- Email: [email protected]
Are the Recommended Dietary Allowances for Vitamins Appropriate for Elderly People?
RESEARCH
Original Research
Are the Recommended Dietary Allowances for Vitamins Appropriate for Elderly People? Francesco Bolzetta, MD; Nicola Veronese, MD; Marina De Rui, MD; Linda Berton, MD; Elena Debora Toffanello, MD; Sara Carraro, MD; Fabrizia Miotto, RD*; Eminè Meral Inelmen, MD; Lorenzo Maria Donini, MD; Enzo Manzato, MD; Alessandra Coin, MD; Egle Perissinotto, ScD; Giuseppe Sergi, PhD, MD ARTICLE INFORMATION Article history: Submitted 27 July 2014 Accepted 10 April 2015
Keywords: Vitamins Recommended Dietary Allowances (RDA) Micronutrient Older people 2212-2672/Copyright ª 2015 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2015.04.013 *
Certified in Italy.
ABSTRACT Background An adequate vitamin intake is essential for a good nutritional status, especially in older women, who are more sensitive to nutritional deficiencies. The American, European and Italian Recommended Dietary Allowances (RDAs) derive mainly from studies on adults, and it is not clear whether they also apply to elderly people. Comparing the RDAs with the actual vitamin intake of a group of healthy older women could help to clarify the real needs of elderly people. Objective Our aim was to compare the American, European, and Italian RDAs with the actual vitamin intake of a group of healthy older women. Design This was a cross-sectional study. Participants The study included 286 healthy women aged older than 65 years. Main outcome measures For each micronutrient, the 50th percentile of the distribution of its intake was considered as the average requirement, and the corresponding calculated RDA for our sample was the average requirement1.2, as recommended by the US Food and Nutrition Board. This calculated RDA was then compared with the American, European, and Italian RDAs. Statistical analyses performed Student’s t test or the Mann-Whitney test (after checking the normal distribution of the micronutrient) for continuous variables; the c2 test for categorical variables. Results The calculated RDA were 2,230 mg retinol equivalents for vitamin A, 2.8 mg for vitamin B-12, 0.9 mg for thiamin, 1.4 mg for riboflavin, 3.6 mg for pantothenic acid, 1.4 mg for vitamin B-6, 320 mg for folic acid, and 115 mg for vitamin C. Conclusions Our findings suggest that the current RDAs are adequate for older women’s intake of riboflavin, vitamin B-6, and folic acid, but should be raised for vitamin B-12 and for vitamin C. J Acad Nutr Diet. 2015;-:---.
N
UTRITION IN OLDER PEOPLE IS A TOPIC OF growing interest because good nutritional status is associated with successful aging, lower susceptibility to disease, better cognitive and physical performance, and quality of life. An inadequate dietary intake of energy foods and micronutrients, such as folate, calcium, zinc and vitamins D and B-6 has been reported in community-dwelling people older than 60 years of age.1-3 Older women, in particular, seem to ingest smaller amounts of food than men, making them more susceptible to deficiencies in the main micronutrients.4 The appropriateness of people’s nutritional intake is generally estimated by comparing their actual intake of a given nutrient with the corresponding Recommended Dietary Allowance (RDA), which is an indicator of the amount that most individuals in a population need to ingest to meet their body’s need. For many nutrients, an adequate intake is also confirmed by physiologic and biohumoral indices. The European Union has developed its own RDAs, based on values proposed by its Member States, but no specific values ª 2015 by the Academy of Nutrition and Dietetics.
are recommended for older people.5,6 The US Food and Nutrition Board and the Italian Society of Human Nutrition have published RDAs for older people, but for several micronutrients they are essentially the same as for younger adults.6,7 The lack of specific RDAs for older people is also due to the fact that physiologic changes in aging make longitudinal studies on nutrient requirements very difficult to interpret, consequently limiting research on this topic. Aging entails variations in metabolic processes, physical functioning, body composition and food absorption, and physiological aging, frailty, comorbidities, and polypharmacy can interfere with people’s nutritional needs.8 An inadequate micronutrient status is associated with higher morbidity and frailty in elderly people, and might be due to the inappropriate use of medication as well as dietary issues.9 As a result, the nutritional requirements of elderly people (and older women in particular) may differ from those of younger adults in many respects. The European Food Safety Authority has established average requirements based on the intake of a nutrient that JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1
RESEARCH suffices for half of the people in a healthy population group. These average requirements can be used to estimate daily nutritional requirements with the aid of an equation developed by the US Food and Nutrition Board.6 The aim of the present study was to compare the American, European, and Italian RDAs with the values calculated from the average daily intake of a group of free-living, healthy, and still physically active older women.
MATERIALS AND METHODS Subjects The study was conducted at the Geriatrics Section of Padova University in 2010 and 2011. We recruited 324 women on a voluntary basis from among those older than 65 years of age attending a twice-weekly fitness program of aerobic and resistance exercises at public gyms in Padova. Participants were approached in person by members of our team. Their clinical condition was ascertained by trained physicians from their clinical history and a clinical examination. Individuals with severe cardiovascular or pulmonary diseases, metabolic diseases, cancer, and inflammatory conditions were ruled out. Any use of drugs (eg, corticosteroids or hormones) that might interfere with body composition was also a reason for exclusion. Only individuals with a Mini Mental State Examination score >24 were considered. The final study sample comprised 286 women who met these inclusion and exclusion criteria. A blood sample was drawn after overnight fasting for routine biochemical tests (albumin, glucose, and electrolyte concentrations, renal and liver function tests, and a complete blood count). The normal values for albumin10 (a commonly used indicator of protein nutrition) at our laboratory are between 35 and 45 g/L. The Institutional Review Board of Padova (Italy) approved the study protocol and all participants provided written informed consent. The study was designed in accordance with the Helsinki Declaration.
Study Design All patients underwent the following tests: 1.
2.
2
Anthropometric measurements: Body weight was measured to the nearest 0.1 kg and height to the nearest 0.1 cm using a standard balance and stadiometer (Seca) with subjects wearing light clothing and no shoes. Body mass index (BMI) was calculated as their weight in kilograms divided by their height in meters squared. The reference standards for BMI were those proposed by the World Health Organization.11 Body composition: Fat-free mass (FFM) and fat mass were ascertained by dual-energy x-ray absorptiometry using fan-beam technology (Hologic QDR 4500 W). An FFM index was calculated as the ratio between FFM and height in meters squared. The values of our population were compared with the FFM index calculated for the Italian population, taking the interquartile range as a reference for assuming normality.12 The dual-energy x-ray absorptiometry method has good reproducibility in measuring softtissue composition, producing consistent results in elderly people also.13
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
3.
Dietary assessment: Individuals’ food intake was recorded by the same dietitian using a modified dietary assessment method consisting of an eating frequency questionnaire14: Each patient was asked to report the frequency with which they had habitually eaten a given food in the previous 6 months. Portion sizes were assumed to coincide with standard portion sizes from an illustrated food atlas15 or they were weighed. The usual food intake was converted into macronutrients and micronutrients using a national food composition table.16 The EUROCODE system was used to arrange the foods into groups and subgroups based on their origin, composition, and function in the diet.17 The method’s validation has been reported elsewhere.18
Data Interpretation Certain criteria were taken into account in our comparison between the American and European RDAs and our sample’s actual micronutrient intake. Given our population’s characteristics (eg, no major diseases, independence in activities of daily living, and no known nutritional problems), we assumed that these women could be considered as a model of appropriate nutrition in elderly people. We identified the 50th percentile of each micronutrient’s distribution and considered this value as the average requirement. Then we obtained an RDA calculated for our women using the equation recommended by the US Food and Nutrition Board6 using the formula: calculated RDA¼average requirements1.2. This calculated RDA was then compared with the American, European, and Italian RDAs. We considered the calculated RDA to be similar if it was within a difference of 10% for the recommendation suggested by each Society.
Statistical Analysis Data were analyzed using SPSS for Windows, release 19.0 (2010, SPSS Inc), expressing the results as meansstandard deviations or percentages, as appropriate. Differences in proportions and means of covariates by age (younger than 70 years and 70 years and older) were assessed with Student’s t test or the Mann-Whitney test after checking the normal distribution of the micronutrient. The cumulative frequencies of consumption of each vitamin by the population as a whole, and the corresponding percentile values were computed to describe the distribution of the vitamins in detail. The percentages of subjects with vitamin deficiencies were estimated by comparing the individual intakes with the European RDAs. In all analyses, P<0.05 was considered statistically significant.
