Geriatric nutrition: Nutritional issues in older adults

INTRODUCTION

Changes associated with normal aging increase nutritional risk for older adults. Aging is characterized by diminished organ system reserves, weakened homeostatic controls, and increased heterogeneity among individuals, influenced by genetic and environmental factors.

Nutritional needs of the older individual are determined by multiple factors, including specific health problems and related organ system compromise; an individual's level of activity, energy expenditure, and caloric requirements; the ability to access, prepare, ingest, and digest food; and personal food preferences.

This topic will discuss assessment of nutrition in the older adult, as well as the etiology, evaluation, and treatment of weight loss, overnutrition, and specific common nutrient deficiencies. Related issues of geriatric health maintenance and nutritional assessment are discussed separately. (See "Geriatric health maintenance" and "Approach to the patient with weight loss" and "Dietary and nutritional assessment in adults" and "Vitamin supplementation in disease prevention".)

SCREENING FOR NUTRITIONAL STATUS

Data from studies of acute hospitalization in older patients suggest that up to 71 percent are at nutritional risk or are malnourished [1]. Malnutrition is associated with increased mortality risk [2]. The following criteria for the diagnosis of malnutrition have been recommended in a consensus statement from the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) [3]:

Two or more of the following six characteristics:

                              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2014. | This topic last updated: Jul 10, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. de Luis D, Lopez Guzman A, Nutrition Group of Society of Cstilla-Leon (Endocrinology, Diabetes and Nutrition). Nutritional status of adult patients admitted to internal medicine departments in public hospitals in Castilla y Leon, Spain - A multi-center study. Eur J Intern Med 2006; 17:556.
  2. Wallace JI, Schwartz RS, LaCroix AZ, et al. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc 1995; 43:329.
  3. White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr 2012; 36:275.
  4. Wannamethee SG, Shaper AG, Lennon L. Reasons for intentional weight loss, unintentional weight loss, and mortality in older men. Arch Intern Med 2005; 165:1035.
  5. Gregg EW, Gerzoff RB, Thompson TJ, Williamson DF. Intentional weight loss and death in overweight and obese U.S. adults 35 years of age and older. Ann Intern Med 2003; 138:383.
  6. Newman AB, Yanez D, Harris T, et al. Weight change in old age and its association with mortality. J Am Geriatr Soc 2001; 49:1309.
  7. Locher JL, Roth DL, Ritchie CS, et al. Body mass index, weight loss, and mortality in community-dwelling older adults. J Gerontol A Biol Sci Med Sci 2007; 62:1389.
  8. Bales CW, Buhr G. Is obesity bad for older persons? A systematic review of the pros and cons of weight reduction in later life. J Am Med Dir Assoc 2008; 9:302.
  9. Shea MK, Houston DK, Nicklas BJ, et al. The effect of randomization to weight loss on total mortality in older overweight and obese adults: the ADAPT Study. J Gerontol A Biol Sci Med Sci 2010; 65:519.
  10. Villareal DT, Chode S, Parimi N, et al. Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med 2011; 364:1218.
  11. Zawada ET Jr. Malnutrition in the elderly. Is it simply a matter of not eating enough? Postgrad Med 1996; 100:207.
  12. Health Care Financing Administration. Long Term Care Facility Resident Assessment (RAI) User's Manual, Minimum Data Set, Version 2, Eliot Press, Natick, MA 1999.
  13. Kondrup J, Rasmussen HH, Hamberg O, et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003; 22:321.
  14. Skipper A, Ferguson M, Thompson K, et al. Nutrition screening tools: an analysis of the evidence. JPEN J Parenter Enteral Nutr 2012; 36:292.
  15. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 2005; 82:1074.
  16. Keller HH, Goy R, Kane SL. Validity and reliability of SCREEN II (Seniors in the community: risk evaluation for eating and nutrition, Version II). Eur J Clin Nutr 2005; 59:1149.
  17. Tools can be purchased from Professor Heather Keller, RD, PhD. Contact hkeller@uoguelph.ca.
  18. Stratton RJ, King CL, Stroud MA, et al. 'Malnutrition Universal Screening Tool' predicts mortality and length of hospital stay in acutely ill elderly. Br J Nutr 2006; 95:325.
