Overview
Methods to Study the Association Between Nutrition and Frailty
Diet is one of the most important modifiable factors that can affect frailty and the aging process (Kiefte-de Jong et al. 2014; Schoufour et al. 2019b). It can be studied from different perspectives. Traditionally, most research on nutrition and frailty is concentrated on the effects of single nutrients (e.g., proteins, vitamin D), single foods (e.g., kiwis, wine), or food groups (e.g., vegetables, dairy). The advantage of this approach is that they lead to clear dietary advice, often supported by biological pathways. For example, the established association between low protein intake and frailty has led to increased awareness of protein supplementation in frail older populations. Nevertheless, this approach also has its limitations. People do not consume single nutrients but foods that are combined into meals and follow a pattern throughout the day. Nutrients and foods may interact together in influencing physiological processes. Additionally, the intake of nutrients and foods is highly correlated with each other (Cespedes and Hu 2015). For example, people consuming a high amount of fatty fish generally also consume more fruits and vegetables. These interactions and correlations can be captured in dietary pattern analyses – a method that has emerged as an important research field complementary to the focus on single compounds (Kant 2004; Hu 2002).
Malnutrition Among Older Adults
Malnutrition, which is very prevalent in geriatric populations, has been identified as one of the major risk factors for frailty (Artaza-Artabe et al. 2016). Malnutrition is a condition in which one or more nutrients are either deficient or abundant. Malnutrition can involve calories, macronutrients, or micronutrients. Both undernutrition and overnutrition (obesity) are associated with an increased risk to develop frailty in community-dwelling older adults (Cruz-Jentoft et al. 2017; Hubbard et al. 2010; Bollwein et al. 2013b). In a metabolic state, there is sufficient energy for organs and muscles to function. If insufficient energy is consumed, the body starts to catabolize fat mass and muscle mass to provide this energy. Older adults often do not consume sufficient calories, as a result of among others reduced appetite, physiological changes, and tooth problems (Kruizenga et al. 2003; Agarwal et al. 2013). When muscle mass is lost, this will eventually also lead to loss of muscle function and physical performance, both important aspects of frailty. Indeed, several studies show that a lower energy intake is associated with a higher prevalence of frailty and higher risk to develop frailty (Schoufour et al. 2019a; Bartali et al. 2006; Smit et al. 2013).
Physical Frailty
By far, most research on nutrition and frailty focused on physical frailty (Fried et al. 2001). In a recent review, Lorenzo-López et al. identified five studies that found independent associations between a broad range of micronutrients and frailty (Lorenzo-López et al. 2017). Among others, frailty has been linked to low levels of vitamin D, vitamin C, vitamin E, and β-carotene (Kelaiditi et al. 2015; Bollwein et al. 2013a; Bonnefoy et al. 2015; Artaza-Artabe et al. 2016).
Because physical frailty is highly influenced by loss of muscle mass and muscle strength (Cesari et al. 2014; Keevil and Romero-Ortuno 2015), the effect of the macronutrient protein has received particular attention. Dietary protein stimulates skeletal protein synthesis, and insufficient supply can affect muscle integrity (Beasley et al. 2013; Cermak et al. 2012). Nevertheless, not all observational studies report a beneficial association of protein intake with frailty (Artaza-Artabe et al. 2016; Schoufour et al. 2019a). These inconsistencies could be caused by other factors that may influence the association, such as physical activity (Tribess et al. 2012; Blodgett et al. 2015; Tieland et al. 2012), protein source (i.e., plant- versus animal-derived), and the distribution of protein throughout the day (Bonnefoy et al. 2015; Lana et al. 2015). Other macronutrients received far less attention. One cross-sectional study taking into account the intake of proteins, carbohydrates, and fats did not find any association with frailty (Schoufour et al 2019a).
