Age and Ageing 2018; 0: 1–8 © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. doi: 10.1093/ageing/afy105 All rights reserved. For permissions, please email: [email protected] Low vitamin intake is associated with risk of frailty in older adults 1 2,3 2,3,4 2,3 TERESA BALBOA-CASTILLO ,ELLEN A. STRUIJK ,ESTHER LOPEZ-GARCIA ,JOSÉ R. BANEGAS , 2,3,4 2,3,4,5 FERNANDO RODRÍGUEZ-ARTALEJO ,PILAR GUALLAR-CASTILLON 1Department of Public Health—EPICYN Research Center, School of Medicine, Universidad de La Frontera, Temuco, Chile 2Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid-IdiPaz, Madrid, Spain 3CIBERESP (CIBER of Epidemiology and Public Health), Madrid, Spain 4IMDEA-Food Institute, CEI UAM+CSIC, Madrid, Spain 5Johns Hopkins Bloomerg School of Public Health, Baltimore, USA Address correspondence to: T. Balboa-Castillo. Tel: +56 45 2734172; Fax: +56 45 2592139. Email: [email protected] Abstract Background: the association between vitamin intake and frailty has hardly been studied. The objective was to assess the association of dietary vitamin intake with incident frailty in older adults from Spain. Methods: data came from a cohort of 1,643 community-dwelling individuals aged ≥65, recruited in 2008–10 and followed up prospectively throughout 2012. At baseline, 10 vitamins were assessed (vitamin A, thiamine, riboflavin, niacin, vitamins B6, B12, C, D, E and folates) using a validated face-to-face diet history. Incident frailty was identified using Fried’sdefinition as having ≥3 of the following five criteria: unintentional weight loss of ≥4.5 kg, exhaustion, weakness, slow walking speed and low physical activity. Nonadherence to the recommended dietary allowances (RDA) was considered when the intake of a vita- min was below the recommendation. Analyses were performed with logistic regression and adjusted for main confounders. Results: during a 3.5-year follow-up, 89 (5.4%) participants developed frailty. The odds ratios (95% confidence interval) of frailty for those in the lowest versus the highest tertile of vitamin intake were 2.80 (1.38–5.67), P-trend: 0.004, for vitamin B6; 1.65 (0.93–2.95), P-trend: 0.007, for vitamin C; 1.93 (0.99–3.83), P-trend: 0.06, for vitamin E and 2.34 (1.21–4.52), P-trend: 0.01, for folates. Nonadherence to the RDAs of vitamins was related to frailty for thiamine odds ratio (OR): 2.09 (1.03–4.23); niacin OR: 2.80 (1.46–5.38) and vitamin B6; 2.23 (1.30–3.83). When considering tertiles of RDAs for the 10 vitamins those who met <5 RDAs had a higher risk of frailty, OR: 2.84 (1.34–6.03); P-trend: <0.001, compared to those who met >7. Conclusion: a lower intake of vitamins B6, C, E and folates was associated with a higher risk of frailty. Not meeting RDAs for vitamins was also strongly associated. Keywords: frailty, vitamin intake, older people, recommended dietary allowances, diet quality Introduction adults in clinical settings as well as for research purposes. Identifying frail older adults is of relevance because frailty is Frailty is a geriatric syndrome that has sarcopenia as its patho- potentially reversible after being treated with physical activity physiological basis. Age-related musculoskeletal changes and and an appropriate diet [6]. anorexia of ageing are also considered two main pathways for There is evidence that poor nutrition is related to frailty this syndrome. To be frail implies some degree of functional [1, 7, 8], so, to some extent, frailty can also be considered damage, and frail older adults experience a decrease in func- as a nutrition-related condition [9]. Some physiological tional reserve and a lack of adequate response even to minor changes occur in the gastrointestinal system with ageing stressors (e.g. a cold, diarrhoea or dehydration). As a conse- (such as alterations in taste and smell, reduction of gastric quence, frail subjects have increased vulnerability to developing motility and changes in gastrointestinal hormones). All adverse health outcomes, including falls, disabilities and mor- these changes can modify dietary preferences, dietary intake tality [1–4]. Fried et al. [5] provided an operational definition and impair absorption of macro and micronutrients, leading to identify frailty that can be used to recognise frail older to malnutrition and vitamin deficiencies. In addition, as we 1 Downloaded from https://academic.oup.com/ageing/advance-article-abstract/doi/10.1093/ageing/afy105/5058977 by UNIVERSITY OF CALIFORNIA, Berkeley user on 26 July 2018 T. Balboa-Castillo et al. get older, poor adherence to a healthy diet can arise due to were asked to indicate how frequently each specificfoodand social reasons such as lack of access to fresh food or diffi- beverage was habitually consumed in the preceding year. culties in handling and cooking