Integrazione
g
nutrizionale
nell’anziano: CONTRO
Prof. Mauro Zamboni
Cattedra di Geriatria
Università di Verona
Strategy to complement the habitual
di t
dietary
i t k s of
intakes
f older
ld adults
d lts
1. Meal enhancement
2. Multivitamin/multimineral
supplements (MVM)
3. Oral liquid
q
nutrition supplements
pp
(ONS)
Heidi J Silver, Nutrition Review, 2009
MVM supplements
• Multivitamin/multiminerals formulas.
• Wide variety of formulation.
• Usually
U
ll included
i l d d antioxidants
ti id t and/or
d/
herbal, fruit and vegetable extracts
Heidi J Silver, Nutrition Review, 2009
The use of MVM supplements in USA
10% higher
Bailey RL et al. J Nutr 2011
Prev
velance o
of dietary supplem
ment use
NHANES 2003-2006:
9957 subjects, between 19 and >71 years old
80%
65%
70%
60%
50%
71%
49%
39%
40%
30%
20%
10%
0%
19-30 anni
31-50anni
51-70anni
>71 anni
Bailey RL et al. J Nutr 2011
NHANES 2003-2006:
9957 subjects
subjects, between 19 and >71 years old
MVM 33% (B-6, B-12, vit C, A, E, K)
Botanical suppl 14%
EAA 4%
Bailey RL et al. J Nutr 2011
NHANES 2003-2006:
9957 subjects
subjects, between 19 and >71 years old
Bailey RL et al. J Nutr 2011
EPIC study (1995-2000): 36034 subjects between
35-74
35
74 years from 8 european states (23 centers)
10%
Skeie G. et al.,2009
The use of dietary supplements in Italy
EPIC study 1995-2000
(3953 subjects between 35 e 75y)
Skeie G. et al., 2009
MVM
Outcomes
Effects of multivitamin and mineral supplementation on
episodes of infection in Nursing Home Residents
RCT, 763 subjects, 21 long-term-care facilities, average age 83 years
18 months supplementation (multivitamin and multimineral)
18-
Nel modello multivariato nessuna differenza significativa
anche
h nell’assunzione
ll’ ss
i
di antibiotici
tibi ti i ttra i d
due gruppii
Liu BA et al., J Am Geriatr Soc., 2007
18 published studies and 2 abstracts: all RCT
Stephen AL et al., J Hum Nutr Diet, 2006
Effects of multivitamin and multi mineral
supplementation
pp
on cognitive
g
function in men and
women aged 65 years and over
MAVIS study (RCT): 910 patients from 6 centers, average age 71 years
one tablet daily for
f 12 month period
McNeil G et al. Nutr J 2007
MVM
Outcomes
per sottogruppi
The number of episodes of infection was significantly reduced in older
people
l when
h they
h were in
i an undernourished
d
i h d state at baseline
b
li and
d were
supplemented for more than 6 months.
Stephen AL et al., J Hum Nutr Diet, 2006
Supplementazione
S
l
t i
vitaminica
Outcomes
O
t m
i soggetti
in
tti con carenza
vitaminica
Distribuzione dell’apporto di nutrienti negli uomini
Continuing Survey of Food Intakes by Individuals (15000 subjects, 9070, 60 y or older)
Vit B12
(mg)
RDA
2.4μg
60-69 aa
70-79 aa
80+ aa
Folati
(µg)
RDA
400μg
Percentili
Wakimoto & Block, 2001
Distribuzione dell’apporto di nutrienti nelle donne
Continuing
g Survey
y off Food Intakes by
y Individuals ((15000 subjects,
j
, 9070,, 60 y or older))
Vitt B12
V
B
(μg)
RDA
2.4μg
60-69 aa
70-79 aa
80+ aa
Folati
( )
(µg)
RDA
400μg
Percentili
Wakimoto & Block, 2001
Prevalenza di ipovitaminosi D in uomini e donne anziane
Donne
Uomini
The European
Th
E
Survey
S
on N
Nutrition
t iti and
d th
the Elderly
Eld l
%
55.4%
(SENECA) on independently
living older persons showed
that 40% had serum 25
25-hydroxyvitamin
hydroxyvitamin D (25OH)D
35.1%
levels below 30
nmol/l
(de Groot et al. 2004).
