Energy intake, energy required and mortality in an older population

Association between doubly labelled water-calibrated energy intake and objectively measured physical activity with mortality risk in older adults

BACKGROUND

Physical activity or biomarker-calibrated energy intake (EI) alone is associated with mortality in older adults; the interaction relationship between the combined use of both factors and mortality has not been examined. We evaluated the relationship between mortality and calibrated EI and step counts in older adults.

METHODS

This prospective study included 4,159 adults aged ≥65 years who participated in the Kyoto-Kameoka study in Japan and wore a triaxial accelerometer between 1 April and 15 November 2013. The calibrated EI was calculated based on a previously developed equation using EI biomarkers. The step count was obtained from the accelerometer ≥ 4 days. Participants were classified into the following four groups: low EI (LEI)/low step counts (LSC) group (EI: <2,400 kcal/day in men and <1,900 kcal/day in women; steps: <5,000 /day), n = 1,352; high EI (HEI)/LSC group (EI: ≥2,400 kcal/day in men and ≥1,900 kcal/day in women; steps: <5,000 /day), n = 1,586; LEI/high step counts (HSC) group (EI: <2,400 kcal/day in men and < 1,900 kcal/day in women; steps: ≥5,000 /day), n = 471; and HEI/HSC group (EI: ≥2,400 kcal/day in men and ≥1,900 kcal/day in women; steps: ≥5,000 /day), n = 750. Mortality-related data were collected until 30 November 2016. We performed a multivariable Cox proportional hazard analysis.

RESULTS

The median follow-up period was 3.38 years (14,046 person-years), and 111 mortalities were recorded. After adjusting for confounders, the HEI/HSC group had the lowest all-cause mortality rate compared to other groups (LEI/LSC: reference; HEI/LSC: hazard ratio [HR]: 0.71, 95% confidence interval [CI]: 0.41-1.23; LEI/HSC: HR: 0.59, 95% CI: 0.29-1.19; and HEI/HSC: HR: 0.10, 95% CI: 0.01-0.76). No significant interaction was observed between the calibrated EI and steps with mortality. The spline model showed that 35-42 kcal/100 steps/day of EI/100 steps was associated with the lowest mortality risk.

CONCLUSIONS

HR mortality risk was lowest at 35-42 kcal/100 steps/day, suggesting that very high (≥56 kcal) or low (<28 kcal) EI/100 steps are not inversely associated with mortality. Adherence to optimal EI and adequate physical activity may provide sufficient energy balance to explain the inverse association with mortality among older Japanese adults.

A multivariate joint model to adjust for random measurement error while handling skewness and correlation in dietary data in an epidemiologic study of mortality

PURPOSE

A substantial proportion of global deaths is attributed to unhealthy diets, which can be assessed at baseline or longitudinally. We demonstrated how to simultaneously correct for random measurement error, correlations, and skewness in the estimation of associations between dietary intake and all-cause mortality.

METHODS

We applied a multivariate joint model (MJM) that simultaneously corrected for random measurement error, skewness, and correlation among longitudinally measured intake levels of cholesterol, total fat, dietary fiber, and energy with all-cause mortality using US National Health and Nutrition Examination Survey linked to the National Death Index mortality data. We compared MJM with the mean method that assessed intake levels as the mean of a person's intake.

RESULTS

The estimates from MJM were larger than those from the mean method. For instance, the logarithm of hazard ratio for dietary fiber intake increased by 14 times (from -0.04 to -0.60) with the MJM method. This translated into a relative hazard of death of 0.55 (95% credible interval: 0.45, 0.65) with the MJM and 0.96 (95% credible interval: 0.95, 0.97) with the mean method.

CONCLUSIONS

MJM adjusts for random measurement error and flexibly addresses correlations and skewness among longitudinal measures of dietary intake when estimating their associations with death.

Nutritional status and the risk of malnutrition in older adults with chronic kidney disease - implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN

Increased life expectancy is posing unprecedented challenges to healthcare systems worldwide. These include a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In older adults with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities. To address these issues, the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) have prepared this conjoint critical review paper, whose objective is to summarize key concepts related to prevention and treatment of both CKD progression and impaired nutritional status using dietary approaches, and to provide guidance on how to define optimal protein and energy intake in older adults with differing severity of CKD. Overall, the authors support careful assessment to identify the most urgent clinical challenge and the consequent treatment priority. The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient's preferences and quality of life. CKD progression and advanced CKD stage support prioritization of protein restriction in the presence of a good nutritional status. Individual risk-benefit assessment and appropriate nutritional monitoring should guide the decision-making process. Higher awareness of the challenges of nutritional care in older adult patients with CKD is needed to improve care and outcomes. Research is advocated to support evidence-based recommendations, which we still lack for this increasingly large patient subgroup.

