Nutrients and Noncommunicable Diseases Management during Aging

Nutrients and Noncommunicable Diseases Management during Aging: Comparison

Please note this is a comparison between Version 1 by Maaike Bruins and Version 2 by Peter Tang.

Dietary and nutritional approaches are of paramount importance in the management of noncommunicable diseases (NCDs). Vitamin and mineral deficiencies in older adults are related to increased risk of NCDs including fatigue, cardiovascular disease, and cognitive and neuromuscular function impairments.

chronic disease
noncommunicable disease
nutrient inadequacies and deficiencies
nutrient interventions
public health
musculoskeletal disorders
dementia
eye disorders
cardiovascular disease

1. Introduction

Globally, significant gains in human longevity have been made in the last couple of decades as evidenced by an average 5.5-year increase in life expectancy between 2000 and 2016 [1]. In many countries average life expectancy currently exceeds 80 years [1]. These longevity gains have come at a cost, however, with the most obvious being an increase in age-related diseases [2]. Noncommunicable diseases (NCDs) such as diabetes, musculoskeletal disorders, cardiovascular diseases, neurological disorders, and cancers increase with age, and place a burden on individuals and healthcare systems [3]. Supporting healthy aging by preventing NCDs is a major priority for agencies such as the World Health Organization (WHO) and United Nations ^[4][5][4,5].

The WHO estimates that NCDs contribute 1.6 billion disability-adjusted life-years (DALYs) to the global burden of disease and identified unhealthy diets and physical inactivity are among the main modifiable risk factors, together with excess alcohol and tobacco use [6]. Nutrition is an important determinant of human health by providing the essential building blocks for growth, development, and maintenance of a healthy status throughout life ^[7][8][7,8]. In this context, the co-existing burdens of undernutrition and overnutrition represent a paradigm shift for health authorities requiring appropriate dietary management recommendations [9]. Modern lifestyles and easy access to high-energy, low-nutrient rich foods are considered part of the problem ^{[3][10][11][12]}[3,10,11,12]. For example, the economic costs of unhealthy diets and low physical activity in the EU were calculated to be €1.3 billion per year [13].

Currently, health authorities mainly target problems associated with obesity and cardiovascular diseases by focusing on reducing excess intake of calories, sugar, salt, and saturated fats. However, the importance of a positive message associated with promoting adequate nutrient intake as part of a balanced diet should not be overlooked [4]. There is considerable variation in the consumption of food items that need to be encouraged and food items which should be limited, both between and within different countries. This was reflected in a recent study in European countries showing suboptimal nutrient-density of diets and significant proportions of the population consuming excess amounts of salt, sugar and saturated fat, as well as significant proportions of the population not meeting the required or adequate intakes for various essential nutrients (Table 1) [12].

Table 1. Percentage of adults with nutrient intakes meeting the estimated average requirement (EAR) or adequate intake (AI) or exceeding the maximum reference value (MRV) [12].

% Meeting EAR or AI	EAR or AI	Denmark n = 2025 people	Czech Republic n = 1869 people	Italy n = 2831 people	France n = 2624 people
Protein, g/d	0.66 g/kg BW	84%	88%	99%	98%
MUFA, E%	10–20 E%	69%	92%	75%	77%
Dietary fiber, g/d	25	19%	4%



85%

RE: retinol equivalents, DFE: dietary folate equivalents, E%: energy percentage, MUFA: mono-unsaturated fatty acids, SFA: saturated fatty acids. The red, orange, yellow, light green and dark green signals, respectively, represent ≤5%, 6–35%, 36–65%, 66–95%, and ≥96% of people meeting the EAR.

The health consequences of poor nutrition almost certainly accumulate over the lifespan of the individual. Table 2 presents information regarding some of the more frequently reported chronic clinical signs associated with certain vitamin and mineral deficiencies in older adults. Clinical signs and symptoms are mostly nonspecific and difficult to diagnose. During the aging process, a number of changes occur, such as increased medication use, reduced food intake due to lower food appeal, and compromised nutrient absorption. These complex changes prevent elderly persons from meeting their nutritional requirements. This consequently leads to increased risk of malnutrition, frailty, and reduced quality of life (QoL) ^{[14][15][16][17]}[14,15,16,17].

Table 2.

Critical nutrients in older adults [18].

