of residents in a long term care facility to 5% or lower. Residents in the long-term care setting often display weight loss associated with disease progression. Commercial liquid supplementation is most often the primary choice for nutritional intervention. This frequently interferes with meal intakes by

233 Nutri-Senex: State of the art report – task 2.1 decreasing the desire to eat traditional foods. In one long term care facility, unexpected weight loss averaged 10% over a six-month period. Our purpose was to develop a Weight Wellness program that utilized a multidisciplinary approach to improve overall weight status by assessing the cause for weight loss and developing a resident specific nutritional intervention plan. The multidisciplinary team included the Registered Dietician, Unit Nurse Managers, Certified Nursing Assistants, Occupational and Speech Therapists, and Food Service Director. All residents with significant weight loss (as defined by the Omnibus Budget Reconciliation Act guidelines) and those who showed a subtle persistent pattern of weight loss were reviewed monthly. Valuable information about food preferences and habits, feeding skills and chewing/swallowing abilities were provided for each resident addressed Careful review of this information was utilized to develop individualized meal plans that included finger foods, high calorie, high protein items and a snack program that replaced liquid supplements, featuring resident's favourite foods. Training the Nursing staff and involving them in the nutrition intervention process was crucial for the success of this program. Unexpected weight loss statistics were tracked for one year. Total unexpected weight loss was decreased from an average of 10% to an average of 4.6%. In conclusion, implementing a Weight Wellness program within a long-term care facility has been shown to decrease the incidence of overall weight loss through a multidisciplinary approach and involvement on an on-going basis. Copyright 1995 American Dietetic Association. Publisher: Elsevier Science U.S.A Doi 10.1016/S0002-8223(95)00547-1

Developments in Clinical Interventions for Older Adults: A Review.

Contributors: Nancy A. Pachana Journal Title: New Zealand Journal of Psychology. Volume: 28. Issue: 2. Publication Year: 1999. Page Number: 107

Older adults are increasing as a percentage of the population in many nations, including New Zealand (Statistics New Zealand, 1995). In response to this trend, world-wide research in health care has increased its focus on successful ageing as well as disorders occurring later in life. Clinical psychology is not exempt from this upsurge in gerontological research, and our knowledge of many aspects of the psychology of ageing has grown exponentially in recent years. Yet to a certain extent, the psychology of later life; continues to be overshadowed by the more; established literature on younger adults Diagnostic categories and treatment approaches which are well-validated for younger populations remain under- researched or even wholly unexamined in older adults. Also, biases and assumptions about older adults can help instil a false sense of security in clinical work with older patients.

234 Nutri-Senex: State of the art report – task 2.1

What follows is an attempt to highlight selected areas of new research as well as recent attempts to consolidate theoretical knowledge about diagnosis and treatment of older adults. Such a review cannot hope to be comprehensive in such a limited space. Topics were chosen to illustrate areas of new and innovative study (e.g. substance abuse, family therapy), areas in which much has been written but perhaps popular biases remain (e.g. bereavement, caregiving) and areas in which psychologists still have much to contribute (e.g. combined psychological and pharmacological approaches, dementia care).

Care and Nutrition: Concepts and Measurement

Patrice L. Engle, Food Consumption and Nutrition DivisionInternational Food Policy Research Institute 1200 Seventeenth Street, N.W. Washington, D.C. 20036-3006 U.S.A. (202) 862-5600 August 1996

The concept of "care" as an analytical construct is still new to many outside the nutrition field. Moreover, for those in the field, care is problematic from the measurement point of view. Our hope is that this paper provides an effective introduction to care for the former group, and a useful summary for the latter group of attempts to develop care indicators.

Care is the provision in the household and the community of time, attention and support to meet the physical, mental, and social needs of the growing child and other household members. The significance of care has been best articulated in the UNICEF framework. This paper extends the model presented by UNICEF by defining resources for care and specific care behaviours, and presenting an argument for the importance of child characteristics in determining the level of care received. Resources for care are defined as caregiver education, knowledge and beliefs, caregiver physical health and nutritional status, caregiver mental health and self-confidence, autonomy and control of resources, workload and time availability, and family and community social support. Care behaviours discussed here are two of the six proposed: feeding and psychosocial care. This paper also proposes an orientation to the measurement of care, and provides suggestions for indicators for care resources and the two care behaviours, based on a summary of recent literature. Finally, the paper argues for greater attention to research on the causal linkages between care and child nutrition.

235 Nutri-Senex: State of the art report – task 2.1

Frail elderly, nutritional status and drugs

G. Pickering Archives of Gerontology and Geriatrics Volume 38, Issue 2 , March-April (2004), Pages 174-180

This review focuses on the interactions between nutritional status and drugs in frail elderly persons. Impairment of nutritional status, a component of clinical presentation in the frail elderly, has a major impact on the pharmacology of many drugs devolving from the physiological alterations it generates. Food itself plays a central role in nutritional status and in possible interactions with drugs. Conversely, drugs have often, directly and indirectly, a deleterious effect on the nutritional state of the elderly. However, research in this domain is scarce, and future clinical studies will need to include more elderly and frail elderly individuals, to help clinicians to better understand these interactions.

The impact of malnutrition on the quality of life in the elderly

F. Vetta et al., Clinical Nutrition Volume 18, Issue 5 , October 1999, Pages 259-267

Malnutrition is a frequent condition, both widely represented in geriatric population and under-estimated in diagnostic and therapeutic work-up, and is known to affect health status and life expectancy of elderly people. The unexpected weight loss is a pathological condition, recently classified in three different ways (sarcopenia, wasting and cachexia) according to criteria of nutritional intake, functional abilities and age-related body composition modifications, that is caused by social psychological and medical factors. In this review, the authors highlight the ways that, through malnutrition, could lead to an impairment ofquality of life in elderly people. Notwithstanding the great impreciseness and confusion that surrounds the term ‘quality of life’, the authors focus their attention on the correlation existing with the recently occurring changes to patients' health status and life- style, analysing the relationship with frailty, failure to thrive and homeostatic balance failure syndrome. With the latter term, the authors introduce a pathological condition widely represented in the late stages of malnutrition that often evolves in multiple organ failure and lastly in the death.

