A Randomized Controlled Trial to Examine the Effect of 2-Year Vitamin B12 and Folic Acid Supplementation on Physical Performance, Strength, and Falling: Additional Findings from the B-PROOF Study

Cardio-metabolic-related plasma proteins reveal biological links between cardiovascular diseases and fragility fractures: a cohort and Mendelian randomisation investigation

BACKGROUND

How cardiovascular diseases (CVD) predispose to a higher risk of fragility fractures is not well understood. Both contribute to significant components of disease burden and health expenditure. Poor bone quality, central obesity, sarcopenia, falls, and low grip strength are independent risk factors for hip and other fragility fractures and also for CVD and early death.

METHODS

We used proteomics and a cohort design combined with Mendelian randomisation analysis to understand shared mechanisms for developing CVD and fragility fractures, two significant sources of disease burden and health expenditure. We primarily aimed to discover and replicate the association of 274 cardio-metabolic-related proteins with future rates of hip and any fracture in two separate population-based cohorts, with a total of 12,314 women and men.

FINDINGS

The average age at baseline was 68 years in the discovery cohort of women and 74 years in the mixed-sex replication cohort. During 100,619 person-years of follow-up, 2168 had any fracture, and 538 had a hip fracture. Our analysis resulted in 24 cardiometabolic proteins associated with fracture risk: 20 with hip fracture, 9 with any fracture, and 5 with both. The associations remained even if protein concentrations were measured from specimens taken during preclinical stages of cardio-metabolic diseases, and 19 associations remained after adjustment for bone mineral density. Twenty-two of the proteins were associated with total body fat mass or lean body mass. Mendelian randomisation (MR) analysis supported causality since genetically predicted levels of SOST (Sclerostin), CCDC80 (Coiled-coil domain-containing protein 80), NT-proBNP (N-terminal prohormone brain natriuretic peptide), and BNP (Brain natriuretic peptide) were associated with risk of hip fracture. MR analysis also revealed a possible negative impact on bone mineral density (BMD) by genetically predicted higher levels of SOST, CCDC80, and TIMP4 (Metalloproteinase inhibitor 4). The MR association with BMD was positive for PTX3 (Pentraxin-related protein) and SPP1 (Osteopontin). Genetically predicted higher concentrations of SOST and lower concentrations of SPP1 also conferred a higher risk of falls and lowered grip strength. The genetically determined concentration of nine proteins influenced fat mass, and one influenced lean body mass.

INTERPRETATION

These data reveal biological links between cardiovascular diseases and fragility fractures. The proteins should be further evaluated as shared targets for developing pharmacological interventions to prevent fractures and cardiovascular disease.

FUNDING

The study was supported by funding from the Swedish Research Council (https://www.vr.se; grants No. 2015-03257, 2017-00644, 2017-06100, and 2019-01291 to Karl Michaëlsson) and funding from Olle Engkvist Byggmästares stiftelse (SOEB).

Vitamin B12 status and skeletal muscle function among elderly: A literature review and pilot study on the effect of oral vitamin B12 supplementation in improving muscle function

Objectives

The objective of this study is to understand the role of vitamin B12 supplementation in improving skeletal muscle function among the elderly.

Methods

A literature review in the Medline database was conducted to understand the association between vitamin B12 and muscle function in Section A. In Section B, 28 healthy elderly participants aged ≥60 years were recruited in a cross-sectional design for estimation of plasma vitamin B12 status and assessment of upper limb muscle strength Maximal voluntary contraction (MVC) and muscle quality (expressed as MVC/total muscle mass). Participants were grouped based on vitamin B12 status into vitamin B12-depleted (<148 pmol/L) and replete (≥148 pmol/L) groups. In a quasi-experimental study design, the vitamin B12-depleted group (n = 14) received daily oral vitamin B12 supplementation of 100 μg for 3 months. All the study measures were repeated post-supplementation.

Results

Vitamin B12 deficiency was identified to contribute adversely to muscle strength, quality, and physical performance among older people in the extensive literature review. The pilot intervention study showed significant improvement in MVC and muscle quality (p < 0.050) post-vitamin B12 supplementation, comparable to the vitamin B12-replete group.

Conclusions

Vitamin B12 may have a crucial role in the maintenance of muscle function. 3-month oral vitamin B12 supplementation among subclinical vitamin B12 deficient elderly improved muscle strength and quality and reached levels similar to the vitamin B12 replete group.

The role of plasma concentrations and drug characteristics of beta-blockers in fall risk of older persons

Beta-blocker usage is inconsistently associated with increased fall risk in the literature. However, due to age-related changes and interindividual heterogeneity in pharmacokinetics and dynamics, it is difficult to predict which older adults are more at risk for falls. Therefore, we wanted to explore whether elevated plasma concentrations of selective and nonselective beta-blockers are associated with an increased risk of falls in older beta-blocker users. To answer our research question, we analyzed samples of selective (metoprolol, n = 316) and nonselective beta-blockers (sotalol, timolol, propranolol, and carvedilol, n = 179) users from the B-PROOF cohort. The associations between the beta-blocker concentration and time to first fall were assessed using Cox proportional hazard models. Change of concentration over time in relation to fall risk was assessed with logistic regression models. Models were adjusted for potential confounders. Our results showed that above the median concentration of metoprolol was associated with an increased fall risk (HR 1.55 [1.11-2.16], p = .01). No association was found for nonselective beta-blocker concentrations. Also, changes in concentration over time were not associated with increased fall risk. To conclude, metoprolol plasma concentrations were associated with an increased risk of falls in metoprolol users while no associations were found for nonselective beta-blockers users. This might be caused by a decreased β1-selectivity in high plasma concentrations. In the future, beta-blocker concentrations could potentially help clinicians estimate fall risk in older beta-blockers users and personalize treatment.

