National Diet and Nutrition Survey:
people aged 65 years and over.
Published 1995 HMSO London
An analysis by
Dr Alan Stewart MRCP
www.stewartnutrition.co.uk
Purpose of the Study
“This provides a sound basis for the development
of future food and heath policies for this
increasingly important group in our society“
Tessa Jowell Minister for Public health DoH
Jeff Rooker Minister of State MAFF
The NDNS are undertaken by the Department of Health
and Ministry of Agriculture Fisheries and Food with the
support of outside agencies
Important Note from Dr Alan Stewart
• Dr Stewart took no part in the study and reports here as
an independent physician with an interest in nutrition
• The findings of this survey are not well-known and are
not currently available at the Department of Health
website nor the Office of National Statistics despite being
listed on the latter site as available. The printed report
can be purchased from The Stationery Office
www.tsoshop.co.uk
• The findings of this survey will be superseded by the
NDNS Rolling Programme, which includes those aged
over 65 yrs and is due to finish reporting years 1 and 2 of
the three year programme toward the end of 2012
NDNS65+: Background
• Part of a rolling programme of national nutritional surveys of
different sectors of the British population
• Previous study of a non-representative sample of 365 elderly
>70 years showed:
- malnutrition in 7%,
anaemia in 12.5%
- vitamin B12 deficiency 2.5%,
folate deficiency 5.4%
- vitamin B1 deficiency 8%,
vitamin B12 deficiency 30%
(DHSS 1979)
• Risk of deficiency rose with increasing age, prevalence of
chronic illness and socio-economic deprivation
• Link between poor nutrition and common diseases;
cardiovascular, poor immunity, osteoporosis and possibly
mental illness and early dementia
• A study of acutely ill geriatric patients in Leeds revealed a
high incidence of nutritional deficiencies (next two slides)
Nutritional Deficiencies in Acutely ill Geriatric Patients:
Prevalence of Haematological Deficiencies 1973/75
100%
Age 65-70yrs (n=16)
90%
70-79yrs (n=53)
80%
80+yrs (n=24)
70%
60%
50%
40%
30%
20%
10%
0%
Anaemia
RBC Folate
Vitamin B12
% Low Iron Sat
•
•
•
93 acutely ill patients >65yrs: male = 35, female = 58 in Yorkshire
Folate and vitamin B12 were measured using micobiological assays
9/93 = plasma albumin ,<28g/l, 29/93 = plasma albumin 28-34g/l
•
Morgan AG et al. Int J Vit and Nut Res. 1973:43;46-471 & 1975:45:448-462
Vitamin Deficiencies in Acutely ill Geriatric Patients
Prevalence of various vitamin deficiencies 1973/75
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Age 65-70yrs (n=16)
70-79yrs (n=53)
80+yrs (n=24)
Vit A
•
•
•
PTT
TPP
Vit B2
Vit B3
WBC Vit C
93 acutely ill patients >65yrs: male = 35, female = 58
PTT = prothrombin time (Vit K), TPP = thiamin pyrophosphate effect (vit B1)
Vit B2 = whole blood riboflavin, Vit B3 = urine n-methyl nicotinamide level
Morgan AG et al. Int J Vit and Nut Res. 1975:45:448-462
NDNS65+: Methodology
• Two nationally representative samples:
- free-living
- institutionalised
• Individuals were identified by their postal addresses
• Men equalled women except those aged 85+ (more women)
• In each co-operating institution three residents were selected
• Initial assessment by interview
• Consent or proxy-consent obtained for participation and
permission to flag the NHS Central Register of Births and
Deaths to give future notice of death or cancer development
• Payment of £10 on completion of dietary record
• Survey completed between October 1994 to September 1995
• Acutely ill elderly are unlikely to have participated in NDNS
65+; prevalence of poor nutrition is thus likely to be at least as
great in ill patients in the care of medical staff
NDNS 65+: data collected
• Interviewer-administered questionnaire about dietary
habits, medication use, nutritional supplements, physical
activity and health
• Four-day weighed dietary record of all food and drink
consumed in and out of the home
• Seven-day record of bowel movements
• Memory and depression questionnaires
• Physical measurements: height, weight, mid-arm
circumference, hand grip strength and visual acuity
• Blood and urine (not 24 hours) tests
• Dental examination (see separate report)
NDNS65+: Response to the Survey - Free-living
• 30, 546 sample addresses
• 23, 486 positive responders
• 6,445 eligible households
• 2172 initially selected
Eligible sample 100%
• 1632 completed interview
Responding sample 75%
• 1275 completed dietary record Diary sample 59%
• 986 provided blood sample
45%
• 1115 provided urine sample
51%
NDNS65+: Response to the Survey-Institutions
• 454 initially identified
Eligible sample 100%
• 428 completed interview
Responding sample 94%
• 412 completed diet record
Diary sample 91%
• 290 provided blood sample
64%
• 310 provided a urine sample
68%
Some weighting for disproportionate sampling of sex, age,
over-representation of people living alone and regional
variations
Defining Nutritional Deficiency
• Nutritional deficiency can develop as a result of an inadequate
intake, poor absorption, illness, alcohol excess & other factors
• In the UK nutrient intake requirements are given in:
Dietary Reference Values for Food Energy and Nutrients for
the United Kingdom (1991 – TSO)
• The report defines The Lower Reference Nutrient Intake,
LRNI, for protein or a vitamin or mineral as “an amount of the
nutrient that is enough for only a few people in a group who
have low needs”.
• In practice this means that if the percentage of a population
with an intake below the LRNI for a particular nutrient exceeds
3% then it is likely that a percentage of the population will be
deficient in the nutrient
• Also deficiency is likely, but not certain, if, on testing its blood
level is below the lower end of an accepted normal range.
