Expected life span is gradually increasing worldwide. Healthy dietary and exercise habits contribute to healthy ageing. Certain types of diet can prevent or reduce obesity, and may reduce the risk of diseases (e.g. cardiovascular disease). Exercise also reduces the risk of diseases (e.g. cardiovascular disease, osteoporosis, some cancers and some mental disturbances). A less sedentary life style seems at least as important as regular exercise. Exercise can probably be tailored to reduce the risk of cardiovascular disease and extent of bone loss. To ensure adherence, it is important to increase slowly the frequency, duration and intensity of exercise, and to find activities that suit the individual. More research is needed to find ideal modes and doses of exercise, and to increase long-term adherence. Dietary and exercise modification seem to be strong promoters of healthy ageing.
Introduction
Elderly people are among the fastest growing segment of the population. It has been estimated that the number of centenarians will approach 3.2 million worldwide by 2050, which is more than an 18-fold increase from the turn of the 21st century. Additionally, the World Health Organization estimates that, by 2025, 120 countries will have reached total fertility rates below the replacement level, compared with 22 countries in the 1970s. With increasing emphasis on health, and progressive lengthening of the average life span, examining new ways of improving wellbeing and preventing disease at every stage of life is needed. Globally, cardiovascular disease (CVD) and cancer are the leading causes of mortality and loss of disability-adjusted life years.
As the population ages, it is important to understand the effect of modifiable lifestyle factors (i.e. diet, nutrition, and physical fitness) on the achievement of longevity, and also the role of these factors in maintaining optimal cognitive, mental, and physical health into advanced age. In this chapter, we review current knowledge of age-adjusted nutrition and physical fitness in elderly people.
Age adjusted nutrition
Obesity
Obesity and aging
The rising percentage of obese individuals on a global scale has led the scientific community to seek to determine the causes for this increase and the factors causing the disease. Why do obese people eat more than the non-obese people? Besides over-consumption of high-caloric foods, endocrine dysfunction and sedentary lifestyle, the hypothesis that food addiction is a leading cause for obesity is now being more widely accepted. Furthermore, evidence shows that obesity-related behaviours (regarding both physical activity and diet) from childhood predispose to adulthood behaviours. Both food choice and physical activity, however, are modifiable behaviours, and changing them to more healthful behaviours in childhood may lead to more healthy adult behaviours and a subsequent reduced risk of obesity and obesity-related disease.
Data from large population studies show that mean body weight and body-mass index (BMI) gradually increase during most of adult life, and reach peak values at 50–59 years of age in men and women. Ageing is associated with considerable changes in body composition. After 20–30 years of age, fat-free mass progressively decreases, whereas fat mass increases. The fat-free mass decreases on average by up to 40% between the ages of 20 years and 70 years of age. The maximal fat-free mass is usually reached at 20 years of age, and the maximal fat mass is usually reached between 60 and 70 years of age; both measures subsequently decline thereafter. Accordingly, both fat-free mass and fat mass decrease after the age of 70 years. Ageing is also associated with a redistribution of body fat. Also, with ageing, the relative increase in intra-abdominal fat is greater than in subcutaneous or total body fat.
Definition and adverse effects of obesity
Obesity is still widely defined in terms of BMI, even though this is not the most accurate predictor of diabetes or vascular risk. It is a simple index derived from the weight-to-height ratio defined as weight in kilograms divided by the square of height in meters (kg/m 2 ). This index is used to classify individuals as underweight (BMI < 18.5), normal weight (18.5–24.99), overweight (25.0–29.99) or obese (≥30.0), which are the most commonly used definitions, established by the World Health Organization (WHO). As Asian people develop negative health consequences already at a lower BMI than white people, some nations have redefined obesity; in Japan obesity, has been defined as any BMI greater than 25, whereas China uses a BMI of greater than 28.