Associations between Serum Folate Concentrations and Functional Disability in Older Adults

Folate may have beneficial effects on physical function through its antioxidant effect. Thus, we investigated the associations between serum folate and functional disability in older adults. Data from the National Health and Nutrition Examination Survey 2011–2018 were used. Serum folate included 5-methyltetrahydrofolate and total folate. Five domains of functional disability, including lower extremity mobility (LEM), instrumental activities of daily living (IADL), activities of daily living (ADL), leisure and social activities (LSA), and general physical activities (GPA), were self-reported. Multivariable-adjusted logistic regression models and restricted cubic splines were employed. 5-Methyltetrahydrofolate was inversely associated with IADL and GPA disability, and the multivariate-adjusted ORs (95% CIs) in the highest versus lowest quartiles were 0.65 (0.46–0.91) and 0.70 (0.50–0.96), respectively. The total folate was also inversely associated with IADL (OR quartile 4vs1 = 0.65, 95% CI: 0.46–0.90) and GPA (OR quartile 3vs1 = 0.66, 95% CI: 0.44–0.99) disability. The dose–response relationships showed a gradual decrease in the risk of IADL and GPA disability as serum folate increased. In the sex, age, BMI, and alcohol consumption subgroup analyses, we saw that the associations were primarily found in females, under 80 years old, normal weight, and non-drinkers. Sensitivity analyses further confirmed the robustness of our results. Our results indicated that serum folate concentrations were negatively associated with IADL and GPA disability, especially in females. In other subgroup analyses, we discovered that these negative associations were primarily prevalent in participants under 80 years old, normal weight, and non-drinkers.

Are higher antidepressant plasma concentrations associated with fall risk in older antidepressant users?

PURPOSE

Antidepressants are well-established fall-risk increasing drugs (FRIDs) and therefore falls should be considered an important adverse drug event (ADE) of antidepressants. However, not all antidepressant users experience fall incidents and factors associated with increased fall risk among antidepressant users are incompletely understood. Our objective was to explore whether antidepressant plasma concentrations are associated with falls in older antidepressant users.

METHODS

For this study, we included antidepressant users of the multicenter B-PROOF study. Fall incidents were recorded prospectively using fall calendars. Antidepressant plasma concentrations were analyzed by Liquid chromatography-mass spectrometry (LC-MS) at baseline and at 2 years follow-up. The associations between the observed antidepressant concentration and fall risk were assessed using Cox proportional hazard and logistic regression models and adjusted for potential confounders.

RESULTS

In total 93 selective serotonin reuptake inhibitor (SSRI) and 41 antidepressant (TCA) users were identified. There was a significant association between baseline TCA plasma concentration and fall risk within users (HR 2.50, 95% CI 1.07-5.87, crude model). In the adjusted model, there were no significant associations between concentrations of SSRIs and fall risk.

CONCLUSION

There might be an association between plasma concentrations of TCAs and the risk of falling in older users. However, these results needs to be interpreted with caution considering the small sample size and accompanying limitation of confinement to crude analyses. Therefore, these novel findings need to replicated in a larger cohort, preferably including adjustment for potential confounders and more frequent measures of plasma concentrations is needed.

Relationship between hyperhomocysteinemia and coexisting obesity with low skeletal muscle mass in asymptomatic adult population

The relationship between hyperhomocysteinemia (HHcy) and obesity with low skeletal muscle mass (LMM) has not been established. We aim to assess the association between HHcy and the coexistence of obesity and LMM in asymptomatic adult population. We conducted a population-based cross-sectional study among asymptomatic individuals who underwent measurements of plasma homocysteine and body composition analysis. HHcy was defined as > 15 umol/L, obesity as body mass index ≥ 25 (kg/m²), and LMM as skeletal muscle index less than 2 SD below the sex-specific mean of young adults. The participants were classified into ‘control’, ‘obesity alone’, ‘LMM alone’, and ‘obesity with LMM’. Among 113,805 participants, the prevalence of HHcy was 8.3% in control, 8.7% in obesity alone, 10.0% in LMM alone, and 13.0% in obesity with LMM (p for trend < 0.001). In a multivariable logistic regression analysis, the associations showed a positive trend for HHcy along the groups from obesity alone, to LMM alone, and to obesity with LMM. HHcy was independently associated with the presence of LMM alone (adjusted odds ratio 1.186 [95% confidence interval 1.117–1.259]) and obesity with LMM (1.424 [1.134–1.788]), respectively. This study demonstrated that HHcys was more strongly associated with coexistence of obesity and LMM than either condition alone in the adult population.

Causal effects of homocysteine levels on the components of sarcopenia: A two-sample mendelian randomization study

Background: Currently, it is unclear whether there is a causal association between genetically predicted plasma homocysteine (Hcy) levels and the risk of sarcopenia. We performed a Mendelian randomization (MR) study to assess the association between circulating Hcy levels and the components [grip strength, walking pace, and appendicular lean mass (ALM)] of sarcopenia. Methods: Independent single nucleotide polymorphisms (SNPs) significantly associated with plasma Hcy levels served as instrumental variables. Summary-level data regarding the components of sarcopenia. Were obtained from the UK Biobank. Inverse variance weighted (IVW) as the primary method was used for Mendelian randomization (MR) analysis. We also use four models, weighted median, MR-Egger regression, Maximum likelihood, and Penalised weighted median, as supplementary methods to IVW. The MR-Egger intercept test, Cochran's Q test, and "leave-one-out" sensitivity analysis were performed to evaluate the horizontal pleiotropy, heterogeneities, and stability of the causal association between Hcy levels and the components of sarcopenia. Results: The IVW-MR analysis suggested significant negative associations of increased plasma Hcy levels with grip strength (right: effect = -0.036, SE = 0.032, p = 5.53E-4; left: effect = -0.045, SE = 0.010, p = 1.45E-5), walking pace (effect = -0.038, SE = 0.011, p = 3.18E-4), and ALM (effect = -0.058, 0.013, p = 1.03E-5). However, there were no significant associations of decreased plasma Hcy levels with grip strength (right: effect = 0.005, SE = 0.021, p = 0.82; left: effect = -0.006, SE = 0.014, p = 0.64), walking pace (effect = 0.01, 0.020, p = 0.61), or ALM (effect = -0.034, SE = 0.018, p = 0.06).The accuracy and robustness of these findings were confirmed by sensitivity tests. Conclusion: Increased circulating Hcy levels were associated with lower grip strength, slower walking pace, and decreased ALM.

