Malnutrition in the elderly and its effects on bone health – A review

Relationship Between Serum 25-Hydroxyvitamin D and Bone Mineral Density, Fracture Risk, and Bone Metabolism in Adults With Osteoporosis/Fractures

OBJECTIVE

To evaluate the association of serum 25-hydroxyvitamin D (25(OH) D) levels with bone mineral density (BMD), fracture risk, and bone metabolism.

METHODS

This multicenter cross-sectional study recruited menopausal females and males greater than or equal to 50 year old with osteoporosis/fractures between September 2016 and September 2021. Assessment included clinical data, 25(OH)D, intact parathyroid hormone (iPTH), procollagen type 1 amino-terminal propeptide (P1NP), carboxy-terminal collagen crosslinks (CTX), lateral thoracolumbar spine x-rays, and BMD.

RESULTS

A total of 3003 individuals were stratified by 25(OH) D levels: 720 individuals (24%) <20 ng/mL, 1338 individuals (44.5%) 20 to 29 ng/mL, and 945 individuals (31.5%) ≥30 ng/mL. In unadjusted and multivariable models, BMD T-score, except spine, was significantly and positively associated with 25(OH)D levels. 25(OH) D levels were inversely associated with Fracture Risk Assessment Tool scores. Patients with 25(OH)D <20 ng/mL had significantly higher iPTH and bone turnover markers (P1NP and CTX) than patients with 25(OH)D ≧20 ng/mL in all models. When analyzing bone-related markers and BMD, total hip and femoral neck BMD T-scores were positively correlated with 25(OH)D concentrations and BMI but negatively correlated with iPTH, P1NP, CTX, and age. In multivariate models with all bone-related markers, only 25(OH)D levels were significantly associated with total hip and femoral neck BMD.

CONCLUSION

Vitamin D deficiency is significantly associated with decreased total hip and femoral neck BMD and increased fracture risk as assessed by Fracture Risk Assessment Tool. In those with osteoporosis/fractures, vitamin D is implicated in the causal relationship between bone remodeling and BMD. Assessing vitamin D status is imperative for those at risk for osteoporosis/fractures.

Geriatric nutritional risk index predicts postoperative prognosis in older patients with hip fracture: A meta-analysis

BACKGROUND

Hip fracture is common in elderly individuals and is accompanied by a relatively high mortality rate. However, it is currently difficult to accurately predict postoperative prognosis for older patients with hip fractures. The aim of this meta-analysis was to further determine the prognostic value of the geriatric nutritional risk index (GNRI) for patients who underwent hip fracture surgery.

METHODS

The Medline, EMBASE, Web of Science, and CNKI databases were searched up to September 19, 2023, for available studies. The primary and secondary outcomes were the mortality and complication rates, respectively. Hazard ratios (HRs) and relative risks with corresponding 95% confidence intervals (CIs) were separately combined to assess the associations between the GNRI and mortality and complication rates. All the statistical analyses were performed with STATA 15.0 and SPSS 22.0 software.

RESULTS

A total of 9 studies with 3959 patients were included. The pooled results demonstrated that a lower GNRI was significantly related to an increased risk of postoperative mortality (HR = 0.82, 95% CI = 0.72-0.92, P = .001). In addition, the GNRI predicted the risk of overall postoperative complications (52% vs 35.5%, P = .04) and pneumonia (33.3% vs 13.6%, P = .010).

CONCLUSION

The GNRI might serve as a novel prognostic indicator for older patients with hip fractures, and a lower GNRI indicates an increased risk of postoperative mortality and complication rates.

Predictive factors of osteoporotic hip fracture in octogenarians

OBJECTIVE

This study aims to identify the risk factors associated with osteoporotic hip fractures in octogenarians and seeks to refine primary prevention strategies for these fractures.

MATERIAL AND METHODS

We conducted a case-control study involving individuals aged 79 years and older with hip fractures, comparing them to age- and sex-matched controls without a history of hip fractures. We collected epidemiological, clinical, anthropometric, and analytical factors. We evaluated the presence of osteoporosis using bone densitometry. We defined sarcopenia according the European Working Group on Sarcopenia in Older People criteria (EWGSOP2).