Micronutrient	Challenges, Clinical Signs, and Symptoms in Older Adults
Vitamin B12 (cobalamin)	Deficiencies common in older adults, often underdiagnosed. Role in reducing elevated homocysteine, a cardiovascular risk factor. Absorption decreases mainly due to high prevalence of age-related atrophic gastritis. Among the common causes of anaemia in older adults, leading to weakness and fatigue. Low status increases the risk for cardiovascular disease and cognitive impairment.
Folate	Deficiencies common in older adults. Role in reducing elevated homocysteine, a cardiovascular risk factor. Closely related to vitamin B12 and B6. Among the common causes of anaemia in older adults, leading to weakness and fatigue. Deficiencies linked to depression and dementia.
Vitamin B6	Deficiencies common in older adults. Role in reducing elevated homocysteine, a cardiovascular risk factor. Closely related to vitamin B12 and folate.			12%	9%
Calcium, mg/d
Thiamine (vitamin B1)	750	70%	Deficiencies common in older adults, often underdiagnosed. Risk factor for heart failure, peripheral neuropathy, and encephalopathy. 31%	43%	62%
	Iron, mg/d	M: 6; F: 7
Calcium	Deficiencies common in senior women. Mean intake decreases with age, probably related to general change in diet. Associated with low bone mass, rapid bone loss, and high fracture rates.	92%	96%	98%	98%
Potassium, mg/d
Vitamin D	3500	31%	4%	19%		Older adults are less exposed to sun and have diminished ability of the skin to synthesize vitamin and the liver and kidney to hydrolyze vitamin D with age. Deficiency is a risk factor low bone mass, rapid bone loss, high fracture rates, and muscle weakness. 18%
Magnesium, mg/d	M: 350; F: 300
Vitamin C	Prevalence of inadequate intake is very high among adults. May help elderly maintain immune cells and function. Smoking increases need.	46%	25%	20%	23%
Zinc, mg/d
Iron	M: 7.5; F: 6.2	Women’s iron requirements decrease after the menopause. Deficiencies are mainly seen among hospitalized, institutionalized, or chronically ill older adults. Among the common causes of anaemia in older adults, leading to weakness and fatigue. 90%	48%	97%	91%
Vitamin A, µg RE/d	M: 570; F490
Zinc		77%	38%		Deficiency is common in the elderly. Risk factor for immune deficiency and susceptibility to infection in the elderly.66%	77%
	Vitamin C, mg/d	M: 90; F: 80	50%
Selenium	35%		Deficiency deficiency may increase risk of diseases of aging such as cardiovascular disease, reduced immune response, and cognitive decline.	62%	44%
Vitamin E, mg/d	M: 13; F: 11	5%	44%
Magnesium				47%	34%
Vitamin D, µg/d	15	3%	1%	1%	1%
	Often deficient in older adults. Maintains muscle integrity and function.	Vitamin B₁, mg/d	36%	52%	50%
Folate, µg DFE/d	250	59%	24%	77%	51%
% exceeding MRV		MRV
	0.6	97%	98%	47%	100%
Vitamin B₂, mg/d	M: 1.1; F: 0.9	80%	35%	84%	92%
Vitamin B₁₂, µg/d	4	55%	SFA, E%	<10 E%	86%	80%	62%	91%
Added sugar, E%	<10 E%	32%	21%	24%
Sodium, mg/d	<2400 mg/d	80%	98%	13%

2. Musculoskeletal Health in the Older Adult

The gradual loss of bone mass and disruption of bone architecture associated with osteoporosis results in an increased risk of bone fractures, particularly of the hip, spine, and wrist. It is an age-related chronic, complex, multifactorial skeletal disorder which affects both men and women, particularly postmenopausal women ^[19][25]. Osteoporosis places a huge personal and economic burden on society. In Europe, for example, the disability caused by the disease is greater than that caused by cancers (with the exception of lung cancer) and is comparable or greater than that caused by a variety of chronic NCDs, such as rheumatoid arthritis, asthma and hypertension-related heart disease ^[20][26].