Association of vitamin and/or nutritional supplements with fall among patients with diabetes: A prospective study based on ACCORD and UK Biobank

Aims

To assess the associations of vitamin and/or nutritional supplements (VNS) with falls among patients with diabetes.

Methods

9,141 and 21,489 middle-aged participants with diabetes from Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial and UK Biobank were included. Use of VNS was collected at baseline, and fall events were recorded using annual questionnaires in ACCORD and electric records in UK Biobank during follow-up. The associations of VNS use with fall risk were analyzed using logistic regression models in ACCORD and Fine-Gray sub-distribution hazard models in UK Biobank. The role of specific supplements was also estimated in UK Biobank, adjusting for confounding factors and multiple comparisons.

Results

45.9% (4,193/9,141, 5.5 median follow-up years) patients in ACCORD and 10.5% (2,251/21,489, 11.9 median follow-up years) in UK Biobank experienced fall and in-patient events during follow-up, respectively. In ACCORD, VNS using was associated with an increased risk of fall (full-adjusted odds ratio [OR]: 1.26, P < 0.05). In UK Biobank, despite no significant association between VNS overall and in-patient fall, vitamin B, calcium, and iron using increased the risk of falls significantly (full-adjusted hazard ratio range: 1.31-1.37, P < 0.05).

Conclusions

Use of specific VNS increased the risk of fall among patients with diabetes. The non-indicative use of nutritional supplements for patients with diabetes might be inadvisable.

Folic Acid Is Related to Muscle Strength and Vitamin A Is Related to Health-Related Quality of Life: Results of the Korea National Health and Nutrition Examination Survey (KNHANES VII 2016-2018)

This study investigated how folic acid affects muscle strength and the effects of vitamin A on quality of life in adults. Baseline data from the Korea National Health and Nutrition Examination Survey (KNHANES VII 2016–2018) was used to find 6112 adults (ages 19–80) meeting study criteria. The participants were divided into three groups: young adults (ages 19–39), middle-aged (ages 40–64), and elderly (≥65 years). Muscle strength was measured using a digital grip strength dynamometer. The EuroQol five-dimension questionnaire measured quality of life. Associations were assessed using multivariate regression and logistic regression. Vitamins and handgrip strength were divided into low and high groups based on the mean. Although vitamin A and folate levels were related to handgrip strength in all subjects, regression demonstrated a significant association between folate and handgrip strength in the elderly. The odds ratios (OR) of higher handgrip strength were statistically significant for elderly participants with high levels of folate compared to those with low levels (OR: 1.55). Vitamin A was associated with quality of life, especially in the self-care dimension for the elderly. Further longitudinal research is needed to examine the relationship between vitamins and muscle strength, as well as vitamins and quality of life.

Retraction

Li, J., Tong, D., Wang, Y., Liu, Y., Zhang, X., Liu, N., Wang, S., Xu, Y., Li, Y., Yin, X., Liu, W. and Shao, Y. (2021), Neutrophil extracellular traps enhance procoagulant activity in patients with essential hypertension. J Thromb Haemost. https://doi.org/10.1111/jth.15210 The above article, published online on 12 December 2020 on Wiley Online Library (wileyonlinelibrary.com), has been retracted by mutual agreement among the authors, the journal co- Editors-in-Chief, David Lillicrap, MD, FRCPC and James Morrissey, PhD, the International Society on Thrombosis and Haemostasis, and Wiley Periodicals LLC The retraction has been issued due to unattributed overlap between this article and the following article published in Thrombosis Research, "Neutrophil extracellular traps exacerbate coagulation and endothelial damage in patients with essential hypertension and hyperhomocysteinemia" by Li, J-H, Tong, D-X, Wang, Y, Gao, L, Liu, Y, Zhang, X-H, Chen, W-J, Chi, J-Y, Liu N, Yang, K, Wang, S-P, Xu, Y, Li, Y, Yin, X-H, Liu, W-X. Volume 197, 2021, pages 36-43. https://doi.org/10.1016/j.thromres.2020.10.028.

A Propensity Score Matched Approach to Assess the Associations of Commonly Prescribed Medications with Fall Risk in a Large Harmonized Cohort of Older Ambulatory Persons

Introduction

Several medication classes are considered to present risk factors for falls. However, the evidence is mainly based on observational studies that often lack adequate adjustment for confounders. Therefore, we aimed to assess the associations of medication classes with fall risk by carefully selecting confounders and by applying propensity score matching (PSM).

Methods

Data from several European cohorts, harmonized into the ADFICE_IT cohort, was used. Our primary outcome was time until the first fall within 1-year follow-up. The secondary outcome was a fall in the past year. Our exposure variables were commonly prescribed medications. We used 1:1 PSM to match the participants with reported intake of specific medication classes with participants without. We constructed Cox regression models stratified by the pairs matched on the propensity score for our primary outcome and conditional logistic regression models for our secondary outcome.

Results

In total, 32.6% of participants fell in the 1-year follow-up and 24.4% reported falling in the past year. ACE inhibitor users (prevalence of use 15.3%) had a lower fall risk during follow-up when matched to non-users, with a hazard ratio (HR) of 0.82 (95% CI 0.68–0.98). Also, statin users (prevalence of use 20.1%) had a lower risk, with an HR of 0.76 (95% CI 0.65–0.90). Other medication classes showed no association with risk of first fall. Also, in our secondary outcome analyses, statin users had a significantly lower risk. Furthermore, β-blocker users had a lower fall risk and proton pump inhibitor use was associated with a higher risk in our secondary outcome analysis.

Conclusion

Many commonly prescribed medication classes showed no associations with fall risk in a relatively healthy population of community-dwelling older persons. However, the treatment effects and risks can be heterogeneous between individuals. Therefore, focusing on identification of individuals at risk is warranted to optimize personalized falls prevention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00876-0.