RESULTS

Ninety-five patients per group were analyzed, with a mean age of 82 years, of which 74% were women. The multivariate analysis included statistically significant factors found in the univariate analysis (p < 0.05). These factors included the Barthel Index, nutritional assessment using the CONUT tool, folic acid, vitamin D deficiency, presence of previous fractures, loss of visual acuity, bicipital circumference, sarcopenia, and osteoporosis (densitometry in the neck of the femur). The Nutritional state (OR: 0.08 [0.01-0.61]), the folic acid levels (OR 0.32 [0.1-1]), and a loss of visual acuity (OR 33.16 [2.91-377.87]) were the independent risk factors associated with hip fracture.

CONCLUSIONS

The assessment of nutritional status in elderly patients, coupled with a comprehensive geriatric assessment, represents easily reproducible and cost-effective tools. These tools can effectively aid in identifying individuals at risk of hip fractures, thereby contributing to more targeted and efficient preventive measures.

The interaction between aging and protein malnutrition modulates peritoneal macrophage function: An experimental study in male mice

Malnutrition is considered one of the most common problems in the elderly population worldwide and can significantly interfere in health evolution in these individuals, predisposing them to increased infection susceptibility. The immune response triggered by infections comprises several mechanisms, and macrophages play important roles in this response. This study aimed to evaluate mechanisms related to macrophage function in a model of protein malnutrition in the elderly. Two age groups (young: 3-5 months and elderly: 18-19 months) male C57BL/6NTac mice were subjected to protein malnutrition with a low-protein diet (2 %). The nutritional status, hemogram and number of peritoneal cells were affected by both age and nutritional status. Additionally, the spreading capacity as well as the phagocytic and fungicidal activity of peritoneal macrophages were affected by the nutritional status and age of the animal. Interestingly, the percentages of F4/80⁺/CD11b⁺ and CD86⁺ cells were reduced mostly in elderly animals, while the TLR-4⁺ population was more affected by nutritional status than by age. The production of pro-inflammatory cytokines such as TNF-α, IL-1α, and IL-6 was also influenced by nutritional status and/or by age, and malnourished animals of advanced age produced higher amounts of the anti-inflammatory cytokine IL-10. Furthermore, the phosphorylation ratio of the transcription factor NFκB (pNFκB/NFκB) was directly affected by the nutritional status, independently of age. Thus, these results allow us to conclude that aging and protein malnutrition compromise macrophage function, likely affecting their immune function, and in aged protein-malnourished animals, this impairment tends to be more pronounced.

Risk Factors of Frailty in Patients with Distal Radius Fractures

Aim

The aim of this study was to determine risk factors for the incidence of frailty in patients with distal radius fractures (DRFs).

Methods

In total, 116 patients (mean age, 66.3 ± 7.7 years) with DRFs were recruited. The participants were categorized into two groups, “frail” and “non-frail,” according to the presence or absence of frailty, respectively. The areal bone mineral densities (aBMDs) of the total hip, femoral neck, and lumbar spine were measured using dual-energy x-ray absorptiometry. The participants’ levels of resilience, depression, anxiety, nutritional intake, oral health-related quality of life, and social support were evaluated by self-reported questionnaires. The participants’ grip strength, gait speed, number of teeth present in their oral cavities, circumference of their upper arms and calves, and serum levels of vitamin D were also assessed.

Results

The participants in the “frail” group seemed to have lower aBMDs and muscle function and mass than those in the “non-frail” group. There were significant differences in grip strength, calf circumference, gait speed, and aBMD of the total hip, femoral neck, and lumbar spine between the groups. There were also significant differences in the levels of resilience and depression between the groups. A multivariate logistic regression analyses demonstrated that levels of sarcopenia, malnutritional status, and aBMDs of the total hip and femoral neck had significant relationships with the development of frailty in patients with DRFs.

Conclusions

An interdisciplinary approach involving the management of osteoporosis, sarcopenia, oral health, social relationships, and psychological support would be required for the proper management of DRF patients in preventing frailty.

Perioperative Nutritional Support: A Review of Current Literature

Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.

