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Stepaniak U, Grosso G, Polak M, Gradowicz-Prajsnar B, Kozela M, Bobak M, Sanchez-Niubo A, Stefler D, Haro JM, Pająk A. Association between dietary (poly)phenol intake and the ATHLOS Healthy Ageing Scale in the Polish arm of the HAPIEE study. GeroScience 2024:10.1007/s11357-024-01275-0. [PMID: 38985401 DOI: 10.1007/s11357-024-01275-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/28/2024] [Indexed: 07/11/2024] Open
Abstract
Inverse association between (poly)phenol intake and age-related disorders has been demonstrated; however, little is known whether they affect comprehensively assessed healthy aging. The aim of this study was to evaluate the associations between the intake of (poly)phenol (including selected classes and subclasses) and healthy aging scores related to biopsychosocial aspects of health and functioning. A cross-sectional study was performed using data on 9774 randomly selected citizens of Krakow (Poland) who were 45-69 years of age. Dietary (poly)phenol intake was evaluated using a food frequency questionnaire and matching food consumption data with the Phenol-Explorer database. The healthy aging scores were estimated from the ATHLOS Healthy Ageing Scale (HAS) developed by the Ageing Trajectories of Health-Longitudinal Opportunities and Synergies (ATHLOS) consortium. Beta coefficients were calculated using multivariable linear regression models. In multivariable adjusted models, there were significant positive associations between the ATHLOS HAS score and intake of total (poly)phenols (b per increase of 100 mg/day = 0.081; 95% CI, 0.050; 0.112) and among main classes of (poly)phenols with phenolic acids (b = 0.139; 95% CI, 0.098; 0.180). Intake of remaining classes of (poly)phenols (flavonoids, lignans, stilbenes, and others) was not related to the ATHLOS HAS score. Among individual classes studied, hydroxycinnamic acids, flavonols, flavones, and dihydrochalcones were associated with better healthy aging. The findings suggest the beneficial effect of total dietary (poly)phenol and some classes and subclasses of (poly)phenol intake in terms of healthy aging in Poland. These findings should be confirmed in other settings and with prospective data.
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Affiliation(s)
- Urszula Stepaniak
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, Skawinska Street 8, 31-066, Krakow, Poland.
| | - Giuseppe Grosso
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Maciej Polak
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, Skawinska Street 8, 31-066, Krakow, Poland
| | - Barbara Gradowicz-Prajsnar
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, Skawinska Street 8, 31-066, Krakow, Poland
| | - Magdalena Kozela
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, Skawinska Street 8, 31-066, Krakow, Poland
| | - Martin Bobak
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Albert Sanchez-Niubo
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
- Department of Social Psychology and Quantitative Psychology, University of Barcelona, Barcelona, Spain
- Research, Innovation and Teaching Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Denes Stefler
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Josep Maria Haro
- Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain
- Research, Innovation and Teaching Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Andrzej Pająk
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, Skawinska Street 8, 31-066, Krakow, Poland
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Fátima Heredia R, Riestra-Ayora JI, Yanes-Díaz J, Thuissard Vasallo IJ, Andreu-Vázquez C, Sanz-Fernández R, Sánchez-Rodríguez C. Cocoa Polyphenols Prevent Age-Related Hearing Loss and Frailty in an In Vivo Model. Antioxidants (Basel) 2023; 12:1994. [PMID: 38001847 PMCID: PMC10669688 DOI: 10.3390/antiox12111994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Age-related hearing loss (ARHL) impairs the quality of life in elderly persons. ARHL is associated with comorbidities, such as depression, falls, or frailty. Frailty syndrome is related to poor health outcomes in old age. ARHL is a potentially modifiable risk factor for frailty. Oxidative stress has been proposed as a key factor underlying the onset and/or development of ARHL and frailty. Cocoa has high levels of polyphenols and provides many health benefits due to its antioxidant properties. Male and female C57Bl/6J mice were randomly assigned to two study groups: animals receiving a cocoa-supplemented diet and the other receiving a standard diet. Then, at the ages of 6, 14, and 22 months, hearing and frailty were measured in all mice. Auditory steady-state responses (ASSR) threshold shifts were measured to different frequencies. The frailty score was based on the "Valencia Score" adapted to the experimental animals. The total antioxidant capacity and total polyphenols in urine samples were also measured. Significant improvements in hearing ability are observed in the cocoa groups at 6, 14, and 22 months compared to the no cocoa group. The cocoa diet significantly retards the development of frailty in mice. Cocoa increases the concentration of polyphenols excreted in the urine, which increases the total antioxidant capacity. In conclusion, cocoa, due to its antioxidant properties, leads to significant protection against ARHL and frailty.
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Affiliation(s)
- Rosalía Fátima Heredia
- Department Clinical Analysis, Hospital Universitario de Getafe, Carretera de Toledo, km 12.500, 28905 Getafe, Madrid, Spain;
| | - Juan I. Riestra-Ayora
- Otolaryngology Department, Hospital Universitario de Getafe, Carretera de Toledo, km 12.500, 28905 Getafe, Madrid, Spain; (J.I.R.-A.); (J.Y.-D.); (R.S.-F.)
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Madrid, Spain; (I.J.T.V.); (C.A.-V.)
| | - Joaquín Yanes-Díaz
- Otolaryngology Department, Hospital Universitario de Getafe, Carretera de Toledo, km 12.500, 28905 Getafe, Madrid, Spain; (J.I.R.-A.); (J.Y.-D.); (R.S.-F.)
| | - Israel John Thuissard Vasallo
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Madrid, Spain; (I.J.T.V.); (C.A.-V.)
| | - Cristina Andreu-Vázquez
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Madrid, Spain; (I.J.T.V.); (C.A.-V.)
| | - Ricardo Sanz-Fernández
- Otolaryngology Department, Hospital Universitario de Getafe, Carretera de Toledo, km 12.500, 28905 Getafe, Madrid, Spain; (J.I.R.-A.); (J.Y.-D.); (R.S.-F.)
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Madrid, Spain; (I.J.T.V.); (C.A.-V.)
| | - Carolina Sánchez-Rodríguez
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Madrid, Spain; (I.J.T.V.); (C.A.-V.)
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Yang Y, Zhang D, Yuan G, Wu Y, Huang X. Association between nut consumption and frailty in the elderly: a large sample cross-sectional study. J Hum Nutr Diet 2023; 36:1845-1856. [PMID: 37448140 DOI: 10.1111/jhn.13208] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Limited literature has addressed the impact of nut consumption in mitigating frailty. This study aimed to investigate the association between nut consumption and frailty among Americans aged above 60 years, employing two 24-h dietary recalls for analysis. METHODS The data sets of the National Health and Nutrition Examination Survey (NHANES) (2003-2018) and the Food Patterns Equivalents Database were utilised for a weighted multiple logistic regression model to evaluate the association between nut consumption and frailty in elderly adults. Furthermore, a restricted cubic spline model was employed to investigate the nonlinear relationship between nut intake and frailty. Besides, stratified and interaction analyses were conducted to explore the sensitivity of nut consumption in reducing the risk of frailty in diverse subgroups. RESULTS The research study comprised 10,033 individuals aged 60 years or above, of whom 3591 were classified as frailty and 5302 consumed nuts. In the multivariate logistic regression analysis that adjusted for covariates, the weighted multivariate adjusted odds ratios demonstrated that the prevalence of frailty was lower in the nut intake group than in nonconsumers. The stratified analysis indicated that nearly all subgroups who consumed nuts had a significantly lower risk of frailty compared to nonconsumers, and an interaction was observed between nut intake and nonhypertensive populations. The optimal threshold for nut intake to decrease the risk of frailty was identified as 1.02 ounces. CONCLUSIONS The study concluded that nut consumption has a constructive impact on averting frailty in elderly adults, particularly in nonhypertensive individuals. Nut intake of ~1.02 ounces per day is advantageous in improving the quality of life in elderly adults.
