Committee for Healthy Ageing Bulletin No 13, March 2013 OLDER PEOPLE AND FUNCTIONAL FOODS

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1 Committee for Healthy Ageing Bulletin No 13, March 2013 Welcome to the thirteenth issue of our Bulletin, updating you on issues of importance or topical interest relating to nutrition and physical activity of older people. OLDER PEOPLE AND FUNCTIONAL FOODS In November 2010, the ILC-UK published a comprehensive report Older people and functional foods: The importance of diet in supporting older people s health; what role for functional foods? The full report is 85 pages long, plus references. This bulletin presents key findings from the study, and where appropriate, introduces a New Zealand perspective. The study focused on older people living independently in the community, and considered two age groups years, and the over-75s. Among the aims and objectives of this study seeking to understand the role of nutrition in supporting healthy older age, researchers investigated: The development of functional foods to support specific health and nutritional needs, and The role of functional foods in supporting older people to remain well-nourished and healthy. Introduction Functional foods are defined as conventional food products modified in some way to give a health benefit above and beyond basic nutrition. This term may be confused with nutraceuticals and food supplements. Some workers use nutraceuticals as another term for functional foods, but others define nutraceuticals sensibly as a product isolated or purified from foods that is generally sold in medicinal forms not usually associated with foods. Food supplements are defined as supplementing the normal diet and made of concentrated sources of nutrients or other substances, e.g. a vitamin, mineral, amino acid, herb or other botanical, with a nutritional or physiological effect, alone or in combination, marketed in dose form, that is, capsules, pills, powders, drops, etc, taken in measured small unit quantities. In New Zealand, these are covered by the Dietary Supplements Amendment Regulations 2010, and include probiotic and prebiotic products. By comparison, a functional food is a normal type of food with an additional component that may be a nonnutrient, such as plant sterols to reduce cholesterol, or a nutrient or micronutrient which should be in quantities higher than daily recommendations and directly linked to the health and well-being of the consumer, such as Vitamin D to reduce risk of developing osteoporosis. The most common functional foods are those that target: 1

2 Gastrointestinal function Cardiovascular disease Bone health The ILC-UK report describes three case studies undertaken to consider whether functional foods have a role in supporting older people to remain well-nourished and healthy: Probiotic yoghurts and drinks Cholesterol-lowering margarine/yoghurts/drinks Vitamin D and calcium fortified products. A fourth group, Omega-3 functional foods, was not studied in detail. Omega-3 fatty acids are the latest substances to be added to a variety of food products, including margarine, milk, eggs and fruit juice, to make functional foods for a cardiovascular risk reduction effect. An extensive review of the literature was undertaken to investigate these cases. Case study one: probiotic yoghurts and drinks These are marketed as health promoting alternatives to non-probiotic yoghurts and drinks. The health benefits claimed include: Improvement in general digestive comfort/functioning Improvement in immunity Improvement and management of various gastrointestinal disorders Prevention of colon cancer. Further research into other possible health benefits, including respiratory and genito-urinary infections, allergic diseases, energy metabolism and dyslipidaemia, is ongoing. The literature review concluded there is sufficient evidence that probiotic yoghurts and drinks can help support health in older people with certain health problems. The strongest arguments relate to the use of probiotics to treat antibiotic-associated diarrhoea, which is a significant health risk for older people, and can lead to malnutrition and weaken the immune system. Treatment and management of irritable bowel syndrome with probiotics shows potential. For older people who suffer non-specific digestive discomfort, probiotic products may help, but outcomes vary. However, symptoms of digestive discomfort can sometimes signal more serious health problems, and clinical investigations of these symptoms occurring for the first time should be undertaken to rule out serious digestive disorders. Case study two: cholesterol-lowering functional foods The most common cholesterol-lowering functional foods are the plant stanol/sterol-containing margarines. Initially, plant stanols/sterols were used only in fat-containing products such as margarines, oils, and salad dressings, but further development has led to them being emulsified in lecithin and added to non-fat or low-fat foods like yoghurt, yoghurt drinks, breads and cereals. There is ongoing research at Auckland University on these emulsions. The nutritional health benefits of cholesterol-lowering functional foods is that they lower cholesterol, specifically low density lipoprotein (LDL) cholesterol and total cholesterol, but do not affect high density 2