236 Nutri-Senex: State of the art report – task 2.1

Facilitated feeding in disabled elderly.

Powers J.S. Current opinion in clinical nutrition and metabolic care. (2002) May;5 (3):315-9.

Nutrition and health are major concerns to older individuals. Whereas illness associated with overnutrition has been well characterized, poor health associated with undernutrition has received less attention. Malnutrition continues to plague the elderly in developed and underdeveloped countries alike, and is becoming of more concern as global demographic changes predict increasing proportions of elderly in all societies. Nutrition influences many chronic disease processes affecting older individuals. In addition, changes in physiology, metabolism, and function accompanying aging result in altered nutritional requirements. The enhancement and maintenance of health and function are now more possible with the new knowledge of nutritional needs in old age. Designing nutritional therapy to treat malnutrition associated with illness in older patients requires an understanding of the aging processes, a careful setting of treatment goals, and multidisciplinary collaboration.

Nutritional status and associated factors on geriatric admission. Poulsen I, et al., J Nutr Health Aging. (2006) Mar-Apr;10(2):84-90.

The proportion of elderly patients who are undernourished is high and undernutrition has serious health implications. No consensus exists regarding nutritional screening measurements suitable for elderly patients. There is a need to identify risk factors for undernutrition in elderly patients to enable prevention and treatment. AIM: To identify clinically identifiable risk factors for undernutrition in geriatric patients on admission. METHODS: Newly admitted patients (n=196, mean age 83.7 years) were examined for nutritional risk factors by the nursing staff. Analyses of variance and multiple regression analyses were used to identify risk factors for undernutrition. RESULTS: Undernutrition was present in 41% of the patients using a Body Mass Index cut-off < 22 (kg/m2) as definition of undernutrition. Poor appetite, oral cavity problems, constipation and nausea or vomiting were frequent problems; the patients also used a high number of medical preparations, including preparations that induced nausea. No help with cooking before admission, poor appetite, oral cavity problems and high age were all significantly associated with undernutrition. To improve nursing care and to prevent undernutrition, it is recommended to routinely examine the patient's mouth and teeth on admission and to assess patients not only for their physical condition (appetite, oral health and nutritional status), but also for their living conditions e.g. help with cooking.

237 Nutri-Senex: State of the art report – task 2.1

Sarcopenia and frailty in geriatric patients: Implications for training and prevention

Muhlberg W, et al., Zeitschrift für Gerontologie und Geriatrie : Organ der Deutschen 2004 Feb;37(1):2-8.

Sarcopenia, the loss of muscle mass and strength, is a constant phenomenon in aging. Physiologic age-dependent changes (drop in growth hormone (GH), IGF-1, menopause/andropause) explain the impaired protein synthesis, the decline of muscle mass, strength, and bone density. Harmful consequences of sarcopenia in old age are loss of muscle strength, inducing itself loss of mobility, neuromuscular impairment, and homeostatic balance failure syndrome with gait and balance disorders. All these sarcopenia-induced disabilities are important factors for an increased rate of falls and fractures in old age. Both falls and fractures cause hospitalisation and immobilisation which again induces sarcopenia. Once the physiological age-dependent decline of protein synthesis has started, some connected "vicious loops" occur in frail elderly patients, forming a typical pattern in geriatric medicine. There is a vicious loop between sarcopenia and immobilisation: sarcopenia --> neuromuscular impairment --> falls and fractures --> immobilisation --> sarcopenia. Another loop is the "nutritional" vicious loop between sarcopenia and malnutrition: sarcopenia --> immobilisation --> decline of nutrition skills ("empty refrigerator") --> malnutrition --> impaired protein synthesis --> sarcopenia. There is also a third "metabolic" vicious loop between sarcopenia and the decline of the protein reserve of the body: sarcopenia --> decline of the protein reserve of the body --> diminished capacity to meet the extra demand of protein synthesis associated with disease and injury --> sarcopenia. Frailty, a term not precisely defined, results from these different "vicious loops" including sarcopenia, neuromuscular impairment, falls and fractures, immobilisation, malnutrition, impaired protein synthesis, and decreased protein reserve of the body. Implications for training: main possibilities for training and prevention (of sarcopenia and frailty) are: a) continuous neuromuscular training (including training of balance) b) mobilisation c) prevention of falls d) training of nutrition skills and improvement of nutrition e) improvement of the impaired protein synthesis (with hormones etc.), and f) avoidance of dangerous drugs (drugs which cause neuromuscular impairment).

238 Nutri-Senex: State of the art report – task 2.1

Immunity and immunization in elderly

Patrice Bourée. Pathologie Biologie Vollume 51, Issue 10 , December 2003, Pages 581-585

As the average life expectancy increases, retired people want to travel. Five to 8% of travellers in tropical areas are old persons. Immune system suffers of old age as the other organs. The number and the functions of the T-lymphocytes decrease, but the B- lymphocytes are not altered. So, the response to the vaccinations is slower and lower in the elderly. Influenza is a great cause of death rate in old people. The seroconversion, after vaccine, is 50% from 60 to 70 years old, 31% from 70 to 80 years old, and only 11% after 80 years old. But in public health, the vaccination reduced the morbidity by 25%, admission to hospital by 20%, pneumonia by 50%, and mortality by 70%. Antipoliomyelitis vaccine is useful for travellers, as the vaccines against hepatitis and typhoid fever. Pneumococcal vaccine is effective in 60%.Tetanus is fatal in at last 32% of the people above 80 years, therefore this vaccine is very important.

