THE NUTRITIONAL NEEDS OF MIDDLE-AGED AND OLDER ADULTS: THE EUROPEAN UNION PERSPECTIVE

Susanne Bügel¹, Balz Frei²

1. Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark;
2. Linus Pauling Institute and Department of Biochemistry & Biophysics, Oregon State University, Corvallis, Oregon, USA.

Corresponding to: Susanne Bügel, MSc, PhD, Professor, Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark, Phone: +45 35 33 24 90, E-mail: shb@nexs.ku.dk
Care Weekly 2019;
Published online May 6, 2019, http://dx.doi.org/10.14283/cw.2019.4

Abstract

This narrative review describes the distinct nutritional needs of middle-aged and older adults in the European Union. Literature reviews were conducted to identify sources evaluating nutritional status and interventions relevant to these populations. Emphasis was placed on dietary guidelines, systematic reviews, and meta-analyses examining relevant macronutrients and micronutrients and important diseases or conditions related to aging (e.g. cardiovascular disease, infections, osteoporosis, cognition, immunity). Middle-aged and older adults in the European Union frequently do not obtain recommended amounts of key macronutrients and micronutrients necessary for maintaining health. In addition to the nutritional benefits of a healthful diet and contact with professionals to identify nutritional barriers, problem-solving techniques and micronutrient and macronutrient goals can improve the outcomes of dietary interventions in these individuals. Nutrition education programs, particularly those with specific recommendations, are effective for improving the nutritional status of these populations. For those who do not obtain adequate amounts of macronutrients and micronutrients from their diets, adhering to dietary guidelines and, when warranted, supplementation should be considered to improve nutritional status. The findings from randomized, controlled trials suggest that dietary interventions and supplementation can correct nutritional deficiencies and inadequacies that are important to the health of middle-aged and older adults. However, it is important to evaluate nutrient intake from the diet, supplementation, and fortified food to avoid exceeding tolerable upper intake levels of certain nutrients and limit potential adverse outcomes. Medical histories, medication use, dietary patterns, and other risk factors should be considered when recommending dietary improvements and supplements in these populations.

Key words: Aging, malnutrition, micronutrients, nutritional deficiencies.

Introduction

Life expectancies in European Union (EU) countries continue to rise, expanding the aging population. It has been estimated that by 2050 greater than 25% of the EU population will be ≥65 years of age, which has the potential to challenge the healthcare system (1). According to the European Health Report, important non-communicable diseases (NCDs) associated with aging include cardiovascular disease (CVD), certain cancers, and type 2 diabetes (1). Because these NCDs are the leading causes of early mortality in the EU, primary and secondary prevention efforts are needed to reduce NCD-related morbidity and mortality (1). To allow older individuals to live more independently and remain integrated in society, the World Health Organization’s agenda for preventing NCDs includes increasing physical activity, reducing tobacco and alcohol use, and reducing the risk of malnutrition, a condition in which many nutrient requirements are not met (2). The European Food Safety Authority (EFSA) reference intakes for selected micronutrients in adults >50 years of age are listed in Table 1 (3).

Table 1. European Food Safety Authority (EFSA) daily reference intakes for selected micronutrients in adults >50 years of age (3)

*1 μg of DFE equals 1 μg of food folate=0.6 μg of folic acid from fortified food=0.5 μg of a folic acid supplement; †1 μg RE equals 1 μg of retinol, 6 μg of β-carotene, and 12 μg of other provitamin A carotenoids; DFE, dietary folate equivalent; RE, retinol equivalent.

According to a systematic review of longitudinal data, risk factors for malnutrition include frailty, excessive polypharmacy, declining physical functioning and cognition, depression, dysphagia, and institutionalization (4). Multiple physical, socioeconomic, and cultural factors affect the nutritional status of older individuals, including changes in the ability to absorb nutrients, reduced appetite, and decreased ability to chew (4, 5). Furthermore, there are multiple drug-nutrient interactions that should be considered for this population (Table 2) (6). Insufficient energy intake associated with aging is complex and may involve chronic illnesses and reduced ability and desire to prepare and eat meals (7). Micronutrient intake below recommended amounts increases NCD risks (8). For example, micronutrient deficiencies can cause mitochondrial decay, a mechanism contributing to aging and development of diseases including cancer and neural decay (8). A relationship has been observed between the intake of certain micronutrients (i.e. vitamins D, B6, B12, and E and folate) and frailty in older adults (9). Values for ranges of nutrient intakes in the EU are described in Table 3 (10).

Table 2. Common drug-micronutrient interactions and consequences of the interaction(s) (6)

Table 3. Nutrient intake in the European Union based on national data (10)

*Intakes reported for individuals 19–64 years of age for all countries except the following: Greece: 22±2 years of age; Hungary: ≥18 years of age; United Kingdom: 25–64 years of age; †Intakes reported for individuals >64 years of age for all countries except Hungary (>59 years of age); ‡Folate equivalent; 1 μg food folate=0.5 μg folic acid (PGA)=0.6 μg folic acid taken with meals; §RRR-α-tocopherol equivalent=mg α-tocopherol + mg β-tocopherol x 0.5 + mg y-tocopherol x 0.25 + mg α-tocotrienol x 0.33. DFE, dietary folate equivalent; PGA, pteroyl glutamic acid.

This narrative review describes the nutritional needs of middle-aged (50–64 years) and older (≥65 years) adults in the EU and interventions healthcare professionals should consider. Literature searches were conducted to identify sources that evaluated the nutritional status and interventions relevant to this population, with an emphasis placed on systematic reviews, meta-analyses, and dietary guidelines. Notably, some meta-analyses also included other ages (<50 years), but those that are included primarily assessed older individuals.

Protein

Aging leads to a loss of muscle mass and strength and poor physical performance (i.e. sarcopenia) that has been associated with macro- and micronutrient deficiencies, suggesting that a high-quality diet that includes optimal protein and nutrient intake combined with physical exercise can reduce this risk (11). Sarcopenia can increase the risk for falls, fractures, disability, loss of independence, and increased mortality (11). The prevalence of sarcopenia is approximately 1–29% in community-dwelling older adults and 10–33% in those living in long-term care and acute hospital settings (12).
Adequate protein intake is important to healthy aging, and higher intakes may be necessary to compensate for the difficulty of maintaining muscle mass; however, recommendations vary by country (13). The EFSA recommendation for protein intake for adults is 0.83 g/kg/d (3), yet, the PROT-AGE Study Group recommends protein intakes in older adults of 1.0–1.2 g/kg/d (13). The authors state that those with chronic diseases, severe illnesses, injury, or malnutrition may require higher intakes (i.e. 1.2–1.5 and 2.0 g/kg/d, respectively) (13). Higher protein intake can negatively impact kidney function in those with severe kidney disease not receiving dialysis; therefore, caution should be taken in this population (13). The Nordic Nutrition Recommendations set a tentative recommendation of 1.2–1.5 g/kg/d while stressing that adequate data do not exist to estimate an optimal protein intake (14).
Protein quality, timing of administration, whether to supplement with single amino acids, and the addition of physical exercise should be considered (13). Protein supplementation immediately following resistance training exercise is beneficial for muscle mass and strength (13). A recent meta-analysis of randomized, controlled trials (RCTs) conducted with whey-, leucine-, and casein-based protein supplements combined with resistance training reported that elderly individuals adhering to this regimen improved lean body and appendicular mass, body fat and mass, muscle strength, and mobility (15). However, the International Sarcopenia Initiative stated that protein supplements alone or combined with resistance training have shown inconsistent effects on muscle mass and function in individuals ≥50 years of age (12).