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Affiliation(s)
- Yaqin Yang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Duo Zhang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Guowei Yuan
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuchi Wu
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xinyan Huang
- Hengyang Hospital of Traditional Chinese Medicine, Hunan, Hengyang, China
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Oei S, Millar CL, Nguyen Lily TN, Mukamal KJ, Kiel DP, Lipsitz LA, Hannan MT, Sahni S. Higher intake of dietary flavonols, specifically dietary quercetin, is associated with lower odds of frailty onset over 12 years of follow-up among adults in the Framingham Heart Study. Am J Clin Nutr 2023; 118:27-33. [PMID: 37061164 PMCID: PMC10447475 DOI: 10.1016/j.ajcnut.2023.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 04/17/2023] Open
Abstract
BACKGROUND Polyphenolic antioxidants derived from plant foods may reduce oxidative stress and frailty, but the effect of the polyphenol subclass of dietary flavonoids and their subclasses on frailty is uncertain. OBJECTIVES To determine the association between dietary flavonoids, their subclasses, quercetin (a specific flavonol), and frailty onset in adults. METHODS This prospective cohort study included individuals from the Framingham Heart Study with no frailty at baseline. Intake of total flavonoids, subclasses of flavonoids (flavonols, flavan-3-ols, flavonones, flavones, anthocyanins, and polymeric flavonoids), and quercetin were estimated via semi-quantitative FFQ along with frailty (Fried phenotype), and covariates at baseline (1998-2001). Frailty was re-evaluated in 2011-2014. Logistic regression estimated OR and 95% CIs for each flavonoid variable and frailty onset. RESULTS Mean age was 58.4 y (SD ± 8.3, n = 1701; 55.5% women). The mean total flavonoid intake was 309 mg/d (SD ± 266). After 12.4 (SD ± 0.8) y, 224 (13.2%) individuals developed frailty. Although total flavonoid intake was not statistically associated with frailty onset (adjusted OR: 1.00; 95% CI: 0.99-1.01), each 10 mg/d of higher flavonol intake was linked with 20% lower odds of frailty onset (OR: 0.80; 95% CI: 0.67-0.96). Other subclasses showed no association (P values range: 0.12-0.99), but every 10 mg/d of higher quercetin intake was associated with 35% lower odds of frailty onset (OR: 0.65; 95% CI: 0.48-0.88). CONCLUSIONS Although no association was observed between total flavonoid intake and frailty onset in adults, a higher intake of flavonols was associated with lower odds of frailty onset, with a particularly strong association for quercetin. This hypothesis-generating study highlights the importance of assessing specific subclasses of flavonoids and the potential of dietary flavonols and quercetin as a strategy to prevent the development of frailty.
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Affiliation(s)
- Steven Oei
- Division of Human Nutrition and Health, Wageningen University, Wageningen, the Netherlands; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Courtney L Millar
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | | | - Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Douglas P Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Lewis A Lipsitz
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Marian T Hannan
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
| | - Shivani Sahni
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States.
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Dominguez-López I, Pérez M, Lamuela-Raventós RM. Total (poly)phenol analysis by the Folin-Ciocalteu assay as an anti-inflammatory biomarker in biological samples. Crit Rev Food Sci Nutr 2023:1-7. [PMID: 37283051 DOI: 10.1080/10408398.2023.2220031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The Folin-Ciocalteu method is a well-established and widely used assay for measuring total (poly)phenol content in food/plant products. In recent years, there has been growing interest in applying this method to human samples due to its simplicity and efficacy. However, biological matrices such as blood and urine contain several interference substances that must be eliminated beforehand. This mini-review summarizes the current state of knowledge regarding the use of the Folin-Ciocalteu assay to measure total phenolic content in human urine and blood samples, as well as the preceding cleaning methods to remove interferences. Higher total (poly)phenol levels measured by the Folin-Ciocalteu method have been associated with a decrease in mortality and several risk variables. We focus on the application of this sustainable assay as a biomarker of poly(phenol) intake and its potential use as an anti-inflammatory biomarker in clinical laboratories. The Folin-Ciocalteu method, with a clean-up extraction step, is a reliable tool for determining total (poly)phenol consumption. Here, we also recommend using the Folin-Ciocalteu assay as means to measure anti-inflammatory activity.
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Affiliation(s)
- Inés Dominguez-López
- Polyphenol Research Group, Department of Nutrition, Food Science and Gastronomy, XIA, Faculty of Pharmacy and Food Sciences, Institute of Nutrition and Food Safety (INSA-UB), University of Barcelona, Barcelona, Spain
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Maria Pérez
- Polyphenol Research Group, Department of Nutrition, Food Science and Gastronomy, XIA, Faculty of Pharmacy and Food Sciences, Institute of Nutrition and Food Safety (INSA-UB), University of Barcelona, Barcelona, Spain
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Rosa M Lamuela-Raventós
- Polyphenol Research Group, Department of Nutrition, Food Science and Gastronomy, XIA, Faculty of Pharmacy and Food Sciences, Institute of Nutrition and Food Safety (INSA-UB), University of Barcelona, Barcelona, Spain
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Disentangling the Complexity of Nutrition, Frailty and Gut Microbial Pathways during Aging: A Focus on Hippuric Acid. Nutrients 2023; 15:nu15051138. [PMID: 36904138 PMCID: PMC10005077 DOI: 10.3390/nu15051138] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 02/26/2023] Open
Abstract
Hippuric acid (HA) is a metabolite resulting from the hepatic glycine conjugation of benzoic acid (BA) or from the gut bacterial metabolism of phenylalanine. BA is generally produced by gut microbial metabolic pathways after the ingestion of foods of vegetal origin rich in polyphenolic compounds, namely, chlorogenic acids or epicatechins. It can also be present in foods, either naturally or artificially added as a preservative. The plasma and urine HA levels have been used in nutritional research for estimating the habitual fruit and vegetable intake, especially in children and in patients with metabolic diseases. HA has also been proposed as a biomarker of aging, since its levels in the plasma and urine can be influenced by the presence of several age-related conditions, including frailty, sarcopenia and cognitive impairment. Subjects with physical frailty generally exhibit reduced plasma and urine levels of HA, despite the fact that HA excretion tends to increase with aging. Conversely, subjects with chronic kidney disease exhibit reduced HA clearance, with HA retention that may exert toxic effects on the circulation, brain and kidneys. With regard to older patients with frailty and multimorbidity, interpreting the HA levels in the plasma and urine may result particularly challenging because HA is at the crossroads between diet, gut microbiota, liver and kidney function. Although these considerations may not make HA the ideal biomarker of aging trajectories, the study of its metabolism and clearance in older subjects may provide valuable information for disentangling the complex interaction between diet, gut microbiota, frailty and multimorbidity.
