This document provides an overview of supplement use in aging populations. It discusses factors that increase nutritional risk for older adults, such as difficulty swallowing, drug interactions, and financial limitations. The document then reviews evidence on multivitamins, antioxidants, herbal preparations, and other supplements. Several studies are summarized that look at supplements for conditions like infections, bone health, cognitive decline, and skin aging. The evidence for supplements is mixed, with some studies finding benefits and others finding no effects or increased mortality with multivitamin use.

1. Supplements in the Care of the
Aging
MARC EVANS M. ABAT, MD, FPCP, FPCGM
Internal Medicine-Geriatric Medicine
Head, Center for Healthy Aging ,and Section Head, Geriatrics, The Medical City
Clinical Associate Professor, Section of Adult Medicine, Department of Medicine
PGH

2. Outline
• Conceptual Framework for Supplementation
• Summary of Evidence
– Multivitamins and Minerals
– Antioxidants
– Herbal Preparations
– Nutraceuticals
– Hormonals

3. Conceptual Framework

4. Contributors to risk of malnutrition
• The elderly are at higher risk of developing
protein-calorie malnutrition and other vitamin
and mineral deficiencies.
• The frequency of these events increases with
advancing age due to problems such as poor
dentition, loss of taste, difficulty swallowing,
malabsorption, and drug-nutrient interaction

5. Contributors to risk of malnutrition
• Other physical limitations such as inability to
obtain necessary food due to lack of
transportation and dependence on others for
shopping, lack of financial resources, and
functional limitations can contribute to
nutritional deficiencies

6. Contributors to risk of malnutrition
• Non-perishable foods frequently contain high amounts
of sodium and nitrates, and processing can remove
vitamins.
• Many drugs cause anorexia, gustatory changes, and
anosmia as major side effects.
• Medications can also interfere with nutrient
availability

7. Risk Factors for Poor Nutrition Status
Alcohol or substance abuse Limited mobility, transportation
Cognitive dysfunction Medical problems, chronic diseases
Decreased exercise Medications
Depression, poor mental health Poor dentition
Functional limitations Restricted diet, poor eating habits
Inadequate funds Social isolation
Limited education

8. Physiology-the “anorexia of aging”

9. Physiology
• Changes in body composition
– Decreased bone mass
– Decreased lean mass
– Decreased water content
– Increased total body fat (greater intra-abdominal fat
stores)
• Decline in organ function is highly variable among
individuals and may affect assessment and
intervention options

10. Drugs that can cause ANOREXIA
• digoxin
• phenytoin
• SSRI’s / lithium
• Ca++ channel blockers
• H2 receptor antagonists
/ PPIs
• Any chemotherapy
• metronidazole
• narcotic analgesics
• K+ supplements
• furosemide
• ipratropium bromide
• theophylline
• spironolactone
• levodopa
• fluoxetine

11. Drugs That Interfere With Gustation (taste) and
Olfaction (smell)
Gustation
• Allopurinol
• Amitriptyline
• Ampicillin
• Baclofen
• Dexamethasone
• Diltiazem
• Enalapril
• Hydrochlorothiazide
• Imipramine
• Labetalol
• Mexiletine
• Ofloxacin
• Nifedipine
• Phenytoin
• Promethazine
• Propranolol
• Sulfamethoxazole
• Tetracyclines
Olfaction
• Amitriptyline
• Codeine
• Dexamethasone
• Enalapril
• Flunisolide
• Flurbiprofen
• Hydromorphone
• Levamisole
• Morphine
• Pentamidine
• Propafenone

12. Drug-Nutrient Interaction
Drug Reduced Nutrient Availability
Alcohol Zinc, vitamins A, B1, B2, B6, folate, vitamin B12
Antacids Vitamin B12, folate, iron, total kcal
Antibiotics, broad-spectrum Vitamin K
Digoxin Zinc, total kcal (via anorexia)
Diuretics Zinc, magnesium, vitamin B6, potassium, copper
Laxatives Calcium, vitamins A, B2, B12, D, E, K
Lipid-binding resins Vitamins A, D, E, K
Metformin Vitamin B12, total kcal
Phenytoin/Salicylates Vitamin D, folate/Vitamin C, folate
SSRIs Total kcal (via anorexia)
Trimethoprim Folate

13. Some Evidence

14. Probiotics and Common Acute Respiratory Infections
British Journal of Nutrition (2014), 112, 41–54

15. Probiotics for Antibiotic-Associated
Diarrhea and C. difficile

16. Multivitamins for Post-MI Patients in Trial
to Assess Chelation Therapy (TACT)
• 1708 patients, age ≥50 years, ≥6 weeks post
myocardial infarction, with creatinine level ≤
176.8 μmol/L (2.0 mg/dL).
• 2x2 factorial design
• Patients were randomly assigned to an oral 28-
component high-dose multivitamin and
multimineral mixture or placebo.
• Intention to treat
• The primary endpoint was time to total mortality,
recurrent myocardial infarction, stroke, coronary
revascularization, or hospitalization for angina.
Ann Intern Med. 2013 December 17; 159(12): 797–805.