Nutritional issues in the care of the elderly patient

Federico Bozzetti, Critical Reviews in Oncology/Hematology Volume 48, Issue 2 , November 2003, Pages 113-121

Aging is associated with a progressive decline in the function of many organs and apparatus. In a medical context, depletion of lean body mass and muscle mass in particular, and alteration of the immune system are of utmost importance. A defective immune response is associated with an increased incidence of inflammatory, infective and neoplastic diseases in the elderly as well as with a slow and sluggish recovery after illness or other injury. Depletion of muscle mass, the so-called sarcopenia, is responsible for the typical frailty of the elderly. Moreover, since muscle represents the protein reserve of the body, its progressive erosion not only results in a poor mobility and disability of these subjects, with associated complications, but with a diminished capacity to meet the extra demand of protein synthesis associated with disease and injury. In cancer patients, as in other elderly patients with different pathologies, it is important to evaluate the nutritional status, since frailty of these individuals recognizes as a relevant etiopathogenetic cofactor, a defective food intake. Nutritional support should aim at meeting the requirements in macronutrients, in water and in micronutrients. Requirements are not so different from those of adult subjects, since the decrease in energy expenditure due to a lower physical activity is compensated by the increase due to the disease. Particular attention must be given to fluid administration, since the elderly tolerate fluid overload less than hypohydration. Elderly patients quite frequently

239 Nutri-Senex: State of the art report – task 2.1 suffer from long-standing undernutrition; this means that nutritional repletion will take more time than is usually expected with use of medication. If a correct feeding program is performed for a few weeks, a benefit can be observed not only on the nutritional status but also in the clinical outcome. In fact nutritional support may have a permissive role in the administration of aggressive (oncologic) treatment than may be otherwise denied to elderly patients.

How to promote food intake in the elderly

Bruno Lesourd et al., lNutrition Clinique et Métabolisme Volume 15, Issue 3 , 2001, Pages 177-188

Insufficiency of the nutritional intakes is a common situation for aged persons. Anorexia, as defined by intakes below 1 000 kcal/d, leads to protein-energy malnutrition (MPE) and therefore initiates a vicious circle that accelerates the ageing process. Ageing is an important component of the decrease in intakes in the aged persons. In fact ageing leads to decreased smell and taste sensory perception which progressively induces lower intakes. Such changes are particularly dangerous for the aged individuals since they appear very slowly and therefore are not consciously perceived by the elderly. In addition, deterioration in the dental status and slowing of the rate of gastric emptying also lead to lower intakes. The most important change is the inability of the aged persons to react appropriately to nutritional stress. The elderly must learn to consciously react to any nutritional stress. Guidelines have been established to help the aged individual to preserve sufficient and well-balanced food intake. In order to help aged persons and their aides to deal with this problem, those rules are presented at the end of this paper. In order to warrant sufficient intakes, food must be regular, well-balanced, tasty, pleasant, and adapted to personal capacities. One must tend to very personalised meals.

240 Nutri-Senex: State of the art report – task 2.1

The impact of malnutrition on the quality of life in the elderly

F. Vetta, et al Clinical Nutrition Volume 18, Issue 5 , October 1999, Pages 259-267

Malnutrition is a frequent condition, both widely represented in geriatric population and under-estimated in diagnostic and therapeutic work-up, and is known to affect health status and life expectancy of elderly people. The unexpected weight loss is a pathological condition, recently classified in three different ways (sarcopenia, wasting and cachexia) according to criteria of nutritional intake, functional abilities and age-related body composition modifications, that is caused by social psychological and medical factors. In this review, the authors highlight the ways that, through malnutrition, could lead to an impairment ofquality of life in elderly people. Notwithstanding the great impreciseness and confusion that surrounds the term ‘quality of life’, the authors focus their attention on the correlation existing with the recently occurring changes to patients' health status and life- style, analysing the relationship with frailty, failure to thrive and homeostatic balance failure syndrome. With the latter term, the authors introduce a pathological condition widely represented in the late stages of malnutrition that often evolves in multiple organ failure and lastly in the death.

241 Nutri-Senex: State of the art report – task 2.1

Reference: www.sciencedirect.com http://www.ingenta.com/ http://www.the-scientist.com/ http://hkrt.wok.mimas.ac.uk http://www.blackwell-synergy.com/servlet/useragent?func=showHome http://www.google.com/search?q=site:citeseer.nj.nec.com http://www.metacrawler.com/ http://citeseer.ist.psu.edu/

242 Nutri-Senex: State of the art report – task 2.1

6 Patent Search

Category Date Publcation Number Description & Details

Nutritional coffee composition Composition 25.06.1997 EP0780055

Nutritional Composition Composition 28.02.2002 CA2418285

Derivatives of 1,2,3,4-tetrahydro-9- Composition 24.11.1999 EP0628548B1 acridinamine

Composition 03.04.2002 EP0745333B1 Nutritional compositions in various forms

Composition 11.12.2002 EP0780055B1 Nutritional coffee composition

Novel triglyceride and composition Composition 16.04.2003 EP0965578B1 comprising the same Nutritional composition Composition 18.04.2002 US2002044957

Composition 30.10.2003 US2003202992 Nutritional Composition Derivatives of 1,2,3,4-tetrahydro-9- Composition 12.03.1991 US4999430 acrisinamine Substituted oxazolidin-2-ones and 1,2,4- Composition 19.11.1991 US5066662 oxadiazolin-5-ones and derivatives thereof acting at muscarinic receptors Substituted furans and derivatives thereof Composition 26.11.1991 US5068237 acting at muscarinic receptors

Composition 26.03.1996 US5501857 Oral nutritional and dietary composition

Cytoskeletal active agents for glaucoma Composition 25.08.1998 US5798380 therapy Composition 29.12.1998 US5854414 Human mitochondrial membrane protein Dietetic phospholipid compositions and Composition 09.02.1999 US5869530 use thereof as a dietary supplement Human phosphatidylinositol synthase Composition 29.06.1999 US5916764