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Tor-Roca A, Mayordomo-Cava J, Andres-Lacueva C, Serra-Rexach JA, Urpi-Sarda M. Adherence to Mediterranean Diet and Response to an Exercise Program to Prevent Hospitalization-Associated Disability in Older Adults: A Secondary Analysis from a Randomized Controlled Trial. J Nutr Health Aging 2023; 27:500-506. [PMID: 37498097 DOI: 10.1007/s12603-023-1929-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/10/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES To investigate the relationship between Mediterranean diet (MedDiet) adherence and response to an exercise and health education program to prevent hospitalization-associated disability (HAD) in acutely hospitalized older adults. DESIGN Randomized controlled trial. SETTING AND PARTICIPANTS Secondary analysis of a subset of 109 participants from AGECAR-PLUS study with available data on MedDiet adherence (mean age 87, and range 75-98). INTERVENTION Participants were randomized into the control group (n = 46, usual care) or the intervention group (n = 63, supervised exercise and health education) at admission. MEASUREMENTS MedDiet adherence was measured with MEDAS and through urinary total polyphenols (UTP). Functional status was assessed with the Barthel Index. RESULTS At discharge, patients in the intervention group who had low levels of MedDiet or UTP showed an increase in functional status [adjusted mean (95% CI) = 77.8 (70.8-84.8) points, p = 0.005, and adjusted mean (95% CI) = 78.0 (68.3-87.7) points, p = 0.020, respectively]. CONCLUSION Older individuals over age 75 with low MedDiet adherence were likely to benefit more from a physical exercise and health education intervention.
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Affiliation(s)
- A Tor-Roca
- Mireia Urpi-Sarda, C/Prat de la Riba, 171, 08921 Santa Coloma de Gramenet, Spain, Tel. 00-34-934021969, e-mail:
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De Simone G, Balducci C, Forloni G, Pastorelli R, Brunelli L. Hippuric acid: Could became a barometer for frailty and geriatric syndromes? Ageing Res Rev 2021; 72:101466. [PMID: 34560280 DOI: 10.1016/j.arr.2021.101466] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022]
Abstract
Aging is a natural biological event that has some downsides such as increased frailty, decline in cognitive and physical functions leading to chronical diseases, and lower quality of life. There is therefore a pressing need of reliable biomarkers to identify populations at risk of developing age-associated syndromes in order to improve their quality of life, promote healthy ageing and a more appropriate clinical management, when needed. Here we discuss the importance of hippuric acid, an endogenous co-metabolite, as a possible hallmark of human aging and age-related diseases, summarizing the scientific literature over the last years. Hippuric acid, the glycine conjugate of benzoic acid, derives from the catabolism by means of intestinal microflora of dietary polyphenols found in plant-based foods (e.g. fruits, vegetables, tea and coffee). In healthy conditions hippuric acid levels in blood and/or urine rise significantly during aging while its excretion drops in conditions related with aging, including cognitive impairments, rheumatic diseases, sarcopenia and hypomobility. This literature highlights the utility of hippuric acid in urine and plasma as a plausible hallmark of frailty, related to low fruit and vegetable intake and changes in gut microflora.
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Affiliation(s)
- Giulia De Simone
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Claudia Balducci
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | | | - Laura Brunelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.
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Ghoreishy SM, Asoudeh F, Jayedi A, Mohammadi H. Fruit and vegetable intake and risk of frailty: A systematic review and dose response meta-analysis. Ageing Res Rev 2021; 71:101460. [PMID: 34534684 DOI: 10.1016/j.arr.2021.101460] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 08/19/2021] [Accepted: 09/11/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE This systematic review and dose-response meta-analysis of observational studies was conducted to summarize available findings on the association between fruits and vegetables (FVs) consumption and risk of frailty. METHODS Online databases including Medline, Scopus, and Embase were searched to detect related publications up to February 2021. Study selection and data extraction were performed by two investigators working in parallel. In most included studies, frailty was defined according to the Fried criteria. Overall, 14 articles with 18,616 subjects with frailty and 101,969 controls were included. To combined data, a random effect model was used. Dose-response associations were also evaluated. RESULTS Fourteen studies (10 cohorts and four cross-sectional) were included. Pooled effect size for the highest versus lowest category of FVs consumption showed an inverse association with risk of frailty (RR cohort = 0.65; 95% CI: 0.50-0.84; I2 = 81%, n = 7). Every one serving (200 g) per day increment in FVs intake was associated with a 14% lower risk of frailty. The risk of frailty decreased linearly up to FVs consumption of 3.5 servings/d, with flattening the curve at higher intake. Pooled analysis regarding fruits and vegetables separately did not indicate a significant association with the risk of frailty. Indeed, the results of the meta-analysis correspond only to the cohort studies. Based on the NutriGrade score, the quality of evidence for a protective effect of FV on frailty was "moderate". CONCLUSIONS FVs consumption was associated with a decreased risk of frailty. Further large-scale prospective cohort studies are needed to reach more confident conclusions.
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Sears B, Saha AK. Dietary Control of Inflammation and Resolution. Front Nutr 2021; 8:709435. [PMID: 34447777 PMCID: PMC8382877 DOI: 10.3389/fnut.2021.709435] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/13/2021] [Indexed: 12/18/2022] Open
Abstract
The healing of any injury requires a dynamic balance of initiation and resolution of inflammation. This hypothesis-generating review presents an overview of the various nutrients that can act as signaling agents to modify the metabolic responses essential for the optimal healing of injury-induced inflammation. In this hypothesis-generating review, we describe a defined nutritional program consisting of an integrated interaction of a calorie-restricted anti-inflammatory diet coupled with adequate levels of omega-3 fatty acids and sufficient levels of dietary polyphenols that can be used in clinical trials to treat conditions associated with insulin resistance. Each dietary intervention works in an orchestrated systems-based approach to reduce, resolve, and repair the tissue damage caused by any inflammation-inducing injury. The orchestration of these specific nutrients and their signaling metabolites to facilitate healing is termed the Resolution Response. The final stage of the Resolution Response is the activation of intracellular 5' adenosine monophosphate-activated protein kinase (AMPK), which is necessary to repair tissue damaged by the initial injury-induced inflammation. The dietary optimization of the Resolution Response can be personalized to the individual by using standard blood markers. Once each of those markers is in their appropriate ranges, activation of intracellular AMPK will be facilitated. Finally, we outline how the resulting activation of AMPK will affect a diverse number of other intercellular signaling systems leading to an extended healthspan.