Dietary fiber

Dietary fiber is critical to maintaining proper laxation and a healthy microbiome and is involved in many physiological activities including protecting against CVD (5). EFSA recommends that older adults consume 25 g/d of total fiber (3), but few meet this goal (5). The European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) recommendations for managing dyslipidemia include consuming 45% to 55% of energy from carbohydrates, including fruit, vegetables, whole grains, legumes, and nuts, and 25-40 grams of total dietary fiber, such as β-glucan from oat and barley (16).
A meta-analysis of 67 RCTs reported that consuming high-fiber diets significantly reduced total and low-density lipoprotein (LDL) cholesterol, but not high-density lipoprotein cholesterol (17). Other meta-analyses of RCTs reported that using different fiber supplements significantly reduced diastolic blood pressure, an effect that was more pronounced in adults >40 years of age compared with younger adults (18), and significantly reduced glycated hemoglobin in middle-aged and older adults with type 2 diabetes (19).

Omega-3 fatty acids

Omega-3 fatty acids have anti-inflammatory properties, and higher intakes have been linked to reductions in CVD risk and cognitive impairment (5). Omega-3 fatty acids cannot be efficiently converted from dietary alpha-linolenic acid in the body; therefore, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) often do not reach adequate levels. Dietary sources of omega-3 fatty acids include oily fish, flaxseed, and walnuts (5). EFSA recommends that adults consume 0.5% of their energy in the form of alpha-linolenic acid and 250 mg/d EPA plus DHA (3). ESC and EAS recommendations include 2–3 g/d of long-chain omega-3 fatty acid supplements to reduce triglycerides and regular consumption of fish and nuts for preventing CVD (20).
Meta-analyses of RCTs conducted in adults with or without cardiovascular comorbidities (e.g. coronary heart disease, heart failure) receiving DHA and EPA through the diet or supplementation reported a greater risk reduction among individuals with elevated triglyceride and LDL cholesterol levels (21) and significantly improved brain natriuretic peptide and serum norepinephrine levels (22). The Multicenter Osteoarthritis Study, a prospective cohort study of individuals (mean age: 60 years) with, or at high risk for, knee osteoarthritis (OA) reported that individuals with high plasma omega-3 fatty acid levels, especially DHA, had less patellofemoral cartilage loss (23). Well-controlled RCTs are necessary to support using omega-3 fatty acid supplements for OA.
Due to the association between inadequacies in omega-3 fatty acid status and cognitive decline, a number of studies have been conducted to evaluate the effects of omega-3 fatty acids on cognitive functioning. Meta-analyses of observational studies and RCTs conducted in middle-aged and older adults reported significant improvements in cognitive functioning (i.e. attention, executive functioning, memory), but no improvements in other cognitive parameters were observed (24, 25). A more recent meta-analysis of omega-3 fatty acid trials in adults (>40 years of age) did not observe improvements in cognitive functioning (26).

Folate and vitamins B6 and B12

Folate is a B-vitamin involved in the metabolism of nucleic acid precursors, DNA methylation, homocysteine metabolism, and cognition (5). Vitamin B6 is essential for many enzymatic reactions involved in protein metabolism, while vitamin B12 is involved in folate metabolism and neurological functioning. Deficiencies in vitamin B12 can cause peripheral neuropathy and cognitive dysfunction (3, 5). EFSA recommends that adults consume 250 μg/d folate, 4.0 μg/d vitamin B12, and 1.5 mg/d and 1.3 mg/d vitamin B6, in men and women, respectively (3). Deficiencies and inadequacies in folate and vitamins B6 and B12 can increase homocysteine concentrations, weaken immunity, and increase risk of CVD, stroke, cognitive dysfunction, depression, osteoporosis, and fracture risk (5, 27). In the EU up to 20% of older adults (>64 years) do not obtain adequate amounts of vitamin B12, and a substantial proportion (17–46%) do not achieve adequate intake of folate (28). Older adults may have difficulty extracting vitamin B12 from natural food sources due to an age-related decline in gastric acid secretion (5), which reduces the ability of vitamin B12 to bind to intrinsic factor (29).
Meta-analyses of folic acid supplement RCTs in middle-aged and older adults reported significant risk reductions in stroke and CVD-related events (30) and significant reductions in plasma homocysteine concentration, with further reductions when vitamin B12 was co-administered (31).
Folic acid and vitamin B12 supplementation may also improve bone health, primarily due to the effects on homocysteine levels (32). However, an RCT conducted in older individuals (≥65 years) with elevated homocysteine levels supplemented with folic acid and vitamin B12 reported no reduction in fracture risk, aside from a sub-group of individuals >80 years of age (32).
A meta-analysis of case-control studies reported significant associations between higher folate intake and decreased risk of head and neck squamous cell carcinoma (33). Despite these potential benefits, excessive intake of synthetic folic acid can increase the risk of certain cancers (34). Therefore, it is important to determine an individual’s intake of dietary folate and folic acid from supplements and fortification to avoid reaching levels that can cause adverse health outcomes.
In meta-analyses of RCTs of folic acid in subjects ≥45 years of age without dementia (35) and vitamin B6 and B12 in subjects ≥40 years of age who were healthy or at risk for CVD (26), no improvements in cognitive functioning were found. Another trial that administered folic acid and vitamin B12 to older adults (60–74 years) reported significant improvements in overall cognitive functioning and immediate and delayed recall (36).

Vitamin A

Vitamin A is a fat-soluble vitamin found either as preformed vitamin A (retinol) in animal products such as liver and dairy, or as provitamin A carotenoids such as β-carotene in fruit and vegetables (3, 37). Vitamin A is involved in regulating cellular growth and differentiation and is required for healthy immune function and vision (3, 37). EFSA recommends that adult men and women consume 750 μg/d and 650 μg/d vitamin A (as Retinol Equivalents, Table 1), respectively, from a mixture of preformed vitamin A and provitamin A carotenoids (3).
A critical issue with vitamin A is its toxicity (hypervitaminosis A) caused by excessive retinol intake; middle-aged and older adults may be particularly susceptible to vitamin A toxicity (38). Additionally, several prospective cohort studies have reported that higher intakes of retinol are associated with an increased risk of hip fractures in primarily middle-aged and older adults (39), and two RCTs found that high-dose supplementation with β-carotene (alone or combined with retinol) further increased the risk of lung cancer in at-risk populations (e.g. smokers, asbestos-exposed workers) (38). However, a meta-analysis of four RCTs found no effect on lung cancer risk with retinol or β-carotene supplementation in healthy adults (40).