Body-mass index is widely used in epidemiological studies, as measurements of height and weight are usually available; however, BMI does not accurately reflect fat mass or fat distribution. Abdominal obesity is a well-established phenotypic companion of a cluster of metabolic abnormalities characterised by insulin resistance, and abdominal obesity is the best obesity-related predictor of type 2 diabetes. Waist circumference is currently the most commonly used measure of abdominal obesity, and it is highly associated with CVD. The International Diabetes Federation suggests ethnic-specific waist circumference cut-offs for the definition of central obesity ; Europids: men ≥ 94 cm, women ≥ 80 cm, South Asians and Chinese: men ≥ 90 cm, women ≥ 80 cm, Japanese: men ≥ 85 cm, women ≥ 90 cm.
Sagittal abdominal diameter has been proposed as an estimate of visceral adipose tissue and is seen as being essential to clinical practice because it predicts cardiovascular and metabolic risks. Sagittal abdominal diameter shows the strongest correlation to visceral adipose tissue, irrespective of age, sex, and the degree of obesity compared with other anthropometric measures.
Powerful epidemiological associations exist between obesity and type 2 diabetes; together, being overweight and obese account for about two-thirds of cases of type 2 diabetes. Furthermore, the prevalence of type 2 diabetes is increasing sharply people aged between 50 and 60 years and older, as shown in Fig. 1 . A truncal distribution of body fat due to visceral fat accumulation confers the greatest risk of developing the disease. Furthermore, increased body weight is associated with increased death rates for all cancers combined and for cancers at multiple specific sites. The heaviest men and women (BMI of at least 40.0) in a large prospectively studied cohort had death rates from all cancers that were 52% and 62% higher, respectively, than the rates in men and women of normal weight. In a US study, it was forecasted that, provided current obesity trends continue, the negative health effects on the US population will increasingly outweigh the positive effects gained from the declining rate of smoking. In menopausal women, obesity confers a lower risk of osteoporosis, probably due to combined effects of weight-bearing and aromatisation of adrenal androgens to oestrogens affecting bone metabolism.
As body weight is the most important determinant of bone density, intentional weight reduction or eating disorders, such as anorexia nervosa, confer an increased risk of osteoporosis, and bone loss may never recover completely even once weight is restored.
Also, in postmenopausal women, the negative effect of bone loss is not reversed when weight partially rebounds once active intervention programmes have ended.
In a 10-year prospective observational study on postmenopausal women, the health-related risks of high BMI outweighed the protective effects of high BMI on bone mass, and weight gain increased the risk of hypertension, breast cancer and diabetes. Furthermore, obesity was also related to an increased risk of several less life-threatening conditions, such as osteoarthritis, chronic back pain and poor self-assessed health.
On the other hand, a low BMI is also often associated with an increased risk of mortality in seriously ill or hospitalised older adults, whereas people with a high BMI who are overweight or obese are more closely associated with chronic health conditions. Some problems, however, are associated with the use of BMI as an indicator of health and nutritional status in older adults, including the difficulty of adjusting for loss of height with age and inability to obtain a true measure of height due to inability to stand or due to amputations.
Furthermore, CVD, arthritis, falls and fractures also reduce mobility. Although all these conditions can contribute to weight gain, they can also lead to unintentional weight loss (anorexia of ageing). The non-physiological causes of anorexia of ageing include social (e.g. poverty, isolation), psychological (e.g. depression, dementia), medical and pharmacological factors. Physiological factors include changes in taste and smell, diminished sensory-specific satiety, delayed gastric emptying, altered digestion-related hormone secretion and hormonal responsiveness, as well as food intake-related regulatory impairments, for which specific mechanisms remain largely unknown.
Sarcopenia
The term sarcopenia derives from the Greek terms ‘sarx’ (meat) and ‘penia’ (loss). Sarcopenia, defined as a syndrome rather than as a pathology, is the loss of muscle mass and function associated with normal ageing. Although interest in investigating the functional consequences and biologic mechanisms of sarcopenia has increased, no international definition has been proposed to identify individuals with sarcopenia.