Cow products: boon to human health and food security

The world population exceeded 7.8 billion people in 2020 and is predicted to reach 9.9 billion by 2050 as per the current increasing rate of 25%. In view of this, ensuring human health and food security has become an issue of key importance to countries with different degrees of economic development. At the same time, the livestock sector plays a strategic role in improving the economic, environmental, and sociocultural stewardship of any nation. The cow (Bos indicus) has held a distinctive role in human history ever since its domestication because of its valued harvests like dairy products (milk, clarified butter, yogurt, curd, and buttermilk) excreta like dung and urine. These products, except dung, provide all the necessary energy and nutrients to ensure the proper growth and development of the human. They are the source of many bioactive substances, which possess immense pharmacotherapeutic action against various physiological, metabolic and infectious disorders, including COVID-19. The use of urine and dung can be considered a low-cost agricultural practice for farmers and has been extensively used in modern agriculture practices to ensure food security via soil fertility, plant pathogens, and pests. Cow urine mediated synthesized nanomaterial also display distinctive characteristics and novel applications in various fields of science and technology. Thus, this paper aims to provide a comprehensive overview of cow products, describing their biochemical constituents, bioactivities, and their utilization in the area ranging from human welfare to agriculture sustainability. An attempt is also made to present possible applications in bioenergy production and pollution reduction.

Effect of nutritional and physical exercise intervention on hospital readmission for patients aged 65 or older: a systematic review and meta-analysis of randomized controlled trials

Background

Unplanned readmission may result in consequences for both the individual and society. The transition of patients from hospital to postdischarge settings often represents a discontinuity of care and is considered crucial in the prevention of avoidable readmissions. In older patients, physical decline and malnutrition are considered risk factors for readmission. The purpose of the study was to determine the effects of nutritional and physical exercise interventions alone or in combination after hospital admission on the risk of hospital readmission among older people.

Methods

A systematic review and meta-analysis of randomized controlled studies was conducted. The search involved seven databases (Medline, AMED, the Cochrane Library, CINAHL, Embase (Ovid), Food Science Source and Web of Science) and was conducted in November 2018. An update of this search was performed in March 2020. Studies involving older adults (65 years and above) investigating the effect of nutritional and/or physical exercise interventions on hospital readmission were included.

Results

A total of 11 randomized controlled studies (five nutritional, five physical exercise and one combined intervention) were included and assessed for quality using the updated Cochrane Risk of Bias Tool. Nutritional interventions resulted in a significant reduction in readmissions (RR 0.84; 95% CI 0.70–1.00, p = 0.049), while physical exercise interventions did not reduce readmissions (RR 1.05; 95% CI 0.84–1.31, p-value = 0.662).

Conclusions

This meta-analysis suggests that nutrition support aiming to optimize energy intake according to patients’ needs may reduce the risk of being readmitted to the hospital for people aged 65 years or older.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01123-w.

Nutrition Mediates the Relationship between Osteosarcopenia and Frailty: A Pathway Analysis

Osteosarcopenia is associated with increased risk of adverse outcomes such as falls and fractures. Its association with frailty is less well-described, particularly in independent community-dwelling older adults. Although nutrition plays a crucial role in maintaining bone and muscle health, the complex relationship between osteosarcopenia and nutrition in the pathogenesis of frailty remains to be elucidated. In this cross-sectional analysis of 230 independent, community-dwelling individuals (mean age 67.2 ± 7.4 years), we examined the associations between osteosarcopenia with nutritional status and frailty, and the mediating role of nutrition in the association between osteosarcopenia and frailty. Osteosarcopenia was defined as fulfilling both the Asian Working Group for Sarcopenia 2019 consensus definition (low relative appendicular skeletal muscle mass adjusted for height, in the presence of either of either low handgrip strength or slow gait speed) and T-score ≤ -2.5 SD on bone mineral densitometry. We assessed frailty using the modified Fried criteria and nutrition using the Mini-Nutritional Assessment. We performed multiple linear regression, followed by pathway analysis to ascertain whether nutrition mediates the relationship between osteosarcopenia and frailty. Our study population comprised: 27 (11.7%) osteosarcopenic, 35 (15.2%) sarcopenic, 36 (15.7%) osteoporotic and 132 (57.4%) normal (neither osteosarcopenic, sarcopenic nor osteoporotic). Osteosarcopenia (β = 1.1, 95% CI 0.86-1.4) and sarcopenia (β = 1.1, 95% CI 0.90-1.4) were significantly associated with frailty, but not osteoporosis. Nutrition mediated the association between osteosarcopenia and frailty (indirect effect estimate 0.09, bootstrap 95% CI 0.01-0.22). In conclusion, osteosarcopenia is associated with frailty and poorer nutritional status, with nutrition mediating the association between osteosarcopenia and frailty. Our findings support early nutritional assessment and intervention in osteosarcopenia to mitigate the risk of frailty.