In a WHO report it was noted that the remaining lifetime risk of an osteoporotic fracture in women aged 50 years in developed countries was >40% (>20% for hip fracture) ^[21][27]. At the time of this report, osteoporotic fractures had the sixth highest disease burden in the Americas and Europe combined, as estimated by disability-adjusted life years ^[21][22][27,28]. In 27 countries in the European Union, based upon the overall epidemiology of 22 million women and 5.5 million men with osteoporosis, it was calculated that this would result in 3.5 million new bone fractures (hip, 610,000; vertebral, 520,000; forearm, 560,000; and others 1.8 million) ^[22][28]. The economic burden to manage these incident and prior bone fractures was calculated to be €37 billion.

In the elderly, both micronutrient and macronutrient deficiencies appear to contribute to the pathogenesis of skeletal fractures as a consequence of age-related bone loss and frailty [16]. Nutrients that play a role in bone metabolism include vitamin D and vitamin K, calcium, magnesium, phosphorus, proteins, and fatty acids.

3. Cognitive Disorders

Dementia is a term that describes a decline in cognitive abilities including memory, and reduction in a person’s ability to perform everyday activities ^[23][44]. Dementia prevalence is forecast to increase dramatically in future years ^[24][45]. At present about 50 million people have dementia worldwide, and this is projected to reach 80 million by 2030 and 150 million by 2050 ^[25][46]. Alzheimer’s disease (AD) is the most common form of dementia in people aged >60 years, accounting for 60–70% of the total number of cases and is the major focus of this section ^[25][46]. Vascular dementia is the second most common cause of dementia with at least 20% of dementia cases. Alzheimer’s disease is a complex, progressive, multifactorial, neurodegenerative disease ^[24][26][24,45]. The presentation generally involves progressive memory loss, impaired thinking, disorientation, and changes in personality and mood. As the disease advances there is a marked reduction in cognitive and physical functioning ^[27][28][47,48]. Genetic factors account for about 70% of the risk contributing to AD, while modifiable factors related to general health and lifestyle may also be involved ^[28][48]. Risk factors for vascular dementia are predominantly modifiable and of vascular origin (including hypertension, diabetes mellitus, dyslipidemia, and the metabolic syndrome). Managing non-genetic risk factors effectively may provide opportunity to prevent and treat the progressive cognitive decline associated with AD ^[27][47]. In terms of a link between nutrient status in older adults and cognition, evidence exists for B-vitamins, and vitamin C, D, and E, as well as the omega-3 long chain polyunsaturated fatty acids (LCPUFAs) docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), as has been reviewed ^[22][28].