The factors that contribute to the development of sarcopenia in elderly people are as follows: the state of chronic inflammation, atrophy of motorneurons, reduced protein intake and immobility. Sarcopenia is associated with adverse clinical outcomes, such as mobility limitations, functional impairment and fractures. People with sarcopenic obesity are defined by high fat mass and low muscle mass, and are even more susceptible to mobility and disability problems than those who only have obesity or sarcopenia.
It has not been proven that elderly people who take nutritional supplements have an increase in muscle mass; however, sarcopenia has been shown to be present in all malnourished people. In an overview of sarcopenia and age-related endocrine functions, Sakuma and Yamaguchi mentioned myostatin inhibition, testosterone supplementation, and IGF-1 as future treatment options. They also pointed out that treatment with ghrelin may ameliorate the muscle atrophy elicited by age-dependent decreases in growth hormone, and that ghrelin may be administered orally.
The practice of physical resistance exercise has been shown to improve muscle mass and strength in older adults, but is not always feasible in elderly people, and it is not yet known how long its effects last after it is discontinued.
In conclusion, weight-loss treatment that minimises muscle and bone loss is recommended for older people who are obese and who have functional impairments or metabolic complications that can benefit from weight loss. Furthermore, exercise and physical activity can effectively prevent weight gain in older adults and postmenopausal women either in terms of weight loss or maintenance.
Age adjusted nutrition
Obesity
Obesity and aging
The rising percentage of obese individuals on a global scale has led the scientific community to seek to determine the causes for this increase and the factors causing the disease. Why do obese people eat more than the non-obese people? Besides over-consumption of high-caloric foods, endocrine dysfunction and sedentary lifestyle, the hypothesis that food addiction is a leading cause for obesity is now being more widely accepted. Furthermore, evidence shows that obesity-related behaviours (regarding both physical activity and diet) from childhood predispose to adulthood behaviours. Both food choice and physical activity, however, are modifiable behaviours, and changing them to more healthful behaviours in childhood may lead to more healthy adult behaviours and a subsequent reduced risk of obesity and obesity-related disease.
Data from large population studies show that mean body weight and body-mass index (BMI) gradually increase during most of adult life, and reach peak values at 50–59 years of age in men and women. Ageing is associated with considerable changes in body composition. After 20–30 years of age, fat-free mass progressively decreases, whereas fat mass increases. The fat-free mass decreases on average by up to 40% between the ages of 20 years and 70 years of age. The maximal fat-free mass is usually reached at 20 years of age, and the maximal fat mass is usually reached between 60 and 70 years of age; both measures subsequently decline thereafter. Accordingly, both fat-free mass and fat mass decrease after the age of 70 years. Ageing is also associated with a redistribution of body fat. Also, with ageing, the relative increase in intra-abdominal fat is greater than in subcutaneous or total body fat.
Definition and adverse effects of obesity
Obesity is still widely defined in terms of BMI, even though this is not the most accurate predictor of diabetes or vascular risk. It is a simple index derived from the weight-to-height ratio defined as weight in kilograms divided by the square of height in meters (kg/m 2 ). This index is used to classify individuals as underweight (BMI < 18.5), normal weight (18.5–24.99), overweight (25.0–29.99) or obese (≥30.0), which are the most commonly used definitions, established by the World Health Organization (WHO). As Asian people develop negative health consequences already at a lower BMI than white people, some nations have redefined obesity; in Japan obesity, has been defined as any BMI greater than 25, whereas China uses a BMI of greater than 28.
Body-mass index is widely used in epidemiological studies, as measurements of height and weight are usually available; however, BMI does not accurately reflect fat mass or fat distribution. Abdominal obesity is a well-established phenotypic companion of a cluster of metabolic abnormalities characterised by insulin resistance, and abdominal obesity is the best obesity-related predictor of type 2 diabetes. Waist circumference is currently the most commonly used measure of abdominal obesity, and it is highly associated with CVD. The International Diabetes Federation suggests ethnic-specific waist circumference cut-offs for the definition of central obesity ; Europids: men ≥ 94 cm, women ≥ 80 cm, South Asians and Chinese: men ≥ 90 cm, women ≥ 80 cm, Japanese: men ≥ 85 cm, women ≥ 90 cm.