Polynucleotides encoding human Composition 04.01.2000 US6010879 mitochondrial chaperone proteins Compositions containing a high percent Composition 22.08.2000 US6107261 saturation concentration of antibacterial agent Antibacterial compositions containing a Composition 20.03.2001 US6204230 solvent, hydrotrope, and surfactant Triglyceride and composition comprising Composition 19.06.2001 US6248909 the same Composition 28.05.2002 US6395468 Human phosphatidylinositol synthase

Oxalic acid or oxalate compositions and Composition 18.06.2002 US6407141 methods for vascular disorders, diseases,

243 Nutri-Senex: State of the art report – task 2.1

and calcerous conditions

Compositions containing a high percent Composition 17.09.2002 US6451748 saturation concentration of antibacterial agent 94 Human Secreted Proteins Composition 05.11.2002 US6475753

Secreted protein HNFGF20 Composition 05.11.2002 US6476195

Compositions treating, preventing or Composition 04.03.2003 US6528496 reducing elevated metabolic levels Composition 18.03.2003 US6534631 Secreted protein HT5GJ57 Composition 20.05.2003 US6566325 49 human secreted proteins Electrolyte gels for maintaining hydration Composition 03.06.2003 US6572898 and rehydration Protein HOFNF53 Composition 12.08.2003 US6605592

Antibacterial compositions Composition 09.09.2003 US6616922

Herbal compositions and methods for Composition / Method 15.04.2004 US2004071799 effecting weight loss in humans Oral composition with insulin-like activities Composition / Method 11.05.2004 US6733793 and methods of use Methods for preparing a deep frozen, disc- Composition / Method 06.11.2003 WO03090568 shaped unit of processed food and for preparing the same for consumption Composition / Method 28.01.1986 US4567185 Endorphin blockage Use of pyridoxine derivatives in the Composition / Method 23.05.2000 US6066659 prevention and treatment of hyperlipidaemia and atherosclerosis Therapeutically effective 1.alpha.,25- Composition / Method 15.08.2000 US6103709 dihydroxyvitamin D3 analogs and methods for treatment of vitamin D diseases Oxalic acid or oxalate composition and Composition / Method 17.10.2000 US6133317 method of treatment Oxalic acid or oxalate compositions and Composition / Method 17.10.2000 US6133318 methods for bacterial, viral, and other diseases or conditions Luciferases, fluorescent proteins, nucleic acids encoding the luciferases and Composition / Method 15.05.2001 US6232107 fluorescent proteins and the use thereof in diagnostics, high throughput screening and novelty items Method of improving the immune Composition / Method 12.06.2001 US6245340 response and compositions therefor

244 Nutri-Senex: State of the art report – task 2.1

Methods and compositions comprising R- Composition / Method 03.07.2001 US6255347 ibuprofen Frozen product and method of oral Composition / Method 10.07.2001 US6258384 delivery of active ingredients Luciferases, fluorescent proteins, nucleic acids encoding the luciferases and Composition / Method 20.08.2002 US6436682 fluorescent proteins and the use thereof in diagnostics, high throughput screening and novelty items Compounds & methods for genetic Composition / Method 11.05.2000 WO0025820 immunisation Composition & method for use in intestinal Composition / Method 25.03.2004 WO2004024168 cleansing procedures

Composition / Method 17.11.2005 US2005256031 Composition for relieving discomfort

Methods of treating bone or cartilage Composition / Method 21.04.2005 US2005085543 conditions by the administration of creatine Composition and method for use in Composition / Method 10.03.2005 US2005054611 intestinal cleansing procedures

Composition / Method 14.07.2005 US2005152975 Pharmaceutical composition

Herbal composition for improving anticancer activity, immune response and Composition / Method 07.10.2004 US2004197427 hematopoiesis of the body, and protecting the body from oxidative damage, and the method of preparing the same Pharmaceutical composition containing Composition / Method 27.06.2002 EA2492 vitamin D and calcium, methods for preparing and therapeutical use Method for providing nutrition to elderly Composition / Method 31.08.1999 USRE36288E patients Method for providing nutrition to elderly Composition / Method 16.01.2001 USRE37020E patients Method for providing nutrition to elderly Composition / Method 11.11.1997 US5686429 patients Composition for treating chronic venous Composition / Treatment 01.04.2004 US2004062824 insufficiencies using an extract of red vine leaves Topical composition comprising powder of safflower seed for the treatment of Composition / Treatment 11.09.2002 EP0846466B1 rheumatoid-based arthritic diseases and menopause Quinuclidine-substituted aryl compounds Composition / Treatment 10.12.2002 US6492386 for treatment of disease

Composition / Treatment 20.01.2004 US6680168 Passive immunization against clostridium

245 Nutri-Senex: State of the art report – task 2.1

difficile disease

Phenylethylamines and condensed rings Composition / Treatment 27.01.2004 US6683087 variants as prodrugs of catecholamines, and their use Formulations for the treatment of insulin Composition / Treatment 10.02.2004 US6689385 resistance and type 2 diabetes mellitus Biguanide and sulfonylurea formulations Composition / Treatment 17.02.2004 US6693094 for the prevention and treatment of insulin resistance and type 2 diabetes mellitus Container for storing hospital and agri- Device 04.06.2003 CN1422231T food & industry waste

Device 19.12.1996 DE19522784 Device for recording taking of medication

Disposable insertion cannula for Device 02.07.1987 DE3639457 suppositories Device for reliable dosage of insulin units Device 03.11.1988 DE3809707 in disposable syringes Storage and dispensing blister pack - comprises container with pusher Device 17.01.1991 DE3922763 facilitating extraction of each pill separately Battery operated microcomputer for mobile patient data documentation - Device 29.05.1991 DE4025830 incorporates program and data memories with audible alarm, visual display and serial interface to external processor Blocking flow of blood through vein - by Device 27.08.1992 DE4115515 double slotted plate which can be adjusted to suit dia. of vein Presentation dish for food which simplifies Device 23.07.1999 FR2773697 large scale preparation of meals and is particularly suitable for hospital use A platter for serving a meal in hospital Device 17.09.1999 FR2775886 made up of both hot and cold food Unit for maintaining food in a heated Device 03.11.1965 GB1009129 condition Improvements in or relating to cases for Device 28.07.1921 GB166737 holding food Automatic urine collecting system Device 14.01.1981 GB2050838