RESULTS Thirty-eight subjects were excluded because 12 were newly diagnosed with diabetes, 10 used cortisone at the time of enrollment, 6 used hormonal preparation, and 6 scored <24 on the Mini Mental State Examination. Mean age of our study population was 71.14.7 years (range¼65 to 84 years), and mean BMI was 27.023.82. In the sample as a whole, 23% of participants were obese, with a BMI >30. None of the participants had serum albumin <35 g/L. Table 1 shows the sample’s anthropometric characteristics, and the women’s daily energy and macronutrient --
2015 Volume
-
Number
-
RESEARCH Table 1. Anthropometric features, biohumoral characteristics, and daily energy and macronutrient intake in a cohort of 286 community-dwelling healthy older women in Italy Whole group (n[286)
Aged <70 y (n[111)
Aged ‡70 y (n[175)
P valuea
meanstandard deviation! Body mass index
27.023.82
26.613.57
27.273.95
0.15
Weight, kg
65.929.76
66.369.40
65.649.99
0.55
Fat mass, %
37.315.29
36.685.39
37.705.19
0.12
Fat-free mass index
16.692.19
16.892.20
16.372.14
0.05
Albumin, g/L
43.71.9
43.51.7
43.82.0
0.20
Energy, kcal
1,513.66357.90
1,535.56322.83
1,499.77378.72
0.39
Proteins, g Proteins/weight, g/kg Carbohydrate, g
55.2513.20
56.8011.48
54.2614.13
0.11
0.860.25
0.870.21
0.850.28
0.46
204.6159.55
207.2554.12
202.9362.85
0.54
Fat, g
50.3716.61
51.2612.61
49.8018.72
0.43
Dietary fiber, g
16.624.84
16.574.81
16.654.88
0.89
Alcohol, g
10.0311.79
10.2211.88
0.74
9.7411.68
P values were obtained using Student’s t test for independent samples.
a
intake by age group. Mean calorie intake was 1,513.66357.9 kcal, and 50.8% of these calories came from carbohydrates, 30% from fats, and 14.1% from proteins. There were no significant differences between the younger than 70 years and the 70 years and older age groups; daily energy intake (P¼0.39); carbohydrate, protein, or fat intake (P¼0.54, P¼0.11, and P¼0.43, respectively). There were also no significant differences between the two age groups’ BMI (P¼0.15) or mean weight (P¼0.55). Mean micronutrient intake in the sample as a whole only reached the corresponding European RDAs for vitamins A, C, B-12, and B-6 (Table 2). When the women were divided by age, the intakes of riboflavin (P¼0.02) and vitamin B-6 (P¼0.05) were lower in the older group. Table 2 also shows the percentile distribution for the intake of each micronutrient by age group. The Figure shows the cumulative frequencies of the whole sample’s vitamin intake. For vitamins A and C and folic acid, most of our sample reached the European RDAs (86% for vitamin A, 62% for vitamin C, and 82% for folic acid), and a large proportion of the sample fell below the recommended intake of B-group vitamins (93% of the women for thiamin, 74% for riboflavin, 99% for vitamin B-5, and 59% for vitamin B-12). The American, European, Italian, and our own RDAs (calculated as suggested by the US Food and Nutrition Board) are compared in Table 3. Our calculated RDA for older people proved very similar to the American, European, and Italian values for riboflavin and vitamin B-6, and for vitamin C, vitamin B-12, and especially vitamin A, our calculated RDA was higher than the one generally recommended for adults. Our RDAs calculated for pantothenic acid and thiamin were below the levels suggested by the European Union and the Italian Italian Society of Human Nutrition, while our calculated RDA for folic acid was higher than the European, but lower than the Italian and American RDAs. --
2015 Volume
-
Number
-
DISCUSSION Our study compared the RDAs for micronutrients published by the US Food and Nutrition Board, the European Union, and the Italian Society of Human Nutrition in Italy with those calculated from the intake of a group of fit and healthy older women. Mean BMI of our sample indicated that they were often overweight, with about one in four participants with a BMI between 30 and 35. It is common knowledge that this anthropometric parameter is not very reliable in elderly people, however, because it fails to take changes typical of aging into account and such measures have rarely been derived from populations that included a sufficient proportion of elderly individuals. This impression is supported by the fact that the mean fat mass and FFM values of our sample were consistent with the 50th percentile of a large group of older Italian women.12 The mean BMI of our sample also coincides with the lowest mortality risk group, according to a previous Italian study on older people.19 Finally, none of the participants had protein malnutrition, judging from their serum albumin levels. All these data confirm that our sample had good nutritional status.
Vitamins for Which Our RDA Calculated Was Higher than the American, European Union, and Italian RDAs Vitamin A. This vitamin is important for normal vision, cell differentiation, and efficient immune function.4 Only 13% of our sample had an intake below the RDA for vitamin A (800 mg retinol equivalents [RE]/day), a finding consistent with previous studies. In the SENECA (Survey Europe on Nutrition in the Elderly: A Concerted Action) study, for instance, the prevalence of vitamin A deficiency was near 0 at baseline (1988 to 1989) and remained so after 4 years of follow up.20 Our calculated RDA was 2,230 mg RE/day, much higher than JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
3
RESEARCH Table 2. Daily vitamin intake and some relevant percentiles (5th, 25th, 50th, and 75th) in a cohort of 286 community-dwelling healthy older women in Italy
Vitamin
Whole group (n[286)
Aged <70 y (n[111)
Aged ‡70 y (n[175)
2,185.231,466.91
2,258.781,422.1
2,138.571,496.79
P valuea
Vitamin A, mg REb Mean intakeSDc Percentile 5th
303.66
459.91
285.26
25th
1,121.99
1,216.25
1,034.11
50th
1,857.13
2,019.37
1,771.69
75th
2,902.59
3,013.17
2,873.08
2.762.13
3.031.93
2.592.23
Vitamin B-12 (cobalamin), mg Mean intakeSD
0.08
Percentile 5th
0.80
0.90
0.76
25th
1.43
1.63
1.36
50th
2.31
2.50
2.11
75th
3.36
3.74
2.87
Thiamin, mg Mean intakeSD
0.770.22
0.790.23
0.750.22
0.11
Percentile 5th
0.45
0.46
0.44
25th
0.62
0.66
0.60
50th
0.75
0.79
0.73
75th
0.89
0.94
0.89
Riboflavin, mg Mean intakeSD
1.190.35
1.260.37
1.150.33
0.02
Percentile 5th
0.70
0.76
0.67
25th
0.96
0.98
0.95
50th
1.19
1.21
1.12
75th
1.41
1.47
1.36
Pantothenic acid (B-5), mg Mean intakeSD
3.090.98
3.200.99
3.020.97
0.13
Percentile 5th
1.65
1.66
1.64
25th
2.39
2.68
2.32
50th
3.04
3.13
3.01
75th
3.69
3.81
3.60
Pyridoxine (B-6), mg Mean intakeSD
1.390.68
1.490.68
1.330.68
0.05
Percentile 5th
0.68
0.75
0.65
25th
1.00
1.10
0.93 (continued on next page)
4
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
--
2015 Volume
-
Number
-
RESEARCH Table 2. Daily vitamin intake and some relevant percentiles (5th, 25th, 50th, and 75th) in a cohort of 286 community-dwelling healthy older women in Italy (continued)
Vitamin
Whole group (n[286)
Aged <70 y (n[111)
Aged ‡70 y (n[175)
50th
1.21
1.26
1.18
75th
1.56
1.67
1.49
P valuea
Folic acid, mg Mean intakeSD
279.43112.13
291.22109.68
271.95113.33
0.15
Percentile 5th
119.42
129.71
117.02
25th
205.62
217.51
195.63
50th
265.53
276.18
249.97
75th
334.79
356.59
334.19
Vitamin C, mg Mean intakeSD
111.8469.39
119.7465.53
106.8371.47
0.12
Percentile 5th
29.82
38.77
21.95
25th
64.48
74.16
57.45
50th
96.00
104.37
92.70
75th
149.04
148.90
149.46
P values obtained by analysis of variance between age groups using Student’s t test on independent samples. RE¼retinol equivalents. SD¼standard deviation.
a
b c
the recommendations of the European Union and Italian Society of Human Nutrition for adults generally. This finding is also consistent with other studies: in a sample of 212 Brazilian older adults, vitamin A intake ranged between 1,112.20 mg RE/day for the 25th percentile and 2,430.80 mg RE/day for the 75th percentile.21 Similar results were reported for American adults.4 However, because the literature has shown that older people’s livers are less able to clear vitamin A toxins,22,23 it remains to be seen whether the RDA should be raised in this population.