The relationship between serum folate and grip strength in American adults

We used data from NHANES to explore the associations between serum folate and grip strength, and found that high levels of serum folate were associated with increased grip strength among females rather than males. It is recommended to maintain a proper level of serum folate, especially in women.

PURPOSE

Associations and dose-response relationships between serum total folate, 5-methyltetrahydrofolate, and grip strength in general adults were unknown. Thus, we conducted this analysis for further exploration.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) database of 2011-2014 cycle were used. The independent variables including serum total folate, combined total folate (total folate plus Mefox), and 5-methyltetrahydrofolate. The dependent variable was BMI-corrected grip strength. Linear regression and the restricted cubic splines were used in our analyses.

RESULTS

A total of 9079 adults aged over 20 years were included. In multivariate-adjusted model 2, compared with quartile (Q) 1, grip strength increased in Q3 of combined total folate and total folate, and the weighted β values with 95% confidence intervals (CIs) of grip strength were 0.06 (0.01, 0.12) and 0.06 (0.00, 0.10) for combined total folate and total folate, respectively. In the stratified analysis by gender, positive relationships between combined total folate, total folate, and 5-methyltetrahydrofolate and grip strength were found only in females, with β (95% CIs) of 0.07 (0.02, 0.12), 0.07 (0.03, 0.12), and 0.09 (0.05, 0.13) for combined total folate, total folate, and 5-methyltetrahydrofolate in Q4, respectively. Non-linear positive dose-response relationships between serum folate and grip strength were also found only in females, not in males.

CONCLUSION

Our study suggested a positive association between serum folate and grip strength, while this positive association was only found in females; besides, the dose-response relationships were in a non-linear trend. Thus, it is recommended to maintain a proper serum folate level to keep better muscle strength, especially for women.

Perspective: Practical Approach to Preventing Subclinical B12 Deficiency in Elderly Population

Vitamin B12 (also known as cobalamin) is an essential water-soluble vitamin that plays a pivotal role for several physiologic functions during one's lifespan. Only certain microorganisms are able to synthetize B12, thus humans obtain cobalamin exclusively from their diet, specifically from animal-derived foods. Specific sub-group populations are at risk of vitamin B12 subclinical deficiency due to different factors including poor intake of animal source foods and age-dependent decrease in the capacity of intestinal B12 uptake. Consumption of animal products produces some negative health issues and negatively impacts sustainability while a plant-based diet increases the risk of B12 deficiency. Taking a cue from the aforementioned considerations, this narrative review aims to summarize facts about B12 deficiency and the burden of inadequate dietary intake in elderly population, as well as to discuss sustainable approaches to vitamin B12 deficiency in aging population.

Micronutrients and sarcopenia: current perspectives

Sarcopenia, a skeletal muscle disorder that is characterised by loss of muscle strength and mass, is common in older populations and associated with poorer health outcomes. Although the individual and economic costs of sarcopenia are widely recognised, current understanding of its pathophysiology is incomplete, limiting efforts to translate research evidence into effective preventive and treatment strategies. While nutrition is a key field of sarcopenia research, the role of differences in habitual diets, and the effectiveness of dietary change as a prevention or treatment strategy, is uncertain. There is a growing evidence base that links low micronutrient intakes to sarcopenia risk and/or its components (low muscle strength and mass, impaired physical performance), although there remain many gaps in understanding. There is some consistency in findings across studies highlighting potential roles for antioxidant nutrients, B vitamins and magnesium; however, the evidence is largely observational and from cross-sectional studies, often describing associations with different muscle outcomes. As low intakes of some micronutrients are common in older populations, there is a need for new research, particularly from well-characterised prospective cohorts, to improve the understanding of their role and importance in the aetiology of sarcopenia and to generate the evidence needed to inform dietary guidelines to promote muscle health.

Risk factors for high fall risk in elderly patients with chronic kidney disease

PURPOSE

Patients with chronic kidney disease (CKD) usually represent an aging population, and both older age and CKD are associated with a higher risk of falling. Studies on risk factors among subjects with CKD are lacking.

METHODS

Records of outpatients from one geriatric clinic in Turkey were retrospectively reviewed. A result of ≥ 13.5 s on the timed up and go (TUG) test was accepted as a high risk of falls. Independent predictors of an increased risk of falls among subjects with CKD (estimated glomerular filtration rate of < 60 mL/min/1.73 m²) were identified using logistic regression models.

RESULTS

Patients with CKD (n = 205), represented the 20.2% of the entire cohort and was identified as an independent predictor of increased fall risk (OR 2.59). Within the CKD cohort, serum folic acid levels and frailty were independent predictors of an increased risk of falls. The CKD/fall risk group was older, had a lower median years of education, lower vitamin D levels, and lower serum folic acid levels than the CKD/non-fall risk group. In addition to higher serum creatinine and potassium levels, the only significant difference between patients with CKD/fall risk and a matched non-CKD/fall risk was a lower median folic acid level in the former group.

CONCLUSIONS

Frailty and low folic acid levels are independently associated with an increased risk of falls among elderly outpatients with CKD. Prevention of frailty may reduce the risk of falls in these subjects. Possible benefit of folic acid supplementation requires further studies.

Sarcopenia and homocysteine: is there a possible association in the elderly? A narrative review

BACKGROUND

Sarcopenia (SA) is a progressive skeletal muscle disorder, associated with increased risk of adverse outcomes, including falls, fractures, physical disability and mortality. Several risks factors may contribute to the development of SA in the elderly; among them, nutrition plays a key role in muscle health. The elderly are at risk of inadequate intake in terms of micronutrients affecting muscle homeostasis, such as B vitamins, related to homocysteine (Hcy) metabolism.

OBJECTIVES AND METHODS

This narrative review analysed the association between increased Hcy levels and SA, according to the criteria of the International Working Group on Sarcopenia, the European Working Group on Sarcopenia in Older People and the Asian Working Group for Sarcopenia. The authors focused not only on SA per se but also on exploring the association between increased Hcy levels and components of SA, including muscle mass, muscle strength and physical performance.