Doubly labelled water-calibrated energy intake associations with mortality risk among older adults

BACKGROUND

The body mass index (BMI) is closely related to mortality risk, and energy intake (EI) is essential for maintaining energy balance in weight control. However, self-reported EI has been shown to lead to a systematic underestimation. Total energy expenditure measured using the doubly labelled water (DLW) method is considered an objective biomarker of EI and the gold standard for its estimation in individuals with stable body weight. We aimed to examine the association between DLW-calibrated EI and BMI on overall mortality risk in older adults.

METHODS

A prospective cohort study was performed using data of 8051 (4267 women and 3784 men) Japanese older adults from the Kyoto-Kameoka Study in Japan. Calibrated EI was calculated from the estimated EI using a food frequency questionnaire and equation developed based on DLW. Participants were classified by quartiles based on their EI stratified by sex. BMI was calculated using self-reported height and body weight. Mortality data were collected between 30 July 2011 and 30 November 2016. Statistical analysis was performed using the multivariable-adjusted Cox proportional hazard model with a restricted cubic spline.

RESULTS

The 8051 participants' mean (standard deviation) age and BMI were 73.5 (6.1) years and 22.6 (3.0) kg/m2 , respectively. The mean (standard deviation) EI with and without calibration was 1909 (145) kcal/day and 1569 (358) kcal/day in women and 2383 (160) kcal/day and 1980 (515) kcal/day in men, respectively. During the median 4.75 years of follow-up (36 552 person-years), 661 deaths were recorded. In both women (hazard ratio [HR], 0.63; 95% confidence interval [CI] [0.41, 0.98]) and men (HR, 0.62; 95% CI [0.44, 0.87]), after adjusting for confounders, the top quartile as compared with the bottom calibrated EI quartile showed a negative association with risk of all-cause mortality. The lowest HR for all-cause mortality was 1900-2000 kcal/day in women and 2400-2600 kcal/day in men. However, after adjusting for BMI, no significant association was observed between the calibrated EI and the risk of death. These associations could not be confirmed in the uncalibrated EI. The HR for mortality was minimal at a BMI of 23 kg/m2 in both men and women, with or without adjustment for the calibrated EI.

CONCLUSIONS

Calibrated EI was negatively associated with mortality risk but not uncalibrated EI. This may be mediated by an increase in body weight over time. Caution is required when interpreting the association between EI and mortality risk without adjusting for self-reported measurement errors and outcomes.

Association of Dietary Live Microbe Intake with Cardiovascular Disease in US Adults: A Cross-Sectional Study of NHANES 2007-2018

Objective: To detect the potential association between dietary live microbe and cardiovascular diseases (CVD). Methods: Data of 10,875 participants aged 18 years or older in this study were collected from the National Health and Nutrition Examination Survey (NHANES). Participants in this study were divided into three groups according to the Sanders dietary live microbe classification system: low, medium, and high dietary live microbe groups. CVD was defined by a combination of self-reported physician diagnoses and standardized medical status questionnaires. The analyses utilized weighted logistic regression models. Results: After the full adjustment for confounders, patients in the medium dietary live microbe group had a low prevalence of CVD in contrast to those in the low dietary live microbe group (OR: 0.78, 95% CI: 0.52−0.99, and p < 0.05), but no significant association with CVD was detected between the high and low dietary live microbe groups. Higher dietary live microbe groups were negatively associated with the prevalence of stroke (p for trend = 0.01) and heart attack (p for trend = 0.01). People who were male were more likely to suffer stroke due to low dietary live microbe (p for interaction = 0.03). Conclusion: A high dietary live microbe intake was associated with a low prevalence of CVD, and the significant association was detected when the analysis was limited to stroke and heart attack.