Distribution of Nutrient Requirements
Assumes a Gaussian (normal) distribution
Dietary Reference Values:
Dept of Health 1991
• LRNI “An amount enough for
only the few people in a
group who have low needs”
• EAR “About half will usually
need more than the EAR and
half less”
• RNI “An amount of the
nutrient that is enough, or
more than enough, for about
97% of people in a group”
What can Nutritional Surveys Tell Us?
• Two main types of data:
- dietary habits and intake of nutrients
- test information on nutrient levels in blood and urine
• Assess the prevalence of both types of malnutrition:
- undernutrition
- overnutrition
• Data about social circumstances, alcohol and smoking
that allows identification of those at risk of malnutrition
• Data about the health of the survey group may examine
the possible health consequences of malnutrition
How Do Nutritional Deficiencies Develop?
Develop over days to years in a logical and recognizable sequence
• State of Adequacy
• State of Negative Balance
• Decline in Tissue Stores
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
What Components were Surveyed in NDNS?
NDNS = National Diet and Nutrition Survey
Stage
NDNS 65+ Component
• State of Adequacy
• State of Negative Balance
1. Poor intake
2. Reduced absorption
3. Increased losses
4. Increased requirement
5. Altered metabolism
• Decline in Tissue Stores
Diet + Supplements
Alcohol, drugs, liver and renal
Tests – blood and urine
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
Depression
BMI
Renal and Liver Function Tests
Collected 17 yrs later
NDNS: Prevalence of Deficiency - Low Intake
Total Intakes (Food and Supplements) below LRNI for males and females
39%
36%
Calcium
33%
Potassium
30%
Magnesium
27%
24%
Iron
21%
Zinc
18%
Vitamin A
15%
Vitamin B12
12%
9%
Folate
6%
Vitamin C
3%
0%
Fre e -living Elde rly
•
•
Ins titution Elde rly
“Lower Reference Nutrient Intake – an amount of the nutrient that is enough for only
the few people in a group who have low needs” = 3% of the population
Prevalence rates >3% suggest that a significant % of the population could be deficient
Use of Nutritional Supplements – NDNS 65+
50%
Total
45%
Multi Vit+Mins
40%
Multivitamins
35%
Vits A,C+D
30%
Multivits+Iron
25%
Vitamin C
20%
Iron only
15%
Minerals
10%
CLO +Fish Oil
EPO
5%
0%
Adults
•
•
F-L Elde rly
Supplement categories have slight differences between the surveys
Females are usually larger consumers of supplements than males
Prevalence of low Potassium Intake <LRNI
Male
60%
Female
50%
40%
30%
20%
10%
0%
65-74yr
•
•
•
•
75-84yr
85+yr
Institution
65-84yr
Institution
85+yr
Potassium content of the body is related to its water content and muscle bulk
There are no differences in LRNI between the sexes despite physical differences
The high LRNI for women results in a high percentage appearing deficient
Plasma or serum potassium levels were not measured as part of any of the NDNS
Prevalence of a low Body Mass Index - NDNS
20%
Men <18.5kg/m2
18%
Men 18.5-20.0kg/m2
16%
Women <18.5kg/m2
14%
Women 18.5-20.0kg/m2
12%
10%
8%
6%
4%
2%
0%
65-74yrs
•
•
75-84yrs
85+yrs
Inst 6584yrs
Inst 85+yrs
Percentages for age >65 years are the author’s estimates from presented data
Underweight + ill individuals are likely to have been under-represented in NDNS
Nutrition Support in Adults NICE Feb. 2006
www.nice.org.uk/cg032
Based on Malnutrition Universal Screening Tool - MUST
• Underweight
BMI >18.5kg/m2
• Unintentional weight loss
Loss >10% within the last 3 – 6 months
• Underweight + Unintentional Weight Loss
BMI 18.5 - 20kg/m2 and Wt Loss >5% within the last 3 – 6 mo.
• Others Risk Factors
Eaten little or nothing or unlikely to for >5 days
Poor absorptive capacity, high nutrient losses or increased needs
Nutritional Assessment - Risk Factors
NICE guidelines www.nice.org.uk/cg032 (2006) and others
•
•
•
•
•
•
•
•
•
•
Fragile skin
Poor wound healing
Apathy
Wasted muscles
Poor appetite
Altered taste sensation
Impaired swallowing
Altered bowel habit
Loose fitting clothes
Prolonged illness:
chronic infection,
chest disease,
cardiac failure,
cancer etc.
Nutritional Assessment - Risk Factors
NICE guidelines www.nice.org.uk/cg032 (2006) and others
•
•
•
•
•
•
•
•
•
•
Fragile skin
Poor wound healing
Apathy
Wasted muscles
Poor appetite
Altered taste sensation
Impaired swallowing
Altered bowel habit
Loose fitting clothes
Prolonged illness:
chronic infection,
chest disease,
cardiac failure,
cancer etc.