Sagittal abdominal diameter has been proposed as an estimate of visceral adipose tissue and is seen as being essential to clinical practice because it predicts cardiovascular and metabolic risks. Sagittal abdominal diameter shows the strongest correlation to visceral adipose tissue, irrespective of age, sex, and the degree of obesity compared with other anthropometric measures.
Powerful epidemiological associations exist between obesity and type 2 diabetes; together, being overweight and obese account for about two-thirds of cases of type 2 diabetes. Furthermore, the prevalence of type 2 diabetes is increasing sharply people aged between 50 and 60 years and older, as shown in Fig. 1 . A truncal distribution of body fat due to visceral fat accumulation confers the greatest risk of developing the disease. Furthermore, increased body weight is associated with increased death rates for all cancers combined and for cancers at multiple specific sites. The heaviest men and women (BMI of at least 40.0) in a large prospectively studied cohort had death rates from all cancers that were 52% and 62% higher, respectively, than the rates in men and women of normal weight. In a US study, it was forecasted that, provided current obesity trends continue, the negative health effects on the US population will increasingly outweigh the positive effects gained from the declining rate of smoking. In menopausal women, obesity confers a lower risk of osteoporosis, probably due to combined effects of weight-bearing and aromatisation of adrenal androgens to oestrogens affecting bone metabolism.
As body weight is the most important determinant of bone density, intentional weight reduction or eating disorders, such as anorexia nervosa, confer an increased risk of osteoporosis, and bone loss may never recover completely even once weight is restored.
Also, in postmenopausal women, the negative effect of bone loss is not reversed when weight partially rebounds once active intervention programmes have ended.
In a 10-year prospective observational study on postmenopausal women, the health-related risks of high BMI outweighed the protective effects of high BMI on bone mass, and weight gain increased the risk of hypertension, breast cancer and diabetes. Furthermore, obesity was also related to an increased risk of several less life-threatening conditions, such as osteoarthritis, chronic back pain and poor self-assessed health.
On the other hand, a low BMI is also often associated with an increased risk of mortality in seriously ill or hospitalised older adults, whereas people with a high BMI who are overweight or obese are more closely associated with chronic health conditions. Some problems, however, are associated with the use of BMI as an indicator of health and nutritional status in older adults, including the difficulty of adjusting for loss of height with age and inability to obtain a true measure of height due to inability to stand or due to amputations.
Furthermore, CVD, arthritis, falls and fractures also reduce mobility. Although all these conditions can contribute to weight gain, they can also lead to unintentional weight loss (anorexia of ageing). The non-physiological causes of anorexia of ageing include social (e.g. poverty, isolation), psychological (e.g. depression, dementia), medical and pharmacological factors. Physiological factors include changes in taste and smell, diminished sensory-specific satiety, delayed gastric emptying, altered digestion-related hormone secretion and hormonal responsiveness, as well as food intake-related regulatory impairments, for which specific mechanisms remain largely unknown.
Sarcopenia
The term sarcopenia derives from the Greek terms ‘sarx’ (meat) and ‘penia’ (loss). Sarcopenia, defined as a syndrome rather than as a pathology, is the loss of muscle mass and function associated with normal ageing. Although interest in investigating the functional consequences and biologic mechanisms of sarcopenia has increased, no international definition has been proposed to identify individuals with sarcopenia.
The factors that contribute to the development of sarcopenia in elderly people are as follows: the state of chronic inflammation, atrophy of motorneurons, reduced protein intake and immobility. Sarcopenia is associated with adverse clinical outcomes, such as mobility limitations, functional impairment and fractures. People with sarcopenic obesity are defined by high fat mass and low muscle mass, and are even more susceptible to mobility and disability problems than those who only have obesity or sarcopenia.