3 lipoprotein (HDL) cholesterol or triaglycerol. High LDL cholesterol is a major risk factor for cardiovascular disease (CVD). The scientific literature is overwhelming when it comes to the effectiveness of a daily intake of 2g plant sterols/stanols in reducing LDL and total cholesterol in people with normal and high levels. Given the risk of cardiovascular disease increases with age, and the overwhelming evidence for the effectiveness of cholesterol-lowering functional foods, it appears they do have a role to play in supporting older people reduce their cardiovascular risk. The study team recommends Men and women aged would benefit from including 2g of plant sterols/stanols via cholesterol-lowering functional foods in their daily diet, as part of a healthy lifestyle approach to reduce the risk of developing CVD. This is strongly encouraged for those already experiencing hypercholesterolaemia and could prevent or delay the need for statins. Men and women aged would also benefit from including 2g of plant sterols/stanols via cholesterol-lowering functional foods in their daily diet, as part of a healthy lifestyle approach to manage the risks associated with CVD. For those taking statins, cholesterol-lowering functional foods could be considered as an addition to statin treatment this has been shown to be more effective than increasing statin dosage. As the role of high cholesterol as a risk factor for CVD becomes less significant as one ages, it would not seem necessary to include cholesterol-lowering functional foods in the diets of the over 75s, when other aspects of diet are more important. It is important to note the cost of cholesterol-lowering functional foods may be a deterrent to incorporating these in the diet as a lifestyle factor, or in the diets of those who already have elevated cholesterol levels. It is also important to recognise a lifestyle approach should include healthy eating and physical activity. Cholesterol-lowering functional foods are not the be all and end all to reducing cardiovascular risk, and a small number of people may not respond to plant stanols/sterols. Case study three: calcium and vitamin D This case study focuses on these two nutrients, rather than products containing them, because even though there are many functional foods containing these nutrients, the product specific literature is insufficient. However, there is sufficient literature focusing on the role of these two nutrients in older people s nutrition, and the review in this section of the report makes interesting reading. There is clearly a need to improve vitamin D intake to support older people s bone health and some evidence on the need to improve calcium intake, especially in older women. Older people obtain most of their dietary calcium from dairy products, green vegetables, fish with edible soft bones, and fortified foods such as soy milk and orange juice. However, it is important to note older people are more likely to suffer from lactose intolerance due to physiological changes reducing lactase production. Calcium bioavailability can vary according to the food product being fortified. One study reviewed reported calcium-enriched soy milk showed calcium absorbability of about 25% less than cow s milk, but this was superior to calcium-enriched orange juice. There is compelling evidence vitamin D deficiency is a problem among older people, especially postmenopausal women who are at highest risk of osteoporosis. Insufficient vitamin D is associated with reduced muscle function and an increased risk of falls. 3