• Life Stage:
- extremes of age
- infants, adolesence, pregnancy
• Social Circumstances:
- in receipt of benefits
- living alone – especially men
• Medical History:
- loss: bleed, vomiting, diarrhoea
- chronic illness/organ failure
• Family History/Genetic Factors
• Medical Drug Use
• Poor mobility/lack of sun
• Smoking
• Symptoms and Physical Signs
Influence of Household Income on Average Intake
of Nutrients in Elderly Men [NDNS 1998]
160%
<4K/yr
140%
4-6K/yr
120%
6-10K/yr
100%
>10K/yr
80%
60%
40%
20%
0%
Energy
•
•
Protein
Vitamin C
Vitamin
B12
Folate
Annual income in £000s; upper income bands are compared with lowest <4k/year
Increasing income is associated with higher intake of protein and many nutrients
Daily Alcohol Intake and Nutritional Status: NDNS 65+
% difference in status compared with non/low drinkers
Males <10g
Males 10-20g
Males =/>20g
Females <10g
Females =/>10g
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
-10.00%
-20.00%
-30.00%
Plasma
Vitamin C
•
•
•
Plasma
Vitamin D
Red Cell
Folate
Serum
Vitamin B12
Intake determined from 4 day diary
Caution, no adjustment for age, health, diet or supplements was made
Non-drinkers were more likely to be older and have abnormal liver test
Diagnosing Malnutrition: Under and Overnutrition
1. History
Intake: diet + supplements
Risk Factors for deficiency/XS
Symptoms of deficiency/XS
2. Physical
Examination
Anthropometric Measures
(Body Mass Index - kg/m2)
Signs of Deficiency
Signs of Underlying Disease
3. Laboratory
Investigation
Blood and Urine Tests
Bone Mineral Density
X-Ray
Making a Diagnosis: History is Paramount
Nottingham 1975 W. Virginia 1992
History
82.5%
76%
Examination
8.75%
12%
Investigation
8.75%
11%
• Both studies assessed new patients, with no clear diagnosis who
were referred to a medical outpatient clinic
• The percentages relate to the information that was required to reach
the final diagnosis
• References:
Hampton JR et al. BMJ. 1975;2:486-9
Peterson MC et al. West Med J. 1992;156(2):163-5
NDNS65+: Prevalence of Anaemia
Male
30%
Female
25%
20%
15%
10%
5%
0%
65-74yr
•
•
•
75-84yr
85+yr
Institution Institution
65-84yr
85+yr
World Health Organisation Normal Ranges were used; women >12.0g/dl, men
>13.0g/dl. British laboratories often use a normal range of >11.5g/dl for women
Levels of 11.5-11.9g/dl in women can result in symptomatic iron deficiency
In the elderly anaemia results from: poor nutrient intake + bleeding, chronic
illness and unknown factors in equal frequency
NDNS65+: Prevalence of Iron Deficiency
Low Plasma Ferritin: Range < 10-20ug/l
Male
30%
Female
25%
20%
15%
10%
5%
0%
65-74yr
75-84yr
85+yr
Institution
65-84yr
Institution
85+yr
• Normal ranges: females > 15.0ug/l, males > 20.0ug/l
• Plasma ferritin can be elevated by acute or chronic
inflammation, infection or liver disease and may not be a
reliable measure of iron status in ill and elderly people
NDNS65+: Prevalence of Vitamin B12 Deficiency
Plasma vitamin B12 <118 pmol/l (154pg/ml)
Male
30%
Female
25%
20%
15%
10%
5%
0%
65-74yr
•
•
•
75-84yr
85+yr
Institution
65-84yr
Institution
85+yr
Macrocytosis (MCV >101fl) was seen in: 2% of free-living elderly and 3% of
elderly in institutions.
Macrocytosis can be due to vit B12/folate deficiency or alcohol excess
Only a minority of those with vitamin B12 deficiency also had macrocytosis
NDNS65+: Prevalence of low Red Cell Folate
50%
Male
45%
Female
40%
35%
30%
25%
20%
15%
10%
5%
0%
65-74yr
•
•
75-84yr
85+yr
Institution Institution
65-84yr
85+yr
The normal ranges for red cell folate and method of analysis varied from other
NDNS
Folate status is influenced by dietary intake, illness, alcohol excess and altered
metabolism
NDNS 65+: Prevalence of Vitamin D Deficiency
Plasma 25-hydroxyvitamin D <25nmol/l
50%
Male
45%
Female
40%
35%
30%
25%
20%
15%
10%
5%
0%
65-74yr
•
•
•
75-84yr
85+yr
Institution
65-84yr
Institution
85+yr
Plasma 25-OHD levels show considerable seasonal variation with low
levels being commonplace in late winter and spring.
Dietary sources provide approximately 10% of intake of the vitamin.
Preferred level for those with osteoporosis is >75 nmol/l
NDNS65+: Prevalence of Vitamin C Deficiency
plasma Vit. C<11.0umol/l - NDNS data
50%
Male
45%
Female
40%
35%
30%
25%
20%
15%
10%
5%
0%
65-74yr
•
•
•
•
75-84yr
85+yr
Institution Institution
65-84yr
85+yr
Vitamin C status is adversely affected by smoking, use of aspirin and NSAIDS
Approximately 12% of the elderly took supplements likely to contain vitamin C
Approximately 28% of British adults smoke and less after the age of 65 years
Aspirin was taken by 20% of free-living elderly and 24% of institutionalised
NDNS65+: Prevalence of Vitamin A Deficiency
Percentage of Population with a plasma Retinol < 0.7mmol/l
Male
10%
Female
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
65-74yr
•
•
•
75-84yr
85+yr
Institution
65-84yr
Institution
85+yr
WHO lower end of normality, plasma level < 0.7 mmol/
Plasma retinol levels may be temporarily lowered as a result of
infection and the acute phase response
Severe deficiency, plasma <0.35 mmol/l, is very rare
Nutritional Supplements and the Elderly
“Many would agree that iron, vitamin C, vitamin D
and B complex vitamins should be given for
three to four weeks to elderly patients recovering
from a severe illness of any type ...”
Editorial British Medical Journal. Nutrition in the Elderly
1974:1;212-3.