Several studies observed that a high dietary quality is inversely associated with the risk of being frail. Both adherence to the Mediterranean diet and local dietary guidelines have been associated with lower frailty risks in different populations (Bollwein et al. 2013a; Talegawkar et al. 2012; León-Muñoz et al. 2014; Haines et al. 1999; Shikany et al. 2014). Additionally, diets high in antioxidants may prevent frailty (Cruz-Jentoft et al. 2017; Kim et al. 2010). These results indicate that nutrition can play a key role in the prevention of frailty. Specifically, among older adults that are already frail, protein-energy supplementation may reduce the further progression of frailty and functional decline (Cruz-Jentoft et al. 2017). However strong evidence, based on large longitudinal studies and/or clinical trials, is still required.
Frailty as a Measure of Overall Health
In addition to the well-known physical frailty definition, Rockwood and Mitnitski presented their operationalization of frailty as the accumulation of deficit approach (Mitnitski et al. 2001). These deficits cover multiple health domains and can include variables such as diseases, disabilities, abnormalities, and symptoms. As such, the frailty index can be considered an overall measure of health. Only few studies focused on the association between nutrition and the frailty index. In a study among 3378 Hong Kong inhabitants (65 years and over), it was observed that a high dietary quality was associated with less frailty (Woo et al. 2010). Similarly, in a large Dutch cohort, it was found that adherence to the Dutch dietary guidelines could help to prevent, delay, or even reverse frailty levels (de Haas et al. 2018; Brinkman et al. 2018). Furthermore, there was no association found between the intake of fat or carbohydrates and the frailty index overtime in 5205 Dutch middle-aged elderly. The authors did observe that people consuming more animal protein had higher frailty scores (Verspoor et al. 2019).
Prospects and Summary
Although the number of studies looking into nutrition and frailty is increasing, there are still several gaps in knowledge that hamper strong conclusions. First of all, most studies are based on observational data. Confounding by other lifestyle factors such as smoking and physical activity and socioeconomic factors makes it complicated to determine the causality of such associations. Second, the association between nutrition and more holistic frailty approaches is lacking. Regardless of these limitations, diet seems to be an important modifiable determinant of frailty. Although clinical trials are required to strengthen the evidence, the abovementioned studies suggest that a diet with a sufficient amount of protein and high in fruits, vegetables, legumes, fish, and whole grains and low in red meat and sugar-rich foods could help with the prevention of frailty.
References
Agarwal E, Miller M, Yaxley A, Isenring E (2013) Malnutrition in the elderly: a narrative review. Maturitas 76:296–302. https://doi.org/10.1016/j.maturitas.2013.07.013
Artaza-Artabe I, Sáez-López P, Sánchez-Hernández N, Fernández-Gutierrez N, Malafarina V (2016) The relationship between nutrition and frailty: effects of protein intake, nutritional supplementation, vitamin D and exercise on muscle metabolism in the elderly. A systematic review. Maturitas 93:89–99. https://doi.org/10.1016/j.maturitas.2016.04.009
Bartali B, Frongillo EA, Bandinelli S, Lauretani F, Semba RD, Fried LP, Ferrucci L (2006) Low nutrient intake is an essential component of frailty in older persons. J Gerontol A Biol Sci Med Sci 61:589–593. https://doi.org/10.1093/gerona/61.6.589