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Affiliation(s)
- Barry Sears
- Inflammation Research Foundation, Peabody, MA, United States
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Sears B, Perry M, Saha AK. Dietary Technologies to Optimize Healing from Injury-Induced Inflammation. Antiinflamm Antiallergy Agents Med Chem 2021; 20:123-131. [PMID: 32394845 PMCID: PMC9906631 DOI: 10.2174/1871523019666200512114210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 11/22/2022]
Abstract
Inflammation is an acute adaptive response to injury. However, if the initial inflammatory response to an injury is not completely healed, it becomes chronic low-level inflammation that is strongly associated with many chronic disease states, including metabolic (obesity and diabetes), cardiovascular, auto-immune, and neurogenerative disorders as well as cancer. The healing process is far more complex than the initiation of inflammation. Within that complexity of healing is a sequence of events that are under profound dietary control and can be defined by specific blood markers. Those molecular events of the healing process that are under significant dietary control are termed as the Resolution Response. The purpose of this review is to describe the molecular components of the Resolution Response and how different dietary factors can either optimize or inhibit their actions. In particular, those dietary components that optimize the Resolution Response include a calorie-restricted, protein-adequate, moderate-carbohydrate, low-fat diet referred to as the Zone diet, omega-3 fatty acids, and polyphenols. The appropriate combination of these dietary interventions constitutes the foundation of Pro-Resolution Nutrition. The effect of these dietary components the actions of NF-κB, AMPK, eicosanoids, and resolvins are described in this review, as well as ranges of appropriate blood markers that indicate success in optimizing the Resolution Response by dietary interventions.
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Affiliation(s)
- Barry Sears
- Inflammation Research Foundation, Peabody, MA 01960, USA,Address correspondence to these authors at the Inflammation Research Foundation, Peabody, MA 01960, USA; E-mails: and
| | - Mary Perry
- Inflammation Research Foundation, Peabody, MA 01960, USA
| | - Asish K. Saha
- Inflammation Research Foundation, Peabody, MA 01960, USA,Address correspondence to these authors at the Inflammation Research Foundation, Peabody, MA 01960, USA; E-mails: and
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Davinelli S, Corbi G, Scapagnini G. Frailty syndrome: A target for functional nutrients? Mech Ageing Dev 2021; 195:111441. [PMID: 33539905 DOI: 10.1016/j.mad.2021.111441] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 12/20/2022]
Abstract
Frailty is a late life phenotype characterized by a decline in physiological reserve across several organ systems, resulting in the increased susceptibility to endogenous and/or exogenous stressors. Although the etiology of frailty remains poorly understood, an interconnected network of putative mechanisms linked to the ageing process has been proposed. However, frailty is a dynamic process that may be prevented, delayed, or even reversed. The syndromic nature of frailty requires a multidomain approach, such as proper nutrition, as part of modifiable environmental factors, and represents one of the most promising and least costly ways to prevent and reduce frailty among older adults. Nutrient deficiencies have been consistently associated with frailty; however, mounting evidence also supports the hypothesis that beyond the traditional nutritional value, specific dietary components may exert function-enhancing effects and mitigate the extent of frailty. Thus, further mechanistic studies, along with large clinical trials, are imperative to establish the exact role of functional nutrients in the clinical management of frailty. Here, we provide a contemporary discussion of how emerging functional nutrients may contribute to modify the trajectory of the frailty syndrome.
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Affiliation(s)
- Sergio Davinelli
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.
| | - Graziamaria Corbi
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Giovanni Scapagnini
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
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Regional Differences in the Association between Dietary Patterns and Muscle Strength in Korean Older Adults: Data from the Korea National Health and Nutrition Examination Survey 2014-2016. Nutrients 2020; 12:nu12051377. [PMID: 32408472 PMCID: PMC7284570 DOI: 10.3390/nu12051377] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/29/2020] [Accepted: 05/06/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives: Adequate nutrition is an important factor to prevent sarcopenia in older adults. The purpose of this study was to identify the regional differences in the association between dietary pattern and muscle strength in older Korean adults. Methods: This study was based on data from the Korea National Health and Nutrition Examination Survey (KNHANES) in 2014–2016. Muscle strength was measured by grip strength, and dietary patterns were derived by a cluster analysis using the k-means algorithm. Multiple logistic regression analyses were applied to determine the associations between factors (dietary patterns and residential areas) and grip strength. Results: Most participants in the rural area group (50.4%) had the Cluster Three dietary pattern (diet dominant in white rice and kimchi), while most people in the urban area group (43.8%) and the metropolitan area group (53.2%) had the Cluster One dietary pattern (diet dominant in fruits and fish). Those having poor hand grip strength represented 25.8% of the total in rural, 20.6% in urban, and 17.9% in metropolitan (p = 0.009) areas. Upon adjustment for socio-demographic characteristics, health behaviors, and co-morbidity, the odds ratio of Cluster Two (diet dominant in meat) was 1.601 (95%, CI: 1.001–2.563, p = 0.050) compared to the Cluster Three dietary pattern, but there was no significant difference in residence. Conclusions: Muscle strength in the elderly was more related to dietary pattern than was residence. Education and support for conveying the importance of protein intake in the elderly are required to motivate adequate nutrition. In addition, these actions should lead to prevention of muscle weakness and further prevent frailty.
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Panchenko AV, Tyndyk ML, Fedoros EI, Maydin MA, Semenov AL, Gubareva EA, Golubev AG, Anisimov VN. Comparative Analysis of Experimental Data on the Effects of Different Polyphenols on Lifespan and Aging. ADVANCES IN GERONTOLOGY 2020. [DOI: 10.1134/s2079057019040131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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15
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Hoogendijk EO, Stenholm S, Ferrucci L, Bandinelli S, Inzitari M, Cesari M. Operationalization of a frailty index among older adults in the InCHIANTI study: predictive ability for all-cause and cardiovascular disease mortality. Aging Clin Exp Res 2020; 32:1025-1034. [PMID: 32006385 PMCID: PMC7260260 DOI: 10.1007/s40520-020-01478-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/10/2020] [Indexed: 12/31/2022]
Abstract
Background The frailty index (FI) is a sensitive instrument to measure the degree of frailty in older adults, and is increasingly used in cohort studies on aging. Aims To operationalize an FI among older adults in the “Invecchiare in Chianti” (InCHIANTI) study, and to validate its predictive capacity for mortality. Methods Longitudinal data were used from 1129 InCHIANTI participants aged ≥ 65 years. A 42-item FI was operationalized following a standard procedure using baseline data (1998/2000). Associations of the FI with 3- and 6-year all-cause and cardiovascular disease (CVD) mortality were studied using Cox regression. Predictive accuracy was estimated by the area under the ROC curve (AUC), for a continuous FI score and for different cut-points. Results The median FI was 0.13 (IQR 0.08–0.21). Scores were higher in women, and at advanced age. The FI was associated with 3- and 6-year all-cause and CVD mortality (HR range per 0.01 FI increase = 1.03–1.07, all p < 0.001). The continuous FI score predicted the mortality outcomes with moderate-to-good accuracy (AUC range 0.72–0.83). When applying FI cut-offs between 0.15 and 0.35, the accuracy of this FI for predicting mortality was moderate (AUC range 0.61–0.76). Overall, the predictive accuracy of the FI was higher in women than in men. Conclusions The FI operationalized in the InCHIANTI study is a good instrument to grade the risk of all-cause mortality and CVD mortality. More measurement properties, such as the responsiveness of this FI when used as outcome measure, should be investigated in future research. Electronic supplementary material The online version of this article (10.1007/s40520-020-01478-3) contains supplementary material, which is available to authorized users.