  19. Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999; 15:458.
  20. MNA Mini nutritional assessment. Available at: www.mna-elderly.com (Accessed on November 11, 2010).
  21. Charlton KE, Kolbe-Alexander TL, Nel JH. The MNA, but not the DETERMINE, screening tool is a valid indicator of nutritional status in elderly Africans. Nutrition 2007; 23:533.
  22. Sieber CC. Nutritional screening tools--How does the MNA compare? Proceedings of the session held in Chicago May 2-3, 2006 (15 Years of Mini Nutritional Assessment). J Nutr Health Aging 2006; 10:488.
  23. Vellas B, Guigoz Y, Garry PJ, et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999; 15:116.
  24. Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13:782.
  25. Kaiser MJ, Bauer JM, Rämsch C, et al. Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc 2010; 58:1734.
  26. Shen HC, Chen HF, Peng LN, et al. Impact of nutritional status on long-term functional outcomes of post-acute stroke patients in Taiwan. Arch Gerontol Geriatr 2011; 53:e149.
  27. Baumeister SE, Fischer B, Döring A, et al. The Geriatric Nutritional Risk Index predicts increased healthcare costs and hospitalization in a cohort of community-dwelling older adults: results from the MONICA/KORA Augsburg cohort study, 1994-2005. Nutrition 2011; 27:534.
  28. Leandro-Merhi VA, de Aquino JL, Sales Chagas JF. Nutrition status and risk factors associated with length of hospital stay for surgical patients. JPEN J Parenter Enteral Nutr 2011; 35:241.
  29. Mudge AM, Ross LJ, Young AM, et al. Helping understand nutritional gaps in the elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients. Clin Nutr 2011; 30:320.
  30. Roberts SB. Regulation of energy intake in relation to metabolic state and nutritional status. Eur J Clin Nutr 2000; 54 Suppl 3:S64.
  31. Winkels RM, Jolink-Stoppelenburg A, de Graaf K, et al. Energy intake compensation after 3 weeks of restricted energy intake in young and elderly men. J Am Med Dir Assoc 2011; 12:277.
  32. de Castro JM, Brewer EM. The amount eaten in meals by humans is a power function of the number of people present. Physiol Behav 1992; 51:121.
  33. Locher JL, Robinson CO, Roth DL, et al. The effect of the presence of others on caloric intake in homebound older adults. J Gerontol A Biol Sci Med Sci 2005; 60:1475.
  34. Wilson MM, Vaswani S, Liu D, et al. Prevalence and causes of undernutrition in medical outpatients. Am J Med 1998; 104:56.
  35. Thompson MP, Morris LK. Unexplained weight loss in the ambulatory elderly. J Am Geriatr Soc 1991; 39:497.
  36. Rabinovitz M, Pitlik SD, Leifer M, et al. Unintentional weight loss. A retrospective analysis of 154 cases. Arch Intern Med 1986; 146:186.
  37. Achem SR, Devault KR. Dysphagia in aging. J Clin Gastroenterol 2005; 39:357.
  38. Keller HH. Malnutrition in institutionalized elderly: how and why? J Am Geriatr Soc 1993; 41:1212.
  39. Mann G, Hankey GJ, Cameron D. Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis 2000; 10:380.
  40. Edwards LL, Quigley EM, Pfeiffer RF. Gastrointestinal dysfunction in Parkinson's disease: frequency and pathophysiology. Neurology 1992; 42:726.
  41. Guérin O, Andrieu S, Schneider SM, et al. Characteristics of Alzheimer's disease patients with a rapid weight loss during a six-year follow-up. Clin Nutr 2009; 28:141.
  42. Ritchie CS, Joshipura K, Silliman RA, et al. Oral health problems and significant weight loss among community-dwelling older adults. J Gerontol A Biol Sci Med Sci 2000; 55:M366.
  43. Rolls BJ. Do chemosensory changes influence food intake in the elderly? Physiol Behav 1999; 66:193.
  44. Horowitz M, Maddern GJ, Chatterton BE, et al. Changes in gastric emptying rates with age. Clin Sci (Lond) 1984; 67:213.