17. Ann Intern Med. 2013 December 17; 159(12): 797–805.

18. Ann Intern Med. 2013 December 17; 159(12): 797–805.

19. Vitamin C and Risk for Stroke
J Am Heart Assoc. 2013;2:e000329

20. J Am Heart Assoc. 2013;2:e000329

21. Vitamin B Complex and Stroke
PLoS ONE 8(11): e81577. doi:10.1371/journal.pone.0081577

22. Vitamin B12 in Cognitive Decline
• there does appear to be an association between elevated
plasma homocysteine levels (a by-product of B vitamins)
and the onset of dementia (very low quality evidence).
• treatment with B12 supplementation does not appreciably
change cognitive function (moderate quality evidence, but
with less than optimal duration of follow-up)
• treatment with vitamin B12 and folate in patients with mild
cognitive impairment seems to slow the rate of brain
atrophy (low to moderate quality of evidence)
• oral vitamin B12 is as effective as parenteral vitamin B12 in
patients with confirmed B12 deficiency (moderate quality
evidence).
Ontario Health Technology Assessment Series; Vol. 13: No. 23, pp. 1–45, November 2013

23. Multivitamins and mineral supplementation in
cognitively-impaired elderly
• Increase in serum levels
• No increase in intracellular levels
• Changes in intracellular metabolic markers
noted
• No change in Mini-Mental State examination
Nutrition Journal 2013, 12:148

24. Calcium and Community-Dwelling Chinese
PLoS ONE 8(11): e80895. doi:10.1371/journal.pone.0080895

25. Vitamin E Deficiency and Fracture Risk
Am J Clin Nutr 2014;99:107–14.

26. Am J Clin Nutr 2014;99:107–14.

27. Vitamin D Supplementation
BMJ 2014;348:g2035

28. BMJ 2014;348:g2035

29. Multivitamins and minerals vs.
infection
• Meta-analysis
• Poor or moderate
quality
• Heterogenous
– Variable and surrogate
outcomes
• Results do not support
supplementing in
older persons
BMJ 2005;331:142

30. Plant Sterols/Stanols for Cholesterol
J Acad Nutr Diet. 2014;114:244-249.

31. Supplements for Osteoarthritis
Int. J. Mol. Sci. 2013, 14, 23063-23085

32. Int. J. Mol. Sci. 2013, 14, 23063-23085

33. Int. J. Mol. Sci. 2013, 14, 23063-23085

34. Int. J. Mol. Sci. 2013, 14, 23063-23085

35. Int. J. Mol. Sci. 2013, 14, 23063-23085

36. Multi-component supplement for joint
pain
• joint pain supplement containing glucosamine
sulfate, methylsufonlylmethane (MSM), white
willow bark extract (15% salicin), ginger root
concentrate, boswella serrata extract (65%
boswellic acid), turmeric root extract,
cayenne, and hyaluronic acid.
Nutrition Journal 2013, 12:154

37. Nutrition Journal 2013, 12:154

38. Micronutrient Supplementation and
Skin Aging
• 80 female volunteers with
phototype II-IV skin
• Randomized to received
placebo vs. 2 tablets of oral
proprietary supplement x 4
months
• skin microrelief as the main
outcome, and the secondary
outcomes were results on
standard macrophotography,
skin tension, skin high-frequency
ultrasound, and self-assessment.
Clinical Interventions in Aging 2013:8 1527–1537

39. • Results
– For all pseudoroughness and microrelief indicators,
there was a significant increase from baseline to
month 4 in the placebo group (P,0.05)
– a significant and dramatic difference between
baseline and month 4 and between baseline and
month 5.5 (P,0.05) in the active group, indicating
decreasing anisotropy of the skin
– skin thickness was significantly decreased in the
placebo group during winter but was stable in the
treated group (P,0.01).
– The photography scaling and self-assessment
questionnaire revealed no significant changes in
either group.
Clinical Interventions in Aging 2013:8 1527–1537

40. Supplements used in a Mid-Western
Cohort
BMC Complementary and Alternative Medicine 2013, 13:339

41. Supplements used in a Mid-Western
Cohort
BMC Complementary and Alternative Medicine 2013, 13:339

42. Omega-3 supplementation to lower
homocysteine in CKD patients
• 88 patients randomized in 2 groups, with 1
group receiving 3g/day of omega-3
supplementation
• Groups similar at baseline
Within group comparison
IJKD 2013;7:479-84

43. Glutamine in infections
• 120 patients, divided into 4 groups receiving
IV glutamine, enteral glutamine , combined or
enteral feeding only
• demonstrated that, a combined route of
glutamine supplementation resulted in the
most positive outcome in transferrin,
creatinine/height index and nitrogen balance
(at day 7 and 15) during the catabolic phase,
in septic patients with malnutrition.
Asia Pac J Clin Nutr 2014;23(1):34-40