RESULTS

Results are inconsistent, except for muscle mass, showing no significant associations with Hcy levels.

CONCLUSIONS

Few and conflicting data emerged in this review on the association between SA and increased Hcy levels due to numerous differences between studies that change the significance of the association of Hcy and SA, as well as the muscle strength, muscle mass and physical performance. Furthermore, because the ageing process is not uniform in the population owing to differences in genetics, lifestyle and general health, chronological age fails to address the observed heterogeneity among the 'elderly' of the studies reported in this revision. Therefore, further studies are still needed.

Neutrophil extracellular traps exacerbate coagulation and endothelial damage in patients with essential hypertension and hyperhomocysteinemia

Patients with essential hypertension (EH) and hyperhomocysteinemia (HHCY) suffer from more increased thrombotic events than those in EH alone. However, the underlying mechanisms for this effect are not well understood. This study hypothesized that neutrophil extracellular trap (NET) releasing may be triggered by HHCY in patients in EH, thereby predisposing them to a more hypercoagulable state. Using a modified-capture enzyme-linked immunosorbent assay (ELISA) method, we observed that cell-free DNA (CF-DNA) and myeloperoxidase DNA (MPO-DNA) in patients With EH and HHCY were significantly higher. The NET formation was also positively correlated with homocysteine levels, neutrophil-lymphocyte ratio (NLR), and hypercoagulable markers (thrombin-antithrombin complex, D-dimers). Furthermore, neutrophils from patients in EH with HHCY were found to be predisposed to amplified NET release when compared to patients in EH without HHCY or CTR. Coagulation function assays showed that NETs in patients With EH and HHCY resulted in a significantly increased ability to generate thrombin and fibrin than in those in EH without HHCY or CTR. These procoagulant effects of NETs in patients With EH and HHCY were markedly inhibited (approximately 70%) by the cleavage of NETs with DNase I. Isolated NETs from patients With EH and HHCY neutrophils also exerted a strong cytotoxic effect on endothelial cells (ECs), converted them to apoptosis. This study revealed a previously unrecognized association between the hypercoagulable state and neutrophils in patients With EH and HHCY. Therefore, blocking NETs may represent a new therapeutic objective for preventing thrombosis in these patients.

Association between frailty and vitamin B12 in the older Korean population

Frailty is a common geriatric condition due to aging and defined as a decline in strength and a decrease in the physiologic ability to maintain the homeostasis. Vitamin B12 (B12), water-soluble vitamins, are a cofactor in DNA synthesis and involved in the metabolism of every cell in the human body, including the central nervous system. Demyelination neuromuscular symptoms observed in the peripheral nervous system, along with signs of significant damage to nerve fibers, often cause weakness, numbness in distal limbs, impaired balance, gait ataxia, and even physical frailty. In this cross-sectional study, we aimed to investigate the relationship between frailty and B12 level in community-dwelling Korean older adults.Using the data from the Korean Frailty and Aging Cohort Study, 2938 participants (1400 men and 1538 women) were recruited in this study. To evaluate frailty, we compared the frail group and not-frail group based on the modified Korean version of the cardiovascular health study frailty index developed by Fried. SARC-F is used to screen for sarcopenia. The short physical performance battery (SPPB) timed up and go (TUG) test and activities-specific balance confidence scale used to evaluate the physical function and fall risk of participants. B12 concentrations were classified into clinically relevant categories: insufficient (<350 pg/mL) and sufficient (≥350 pg/mL). Linear and logistic regression analyses were used to evaluate the relationship between frailty and B12 levels.The mean age of the frail group was 77.8 (standard deviation = 3.7) years, while that of the not-frail group was 76.7 (SD = 4.0); of which the frail group's mean age was significantly high. In the unadjusted model, frailty was highly prevalent in the B12 insufficient group (odds ratio = 1.298). In the model fully adjusted for demographic data and comorbidities, these associations were attenuated. The B12 sufficiency group showed better total SPPB and TUG test scores. However, they were not statistically significant in the fully adjusted model.In this cross-sectional study, low B12 increased the incidence of frailty and affected physical performance, but it does not increase the incidence of frailty when considering the confounding factors. Frailty is caused by several factors rather than 1 factor, and B12 is one of these factors.

Homocysteine: Its Possible Emerging Role in At-Risk Population Groups

Increased plasma homocysteine is a risk factor for several pathological disorders. The present review focused on the role of homocysteine (Hcy) in different population groups, especially in risk conditions (pregnancy, infancy, old age), and on its relevance as a marker or etiological factor of the diseases in these age groups, focusing on the nutritional treatment of elevated Hcy levels. In pregnancy, Hcy levels were investigated in relation to the increased risk of adverse pregnancy outcomes such as small size for gestational age at birth, preeclampsia, recurrent abortions, low birth weight, or intrauterine growth restriction. In pediatric populations, Hcy levels are important not only for cardiovascular disease, obesity, and renal disease, but the most interesting evidence concerns study of elevated levels of Hcy in autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). Finally, a focus on the principal pathologies of the elderly (cardiovascular and neurodegenerative disease, osteoporosis and physical function) is presented. The metabolism of Hcy is influenced by B vitamins, and Hcy-lowering vitamin treatments have been proposed. However, clinical trials have not reached a consensus about the effectiveness of vitamin supplementation on the reduction of Hcy levels and improvement of pathological condition, especially in elderly patients with overt pathologies, suggesting that other dietary and non-dietary factors are involved in high Hcy levels. The importance of novel experimental designs focusing on intra-individual variability as a complement to the typical case-control experimental designs and the study of interactions between different factors it should be emphasized.

The association between apathy, decline in physical performance, and falls in older persons

BACKGROUND

Symptoms of apathy are common in older persons. Negative effects on physical performance and fall risk are plausible, considering the pathophysiology of apathy. However, literature is scarce.