Vitamin D

Vitamin D plays critical roles in calcium metabolism and bone health but is also involved in other health outcomes, such as neurological conditions, autoimmune diseases, NCDs (e.g. type 2 diabetes, cancers), and infections (5, 41). EFSA recommends vitamin D intake of 15 µg/d for adults (3), while the International Osteoporosis Foundation recommends average daily intake of 20–25 µg/d for older adults (41). Older adults may be at particular risk for insufficiency and deficiency due to lower sunlight exposure, reduced ability of the skin to synthesize vitamin D from 7-dehydrocholesterol upon sunlight exposure, and limited consumption of food sources of vitamin D (e.g. fortified milk, oily fish) (5). Across the EU, the percentage of the older population (>64 years) not obtaining adequate amounts of vitamin D is approximately 90% in most areas except Norway, Finland, and Spain (28). A systematic review of 195 studies reported that mean 25(OH)D values for those >65 years of age in the EU were 51.7 nmol/L (42). European League Against Rheumatism (EULAR) and European Federation of National Associations of Orthopaedics and Traumatology (EFORT) recommendations for preventing future fractures in those ≥50 years of age with previous fractures taking anti-osteoporosis drugs include supplementation with 800 IU/d (equivalent to
20 µg/d) vitamin D with adequate calcium intake (1000–1200 mg/d) (43). This recommendation is based on a meta-analysis of RCTs demonstrating a significant reduction in the risk of falling with 700–1000 IU/d (17.5–25 µg/d) vitamin D or 25(OH)D levels of 60–95 nmol/L (44) and a pooled analysis demonstrating a reduced risk of hip fractures with ≥800 IU/d (≥20 µg/d) vitamin D or baseline 25(OH)D levels >60 nmol/L in elderly individuals (≥65 years) (45). A separate meta-analysis of RCTs reported that vitamin D at 482–770 IU/d (12–19 µg/d) reduced the risk for non-vertebral and hip fractures by 20% (44), while a National Osteoporosis Foundation meta-analysis of RCTs reported that vitamin D supplements of 400–800 IU/d (10–20 µg/d) and calcium of 500–1200 mg/d reduced the risk of total and hip fractures by 15% and 30%, respectively (46). Evidence for the effectiveness of vitamin D supplements in reducing the risk of falling is inconsistent, and bolus doses have been shown to increase the risk for falling (47).
It has been suggested that vitamin D can have positive effects on other health outcomes, including autoimmune diseases and CVD, type 2 diabetes, and cancer (48). Deficiencies in 25(OH)D levels may also be associated with increased risk of colorectal and breast cancer, cardiovascular events, and mortality (48). Aggregated evidence from RCTs suggests that vitamin D supplementation could effectively prevent respiratory tract infections (49, 50), which caused 2.8 million deaths worldwide in 2010 (49) and affect the elderly at increased rates (50).

Calcium

Calcium is an essential mineral that is involved in promoting bone health but is also associated with other health outcomes such as controlling blood pressure (5). While EFSA recommends 750 mg/d total calcium intake in adults >50 years of age (3), EULAR/EFORT recommends 1000–1200 mg/d for preventing fractures in those using anti-osteoporosis drugs, with supplementation as necessary (43). EULAR/EFORT also cautions that calcium supplements may produce adverse gastrointestinal and possibly cardiovascular effects (43). Across the EU, the percentage of the older population (>64 years of age) not obtaining adequate amounts of calcium ranges from 48–100% (28).
A meta-analysis of 29 RCTs that evaluated calcium supplementation with or without vitamin D on bone health outcomes in middle-aged and older individuals (≥50 years of age) observed significant reductions in fracture risk and bone loss (51). Concern has been raised about the potential for calcium supplements to increase the risk for CVD, but a long-term study specifically designed to evaluate this potential found no evidence of increased risk in older women (mean age: 75 years) in relation to placebo (52). Another meta-analysis reported that total calcium intake (diet and supplementation) below the tolerable upper intake level (UL) is not associated with an increased risk for CVD (53). However, caution should be taken when recommending calcium supplementation to those already obtaining adequate dietary intake (53).

Vitamin K

Vitamin K describes a group of related fat-soluble vitamins critically involved in coagulation and bone health by activating specific proteins in the bloodstream and bone (3, 5, 54). Vitamin K1 (phylloquinone) is the primary dietary form of vitamin K, which is found in green leafy vegetables and vegetable oils, while vitamin K2 (menaquinone) is primarily found in animal-based or fermented foods (3, 54). EFSA recommends that adults consume 70 µg/d vitamin K (3). The mechanism of action for a class of anticoagulant therapies (e.g. warfarin) used for preventing atrial fibrillation and other cardiovascular events involves vitamin K antagonism; therefore, balancing the dose of these treatments and dietary vitamin K intake should be considered (55). However, studies have provided conflicting results; some show a negative relationship between coagulation stability and vitamin K intake and others suggest that some amount of vitamin K intake is necessary to produce an adequate response (55). A Cochrane database review reported that only one study showed this additive anticoagulant effect, indicating that the current evidence is insufficient to recommend vitamin K for those with unstable response to warfarin (56). Supplemental vitamin K has a strong anticoagulant effect, and consuming high levels of vitamin K-rich foods may interact with anticoagulant treatment (57). Vitamin K1 supplementation combined with calcium and vitamin D3 has also been shown to modestly improve bone mineral content in older non-osteoporotic women; however, these effects were not observed with vitamin K1 alone, suggesting that there may be a synergistic effect of these nutrients (58). Vitamin K2 has also been shown to produce benefits in arterial stiffness and bone mineral density (59, 60).

Vitamin E

Vitamin E (α-tocopherol) is a fat-soluble vitamin with antioxidant properties that are critical for protecting polyunsaturated fatty acids in membrane phospholipids and plasma lipoproteins from oxidative damage (3); it is also involved in immune function (5). α-Tocopherol deficiency causes the development of neurological symptoms (e.g. ataxia) (3). EFSA recommends that adult males and females consume 13 mg/d and 11 mg/d vitamin E, respectively (3), yet those >64 years of age have been shown to consume only between 6.3 and 13.7 mg/d (10). Very few individuals meet intake recommendations for vitamin E through diet alone (5). A meta-analysis of dietary intake studies reported that vitamin E is associated with a dose-dependent reduction in lung cancer risk (61), but another meta-analysis reported no effect on total or cancer-related mortality, aside from a significant reduction in the incidence of prostate cancer when vitamin E was consumed with other nutrients (62). Another meta-analysis of RCTs reported a decreased risk of ischemic stroke but an increased risk for hemorrhagic stroke. Notably, the doses of vitamin E administered substantially exceeded recommended intake levels (63).