Improvements in heat-insulated apparatus Device 21.08.1924 GB220437 for use in serving food Latent heat storage device Device 03.11.1999 GB2336899

Device 29.12.1960 GB857562 Isothermal tray for transporting meals

246 Nutri-Senex: State of the art report – task 2.1

Container for storing hospital and agri- Device 26.06.2003 US2003116569 food industry waste Automatic urine collecting apparatus Device 04.08.1981 US4281655

Device 19.07.1994 US5329941 Orthotic hand and forearm support device

Frozen oral medication delivery system Device 11.07.1995 US5431915 and method Drink carton for the elderly and infirm Device 15.10.1996 US5564621

Enema nozzle with self-adhesive securing Device 26.11.1996 US5578017 means Medication compliance, co-ordination and Device 08.07.1997 US5646912 dispensing system Quiet films and sheets and method of Device 04.01.2001 WO0100408 using them Monitoring device for, e.g. baby, patient, Device 02.01.1998 DE19625608 elderly Data collection and evaluation apparatus Device 02.04.1998 DE19637383 for single elderly person Device 03.05.2000 EP0802813B1 DOSIMETRIC SPACER Fiber optic interferometric vital sign monitor for use in magnetic resonance Device 22.05.2003 US2003095263 imaging, confined care facilities and in- hospital Transfer assembly for use by caregivers Device 12.02.2004 US2004025250 to lift, support and move the elderly or infirm

Device 23.09.1975 US3906744 Passively cooled fluid storage apparatus

Food serving system Device 06.06.1978 US4093041

Patient tracking system Device 21.03.1989 US4814751

Medicine scheduler Device 28.02.1995 US5393100

Computerized medical diagnostic system Device 14.01.1997 US5594638 including re-enter function and sensitivity factors Computerized medical diagnostic and Device 26.08.1997 US5660176 treatment advice system Device for delivering and deploying Device 16.12.1997 US5697948 intraluminal devices Computerized medical advice system and Device 27.01.1998 US5711297 method including meta function

247 Nutri-Senex: State of the art report – task 2.1

Computerized medical diagnostic system Device 10.03.1998 US5724968 including meta function Dosimetric spacer for calculating dosage Device 01.12.1998 US5842468 administered Computerized medical diagnostic and Device 09.02.1999 US5868669 treatment advice system Chronological food bar Device 25.05.1999 US5906833

Computerized medical diagnostic and Device 08.06.1999 US5910107 treatment advice method

Device 22.06.1999 US5913826 Wideband external pulse cardiac monitor

Computerized medical diagnostic and Device 08.02.2000 US6022315 treatment advice system including network access Computerized medical diagnostic and Device 05.09.2000 US6113540 treatment advice system Computerized medical diagnostic and Device 27.03.2001 US6206829 treatment advice system including network access Device 02.04.2002 US6363555 Patient positioning apparatus System for monitoring and managing the Device 07.05.2002 US6385589 health care of a patient population Orthopedic garment for dynamically Device 27.08.2002 US6440094 enhancing proper posture Computerized medical diagnostic and Device 19.11.2002 US6482156 treatment advice system including network access System for storage and delivery of Device 28.10.2003 US6638549 powdered nutritional supplements Hand-held apparatus for monitoring drug- Device 24.02.2004 US6696924 nutrient-mineral interactions and method therefor Hand-held surface ECG and RF Device 08.06.2004 US22095093A1 apparatus incorporated with a medical device Fluid Routing Device Device 10.08.2000 WO0045876

Universal mobile interactive information Device 15.05.2003 WO03040984 equipment that is used, in particular, to monitor dependant elderly people

Device 25.01.2002 CA2314596 the wheel chair guirney

Automated prescription reminder, Device 17.08.2006 US2006180600 dispenser, and monitor

Device 10.08.2006 US2006178707 Method and apparatus for identifying

248 Nutri-Senex: State of the art report – task 2.1

patients with wide QRS complexes

Device 22.06.2006 JP2006158918 MMovement assisting walker

Device 13.07.2006 US2006150332 Patient care bed with network

System and method for automatically Device 06.07.2006 US2006149599 generating physician orders for urgent care

Device 01.06.2006 JP2006136622 Human body conveying device

System and method for managing Device 22.06.2006 US2006136265 restorative care Method of determining mental health Device / Method 06.06.2000 US6071236 status in a computerized medical diagnostic system Communication system for an Device / Method 06.02.2001 US6184797 instrumented orthopedic restraining device and method therefor Method and apparatus for monitoring Device / Method 22.05.2001 US6236317 actions taken by a user for enhancing hygiene

System and method of monitoring and Device / Method 24.06.2003 US6582380 modifying human activity-based behavior

Method and device for the noninvasive Device / Method 09.12.2003 US6662031 determination of hemoglobin and hematocrit Computerized medical diagnostic and Device / Method 20.04.2004 US6725209 treatment advice system and method including mental status examination Preserved Product for Gerondodietetic Gerondodietetic 20.04.2001 RU2165153 Nutrition Preserves for Gerondodietetic Nutrition Gerondodietetic 20.04.2001 RU2165154

Preserved Product for Gerondodietetic Gerondodietetic 20.04.2001 RU2165156 Nutrition Product for Gerondodietetic Nutrition Gerondodietetic 20.04.2001 RU2165157

Product for Gerondodietetic Nutrition Gerondodietetic 20.04.2001 RU2165158

Product for Gerondodietetic Nutrition Gerondodietetic 20.04.2001 RU2165159

Outside-hospital food management Method 21.10.2002 TW507145 method and system Method of dietary supplementation Method 25.03.2004 US2004058012