It has not been proven that elderly people who take nutritional supplements have an increase in muscle mass; however, sarcopenia has been shown to be present in all malnourished people. In an overview of sarcopenia and age-related endocrine functions, Sakuma and Yamaguchi mentioned myostatin inhibition, testosterone supplementation, and IGF-1 as future treatment options. They also pointed out that treatment with ghrelin may ameliorate the muscle atrophy elicited by age-dependent decreases in growth hormone, and that ghrelin may be administered orally.
The practice of physical resistance exercise has been shown to improve muscle mass and strength in older adults, but is not always feasible in elderly people, and it is not yet known how long its effects last after it is discontinued.
In conclusion, weight-loss treatment that minimises muscle and bone loss is recommended for older people who are obese and who have functional impairments or metabolic complications that can benefit from weight loss. Furthermore, exercise and physical activity can effectively prevent weight gain in older adults and postmenopausal women either in terms of weight loss or maintenance.
Nutrition
Dietary recommendations
It could be speculated that dietary habits reported by elderly people could serve as a recommendation for the ageing population to remain in good health for many years. Studies from around the world, however, suggest that considerable heterogeneity exists in dietary patterns and nutritional status of centenarians. The studies indicate that BMI and nutritional status, as indicated by circulating levels of antioxidant vitamins, vitamin B12, folate, homocysteine and 25(OH) vitamin D of centenarians, are quite heterogeneous. They are also influenced by region of residency and many of the demographic, dietary and lifestyle factors that influence nutritional status in other older adults. Thus, at this time, it seems unlikely that one particular dietary pattern that promotes exceptional longevity.
Low rates of CVD, observed during the 1950s and 1960s in the Mediterranean basin, however, launched the hypothesis of beneficial health effects from the Mediterranean type of diet.
The Lyon Diet Heart Study has received much attention. In this trial, 605 people who survived a first myocardial infarction were randomised to either a control or a Mediterranean diet. The control group was advised to follow a ‘prudent diet’. The trial was discontinued early owing to the significant superiority of the Mediterranean diet shown by an interim analysis. After publication of the initial results, the two groups were followed up for a mean of 4 years. The composite outcome, which factored in myocardial infarction, cardiovascular death, episodes of unstable angina, overt heart failure, stroke and pulmonary or peripheral embolism, was reduced by 70% in the group on the Mediterranean diet relative to the control group.
A recent systematic review concluded that a large number of observational studies throughout the world have shown that a high adherence to a Mediterranean type of diet is associated with reduced risk of CVD and some types of cancer in elderly people. The beneficial effects on human health have been attributed to several surrogate markers, including blood pressure, lipids, inflammation and oxidative stress levels and body fat. It seems that the high consumption of vegetables, fruits, legumes, nuts, cereals, olive oil, fish, together with moderate consumption of alcohol, predominantly wine, leads to a high ratio of monounsaturated-to-saturated fatty acids, a low intake of trans-fatty acids, and a high ingestion of dietary fibre, antioxidants, polyphenols and magnesium, all beneficial for human health.
The recently launched term ‘nutrigenomics ’ refers to the new nutritional science in which researchers use high throughput tools to investigate interactions between nutrition and the genome, and their consequences for gene expression, cell function and human health. Nutrigenomics aims to personalise or stratify dietary advice based upon modification of risk associated with genetic susceptibility to chronic diseases.
Oxidative stress
Oxidative stress increases with ageing, as it is involved in virtually all the diseases associated with obesity. Obesity causes an increase of interleukin (IL) 1, IL-6, tumour necrosis factor, C-reactive protein, cholesterol and triglycerides, excessive hormone production (the renin–angiotensin system hormones), and insulin resistance. With advancing age, these aforementioned changes, in combination with the low antioxidant intake and physical activity, contribute to the exacerbation of the oxidative stress. Moderate physical activity may generate mild oxidative stress that activates cellular stress response, which signals and potentiates cellular antioxidant defence capacity, whereas exhaustive exercise may cause accumulation of reactive oxygen species that can damage DNA, cause mutations, or promote carcinogenesis.