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Del Bo' C, Bernardi S, Marino M, Porrini M, Tucci M, Guglielmetti S, Cherubini A, Carrieri B, Kirkup B, Kroon P, Zamora-Ros R, Liberona NH, Andres-Lacueva C, Riso P. Systematic Review on Polyphenol Intake and Health Outcomes: Is there Sufficient Evidence to Define a Health-Promoting Polyphenol-Rich Dietary Pattern? Nutrients 2019; 11:nu11061355. [PMID: 31208133 PMCID: PMC6627994 DOI: 10.3390/nu11061355] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 12/21/2022] Open
Abstract
Growing evidence support association between polyphenol intake and reduced risk for chronic diseases, even if there is a broad debate about the effective amount of polyphenols able to exert such protective effect. The present systematic review provides an overview of the last 10-year literature on the evaluation of polyphenol intake and its association with specific disease markers and/or endpoints. An estimation of the mean total polyphenol intake has been performed despite the large heterogeneity of data reviewed. In addition, the contribution of dietary sources was considered, suggesting tea, coffee, red wine, fruit and vegetables as the main products providing polyphenols. Total flavonoids and specific subclasses, but not total polyphenols, have been apparently associated with a low risk of diabetes, cardiovascular events and all-cause mortality. However, large variability in terms of methods for the evaluation and quantification of polyphenol intake, markers and endpoints considered, makes it still difficult to establish an evidence-based reference intake for the whole class and subclass of compounds. Nevertheless, the critical mass of data available seem to strongly suggest the protective effect of a polyphenol-rich dietary pattern even if further well targeted and methodologically sound research should be encouraged in order to define specific recommendations.
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Affiliation(s)
- Cristian Del Bo'
- Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, 20133 Milan, Italy.
| | - Stefano Bernardi
- Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, 20133 Milan, Italy.
| | - Mirko Marino
- Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, 20133 Milan, Italy.
| | - Marisa Porrini
- Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, 20133 Milan, Italy.
| | - Massimiliano Tucci
- Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, 20133 Milan, Italy.
| | - Simone Guglielmetti
- Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, 20133 Milan, Italy.
| | - Antonio Cherubini
- Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, 60127 Ancona, Italy.
| | - Barbara Carrieri
- Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, 60127 Ancona, Italy.
- Department of Life and Environmental Sciences, Polytechnic University of Marche, Via Brecce Bianche, 60131 Ancona, Italy.
| | - Benjamin Kirkup
- Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UG, UK.
| | - Paul Kroon
- Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UG, UK.
| | - Raul Zamora-Ros
- Unit of Nutrition and Cancer, Cancer Epidemiology Research Programme, Catalan Institute of Oncology (ICO), Bellvitge Biomedical Research Institute (IDIBELL), 08908 L'Hospitalet de Llobregat, Spain.
| | - Nicole Hidalgo Liberona
- Biomarkers and Nutrimetabolomics Laboratory, Department of Nutrition, Food Sciences and Gastronomy, XaRTA, INSA, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain.
- CIBER Fragilidad y Envejecimiento Saludable (CIBERfes), Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - Cristina Andres-Lacueva
- Biomarkers and Nutrimetabolomics Laboratory, Department of Nutrition, Food Sciences and Gastronomy, XaRTA, INSA, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain.
- CIBER Fragilidad y Envejecimiento Saludable (CIBERfes), Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - Patrizia Riso
- Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, 20133 Milan, Italy.
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Zhao D, Simon JE, Wu Q. A critical review on grape polyphenols for neuroprotection: Strategies to enhance bioefficacy. Crit Rev Food Sci Nutr 2019; 60:597-625. [PMID: 30614258 DOI: 10.1080/10408398.2018.1546668] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The aging of populations worldwide is driving greater demands for dietary polyphenols which have been recognized as promising prophylactic and/or therapeutic agents in the context of neurodegeneration, and are ubiquitously present in plant-based diets. In particular, grape-derived products encompass a wide array of phenolic compounds purported with multiple health benefits including neuroprotective efficacy. Despite the increasing preclinical and clinical evidence demonstrating high potential of grape polyphenol (GPP)-rich botanicals in preventing and attenuating diverse neurodegenerative disorders, the limited bioavailability of GPPs, especially in the brain, generates questions as to their applications and effectiveness in neuroprotection. To address this issue, significant research efforts have been made to enhance oral bioavailability of GPPs via application of novel strategies. This review highlights some critical issues related to the bioavailability and neuroprotective efficacy of GPPs and GPP-rich botanicals. The representative bioavailability-enhancing strategies are critically reviewed to provide practical solutions for augmenting the bioefficacy of GPP-rich botanicals. Synergistic applications of encapsulation techniques (for physiochemical protection and bypassing xenobiotic metabolism) and dietary intervention strategies involving modulation of gut microbiota (for generating more bioavailable phenolic metabolites) appear promising, and may substantially enhance the bioefficacy, especially the neuroprotective efficacy, of orally consumed GPPs.
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Affiliation(s)
- Danyue Zhao
- New Use Agriculture and Natural Plant Products Program, Department of Plant Biology, School of Environmental and Biological Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - James E Simon
- New Use Agriculture and Natural Plant Products Program, Department of Plant Biology, School of Environmental and Biological Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Qingli Wu
- New Use Agriculture and Natural Plant Products Program, Department of Plant Biology, School of Environmental and Biological Sciences, Rutgers University, New Brunswick, New Jersey, USA
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Wang J, Maxwell CA, Yu F. Biological Processes and Biomarkers Related to Frailty in Older Adults: A State-of-the-Science Literature Review. Biol Res Nurs 2018; 21:80-106. [DOI: 10.1177/1099800418798047] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The objectives of this literature review were to (1) synthesize biological processes linked to frailty and their corresponding biomarkers and (2) identify potential associations among these processes and biomarkers. In September 2016, PubMed, Cumulative Index to Nursing and Allied Health, Cochrane Library, and Embase were searched. Studies examining biological processes related to frailty in older adults (≥60 years) were included. Studies were excluded if they did not employ specific measures of frailty, did not report the association between biomarkers and frailty, or focused on nonelderly samples (average age < 60). Review articles, commentaries, editorials, and non-English articles were also excluded. Fifty-two articles were reviewed, reporting six biological processes related to frailty and multiple associated biomarkers. The processes (biomarkers) include brain changes (neurotrophic factor, gray matter volume), endocrine dysregulation (growth hormones [insulin-like growth factor-1 and binding proteins], hormones related to glucose and insulin, the vitamin D axis, thyroid function, reproductive axis, and hypothalamic–pituitary–adrenal axis), enhanced inflammation (C-reactive protein, interleukin-6), immune dysfunction (neutrophils, monocytes, neopterin, CD8+CD28−T cells, albumin), metabolic imbalance (micronutrients, metabolites, enzyme-activity indices, metabolic end products), and oxidative stress (antioxidants, telomere length, glutathione/oxidized glutathione ratio). Bidirectional interrelationships exist within and between these processes. Biomarkers were associated with frailty in varied strengths, and the causality remains unclear. In conclusion, frailty is related to multisystem physiological changes. Future research should examine the dynamic interactions among these processes to inform causality of frailty. Given the multifactorial nature of frailty, a composite index of multisystem biomarkers would likely be more informative than single biomarkers in early detection of frailty.