249 Nutri-Senex: State of the art report – task 2.1

Method for cleaning and sanitizing Method 27.04.1999 US5896872 packages containing an edible product Method and system for heath care Method 14.11.2002 WO02091276 administration through the internet A method of normalising insulin levels Method 13.05.2004 WO2004039356

Use of sulfomucopolysaccharides in the Method 25.09.1991 EP0293974B1 therapeutical treatment of Alzheimer-type senile dementia Method for evaluating the state of Method 27.04.2003 RU2202943 cardiosystem Dry sustained release theophylline oral Method 06.05.1986 US4587118 formulation Use of sulfomucopolysaccharides in the Method 11.09.1990 US4956347 treatment of Alzheimer-type senile dementia Method for providing nutrition to elderly Method 31.12.1996 US5589468 patients Method for detection of surfaces Method 29.04.1997 US5624810 contaminants Method for providing nutrition to elderly Method 11.11.1997 US5686429 patients

Method for estimating creatinine clearance Method 03.03.1998 US5722396 using measurements of body cell mass

Method 07.04.1998 US5736351 Method for detection of contaminants

Method for estimating creatinine clearance Method 02.02.1999 US5865763 in obese and malnourished subjects using measurements of body cell mass Method for cleaning and sanitizing Method 27.04.1999 US5896872 packages containing an edible product Nutritional optimization method Method 21.09.1999 US5954640

Method of producing a vitamin product Method 31.10.2000 US6139872

Embedding and encapsulation of Method 20.02.2001 US6190591 controlled release particles Screening for SUR1 antagonists using Method 05.06.2001 US6242200 adipocytes Use of phage associated lytic enzymes for Method 28.05.2002 US6395504 the rapid detection of bacterial contaminants Production of oil encapsulated minerals Method 20.08.2002 US6436453 and vitamins in a glassy matrix

250 Nutri-Senex: State of the art report – task 2.1

Encapsulation of sensitive components Method 31.12.2002 US6500463 into a matrix to obtain discrete shelf-stable particles Process for preparing chewing gum Method 24.06.2003 US6582738 containing a nutritional supplement Encapsulation of components into edible method 20.04.2004 US6723358 products Method for providing nutrition to elderly Method 31.08.1999 USRE36288E patients Method for providing nutrition to elderly Method 16.01.2001 USRE37020 patients Method for providing nutrition to elderly Method 16.01.2001 USRE37020E patients METHODS AND COMPOSITIONS FOR Method / Composition 03.11.1999 EP0741785B1 STIMULATING BONE CELLS

Diagnosis and interpretation methods and Method / Device 21.01.2003 US6510430 apparatus for a personal nutrition program

Passive immunization against Clostridium Method / Pharmaceutical 10.04.2001 US6214341 difficile disease A container for pills and a method of Method / Pharmaceutical 29.09.2005 CA2554093 forming such a container Method of treating memory disorders of Method / Pharmaceutical 12.09.1985 WO8503869 the elderly

Method for manufacturing a balanced, Method / Supplement 18.05.1999 US5904948 nutritionally complete coffee composition

Method / Supplement 17.11.2005 US2005256031 Composition for relieving discomfort

Method / Supplement 30.10.2003 US2003202992 Nutritional composition

Immune stimulating dietary supplement Method / Supplement 11.04.2003 US6642259 and method of use thereof

Method / Supplement 28.02.2002 WO0215719 Nutritional composition

Method of treating patients suffering from Method / Treatment 20.01.1998 RU2102054 Atopic Dermatitis Dihydro-triterpenes in the treatment of Method / Treatment 18.03.2004 US2004054004 viral infections, cardiovascular disease, inflammation, hypersensitivity or pain Method of treating the symptoms of cognitive decline in an elderly patient Method / Treatment 11.12.1990 US4977172 employing (S)-3-ethyl-4-[(1-methyl-1H- imidazol-5-yl)-methyl]-2-oxazolidinone Method of treating memory disorders of Method / Treatment 12.09.1985 WO8503869 the elderly Use of tiagabine for the treatment of sleep Method / Treatment 24.10.2001 EP0867184B1 disorders

251 Nutri-Senex: State of the art report – task 2.1

METHOD FOR TREATING AND PREVENTING NEURODEGENERATIVE Method / Treatment 24.09.2003 EP0914122B1 DISORDERS BY ADMINISTERING A THIAZOLIDINONE Method of treating the symptoms of cognitive decline in an elderly patient Method / Treatment 11.12.1990 US4977172 employing (S)-3-ethyl-4-[(1-methyl-1H- imidazol-5-yl)-methyl]-2-oxazolidinone Methods of treatment and devices Method / Treatment 06.06.1995 US5422115 employing lithium salts Method for treating and preventing Method / Treatment 15.06.1999 US5912259 neurodegenerative disorders by administering a thiazolidinone Modulation of the sulfonylurea receptor Method / Treatment 08.08.2000 US6100047 and calcium in adipocytes for treatment of obesity/diabetes Method for treatment and prevention of Method / Treatment 27.03.2001 US6207651 deficiencies of vitamins B12, folic acid, and B6 Method for treatment, preventing and Method / Treatment 02.10.2001 US6297224 reduction of elevated serum metabolite levels Therapeutically effective 1.alpha., 25- Method / Treatment 11.12.2001 US6329357 dihydroxyvitamin D3 analogs and methods for treatment of vitamin D diseases Administration of carvedilol to mitigate Method / Treatment 02.04.2002 US6365618 tardive movement disorders, psychosis, mania, and depression Methods of pharmacological treatment Method / Treatment 05.11.2002 US6476058 using S(-) amlodipine Method of sterilizing and deodourizing Method / Treatment 24.09.2002 JP2002272825 medical treatment and elderly person facility by ozone water and device therefor Method for preventing postoperative Method / Treatment 15.09.2004 UA69767 complications in elderly patients A process for the preparation of granulate Pharmaceutical 04.02.1999 CA2298487 suitable to the preparation of rapidly disintegrable mouth soluble tablets Pharmaceutical Compositions for Pharmaceutical 27.07.2000 CA2359592 Alleviating Discomfort Polymorphic forms of a growth hormone Pharmaceutical 28.10.1999 EA528 secretagogue NEW PHARMACEUTICAL USES OF Pharmaceutical 20.03.2002 EP0642351B1 KRILL ENZYMES