Correlations between intake and blood levels
• NDNS 65+ and other surveys calculated the correlation
coefficients between the intake of many nutrients and it’s
level in the blood
• The degree of correlation between these two was often
less than 50% and is usually best for the more watersoluble and better absorbed nutrients
• The reason for low correlation are many and include:
level of intake, limited or poor absorption, smoking and
alcohol, and differences in metabolism/transport of the
nutrient
• In practice this means that clinicians should not rely too
heavily on dietary assessment but consider many other
risk factors for under and overnutrition
Correlation Coefficients: Vitamin C
Plasma Ascorbate and Total Intake
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Male
Female
1.5-4.5 yrs
4-18 yrs
19-64 yrs
65+ yrs
Correlation Coefficients: Folate
Red Cell Folate and Total Intake
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Male
Female
1.5-4.5 yrs
4-18 yrs
19-64 yrs
65+ yrs
Correlation Coefficients: Retinol
Plasma Retinol and Intake (Retinol Equivalents)
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Male
Female
1.5-4.5 yrs
4-18 yrs
19-64 yrs
65+ yrs
Correlation Coefficients Iron
Haemoglobin and Total Intake of Iron
1
0.8
0.6
0.4
Male
Female
0.2
0
-0.2
-0.4
1.5-4.5 yrs
4-18 yrs
19-64 yrs
65+ yrs
Correlation Coefficients B Vitamins in Elderly
NDNS 65+ Free-Living only
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Male
Female
Vitamin B2
•
•
•
Folate
Vitamin B1
Vitamin B12
Tests – red cell folate, serum vitamin B12; vitamins B1 & 2 by enzyme
activation, which increase with increasing deficiency
CCs for vitamins B1 & 2 are -ve but are presented as +ve
All CCS are significant (p<0.01) except vitamin B12 in men
NDNS 65+: What Have we Learnt so Far?
• This important survey, though conducted 20 years ago
reveals that:
- poor intake of micronutrients is common
- low BMI, anaemia and micronutrient deficiencies are
common
• Risk factors for undernutrition include:
- low income – or being in receipt of benefits
- increasing age
- smoking
- alcohol excess but not moderate intake
- illness especially chronic illness
- multiple drug therapy
• Risk Factors for undernutriiton detailed by NICE are
presented next
Nutritional Assessment - Risk Factors
NICE guidelines www.nice.org.uk/cg032 (2006) and others
NICE Listed
•
•
•
•
•
•
•
•
•
•
Fragile skin
Poor wound healing
Apathy
Wasted muscles
Poor appetite
Altered taste sensation
Impaired swallowing
Altered bowel habit
Loose fitting clothes
Prolonged intercurrent illness:
chronic infection,
chest disease,
cardiac failure,
cancer etc.
NDNS 65+: Prevalence of Overnutrition
figures are for free-living
• Obesity BMI >30 kg/m2 M - 17%, F – 23%
• Alcohol excess >21/14 units/week ~ 10%
• Dietary Salt Intake >6g/day estimated at ~80%
risk of:hypertension, stroke, osteoporosis and heart failure
• Retinol - elevated plasma level ~10%
risk of:osteoporosis, hypercalcaemia (cc%)
• Iron excess - haemochromatosis ~1.5%
iron saturation >55%
• Trace element excess - reduced excretion due to:
renal disease (?<5%) – vitamin A and potassium
liver disease (10-20%) – iron, manganese and copper
• Excessive intake of nutrients from supplements
retinol (5-10%) and possibly manganese (not assessed)
Safety of Vitamin A: SACN Sept 2005
•
•
•
•
•
•
•
•
Total Safe Intake, TSI 1500 ug/day
Diet provides average 700 ug/day
Supplements limited to 800 ug/day
% NDNS 65+ intakes >TSI
- F-L Males 11%, Females 10%
- Inst. Males 7%, Females 6%
High intakes from:
- food – liver, very high dairy
- supplements high intake & overages
Acute Toxicity: – rare >50,000ug/day
- liver failure, death
Chronic Toxicity:
- osteoporosis (vit D antagonist)
- hair loss, dry skin
- hypercalcaemia (PTH excess)
Risk increased by: renal impairment,
alcohol excess and obesity
Retinol Status of the British Population (estimates)
Plasma Retinol Levels NDNS 65+ Data
90.00%
Deficient <0.7/0.75 umol/l
Borderline 0.75-1.0 umol/l
Adequate 1.0-2.8 umol/l
Mild Excess 2.8-3.5 umol/l
Severe Excess >3.5 umol/l
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Free-Living
Institutionalised
Renal Function and Plasma Retinol: NDNS 65+
Correlation between deteriorating renal function and plasma retinol
UK Supplements – Retinol Content
FSA (2003) and SACN (2005) - Safe Upper Level of 800 ug/day
•
•
•
•
•
•
Cod Liver Oil 10 mls
Holford Multivitamin
HealthSpan Multi 50+
H and B ABC Plus Senior
Solgar Solovit
Biocare Adult Multi
1,800ug
1,200ug
1,000 ug
1,050 ug