  45. Parker BA, Chapman IM. Food intake and ageing--the role of the gut. Mech Ageing Dev 2004; 125:859.
  46. Donini LM, Poggiogalle E, Piredda M, et al. Anorexia and eating patterns in the elderly. PLoS One 2013; 8:e63539.
  47. Engel JH, Siewerdt F, Jackson R, et al. Hardiness, depression, and emotional well-being and their association with appetite in older adults. J Am Geriatr Soc 2011; 59:482.
  48. Evans WJ, Morley JE, Argilés J, et al. Cachexia: a new definition. Clin Nutr 2008; 27:793.
  49. Martinez M, Arnalich F, Hernanz A. Alterations of anorectic cytokine levels from plasma and cerebrospinal fluid in idiopathic senile anorexia. Mech Ageing Dev 1993; 72:145.
  50. Oldenburg HS, Rogy MA, Lazarus DD, et al. Cachexia and the acute-phase protein response in inflammation are regulated by interleukin-6. Eur J Immunol 1993; 23:1889.
  51. Aggarwal BB, Puri RK. Human Cytokines: Their Role in Disease and Therapy, Blackwell Science, Cambridge, MA 1995.
  52. Roubenoff R, Harris TB, Abad LW, et al. Monocyte cytokine production in an elderly population: effect of age and inflammation. J Gerontol A Biol Sci Med Sci 1998; 53:M20.
  53. Roubenoff R. Origins and clinical relevance of sarcopenia. Can J Appl Physiol 2001; 26:78.
  54. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010; 39:412.
  55. Janssen I. The epidemiology of sarcopenia. Clin Geriatr Med 2011; 27:355.
  56. Baumgartner RN, Waters DL, Gallagher D, et al. Predictors of skeletal muscle mass in elderly men and women. Mech Ageing Dev 1999; 107:123.
  57. Muscaritoli M, Anker SD, Argilés J, et al. Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) "cachexia-anorexia in chronic wasting diseases" and "nutrition in geriatrics". Clin Nutr 2010; 29:154.
  58. Janssen I. Influence of sarcopenia on the development of physical disability: the Cardiovascular Health Study. J Am Geriatr Soc 2006; 54:56.
  59. Lindle RS, Metter EJ, Lynch NA, et al. Age and gender comparisons of muscle strength in 654 women and men aged 20-93 yr. J Appl Physiol (1985) 1997; 83:1581.
  60. Joseph C, Kenny AM, Taxel P, et al. Role of endocrine-immune dysregulation in osteoporosis, sarcopenia, frailty and fracture risk. Mol Aspects Med 2005; 26:181.
  61. Szulc P, Duboeuf F, Marchand F, Delmas PD. Hormonal and lifestyle determinants of appendicular skeletal muscle mass in men: the MINOS study. Am J Clin Nutr 2004; 80:496.
  62. Kenny AM, Dawson L, Kleppinger A, et al. Prevalence of sarcopenia and predictors of skeletal muscle mass in nonobese women who are long-term users of estrogen-replacement therapy. J Gerontol A Biol Sci Med Sci 2003; 58:M436.
  63. Wittert GA, Chapman IM, Haren MT, et al. Oral testosterone supplementation increases muscle and decreases fat mass in healthy elderly males with low-normal gonadal status. J Gerontol A Biol Sci Med Sci 2003; 58:618.
  64. Rasmussen BB, Fujita S, Wolfe RR, et al. Insulin resistance of muscle protein metabolism in aging. FASEB J 2006; 20:768.
  65. US Department of Health and Human Services. Healthy People 2010, 2nd ed. Government Printing Office; US Department of Health and Human Services, Washington, DC.
  66. Rantanen T, Era P, Heikkinen E. Physical activity and the changes in maximal isometric strength in men and women from the age of 75 to 80 years. J Am Geriatr Soc 1997; 45:1439.
  67. Kyle UG, Morabia A, Schutz Y, Pichard C. Sedentarism affects body fat mass index and fat-free mass index in adults aged 18 to 98 years. Nutrition 2004; 20:255.
  68. Garry PJ, Goodwin JS, Hunt WC, et al. Nutritional status in a healthy elderly population: dietary and supplemental intakes. Am J Clin Nutr 1982; 36:319.