AIM

To longitudinally assess the association between apathy and (1) decline of physical performance and (2) the number of falls in older community-dwelling persons.

METHODS

The 'B vitamins for the PRevention Of Osteoporotic Fractures' study provided data on 2919 older persons over a period of 2 years. Apathy was assessed using the Geriatric Depression Scale 3. A physical performance score (PPS) was calculated using three performance tests. Falls were registered prospectively. We calculated adjusted odds ratios (ORs), Incidence Rate Ratios (IRRs), and their 95% confidence intervals. Effect modification by age and gender was investigated. We also investigated mediation by baseline PPS for the association between apathy and the number of falls.

RESULTS

Apathy and decline of PPS were independently associated. After stratification, the effect only remained in men. Age was an effect modifier; higher ORs for decreasing age. Apathy was also independently associated with the number of falls. After stratification, women had higher IRRs than men. Age modified the association in the opposite direction: higher IRRs for increasing age. Baseline PPS was a mediator in the association.

CONCLUSION

The impact of apathy on physical performance and fall incidents varied with age and gender. Potentially, in older individuals with apathy, fall risk is preceded by a decline in physical performance. In clinical practice, identifying apathy in older persons might be useful to target mobility preserving interventions.

Combining a high DHA multi-nutrient supplement with aerobic exercise: Protocol for a randomised controlled study assessing mobility and cognitive function in older women

There is a complex interplay between cognition and gait in older people, with declines in gait speed coexisting with, or preceding cognitive decline. Omega-3 fatty acids, B vitamins, vitamin E, phosphatidylserine, and Ginkgo Biloba show promise in preserving mobility and cognitive function in older adults. Exercise benefits mobility and there is evidence suggesting positive interactions between exercise and omega-3 fatty acids on physical and cognitive function in older adults. Non-frail or pre-frail females aged ≥60 years are included in a randomized placebo controlled study. Intervention groups are: high DHA multi-nutrient supplement and exercise, placebo supplement and exercise, high DHA multi-nutrient supplement, and placebo supplement. Dietary supplementation is 24 weeks. The exercise intervention, two cycle ergometer classes per week, is for the final 12 weeks. The primary outcome is habitual walking speed, secondary outcomes include gait variables under single and dual task, five times sit to stand, verbal and spatial memory, executive function, interference control and health related quality of life. Blood fatty acids, serum homocysteine, dietary intake, physical activity, and verbal intelligence are measured to assess compliance and control for confounding factors. The study is registered at www.clinicaltrials.gov (NCT03228550).

Relationship between Homocysteine and Muscle Strength Decline: The Baltimore Longitudinal Study of Aging

Background

Decreased muscle strength is strongly associated with future mobility limitations in older adults. Homocysteine is a risk factor for vascular disease and may exacerbate muscle strength decline. The present study aimed to examine the association between homocysteine levels and muscle strength in adults aged 50 years or older.

Methods

Data were from 1,101 participants of The Baltimore Longitudinal Study of Aging between December 2004 and March 2015. Muscle strength was measured using grip strength. Mixed effects linear regression was used to estimate the association between homocysteine and muscle strength in men and women, separately.

Results

Total mean follow-up time was 4.7 ± 3.1 years, range from 0 to 10.1 years. Baseline mean grip strength was 39.9 kg for men and 25.5 kg for women. Grip strength declined over the follow-up time for both men and women. Among women, there was a significant inverse relationship between homocysteine and grip strength, where grip strength declined as a function of increasing homocysteine over time (β = -0.05, p = .031). Among men, an increase of 1 μmol/L in homocysteine was associated with -0.10 kg decrease in grip strength, though not significantly.

Conclusions

In this study of healthy older adults aged 50 years or older, higher homocysteine was related to lower muscle strength in women. This is the first study to characterize the relationship over a long follow-up period. Future research should focus on assessing homocysteine as a marker of physical function decline and translating the relationship into clinical and public health practice.

Selected B vitamins and their possible link to the aetiology of age-related sarcopenia: relevance of UK dietary recommendations

The possible roles of selected B vitamins in the development and progression of sarcopenia are reviewed. Age-related declines in muscle mass and function are associated with huge and increasing costs to healthcare providers. Falls and loss of mobility and independence due to declining muscle mass/function are associated with poor clinical outcomes and their prevention and management are attractive research targets. Nutritional status appears a key modifiable and affordable intervention. There is emerging evidence of sarcopenia being the result not only of diminished anabolic activity but also of declining neurological integrity in older age, which is emerging as an important aspect of the development of age-related decline in muscle mass/function. In this connection, several B vitamins can be viewed as not only cofactors in muscle synthetic processes, but also as neurotrophic agents with involvements in both bioenergetic and trophic pathways. The B vitamins thus selected are examined with respect to their relevance to multiple aspects of neuromuscular function and evidence is considered that requirements, intakes or absorption may be altered in the elderly. In addition, the evidence base for recommended intakes (UK recommended daily allowance) is examined with particular reference to original datasets and their relevance to older individuals. It is possible that inconsistencies in the literature with respect to the nutritional management of sarcopenia may, in part at least, be the result of compromised micronutrient status in some study participants. It is suggested that in order, for example, for intervention with amino acids to be successful, underlying micronutrient deficiencies must first be addressed/eliminated.

Vitamin B12 deficiency and impaired expression of amnionless during aging

BACKGROUND

Physical frailty and loss of mobility in elderly individuals lead to reduced independence, quality of life, and increased mortality. Vitamin B12 deficiency has been linked to several age-related chronic diseases, including in the musculo-skeletal system, where vitamin B12 deficiency is generally believed to be linked to poor nutritional intake. In the present study, we asked whether aging and frailty associate with altered vitamin B12 homeostasis in humans and investigated the underlying molecular mechanisms using preclinical models.