750 ug
600 ug
• According to industry overages are
commonly 20% to 30% more than
the label claim
NDNS 65+ The Spread of Malnutrition
• The following slides detail the spread and extremes of
nutrient intake and laboratory findings from the free-living
NDNS 65+ population
• These show the means, 95% limits and highest and
lowest values for a number of measures of nutrients
• These findings make the point that both under and over
nutrition occur
• They help the practitioner put into perspective the results
that they might obtain when assessing their own patients
• Such data is unique and is unlikely to be reported in
future survey
The Spread of Malnutrition: Energy & BMI
NDNS 65 + Free-living M = 538, F = 516
Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053
Parameter
Lowest 2.5
pc
Mean
M
65
75.8
96
F
65
77.3
99
Energy Intake
Kcal/day
M
819
2101
1892
2838
4117
F
455
756
1416
2101
2325
Height m
M
1.49
156.5 1.69
185.6
1.98
F
1.2
142.3 1.55
168.2
1.75
M
38.7
53.6
75.2
101
121
F
32.5
42.6
64
90.5
112.9
M
16.3
19.6
26.3
34.3
43.2
F
14.4
18.3
26.6
36.7
44.46
Age years
Weight kg
Body Mass Index
kg/m2
97.5
pc
Highest
The Spread of Malnutrition: Iron and Anaemia
NDNS 65 + Free-living M = 538, F = 516
Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053
Parameter
and norm
Lowest 2.5
pc
Mean
97.5
pc
Highest
Total Iron Intake
non-haem mg/day
M
1.7
11.4
174.2
F
2.3
10.9
201.2
Iron Intake -haem
mg/day
M
0
0.72
4.83
F
0
0.53
4.8
Iron Saturation
15% - 55%
M
4.1
11.6
28.1
53.4
91.2
F
4.0
7.0
24.2
46.9
82.7
Serum Ferritin ug/l
M 20-300, F 15-150
M
4.0
120.9
420.5
F
9.0
90.2
376.4
Haemoglobin g/dl
M 13-18, F 12-16.5
M
11.5
14.5
16.7
F
11
13.5
15.5
The Spread of Malnutrition: Retinol & Carotenoids
NDNS 65 + Free-living M = 538, F = 516
Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053
Parameter and
Normal Range
Lowest
2.5
pc
Mean
97.5
pc
Highest
Retinol Intake
ug/day 300 – 1,500
M
10
161
940
5996 20,400
F
60
121
850
6068 18.800
Plasma retinol
1.0 – 2.8 umol/l
M
0.85
1.25
2.21
3.54
5.55
F
0.42
1.17
2.18
3.56
6.8
Total carotenoids
Intake mg/day
M
0.1
222
1.97
5760 12,000
F
60
196
1.62
5367 9,970
Plasma betacarotene nmol/l
M
8.0
54
323
828
F
37
79
405
1011 1,960
1,674
Renal Function and Plasma Retinol: NDNS 65+
Correlation between deteriorating renal function and plasma retinol
The Spread of Malnutrition: Vitamins C and E
NDNS 65 + Free-living M = 538, F = 516
Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053
Parameter
Normal Range
Lowest 2.5
pc
Mean
97.5
pc
Highest
Total Intake
Vitamin C mg/day
M
4.9
12.1
71.1
196.1
1,023
F
1.0
12.4
65.4
223
601
Plasma vitamin C
umol/l (>11.0)
M
<3
3.0
38.2
80.4
101.5
F
<3
2.3
45.8
96
116.5
Total Intake
Vitamin E mg/day
M
0.8
2.7
9.51
24.4
114
F
[0.06]
1.8
10.69
28.1
[18.8]
Plasma alphatocopherol umol/l
M
[0.45]
18.9
35
57.3
[7.49]
F
10.3
19.1
39.1
66.8
128
Plasma gammatocopherol umol/l
M
0.45
0.82
2.24
5.02
7.49
F
0.57
0.78
2.53
5.53
8.65
The Spread of Malnutrition: Homocysteine Nutrients
NDNS 65 + Free-living M = 538, F = 516
Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053
Parameter
(norm or RNI)
Lowest 2.5
pc
Mean
97.5
pc
Highest
Pl. Homocysteine
<12 umol/l
M
5.8
16.3
95.6
F
4.4
15.2
54.9
Total Folate Intake
ug/day (200)
M
75
116
263.4
455
728
F
27
86
204
385
535
Red Cell Folate
nmol/l (>350)
M
60
155
496
1170
2216
F
78
139
507
1238
2357
Total Vitamin B12
Intake ug/day (1 )
M
0.55
1.8
5.9
19.5
87.2
F
0.66
1.2
4.3
17.9
42.8
Serum Vit. B12
pmol/l (>118)
M
49
90
226
436
737
F
48
103
238
[728]
[737]
Folate/Folic Acid and Cancer Risk
Ulrich CM. Editorial Am J Clin Nutr 2007;86:271-3
• Low intakes of folate
increase the risk of
alcohol-associated
breast cancer
• Moderate intakes have
no effect on risk
• High intakes of folic
acid from supplements
may increase the
growth of an existing
tumor
• The effect of folate/folic
acid may be influenced
by other nutrients and
genetic factors
Problems with Folate and Vit. B12 in UK Elderly
• Deficiencies of both are common in NDNS 65+
• Supplement use is associated with better folate status
but only slightly better vit B12 status
Dangour A et al J. Nutr. 2008 138;1121-1128
• US NHANES III: those with a serum B12 <148 pmol/l
(~35% of UK elderly) increasing serum folate was
associated with increased HCys and MMA levels
Selhub J et al Am J Clin Nutr 2009;89(2):702S-706S
• European EPIC no overall association of prostate cancer
risk and the status of these nutrients
However in those with a high vitamin B12 level there
was an increased risk of more advanced disease.