Vitamin B-12. Judging from the European RDA (2.5 mg/day), about 59% of our sample had an inadequate vitamin B-12 intake. This vitamin is essential to the development and normal functioning of the central nervous system. The interaction between folate and vitamin B-12 is responsible for the megaloblastic anemia seen in deficiencies of both these micronutrients.24 A decline in gastric acid secretion due to type B chronic atrophic gastritis is the main cause of vitamin B-12 deficiency in elderly people. Older women also tend to have a lower consumption of foods rich in vitamin B12, particularly animal proteins, possibly because they are expensive and difficult to chew.25 This attitude probably contributes to deficiency in other vitamins belonging to the B family. Bacterial overgrowth in the gut can also be a factor responsible for reducing the bioavailability of vitamin B-12.4 Given these premises, the RDA of this vitamin for older women should be higher than for adults generally in the attempt to override the lower absorption typical of old age. In --
2015 Volume
-
Number
-
fact, our calculated RDA for vitamin B-12 was 2.8 mg/day, which is higher than the European, American, and Italian Society of Human Nutrition RDAs. Data in the literature are not consistent: while low vitamin B-12 intake was also reported in another Italian study on elderly patients,26 a daily consumption higher than the RDA (about 5.3 mg/day) was identified in a multicenter European study on older women.27
Vitamin C. Vitamin C is a co-factor in the hydroxylation reactions needed for collagen synthesis. Vitamin C also plays an important part in maintaining antioxidant protection,28 and consequently in preventing atherosclerosis, cancer, senile cataracts, and degenerative diseases.4 Given the high prevalence of such diseases in older people, vitamin C requirements are believed to increase with age, particularly in smokers.4,29 Based on our sample, we calculated an RDA of 115 mg vitamin C, which is higher than the recommendations of all three boards considered for comparison. Judging from the dietary intake of vitamin C in our sample, about 38% of the women failed to reach our calculated RDA. This finding is probably due to the limited use of raw vegetables and fruits rich in vitamin C that is typical of older age.25 Dumartheray and colleagues30 found the 64.3% of Swiss women remained below the RDA, and Fritz and colleagues31 demonstrated that vitamin C deficiency increased with age among Austrian elderly people, affecting 30% of women older than 84 years of age. Although we saw no sign of any reduction in vitamin C JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
5
RESEARCH
6 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS --
2015 Volume -
Number -
Figure. Cumulative frequencies of vitamin consumption levels in a cohort of 286 community-dwelling healthy older women in Italy.
RESEARCH Table 3. Comparison between American, European, and Italian Recommended Dietary Allowances with those calculated in a cohort of 286 community-dwelling healthy older women in Italy Micronutrient
US RDAab
European RDA
SINUc RDA
RDAcd
Vitamin A, mg REe
700
800
600
2,230
Cobalamin (B-12), mg
2.4
2.5
2.4
2.8
Thiamin, mg
1.1
1.1
1.1
0.9
Riboflavin, mg
1.1
1.4
1.3
1.4
Pantothenic acid (B-5), mg
5
6
5
3.6
Pyridoxine (B-6), mg
1.5
1.4
1.5
1.4
Folic acid, mg
400
200
400
320
Vitamin C, mg
7
80
85
115
a
RDA¼Recommended Dietary Allowance. US RDA for women >70 years old. c SINU¼Società Italiana di Nutrizione Umana. d RDAc¼ Recommended Dietary Allowance calculated; average requirement1.2. e RE¼retinol equivalents. b
intake between our two age groups, Volkert and colleagues32 reported finding that mean vitamin C intake decreased with age, from 151.91 mg/day in young old people to 129.33 mg/ day in those older than 75 years old. Here again, the RDA for this vitamin could be raised, given that the related toxicity is very rare4 and, as recently suggested by a recent metaanalysis, higher vitamin C intake is linearly associated with a lower lung cancer risk.33
Vitamins for Which Our RDA Calculated Was Similar to the American, European Union, and Italian Society of Human Nutrition RDAs Riboflavin. Our calculated RDA for this vitamin was 1.4 mg/ day, exactly the same as what the European Union recommends for adults, but slightly higher than the American RDA. In our sample, however, 74% of the women did not reach a riboflavin intake of 1.4 mg/day. They also revealed a significant age-related decline in riboflavin consumption, from 1.26 mg/day in people younger than 70 years to 1.15 mg/day in those older than 70 years (P¼0.02). Riboflavin is particularly important in a number of redox reactions and it is believed to be involved in protecting against cancer and cardiovascular diseases.34 The mean daily riboflavin intake in our population was 1.19 mg, which is quite similar to the 1.3 mg/day found in two previous studies on older women. Dai and colleagues35 reported a mean riboflavin intake of 0.9 mg/day in a group of >34,000 women aged older than 50 years,35 while a study concerning elderly women in the United Kingdom found a mean riboflavin intake of 1.6 mg/day.36
Vitamin B-6 (Pyridoxine). Vitamin B-6 has antioxidant properties, and vitamin B-6 deficiency has been associated with several negative neurologic and cardiovascular outcomes.37 About 67% of the women in our sample had a vitamin B-6 intake below the European RDA (1.4 mg/day) (Figure). Population studies in the literature have generated conflicting data on the prevalence of vitamin B-6 deficiency,38 possibly --
2015 Volume
-
Number
-
because some of these studies did not consider the oldest old. Our calculated RDA for this vitamin was 1.4 mg/day. Recent studies have suggested, however, that even an apparently adequate B-6 intake may not suffice to guarantee normal plasma levels in elderly people, probably due to its lower absorption, higher catabolism, and impaired phosphorylation.39 Given these premises, the higher RDA adopted by the US Food and Nutrition Board and the Italian Society of Human Nutrition for older women (ie, a daily intake of 1.5 mg), could be appropriate for older women, too.
Folate. Low folate levels have been associated with a higher risk of cardiovascular disease, multiple cancers, and neurodegeneration.40,41 About 18% of our sample had a folic acid intake lower than the European RDA (200 mg/day), a finding at odds with a recent European survey that reported a much higher prevalence of inadequate folic acid intake, involving as many as 33.7% of men and 45.9% of women in some countries. On the other hand, the mean daily intake identified across the various countries was similar to that of our population.42 The calculated RDA from our population’s intake was 320 mg/day, higher than the European RDA for adults. Our suggestion that the European RDA for folic acid be raised is consistent with the recommendations of the US Food and Nutrition Board.6
Vitamins for Which Our RDA Calculated was Lower than the American, European, and Italian Society of Human Nutrition RDAs Vitamin B-5 (Pantothenic Acid). Virtually none of the women in our sample reached the vitamin B-5 intake recommended by the European Union.43 Pantothenic acid deficiency is practically unknown, if we disregard the so-called burning feet syndrome (ie, nutritional melalgia) in severely malnourished prisoners of war in the Far East, which was often attributed to pantothenate deficiency.44 Pantothenate is involved in acetate metabolism, cholesterol, and steroid synthesis, and the acetylation of drugs.45 Our calculated RDA for this vitamin was 3.6 mg/day. To our knowledge, only one JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
7
RESEARCH study has been published on vitamin B-5 intake in elderly people, in which Maisey and colleagues26 found a mean daily intake of 3.18 mg pantothenate in older women, which is consistent with our finding of a mean intake of 3.09 mg. Given the absence of any clinically relevant deficiency in our population, and the findings proposed by literature, we surmise that a lower pantothenic acid intake would suffice in healthy older women.
5.
Commission Directive 2008/100/EC. Official Journal of the European Union. 2008; http://eur-lex.europa.eu/LexUriServ/LexUriServ.do? uri¼OJ:L:2008:285:0009:0012:EN:PDF. Accessed July 15, 2014.
6.
Institute of Medicine. Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals. Washington, DC: Food and Nutrition Board, Institute of Medicine; 2004.
7.
Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. Società Italiana di Nutrizione Umana. 2013. http://www.sinu.it/pubblicazioni.asp. Accessed July 15, 2014.
8.
Sergi G, De Rui M, Sarti S, et al. Polypharmacy in the elderly: Can comprehensive geriatric assessment reduce inappropriate medication use? Drugs Aging. 2011;28(7):509-518.
9.
Fabian E, Bogner M, Kickinger A, Wagner KH, Elmadfa I. Intake of medication and vitamin status in the elderly. Ann Nutr Metab. 2011;58(2):118-125.
10.
Bonjour JP, Schurch MA, Rizzoli R. Nutrition aspects of hip fractures. Bone. 1996;18(3 suppl):139S-144S.
11.
Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894(i-xii): 1-253.
12.
Coin A, Sergi G, Minicuci N, et al. Fat-free mass and fat mass reference values by dual-energy x-ray absorptiometry (DEXA) in a 20-80 year-old Italian population. Clin Nutr. 2008;27(1):87-94.
13.
Baumgartner RN, Stauber PM, McHugh D, et al. Cross-sectional age differences in body composition in persons 60þ years of age. J Gerontol A Biol Sci Med Sci. 1995;50(6):M307-M316.
14.
Coates RJ, Monteilh CP. Assessments of food-frequency questionnaires in minority populations. Am J Clin Nutr. 1997;65(4 suppl): 1108S-1115S.
15.
Turconi G, Roggi C. Atlante Fotografico Alimentare. Rome, Italy: EMSI; 2007.
16.
Carnovale E, Miuccio FC. Tabelle Di Composizione Degli Alimenti. Rome, Italy: Ministry of Agriculture and National Institute of Nutrition; 1989.
17.
Kohlmeier L, Pootvliet EJ. EUROCODE 2 Food Coding System, version 92/1. Berlin, Germany: Institute for Social Medicine and Epidemiology; 1992.
18.
Nes M, van Staveren WA, Zajkas G, et al. Euronut SENECA study on nutrition and the elderly. Validity of the dietary history method in elderly subjects. Eur J Clin Nutr. 1991;45(suppl 3):S97-S104.
19.
Sergi G, Perissinotto E, Pisent C, et al. An adequate threshold for body mass index to detect underweight condition in elderly persons: The Italian Longitudinal Study on Aging (ILSA). J Gerontol A Biol Sci Med Sci. 2005;60(7):866-871.
20.