A Brief Intervention for Malnutrition among Older Adults: Stepping Up Your Nutrition

Despite a multitude of nutritional risk factors among older adults, there is a lack of community-based programs and activities that screen for malnutrition and address modifiable risk among this vulnerable population. Given the known association of protein and fluid consumption with fall-related risk among older adults and the high prevalence of falls among Americans age 65 years and older each year, a brief intervention was created. Stepping Up Your Nutrition (SUYN) is a 2.5 h workshop developed through a public/private partnership to motivate older adults to reduce their malnutrition risk. The purposes of this naturalistic workshop dissemination were to: (1) describe the SUYN brief intervention; (2) identify participant characteristics associated with malnutrition risk; and (3) identify participant characteristics associated with subsequent participation in Stepping On (SO), an evidence-based fall prevention program. Data were analyzed from 429 SUYN participants, of which 38% (n = 163) subsequently attended SO. As measured by the SCREEN II^®, high and moderate malnutrition risk scores were reported among approximately 71% and 20% of SUYN participants, respectively. Of the SUYN participants with high malnutrition risk, a significantly larger proportion attended a subsequent SO workshop (79.1%) compared to SUYN participants who did not proceed to SO (65.8%) (χ² = 8.73, p = 0.013). Findings suggest SUYN may help to identify malnutrition risk among community-dwelling older adults and link them to needed services like evidence-based programs. Efforts are needed to expand the delivery infrastructure of SUYN to reach more at-risk older adults.

Development of a dual-energy X-ray absorptiometry-derived body volume equation in Hispanic adults for administering a four-compartment model

The purpose of the present study was: (1) to develop a new dual-energy X-ray absorptiometry (DXA)-derived body volume (BV) equation with the GE-Lunar prodigy while utilising underwater weighing (UWW) as a criterion and (2) to cross-validate the novel DXA-derived BV equation (4C-DXANickerson), Wilson DXA-derived BV equation (4C-DXAWilson) and air displacement plethysmography (ADP)-derived BV (4C-ADP) in Hispanic adults. A total of 191 Hispanic adults (18–45 years) participated in the present study. The development sample consisted of 120 females and males (50 % females), whereas the cross-validation sample comprised of forty-one females and thirty males (n 71). Criterion body fat percentage (BF %) and fat-free mass (FFM) were determined using a four-compartment (4C) model with UWW as a criterion for BV (4C-UWW). 4C-DXANickerson, 4C-DXAWilson and 4C-ADP were compared against 4C-UWW in the cross-validation sample. 4C-DXANickerson, 4C-DXAWilson and 4C-ADP all produced similar validity statistics when compared with 4C-UWW in Hispanic males (all P > 0·05). 4C-DXANickerson also yielded similar BF % and FFM values as 4C-UWW when evaluating the mean differences (constant error (CE)) in Hispanic females (CE = –0·79 % and 0·38 kg; P = 0·060 and 0·174, respectively). However, 4C-DXAWilson produced significantly different BF % and FFM values (CE = 3·22 % and –2·20 kg, respectively; both P < 0·001). Additionally, 4C-DXAWilson yielded significant proportional bias when estimating BF % (P < 0·001), whereas 4C-ADP produced significant proportional bias for BF % and FFM (both P < 0·05) when evaluated in Hispanic females. The present study findings demonstrate that 4C-DXANickerson is a valid measure of BV in Hispanics and is recommended for use in clinics, where DXA is the main body composition assessment technique.

