di Emine Meral
Cattedra di Geriatria-Direttore: Prof. Enzo Manzato
Dipartimento di Medicina- DIMED
Universita' degli Studi di Padova
It now 100 years since the term "vitamin" was
coined and it have been learned a lot about its role in human
health, yet a considerable proportion of the elderly population
still does not meet recommended vitamin intakes (1). In fact,
the study of Toffanello et al, 2011 (2) confirmed that an
inadequate vitamin intake (hypovitaminosis) is a common finding
in elderly people. The low vitamin status in the elderly may
not come as a surprise considering their dietary habits. In
fact, changes in dietary habits which may occur in advanced
age (3), might influence the variety of an elderly's diet,
leading to a deficient intake of specific vitamins. Various
studies have pointed to the existence of vitamin deficiencies
in the elderly as a result of an inadequate dietary intake;
in fact, it is well known that vitamin intake is positively
associated with energy intake, since it is hard to obtain
adequate supplies of vitamins when a person's energy intake
is lower than 1550 Kcalories (4). A poor intake of such essential
vitamins as vitamin B1 (thiamine), vitamin A, C and D has
been confirmed in large proportion of older people as a consequence
of a reduced food intake due to dietary restrictions (2).
The recommended vitamin levels in elderly : an open-ended
At this point it can be claimed that proper vitamin nutrition
is essential for all people but especially for elderly persons,
because they are at higher risk for deficiency than younger
adults. Factors such as decreased income, physical activity
and energy needs, lack of social contact, dementia and other
psychological factors typically lead to decreased food intake
and consequently affect vitamin status (5).
However, the question of whether vitamin deficiencies might
occur or increase in elderly people remains open (2).
People age differently, and the course of the aging process
beyond 65 years old can be classified as successful, typical
or accelerated, and there is no agreement in the current literature
as to whether a decline in food intake unavoidably occurs
in all elderly, even in those aging successfully (2).
Thus, there are several difficulties in selecting a sample
of elderly people for a food intake study. Some authors suggest
the selection of apparently healthy elderly. Even if it possible
to obtain an almost homogeneous group, this is not a "real"
sample of an elderly population, which is, on the contrary,
characterized by a high heterogeneity of subjects: self-sufficient,
not self-sufficient and institutionalized. In Italy, the recommended
nutrient levels (LARN) are valid for a population up to 60
years old, while all the elderly are placed in an unique "geriatric"
group of age, over 60 (6). Hence, it should be necessary to
know exactly the vitamin intake levels requested by the elderly,
in each decade of advanced age (6), since over the last decade,
a number of studies have explored the effects of vitamin intakes
beyond the daily recommendations on a variety of mostly chronic
diseases (1). Given the magnitude of the problem, Troesch
and Eggersdorfer, 2012 (1) had called to action for all stakeholders
involved-academia, health professionals, industry, funding
agencies, and policy makers-to find ways to close the gap
between recommended and actual vitamin intakes in the elderly.
Recommended vitamin intakes are not met in elderly
In U.S. over 80% of persons age 71 years old had intakes
of "empty calories" (solid fats, added sugars, and
alcoholic beverages) that exceeded the discretionary calorie
allowances (7). This excess appears to be displacing nutrient-rich
food groups and may be contributing to the obesity epidemic
by providing many individuals with unnecessary "empty
calories" (7) and hypovitaminosis. Nearly the entire
U.S. population consumes a diet poor in vitamins, with fewer
vegetables and whole grains than recommended, and a large
majority under-consume fruits, milk, oils relative to recommendations
(7). These findings add another piece to the rather disturbing
picture that is emerging of a nation's diet (7).
In the Italian elderly people also, there is significant
increase in the consumption of "empty calorie" foods
(sugars, sweets), especially in women (2) which might be responsible
for hypovitaminosis (vitamin A and vitamin B2) .
Vitamin reference intakes and aging
To the light of that already said, the effect of aging on
vitamin requirements is not easy to quantify. There are changes
reported in the literature that give the impression that the
demand for some essential vitamins, such as vitamin A and
the vitamin B complex, may increase in later life, possibly
due to chronic conditions and morbidity. The epidemiological
findings suggest that intakes of particular vitamins are related
to the incidence of chronic diseases common in elderly.
The Food and Nutrition Board, the Institute of Medicine,
and the National Academy of Science and Health of Canada have
recently developed a standard set of nutrient recommendations,
known as dietary reference intakes (DRIs), which has added,
with regard to vitamin intakes, the groups for ages 51-70
years and for 70 years and older (5).These recommendations
are listed in Table 1.
Vitamins and chronic diseases
Vitamins that act as antioxidants appear to have a role in
preventing coronary artery disease and cancer (8). Current
work is focusing on the actions of vitamins as related to
immune function, the formation of cataracts, and the development
of osteoporosis, all associated with aging. A low intake in
B vitamins is thought to impair cognitive function and the
capacity to perform the activities of daily living in elderly.
The following paragraphs show the most common vitamins at
which the elderly may be at risk of hypovitaminosis, and their
relation with chronic diseases.