44. Antioxidants
Study Design Intervention Results
Nutr J. 2011 Sep
21;10:94
86 subjects,
randomized
Placebo vs supplement
with Glycine max or
Garcinia cambogia for 10
weeks
No effect on weight loss;
lower total cholesterol and
higher HDL with Glycine
max
Nutr J. 2011 May
12;10:45.
10 subjects, open
pilot, non-randomized
Açai (Euterpe oleracea
Mart.) berry, 100g 2x a day
for 1 month
Decreased total cholesterol
and LDL, chole/HDL ratio
Lipids Health
Dis. 2010 Oct
19;9:119.
51 CHD patients,
double-blind
randomized
Placebo vs. Time-released
garlic powder tablets
16.21% drop-out rate
Significant decrease in total
cholesterol and LDL
compared with baseline
and placebo
Kobe J Med
Sci. 2008 May
23;54(1):E62-72
5 healthy
volunteers
2 weeks of ground green
tea
Increase oxidation time of
plasma and LDL
Maturitas. 2011
Apr;68(4):299-
310.
Meta-analysis Lycopene >25 mg/day,
lower doses
Decrease total cholesterol
and LDL, significant systolic
BP lowering

45. • 67 randomised trials with 232,550 participants
• no significant effect on mortality in a random-effects
meta-analysis (RR 1.02, 95% CI 0.99 to
1.06),
• significantly increased mortality in a fixed-effect
model (RR 1.04, 95% CI 1.02 to 1.06)
• significantly increased mortality by vitamin A
(RR 1.16, 95% CI 1.10 to 1.24), beta-carotene
(RR 1.07, 95% CI 1.02 to 1.11), and vitamin
E (RR 1.04, 95% CI 1.01 to 1.07)
Cochrane Database Syst Rev. 2008 Apr 16;(2):CD007176.

46. Resveratrol
• Mainly animal models
– Decreased hypertension
– Decreased myocardial infarction
– Decresed cerebral infarction
– Cardiac precondition via NO-dependent pathway
PLoS ONE 6(6): e19881. doi:10.1371/journal.pone.0019881

47. Herbal Preparations
J Fam Pract. 2003 Jun;52(6):468-78.

48. J Fam Pract. 2003 Jun;52(6):468-78.

49. J Fam Pract. 2003 Jun;52(6):468-78.

50. J Fam Pract. 2003 Jun;52(6):468-78.

51. J Fam Pract. 2003 Jun;52(6):468-78.

52. Dehydroepiandrosterone
Placebo (n=14) DHEA (n=17) P value
Pre-training Post-training Pre-training Post-training
LDL (mg/ml) 123 (3) 119 (14) 128 (5) 127 (6) 0.339
%Δ −10.2 (−25.9, 8.8; P =
J Clin Endocrinol Metab. 2008 February; 93(2): 534–538.
0.436)
%Δ −1.5 (−17.2, 17.2; P =
0.995)
HDL (mg/ml) 46 (3) 46 (3) 45 (3) 44 (3) 0.949
%Δ −2.2 (−16.4, 14.4; P =
0.979)
%Δ −1.7 (−14.8, 13.3; P =
0.987)
VO2Peak [ml/(
kg FFM ·
min)]
34.3 (1.4) 38.7 (1.3) 35.7 (1.1) 1529 (47) 0.957
%Δ 12.9 (4.5, 21.2; P <
0.001)
%Δ 12.6 (5.3, 19.9; P <
0.001)
Peak power
output (W)
119 (7) 138 (8) 115 (7) 40.2 (1.2) 0.370
%Δ 16.0 (6.9, 25.0; P <
0.001)
%Δ 20.6 (12.2, 29.1; P <
0.001)

53. Age Ageing. 2010 Jul;39(4):451-8

54. European Journal of Endocrinology (2004) 151: 1–14

55. European Journal of Endocrinology (2004) 151: 1–14

56. European Journal of Endocrinology (2004) 151: 1–14

57. Testosterone
Journal of Andrology, Vol. 30, No. 6, November/December 2009

58. Growth Hormone
Parameter No. of studies Result
Lipid profile 5 decreased total and low density lipoprotein
(LDL) cholesterol levels by 4–8% and by 11–
16%, respectively; increased high density
lipoprotein (HDL) only by 17%
Body
composition
6 rhGH did not affect BMI (2 out of 6);
significant decrease in waist circumference (3
studies) and W/H ratios (4 studies)
QoL 5 significant improvements of scores in all
studies.
Cognition 1 No improvement
Adverse
reactions
6 Headaches, edema, arthralgia, impaired
glucose metabolism, cerebrovascular disease,
neoplasms
European Journal of Endocrinology (2011) 164 657–665

59. Comments
• Studies have varied strength/quality
• Studies are heterogenous
• Other studies not mentioned often involved
ANIMAL studies

60. Recommendations
• Supplement use (whether mentioned in this
lecture or not) may boil down to PERSONAL
CHOICE
• Some evidence support the use of certain
supplements in judicious doses
• Weigh risks versus benefits