Personalized Protein Supplementation Improves Total Protein, Leucine, and Energy Intake in (Pre)Sarcopenic Community-Dwelling Older Adults in the ENHANce RCT

Recommendations concerning protein quantity, source, and leucine intake for older adults are difficult to reach by regular dietary intake. This randomized clinical trial assesses in sarcopenic community-dwelling older adults (i) the regular (non-supplemented) daily protein and leucine intake; and (ii) the effect of personalized protein supplementation (aiming for an evenly distributed total protein intake of 1.5 g·kg^-1·d^-1 of body mass, accounting for energy intake) on regular and total (dietary and supplemental) intake. A preliminary feasibility study in participants of the ongoing Exercise and Nutrition for Healthy AgeiNg (ENHANce) study was performed with the objective to assess the intake and distribution of regular dietary protein and leucine, protein source and energy intake in (pre)sarcopenic community-dwelling older adults. Moreover, this study aimed to assess if personalized protein supplementation was feasible without negatively affecting regular dietary intake. ENHANce (NCT03649698) is a 5-armed RCT that assesses the effect of anabolic interventions on physical performance in (pre)sarcopenic older adults. In August 2019, n = 51 participants were included in ENHANce with complete available data on dietary intake at screening and thus eligible for inclusion in present analysis. Of these, n = 35 participants completed the intervention period of ENHANce at the moment of analysis, allowing an exploration of the effect of supplementation on regular dietary intake. The regular dietary protein intake of 51 (pre)sarcopenic adults (73.6 ± 6.5 years) was 1.06 ± 0.3 g·kg^-1·d^-1 of body mass. Protein supplementation (n = 20) improved total protein intake to 1.55 ± 0.3 g·kg^-1·d^-1 of body mass (P < 0.001) without affecting regular dietary protein (P = 0.176) or energy intake (P = 0.167). Placebo supplementation (n = 15) did not affect regular dietary protein intake (P = 0.910) but decreased regular dietary energy intake (P = 0.047). Regular leucine intake was unevenly distributed over the day, but increased by supplementation at breakfast (P < 0.001) and dinner (P = 0.010) to at least 2.46 g leucine·meal^-1, without reducing regular dietary leucine intake (P = 0.103). Animal-based protein intake-the main protein source-was not affected by supplementation (P = 0.358). Personalized protein supplementation ensured an adequate quantity and even distribution of protein and leucine over the day, without affecting regular dietary protein or energy intake.

Prevalence and Mortality of Sarcopenia in a Community-dwelling Older Japanese Population: The Hisayama Study

BACKGROUND

The prevalence of sarcopenia defined using the Asian Working Group for Sarcopenia (AWGS) criteria in Asian communities has not been fully addressed. Moreover, few studies have addressed the influence of sarcopenia on mortality.

METHODS

A total of 1,371 and 1,597 residents aged 65 years or older participated in health surveys in 2012 and 2017. Sarcopenia was determined using the AWGS definition. Factors associated with the presence of sarcopenia were assessed using a logistic regression model in participants in the 2012 survey. Subjects in the 2012 survey were followed-up prospectively for a median of 4.3 years. Mortality risk for subjects with sarcopenia was examined using the Cox proportional hazards model.

RESULTS

The crude prevalence of sarcopenia was 7.4% and 6.6% in participants at the 2012 and 2017 surveys, respectively; there was no significant difference between surveys (P = 0.44). The prevalence of sarcopenia increased significantly with age in both sexes (both P for trend <0.001). Subjects with sarcopenia were more likely to exercise less regularly, to intake less total energy, and to exhibit a disability in activity of daily living than those without. The multivariable-adjusted hazard ratio for all-cause mortality was 2.20 (95% confidence interval, 1.25-3.85) in subjects with sarcopenia, compared to those without.

CONCLUSIONS

Approximately 7% of older subjects had sarcopenia in a community-dwelling older Japanese population. Moreover, subjects with sarcopenia had an increased mortality risk. Our findings suggest that a public health strategy for sarcopenia is needed to extend healthy life expectancy.

Assessing the association between optimal energy intake and all-cause mortality in older patients with diabetes mellitus using the Japanese Elderly Diabetes Intervention Trial

AIM

Selecting optimal energy intake during diet therapy for older patients with diabetes mellitus is difficult because of the large differences in physical function and comorbid diseases. In Japan, although requirements for total energy intake are calculated by multiplying a person's standard bodyweight (BW) by the amount of physical activity, evidence supporting the application of this method among older people is limited. Therefore, we aimed to assess optimal energy intake by evaluating the relationship between energy intake and mortality in older patients.

METHODS

We evaluated data from a 6-year prospective follow up of 756 older patients with diabetes mellitus, and the association between baseline nutrient intake and mortality. Total energy intake and nutrients were evaluated, and energy intake per actual BW was categorized into quartiles (Q). Cox regression analysis was used for statistical analyses. Energy intake per standard BW or age-related target BW was statistically analyzed using the same protocol.