  69. Robinson SM, Jameson KA, Batelaan SF, et al. Diet and its relationship with grip strength in community-dwelling older men and women: the Hertfordshire cohort study. J Am Geriatr Soc 2008; 56:84.
  70. Hernández JL, Riancho JA, Matorras P, González-Macías J. Clinical evaluation for cancer in patients with involuntary weight loss without specific symptoms. Am J Med 2003; 114:631.
  71. Thomas DR, Ashmen W, Morley JE, Evans WJ. Nutritional management in long-term care: development of a clinical guideline. Council for Nutritional Strategies in Long-Term Care. J Gerontol A Biol Sci Med Sci 2000; 55:M725.
  72. Milne AC, Avenell A, Potter J. Meta-analysis: protein and energy supplementation in older people. Ann Intern Med 2006; 144:37.
  73. Feldblum I, German L, Castel H, et al. Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial. J Am Geriatr Soc 2011; 59:10.
  74. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Institute of Medicine and National Acadamies Press 2005. Available at: http://www.nal.usda.gov/fnic/DRI//DRI_Energy/energy_full_report.pdf (Accessed on August 14, 2012).
  75. Rand WM, Pellett PL, Young VR. Meta-analysis of nitrogen balance studies for estimating protein requirements in healthy adults. Am J Clin Nutr 2003; 77:109.
  76. Panel on Macronutrients, Panel on the Definition of Dietary Fiber, Subcommittee on Upper Reference Levels of Nutrients, et al. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients), The National Academies Press, Washington, DC 2005.
  77. Buckler DA, Kelber ST, Goodwin JS. The use of dietary restrictions in malnourished nursing home patients. J Am Geriatr Soc 1994; 42:1100.
  78. Coulston AM, Mandelbaum D, Reaven GM. Dietary management of nursing home residents with non-insulin-dependent diabetes mellitus. Am J Clin Nutr 1990; 51:67.
  79. Simmons SF, Keeler E, Zhuo X, et al. Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance. J Am Geriatr Soc 2008; 56:1466.
  80. Koretz RL, Avenell A, Lipman TO, et al. Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials. Am J Gastroenterol 2007; 102:412.
  81. Rondanelli M, Opizzi A, Antoniello N, et al. Effect of essential amino acid supplementation on quality of life, amino acid profile and strength in institutionalized elderly patients. Clin Nutr 2011; 30:571.
  82. Solerte SB, Gazzaruso C, Bonacasa R, et al. Nutritional supplements with oral amino acid mixtures increases whole-body lean mass and insulin sensitivity in elderly subjects with sarcopenia. Am J Cardiol 2008; 101:69E.
  83. Pascual López A, Roqué i Figuls M, Urrútia Cuchi G, et al. Systematic review of megestrol acetate in the treatment of anorexia-cachexia syndrome. J Pain Symptom Manage 2004; 27:360.
  84. Berenstein EG, Ortiz Z. Megestrol acetate for the treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev 2005; :CD004310.
  85. Yeh SS, Wu SY, Lee TP, et al. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study. J Am Geriatr Soc 2000; 48:485.
  86. Reuben DB, Hirsch SH, Zhou K, Greendale GA. The effects of megestrol acetate suspension for elderly patients with reduced appetite after hospitalization: a phase II randomized clinical trial. J Am Geriatr Soc 2005; 53:970.
  87. Kropsky B, Shi Y, Cherniack EP. Incidence of deep-venous thrombosis in nursing home residents using megestrol acetate. J Am Med Dir Assoc 2003; 4:255.
  88. Sullivan DH, Roberson PK, Smith ES, et al. Effects of muscle strength training and megestrol acetate on strength, muscle mass, and function in frail older people. J Am Geriatr Soc 2007; 55:20.
  89. Beal JE, Olson R, Laubenstein L, et al. Dronabinol as a treatment for anorexia associated with weight loss in patients with AIDS. J Pain Symptom Manage 1995; 10:89.
  90. Jatoi A, Windschitl HE, Loprinzi CL, et al. Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a North Central Cancer Treatment Group study. J Clin Oncol 2002; 20:567.