252 Nutri-Senex: State of the art report – task 2.1

Multi-tablet oxybutynin system for treating Pharmaceutical 19.06.2001 US6248359 incontinence Foaming antacid suspension tablets Pharmaceutical 08.07.2003 US6589507

Pharmaceutical 30.09.2003 US6627741 Antibodies to secreted protein HCEJQ69

Security container with locking closure Pharmaceutical 25.05.2006 US2006108364 and method for locking a closure

Pharmaceutical 27.02.2006 RU2270695 Pharmaceutical composition

Effervescent pharmaceutical compositiond Pharmaceutical 10.02.2005 WO2005011639 containing vitamin D calcium and phosphate and their therapeutic use Combined pharmaceutical composition for Pharmaceutical 22.09.2005 WO2005087212 the inhibition of the decline of cognitive functions Pharmaceutical compositions for Pharmaceutical 31.05.2005 US6900180 alleviating discomfort Pharmaceutical composition containing Pharmaceutical / Composition 27.06.2002 EA2492 vitamin D & calcium, methods for preparation and therapeutical use Cytoskeletal active agents for glaucoma Pharmaceutical / Composition 29.08.2000 US6110912 therapy Pharmaceutical compositions containing Pharmaceutical / Composition 27.06.2006 US7067154 Vitamin D and calcium, their preparation and therapeutic use Compositiond for promoting healing of Pharmaceutical / Composition 18.02.2004 EP1389468 bone fracture Synergistic combinations comprising a Pharmaceutical / Composition 24.03.2005 NZ525795 renin inhibitor for cardiovascular diseases Apocynum venetum extract for use as Pharmaceutical / Therapy 18.05.2004 US6737085 antidepressant Oily capsule homeopathy Pharmaceutical / Therapy 04.07.2000 BE1012213

Agent for treatment of patient with arterial Pharmaceutical / Therapy 10.08.1999 RU2134108 hypertension, methods of treatment of patient with arterial hypertension Application of beta-1,3-1,6-glucan (aureobasidium culture solution) in various Pharmaceutical / Therapy 23.07.2002 JP2002204687 industrial fields including medical, health welfare and food industries Novelty in applying phosholipids of animal Pharmaceutical / Therapy 10.06.2003 RU2205646 orighin in therapy and/or dietology Methods of pharmacological treatment Pharmaceutical / Treatment 25.12.2001 US6333342 using S(-) amlodipine

253 Nutri-Senex: State of the art report – task 2.1

Substituted-heteroaryl-7- Pharmaceutical / Treatment 13.05.2003 US6562816 aza[2.2.1]bicycloheptanes for the treatment of disease Nucleic acids for the diagnosis and Pharmaceutical / Treatment 01.06.2004 US6743903 treatment of giant cell arteritis

Pharmaceutical / Treatment 03.02.2005 US2005026915 2-Aminoquinoline compounds

Multi-vitamin and mineral supplement Supplement 29.04.2004 US2004082536

Prophylactic dietary supplement based on Supplement 01.04.2004 AU771754 milk Immune stimulating dietary supplement Supplement 16.11.2000 CA2373605 and methods of use thereof Micronutrient phosphates as dietary & Supplement 20.02.2003 CA2453884 health supplements

Dietary supplements from wine vinasses Supplement 04.12.2003 CA2454901 and relevant production process

Dietary supplement containing alkaline Supplement 15.04.2004 US2004071752 electrolyte buffers Herbal dietary supplement Supplement 22.04.2004 US2004076641

Dietary supplement comprising Supplement 06.05.2004 US2004086579 parthenolide Dietetic phospholipid compositions and Supplement 09.02.1999 US5869530 use thereof as a dietary supplement Dietary supplement Supplement 09.04.2002 US6368617

Immune stimulating dietary supplement Supplement 04.11.2003 US6642259 and method of use thereof Therapeutic uses of beta-casein A<2> and Supplement 15.04.2004 WO2004030690 dietary supplement containing beta-casein A<2> Agglomerated granular protein-rich Supplement 29.04.2004 WO2004034986 nutritional supplement Immune Stimulating Dietary Supplement Supplement 16.11.2000 CA2373605 and methods of use thereof Nutritional supplement Supplement 27.10.1993 EP0305097B1

Supplement 26.06.2002 EP0721742B1 Nutrition for elderly patients

NUTRITIONAL LIQUID SUPPLEMENT Supplement 19.03.2003 EP0852468B1 BEVERAGE AND METHOD OF MAKING SAME NUTRITIONAL COMPOSITION FOR Supplement 21.05.2003 EP0969744B1 IMPROVEMENTS IN CELL ENERGETICS