Vitamin C

Vitamin C is a water-soluble vitamin with strong reducing and antioxidant properties; it acts as a cofactor in several enzymatic reactions for the synthesis of carnitine, catecholamines, and pro-collagen and for metabolizing cholesterol to bile acids (3). The primary dietary sources of vitamin C include fruit and vegetables and their juices (3). EFSA recommends that adult males and females consume 90 mg/d and 80 mg/d vitamin C, respectively (3). In the EU, the proportion of individuals >64 years of age falling below the average requirement of vitamin C is 4-33% (28).
Population-based studies have shown that plasma vitamin C levels are significantly and inversely related to stroke risk (64). Furthermore, lower vitamin C levels have been linked with a greater risk for Alzheimer’s disease (65, 66). Meta-analyses of RCTs have found that vitamin C supplementation significantly reduces both systolic and diastolic blood pressure (67), improves endothelial function and vasodilation in individuals with cardiometabolic risk factors (68), and decreases risk for lung cancer (69) and age-related cataracts (70).

Magnesium

Magnesium is an essential mineral for many enzymatic reactions involved in the synthesis of carbohydrates, lipids, nucleic acids, and proteins, and serves in various neurological and cardiovascular functions, including regulating blood pressure (3, 5). Magnesium is primarily found in muscle tissues and is an important component of bone (3, 5). Magnesium occurs naturally in a number of food items, including nuts, whole grains, seafood, fruit, and vegetables (3). EFSA recommends that adult men and women consume 350 mg/d and 300 mg/d of magnesium, respectively (3). There are few clear indications of magnesium inadequacies due to its various metabolic effects, and serum magnesium concentration as an indicator of status is questionable since there are no reliable biomarkers for magnesium body status (3).
Meta-analyses of prospective cohort and observational studies conducted primarily in middle-aged individuals have reported an association between higher circulating magnesium concentrations and decreased CVD risk (71), a significant inverse relationship between dietary magnesium intake and risk of metabolic syndrome (72), and a relationship between higher magnesium intake and reductions in colorectal cancer (73). Meta-analyses of RCTs that evaluated magnesium supplementation on diabetes-related outcomes reported improvements in insulin resistance (74) and fasting glucose levels (75) and significant reductions in systolic and diastolic blood pressure (76), including in individuals with insulin resistance, pre-diabetes, and other NCDs (77).

Potassium

Potassium is the primary intracellular cation responsible for maintaining fluid and electrolyte balance in the body and, hence, proper nerve conduction, muscle contraction, blood volume, and blood pressure (3, 5). Potassium occurs naturally in all foods but is particularly represented in root vegetables, fruit, whole grains, coffee, and dairy (3). EFSA recommends that adults consume 3500 mg/d of potassium, but these values can vary by country (3). Insufficient potassium intake causes hypertension and increases the risk of CVD, kidney stones, and osteoporosis (5).
A meta-analysis of prospective cohort studies reported that higher dietary potassium intake reduced the risk of stroke, which the authors attributed to reduced blood pressure (78). Although a 2006 Cochrane database review did not find substantial support for potassium supplementation for hypertension (79), a more recent meta-analysis of RCTs reported that potassium supplementation reduced systolic and diastolic blood pressure in a dose-dependent manner in hypertensive individuals (80).

Ensuring adequate nutrition in middle-aged and older adults

There is a robust body of evidence suggesting that a whole-diet approach not only lowers mortality from NCDs, but also positively impacts physical and cognitive functioning, mental health, and quality of life in older adults (81). However, too few high-quality studies have evaluated these outcomes to make clear recommendations. In addition to the nutritional benefits of a healthful diet, there are psychological benefits to eating that should not be overlooked (82). Increasing contact with professionals, identifying barriers, developing problem-solving techniques, and setting appropriate goals can improve the outcomes of dietary interventions in middle-aged and older individuals (83). Nutrition education programs have been shown to be effective for improving the nutritional status of older adults, particularly when they include specific interventions or multiple sessions (84).
Higher adherence to a Mediterranean Diet has been found to be significantly and inversely related to overall mortality in adults >65 years of age (85) and to reduced all-cause, CVD- and cancer-related mortality (86). Furthermore, a multivitamin/multimineral supplement (MVMS) that provides most micronutrients in recommended amounts can provide nutritional support for those who are unable to reach adequate micronutrient intake levels from their habitual diet, particularly for older individuals who often experience malnutrition with advancing age (87).
Healthcare providers commonly recommend MVMS to older adults, and while MVMS are generally safe (88), their benefits for improving health-related outcomes have been difficult to conclusively demonstrate (89). The Physicians’ Health Study II (PHS II) observed no reduction in the risk for developing CVD (90), but there was a significant 8% reduction in the risk of all types of cancer in this middle-aged and older male population (≥50 years of age) taking a daily MVMS for a mean duration of 11 years (91). The reduction in cancer risk was 12% when excluding prostate cancer from the analysis, and even greater (27%) in men with a baseline history of cancer (91). Despite its long duration and large sample size involving more than 14,000 male physicians, PHS II was insufficiently powered to detect statistically significant effects of MVMS on any individual type of cancer (91).
PHS II also found a significant 9% reduction in total age-related cataracts and an 11% reduction in cataract surgery (92). According to a Cochrane database review, use of an MVMS with antioxidant vitamins and minerals may delay the progression of age-related macular degeneration (AMD) (93). Lutein and zeaxanthin, which are sometimes added to MVMS formulations, also seem to be beneficial for the management of AMD (94). A meta-analysis of eight RCTs utilizing lutein and zeaxanthin supplementation showed improvements in visual acuity and contrast sensitivity in subjects with AMD (95).
Conflicting evidence on cognition has been observed in older adults who use MVMS. One clinical trial in middle-aged and older men reported improvements in episodic memory, including contextual recognition (96), while another trial in healthy middle-aged and older adults reported no benefit in cognitive task performance (97). Both of these studies reported that MVMS use improved some health-related biomarkers (i.e. C-reactive protein, liver function, and vitamin B6 and B12 blood levels, cholesterol, and homocysteine levels) (96, 97). A meta-analysis of 10 RCTs in primarily middle-aged and older adults reported that MVMS modestly improved some aspects of memory (98). An MVMS formulated with folic acid and vitamins B6 and B12 was shown to improve plasma homocysteine concentrations in an RCT in individuals ≥50 years of age (99), and another study in older individuals being treated with metformin demonstrated that use of an MVMS can reduce the risk for metformin-mediated deficiencies in vitamin B12 levels (100).
It is important that an MVMS include nutrients only in amounts that approximate reference intake values, and middle-aged and older adults who decide to use an MVMS should be aware that using additional single-nutrient supplements could result in a total intake exceeding the UL of these nutrients, increasing the risk of adverse health outcomes (87). Furthermore, there may be some individual exceptions to consider for these populations. For example, the typical dose of calcium commonly used in an MVMS may not be sufficient to promote bone health; therefore, dietary intake should be considered (89).