  91. Volicer L, Stelly M, Morris J, et al. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer's disease. Int J Geriatr Psychiatry 1997; 12:913.
  92. Mihara IQ, McCombs JS, Williams BR. The impact of mirtazapine compared with non-TCA antidepressants on weight change in nursing facility residents. Consult Pharm 2005; 20:217.
  93. Goldberg RJ. Weight change in depressed nursing home patients on mirtazapine. J Am Geriatr Soc 2002; 50:1461.
  94. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med 1998; 158:1855.
  95. Allison DB, Gallagher D, Heo M, et al. Body mass index and all-cause mortality among people age 70 and over: the Longitudinal Study of Aging. Int J Obes Relat Metab Disord 1997; 21:424.
  96. Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA 2007; 298:2028.
  97. Diehr P, Bild DE, Harris TB, et al. Body mass index and mortality in nonsmoking older adults: the Cardiovascular Health Study. Am J Public Health 1998; 88:623.
  98. Diehr P, O'Meara ES, Fitzpatrick A, et al. Weight, mortality, years of healthy life, and active life expectancy in older adults. J Am Geriatr Soc 2008; 56:76.
  99. Wee CC, Huskey KW, Ngo LH, et al. Obesity, race, and risk for death or functional decline among Medicare beneficiaries: a cohort study. Ann Intern Med 2011; 154:645.
  100. Kulminski AM, Arbeev KG, Kulminskaya IV, et al. Body mass index and nine-year mortality in disabled and nondisabled older U.S. individuals. J Am Geriatr Soc 2008; 56:105.
  101. Wannamethee SG, Shaper AG, Lennon L, Whincup PH. Decreased muscle mass and increased central adiposity are independently related to mortality in older men. Am J Clin Nutr 2007; 86:1339.
  102. Dolan CM, Kraemer H, Browner W, et al. Associations between body composition, anthropometry, and mortality in women aged 65 years and older. Am J Public Health 2007; 97:913.
  103. Sui X, LaMonte MJ, Laditka JN, et al. Cardiorespiratory fitness and adiposity as mortality predictors in older adults. JAMA 2007; 298:2507.
  104. Villareal DT, Apovian CM, Kushner RF, et al. Obesity in older adults: technical review and position statement of the American Society for Nutrition and NAASO, The Obesity Society. Am J Clin Nutr 2005; 82:923.
  105. Villareal DT, Banks M, Sinacore DR, et al. Effect of weight loss and exercise on frailty in obese older adults. Arch Intern Med 2006; 166:860.
  106. Villareal DT, Fontana L, Weiss EP, et al. Bone mineral density response to caloric restriction-induced weight loss or exercise-induced weight loss: a randomized controlled trial. Arch Intern Med 2006; 166:2502.
  107. Pennypacker LC, Allen RH, Kelly JP, et al. High prevalence of cobalamin deficiency in elderly outpatients. J Am Geriatr Soc 1992; 40:1197.
  108. Lindenbaum J, Savage DG, Stabler SP, Allen RH. Diagnosis of cobalamin deficiency: II. Relative sensitivities of serum cobalamin, methylmalonic acid, and total homocysteine concentrations. Am J Hematol 1990; 34:99.
  109. Andrès E, Affenberger S, Vinzio S, et al. Food-cobalamin malabsorption in elderly patients: clinical manifestations and treatment. Am J Med 2005; 118:1154.
  110. Morris MS, Jacques PF, Rosenberg IH, Selhub J. Folate and vitamin B-12 status in relation to anemia, macrocytosis, and cognitive impairment in older Americans in the age of folic acid fortification. Am J Clin Nutr 2007; 85:193.
  111. Stabler SP. Screening the older population for cobalamin (vitamin B12) deficiency. J Am Geriatr Soc 1995; 43:1290.
  112. Kuzminski AM, Del Giacco EJ, Allen RH, et al. Effective treatment of cobalamin deficiency with oral cobalamin. Blood 1998; 92:1191.
  113. Food and Nutrition Board, Institute of Medicine. Vitamin B12. Dietary Reference Intakes: Thiamin, Riboflavin, Niacin, Vitamin B-6, Vitamin B-12, Pantothenic Acid, Biotin, and Choline, National Academy Press, Washington, DC 1998.