4 Vitamin D3 (cholecalciferol) can be found in food, most commonly vitamin D-fortified margarine, oily fish, e.g. salmon, sardines, and fortified breakfast cereals. Many older people do not obtain sufficient vitamin D from their diet, and studies in the USA and Canada have suggested food fortification is not effective in preventing vitamin D deficiency, and the use of supplements seems more effective. Vitamin D2 (ergocalciferol) is produced by the action of sunlight on the skin. It is difficult to determine the time needed in the sun to obtain sufficient vitamin D because of considerable variations in geography, season and skin type. Again, some studies recommend vitamin D supplements over UV exposure because of these practical difficulties. There is agreement older people need higher levels of vitamin D than current dietary guidelines recommend to maintain bone health and prevent osteoporosis. It appears a consensus for recommended vitamin D intake is 25µg/day. New Zealand recommendations for men and women years is 10µg and for >70 years, 15µg. A consensus for recommendation for calcium intake is 1200mg. In New Zealand, 1000mg is the recommended daily intake for males years, and 1300mg for all women 51 years and over and men over 70. This level of intake is difficult for many older people to achieve using dietary intakes only. Currently, there is no agreement on the best way to provide appropriate levels of calcium and vitamin D to older people. Most obtain their calcium and vitamin D intake from a variety of sources. There are many carrier foods for calcium and vitamin D functional foods, and it is still contentious as to whether it s best to fortify a number of foods to a lower level, or focus on a few highly fortified food products. This is an area for further research. Older consumers behaviour towards functional foods The Food in Later Life project identified that while many older people had heard the term functional foods, few understood what it meant, with confusion between functional ingredients and additives. The project found women aged 65-74, and those living alone in the same age group, viewed functional foods positively, while the over 75s viewed them negatively. Younger cohorts of older people the baby boomers - are more likely to make changes to their diet for health reasons than the very old. Older consumers are most likely to be convinced of the health benefit of a functional food by a health professional more than half the women interviewed in one study did not trust manufacturers product labeling or advertising. Only functional foods that were part of a product category usually included in their diet were likely to be purchased; if the older person never consumed yoghurt, s/he was unlikely to purchase probiotic yoghurt. The baby boomer cohort of older people has been identified as being increasingly proactive in improving their health and well-being through lifestyle change, and this interest in health has been found to be highly relevant in positively influencing the acceptance and consumption of functional foods. 4

5 Functional foods are increasingly targeted at specific health concerns, many of which are the chronic conditions that increase with age. A US survey found the most common health benefit consumers of all ages were trying to achieve through food was lowering cholesterol a health problem far more commonly experienced by older people. A Finnish study showed 9% of Finns aged years used cholesterol-lowering margarine, compared with 1% of year olds. If a functional food is more expensive than a conventional version, older consumers are prepared to pay a price premium, but only if it is affordable. The young cohort of older people years is one of the wealthiest generations ever, and this is leading to their becoming an increasingly targeted market. A market analysis report highlighted bone health, heart health and diabetes as growth opportunities in healthy food and drinks for seniors. Despite contradictory findings on the influence of most socio-economic factors on consumer behaviour (including access, wealth), older consumers, particularly women, are more likely to consume functional foods than other consumers. The most common functional foods, such as probiotic yoghurts and cholesterol-lowering margarines, are widely available in supermarkets and convenience stores. Other issues of concern Current literature and dietary recommendations do not take account of the fact that 55-year olds are likely to have different nutritional needs from 80+ year olds. Age definition in the literature on older people s nutrition ranges begins at over 50 to 65 or older. In New Zealand it is 65 or older for Caucasian and 55 or older for Maori and Pasifika. The age group has similar nutritional needs to younger adults, but may pay extra attention to dietary risk factors for chronic diseases The age group also has similar needs to younger adults, except where there is higher risk of developing chronic disease or slowing the progression of chronic disease may be necessary. There is insufficient research into the dietary habits of the oldest old (85+ years). In the UK, the population of the oldest old is expected to reach 5% of the population by In New Zealand, over 25% of those aged 65+ years will be 85+ years old by Health promotion to encourage better nutrition and appropriate levels of physical activity can bring health benefits to older people, and will become more important with an ageing society. The full report is available at: Heinz-Watties has reprinted the popular Shopping for One resource, a handy shopping guide for older people to help them eat well for one week. nutrition@watties.co.nz to order copies or go to to download copies. You will find other useful resources here, too e.g. Quick and Healthy Recipes, Good Food Safe Food for Older People, 25 Easy Ways to Get More Fruit and 25 Easy Ways to Get More Veges. 5