METHODS

We analysed a subset of the Singapore Longitudinal Aging Study and stratified 238 participants based on age and Fried frailty criteria. Levels of methyl-malonic acid (MMA), a marker for vitamin B12 deficiency, and amnionless, the vitamin B12 co-receptor that anchors the vitamin B12 transport complex to the membrane of epithelial cells, were measured in plasma. In addition, vitamin B12 levels and the molecular mechanisms of vitamin B12 uptake and excretion were analysed in ileum, kidney, liver, and blood using a rat model of natural aging where nutritional intake is fully controlled.

RESULTS

We demonstrate that aging and frailty are associated with a higher prevalence of functional vitamin B12 deficiency that can be detected by increased levels of MMA in blood (ρ = 0.25; P = 0.00013). The decline in circulating vitamin B12 levels is recapitulated in a rat model of natural aging where food composition and intake are stable. At the molecular level, these perturbations involve altered expression of amnionless in the ileum and kidney. Interestingly, we demonstrate that amnionless can be detected in serum where its levels increase during aging in both rodents and human (P = 3.3e-07 and 9.2e-07, respectively). Blood amnionless levels negatively correlate with vitamin B12 in rats (r²  = 0.305; P = 0.0042) and positively correlate with the vitamin B12 deficiency marker MMA in humans (ρ = 0.22; P = 0.00068).

CONCLUSIONS

Our results demonstrate that aging and frailty cause intrinsic vitamin B12 deficiencies, which can occur independently of nutritional intake. Mechanistically, vitamin B12 deficiency involves the physio-pathological decline of both the intestinal uptake and the renal reabsorption system for vitamin B12. Finally, amnionless is a novel biomarker which can detect perturbed vitamin B12 bioavailability during aging and physical frailty.

Role of Water Soluble Vitamins in the Reduction Diet of an Amateur Sportsman

This study is aimed at determining the content of water soluble vitamins in amateur sportsmen before and after the use of reduction diet. Twenty adult male amateur sportsmen aged between 20 and 43 qualified for this study. The participants adhered to individually adjusted reduction diets for 3 months. Diet supplements were excluded from the diet during that time. Vitamins were analyzed before and after the reduction diet using HPLC. The following vitamins were analyzed: B1, B2, B3, PP, B5, B6, B7, B9, B12 and vitamin C. Statistically significant increase of riboflavin in blood plasma (p=0.0254) and statistically significant (p=0.048) decrease in the concentration of niacin was found when compared to the period before the diet. Appropriate level of riboflavin can be obtained by the consumption of proper amount of diary in the diet. Supplementation with PP is advised and, in case of improper diet, the supplementation of B1, B7 and B12 may also be considered.

Beta-blocker use and fall risk in older individuals: Original results from two studies with meta-analysis

AIMS

To investigate the association between use of β-blockers and β-blocker characteristics - selectivity, lipid solubility, intrinsic sympathetic activity (ISA) and CYP2D6 enzyme metabolism - and fall risk.

METHODS

Data from two prospective studies were used, including community-dwelling individuals, n = 7662 (the Rotterdam Study) and 2407 (B-PROOF), all aged ≥55 years. Fall incidents were recorded prospectively. Time-varying β-blocker use was determined using pharmacy dispensing records. Cox proportional hazard models adjusted for age and sex were applied to determine the association between β-blocker use, their characteristics - selectivity, lipid solubility, ISA and CYP2D6 enzyme metabolism - and fall risk. The results of the studies were combined using meta-analyses.

RESULTS

In total 2917 participants encountered a fall during a total follow-up time of 89 529 years. Meta-analysis indicated no association between use of any β-blocker, compared to nonuse, and fall risk, hazard ratio (HR) = 0.97 [95% confidence interval (CI) 0.88-1.06]. Use of a selective β-blocker was also not associated with fall risk, HR = 0.92 (95%CI 0.83-1.01). Use of a nonselective β-blocker was associated with an increased fall risk, HR = 1.22 (95%CI 1.01-1.48). Other β-blocker characteristics including lipid solubility and CYP2D6 enzyme metabolism were not associated with fall risk.

CONCLUSION

Our study suggests that use of a nonselective β-blocker, contrary to selective β-blockers, is associated with an increased fall risk in an older population. In clinical practice, β-blockers have been shown effective for a variety of cardiovascular indications. However, fall risk should be considered when prescribing a β-blocker in this age group, and the pros and cons for β-blocker classes should be taken into consideration.

Vitamin B12 and Homocysteine Associations with Gait Speed in Older Adults: The Baltimore Longitudinal Study of Aging

OBJECTIVES

This study aimed to assess the independent associations of serum levels of vitamin B12 and plasma concentrations of homocysteine with gait speed decline.

DESIGN, SETTING, PARTICIPANTS

This study utilized longitudinal analysis of participants 50 years or older from The Baltimore Longitudinal Study of Aging, N=774.

MEASUREMENTS

Gait speed (m/s) was assessed using the 6-meter usual pace test. Vitamin B12 and homocysteine concentrations were collected using standard clinical protocols. Linear mixed effects regression was stratified by baseline age category (50-69, 70-79, and ≥80 years old).

RESULTS

Mean follow-up time for the total study sample was 5.4 ± 2.0 years. No association between vitamin B12 and gait speed decline over the follow-up time for any age group was found. Elevated homocysteine concentrations were associated with decline in gait speed after adjustment for covariates (50-69: β= -0.005, p=.057; 70-79: β= -0.013, p<.001, ≥80: β= -0.007, p=.054).

CONCLUSION

Homocysteine and vitamin B12 are inversely related, yet only homocysteine was associated with gait speed decline in this population of healthy older adults. Given these results, future research should be directed towards investigating the relationship in populations with greater variation in vitamin B12 concentrations and other mechanisms influencing homocysteine concentrations.

CYP2C9 Genotypes Modify Benzodiazepine-Related Fall Risk: Original Results From Three Studies With Meta-Analysis

OBJECTIVE

To investigate whether the CYP2C9*2 and *3 variants modify benzodiazepine-related fall risk.

DESIGN

Three prospective studies; the Rotterdam Study, B-PROOF, and LASA.

SETTING

Community-dwelling individuals living in or near five Dutch cities.