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Affiliation(s)
- Jinjiao Wang
- School of Nursing, University of Rochester, Rochester, NY, USA
| | | | - Fang Yu
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
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Villani A, Wright H, Slater G, Buckley J. A randomised controlled intervention study investigating the efficacy of carotenoid-rich fruits and vegetables and extra-virgin olive oil on attenuating sarcopenic symptomology in overweight and obese older adults during energy intake restriction: protocol paper. BMC Geriatr 2018; 18:2. [PMID: 29304744 PMCID: PMC5755414 DOI: 10.1186/s12877-017-0700-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 12/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background Weight loss interventions have not been advocated for overweight/obese older adults due to potential loss of skeletal muscle and strength impacting on physical function with potential loss of independence. Carotenoids and polyphenols are inversely associated with sarcopenic symptomology. This paper reports the protocol of a study evaluating the efficacy of a high-protein, energy restricted diet rich in carotenoids and polyphenols on body composition, muscle strength, physical performance and quality of life in overweight and obese older adults. Methods This randomised controlled clinical trial will recruit community-dwelling, healthy overweight and obese older adults (≥60 years) for a 12-week weight loss intervention. Seventy-three participants will be recruited and randomized to an energy restricted (~30% restriction), isocaloric diet (30% protein; 30% carbohydrate; 40% fat) enriched with either: a) 375 g/d of high carotenoid vegetables, 300 g/d high carotenoid fruit, and 40-60 ml extra-virgin olive oil (EVOO); or b) 375 g/d of lower carotenoid vegetables, 300 g/d lower carotenoid fruit, and 40-60 ml Polyunsaturated fatty acid (PUFA) based oil. All participants will receive individual dietary counselling each fortnight for the duration of the study and will be asked to maintain their habitual level of physical activity throughout the study. The primary outcome will be appendicular skeletal muscle (ASM) assessed by dual energy X-ray absorptiometry (DXA). Secondary outcomes will include body weight, fat-free mass (FFM), fat mass (FM), muscle strength (Isometric hand-grip strength), physical performance (Short Physical Performance Battery), physical activity (International Physical Activity Questionnaire) and health related quality of life (SF-36). Outcomes will be measured at baseline and at week 12. Discussion The results of this study will provide a novel insight relating to the potential influence of high carotenoid and polyphenol intakes on attenuation of ASM during dietary energy-restricted weight loss in overweight and obese older adults. Trial registration The trial was registered on the Australia New Zealand Clinical Trials Register (ACTRN12616001400459); Trial registration date: 10th October, 2016.
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Affiliation(s)
- Anthony Villani
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, QLD, Australia.
| | - Hattie Wright
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Gary Slater
- School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Jonathan Buckley
- Alliance for Research in Exercise, Nutrition and Activity (ARENA), Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
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20
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Bauer JM, Morley JE. The relevance of healthy diets for the prevention of frailty and cognitive impairment. Curr Opin Clin Nutr Metab Care 2018; 21:1-3. [PMID: 29049044 DOI: 10.1097/mco.0000000000000438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jürgen M Bauer
- Center for Geriatric Medicine, Agaplesion Bethanien Krankenhaus Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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21
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Affiliation(s)
- B Vellas
- John E. Morley, MB,BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104,
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Adherence to Mediterranean Diet and Frailty. J Am Med Dir Assoc 2017; 19:315-322.e2. [PMID: 29289542 DOI: 10.1016/j.jamda.2017.11.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Το investigate associations between adherence to the Mediterranean diet and frailty in a Greek population of older adults. DESIGN Cross-sectional study. SETTING Data were drawn from the Hellenic longitudinal Investigation of Aging and Diet (HELIAD), a population-based, multidisciplinary study designed to estimate the prevalence and incidence of dementia in the Greek population. PARTICIPANTS Data from 1740 participants aged ≥65 years were included in the present analysis. Participants were selected through random sampling from the records of 2 Greek municipalities. MEASUREMENTS Adherence to Mediterranean diet was evaluated through the MedDietScore, calculated from the information participants provided to a validated food frequency questionnaire. Frailty was assessed using 3 different definitions (the phenotypic approach proposed by Fried et al, the Frailty Index, and the Tilburg Frailty Indicator). Unadjusted and adjusted logistic and linear regression models were performed. RESULTS Of our participants, 70 (4%), 325 (18.7%), and 442 (25.4%) were identified as frail according to the Fried et al definition, the Frailty Index, and the Tilburg Frailty Indicator, respectively. Adjusting for confounding factors, each additional unit in the MedDietScore was associated with a 5% (P = .09), 4% (P = .005), and 7% (P < .001) decrease in the odds for frailty according to the Fried definition, the Frailty Index, and the Tilburg Frailty Indicator, respectively. CONCLUSIONS According to study results, a higher adherence to the Mediterranean diet was associated with lower odds of frailty, irrespective of the definition used. This finding may be of relevance in the setting of population-based prevention efforts as well as in clinical practice.
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McClure R, Villani A. Mediterranean Diet attenuates risk of frailty and sarcopenia: New insights and future directions. JCSM CLINICAL REPORTS 2017. [DOI: 10.17987/jcsm-cr.v2i2.45] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sarcopenia and physical frailty are associated with progressive disability and predictive of negative health outcomes. Dietary interventions are considered the cornerstone in the management of sarcopenic symptomology and physical frailty. However few studies have investigated preventative strategies. Moreover, most studies have focused on the efficacy of individual nutrients or supplements rather than dietary patterns. The Mediterranean Diet (MedDiet) is a dietary pattern that provides evidence for an association between diet quality, healthy ageing and disease prevention. The purpose of this paper was to examine, synthesise and develop a narrative review of the current literature, investigating the potential benefits associated with adherence to a MedDiet and attenuation of physical frailty and sarcopenic symptomology in older adults. We also explored the underlying mechanisms underpinning the potential benefits of the MedDiet on ameliorating physical frailty and sarcopenic symptomology. Synthesis of the reviewed literature is suggestive of a decreased risk of physical frailty and sarcopenic symptomology with greater adherence to a MedDiet. We identified the anti-inflammatory and high antioxidant components of the MedDiet as two potential biological mechanisms involved. Due to a lack of evidence from RCTs to support the proposed physiological mechanisms, we suggest investigating these observations in older adults with type 2 diabetes (T2DM) whom are vulnerable to physical frailty and disability. A number of biological mechanisms describing the pathway to disability in older adults with T2DM have been postulated with many of these mechanisms potentially mitigated with dietary interventions involving the MedDiet. Exploring these mechanisms with the use of well-designed, longer-term dietary intervention studies in older adults with an increased vulnerability to physical frailty and sarcopenia is warranted.