Vitamin D (calciferol) is essential for mineral homeostasis
and for normal mineralization of the skeleton. Vitamin D is
a generic name for allsteroids that show the biological activity
of vitamin D3 (cholecalciferol). It increases the absorption
of calcium and phosphates, and influences kidney re-absorption
of amino acids. Vitamin D deficiency is particularly important
in the elderly population because it is common and has a direct
relationship with increased morbidity (5).The deficiency of
vitamin D is linked to osteomalacia, osteoporosis, and increased
vertebral and non-vertebral fractures. Vitamin D is obtained
from two sources, diet and skin formation: the elderly receive
less exposure to sunlight and synthesis in the skin is reduced
by about 50% (9). In fact, an inverse relation exists between
the concentrations of pro-vitamin D3 in the epidermis with
age (10). Over two thirds of the elderly have vitamin D intakes
that are below two thirds of the RDA (11). Supplementation
has been shown to increase bone mineral density and decrease
fracture risk (12). In fact, in residential aged care, routine
vitamin D supplementation is highly effective in preventing
falls and fractures (13). On the other hand, excessive intakes
cause increased calcium absorption and increased calcium mobilization
from bone, resulting in hypercalcaemia and soft tissue calcification
Alpha-tocopherol is the biologically active form of vitamin
E and is probably the major lipid-soluble antioxidant. Vitamin
E absorption seems to be not altered with aging ; deficiency
of vitamin E has not been reported for healthy elderly people
(14). Low levels of alpha-tocopherol may be associated with
an increased risk of cancer mortality; because of these effects
of vitamin E deficiency, the use of supplemental vitamin E
has been investigated to prevent cancer (14). Clear benefit
has only been associated with reducing the risk of prostate
Also known as ascorbic acid, vitamin C is obtainable only
through dietary sources. It is claimed that five servings
of fruit and vegetables per day can supply the RDA (5). Like
vitamin A and E, vitamin C is an antioxidant and reduces harmful
free radicals (5). The conversion of iron from ferric to ferrous
form requires vitamin C; without this conversion, methaemoglobin
could not be converted to haemoglobin, and iron could not
be absorbed in the duodenum (5). Scurvy is the clinical syndrome
of vitamin C deficiency.
Vitamin A is the generic name for compounds with the qualitative
biological activity of retinol, i.e. retinoids, beta-carotene
and pro-vitamin A carotenoids. Low serum retinol levels indicate
vitamin A deficiency. The effects of vitamin A deficiency
are night blindness (hemeralopy), dry-eyes syndrome, keratomalacia,
Bitot's spots on the conjunctiva, dry skin and follicular
hyperkeratosis. Toxicity has been associated with abuse of
vitamin A supplements and with diets extremely high in vitamin
A content (16).
The forms of vitamin K include phylloquinone, which is found
in plants, and the menaquinones, which are synthesized by
gut bacteria. Vitamin K is necessary for the synthesis of
clotting factors 2, 7,9 and 10 and for the synthesis of protein
C and protein S (17). Causes of vitamin K deficiency include
any source of fat malabsorption and drugs that interfere with
vitamin K metabolism, such as anticonvulsants, warfarin and
certain antibiotics (17). The major clinical feature of vitamin
K deficiency is bleeding.
Vitamin B1 (or thiamine)
The active form of thiamine, thiamine pyrophosphate, is a
coenzyme involved in energy metabolism reactions; the requirement
for thiamine is therefore related to energy expenditure. Patients
at risk for vitamin B1 deficiency include alcoholics, those
on chronic peritoneal dialysis, those re-fed after starvation,
and thiamine-depleted persons who are given glucose. Patients
at high risk, such as alcoholics, may benefit from supplementation
(5). Excessive amounts of ingested thiamine are rapidly cleared
by the kidneys. No evidence exists of thiamine toxicity by
Vitamin B2 is also known as riboflavin. It is an essential
component of flavin mononucleotide and flavin adenine dinucleotide,
both of which are involved in ATP synthesis (5). Deficiency
may result from insufficient dietary intake or from medical
conditions such as chronic diarrhea, alcoholism, or liver
Vitamin B3 is niacin, also known as nicotinic acid. The metabolically
active forms of niacin are the pyridine nucleotides, nicotinamide
adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide
phosphate (NADP) (18). Free forms of the vitamin are white
stable crystalline solids. Only small amounts of the free
forms of niacin occur in nature. Most of the niacin in food
is present as a component of NAD or NADP. Pellagra is the
clinical manifestation of niacin deficiency.
Vitamin B6 occurs in three forms, pyridoxine, pyridoxal and
pyridoxamine; all of them are phosphorylated and pyroxal-5'-phospate
is the active coenzyme form of many enzymes involved in protein
and amino acid metabolism. Deficiency is associated with seborrhoeic
dermatitis, epileptiform convulsions and anaemia (14) .The
elderly tend to be at greater risk of vitamin B6 deficiency,
even if it is widely available in most foods.