Johansson M et al Cancer Epidemiol Biomarkers Prev 2008;17(2):279-85
See also Hultdin J et al Int J Cancer 2004;113:819-24
Plasma Homocysteine and Mortality in UK Older People
Dangour A et al J. Nutr. 2008 138;1121-1128
853 UK M + F >75 yrs. Median follow-up 7.6 yr. 50.3% died. Death rate 1000 per/year
120
100
80
Lowest 1/3
Middle 1/3
Highest 1/3
60
40
20
0
Pl. Folate
Pl. Vit B12
Pl. Hcys
Plasma Homocysteine and Mortality: Characteristics
Dangour A et al J. Nutr. 2008 138;1121-1128
Measure
Plasma HCys concentration
P-trend
Lowest 1/3 Middle 1/3
Highest 1/3
Age yrs
78.2
78.4
79.7
<0.001
Men %
35.5%
45.9%
50.1%
<0.001
HDL Cholesterol mmol/l
1.23
1.27
1.17
0.026
Pl. Vit B12 pmol/l
290.1
264.4
238.3
<0.001
Pl. Folate nmol/l
27.9
21.9
17.4
<0.001
Chronic Kidney Dis. 3 or 4
2.6
9.5
25.3
<0.001
History of Cancer
13.7
5.2
5.4
0.007
Current Smoker %
5.1
7.7
17.2
<0.001
Activity Units/week
3.2
3.5
2.0
0.001
Supplement Use
52.9
45.2
28.6
<0.001
Green Veget. >1 portion/wk
56.4
50.5
42.6
<0.001
The Spread of Malnutrition: Zinc and Copper
NDNS 65 + Free-living M = 538, F = 516
Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053
Parameter
(and norm/RNI)
Lowest
2.5
pc
Mean
97.5 Highest
pc
Total Zinc Intake
4.5-40 mg/day
M
1.86
4.2
8.81
14.7 27.1
F
1.65
3.4
6.96
11.8 23.3
Plasma zinc
M
7.2
9.9
14.2
19.0 20.5
Fasting >10.71 umol/l
Non-fast 9.95 – 20 umol/l
F
8.2
10.0
14.2
19.1 24.2
Total Copper Intake M
1.0-10 mg/day
F
0.29
0.46
1.1
3.37 6.72
0.19
0.35
0.88
2.3
Plasma copper
umol/l
M
10.4
17.4
31.5
F
8.4
19.5
38
5.87
Dietary Copper and Fats and Cognitive Decline
Morris MC et al Arch Neurol. 2006;63(8):1085-8
• Dietary intake and cognitive function were assessed in
3,718 community-dwelling participants age 65 years and
older living in Chicago over 6 years
• Those with a high dietary intake of saturated or trans fats
and a high copper intake had a greater rate of cognitive
decline
• Comparing the highest quintile 2.75 mg/day vs lowest
quintile 0.88 mg/day the difference in decline was -6.14
units/yr or the equivalent of more than 19 yrs of age
• There was a strong dose-response association with
higher dose copper in supplements.
• There was no association in those whose diets were not
high in these fats.
Iowa Women’s Health Study: Supplements & Mortality
Mursu J et al. Arch Intern Med 2011;171(18):1625-33
• 38,772 women mean 61.6 yr in 1986; 40.2% died by end 2008
• Supplement use in 1986, 1997 and 2004 was associated with an
increased mortality, which may have been due to pre-existing illness
• Particular concerns about use of copper-containing products
Nutrient(s) Provided by
Supplement
Hazard
Ratio
Confidence
Intervals
Absolute
Risk
Calcium
0.91
0.8 to 0.94
- 3.8%
Multivitamins
1.06
1.02 to 1.1
+ 2.4%
Vit B6
1.1
1.01 to 1.21
+ 4.1%
Folic acid
1.15
1.00 to 1.32
+ 5.9%
Iron
1.1
1.03 to 1.17
+ 3.9%
Magnesium
1.08
1.01 to 1.15
+ 3.6%
Zinc
1.08
1.01 to 1.15
+ 3.0%
Copper
1.45
1.20 to 1.7
+ 18%
The Spread of Malnutrition: Selenium
NDNS 65 + Free-living M = 538, F = 516
Bates CJ et al. Br. J. Nut. 2010 doi:10.1017/S0007114510003053
Parameter
Normal Range
Lowest 2.5
pc
Mean
97.5
pc
Highest
Plasma selenium
1.0 – 1.8 umol/l
M
0.375
0.95
2.376
F
0.461
0.924
1.786
Blood glutathione
peroxidase nmol
M
59
89
140
223
359
F
85
93
145
245
353
NADPH/mg Hb per min
Serum Selenium and Mortality among US Adults
Bleys J et al. Arch Intern Med 2008;188(4):404-410
• Serum Selenium was measured in 13,887 US adults
• Follow-up mortality data over 12 years
• Serum Selenium levels <130 ng/ml (1.6 umol/l)
Associated with an inverse association between serum selenium
and all-cause and cancer mortalities
• Serum Selenium levels >150 ng/ml (1.9 umol/l)
Associated with a modest increase in all-cause mortality
• No association between serum Se and cardiovascular mortality
• Normal Range:
Serum or Plasma Selenium 80 -150 ng/ml
1.0 -1.85 umol/l
NDNS 65+ Abnormal Liver Function Tests
Prevalence of:
Plasma Alkaline Phosphatase >110 IU/L
Plasma Gamma-Glutamyl Transferase >50/32 IU/L
• Abnormal LFTs in 10% - 30%
of all UK adults
• Elevated Alk. Phosphatase cholestatic liver disease
- reduced excretion of:
Copper and Manganese
and increased mortality
• Elevated Gamma GT
- often alcohol excess
- obesity – NAFLD, hepatitis
and drug-induced
• Chronic Liver Disease:
- elevated plasma retinol
- deficiencies of :
vitamins D, B,
- later vitamins A and K
- zinc
- iron accumulation
50%
40%
30%
20%
10%
0%
50%
40%
Alk P Men
Alk P Women
65-74 yrs 75-84 yrs
85+yrs 65-84 yrs 85+ yrs
Inst
Inst
GGT Men
GGT Women
30%
20%
10%
0%
65-74 yrs 75-84 yrs 85+yrs 65-84 yrs 85+ yrs
Inst
Inst
Liver Disease: Brain Manganese Accumulation
• Primary Biliary Cirrhosis is a not uncommon cause of chronic
liver disease especially in women
• Presents with fatigue and skin itching without jaundice
• Tests reveal raised alkaline phosphatase
• Studied 18 PBC patients 14 with early pre-cirrhotic
• Blood manganese elevated - reduced ability to excrete excess
• Accumulation of mineral in the brain (reduced magnetisation
transfer ratio in the globus pallidus) similar to industrial
manganese excess, which causes Parkinsonism
• Similar changes may occur in infants with biliary atresia
• Manganese accumulation can easily occur in those
with cholestasis or raised alkaline phosphatase level
•
Reference: Fotron DM et al. Gut 2004;53:587-592.