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A systematic review of studies comparing potential biochemical biomarkers of frailty with frailty assessments. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Guo X, Tresserra-Rimbau A, Estruch R, Martínez-González MA, Medina-Remón A, Fitó M, Corella D, Salas-Salvadó J, Portillo MP, Moreno JJ, Pi-Sunyer X, Lamuela-Raventós RM. Polyphenol Levels Are Inversely Correlated with Body Weight and Obesity in an Elderly Population after 5 Years of Follow Up (The Randomised PREDIMED Study). Nutrients 2017; 9:nu9050452. [PMID: 28467383 PMCID: PMC5452182 DOI: 10.3390/nu9050452] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 12/17/2022] Open
Abstract
Overweight and obesity have been steadily increasing in recent years and currently represent a serious threat to public health. Few human studies have investigated the relationship between polyphenol intake and body weight. Our aim was to assess the relationship between urinary polyphenol levels and body weight. A cross-sectional study was performed with 573 participants from the PREDIMED (Prevención con Dieta Mediterránea) trial (ISRCTN35739639). Total polyphenol levels were measured by a reliable biomarker, total urinary polyphenol excretion (TPE), determined by the Folin-Ciocalteu method in urine samples. Participants were categorized into five groups according to their TPE at the fifth year. Multiple linear regression models were used to assess the relationships between TPE and obesity parameters; body weight (BW), body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR). After a five years follow up, significant inverse correlations were observed between TPE at the 5th year and BW (β = −1.004; 95% CI: −1.634 to −0.375, p = 0.002), BMI (β = −0.320; 95% CI: −0.541 to −0.098, p = 0.005), WC (β = −0.742; 95% CI: −1.326 to −0.158, p = 0.013), and WHtR (β = −0.408; 95% CI: −0.788 to −0.028, p = 0.036) after adjustments for potential confounders. To conclude, a greater polyphenol intake may thus contribute to reducing body weight in elderly people at high cardiovascular risk.
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Affiliation(s)
- Xiaohui Guo
- Department of Nutrition, Food Science and Gastronomy, XaRTA, INSA-UB, School of Pharmacy and Food Science, University of Barcelona, 08028 Barcelona, Spain.
| | - Anna Tresserra-Rimbau
- Department of Nutrition, Food Science and Gastronomy, XaRTA, INSA-UB, School of Pharmacy and Food Science, University of Barcelona, 08028 Barcelona, Spain.
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - Ramón Estruch
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Department of Internal Medicine, Hospital Clínic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Miguel A Martínez-González
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Department of Preventive Medicine and Public Health, School of Medicine & IdiSNA (Institute for Health Research), University of Navarra, 31080 Pamplona, Spain.
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA 02115, USA.
| | - Alexander Medina-Remón
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Department of Internal Medicine, Hospital Clínic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Montserrat Fitó
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Cardiovascular Risk and Nutrition Research Group (CARIN, Regicor Study Group), IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain.
| | - Dolores Corella
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Department of Epidemiology, Preventive Medicine and Public Health, School of Medicine, University of Valencia, 46010 Valencia, Spain.
| | - Jordi Salas-Salvadó
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Human Nutrition Unit, University Hospital of Sant Joan de Reus, Department of Biochemistry and Biotechnology, Faculty of Medicine and Health Sciences, IISPV, Rovira i Virgili University, 43201 Reus, Spain.
| | - Maria Puy Portillo
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Nutrition and Obesity Group, Department of Nutrition and Food Science, Faculty of Pharmacy and Lucio Lascaray Research Institute, University of País Vasco (UPV/EHU), 01006 Vitoria, Spain.
| | - Juan J Moreno
- Department of Nutrition, Food Science and Gastronomy, XaRTA, INSA-UB, School of Pharmacy and Food Science, University of Barcelona, 08028 Barcelona, Spain.
| | - Xavier Pi-Sunyer
- New York Obesity Research Center, Department of Medicine and Institute of Human Nutrition, Columbia University, New York, NY 10032, USA.
| | - Rosa M Lamuela-Raventós
- Department of Nutrition, Food Science and Gastronomy, XaRTA, INSA-UB, School of Pharmacy and Food Science, University of Barcelona, 08028 Barcelona, Spain.
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, 28029 Madrid, Spain.
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Yannakoulia M, Ntanasi E, Anastasiou CA, Scarmeas N. Frailty and nutrition: From epidemiological and clinical evidence to potential mechanisms. Metabolism 2017; 68:64-76. [PMID: 28183454 DOI: 10.1016/j.metabol.2016.12.005] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 11/25/2016] [Accepted: 12/06/2016] [Indexed: 12/25/2022]
Abstract
Frailty is a geriatric condition characterized by unintentional weight loss, low muscle strength, feeling of exhaustion, reduced physical activity capacity and slow walking speed. Theoretically, nutrition is a factor closely related to the frailty syndrome: all frailty criteria are more or less affected by poor eating habits, whereas frailty itself may have a negative effect on eating and, thus, on the nutritional status. Indeed, research data suggest an association between frailty and specific constituents of diet, namely protein and energy intake, as well as intakes of specific micronutrients. Furthermore, healthy dietary patterns, such as the Mediterranean diet, have been linked to the frailty prevention. In the present narrative review, we critically evaluate cross-sectional, prospective and intervention studies examining the relationship between diet and frailty development and prevention. Potential mechanisms linking nutrition and frailty as well as directions for future research are discussed.
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Affiliation(s)
- Mary Yannakoulia
- School of Health Sciences and Education, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece.
| | - Eva Ntanasi
- School of Health Sciences and Education, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece; Department of Social Medicine, Psychiatry and Neurology, National and Kapodistrian, University of Athens, Greece
| | - Costas A Anastasiou
- School of Health Sciences and Education, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
| | - Nikolaos Scarmeas
- Department of Social Medicine, Psychiatry and Neurology, National and Kapodistrian, University of Athens, Greece; Taub Institute for Research in Alzheimer's Disease and the Aging Brain, Gertrude H. Sergievsky Center, Department of Neurology, Columbia University, NY, New York, USA
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27
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Morley JE. Nutrition and Aging Well. J Am Med Dir Assoc 2017; 18:91-94. [DOI: 10.1016/j.jamda.2016.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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Affiliation(s)
- John E Morley
- aDivisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, Missouri, USA bCenter for Geriatric Medicine, University Heidelberg, AGAPLESION Bethanien Hospital, Heidelberg, Germany
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Affiliation(s)
- B Fougère
- John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104,
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TAGUCHI C, KISHIMOTO Y, FUKUSHIMA Y, SAITA E, TANAKA M, TAKAHASHI Y, MASUDA Y, GODA T, KONDO K. Dietary Polyphenol Intake Estimated by 7-Day Dietary Records among Japanese Male Workers: Evaluation of the Within- and Between-Individual Variation. J Nutr Sci Vitaminol (Tokyo) 2017; 63:180-185. [DOI: 10.3177/jnsv.63.180] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Chie TAGUCHI
- Endowed Research Department “Food for Health”, Ochanomizu University
| | - Yoshimi KISHIMOTO
- Endowed Research Department “Food for Health”, Ochanomizu University
| | | | - Emi SAITA
- Endowed Research Department “Food for Health”, Ochanomizu University
| | - Miori TANAKA
- Department of Nutrition and Food Science, Graduate School of Humanities and Sciences, Ochanomizu University
| | | | | | - Toshinao GODA
- School of Food and Nutritional Sciences, University of Shizuoka
| | - Kazuo KONDO
- Endowed Research Department “Food for Health”, Ochanomizu University
- Institute of Life Innovations Studies, Toyo University
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31
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Nascimento-Souza MA, de Paiva PG, Pérez-Jiménez J, do Carmo Castro Franceschini S, Ribeiro AQ. Estimated dietary intake and major food sources of polyphenols in elderly of Viçosa, Brazil: a population-based study. Eur J Nutr 2016; 57:617-627. [PMID: 27873069 DOI: 10.1007/s00394-016-1348-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 11/15/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE Epidemiological studies have remarked the beneficial role that polyphenols may have in the elderly population such as cancer and cardiovascular disease prevention. This is particularly relevant considering the global tendency of population aging. Data on polyphenol intake in the elderly population are scarce and usually provide partial information-only for some polyphenol classes. The aim of this study was to estimate the intake of polyphenols and its major dietary contributors in the population of Viçosa. METHODS A cross-sectional population-based survey including 620 elderly was conducted in Viçosa, Brazil. Food intake was estimated by recall of habitual consumption (RHC). Polyphenol intake was calculated by matching food consumption data from the RHC with the polyphenol content in foods listed in the Phenol-Explorer database. RESULTS The average total polyphenol intake was 1198.6 mg/day (533.7 mg/day as aglycone). The main polyphenol classes were phenolic acids (729.5 mg/day) and flavonoids (444.7 mg/day). The main dietary contributors for total polyphenols were coffee (45.8%), beans (32.8%) and polenta (1.3%). A total of 292 polyphenols divided in 14 classes and 23 subclasses were found. The individual compounds with the highest intake were isomers of chlorogenic acid (i.e., 5-caffeoylquinic acid, 4-caffeoylquinic acid and 3-caffeoylquinic acid) among hydroxycinnamic acids that largely originated from coffee. CONCLUSIONS The data reported here can be used to evaluate the association between the amount and type of ingested polyphenols and health outcomes in epidemiological studies in order to eventually establish nutritional recommendations.