Th llatter
The
tt standard
t d d iis much
hb
below
l
th
the currently
tl
proposed level of at least 50 nmol/l
(Mosekilde 2008).
25-OHD
25
OHD < 37.5 nmol/L
Zamboni et al, J Gerontol 2002
11 RCT
31.022
patients
Average
age
76 4 years
76.4
30% riduzione rischio di frattura di anca
con supplementazione
pp
> 800 IU die
Non efficacia con supplementazioni inferiori
11% riduzione rischio di frattura non
vertebrali con supplementazione > 400 IUdie
Non efficacia con supplementazioni inferiori
Bischoff-Ferrari HA et al, 2012
Efficacia dose dipendente, outcome dipendente
Bischoff-Ferrari HA et al, 2012
ONS
• Hi
High
h number
b and
d variety
i
of
f commercial
i l
available formulas;
• Use
U when
h the
h habitual
h bi
l diet
di is
i not meeting
i
nutrient requirements;
• Most
M
frequent
f
dens
d
li
liquid
id polymeric,wholel
i h l
protein, lactose-free, vitamin-supplemented
formulations.
formulations
• Various formulas for management of specific
nutrient needs resulting from a particular
injury, illness or disease condition.
ONS
Outcomes
FOOD trial 2005: usual
p
diet versus usual
hospital
diet plus ONS, in 2149
acute stroke nondysphagic patients,
average age 71 years.
FOOD trial collaboration 2005 Lancet
ONS
Outcomes
per sottogruppi
Meta-analysis on
MORTALITY for
f
nutritional
supplementation
after hip fracture in
old patients:
9 RCT
with 887 patients.
patients
Avenell A et al., 2010
Meta-analysis on UNFAVORABLE OUTCOME (death or
complications) at the end of the study after hip fracture in
old
ld patients:
ti t 4 RCT with
ith 238 patients.
ti t
Avenell A et al., 2010
Meta-analysis on UNFAVOURABLE OUTCOME
(d th or complication)
(death
li ti ) f
for nutritional
t iti
l supplementation
l
t ti after
ft hip
hi
fracture in malnourished patients: 4 RCT with 229 patients.
Avenell A et al., 2010
55 trials RCT
9187 participants
Oral protein or energy
supplementation
Meta-analysis of
mortality
Milne AC et al 2006
Analysis of
participants
p g
developing
complications
Mil AC ett all 2006
Milne
Analysis
A l i of
f
mortality data
b nutritional
by
i i
l
status
Milne AC et al 2006
Editors' Notes
Context
Physicians sometimes recommend nutritional supplementation
for sick, older persons.
p
Contribution
This review summarizes 55 trials of protein and energy
supplementation
pp
in p
people
p older than 65 y
years of age.
g
Compared with placebo or no supplementation, nutritional
supplements did not affect morbidity or mortality in people living
in the community.
Among older and undernourished hospitalized patients, supplements
sometimes reduced mortality and complications, such as infections, poor
wound healing, and pressure sores.
l
l sometimes caused
d nausea, vomiting, and
d diarrhea.
d
h
Orall supplements
also
Cautions
Many trials were small or had short follow-up times
Milne AC et al 2006
Implications for practice
g gain,
g
…there is a small weight
but no
longer supports the finding that
there is a beneficial effect on
t lit overall.
ll
mortality
However, mortality in undernourished
patients may be reduced.
reduced
There is more evidence of a
reduction in complications
p
than in the
previous review.