Beasley JM, Shikany JM, Thomson CA (2013) The role of dietary protein intake in the prevention of sarcopenia of aging. Nutr Clin Pract 28:684–690. https://doi.org/10.1177/0884533613507607
Blodgett J, Theou O, Kirkland S, Andreou P, Rockwood K (2015) The association between sedentary behaviour, moderate-vigorous physical activity and frailty in NHANES cohorts. Maturitas 80:187–191. https://doi.org/10.1016/j.maturitas.2014.11.010
Bollwein J, Diekmann R, Kaiser MJ, Bauer JM, Uter W, Sieber CC, Volkert D (2013a) Dietary quality is related to frailty in community-dwelling older adults. J Gerontol A Biol Sci Med Sci 68:483–489. https://doi.org/10.1093/gerona/gls204
Bollwein J, Volkert D, Diekmann R, Kaiser MJ, Uter W, Vidal K, Sieber CC, Bauer JM (2013b) Nutritional status according to the mini nutritional assessment (MNA®) and frailty in community dwelling older persons: a close relationship. J Nutr Health Aging 17:351–356. https://doi.org/10.1007/s12603-013-0034-7
Bonnefoy M, Berrut G, Lesourd B, Ferry M, Gilbert T, Guérin O, Hanon O, Jeandel C, Paillaud E, Raynaud-Simon A, Ruault G, Rolland Y (2015) Frailty and nutrition: searching for evidence. J Nutr Health Aging 19:250–257. https://doi.org/10.1007/s12603-014-0568-3
Brinkman S, Voortman T, Kiefte-de Jong JC, van Rooij FJA, Ikram MA, Rivadeneira F, Franco OH, Schoufour JD (2018) The association between lifestyle and overall health, using the frailty index. Arch Gerontol Geriatr 76:85–91. https://doi.org/10.1016/j.archger.2018.02.006
Cermak NM, Res PT, de Groot LCPGM, Saris WHM, van Loon LJC (2012) Protein supplementation augments the adaptive response of skeletal muscle to resistance-type exercise training: a meta-analysis. Am J Clin Nutr 96:1454–1464. https://doi.org/10.3945/ajcn.112.037556
Cesari M, Landi F, Vellas B, Bernabei R, Marzetti E (2014) Sarcopenia and physical frailty: two sides of the same coin. Front Aging Neurosci 6:192. https://doi.org/10.3389/fnagi.2014.00192
Cespedes EM, Hu FB (2015) Dietary patterns: from nutritional epidemiologic analysis to national guidelines. Am J Clin Nutr 101:899–900. https://doi.org/10.3945/ajcn.115.110213
Cruz-Jentoft AJ, Kiesswetter E, Drey M, Sieber CC (2017) Nutrition, frailty, and sarcopenia. Aging Clin Exp Res 29:43–48. https://doi.org/10.1007/s40520-016-0709-0
de Haas SCM, de Jonge EAL, Voortman T, Graaff JS, Franco OH, Ikram MA, Rivadeneira F, Kiefte-de Jong JC, Schoufour JD (2018) Dietary patterns and changes in frailty status: the Rotterdam Study. Eur J Nutr 57:2365–2375. https://doi.org/10.1007/s00394-017-1509-9
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA, Cardiovascular Health Study Collaborative Research Group (2001) Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 56:M146–M156. https://doi.org/10.1093/gerona/56.3.m146
Haines PS, Siega-Riz AM, Popkin BM (1999) The Diet Quality Index revised: a measurement instrument for populations. J Am Diet Assoc 99:697–704. https://doi.org/10.1016/S0002-8223(99)00168-6
Hu FB (2002) Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 13:3–9. https://doi.org/10.1097/00041433-200202000-00002
Hubbard RE, Lang IA, Llewellyn DJ, Rockwood K (2010) Frailty, body mass index, and abdominal obesity in older people. J Gerontol A Biol Sci Med Sci 65:377–381. https://doi.org/10.1093/gerona/glp186
Kant AK (2004) Dietary patterns and health outcomes. J Am Diet Assoc 104:615–635. https://doi.org/10.1016/j.jada.2004.01.010
Keevil VL, Romero-Ortuno R (2015) Ageing well: a review of sarcopenia and frailty. Proc Nutr Soc 74:337–347. https://doi.org/10.1017/S0029665115002037
Kelaiditi E, Guyonnet S, Cesari M (2015) Is nutrition important to postpone frailty? Curr Opin Clin Nutr Metab Care 18:37–42. https://doi.org/10.1097/MCO.0000000000000129