Vitamin B12 includes the cobalamins, which can be converted
to methyl- or 5'-deoxyadenosyl cobalamin, which qualitatively
exhibit the biological activity of cyanocobalamin. Deficiencies
due to inadequate intake are rare. However, negative vitamin
B12 balance is often found in the elderly, especially in those
with atrophic gastritis, Helicobacter pylori infection and
use of proton pump inhibitors or other agents that interfere
with gastric acidity (5). A significant increase in malabsorption
of vitamin B12 seems to occur with age (5). The main symptoms
of deficiency are anaemia and/or neuropsychological disorders.
Folate is the generic name for folic acid-related compounds.
They are mainly involved in thymidine synthesis. There seem
to be no age-related changes in folate metabolism. Folate
is ubiquitous in nature and is present in nearly all natural
foods. Deficiencies are characterized by anaemia (megaloblastic),
depression and dermatological lesions. Alcohol and drug intake
increase the risk of deficiency. Folate deficiency can occur
within a few days of insufficient intake. This deficiency
is a particular risk in the elderly who have recently been
institutionalized (5). Deficiency in these persons is presumably
caused by decreased food choices and possibly by depression.
Vitamin requirements and metabolism should be studied more
closely in the elderly. Nutritional guidelines for elderly
people should urge them to consume a variety of foods from
all the food groups and to choose- instead of "empty
calorie" foods- more nutrient-dense foods in order to
ensure that their vitamin intakes reach the recommended levels.
Specific vitamin supplementation may therefore be necessary
in elderly people, even if they are apparently healthy, to
ensure adequate vitamin intake.
(1) Troesch B, Eggersdorfer M, Weber P.
100 years of
Vitamins: Adequate Intake in the Elderly is still a Matter
of Concern. J Nutr 2012; 142: 979-980.
(2) Toffanello ED, Inelmen EM, Minicuci N,
Campigotto F, Sergi G, Coin A, Miotto F, Enzi G, Manzato E.
Ten-Year Trends in Vitamin Intake in Free-Living Healthy Elderly
People: the Risk of Subclinical Malnutrition J Nutr Health
Aging 2011; 15: 99-103.
(3) Inelmen EM, Toffanello ED, Enzi G, Sergi G, Coin A, Busetto
L, Manzato E. Differences in dietary patterns between older
and younger obese and overweight outpatients. J Nutr Health
Aging. 2008 ; 12: 3-8.
(4) De Groot LCPGM, van Staveren WA. Older people, nutritionally
related problems. In: Encyclopedia of Human Nutrition, eds.
MJ Sadler. JJ Strain and B Caballero, pp 1479-1485. London:
Academic Press. 1999.
(5) Johnson KA, Bernard MA, Funderburg K. Vitamin nutrition
in older adults. Clin Geriatr Med 2002; 18: 773-799.
(6) Inelmen EM, Jimenez GF, Gatto MR, Miotto F, Sergi G, Maccari
T, Gonzalez AM, Maggi S, Peruzza S, Pisent C, Enzi G.. Dietary
intake and nutritional status in Italian elderly subjects.
J Nutr Health Aging. 2000; 4:91-101.
(7) Krebs-Smith SM, Guenther PM, Subar AF, Kirkpatrick SI,
Dodd KW. Americans Do Not Meet Federal Dietary Recommendations.
J Nutr 2010; 140: 1832-1838.
(8) Schlenker ED. Vitamins in the aged. In: Smith JM (ed)Nutrition
in aging, 2nd edn. Mobsy-Year Book Inc, Saint Louis, 1993;
(9) Holick MF. Photosynthesis of vitamin D in the
skin: effect of environmental and life-style variables.
Federation Proc 1987; 46:1876-1882.
(10) Mac Laughlin JA, Holick MF Aging decreases
the capacity of human skin to produce vitamin D3. J
Clin Invest 1985; 76:1536-1538.
(11) Delvin EE, Imbach A, Copti M Vitamin D nutritional status
and related biochemical indices in an autonomous elderly population.
Am J Clin Nutr 1988; 48:373-378.
(12) Gloth FM, Tobin JD. Progress in geriatrics: vitamin
D deficiency in older people. J Am Geriatr Soc
1995; 43: 822-828.
(13) Waldron N, Hill AM, Barker A. Falls prevention in older
adults - assessment and management. Aust Fam Physician 2012;41:930-35.
(14) Inelmen EM, Sergi G. Biochemical Parameters of Nutrition
In: Cachexia and Wasting: A Modern Approach edited by Giovanni
Mantovani, Stefan D. Anker, and Akio Inui, et al, New York,
NY, Springer, 2006. Chapter 3.1 pp,1-14.
(15) Stephenson J. Vitamin E and prostate cancer. JAMA 1998;
(16) Guigoz Y Recommended dietary allowances
(RDA) for the free-living elderly. Facts Res Gerontol
(suppl nutrition) 2nd ed. 1994; pp 113-143.
(17) Goljan EF. Disorders of nutrition. In: Pathology.
Saunders, Philadelphia, WB. 1998; pp 115-129.
(18) Swendseid ME, Jacob RA Niacin. In: Shils ME,
Olson JA, Shike M (eds) Modern nutrition in health
and disease. Lippincott Williams, Philadelphia, 1994; pp
Table 1. Recommended Vitamin Intake in
|Gli editoriali più recenti