Haller J, Weggemans RM, Lammi-Keefe CJ, et al. Changes in the vitamin status of elderly Europeans: Plasma vitamins A, E, B-6, B-12, folic acid and carotenoids. SENECA Investigators. Eur J Clin Nutr. 1996;50(suppl 2):S32-S46.
21.
Carmem-Costa-do-Nascimento C, Cristhine-Pordeus-de-Lima R, RiosAsciutti LS, et al. The importance of habitual vitamin A dietary intake on the serum retinol concentration in the elderly: A population-based study. Rev Invest Clin. 2011;63(5):450-460.
22.
Russell RM. The vitamin A spectrum: From deficiency to toxicity. Am J Clin Nutr. 2000;71(4):878-884.
23.
Suter PM, Russell RM. Vitamin requirements of the elderly. Am J Clin Nutr. 1987;45(3):501-512.
24.
Stabler SP. Clinical practice. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-160.
25.
Rothenberg E, Ekman S, Bülow M, et al. Texture-modified meat and carrot products for elderly people with dysphagia: Preference in relation to health and oral status. Scand J Food Nutr. 2007;51(4):141-147.
26.
Maisey S, Loughridge J, Southon S, et al. Variation in food group and nutrient intake with day of the week in an elderly population. Br J Nutr. 1995;73(3):359-373.
27.
Olsen A, Halkjaer J, van Gils CH, et al. Dietary intake of the watersoluble vitamins B1, B2, B6, B12 and C in 10 countries in the European Prospective Investigation into Cancer and Nutrition. Eur J Clin Nutr. 2009;63(suppl 4):S122-S149.
28.
Honarbakhsh S, Schachter M. Vitamins and cardiovascular disease. Br J Nutr. 2009;101(8):1113-1131.
29.
Heseker H, Schneider R. Requirement and supply of vitamin C, E and beta-carotene for elderly men and women. Eur J Clin Nutr. 1994;48(2):118-127.
Thiamin. The most common clinical setting for thiamin deficiency is alcoholism and a poor diet.46 In our sample, 93% of the women had a thiamin intake below the European RDA (1.1 mg/day), with a mean of 0.77 mg/day. This is lower than in other published reports: Sette and colleagues47 found a mean daily thiamin intake of 0.86 mg, for instance, in a group of 136 non-institutionalized Italian elderly women, while it was 0.84 mg in a cohort of older Japanese women, and 1 mg/ day in a large, pan-European multicenter study on older people.27 Our calculated RDA was consequently only 0.9 mg/ day. Although our sample population showed no signs of thiamin deficiency, we consider an RDA of 1.1 mg/day (as indicated by the US Food and Nutrition Board, Italian Society of Human Nutrition, and European Union) appropriate for older women, also in the light of the other studies mentioned.
Limitations Our findings should be considered with the limitations of our study in mind. The main limitation lies in that we did not take serum or biochemical parameters into account (this would have been beyond the aim of our work) for our calculated RDA. Another limitation lies in that we used only one dietary questionnaire, a food frequency questionnaire, which is not universally accepted as a method for estimating dietary micronutrient intake.48 Therefore, we cannot exclude the possibility that using other methods might generate different findings. Finally, our sample consisted of women only, so our findings cannot be generalized to men.
CONCLUSIONS Taking the dietary intake of a group of healthy elderly females as an example, our study suggests that current RDAs for riboflavin, vitamins B-6, and folic acid for adults generally are appropriate for older women, while for vitamins B-12, A, and C, it might be wise to consider recommending intakes higher than the present RDAs. Be that as it may, a greater overall intake of these vitamins should be encouraged, and can be achieved by choosing foods rich in vitamins and minerals and low in calories; for example, vegetables, fruits, and whole-grain cereals.
References 1.
Marshall TA, Stumbo PJ, Warren JJ, et al. Inadequate nutrient intakes are common and are associated with low diet variety in rural, community-dwelling elderly. J Nutr. 2001;131(8):2192-2196.
2.
Ryan AS, Craig LD, Finn SC. Nutrient intakes and dietary patterns of older Americans: A national study. J Gerontol. 1992;47(5):M145M150.
3.
Cid-Ruzafa J, Caulfield LE, Barrón Y, et al. Nutrient intakes and adequacy among an older population on the eastern shore of Maryland: The Salisbury Eye Evaluation. J Am Diet Assoc. 1999;99(5):564-571.
4.
Chernoff R. Micronutrient requirements in older women. Am J Clin Nutr. 2005;81(5):1240S-1245S.
8
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
--
2015 Volume
-
Number
-
RESEARCH 30.
Dumartheray EW, Krieg MA, Cornuz J, et al. Energy and nutrient intake of Swiss women aged 75-87 years. J Hum Nutr Diet. 2006;19(6):431-435.
39.
Kjeldby IK, Fosnes GS, Ligaarden SC, et al. Vitamin B6 deficiency and diseases in elderly people—A study in nursing homes. BMC Geriatr. 2013;8:13.
31.
Fritz K, Elmadfa I. Quality of nutrition of elderly with different degrees of dependency: Elderly living in private homes. Ann Nutr Metab. 2008;52(suppl 1):47-50.
40.
32.
Volkert D, Kreuel K, Heseker H, et al. Energy and nutrient intake of young-old, old-old and very-old elderly in Germany. Eur J Clin Nutr. 2004;58(8):1190-1200.
Qin X, Huo Y, Xie D, et al. Homocysteine-lowering therapy with folic acid is effective in cardiovascular disease prevention in patients with kidney disease: A meta-analysis of randomized controlled trials. Clin Nutr. 2012;32(5):722-727.
41.
Hinterberger M, Fischer P. Folate and Alzheimer: When time matters. J Neural Transm. 2013;120(1):211-224.
33.
Luo J, Shen L, Zheng D. Association between vitamin C intake and lung cancer: A dose-response meta-analysis. Sci Rep. 2014;4: 6161.
42.
Kennedy DA, Stern SJ, Matok I, et al. Folate intake, MTHFR polymorphisms, and the risk of colorectal cancer: A systematic review and meta-analysis. J Cancer Epidemiol; 2012:952508.
34.
Powers HJ. Riboflavin (vitamin B-2) and health. Am J Clin Nutr. 2003;77(6):1352-1360.
43.
Viñas BR, Barba LR, Ngo J, et al. Projected prevalence of inadequate nutrient intakes in Europe. Ann Nutr Metab. 2011;59(2-4):84-95.
35.
Dai Z, Wang R, Ang LW, et al. Dietary B vitamin intake and risk of hip fracture: The Singapore Chinese Health Study. Osteoporos Int. 2012;24(7):2049-2059.
44.
Glusman M. The syndrome of burning feet (nutritional melalgia) as a manifestation of nutritional deficiency. Am J Med. 1947;3(2):211-223.
45.
36.
Bailey AL, Maisey S, Southon S, et al. Relationships between micronutrient intake and biochemical indicators of nutrient adequacy in a ‘free-living’ elderly UK population. Br J Nutr. 1997;77(2): 225-242.
Bender DA. Optimum nutrition: Thiamine, biotin and pantothenate. Proc Nutr Soc. 1999;58(2):427-433.
46.
Harper C. Thiamine (vitamin B1) deficiency and associated brain damage is still common throughout the world and prevention is simple and safe!. Eur J Neurol. 2006;13(10):1078-1082.
37.
Spinneker A, Sola R, Lemmen V, et al. Vitamin B6 status, deficiency and its consequences—An overview. Nutr Hosp. 2007;22(1):7-24.
47.
38.
Joosten E, van den BA, Riezler R, et al. Metabolic evidence that deficiencies of vitamin B-12 (cobalamin), folate, and vitamin B-6 occur commonly in elderly people. Am J Clin Nutr. 1993;58(4): 468-476.
Sette S, Le Donne C, Piccinelli R, et al; INRAN-SCAI 2005-6 Study Group. The third Italian National Food Consumption Survey, INRANSCAI 2005-06-part 1: Nutrient intakes in Italy. Nutr Metab Cardiovasc Dis. 2011;21(12):922-932.
48.
Block G. Human dietary assessment: Methods and issues. Prev Med. 1989;18(5):653-660.
AUTHOR INFORMATION F. Bolzetta is a medical doctor, N. Veronese is a PhD student, M. De Rui is a medical doctor, L. Berton is a medical doctor, E. D. Toffanello is a medical doctor, S. Carraro is a medical doctor, F. Miotto is a dietist, E. M. Inelmen is a researcher, E. Manzato is a full professor, A. Coin is a medical doctor, and G. Sergi is a medical doctor, Department of Medicine, DIMED, Geriatrics Section, and E. Perissinotto is an associate professor, Department of Cardiac, Thoracic and Vascular Sciences, all at the University of Padova, Italy. L. M. Donini is a full professor, Department of Experimental Medicine, Medical Physiopathology, Food Science and Endocrinology Section, Sapienza University of Rome, Italy. Address correspondence to: Nicola Veronese, MD, Department of Medicine (DIMED), Geriatrics Section, University of Padova, Italy. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT There is no funding to disclose.