Fatigue and primary biliary cirrhosis: association of globus pallidus magnestisation
transfer ratio measurements with fatigue severity and blood manganese levels.
Manganese: UK Position
Daily provision:
Multivitamin mineral
0.5 mg
Glucosamine +
Chondroitin*
3.5 mg
*2010 Tesco have agreed to
reduce the Mn content to 0.5 mg
•
•
•
•
Adult intakes average 2.77 – 3.42 [95% CI 1.05-8.11] mg/day
Food sources: grains (50%), tea, beans, supplements 3%
Deficiency rare but may occur in those fed parenterally
1.03% to 4.86% of dietary manganese is absorbed
•
•
•
•
Absorption is increased in iron deficiency or by low intake
Excess is excreted via the bile, if liver function is normal
Safe Upper Level 4 mg but 0.5 mg/day for those aged >50 yrs
Many UK preparations contain 1mg to 10 mg/day often with Glucosamine
but up to 60 mg/day in US imports
Definitions of Safe Levels
• UK Safe Upper Levels (SULs) Guidance Levels (GLs)
“are the doses of vitamins and minerals that susceptible individuals
could take daily on a life-long basis, without medical supervision.”
Single figure, applies to adults only, based on 60 kg female
Total Safe Intakes (TSIs) are set for retinol and some trace elements
• US Tolerable Upper Intake Levels (ULs)
Range of figures depending upon age and sex
“is the highest average daily nutrient intake level likely to pose no
risk of adverse effects for nearly all people in a particular group”
Based on total intake from food, water and supplements
• EU Tolerable Upper Intake Level (UL)
“the maximum level of total chronic daily intake of a nutrient (from all
sources) judged to be unlikely to pose a risk of adverse effects”.
ULs vary with age and sex and exclude “those under medical
supervision and certain disease states” but includes “sensitive
individuals”
NDNS 65+ The Final Analysis
What was surveyed in NDNS?
Stage
NDNS 65+ Component
• State of Adequacy
• State of Negative Balance
1. Poor intake
2. Reduced absorption
3. Increased losses
4. Increased requirement
5. Altered metabolism
• Decline in Tissue Stores
Diet + Supplements
Alcohol, drugs, liver and renal
Tests – blood and urine
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
Depression
BMI
Renal and Liver Function Tests
Data Collected after 14yrs
NDNS 65+: Determinants of Longevity
• During 14 yrs of follow-up the causes of death were recorded
for free-living people; 74% of men and 62% of women died
• Mortality was predicted by baseline measures of:
- poor grip strength (men)
- low intakes of food and protein
- poor renal function - raised plasma creatinine and homocysteine
- raised Hb A1c - prediabetes/diabetes
• Mortality also predicted by plasma levels of nutrients:
- raised copper - infection, cancer, liver or inflammatory disease
- raised plasma retinol – high intake, renal impairment, alcohol XS
- low vitamin C
- low alpha-carotene
- low vitamin B6
- low vitamin D (men)
- low zinc and selenium
• Mortality was not predicted by:
- dietary intakes of folate and vitamin B12
- haemoglobin, serum/plasma vitamin B12, folate and beta-carotene
- serum cholesterol
Physical Health: All-cause mortality NDN 65+
[Hazard Ratio <1.0 = Increased Survival with increased level]
Men and Women
1.5
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
Grip Strength
Mid-Arm Circumf.
BMI
Bates CJ et al Br. J Nutr. 104:893-9 & 105: and Osteop Int 2011
Nutrient Intake: All-Cause Mortality NDNS 65+
[Hazard Ratio <1.0 = Increased Survival with increased level]
1.5
1.4
1.3
1.2
1.1
Men and Women
1
0.9
0.8
0.7
0.6
0.5
Energy
Protein
Vit. C
Phosph.
Calcium
Vit. D
Bates CJ et al Br. J Nutr. 104:893-9 & 105: and Osteop Int 2011
Non-Haem
Iron
Plasma Mineral Level: All-cause mortality NDN 65+
[Hazard Ratio <1.0 = Increased Survival with increased level]
1.5
Men and Women
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
Selenium
Zinc
Iron
Iron Sat
Copper
Bates CJ et al Br. J Nutr. 104:893-9 & 105: and Osteop Int 2011
Vitamin Test Status: All-cause mortality NDN 65+
Plasma Levels [Hazard Ratio <1.0 = Increased Survival]
1.5
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
Men and Women
Vit. D
Vit. B6
P5P
Alpha- Lut. + Zx S. Folate
Carot
S. Vit.
B12
Bates CJ et al Br. J Nutr. 104:893-9 & 105: and Osteop Int 2011
RBC Fol
Laboratory Tests: All-Cause Mortality NDNS 65+
Plasma [Hazard Ratio <1.0 = Increased Survival with increased level]
1.5
Men and Women
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
Albumen T. Chol.
Phos.