4. Eye Disorders

Impairments of the essential senses of vision and hearing are the second-leading cause of years of lived with disability ^[29][58]. The most common causes of vision loss among the elderly are age-related macular degeneration, glaucoma, cataracts, and diabetic retinopathy ^[30][59]. Aging is the greatest risk factor associated with the development of age-related macular degeneration, but also environmental and lifestyle factors such as smoking, oxidative stress, and diet may significantly affect the risk ^[31][60]. Recent studies suggest that increasing exposure to blue light emitted by electronics and energy-efficient lightbulbs over time could lead to damaged retinal cells which on the long-term can cause vision problems like age-related macular degeneration ^[32][61]. Eye health problems in the ever-increasing aging generation, and “exposure to blue light” may result in a new NCD. Carotenoids have a range of functions in human health and, in particular, there is evidence that they have beneficial effects on eye health ^[33][62]. Two dietary carotenoids, lutein and zeaxanthin are macular pigments found in the human retina ^[34][63]. Macular pigment has local antioxidant properties and absorbs high energy, short wavelength blue light protecting the retina from photochemical damage ^[35][64]. Macular pigment can neutralize ROS, protect against UV-induced peroxidation, and reduce the formation of lipofuscin and associated oxidative-stress induced damage ^[34][63]. Thus, the carotenoids provide potential benefits for ocular function and health. Individuals who have low macular pigment optical density levels (0.2 or lower) may benefit from supplementation with lutein/zeaxanthin which can help increase macular pigment optical density levels ^{[36][37][38][39][40][41][42][43]}[65,66,67,68,69,70,71,72]. For retinal protection, macular pigment optical density values of 0.4 to 0.6 are desirable, especially in older adults ^[44][73]. Dietary intake of lutein and zeaxanthin may differ with age, sex, and ethnicity. Across all age groups the intake of lutein is higher than for zeaxanthin and this is independent of sex and ethnicity. In addition, lower zeaxanthin to lutein ratios are reported for groups at risk of age-related macular degeneration (e.g., the elderly and females) ^[45][74]. A number of studies, including some in healthy subjects, have demonstrated that lutein/zeaxanthin supplementation can improve visual performance, including contrast sensitivity, glare tolerance and photo stress recovery ^{[36][37][38][39][40][41][42][43][46][47]}[65,66,67,68,69,70,71,72,75,76]. Age-related macular degeneration is an increasing problem among the elderly and studies of the effects of lutein/zeaxanthin supplementation have produced mixed results. However, important data were provided by secondary analyses of the large Age-Related Eye Disease Study 2 (AREDS2) ^[48][49][77,78]. This randomized trial investigated the effect of adding lutein/zeaxanthin 10/2 mg, DHA (350 mg) + EPA (650 mg), or both to the original AREDS2 formulation (vitamin C, vitamin E, β-carotene, zinc, and copper) or to variations of this formulation (excluding β-carotene and/or with reduced zinc). Participants (n = 4203) were followed for a median 5 years. The primary analysis found no additional beneficial or harmful effect for lutein/zeaxanthin and/or omega-3 fatty acids on progression to late age-related macular degeneration compared with the original AREDS1 formula using β-carotene instead of lutein/zeaxanthin. However, a prespecified secondary analysis found a significant 26% risk reduction for progression to advanced age-related macular degeneration when comparing lutein/zeaxanthin supplementation with no lutein/zeaxanthin supplementation in the quintile with the lowest dietary intake of these two carotenoids (median 0.7 mg/day), as indicated by a hazard ratio of 0.74 (95% confidence interval 0.59–0.94, p = 0.01). In addition, a post hoc analysis showed that lutein/zeaxanthin (excluding β-carotene) was more effective than the original AREDS formulation containing β-carotene but no lutein/zeaxanthin for reducing progression to advanced age-related macular degeneration (hazard ratio 0.82, 95% CI 0.69–0.96, p = 0.02) ^[48][77]. There is also some evidence suggesting there is a relationship between lutein/zeaxanthin status and the risk of developing nuclear cataracts ^[50][79], and in the AREDS2 trial the addition of lutein/zeaxanthin supplementation reduced the risk of cataract surgery in the quintile with the lowest dietary intake of these carotenoids (hazard ratio 0.68, 95% CI 0.48–0.96, p = 0.03) ^[51][80]. If the AREDS2 complex (i.e., vitamin C and E, zinc, copper, lutein/zeaxanthin and omega-3 fatty acids) was used by all adults aged >55 years, it has been estimated this would result in an average of about 1 million avoided age-related macular degeneration and cataract events per year in the USA (based on a risk reduction of 23.6% for age-related macular degeneration and 16.2% for cataracts). This would result in a net annual cost saving of US$1.2 billion, mostly as a consequence of reduced healthcare expenditure ^[52][81]. Establishing intake recommendations for lutein is an important step forward to support optimal visual performance and reduce the risk of age-related macular eye disease in the general population. This would be a relevant contribution to public health in the face of a globally aging population.

5. Cardiovascular Disease

Despite the global decline in cardiovascular mortality, cardiovascular diseases remain the leading cause of morbidity and mortality, contributing to escalating health care cost ^[53][82]. Cardiovascular aging progresses over decades, influenced by risk factors such as tobacco use, poor physical activity and diet, resulting in hypertension, dyslipidemia (high triglycerides and lower HDL), elevated fasting blood glucose, and central obesity ^[54][83]. Cardiovascular disease is the major clinical problem in the older population, with 68% of adults 60–79 years having cardiovascular disease and this increases to 85% after the age of 80 years ^[55][84]. Good nutrition plays an important role in delaying the progression of cardiovascular disease ^[56][57][85,86]. The adverse effects of excess intakes of saturated and trans fats, cholesterol, added sugars, and salt in relation to cardiovascular disease progression has been relatively well-established whereas the effect of addressing inadequate essential nutrients is less well-known. Older adults are highly susceptible to undernutrition due to the various physiological and socioeconomic factors ^[58][87]. In contrast to overnutrition, the potential of addressing undernutrition to optimize cardiovascular health in older adults has received inadequate attention ^[59][88]. Evidence for nutrition in reducing the risk for cardiovascular aging mostly derives from epidemiological studies, whereas fewer interventions studies have been performed. The RCTs addressing cardiovascular disease generally have included, but not exclusively, older adults, not allowing generalizability of results to typical older adults.

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