--
2015 Volume
-
Number
-
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
9
Original Research
Are the Recommended Dietary Allowances for Vitamins Appropriate for Elderly People? Francesco Bolzetta, MD; Nicola Veronese, MD; Marina De Rui, MD; Linda Berton, MD; Elena Debora Toffanello, MD; Sara Carraro, MD; Fabrizia Miotto, RD*; Eminè Meral Inelmen, MD; Lorenzo Maria Donini, MD; Enzo Manzato, MD; Alessandra Coin, MD; Egle Perissinotto, ScD; Giuseppe Sergi, PhD, MD ARTICLE INFORMATION Article history: Submitted 27 July 2014 Accepted 10 April 2015
Keywords: Vitamins Recommended Dietary Allowances (RDA) Micronutrient Older people 2212-2672/Copyright ª 2015 by the Academy of Nutrition and Dietetics. http://dx.doi.org/10.1016/j.jand.2015.04.013 *
Certified in Italy.
ABSTRACT Background An adequate vitamin intake is essential for a good nutritional status, especially in older women, who are more sensitive to nutritional deficiencies. The American, European and Italian Recommended Dietary Allowances (RDAs) derive mainly from studies on adults, and it is not clear whether they also apply to elderly people. Comparing the RDAs with the actual vitamin intake of a group of healthy older women could help to clarify the real needs of elderly people. Objective Our aim was to compare the American, European, and Italian RDAs with the actual vitamin intake of a group of healthy older women. Design This was a cross-sectional study. Participants The study included 286 healthy women aged older than 65 years. Main outcome measures For each micronutrient, the 50th percentile of the distribution of its intake was considered as the average requirement, and the corresponding calculated RDA for our sample was the average requirement1.2, as recommended by the US Food and Nutrition Board. This calculated RDA was then compared with the American, European, and Italian RDAs. Statistical analyses performed Student’s t test or the Mann-Whitney test (after checking the normal distribution of the micronutrient) for continuous variables; the c2 test for categorical variables. Results The calculated RDA were 2,230 mg retinol equivalents for vitamin A, 2.8 mg for vitamin B-12, 0.9 mg for thiamin, 1.4 mg for riboflavin, 3.6 mg for pantothenic acid, 1.4 mg for vitamin B-6, 320 mg for folic acid, and 115 mg for vitamin C. Conclusions Our findings suggest that the current RDAs are adequate for older women’s intake of riboflavin, vitamin B-6, and folic acid, but should be raised for vitamin B-12 and for vitamin C. J Acad Nutr Diet. 2015;-:---.
N
UTRITION IN OLDER PEOPLE IS A TOPIC OF growing interest because good nutritional status is associated with successful aging, lower susceptibility to disease, better cognitive and physical performance, and quality of life. An inadequate dietary intake of energy foods and micronutrients, such as folate, calcium, zinc and vitamins D and B-6 has been reported in community-dwelling people older than 60 years of age.1-3 Older women, in particular, seem to ingest smaller amounts of food than men, making them more susceptible to deficiencies in the main micronutrients.4 The appropriateness of people’s nutritional intake is generally estimated by comparing their actual intake of a given nutrient with the corresponding Recommended Dietary Allowance (RDA), which is an indicator of the amount that most individuals in a population need to ingest to meet their body’s need. For many nutrients, an adequate intake is also confirmed by physiologic and biohumoral indices. The European Union has developed its own RDAs, based on values proposed by its Member States, but no specific values ª 2015 by the Academy of Nutrition and Dietetics.
are recommended for older people.5,6 The US Food and Nutrition Board and the Italian Society of Human Nutrition have published RDAs for older people, but for several micronutrients they are essentially the same as for younger adults.6,7 The lack of specific RDAs for older people is also due to the fact that physiologic changes in aging make longitudinal studies on nutrient requirements very difficult to interpret, consequently limiting research on this topic. Aging entails variations in metabolic processes, physical functioning, body composition and food absorption, and physiological aging, frailty, comorbidities, and polypharmacy can interfere with people’s nutritional needs.8 An inadequate micronutrient status is associated with higher morbidity and frailty in elderly people, and might be due to the inappropriate use of medication as well as dietary issues.9 As a result, the nutritional requirements of elderly people (and older women in particular) may differ from those of younger adults in many respects. The European Food Safety Authority has established average requirements based on the intake of a nutrient that JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1
RESEARCH suffices for half of the people in a healthy population group. These average requirements can be used to estimate daily nutritional requirements with the aid of an equation developed by the US Food and Nutrition Board.6 The aim of the present study was to compare the American, European, and Italian RDAs with the values calculated from the average daily intake of a group of free-living, healthy, and still physically active older women.
MATERIALS AND METHODS Subjects The study was conducted at the Geriatrics Section of Padova University in 2010 and 2011. We recruited 324 women on a voluntary basis from among those older than 65 years of age attending a twice-weekly fitness program of aerobic and resistance exercises at public gyms in Padova. Participants were approached in person by members of our team. Their clinical condition was ascertained by trained physicians from their clinical history and a clinical examination. Individuals with severe cardiovascular or pulmonary diseases, metabolic diseases, cancer, and inflammatory conditions were ruled out. Any use of drugs (eg, corticosteroids or hormones) that might interfere with body composition was also a reason for exclusion. Only individuals with a Mini Mental State Examination score >24 were considered. The final study sample comprised 286 women who met these inclusion and exclusion criteria. A blood sample was drawn after overnight fasting for routine biochemical tests (albumin, glucose, and electrolyte concentrations, renal and liver function tests, and a complete blood count). The normal values for albumin10 (a commonly used indicator of protein nutrition) at our laboratory are between 35 and 45 g/L. The Institutional Review Board of Padova (Italy) approved the study protocol and all participants provided written informed consent. The study was designed in accordance with the Helsinki Declaration.
Study Design All patients underwent the following tests: 1.
2.
2
Anthropometric measurements: Body weight was measured to the nearest 0.1 kg and height to the nearest 0.1 cm using a standard balance and stadiometer (Seca) with subjects wearing light clothing and no shoes. Body mass index (BMI) was calculated as their weight in kilograms divided by their height in meters squared. The reference standards for BMI were those proposed by the World Health Organization.11 Body composition: Fat-free mass (FFM) and fat mass were ascertained by dual-energy x-ray absorptiometry using fan-beam technology (Hologic QDR 4500 W). An FFM index was calculated as the ratio between FFM and height in meters squared. The values of our population were compared with the FFM index calculated for the Italian population, taking the interquartile range as a reference for assuming normality.12 The dual-energy x-ray absorptiometry method has good reproducibility in measuring softtissue composition, producing consistent results in elderly people also.13
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
3.
Dietary assessment: Individuals’ food intake was recorded by the same dietitian using a modified dietary assessment method consisting of an eating frequency questionnaire14: Each patient was asked to report the frequency with which they had habitually eaten a given food in the previous 6 months. Portion sizes were assumed to coincide with standard portion sizes from an illustrated food atlas15 or they were weighed. The usual food intake was converted into macronutrients and micronutrients using a national food composition table.16 The EUROCODE system was used to arrange the foods into groups and subgroups based on their origin, composition, and function in the diet.17 The method’s validation has been reported elsewhere.18
Data Interpretation Certain criteria were taken into account in our comparison between the American and European RDAs and our sample’s actual micronutrient intake. Given our population’s characteristics (eg, no major diseases, independence in activities of daily living, and no known nutritional problems), we assumed that these women could be considered as a model of appropriate nutrition in elderly people. We identified the 50th percentile of each micronutrient’s distribution and considered this value as the average requirement. Then we obtained an RDA calculated for our women using the equation recommended by the US Food and Nutrition Board6 using the formula: calculated RDA¼average requirements1.2. This calculated RDA was then compared with the American, European, and Italian RDAs. We considered the calculated RDA to be similar if it was within a difference of 10% for the recommendation suggested by each Society.
Statistical Analysis Data were analyzed using SPSS for Windows, release 19.0 (2010, SPSS Inc), expressing the results as meansstandard deviations or percentages, as appropriate. Differences in proportions and means of covariates by age (younger than 70 years and 70 years and older) were assessed with Student’s t test or the Mann-Whitney test after checking the normal distribution of the micronutrient. The cumulative frequencies of consumption of each vitamin by the population as a whole, and the corresponding percentile values were computed to describe the distribution of the vitamins in detail. The percentages of subjects with vitamin deficiencies were estimated by comparing the individual intakes with the European RDAs. In all analyses, P<0.05 was considered statistically significant.