Association between malnutrition-inflammation score and risk of subsequent self-reported bone fractures in prevalent kidney transplant recipients

Chronic inflammation and protein energy wasting (PEW) syndrome are common in kidney transplant recipients (KTR). The presence of inflammation and PEW syndrome can directly affect bone resorption and bone formation, leading to bone loss and fractures. We showed PEW is independently associated with new clinically detected bone fractures in prevalent KTR.

INTRODUCTION

Kidney transplant recipients (KTR) have a 4-fold higher risk of fracture compared to the general population. Chronic inflammation and PEW syndrome are common in KTR and are associated with poor outcomes. We hypothesized that the Malnutrition-Inflammation Score (MIS), a validated measure of PEW, is associated with higher risk of bone fractures in KTR.

METHODS

This prospective cohort study included 839 prevalent KTR from a Central European academic center. MIS, a semiquantitative instrument of PEW, was calculated at the study entry. Self-reported history of fractures was recorded during the 2-year follow-up period. The association between MIS and bone fractures was examined in logistic regression analyses with adjustment for age, gender, eGFR, smoking habits, history of pre-transplant bone fractures, and acute rejection.

RESULTS

Mean age was 51 ± 13 years, and 56% of patients were males with median (interquartile range) transplant vintage 69 (38-112) months, estimated glomerular filtration rate 55 ± 21 ml/min/1.73 m², and calculated MIS 3 (2-4) at enrollment. Fifty-five (7%) patients experienced self-reported bone fractures during the 2-year follow-up period. Higher MIS score showed linear association with increased risk of fracture. Each one-point higher MIS was associated with 23% higher risk of bone fractures (odds ratio (OR) and 95% CI 1.23, 1.12-1.34), which remained significant after multivariable adjustments (OR 1.17, 95% CI 1.06-1.29).

CONCLUSION

The MIS is independently associated with new clinically detected bone fractures in prevalent KTR.

The Role of Nutrients in Reducing the Risk for Noncommunicable Diseases during Aging

An increasing aging population worldwide accounts for a growing share of noncommunicable diseases (NCDs) of the overall social and economic burden. Dietary and nutritional approaches are of paramount importance in the management of NCDs. As a result, nutrition programs are increasingly integrated into public health policies. At present, programs aimed at reducing the burden of NCDs have focused mostly on the excess of unhealthy nutrient intakes whereas the importance of optimizing adequate essential and semi-essential nutrient intakes and nutrient-rich diets has received less attention. Surveys indicate that nutrient intakes of the aging population are insufficient to optimally support healthy aging. Vitamin and mineral deficiencies in older adults are related to increased risk of NCDs including fatigue, cardiovascular disease, and cognitive and neuromuscular function impairments. Reviewed literature demonstrates that improving intake for certain nutrients may be important in reducing progress of NCDs such as musculoskeletal disorders, dementia, loss of vision, and cardiometabolic diseases during aging. Current knowledge concerning improving individual nutrient intakes to reduce progression of chronic disease is still emerging with varying effect sizes and levels of evidence. Most pronounced benefits of nutrients were found in participants who had low nutrient intake or status at baseline or who had increased genetic and metabolic needs for that nutrient. Authorities should implement ways to optimize essential nutrient intake as an integral part of their strategies to address NCDs.

Bone health-promoting bioactive peptides

Bioactive peptides, derivatives of proteins, show versatile biological effects and represent potential health-promoting agents as functional food ingredients and/or nutraceuticals. Bone health depends on the balance between bone formation and resorption. When the balance is disrupted, bone diseases such as osteoporosis and fragility fractures may result. Accumulating evidence suggests that peptides derived from endogenous proteins and food proteins enhance bone health. This article reviews the literature on peptides exhibiting bone health-promoting effects. Possible biochemical mechanisms and production of these peptides are briefly discussed. PRACTICAL APPLICATIONS: Bioactive peptides are derived from food proteins via enzymatic hydrolysis, are already commercially available. In vitro and in vivo bone health-promoting effects of bioactive peptides have been shown in several animal models of osteoporosis and fractures. Thus, peptides can be used as functional food ingredients and/or nutraceuticals. However, their exact role and safety in human subjects should be evaluated prior to commercialization.