Results however still require to be
substantiated
b t ti t d as th
there are d
doubts
bt
due to many included trials having
poor study quality.
quality
10187 participants
62 trials
max duration
of intervention 18 months
Milne AC et al 2009
Implications for practice
In hospital or long-term care, at the very least, a
choice
h i of
f attractive
tt
ti and
d acceptable
t bl f
food
d should
h ld b
be
offered along with dietary advice if required.
…
There were too few randomised trials that had
considered other methods of supplementation such
as altering
g the nutrient density
y and diversity
y of the
diet, which may be preferable to sip-feeds for some
elderly people
….
However proprietary protein and energy
supplements used appropriately with nutritionally 'at
risk' patients have a useful role to play as part of a
risk
raft of measures which should be used to improve
the intakes and nutritional status of older people in
h s it l or long-term
hospital
l
t
care.
Milne AC et al 2009
Nutritional therapy led to higher energy intake
but failed to improve the quality of life in
cancer patients
Prospective study
(2 5y) on 58 cancer
(2,5y)
patients, average
age 64years,
BMI<25kg/m2
M
g/m
Individual nutritional
intervention: meal
enhacement, high
protein snacks, ONS
Uster et al. Nutr 2013
Nutrition intervention had no effect on Nutritional
Status and Quality of Life in cancer patients
• 358 patients with histologically proven,
proven metastatic or locally
advanced tumours of the gastrointestinal tract, non-small cell
lung cancer or mesothelioma.
• had lost any weight in the 3 months before presentation,
• had agreed to undergo palliative chemotherapy
• were fit for chemotherapy according to standard local criteria
• Randomly assigned to receive no intervention, dietary advice,
dietary supplementation (588 kcal in 240 mL)
• the trial was stopped early by the independent data monitoring
committee because no benefit was seen.
Baldwin C. et al. J Hum Nutr Diet 2011
RCT with 75 head and neck cancer patients
((age-range
g
g 39-79 y
years)) undergoing
g g radio-therapy
py
G1: counseling based on regular food; G2 supplements; G3: ad libitum intake
Nutrition
Nutr
t on counsel
counseling
ng was more benef
beneficial
c al than ONS in
n improving
mprov ng qual
qualityty
of-life ratings.
Ravasco P et al., Head Neck 2005
Simmoms et al
compliance with ONS
84 orthopaedic patients with postoperative ONS for 18 months,
average age 72 years, mean BMI 26.2kg/m2.
Lawson et al., Clin Nutr 2000
Conclusioni-MVM
u
MVM
• 2006, the National Institutes af Health concluded
that there was “insufficient
insufficient evidence
evidence” to reccomend
for or against the use of MVM’s by the american
public to p
p
prevent chronic disease.
National Institutes of Health State-of-the-Science Conference statement:
multivitamin/mineral supplementsand chronic disease prevention. Am J Clin Nutr
2007
• 2007
2007, the World Cancer Research Fund and the
American Institute for Cancer Researche has
reccomended “Against” the use of dietary
supplements
l
t by
b the
th public,
bli for
f cancer prevention.
ti
Food, nutrition, physical activity, and the porevention of cancer; a global
perspective.
p
p
Washington
g
DC: AICR;2007
;
World Cancer Research fund/american
Institute for Cancer Research
Conclusioni MVM
Conclusioni-MVM
• Non efficaci quando usati a pioggia
• Sicuramente efficaci q
quando utilizzati
in presenza di carenza accertata,
posologia
corretta
e
adeguato
p
g
g
monitoraggio
C
Conclusioni-ONS
l i i ONS
• Non efficaci quando usati in modo
routinario
• Efficaci quando utilizzati in presenza
di Malnutrizione per difetto e
con adeguato monitoraggio clinico
Conclusioni ONS
Conclusioni-ONS
Heidi J Silver, Nutrition Review, 2009
Integrazione nutrizionale nell’anziano
mai a pioggia
sempre mirata