RESULTS Thirty-eight subjects were excluded because 12 were newly diagnosed with diabetes, 10 used cortisone at the time of enrollment, 6 used hormonal preparation, and 6 scored <24 on the Mini Mental State Examination. Mean age of our study population was 71.14.7 years (range¼65 to 84 years), and mean BMI was 27.023.82. In the sample as a whole, 23% of participants were obese, with a BMI >30. None of the participants had serum albumin <35 g/L. Table 1 shows the sample’s anthropometric characteristics, and the women’s daily energy and macronutrient --
2015 Volume
-
Number
-
RESEARCH Table 1. Anthropometric features, biohumoral characteristics, and daily energy and macronutrient intake in a cohort of 286 community-dwelling healthy older women in Italy Whole group (n[286)
Aged <70 y (n[111)
Aged ‡70 y (n[175)
P valuea
meanstandard deviation! Body mass index
27.023.82
26.613.57
27.273.95
0.15
Weight, kg
65.929.76
66.369.40
65.649.99
0.55
Fat mass, %
37.315.29
36.685.39
37.705.19
0.12
Fat-free mass index
16.692.19
16.892.20
16.372.14
0.05
Albumin, g/L
43.71.9
43.51.7
43.82.0
0.20
Energy, kcal
1,513.66357.90
1,535.56322.83
1,499.77378.72
0.39
Proteins, g Proteins/weight, g/kg Carbohydrate, g
55.2513.20
56.8011.48
54.2614.13
0.11
0.860.25
0.870.21
0.850.28
0.46
204.6159.55
207.2554.12
202.9362.85
0.54
Fat, g
50.3716.61
51.2612.61
49.8018.72
0.43
Dietary fiber, g
16.624.84
16.574.81
16.654.88
0.89
Alcohol, g
10.0311.79
10.2211.88
0.74
9.7411.68
P values were obtained using Student’s t test for independent samples.
a
intake by age group. Mean calorie intake was 1,513.66357.9 kcal, and 50.8% of these calories came from carbohydrates, 30% from fats, and 14.1% from proteins. There were no significant differences between the younger than 70 years and the 70 years and older age groups; daily energy intake (P¼0.39); carbohydrate, protein, or fat intake (P¼0.54, P¼0.11, and P¼0.43, respectively). There were also no significant differences between the two age groups’ BMI (P¼0.15) or mean weight (P¼0.55). Mean micronutrient intake in the sample as a whole only reached the corresponding European RDAs for vitamins A, C, B-12, and B-6 (Table 2). When the women were divided by age, the intakes of riboflavin (P¼0.02) and vitamin B-6 (P¼0.05) were lower in the older group. Table 2 also shows the percentile distribution for the intake of each micronutrient by age group. The Figure shows the cumulative frequencies of the whole sample’s vitamin intake. For vitamins A and C and folic acid, most of our sample reached the European RDAs (86% for vitamin A, 62% for vitamin C, and 82% for folic acid), and a large proportion of the sample fell below the recommended intake of B-group vitamins (93% of the women for thiamin, 74% for riboflavin, 99% for vitamin B-5, and 59% for vitamin B-12). The American, European, Italian, and our own RDAs (calculated as suggested by the US Food and Nutrition Board) are compared in Table 3. Our calculated RDA for older people proved very similar to the American, European, and Italian values for riboflavin and vitamin B-6, and for vitamin C, vitamin B-12, and especially vitamin A, our calculated RDA was higher than the one generally recommended for adults. Our RDAs calculated for pantothenic acid and thiamin were below the levels suggested by the European Union and the Italian Italian Society of Human Nutrition, while our calculated RDA for folic acid was higher than the European, but lower than the Italian and American RDAs. --
2015 Volume
-
Number
-
DISCUSSION Our study compared the RDAs for micronutrients published by the US Food and Nutrition Board, the European Union, and the Italian Society of Human Nutrition in Italy with those calculated from the intake of a group of fit and healthy older women. Mean BMI of our sample indicated that they were often overweight, with about one in four participants with a BMI between 30 and 35. It is common knowledge that this anthropometric parameter is not very reliable in elderly people, however, because it fails to take changes typical of aging into account and such measures have rarely been derived from populations that included a sufficient proportion of elderly individuals. This impression is supported by the fact that the mean fat mass and FFM values of our sample were consistent with the 50th percentile of a large group of older Italian women.12 The mean BMI of our sample also coincides with the lowest mortality risk group, according to a previous Italian study on older people.19 Finally, none of the participants had protein malnutrition, judging from their serum albumin levels. All these data confirm that our sample had good nutritional status.
Vitamins for Which Our RDA Calculated Was Higher than the American, European Union, and Italian RDAs Vitamin A. This vitamin is important for normal vision, cell differentiation, and efficient immune function.4 Only 13% of our sample had an intake below the RDA for vitamin A (800 mg retinol equivalents [RE]/day), a finding consistent with previous studies. In the SENECA (Survey Europe on Nutrition in the Elderly: A Concerted Action) study, for instance, the prevalence of vitamin A deficiency was near 0 at baseline (1988 to 1989) and remained so after 4 years of follow up.20 Our calculated RDA was 2,230 mg RE/day, much higher than JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
3
RESEARCH Table 2. Daily vitamin intake and some relevant percentiles (5th, 25th, 50th, and 75th) in a cohort of 286 community-dwelling healthy older women in Italy
Vitamin
Whole group (n[286)
Aged <70 y (n[111)
Aged ‡70 y (n[175)
2,185.231,466.91
2,258.781,422.1
2,138.571,496.79
P valuea
Vitamin A, mg REb Mean intakeSDc Percentile 5th
303.66
459.91
285.26
25th
1,121.99
1,216.25
1,034.11
50th
1,857.13
2,019.37
1,771.69
75th
2,902.59
3,013.17
2,873.08
2.762.13
3.031.93
2.592.23
Vitamin B-12 (cobalamin), mg Mean intakeSD
0.08
Percentile 5th
0.80
0.90
0.76
25th
1.43
1.63
1.36
50th
2.31
2.50
2.11
75th
3.36
3.74
2.87
Thiamin, mg Mean intakeSD
0.770.22
0.790.23
0.750.22
0.11
Percentile 5th
0.45
0.46
0.44
25th
0.62
0.66
0.60
50th
0.75
0.79
0.73
75th
0.89
0.94
0.89
Riboflavin, mg Mean intakeSD
1.190.35
1.260.37
1.150.33
0.02
Percentile 5th
0.70
0.76
0.67
25th
0.96
0.98
0.95
50th
1.19
1.21
1.12
75th
1.41
1.47
1.36
Pantothenic acid (B-5), mg Mean intakeSD
3.090.98
3.200.99
3.020.97
0.13
Percentile 5th
1.65
1.66
1.64
25th
2.39
2.68
2.32
50th
3.04
3.13
3.01
75th
3.69
3.81
3.60
Pyridoxine (B-6), mg Mean intakeSD
1.390.68
1.490.68
1.330.68
0.05
Percentile 5th
0.68
0.75
0.65
25th
1.00
1.10
0.93 (continued on next page)
4
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
--
2015 Volume
-
Number
-
RESEARCH Table 2. Daily vitamin intake and some relevant percentiles (5th, 25th, 50th, and 75th) in a cohort of 286 community-dwelling healthy older women in Italy (continued)
Vitamin
Whole group (n[286)
Aged <70 y (n[111)
Aged ‡70 y (n[175)
50th
1.21
1.26
1.18
75th
1.56
1.67
1.49
P valuea
Folic acid, mg Mean intakeSD
279.43112.13
291.22109.68
271.95113.33
0.15
Percentile 5th
119.42
129.71
117.02
25th
205.62
217.51
195.63
50th
265.53
276.18
249.97
75th
334.79
356.59
334.19
Vitamin C, mg Mean intakeSD
111.8469.39
119.7465.53
106.8371.47
0.12
Percentile 5th
29.82
38.77
21.95
25th
64.48
74.16
57.45
50th
96.00
104.37
92.70
75th
149.04
148.90
149.46
P values obtained by analysis of variance between age groups using Student’s t test on independent samples. RE¼retinol equivalents. SD¼standard deviation.
a
b c
the recommendations of the European Union and Italian Society of Human Nutrition for adults generally. This finding is also consistent with other studies: in a sample of 212 Brazilian older adults, vitamin A intake ranged between 1,112.20 mg RE/day for the 25th percentile and 2,430.80 mg RE/day for the 75th percentile.21 Similar results were reported for American adults.4 However, because the literature has shown that older people’s livers are less able to clear vitamin A toxins,22,23 it remains to be seen whether the RDA should be raised in this population.