Fibrinog. T. Hcys A1 Anti-T Hb A1C
Bates CJ et al Br. J Nutr. 104:893-9 & 105: and Osteop Int 2011
Creatin.
Mortality, Homocysteine and Related Nutrients: NDNS 65+
Bates CJ et al Br J Nutr. 2010;104:893-899
•
•
•
n =1100, 50.2% Female. Baseline 1994/5; follow-up Sept 2008
Mortality data and cause were collected – related to baseline data
Mortality predictable by; plasma tHcys, pyridoxal PO4, creatinine, Glyc Hb,
alpha1-antichymotrypsin, fibrinogen, diet, but not folate/vit B12 intake/status
Biochemical
Measure or
Dietary Factor
All-cause Mortality
died =749, alive =351
Vascular Disease Mortality
died =199, alive =351
Hazard Ratio
95% CI
Hazard Ratio
95% CI
Pl. tHcys umol/l
1.19
1.11, 1.27
1.36
1.13, 1.63
Total Chol mmol/l
0.90
0.83, 0.99
0.89
0.73, 1.08
Blood HbAIc%
1.23
1.14, 1.32
1.32
1.11, 1.57
Pl. Creatinine
1.20
1.10, 1.31
1.25
1.05, 1.49
Energy KJ/day
0.87
0.8, 0.96
0.86
0.72, 1.02
Fat g/day
1.1
0.94, 1.29
0.92
0.79, 1.08
Protein g/day
0.86
0.77, 0.97
0.79
0.67, 0.94
Plasma Nutrient Levels and Specific Mortality: NDNS 65+
Age-and sex-adjusted ;l values outside of 0.9 to 1.1 are significant p<0.05
All Cause
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Vascular
Cancer
Respiratory
Vit C
Alpacarot
Se
Zn
Cu
Fe
Undernutrition: Prevalence and Likely Significance
Nutrient
in NDNS65+ Free-Living Population
% Pop. Clinical Significance
Energy
1 - 5%
Underweight, fatigue, poor immunity, fracture
Protein
1 - 5%
Fatigue, poor wound healing, infection
Fibre
>50%
Constipation, colon cancer, vascular disease
Water
?
Dehydration
Anaemia
Due to deficiency, bleeding, chronic illness
Folate
5 - 30%
Depression, anaemia, vascular disease
Vitamin B
10 - 20% Fatigue, neurological and vascular disease
Vitamin D
Osteoporosis, muscle pain/weak, infection
Iron
1 - 25%
Anaemia, fatigue, heart failure
Calcium
10%
Osteoporosis
Trace
elements
1 - 25%
Poor immunity and reduced longevity; Zn –
taste, vision, wound healing; Cu - anaemia
Overnutrition: Prevalence and Likely Significance
in NDNS65+ Free-Living Population
Nutrient
% Pop.
Clinical Significance
Energy
30%
Obesity, vascular disease and cancer
Saturated Fats
Vascular disease, inflammation
Protein animal 5%
Obesity, osteoporosis ?renal impairment
Sugar NMES
50%
Dental caries, obesity, T2D
Water
Uncertain
Hyponatraemia
Sodium
80%
Hypertension, strokes, fluid retention,
heart failure, osteoporosis and fatigue
Iron
0.6%
Haemochromatosis – fatigue & arthritis
Vitamin A
10-20%
Birth defects, osteoporosis, liver disease
Micronutrients Uncertain
from food water
or supplements
Possible due to excessive intake, liver
or renal disease; concerns about copper
and manganese.
Nutrition and Ageing: Conclusions from NDNS 65+
• Problems of nutritional deficiency and excess are common in
ageing populations and frequently co-exist in patients
• The commonest cause of undernutrition is poor dietary intake
but alcohol excess, illness and medical drugs are also factors
• Both types of problem are under-recognised
• Both under and overnutrition can be detected by careful history
(diet, risk factors and symptoms), examination and investigation
• Many such problems are preventable & treatable but the value
of treating and the best method of doing so are not clear
• Nutrition decline and excess can also be part of the ageing
process and may develop in terminal situations
• Doctors, patients and society in general need to decide just how
far they can go in assessing and managing these problems
NDNS 65+: What has happened in last 20 yrs?
• Current NDNS Rolling Programme includes >65 yrs
data for years 1 and 2 (of 3) have reported on:
- methodology and nutrient intake
- blood data will be reported on in late 2012
• UK Population changes include:
- small increase in fruit and vegetable consumption
- continuing decline in saturate and trans-fats
- increase in alcohol and excessive alcohol consumption continuing low levels of activity by many
- increase in obesity
- increased supplement use especially calcium and vit. D
- increased use of medication
• Increased longevity and increased disease
- longevity improved mainly in non-deprived but more;
T2D, liver/renal disease, cancer, dementia and osteoporosis
Getting it right: what do patients need to know?
Headstone 19th C St Andrews, Scotland - deaths at (M)76 & (F)93 yrs
• Achieve food-based targets for:
protein, fish/oily fish, dairy, nutritious
carbohydrates and fruit & vegetables
• Do not exceed limits for salt, sugar,
alcohol and fats
• Avoid obesity and underweight
• Be active and get out of doors
• Socialise, eat and be active with
others and maintain interests
• Have medical treatment when ill
• Make use of supplements when
necessary and avoid excess
• Encourage others to do likewise
NDNS 65+: The Last Word
• Thank you for your attention
• More information is available in lecture form on:
- Nutritional Assessment
- Low Income Diet and Nutrition Survey
- Safety of Nutritional Supplements
• I would welcome your feedback on this and other
presentations dr.stewart@stewartnutrition.co.uk
• Dr Stewart is available to lecture on these topics