Oxidative stress resulting from the overproduction of reactive oxygen species may play a role in ageing and in the development of diabetes, some malignant diseases and other chronic diseases. It is a deleterious process that results in damage to key cellular components, such as DNA, lipids, and proteins. The effects of oxidative stress are counteracted by several enzymatic and non-enzymatic antioxidant defence systems, with vitamin A, vitamin C, vitamin E, and the carotenoids serving as important components of the primary non-enzymatic antioxidant defence system.
Furthermore, in a prospective, randomised, double-blind, placebo-controlled trial among Swedish citizens aged between 70 and 88 years, it was shown that long-term supplementation of selenium and coenzyme Q10 reduced cardiovascular mortality.
Vitamin B12
Poor vitamin B12 status affects about 10–15% of older adults, and is associated with both neurologic and haematologic disorders, including sensory disturbances to the extremities, gait ataxia, cognitive impairment, mood changes, and anaemia. Risk factors for vitamin B12 deficiency include demographic, dietary and age-related health conditions, including atrophic gastritis. The latter condition affects up to 30% of older adults, reduces the absorption of vitamin B12 from food, and is the most common cause of vitamin B12 deficiency.
Vitamin D status
Vitamin D is acquired through diet and skin exposure to ultraviolet B light. Skin production is determined by length of exposure, latitude, season, and degree of skin pigmentation. Vitamin D deficiency is common among moderately and heavily pigmented immigrants living in Europe; in Pakistani men living in Norway, serious vitamin D deficiency was prevalent and five times as frequent as in native Norwegian men. Furthermore, vitamin D deficiency is a risk for dark skinned children who have emigrated to countries far from the equator (e.g. Denmark).
Poor vitamin D status has been associated with osteoporosis, falls, fractures, cardiovascular diseases, some cancers, autoimmune diseases and other age-related conditions. Risk factors for poor vitamin D status include low cutaneous vitamin D synthesis owing to limited sun exposure, living at higher latitude, increased skin pigmentation, and low intake from foods and supplements. Older individuals are at particular risk for vitamin D deficiency because of a reduced capacity to produce vitamin D precursors in the skin from ultraviolet light, limited sun exposure owing to poor mobility or place of residence, and low intakes of vitamin D.
In conclusion, greater attention to lifestyle factors may be needed, such as increased intake of vitamin-D-rich foods and supplements, which may be an effective strategy for improving vitamin D status and associated function in centenarians.
Caloric restriction
Caloric restriction (i.e. decreasing caloric intake by 20–30%) was first shown to extend life in rats nearly 80 years ago. Populations with an unusually high prevalence of centenarians all tended to be (or had been) physically active, non-obese and small in stature, suggestive of some degree of caloric restriction. Thus, considerable interest has been shown in the ability of caloric restriction to improve multiple parameters of health and to extend lifespan. Furthermore, many religions incorporate one or more forms of food restrictions or religious fasting periods as the Islamic Ramadan.
In summary, caloric restriction has been shown to extend the maximal lifespan of a diverse group of species. This extension of life is maximised when (1) the magnitude of caloric restriction is elevated to the highest possible value before inducing malnutrition; and (2) the duration of caloric restriction is maximised. Animals on caloric restriction regimens experience a variety of improvements in overall health in general, and cardiovascular health, in particular. Unfortunately, the likelihood of discovering whether or not caloric restriction extends human life is rather remote owing to the ethical and logistic limitations of research design. The optimal magnitude and duration of caloric restriction for humans will also likely never be known for the same reason. Nevertheless, many human caloric restriction studies have reported favourable changes in biomarkers related to cardiovascular and glucose metabolism that may relate to longevity. Although caloric restriction has many positive effects on health and longevity, quality of life on a restricted diet, as well as the ability to maintain that diet long term, are concerns that must be considered in humans.
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