Vitamin B-12. Judging from the European RDA (2.5 mg/day), about 59% of our sample had an inadequate vitamin B-12 intake. This vitamin is essential to the development and normal functioning of the central nervous system. The interaction between folate and vitamin B-12 is responsible for the megaloblastic anemia seen in deficiencies of both these micronutrients.24 A decline in gastric acid secretion due to type B chronic atrophic gastritis is the main cause of vitamin B-12 deficiency in elderly people. Older women also tend to have a lower consumption of foods rich in vitamin B12, particularly animal proteins, possibly because they are expensive and difficult to chew.25 This attitude probably contributes to deficiency in other vitamins belonging to the B family. Bacterial overgrowth in the gut can also be a factor responsible for reducing the bioavailability of vitamin B-12.4 Given these premises, the RDA of this vitamin for older women should be higher than for adults generally in the attempt to override the lower absorption typical of old age. In --
2015 Volume
-
Number
-
fact, our calculated RDA for vitamin B-12 was 2.8 mg/day, which is higher than the European, American, and Italian Society of Human Nutrition RDAs. Data in the literature are not consistent: while low vitamin B-12 intake was also reported in another Italian study on elderly patients,26 a daily consumption higher than the RDA (about 5.3 mg/day) was identified in a multicenter European study on older women.27
Vitamin C. Vitamin C is a co-factor in the hydroxylation reactions needed for collagen synthesis. Vitamin C also plays an important part in maintaining antioxidant protection,28 and consequently in preventing atherosclerosis, cancer, senile cataracts, and degenerative diseases.4 Given the high prevalence of such diseases in older people, vitamin C requirements are believed to increase with age, particularly in smokers.4,29 Based on our sample, we calculated an RDA of 115 mg vitamin C, which is higher than the recommendations of all three boards considered for comparison. Judging from the dietary intake of vitamin C in our sample, about 38% of the women failed to reach our calculated RDA. This finding is probably due to the limited use of raw vegetables and fruits rich in vitamin C that is typical of older age.25 Dumartheray and colleagues30 found the 64.3% of Swiss women remained below the RDA, and Fritz and colleagues31 demonstrated that vitamin C deficiency increased with age among Austrian elderly people, affecting 30% of women older than 84 years of age. Although we saw no sign of any reduction in vitamin C JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
5
RESEARCH
6 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS --
2015 Volume -
Number -
Figure. Cumulative frequencies of vitamin consumption levels in a cohort of 286 community-dwelling healthy older women in Italy.
RESEARCH Table 3. Comparison between American, European, and Italian Recommended Dietary Allowances with those calculated in a cohort of 286 community-dwelling healthy older women in Italy Micronutrient
US RDAab
European RDA
SINUc RDA
RDAcd
Vitamin A, mg REe
700
800
600
2,230
Cobalamin (B-12), mg
2.4
2.5
2.4
2.8
Thiamin, mg
1.1
1.1
1.1
0.9
Riboflavin, mg
1.1
1.4
1.3
1.4
Pantothenic acid (B-5), mg
5
6
5
3.6
Pyridoxine (B-6), mg
1.5
1.4
1.5
1.4
Folic acid, mg
400
200
400
320
Vitamin C, mg
7
80
85
115
a
RDA¼Recommended Dietary Allowance. US RDA for women >70 years old. c SINU¼Società Italiana di Nutrizione Umana. d RDAc¼ Recommended Dietary Allowance calculated; average requirement1.2. e RE¼retinol equivalents. b
intake between our two age groups, Volkert and colleagues32 reported finding that mean vitamin C intake decreased with age, from 151.91 mg/day in young old people to 129.33 mg/ day in those older than 75 years old. Here again, the RDA for this vitamin could be raised, given that the related toxicity is very rare4 and, as recently suggested by a recent metaanalysis, higher vitamin C intake is linearly associated with a lower lung cancer risk.33
Vitamins for Which Our RDA Calculated Was Similar to the American, European Union, and Italian Society of Human Nutrition RDAs Riboflavin. Our calculated RDA for this vitamin was 1.4 mg/ day, exactly the same as what the European Union recommends for adults, but slightly higher than the American RDA. In our sample, however, 74% of the women did not reach a riboflavin intake of 1.4 mg/day. They also revealed a significant age-related decline in riboflavin consumption, from 1.26 mg/day in people younger than 70 years to 1.15 mg/day in those older than 70 years (P¼0.02). Riboflavin is particularly important in a number of redox reactions and it is believed to be involved in protecting against cancer and cardiovascular diseases.34 The mean daily riboflavin intake in our population was 1.19 mg, which is quite similar to the 1.3 mg/day found in two previous studies on older women. Dai and colleagues35 reported a mean riboflavin intake of 0.9 mg/day in a group of >34,000 women aged older than 50 years,35 while a study concerning elderly women in the United Kingdom found a mean riboflavin intake of 1.6 mg/day.36
Vitamin B-6 (Pyridoxine). Vitamin B-6 has antioxidant properties, and vitamin B-6 deficiency has been associated with several negative neurologic and cardiovascular outcomes.37 About 67% of the women in our sample had a vitamin B-6 intake below the European RDA (1.4 mg/day) (Figure). Population studies in the literature have generated conflicting data on the prevalence of vitamin B-6 deficiency,38 possibly --
2015 Volume
-
Number
-
because some of these studies did not consider the oldest old. Our calculated RDA for this vitamin was 1.4 mg/day. Recent studies have suggested, however, that even an apparently adequate B-6 intake may not suffice to guarantee normal plasma levels in elderly people, probably due to its lower absorption, higher catabolism, and impaired phosphorylation.39 Given these premises, the higher RDA adopted by the US Food and Nutrition Board and the Italian Society of Human Nutrition for older women (ie, a daily intake of 1.5 mg), could be appropriate for older women, too.
Folate. Low folate levels have been associated with a higher risk of cardiovascular disease, multiple cancers, and neurodegeneration.40,41 About 18% of our sample had a folic acid intake lower than the European RDA (200 mg/day), a finding at odds with a recent European survey that reported a much higher prevalence of inadequate folic acid intake, involving as many as 33.7% of men and 45.9% of women in some countries. On the other hand, the mean daily intake identified across the various countries was similar to that of our population.42 The calculated RDA from our population’s intake was 320 mg/day, higher than the European RDA for adults. Our suggestion that the European RDA for folic acid be raised is consistent with the recommendations of the US Food and Nutrition Board.6
Vitamins for Which Our RDA Calculated was Lower than the American, European, and Italian Society of Human Nutrition RDAs Vitamin B-5 (Pantothenic Acid). Virtually none of the women in our sample reached the vitamin B-5 intake recommended by the European Union.43 Pantothenic acid deficiency is practically unknown, if we disregard the so-called burning feet syndrome (ie, nutritional melalgia) in severely malnourished prisoners of war in the Far East, which was often attributed to pantothenate deficiency.44 Pantothenate is involved in acetate metabolism, cholesterol, and steroid synthesis, and the acetylation of drugs.45 Our calculated RDA for this vitamin was 3.6 mg/day. To our knowledge, only one JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
7
RESEARCH study has been published on vitamin B-5 intake in elderly people, in which Maisey and colleagues26 found a mean daily intake of 3.18 mg pantothenate in older women, which is consistent with our finding of a mean intake of 3.09 mg. Given the absence of any clinically relevant deficiency in our population, and the findings proposed by literature, we surmise that a lower pantothenic acid intake would suffice in healthy older women.
5.
Commission Directive 2008/100/EC. Official Journal of the European Union. 2008; http://eur-lex.europa.eu/LexUriServ/LexUriServ.do? uri¼OJ:L:2008:285:0009:0012:EN:PDF. Accessed July 15, 2014.
6.
Institute of Medicine. Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals. Washington, DC: Food and Nutrition Board, Institute of Medicine; 2004.
7.
Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione Italiana. Società Italiana di Nutrizione Umana. 2013. http://www.sinu.it/pubblicazioni.asp. Accessed July 15, 2014.
8.
Sergi G, De Rui M, Sarti S, et al. Polypharmacy in the elderly: Can comprehensive geriatric assessment reduce inappropriate medication use? Drugs Aging. 2011;28(7):509-518.
9.
Fabian E, Bogner M, Kickinger A, Wagner KH, Elmadfa I. Intake of medication and vitamin status in the elderly. Ann Nutr Metab. 2011;58(2):118-125.
10.
Bonjour JP, Schurch MA, Rizzoli R. Nutrition aspects of hip fractures. Bone. 1996;18(3 suppl):139S-144S.
11.
Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894(i-xii): 1-253.
12.
Coin A, Sergi G, Minicuci N, et al. Fat-free mass and fat mass reference values by dual-energy x-ray absorptiometry (DEXA) in a 20-80 year-old Italian population. Clin Nutr. 2008;27(1):87-94.
13.
Baumgartner RN, Stauber PM, McHugh D, et al. Cross-sectional age differences in body composition in persons 60þ years of age. J Gerontol A Biol Sci Med Sci. 1995;50(6):M307-M316.
14.
Coates RJ, Monteilh CP. Assessments of food-frequency questionnaires in minority populations. Am J Clin Nutr. 1997;65(4 suppl): 1108S-1115S.
15.
Turconi G, Roggi C. Atlante Fotografico Alimentare. Rome, Italy: EMSI; 2007.
16.
Carnovale E, Miuccio FC. Tabelle Di Composizione Degli Alimenti. Rome, Italy: Ministry of Agriculture and National Institute of Nutrition; 1989.
17.
Kohlmeier L, Pootvliet EJ. EUROCODE 2 Food Coding System, version 92/1. Berlin, Germany: Institute for Social Medicine and Epidemiology; 1992.
18.
Nes M, van Staveren WA, Zajkas G, et al. Euronut SENECA study on nutrition and the elderly. Validity of the dietary history method in elderly subjects. Eur J Clin Nutr. 1991;45(suppl 3):S97-S104.
19.
Sergi G, Perissinotto E, Pisent C, et al. An adequate threshold for body mass index to detect underweight condition in elderly persons: The Italian Longitudinal Study on Aging (ILSA). J Gerontol A Biol Sci Med Sci. 2005;60(7):866-871.
20.