RESULTS

Analysis of energy intake per actual BW showed that hazard ratios for mortality was significantly higher in Q1 and Q4. Similar associations were found for energy intake per standard or target BW. Subgroup analysis showed that mortality rate was the lowest in Q2 in the young-old population and in Q3 in the old-old population.

CONCLUSIONS

A U-shaped relationship was observed between energy intake per BW and mortality in older patients with diabetes mellitus, which suggests that the optimal energy intake per actual or target BW should encompass a wide range to prevent malnutrition and excessive nutrition in these patients. Geriatr Gerontol Int 2020; 20: 59-65.

Japanese diet and survival time: The Ohsaki Cohort 1994 study

BACKGROUND & AIMS

Although it has been suggested that the Japanese diet contributes to the longevity of the Japanese population, no study has examined the association between the Japanese diet and survival time. The present study investigated the association between the Japanese diet and survival time.

METHODS

We analyzed 20-year follow-up data from a cohort study of 14,764 Japanese men and women aged 40-79 years. At the baseline survey in 1994, we collected dietary information using a validated 40-item food frequency questionnaire. Adherence to a Japanese diet consisting of nine components (rice, miso soup, seaweeds, pickles, green and yellow vegetables, fish, green tea, beef and pork, and coffee) was assessed in terms of a Japanese dietary index (JDI) score, the total score ranging from 0 to 9. Cox proportional hazards model and Laplace regression analysis were used to estimate the hazard ratios (HRs) and differences in median age at death (50th percentile differences - PDs in age at death) with 95% confidence intervals (CIs) according to the quartiles of the JDI score.

RESULTS

During the follow-up period, we documented 4,619 deaths. We observed that a higher JDI score was associated with a lower risk of mortality and longer survival time: In comparison to participants in the lowest JDI score quartile (0-4), the multivariate-adjusted HR (95% CI) of all-cause mortality was 0.91 (0.83-0.99) and the multivariate-adjusted 50th PD in age at death (95% CI) was 10.2 (3.2-17.2) months longer for those in the highest quartile (7-9).

CONCLUSIONS

Adherence to a Japanese diet is associated with a longer survival time.

Cross-Sectional Analysis of the Correlation Between Daily Nutrient Intake Assessed by 7-Day Food Records and Biomarkers of Dietary Intake Among Participants of the NU-AGE Study

Methods for measuring diet composition and quantifying nutrient intake with sufficient validity are essential to study the association between nutrition and health outcomes and risk of diseases. 7-day food records provides a quantification of food actually and currently consumed and is interesting for its use in intervention studies to monitor diet in a short-term period and to guide participants toward changing their intakes. The objective of this study is to analyze the correlation/association between the daily intake of selected nutrients (collected by a 7-day food records plus a mineral/vitamin supplementation questionnaire) and estimates of energy expenditure as well as blood and urine biomarkers of dietary intakes in 1,140 healthy elderly subjects (65–79 years) at baseline of the NU-AGE intervention study (NCT01754012, clinicaltrials.gov). The results show that: the daily intake of energy correlated significantly with predicted total energy expenditure (pTEE) (ρ = 0.459, p < 0.001, and q < 0.001); protein intake correlated significantly with the ratio of 24 h urinary urea to creatinine excretion (ρ = 0.143 for total protein intake, ρ = 0.296 for animal protein intake, and ρ = 0.359 for protein intake/body weight, p < 0.001 and q < 0.001 for each correlation); vitamin B12 and folate intakes correlated significantly with their serum concentrations (ρ = 0.151 and ρ = 0.363, respectively; p < 0.001 and q < 0.001 for each correlation); sodium and potassium intakes correlated significantly with their 24 h urinary excretion (ρ = 0.298 and ρ = 0.123, respectively; p < 0.001 and q < 0.001 for each correlation); vitamin B12 and folate intakes were negatively associated with plasma homocysteine measure (p = 0.001 and p = 0.004, respectively); stratifying subjects by gender, the correlations between energy intake and pTEE and between potassium intake and its 24 h urinary excretion lost their significance in women. Even if the plasma and urinary levels of these nutrients depend on several factors, the significant correlations between daily reported intake of nutrients (protein, vitamin B12, folate, and sodium) and their blood/urinary markers confirmed that the 7-day food records (plus a supplementation questionnaire) provides reliable data to evaluate short-term current dietary intake in European elderly subjects and it can be exploited to guide and monitor NU-AGE participants through the shift of their diet according NU-AGE recommendations.