of food. However, the lon- This instrument records the consumption of 880 foods, with gitudinal association of vitamin intake with incident frailty a set of coloured photographs to help in the quantification has hardly being studied among the elderly. of portions. Data on food consumption were converted into A cross-sectional analysis of the InCHIANTI Study assessed daily intake energy, macronutrients and micronutrients using the association of vitamin intake with prevalent frailty. This ana- standard food composition tables [16–19]. The intake of 10 a lysis included individuals aged 65 and older and found that a priori relevant vitamins below were assessed: vitamin A, thia- low intake of vitamins D, E, C and folates was independently mine, riboflavin, niacin, vitamin B6, vitamin B12, vitamin C, related to prevalent frailty [10]. Also, one longitudinal study, the vitamin D, vitamin E and folates. Participants were cate- Women’s Health and Aging Study I (WHAS I), assessed the gorisedintosex-specific tertiles for vitamin intake. relationship of some serum vitamins with incident frailty among Nonadherence to the recommended dietary allowances disabled women; a low concentration of carotenoids and vitamin (RDA) was considered when the intake of a vitamin was E was associated with increased risk of frailty [11]. below the recommendation. To assess nonadherence to the Therefore, vitamin intake and its association with frailty RDAs, the Spanish recommendations for older population have not been prospectively and systematically studied in [16] were used: vitamin A μg/day: ≥1,000 in men or ≥800 older adults, neither in men nor in women. Consequently, in women; thiamine mg/day: ≥1inmenor≥0.8 in women; this study assessed the prospective association between riboflavin mg/day: ≥1.4 in men or ≥1.1 in women; niacin both, dietary vitamin intake with incident frailty in older mg/day: ≥16 in men or ≥12 in women; vitamin B6 mg/day: adults from Spain. ≥1.8 in men or ≥1.6 in women; vitamin B12 μg/day: ≥2in men or women; vitamin C mg/day: ≥60 in men or women; vitamin D ≥ percentile 75 in men or women; vitamin E mg/ Methods day: ≥12 in men or women and folates μg/day: ≥400 in Study design and participants men or women. Those who met the corresponding RDA for the Spanish older population were used as reference. Data were taken from the Seniors-ENRICA cohort, its Finally, by summing up the number of RDAs met for – fl methods have been previously reported [12 14]. Brie y, the each participant, we obtained a score ranging from 0 to 10 – cohort was established in 2008 10 with 2,519 individuals that was classified in tertiles according to the number of fi selected by strati ed random sampling from the population recommendations met: <5, 5 to 7 and >7. Those who met aged 60 and older in Spain. At baseline, data were collected >7 recommendations were used as reference. in three stages. Through a phone interview, we obtained information on sociodemographic variables, lifestyle, health Frailty status and morbidity, followed by a home visit to collect fi fi blood and urine samples; finally, a second home visit to car- We used a minor modi cation of the operational de nition of frailty developed by Fried and colleagues in the cardiovas- ry out a physical examination and to collect dietary infor- fi fi mation. Participants were followed up throughout 2012, cular health study [5]. Speci cally, frailty was de ned as hav- ing three or more of the following five criteria: (i) weight when a second wave of data collection was performed to fi ≥ update information on frailty. loss, de ned as unintentional loss of 4.5 kg of body weight For the current analysis, we excluded 372 individuals with- in the preceding year; (ii) exhaustion was evaluated as a posi- out baseline information on diet or with implausibly high or tive answer to either of the following two questions taken – from the Centre for Epidemiologic Studies Depression Scale: low energy intake (outside the range of 800 5,000 kcal/d for ‘ ’ ‘ men or 500–4,000 kcal/d for women), plus 66 participants Do you feel that anything you did was a big effort? and Do you feel you could not keep on doing things?’ at least 3–4 who were taking vitamin supplements. We also excluded 359 fi individuals with prevalent frailty or with limitations in instru- days a week; (iii) weakness, de ned as the lowest quintile in mental activities of daily living measured with the Lawton and the cardiovascular health study of maximum strength of the Brody scale. Of the remaining 1,722 participants, we addition- dominant hand, adjusted for sex and body mass index ally excluded 79 with missing values for confounders. Thus, (BMI). Strength was measured using a Jamar dynamometer, the analyses were conducted with 1,643 individuals.