  114. Andrès E, Kaltenbach G, Noblet-Dick M, et al. Hematological response to short-term oral cyanocobalamin therapy for the treatment of cobalamin deficiencies in elderly patients. J Nutr Health Aging 2006; 10:3.
  115. Holick MF, Matsuoka LY, Wortsman J. Age, vitamin D, and solar ultraviolet. Lancet 1989; 2:1104.
  116. MacLaughlin J, Holick MF. Aging decreases the capacity of human skin to produce vitamin D3. J Clin Invest 1985; 76:1536.
  117. Milaneschi Y, Shardell M, Corsi AM, et al. Serum 25-hydroxyvitamin D and depressive symptoms in older women and men. J Clin Endocrinol Metab 2010; 95:3225.
  118. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, et al. Effect of Vitamin D on falls: a meta-analysis. JAMA 2004; 291:1999.
  119. Gerdhem P, Ringsberg KA, Obrant KJ, Akesson K. Association between 25-hydroxy vitamin D levels, physical activity, muscle strength and fractures in the prospective population-based OPRA Study of Elderly Women. Osteoporos Int 2005; 16:1425.
  120. Anderson JL, May HT, Horne BD, et al. Relation of vitamin D deficiency to cardiovascular risk factors, disease status, and incident events in a general healthcare population. Am J Cardiol 2010; 106:963.
  121. Visser M, Deeg DJ, Puts MT, et al. Low serum concentrations of 25-hydroxyvitamin D in older persons and the risk of nursing home admission. Am J Clin Nutr 2006; 84:616.
  122. Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency. Lancet 1998; 351:805.
  123. Need AG, O'Loughlin PD, Morris HA, et al. The effects of age and other variables on serum parathyroid hormone in postmenopausal women attending an osteoporosis center. J Clin Endocrinol Metab 2004; 89:1646.
  124. Hollis BW. Circulating 25-hydroxyvitamin D levels indicative of vitamin D sufficiency: implications for establishing a new effective dietary intake recommendation for vitamin D. J Nutr 2005; 135:317.
  125. Institute of Medicine. Report at a Glance, Report Brief: Dietary Reference Intakes for Calcium and Vitamin D, released 11/30/2010. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Report-Brief.aspx (Accessed on December 01, 2010).
  126. America's bone health: the state of osteoporosis and low bone mass in our nation, National Osteoporosis Foundation, Washington, DC 2002.
  127. Radimer K, Bindewald B, Hughes J, et al. Dietary supplement use by US adults: data from the National Health and Nutrition Examination Survey, 1999-2000. Am J Epidemiol 2004; 160:339.
  128. Mursu J, Robien K, Harnack LJ, et al. Dietary supplements and mortality rate in older women: the Iowa Women's Health Study. Arch Intern Med 2011; 171:1625.
  129. Johnson KA, Bernard MA, Funderburg K. Vitamin nutrition in older adults. Clin Geriatr Med 2002; 18:773.
  130. Weeden A, Remig V, Holcomb CA, et al. Vitamin and mineral supplements have a nutritionally significant impact on micronutrient intakes of older adults attending senior centers. J Nutr Elder 2010; 29:241.
  131. Sebastian RS, Cleveland LE, Goldman JD, Moshfegh AJ. Older adults who use vitamin/mineral supplements differ from nonusers in nutrient intake adequacy and dietary attitudes. J Am Diet Assoc 2007; 107:1322.
  132. El-Kadiki A, Sutton AJ. Role of multivitamins and mineral supplements in preventing infections in elderly people: systematic review and meta-analysis of randomised controlled trials. BMJ 2005; 330:871.
  133. Liu BA, McGeer A, McArthur MA, et al. Effect of multivitamin and mineral supplementation on episodes of infection in nursing home residents: a randomized, placebo-controlled study. J Am Geriatr Soc 2007; 55:35.
  134. NIH State-of-the-Science Panel. National Institutes of Health State-of-the-science conference statement: multivitamin/mineral supplements and chronic disease prevention. Ann Intern Med 2006; 145:364.