Conclusion

Data from RCTs suggest that dietary interventions and, when warranted, supplementation with MVMS can be used to reduce the risk of experiencing nutritional deficiencies and inadequacies that are detrimental to the health of middle-aged and older adults. For individuals who do not consume adequate protein, fiber, omega-3 fatty acids, and micronutrients from their habitual diet, supplementation may be required. The individual’s medical history, medication use, dietary patterns, and other risk factors should be considered when recommending dietary supplements.

Funding
Medical writing support was provided by Dennis Stancavish of Peloton Advantage, LLC, and was funded by Pfizer.

Role of the Sponsor
The sponsor was involved in the review and approval of the manuscript.

Conflicts of Interest
Susanne Bügel has received research grants from the Software AG Foundation and ERASMUS+. She is a board member of Food, Quality and Health and the Federation of European Nutrition Societies and as such receives travel support for meetings supported by these organizations. Balz Frei is the past recipient of multiple grants from the US National Institutes of Health and currently serves as a consultant for Pfizer Consumer Healthcare and DSM Nutritional Products.

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Online Health Information-Seeking: The Case of Deep Brain Stimulation in Social Media

JULIE M. ROBILLARD^1,2, EMANUEL CABRAL¹, TANYA L. FENG¹

1. Division of Neurology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
2. BC Children’s and Women’s Hospital, Vancouver, BC, Canada
Corresponding to: JM Robillard, PhD, Scientist, Children’s and Women’s Hospital and Health Centres, Assistant Professor of Neurology, The University of British Columbia, B402 Shaughnessy, BC Children’s and Women’s Hospital, 4480 Oak Street, Vancouver, BC V6H 3N1 Canada, [T] 604-875-3697, [F] 604-822-0361, [E] jrobilla@mail.ubc.ca
Care Weekly 2018;2:14-20
Published online November 5, 2018, http://dx.doi.org/10.14283/cw.2018.8

Abstract

Background: Online health information-seeking is a common behavior among caregivers. Social media increasingly plays a role as a source of health information, including for novel or emerging treatments such as deep-brain stimulation.

Objectives: To examine health information-seeking related to deep brain stimulation.

Design: Content analysis was applied to questions and answers related to deep brain stimulation posted online.

Setting: Content was captured from the website Yahoo! Answers between 2006 and 2015.

Participants: No participants were recruited for this study. The analysis was conducted on freely-accessible publicly posted content in online social media.

Results: Most discussions involved information-seeking and -sharing about a disease, treatment, or the procedure for deep brain stimulation. Nearly half of the questions featured some emotional valence, most often negative. Only a minority of questions and answers mentioned risks associated with deep brain stimulation. Deep brain stimulation was most discussed in the context of age-associated movement disorders such as Parkinson disease. Evaluations of the benefits and efficacy of deep brain stimulation for movement disorders differed significantly from evaluations of its use for mental health disorders (X2 [6, N = 432] = 28.46, p < 0.01).

Conclusions: With the increasing use of deep brain stimulation and its expanding application to a variety of age-associated neurological and psychiatric conditions, it is crucial to understand information-seeking trends related to this emerging neurotechnology to inform the development of knowledge dissemination initiatives for the public, patient and caregivers, and heath care providers.
Key words: Deep brain stimulation, social media, Parkinson’s disease, aging, eHealth.

Introduction

Over half of online health information-seekers are doing so on behalf of a person they care for (1). As the information needs of caregivers are not always met through formal health care channels, online resources and social media are increasingly used as sources of health information. Online health information-seeking may be especially relevant for new or emerging interventions, as analyses of social media content from our group and the work of others shows extensive discussions on topics such as gene therapy, stem cells, and optogenetics (2–6). One such intervention is deep brain stimulation (DBS), which is increasingly viewed as a novel neuro-technology with tremendous potential to alleviate symptoms and suffering from a large number of conditions. While one of the primary clinical indications is the treatment of advanced Parkinson’s disease, it has also been approved by the Food and Drug Administration for essential tremor and has humanitarian device exceptions for obsessive-compulsive disorder and dystonia (7). Ongoing research continues to explore applications of DBS for a wide spectrum of other neurological and psychiatric conditions. Clinical trials have shown efficacy for several diseases and disorders to date, including depression, Alzheimer’s disease, and chronic pain (8), many of which are especially relevant for an aging population.
Despite the rapidly expanding applications of DBS, little research has been conducted to examine information-seeking related to this type of intervention. Research specifically investigating perspectives on DBS is scarce and where attitudes have been evaluated, much of the literature has focused primarily on clinician and surgeon opinions (9), patient or research participant attitudes (10, 11), or media portrayals (12). The limited research available on public attitudes and information-seeking towards DBS has highlighted some of the ethical issues contemplated by individuals who have undergone or might undergo DBS. Pervasive themes of risk versus benefit, informed consent and autonomy underlie patient discussions and decision-making. Leykin et al. found that clinical trial participants considering DBS for treatment-resistant depression demonstrated a reasonable awareness of the risks and benefits of the procedure, weighing the risks of an unproven procedure against the harm of remaining clinically depressed (11). Analysis of interviews with patients with Parkinson’s disease who had underdone DBS showed that patients considered the procedure in different ways based on the level of knowledge acquired through the media, the internet, advocacy societies, or friends (13).
The media plays a pervasive role in shaping public opinions and attitudes and can be an important influence on views and behaviours related to health (14). With regards to DBS specifically, content analyses of news reports on neuro-stimulation and DBS treatments have identified predominant themes such as hope and scientific breakthrough (12). As a result, some researchers have expressed concern that overly optimistic media portrayals of DBS may harm informed consent and have suggested that both journalists and scientists should be more careful to include discussion on ethical issues, including greater exposition of the risks and potential limitations when communicating about DBS (15, 16).
In addition to traditional media, social media is used with increasing frequency as a means to both disseminate and access health information and to increase interactions between patients, care providers and researchers (17). Previous research has shown that social media platforms such as Twitter and Yahoo! Answers provide a rich resource for examining the health information being shared by the public and public attitudes, including views towards novel biotechnologies (2, 3, 18). Question-and-answer (Q&A) platforms in particular can yield rich insights into information needs, and attitudes and opinions towards emerging health technologies, as users with varying levels of expertise can both ask and answer questions on a topic. Yahoo! Answers is one of the most popular Q&A forums, with 661 million visits in November, 2017 (19). On this social media platform, users post questions for other members of the community to answer. A Best Answer is selected for each question by either the asker or the community. Categories of discussion vary from society and culture to politics and government and everything in between, and include thousands of health-specific threads.
Investigations of online health conversations about DBS can help elucidate public perspectives and attitudes toward to this novel treatment with expanding applications to several neurological and psychiatric diseases. These perspectives and attitudes can in turn serve as a critical starting point to inform the development of knowledge dissemination initiatives for the public, and for patients and their caregivers. The goal of the present study is to examine information-seeking and discussions of DBS through a content analysis of questions and answers on Yahoo! Answers.