254 Nutri-Senex: State of the art report – task 2.1

NUTRITIONAL SUPPLEMENT Supplement 04.07.2001 EP0973415B1

Zeaxanthin formulations for human Supplement 12.06.2003 US2003108598 ingestion Nutritional liquid supplement beverage Supplement 24.06.1997 US5641531 and method of making same Nutritional supplements for improving Supplement 24.03.1998 US5730988 glucose metabolism Zeaxanthin formulations for human Supplement 27.10.1998 US5827652 ingestion Supplement 16.03.1999 US5883086 DHEA-containing nutritional supplement Nutritional supplement for use in the Supplement 11.05.1999 US5902797 treatment of attention deficit Softgel capsule containing DHA and Supplement 21.09.1999 US5955102 antioxidants Nutritional supplement for preoperative Supplement 19.10.1999 US5968896 feeding Nutritional supplement composition and Supplement 02.11.1999 US5976548 use Complete, nutritionally balanced coffee Supplement 14.03.2000 US6036984 drink Nutritional fortification of natural cheese Supplement 18.07.2000 US6090417 and method of making Softgel capsule containing Dha and Supplement 13.03.2001 US6200601 antioxidants Nutritional supplement for cardiovascular Supplement 20.03.2001 US6203818 health Foods containing thermally-inhibited Supplement 24.04.2001 US6221420 starches and flours Nutritional supplement for facilitating skeletal muscle adaptation to strenuous Supplement 12.06.2001 US6245378 exercise and counteracting defatigation in asthenic individuals Folic acid supplement Supplement 17.07.2001 US6261600

Nutritional supplement composition and Supplement 07.08.2001 US6270774 use Nutritional supplements Supplement 07.08.2001 US6270809

Thermally-inhibited starch prepared with Supplement 21.08.2001 US6277186 oligosaccharides

Nutritional supplement for patients with Supplement 02.04.2002 US6365176 type 2 diabetes mellitus for lipodystrophy

Supplement 09.04.2002 US6368617 Dietary supplement Supplement 30.07.2002 US6426102 Shredded cheese

255 Nutri-Senex: State of the art report – task 2.1

Supplement 13.08.2002 US6432915 Human mitochondrial chaperone protein Oligosaccharide encapsulated mineral Supplement 22.10.2002 US6468568 and vitamin ingredients

Supplement 17.12.2002 US6495177 Orally dissolvable nutritional supplement

Dual iron containing nutritional Supplement 18.02.2003 US6521247 supplement Nutritional composition Supplement 15.07.2003 US6592863

Nutritional supplement and methods of Supplement 22.07.2003 US6596313 using it Protein enhanced gelatin-like dessert Supplement 29.07.2003 US6599551

Protein enhanced gelatin-like dessert Supplement 19.08.2003 US6607776

Immune stimulating dietary supplement Supplement 04.11.2003 US6642259 and method of use thereof Nutritional supplement for the Supplement 01.06.2004 US6743770 management of stress Product which is fermented without Supplement 10.11.2005 WO2005104862 lactose from shake comprising non- vegetable dried fruits and/or orgeat

Supplement 18.08.2005 JP2005219785 Container having dispenser

Processes for the preparation of Supplement / Method 25.09.2002 EP0672352B1 glutamine-rich peptides and food preparations made therewith Food or nutritional supplement, Supplement / Method 12.02.2002 US6346284 preparation method and uses Paste-form natto and a process for Supplement / Method 02.04.2002 US6365206 producing the same

Supplement / Method 22.07.2003 US6596707 Monovalent saccharides and uses thereof

Novelty in applying phospholipids of Therapy / Method 10.06.2003 RU2205646 animal origin in therapy and / or dietology

Method for treating cognitive disorders in Therapy / Method 10.012006 RU2268723 patients with cerebrovasculare diseases Therapeutical food composition. Therapy / Treatment 14.03.1990 EP0358008

Treatment of iatrogenic and age-related Therapy / Treatment 26.11.2002 NZ508142 hypertension with vitamin B6 or derivatives thereof Method for treating patients with gastric Therapy / Treatment 27.06.2005 RU2254889 and duodenal ulcerous disease Method for preventing paroxysms of the Therapy / Treatment 15.10.2004 UA70535 atrial fibrillamethod for preventing

256 Nutri-Senex: State of the art report – task 2.1

paroxysms of atrial fibrillation in ischemic disease of heart in elderlytion in ischemic disease of heart in elderly Method for treating chronic Therapy / Treatment 27.01.2005 RU2245146 - lympholeukosis Variable weight and height adustable Therapy / Treatment 07.08.2003 US2003145881 therapeutic cane Method for treatomg alexithymia in case of Therapy / Treatment 27.04.2003 RU2203053 stenocardia in elderly patients Method for surgical treatment of rectal Therapy / Treatment 20.08.2002 RU2187250 prolapse in elderly and senile patients THIP FOR TREATING SLEEP Treatment 24.10.2001 EP0840601B1 DISORDERS Non-allosteric GABA A agonists for Treatment 24.10.2001 EP0867178B1 treating sleep disorders Method of treatment of Treatment 27.12.2001 RU2177319 Hyperendotoxinemia Treatment for human memory impairment Treatment 24.05.1983 US4385053 associated with aging Agent for prevention or alleviation of Treatment 13.07.1999 US5922760 allergy symptoms Modulation of the sulfonylurea receptor Treatment 10.12.2002 US6492130 and calcium in adipocytes for treatment of obesity/diabetes Quinuclidine-substituted heteroaryl Treatment 31.12.2002 US6500840 moieties for treatment of disease Modulation of the sulfonylurea receptor Treatment 27.05.2003 US6569633 and calcium in adipocytes for treatment of obesity/diabetes RFID system used in the monitoring and Treatment 11.11.2005 TW243345B analysis (diagnosis) of specific personnel (diseases) and/or objects Composition, system and method of Treatment 04.05.2006 US2006094760 treatment of gastrointestinal disorders with nizatidine oral solution

Treatment 2006-03-02 US2006047288 DiamAbrasion system

4-sulfonyl-substituted benzoylalainine Treatment 2006-02-09 WO2006013085 derivates useful as kunurenine – aminotransferase inhibitors 2005-12- Treatment JP2005334169 Pillow for lateral position 08 Use of a cysteine-containing substance to Treatment 13.04.2005 US2005009914 increase the ventilatory activity and erythropoientin production

257 Nutri-Senex: State of the art report – task 2.1

Treatment 14.09.2005 CN1666745 Drug composition for treating osteoporosis

Treatment and rehydration composition Treatment 22.04.2004 WO2004032823 which is used to limit side effects of gastro-enteritis in adults

258