Haller J, Weggemans RM, Lammi-Keefe CJ, et al. Changes in the vitamin status of elderly Europeans: Plasma vitamins A, E, B-6, B-12, folic acid and carotenoids. SENECA Investigators. Eur J Clin Nutr. 1996;50(suppl 2):S32-S46.
21.
Carmem-Costa-do-Nascimento C, Cristhine-Pordeus-de-Lima R, RiosAsciutti LS, et al. The importance of habitual vitamin A dietary intake on the serum retinol concentration in the elderly: A population-based study. Rev Invest Clin. 2011;63(5):450-460.
22.
Russell RM. The vitamin A spectrum: From deficiency to toxicity. Am J Clin Nutr. 2000;71(4):878-884.
23.
Suter PM, Russell RM. Vitamin requirements of the elderly. Am J Clin Nutr. 1987;45(3):501-512.
24.
Stabler SP. Clinical practice. Vitamin B12 deficiency. N Engl J Med. 2013;368(2):149-160.
25.
Rothenberg E, Ekman S, Bülow M, et al. Texture-modified meat and carrot products for elderly people with dysphagia: Preference in relation to health and oral status. Scand J Food Nutr. 2007;51(4):141-147.
26.
Maisey S, Loughridge J, Southon S, et al. Variation in food group and nutrient intake with day of the week in an elderly population. Br J Nutr. 1995;73(3):359-373.
27.
Olsen A, Halkjaer J, van Gils CH, et al. Dietary intake of the watersoluble vitamins B1, B2, B6, B12 and C in 10 countries in the European Prospective Investigation into Cancer and Nutrition. Eur J Clin Nutr. 2009;63(suppl 4):S122-S149.
28.
Honarbakhsh S, Schachter M. Vitamins and cardiovascular disease. Br J Nutr. 2009;101(8):1113-1131.
29.
Heseker H, Schneider R. Requirement and supply of vitamin C, E and beta-carotene for elderly men and women. Eur J Clin Nutr. 1994;48(2):118-127.
Thiamin. The most common clinical setting for thiamin deficiency is alcoholism and a poor diet.46 In our sample, 93% of the women had a thiamin intake below the European RDA (1.1 mg/day), with a mean of 0.77 mg/day. This is lower than in other published reports: Sette and colleagues47 found a mean daily thiamin intake of 0.86 mg, for instance, in a group of 136 non-institutionalized Italian elderly women, while it was 0.84 mg in a cohort of older Japanese women, and 1 mg/ day in a large, pan-European multicenter study on older people.27 Our calculated RDA was consequently only 0.9 mg/ day. Although our sample population showed no signs of thiamin deficiency, we consider an RDA of 1.1 mg/day (as indicated by the US Food and Nutrition Board, Italian Society of Human Nutrition, and European Union) appropriate for older women, also in the light of the other studies mentioned.
Limitations Our findings should be considered with the limitations of our study in mind. The main limitation lies in that we did not take serum or biochemical parameters into account (this would have been beyond the aim of our work) for our calculated RDA. Another limitation lies in that we used only one dietary questionnaire, a food frequency questionnaire, which is not universally accepted as a method for estimating dietary micronutrient intake.48 Therefore, we cannot exclude the possibility that using other methods might generate different findings. Finally, our sample consisted of women only, so our findings cannot be generalized to men.
CONCLUSIONS Taking the dietary intake of a group of healthy elderly females as an example, our study suggests that current RDAs for riboflavin, vitamins B-6, and folic acid for adults generally are appropriate for older women, while for vitamins B-12, A, and C, it might be wise to consider recommending intakes higher than the present RDAs. Be that as it may, a greater overall intake of these vitamins should be encouraged, and can be achieved by choosing foods rich in vitamins and minerals and low in calories; for example, vegetables, fruits, and whole-grain cereals.
References 1.
Marshall TA, Stumbo PJ, Warren JJ, et al. Inadequate nutrient intakes are common and are associated with low diet variety in rural, community-dwelling elderly. J Nutr. 2001;131(8):2192-2196.
2.
Ryan AS, Craig LD, Finn SC. Nutrient intakes and dietary patterns of older Americans: A national study. J Gerontol. 1992;47(5):M145M150.
3.
Cid-Ruzafa J, Caulfield LE, Barrón Y, et al. Nutrient intakes and adequacy among an older population on the eastern shore of Maryland: The Salisbury Eye Evaluation. J Am Diet Assoc. 1999;99(5):564-571.
4.
Chernoff R. Micronutrient requirements in older women. Am J Clin Nutr. 2005;81(5):1240S-1245S.
8
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
--
2015 Volume
-
Number
-
RESEARCH 30.
Dumartheray EW, Krieg MA, Cornuz J, et al. Energy and nutrient intake of Swiss women aged 75-87 years. J Hum Nutr Diet. 2006;19(6):431-435.
39.
Kjeldby IK, Fosnes GS, Ligaarden SC, et al. Vitamin B6 deficiency and diseases in elderly people—A study in nursing homes. BMC Geriatr. 2013;8:13.
31.
Fritz K, Elmadfa I. Quality of nutrition of elderly with different degrees of dependency: Elderly living in private homes. Ann Nutr Metab. 2008;52(suppl 1):47-50.
40.
32.
Volkert D, Kreuel K, Heseker H, et al. Energy and nutrient intake of young-old, old-old and very-old elderly in Germany. Eur J Clin Nutr. 2004;58(8):1190-1200.
Qin X, Huo Y, Xie D, et al. Homocysteine-lowering therapy with folic acid is effective in cardiovascular disease prevention in patients with kidney disease: A meta-analysis of randomized controlled trials. Clin Nutr. 2012;32(5):722-727.
41.
Hinterberger M, Fischer P. Folate and Alzheimer: When time matters. J Neural Transm. 2013;120(1):211-224.
33.
Luo J, Shen L, Zheng D. Association between vitamin C intake and lung cancer: A dose-response meta-analysis. Sci Rep. 2014;4: 6161.
42.
Kennedy DA, Stern SJ, Matok I, et al. Folate intake, MTHFR polymorphisms, and the risk of colorectal cancer: A systematic review and meta-analysis. J Cancer Epidemiol; 2012:952508.
34.
Powers HJ. Riboflavin (vitamin B-2) and health. Am J Clin Nutr. 2003;77(6):1352-1360.
43.
Viñas BR, Barba LR, Ngo J, et al. Projected prevalence of inadequate nutrient intakes in Europe. Ann Nutr Metab. 2011;59(2-4):84-95.
35.
Dai Z, Wang R, Ang LW, et al. Dietary B vitamin intake and risk of hip fracture: The Singapore Chinese Health Study. Osteoporos Int. 2012;24(7):2049-2059.
44.
Glusman M. The syndrome of burning feet (nutritional melalgia) as a manifestation of nutritional deficiency. Am J Med. 1947;3(2):211-223.
45.
36.
Bailey AL, Maisey S, Southon S, et al. Relationships between micronutrient intake and biochemical indicators of nutrient adequacy in a ‘free-living’ elderly UK population. Br J Nutr. 1997;77(2): 225-242.
Bender DA. Optimum nutrition: Thiamine, biotin and pantothenate. Proc Nutr Soc. 1999;58(2):427-433.
46.
Harper C. Thiamine (vitamin B1) deficiency and associated brain damage is still common throughout the world and prevention is simple and safe!. Eur J Neurol. 2006;13(10):1078-1082.
37.
Spinneker A, Sola R, Lemmen V, et al. Vitamin B6 status, deficiency and its consequences—An overview. Nutr Hosp. 2007;22(1):7-24.
47.
38.
Joosten E, van den BA, Riezler R, et al. Metabolic evidence that deficiencies of vitamin B-12 (cobalamin), folate, and vitamin B-6 occur commonly in elderly people. Am J Clin Nutr. 1993;58(4): 468-476.
Sette S, Le Donne C, Piccinelli R, et al; INRAN-SCAI 2005-6 Study Group. The third Italian National Food Consumption Survey, INRANSCAI 2005-06-part 1: Nutrient intakes in Italy. Nutr Metab Cardiovasc Dis. 2011;21(12):922-932.
48.
Block G. Human dietary assessment: Methods and issues. Prev Med. 1989;18(5):653-660.
AUTHOR INFORMATION F. Bolzetta is a medical doctor, N. Veronese is a PhD student, M. De Rui is a medical doctor, L. Berton is a medical doctor, E. D. Toffanello is a medical doctor, S. Carraro is a medical doctor, F. Miotto is a dietist, E. M. Inelmen is a researcher, E. Manzato is a full professor, A. Coin is a medical doctor, and G. Sergi is a medical doctor, Department of Medicine, DIMED, Geriatrics Section, and E. Perissinotto is an associate professor, Department of Cardiac, Thoracic and Vascular Sciences, all at the University of Padova, Italy. L. M. Donini is a full professor, Department of Experimental Medicine, Medical Physiopathology, Food Science and Endocrinology Section, Sapienza University of Rome, Italy. Address correspondence to: Nicola Veronese, MD, Department of Medicine (DIMED), Geriatrics Section, University of Padova, Italy. E-mail: [email protected]
STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT There is no funding to disclose.
--
2015 Volume
-
Number
-
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
9