Methods

Sample

A customized, automatic data mining program was used to collect Yahoo! Answers threads using the keywords “deep brain stimulation”, “brain pacemaker”, “brain surgery”, “brain electrode”, and “psychosurgery” across a 10-year period from 2006 to 2015. A thread is defined here as a question and its associated answers. Duplicates were manually removed in cases where different keywords retrieved identical threads. Where a question was posted multiple times and elicited different answers, identical questions were removed and unique answers were collected under a single thread. In order to select for DBS-relevant threads, we only included those that referenced “electrode in the brain” or in a specific deep brain region, “deep brain stimulation” or “DBS”, either in the questions or in their respective answers. Threads that did not discuss DBS for human applications were removed. Questions in the final sample were categorized into discreet and mutually exclusive question types.
To extract a sample of answers with entries focused on DBS, answers were collected from a subsample of questions that were categorized into question types where DBS was mentioned in greater than 10% of the questions. Answers that did not mention DBS and were not answering a question that mentioned DBS were removed to produce the final sample of answers (Appendix 1).

Content analysis

Questions

Emergent coding was employed to develop the coding guide for analysis of the questions, based on a pilot analysis of a random 10% of the sample conducted independently by two coders (JMR and EC) to capture salient themes. The final coding guide was developed through discussion (Appendix 2). The unit of analysis was each individual question or answer. A rich coding strategy was employed, allowing for each question or answer to be categorized into multiple codes. The entire question sample was coded by EC, and TF coded 20% of the sample in order to determine inter-coder reliability. Agreement was initially 95% and disagreements were resolved through discussion.

Answers

The same coding guide development process was repeated for the answers (Appendix 3). The entire answer sample was coded by one researcher (EC) and a second researcher (TF) coded 35% of the sample. After an iterative process of comparing coding results and refining the coding guide, a final agreement of 92% was obtained. Remaining differences were resolved through discussion.

Results

Sample

A total of 4860 questions were retrieved using the keywords and 776 questions remained after duplicates were removed. Of these, 645 questions met the inclusion criteria and comprised the final sample for analysis.

Questions

The questions were sorted into the following 13 categories (Appendix 2): application, opinion, information-sharing, access, health advice, information-seeking about procedure, information-seeking about disease, information-seeking about treatment, information-seeking about charity or financial coverage, homework, and experience.

Answers

DBS was mentioned in greater than 10% of questions in the access, application, health advice, homework, experience and information-seeking categories, therefore answers from these 480 questions were collected to form the initial answers sample. Of those questions, 3980 answers that did not mention DBS and were not answering a question that mentioned DBS were removed, resulting in the final answers for analysis (Na = 556).

Content analysis

Questions

The final coding guide comprised the following major themes (Appendix 2): 1) type of question; 2) for whom the question was being asked; 3) emotions expressed in the question; 4) features of DBS; 5) and the impact of illness. Half of all questions (50%, 325/645) specifically requested factual information such as information about diseases (15%, 98/645), treatments (14%, 92/645), or details about a specific procedure (10%, 62/645). In contrast, a different subset of questions asked about or expressed opinions on various subjects (12%, 79/645). While most questions did not explicitly state who the question was for (68%, 436/645), some Yahoo! Answers users mentioned that the question was for an issue that they were personally dealing with (21%, 135/645) or that a family member or friend was dealing with (11%, 74/645).
Among the health conditions mentioned (Figure 1), Parkinson’s disease was mentioned most frequently (28%, 152/543), followed by Tourette syndrome (11%. 59/543) and depression (10%, 54/543). Among the questions with specific mention of the impact of a health condition (n = 151), the main themes were impact on mobility (36%, 55/151), daily activities (31%, 47/151), social isolation (14%, 21/151), work (11%, 17/151) and school (7%, 11/151). Emotions were expressed in 285 questions, sometimes with multiple emotions expressed within the same question (Figure 2). Among these emotions, questions expressed a lack of hope or despair (16%, 45/285), a perceived lack of control or helplessness (14%, 39/285), and pleas for help or information (13%, 37/285).
Various features of DBS were discussed, sometimes within the same question, for a total of 203 mentions (n = 203). This included identifying the use of an electrode (37%, 76/203) and describing the device as a type of pacemaker (5%, 11/203). There was also some mention of risk involved in the procedure (9%, 18/203) and discussion of the use of DBS in children (6%, 13/203).

Figure 1: Frequency of conditions mentioned among those referenced in the questions

Figure 2: Frequency of emotions expressed among emotions referenced in the questions

Answers

The final coding guide for the answers included the following final themes (Appendix 3): 1) type of response; 2) features of DBS; 3) evaluations of DBS. Among the types of answers, there was sharing of information about treatments (48%, 268/556), medical procedures (27%, 152/556) and diseases (24%, 131/556). Some answers used personal experience or personal information (21%, 116/556) to emphasize their point while others provided advice about how to proceed on a medical issue (19%, 106/556; Figure 5).

Figure 3: Frequency of conditions mentioned among all health conditions referenced in the answers as compared between disorders for which DBS was mentioned as effective and for which DBS was mentioned as an experimental treatment (PD: Parkinson disease; TS: Tourette syndrome; DY: dystonia; OCD: obsessive-compulsive disorder; DE: depression; ET: essential tremor; MCS: minimally conscious state)

There were several mentions of conditions that were discussed as targets of DBS (n = 480). Mainly, DBS was mentioned as effective for Parkinson’s disease (36%, 175/480), Tourette syndrome (11%, 53/480) and dystonia (6%, 27/480; Figure 3). We categorized all conditions mentioned in our samples into two separate disease types: movement disorders or mental health disorders based on whether they primarily affect mobility or psychiatric well-being, respectively. The movement disorders category included: Parkinson’s disease, Tourette syndrome, dystonia, minimally conscious state, and essential tremor, while the mental health disorders category included obsessive compulsive disorder and depression. Across these categories, most mentions of conditions described DBS as an effective treatment for movement disorders (64%, 308/480) and some of these mentions described DBS as an effective treatment for mental health disorders (9%, 44/480). We compared whether risk was brought up for these categories of disorders (Figure 4). Overall 19% (90/480) of disease mentions included some discussion of risk, with 20% (72/359) of movement disorder mentions containing discussion of risk and 16% (23/144) of mental health disorder mentions containing discussion of risk. Using a chi-squared analysis, we compared the distributions of risk mentions across the mental health and movement disorder categories, and found no significant difference, X2 (1, N = 480) = 1.12, p = .29.