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Affiliation(s)
| | - Pedro Gontijo de Paiva
- Departament of Chemical Engineering, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Jara Pérez-Jiménez
- Departament Metabolism and Nutrition, Institute of Food Science, Technology and Nutrition, Spanish Research Council (ICTAN-CSIC), Madrid, Spain
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32
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Rabassa M, Zamora-Ros R, Andres-Lacueva C, Urpi-Sarda M, Bandinelli S, Ferrucci L, Cherubini A. Association between Both Total Baseline Urinary and Dietary Polyphenols and Substantial Physical Performance Decline Risk in Older Adults: A 9-year Follow-up of the InCHIANTI Study. J Nutr Health Aging 2016; 20:478-85. [PMID: 27102783 PMCID: PMC5155507 DOI: 10.1007/s12603-015-0600-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
IMPORTANCE The decline in physical performance that occurs in many older subjects is a strong predictor of falls, hospitalization, institutionalization and mortality. Polyphenols are bioactive compounds that may play a preventive role against physical performance decline due to their antioxidant and anti-inflammatory properties. OBJECTIVE To investigate the association between total urinary polyphenols (TUP) and total dietary polyphenols (TDP) and substantial physical performance decline over a nine-year period among older subjects. METHODS This longitudinal study included 368 participants aged 65 years or older from the InCHIANTI (Invecchiare in Chianti) study, an Italian population-based cohort. TUP and TDP concentrations were assessed at baseline using the Folin-Ciocalteau (F-C) assay and a validated food frequency questionnaire, respectively. Physical performance was objectively measured at baseline and at nine-year follow-up using the Short Physical Performance Battery (SPPB). A substantial decline in physical performance was considered as a decrease of three or more points in the SPPB score. RESULTS At the nine-year follow-up assessment, 71 participants had suffered a substantial decline in physical performance. In the fully adjusted logistic regression model, participants in the highest TUP tertile had a lower risk of substantial decline in physical performance than those in the lowest tertile (OR, 0.40; 95% CI, 0.17-0.93; P trend=0.033). However, no significant association between TDP intake and physical performance decline was observed. CONCLUSION This study shows that high TUP concentrations, a biomarker of polyphenol-rich exposure, were associated with lower risk of substantial decline in physical performance in community-dwelling older subjects over a nine-year period. These results suggest that a polyphenol-rich diet may play a role in protecting against physical performance decline in older people.
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Affiliation(s)
- M Rabassa
- C. Andres-Lacueva, Biomarkers and Nutrimetabolomic Laboratory, Nutrition and Food Science Department, Campus Torribera, Pharmacy and Food Sciences Faculty, University of Barcelona, Av. Joan XXIII s/n, 08028 Barcelona, Spain. E-mail:
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Taguchi C, Fukushima Y, Kishimoto Y, Suzuki-Sugihara N, Saita E, Takahashi Y, Kondo K. Estimated Dietary Polyphenol Intake and Major Food and Beverage Sources among Elderly Japanese. Nutrients 2015; 7:10269-81. [PMID: 26690212 PMCID: PMC4690082 DOI: 10.3390/nu7125530] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 11/09/2015] [Accepted: 12/02/2015] [Indexed: 01/11/2023] Open
Abstract
Estimating polyphenol intake contributes to the understanding of polyphenols' health benefits. However, information about human polyphenol intake is scarce, especially in the elderly. This study aimed to estimate the dietary intake and major sources of polyphenols and to determine whether there is any relationship between polyphenol intake and micronutrient intake in healthy elderly Japanese. First, 610 subjects (569 men, 41 women; aged 67.3 ± 6.1 years) completed food frequency questionnaires. We then calculated their total polyphenol intake using our polyphenol content database. Their average total polyphenol intake was 1492 ± 665 mg/day, the greatest part of which was provided by beverages (79.1%). The daily polyphenol intake differed largely among individuals (183-4854 mg/day), also attributable mostly to beverage consumption. Coffee (43.2%) and green tea (26.6%) were the major sources of total polyphenol; the top 20 food items accounted for >90%. The polyphenol intake did not strongly correlate with the intake of any micronutrient, suggesting that polyphenols may exert health benefits independently of nutritional intake. The polyphenol intake in this elderly population was slightly higher than previous data in Japanese adults, and beverages such as coffee and green tea contributed highly to the intake.
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Affiliation(s)
- Chie Taguchi
- Endowed Research Department "Food for Health", Ochanomizu University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo 112-8610, Japan.
| | - Yoichi Fukushima
- Nestlé Japan Ltd., NYK Tennoz Blidg., 2-2-20 Higashi-Shinagawa, Shinagawa-ku, Tokyo 140-0002, Japan.
| | - Yoshimi Kishimoto
- Endowed Research Department "Food for Health", Ochanomizu University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo 112-8610, Japan.
| | - Norie Suzuki-Sugihara
- Department of Nutrition and Food Science, Graduate School of Humanities and Sciences, Ochanomizu University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo 112-8610, Japan.
| | - Emi Saita
- Endowed Research Department "Food for Health", Ochanomizu University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo 112-8610, Japan.
| | - Yoshinari Takahashi
- TES Holdings Co., Ltd., 6F Tokyo University Entrepreneurs Plaza, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Kazuo Kondo
- Endowed Research Department "Food for Health", Ochanomizu University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo 112-8610, Japan.
- Institute of Life Innovation Studies, Toyo University, 1-1-1 Izumino, Itakura-machi, Ora-gun, Gunma 374-0193, Japan.
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