PARTICIPANTS

There were 11,485 participants aged ≥55 years.

MEASUREMENTS

Fall incidents were recorded prospectively. Benzodiazepine use was determined using pharmacy dispensing records or interviews. Cox proportional hazard models adjusted for age and sex were applied to determine the association between benzodiazepine use and fall risk stratified for CYP2C9 genotype and comparing benzodiazepine users to nonusers. The results of the three studies were combined applying meta-analysis. Within benzodiazepine users, the association between genotypes and fall risk was also assessed.

RESULTS

Three thousand seven hundred five participants (32%) encountered a fall during 91,996 follow-up years, and 4% to 15% (depending on the study population) used benzodiazepines. CYP2C9 variants had frequencies of 13% for the *2 allele and 6% for the *3 allele. Compared to nonusers, current benzodiazepine use was associated with an 18% to 36% increased fall risk across studies with a combined hazard ratio (HR) = 1.26 (95% confidence interval [CI], 1.13; 1.40). CYP2C9*2 or *3 allele variants modified benzodiazepine-related fall risk. Compared to nonusers, those carrying a CYP2C9*2 or *3 allele and using benzodiazepines had a 45% increased fall risk (HR, 1.45 95% CI, 1.21; 1.73), whereas CYP2C9*1 homozygotes using benzodiazepines had no increased fall risk (HR, 1.14; 95% CI, 0.90; 1.45). Within benzodiazepine users, having a CYP2C9*2 or *3 allele was associated with an increased fall risk (HR, 1.35; 95% CI, 1.06; 1.72). Additionally, we observed an allele dose effect; heterozygous allele carriers had a fall risk of (HR = 1.30; 95% CI, 1.05; 1.61), and homozygous allele carriers of (HR = 1.91 95% CI, 1.23; 2.96).

CONCLUSIONS

CYP2C9*2 and *3 allele variants modify benzodiazepine-related fall risk. Those using benzodiazepines and having reduced CYP2C9 enzyme activity based on their genotype are at increased fall risk. In clinical practice, genotyping might be considered for elderly patients with an indication for benzodiazepine use. However, because the exact role of CYP2C9 in benzodiazepine metabolism is still unclear, additional research is warranted.

Addition of vitamin B12 to exercise training improves cycle ergometer endurance in advanced COPD patients: A randomized and controlled study

Vitamin B12 is essential in the homocysteine, mitochondrial, muscle and hematopoietic metabolisms, and its effects on exercise tolerance and kinetics adjustments of oxygen consumption (V'O_2p) in rest-to-exercise transition in COPD patients are unknown. This randomized, double-blind, controlled study aimed to verify a possible interaction between vitamin B12 supplementation and these outcomes. After recruiting 69 patients, 35 subjects with moderate-to-severe COPD were eligible and 32 patients concluded the study, divided into four groups (n = 8 for each group): 1. rehabilitation group; 2. rehabilitation plus B12 group; 3. B12 group; and 4. placebo group. The primary endpoint was cycle ergometry endurance before and after 8 weeks and the secondary endpoints were oxygen uptake kinetics parameters (time constant). The prevalence of vitamin B12 deficiency was high (34.4%) and there was a statistically significant interaction (p < 0.05), favoring a global effect of supplementation on exercise tolerance in the supplemented groups compared to the non-supplemented groups, even after adjusting for confounding variables (p < 0.05). The same was not found for the kinetics adjustment variables (τV'O_2p and _MRTV'O_2p, p > 0.05 for both). Supplementation with vitamin B12 appears to lead to discrete positive effects on exercise tolerance in groups of subjects with more advanced COPD and further studies are needed to establish indications for long-term supplementation.

Serum folate predicts muscle strength: a pilot cross-sectional study of the association between serum vitamin levels and muscle strength and gait measures in patients >65 years old with diabetes mellitus in a primary care setting

Background

Old age and diabetes mellitus are risk factors for vitamin deficiencies, weakness and falls.

Deficiencies of vitamin D, and possibly vitamin B12 and folate (which are associated with hyperhomocysteinaemia), contribute to sarcopenia. Determination of the physical effects of vitamin deficiencies in specific groups of people can help to guide public health policy with regard to vitamin supplementation.

Methods

A pilot cross-sectional study was conducted to determine the association of levels of vitamin D, vitamin B12, folate and homocysteine with muscle strength, gait and fall history in 56 patients >65 years old with diabetes mellitus in primary care in Singapore.

Hand-grip and leg-quadriceps strength measures were obtained and divided by body mass index (BMI).

The timed up-and-go and Tinetti tests were used to measure gait. A history of “at least one fall in the preceding year” was obtained.

Results

Vitamin B12 deficiency (<150 pmol/l) was present in 43 % of patients, folate deficiency (<13.5 mmol/l) in 20 %, hyperhomocysteinaemia (≥15.0 μmol/l) in 52 % and vitamin D deficiency (<49.9 nmol/l) in 25 %.

Levels of vitamin D, vitamin B12 and homocysteine did not significantly predict muscle strength in regression analyses.

Folate (B = 0.010, P < 0.01) and gender (B = 0.356, P < 0.001) predicted average grip strength corrected for BMI (F(2,53) = 17.74, P < 0.001, R² = 0.40)

Folate (B = 0.011, P < 0.05) and gender (B = 0.367, P < 0.001) also predicted average leg quadriceps strength corrected for BMI (F(2,53) = 9.79, P < 0.001, R² = 0.27).

Average leg strength and average leg strength corrected for BMI were both negatively associated with the risk of having fallen in the preceding year (odds ratio (OR) = 0.89, 95 % CI 0.80–0.98, P < 0.05 and OR = 0.12, 95 % CI 0.02–0.92, P < 0.05, respectively).

Conclusions

The prevalence of vitamin deficiency was very high in our sample of patients >65 years old with diabetes mellitus. Folate levels were significantly correlated with grip and leg strength (with correction for BMI). Leg strength was positively correlated with gait measures and negatively correlated with a history of falls. The role of folate in muscle weakness and falls warrants further study.