Figure 4: Mention of risk among all answers (N=556) compared between answers mentioning movement disorders (MD) and answers mentioning mental health disorders (MH)

We also compared how answers evaluated DBS and compared these evaluations to the disease types that were mentioned in conjunction with these evaluations (Figure 5). Overall, there were 359 evaluations (n = 359), of which 24% (85/359) described DBS as a last resort, 23% (81/359) described it as an option to consider, and 21% (76/359) expressed some reservation about the procedure. Our chi-squared analysis showed a significant difference between the distribution for the evaluation of DBS among movement disorders when compared to the distribution for the evaluation of DBS among mental health disorders, X2 (6, N = 432) = 28.46, p < 0.01.

Figure 5: a. Evaluations of DBS among all answers; b. Evaluation of DBS among all answers referencing disease, compared between movement disorders (MD) and mental health disorders (MH)

Discussion

Our study builds on previous understanding of public attitudes towards novel medical treatments by examining public information-seeking and opinions towards DBS. Most discussions examined here involved the seeking and sharing of information about a disease, treatment, or procedure for DBS, with minimal discussions of risk in both questions and answers.
In general, DBS was more likely to be discussed in the context of movement disorders than mental health disorders. Furthermore, the distribution of the evaluation of DBS of movement disorders significantly differed from that of mental health disorders. Some questions also mentioned the impact of the condition such as on mobility, daily activities, and social isolation. In addition, almost half of the questions featured some emotional valence, most commonly negative, such as a lack of hope or a perceived lack of control or helplessness.
The predominance of movement disorders over mental health disorders in this analysis may be attributed to the history of clinical applications of DBS, as modern DBS was first used in the treatment of movement disorders and has only more recently been applied to treating psychiatric disorders (7). These circumstances may contribute to less public awareness of the use of DBS in the treatment of mental illnesses, but as research advances, public knowledge of these novel applications may increase.
The differing evaluations of DBS between its use in movement disorders and mental health disorders may be the result of several sociocultural factors. One possible explanation is the mainstream understanding of the self according to the naturalistic notion of personality. Synofzik and Schaepler (20) argue that if we define personality as a “continuum where cognitive and mood representations are complex representations that largely build on more basic sensorimotor and vegetative representations”, DBS for any indication may be perceived to affect personality. However, this alteration of the self is the primary intended outcome of DBS for psychiatric disorders and is necessary for clinical benefit. Perhaps it is this fundamental and unavoidable change in psychiatric applications of DBS that some may find more ethically problematic than the use of DBS for movement disorders. Another explanation for this discrepancy may be the lasting impact of “the troubled history of psychosurgery” (21), namely, the widespread use of lobotomy to treat mental illness, on the public’s perception of DBS.
The paucity of discussion of the risks of DBS parallels the findings of Racine and colleagues in their examination of media portrayals of neurostimulation techniques, as they found that the tone of this coverage was generally optimistic and focused on the benefits of the technology (12). This has implications for raising unrealistic expectations of the benefits of DBS, which may be especially concerning in the present situation given the significant impact of these illnesses and the related themes of hopelessness and despair. This may also have an impact on shaping individuals’ provisional opinions on DBS, which Kimmerle and colleagues demonstrated may subsequently affect how people perceive further information about DBS (22).
As DBS continues to expand in its clinical applications, public views on this neuro-technology will be informed by the information disseminated through various sources, including social media platforms such as Yahoo! Answers as well as traditional media. The scientific community has already called for the responsible reporting of DBS in the media (23), including discussion of its associated ethical issues (15). However, this burden does not fall on the shoulders of journalists alone, as Illes et al. call for greater engagement between neuroscientists and the public in order to improve neuroscience communication and public understanding of the brain (24). This cultural shift is already underway, as a recent analysis of optogenetics-related tweets on Twitter found that academic researchers constituted the largest group involved in the conversation (4). This may be one of the contributing factors to the generally neutral tone of the tweets, compared to discussions of other biotechnologies on Twitter (3).
Public understanding of DBS has critical health implications on the individual scale, such as influencing informed consent and patient and caregiver expectations, as well as a broader societal scale such as determining its acceptance (25). Bell and colleagues (25) also emphasize the potential benefits of increased awareness of DBS, including increased funding and decreased stigma surrounding the treatment and the conditions it is used to treat.
We appreciate the limitations of the present study. While Yahoo! Answers is a popular social media website, future work should examine discussions about DBS taking place on other social media platforms. In addition, due to the anonymity of the users, we cannot conclude that these findings are generalizable to the broader population. Also, although our sample captures threads from a comprehensive 10-year period contributing to the stability of the sample, we did not conduct analyses to determine if and how information-seeking and perspectives on DBS changed over time.
Despite these limitations, this study provides a window into public understanding and perspectives on DBS. With the combination of the lack of discussion on the dangers of the procedure and its current and potential applications to several debilitating conditions, involvement of both the media and the academic community is crucial to ensure an accurate understanding of the benefits and risks of DBS.

Funding
This study was funded by the Canadian Institutes for Health Research, the Foundation for Ethics and Technology, the Vancouver Coastal Research Institute and the BC Children’s Hospital Foundation. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Conflict of Interest
None.

APPENDIX 1 ROBILLARD1

Appendix 2 ROBILLARD

References

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3.    Robillard JM, Cabral E, Hennessey C, Kwon BK, Illes J. Fueling Hope: Stem Cells in Social Media. Stem Cell Rev. 2015 Aug;11(4):540–6.
4.    Robillard JM, Lo C, Feng TL, Hennessey CA. “A Light Switch in the #Brain”: Optogenetics on Social Media. Neuroethics. 2016 Dec 1;9(3):279–88.
5.    Scanfeld D, Scanfeld V, Larson EL. Dissemination of health information through social networks: twitter and antibiotics. Am J Infect Control. 2010 Apr;38(3):182–8.
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GENDER AND AGE DIFFERENCES IN LEVELS, TYPES AND LOCATIONS OF PHYSICAL ACTIVITY AMONG OLDER ADULTS LIVING IN CAR-DEPENDENT NEIGHBORHOODS