Kiefte-de Jong JC, Mathers JC, Franco OH (2014) Nutrition and healthy ageing: the key ingredients. Proc Nutr Soc 73(2):249–259. https://doi.org/10.1017/S0029665113003881
Kim J-S, Wilson JM, Lee S-R (2010) Dietary implications on mechanisms of sarcopenia: roles of protein, amino acids and antioxidants. J Nutr Biochem 21:1–13. https://doi.org/10.1016/j.jnutbio.2009.06.014
Kruizenga HM, Wierdsma NJ, van Bokhorst MA, de van der Schueren HHJ, Jonkers-Schuitema CF, van der Heijden E, Melis GC, van Staveren WA (2003) Screening of nutritional status in The Netherlands. Clin Nutr 22:147–152. https://doi.org/10.1054/clnu.2002.0611
Lana A, Rodriguez-Artalejo F, Lopez-Garcia E (2015) Dairy consumption and risk of frailty in older adults: a prospective cohort study. J Am Geriatr Soc 63:1852–1860. https://doi.org/10.1111/jgs.13626
León-Muñoz LM, Guallar-Castillón P, López-García E, Rodríguez-Artalejo F (2014) Mediterranean diet and risk of frailty in community-dwelling older adults. J Am Med Dir Assoc 15:899–903. https://doi.org/10.1016/j.jamda.2014.06.013
Lorenzo-López L, Maseda A, de Labra C, Regueiro-Folgueira L, Rodríguez-Villamil JL, Millán-Calenti JC (2017) Nutritional determinants of frailty in older adults: a systematic review. BMC Geriatr 17:108. https://doi.org/10.1186/s12877-017-0496-2
Mitnitski AB, Mogilner AJ, Rockwood K (2001) Accumulation of deficits as a proxy measure of aging. Sci World J 1:323–336. https://doi.org/10.1100/tsw.2001.58
Schoufour JD, Franco OH, Kiefte-de Jong JC, Trajanoska K, Stricker B, Brusselle G, Rivadeneira F, Lahousse L, Voortman T (2019a) The association between dietary protein intake, energy intake and physical frailty: results from the Rotterdam Study. Br J Nutr 121:393–401. https://doi.org/10.1017/S0007114518003367
Schoufour JD, Overdevest E, Weijs PJM, Tieland M (2019b) Dietary protein, exercise, and frailty domains. Nutrients 11(10). https://doi.org/10.3390/nu11102399
Shikany JM, Barrett-Connor E, Ensrud KE, Cawthon PM, Lewis CE, Dam T-TL, Shannon J, Redden DT, Osteoporotic Fractures in Men (MrOS) Research Group (2014) Macronutrients, diet quality, and frailty in older men. J Gerontol A Biol Sci Med Sci 69:695–701. https://doi.org/10.1093/gerona/glt196
Smit E, Winters-Stone KM, Loprinzi PD, Tang AM, Crespo CJ (2013) Lower nutritional status and higher food insufficiency in frail older US adults. Br J Nutr 110:172–178. https://doi.org/10.1017/S000711451200459X
Talegawkar SA, Bandinelli S, Bandeen-Roche K, Chen P, Milaneschi Y, Tanaka T, Semba RD, Guralnik JM, Ferrucci L (2012) A higher adherence to a Mediterranean-style diet is inversely associated with the development of frailty in community-dwelling elderly men and women. J Nutr 142:2161–2166. https://doi.org/10.3945/jn.112.165498
Tieland M, Dirks ML, van der Zwaluw N, Verdijk LB, van de Rest O, de Groot LCPGM, van Loon LJC (2012) Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc 13:713–719. https://doi.org/10.1016/j.jamda.2012.05.020
Tribess S, Virtuoso Júnior JS, Oliveira RJ (2012) Physical activity as a predictor of absence of frailty in the elderly. Rev Assoc Med Bras (1992) 58:341–347
Verspoor E, Voortman T, van Rooij FJA, Rivadeneira F, Franco OH, Kiefte-de Jong JC, Schoufour JD (2019) Macronutrient intake and frailty: the Rotterdam Study. Eur J Nutr
Woo J, Chan R, Leung J, Wong M (2010) Relative contributions of geographic, socioeconomic, and lifestyle factors to quality of life, frailty, and mortality in elderly. PLoS One 5:e8775. https://doi.org/10.1371/journal.pone.0008775
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Schoufour, J.D. (2020). Nutrition and Frailty. In: Gu, D., Dupre, M. (eds) Encyclopedia of Gerontology and Population Aging. Springer, Cham. https://doi.org/10.1007/978-3-319-69892-2_362-1
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