W. Li¹, E. Procter-Gray¹, L. Churchill¹, S.E. Crouter², K. Kane¹, J. Tian³, P.D. Franklin⁴, J.K. Ockene¹, J. Gurwitz¹

1. Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA; 2. Department of Kinesiology, Recreation, and Sport Studies, The University of Tennessee Knoxville, 1914 Andy Holt Ave, Knoxville, TN 37996, USA; 3. Department of International Development, Community, and Environment, Clark University, 950 Main Street, Worcester, MA, 01610, USA; 4. Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA..
Corresponding author: Wenjun Li, PhD, Associate Professor, Director, Health Statistics and Geography Lab, Division of Preventive and Behavioral Medicine, Departments of Medicine, University of Massachusetts Medical School, School Building S4-314, 55 Lake Avenue North, Worcester, MA 01655, Phone: 774-455-4215 Fax: 508-856-4543, Email: Wenjun.Li@umassmed.edu

Care Weekly 2017;1:7-13
Published online November 9, 2017, http://dx.doi.org/10.14283/cw.2017.4

Please, note that this article was published also in the Journal of Frailty Aging (JFA) http://dx.doi.org/10.14283/jfa.2017.15

Abstract

Background: A thorough understanding of gender differences in physical activity is critical to effective promotion of active living in older adults. Objectives: To examine gender and age differences in levels, types and locations of physical activity. Design: Cross-sectional observation. Setting: Car-dependent urban and rural neighborhoods in Worcester County, Massachusetts, USA. Participants: 111 men and 103 women aged 65 years and older. Measurements: From 2012 to 2014, participants were queried on type, frequency and location of physical activity. Participants wore an accelerometer for 7 consecutive days. Results: Compared to women, men had a higher mean daily step count (mean (SD) 4385 (2122) men vs. 3671(1723) women, p=0.008). Men reported higher frequencies of any physical activity and moderate-to-vigorous physical activity, and a lower frequency of physical activity inside the home. Mean daily step counts and frequency of physical activity outside the home decreased progressively with age for both men and women. Women had a sharper decline in frequencies of self-reported physical activity. Men had a significant decrease in utilitarian walking, which women did not (p=0.07). Among participants who reported participation in any physical activity (n=190), more women indicated exercising indoors more often (59% vs. 44%, p=0.04). The three most commonly cited locations for physical activity away from home for both genders were streets or sidewalks, shopping malls, and membership-only facilities (e.g., YMCA or YWCA). The most common types of physical activity, performed at least once in a typical month, with over 40% of both genders reporting, included light housework, brisk walking, leisurely walking, and stretching. Conclusion: Levels, types and location preferences of physical activity differed substantially by gender. Levels of physical activity decreased progressively with age, with greater decline among women. Consideration of these gender differences is necessary to improve the effectiveness of active living promotion programs among older adults.

Key words: Gender, physical activity, type, location, aging.

Introduction

Adequate levels and proper type of physical activity are critical for the prevention of chronic diseases and disabilities among older adults (1-3). Moderate physical activity, such as walking, has been widely recommended by the Centers for Disease Control and Prevention (CDC) and health professionals for older adults as a means of reducing risk for chronic conditions and disabilities (4, 5). Older men and women differ in a number of socioeconomic (e.g., education, family income, culture, social norms) and biological factors that influence health behaviors. A better understanding of gender differences in the patterns and determinants of physical activity behaviors may shed light on the design of active living promotion programs that address the specific needs of both genders.
Although personal determinants of physical activity are well documented in the literature, less is known about the adaptation to and use of residential environments among older adults. Several built environment factors have been associated with type and level of adult physical activity (6-8) including low population density in suburbs (9), car dependency (10), proximity to shops and health care facilities (11), lack of access to fitness facilities (12), lower “walkability” (13), limited access to public parks and recreational areas (14), availability and conditions of sidewalks or walkways in neighborhoods (15, 16), and opportunities to make utilitarian walking trips from home (17). Older adults may have more physical limitations and no longer routinely travel outside their neighborhoods to work. Therefore, their daily living, health, and well-being may depend more on neighborhood resources in close proximity to their homes. Compromised mobility and reduced income and ability to drive limit their use of fitness facilities. Therefore, access or proximity to resources critical for healthy aging may influence aging in various aspects. In this study, we investigated gender differences in mobility patterns and levels, types and location of physical activity. Findings from this analysis may have important implications for healthy aging promotion.

Methods

Study area

According to the American Community Survey of 2015, Worcester County, including the City of Worcester, is a metropolitan area in Central Massachusetts, with a population of approximately 680,000 in 2015. The county includes a mix of urban, suburban and rural neighborhoods. The area is highly car-dependent and has infrequent bus services limited to the City of Worcester. Among workers 16 years and over living in households, 96.4% have access to at least one motor vehicle.

Recruitment of participants

Community-dwelling older adults were recruited in the study area. To increase the diversity and representativeness of the study sample, an “area-based” strategy was used for recruitment and oversampling of participants living in rural neighborhoods. Participants were recruited through presentations at community organization meetings, distribution of flyers, and direct mail. Promotional materials, interest surveys and brief presentations were offered at each venue and tailored to meet site preferences. To promote the study, venues included senior centers, veteran’s organizations, and men’s breakfasts at retirement villages. The opportunity to participate was offered, asking those who were interested to complete a form for further contact. In addition, flyers were distributed at the public housing authority, health clubs and at health fairs. Names, home addresses, phone numbers, and email addresses (if available) of potential participants were obtained through the above-mentioned venues as well as through the University of Massachusetts Medical School (UMMS) Centers for Clinical and Translational Science Conquering Diseases database. Letters and interest surveys were mailed to randomly selected addresses in rural, suburban and urban zip codes. Once a prospective participant expressed interest, the program director or designee contacted the person, explained the study, determined eligibility, and mailed the prospective participant a consent form.
To be eligible for the study, individuals had to be aged 65 years or older, able to provide consent, English speaking, ambulatory with or without assistive devices, willing and able to perform all study-related activities independently or with a designated caregiver, and pass cognitive function screening with 3 or fewer errors on the Short Portable Mental Status Questionnaire (18).
The consent form was reviewed with the prospective participant. Once consented, a baseline visit was scheduled for each participant. Multiple methods of participation were offered, including a one-on-one visit with a study team member at UMMS, at a Senior Center, or at their home, according to participant preferences and needs.
Surveys completed at home were returned by mail using a study-provided pre-paid envelope. Each participant completed two batteries of survey instruments, which took about 2-3 hours. The first battery included surveys to assess sociodemographics, health and health care, lifestyle factors, anxiety, lower extremity problems, and fall history and falls efficacy. In the week following the completion of the first battery, participants wore an accelerometer and Global Positioning System device for 7 consecutive days and completed dietary intake measures including 3 24-hour recalls of dietary intake within the 7 days. The second battery included instruments measuring physical activity, activity time and place, and depression. Self-reported weight and height were recorded and used to calculate participant body mass index.
The study protocol was approved by the University of Massachusetts Medical School Institute Review Board (Docket #: H-14793).

Personal data

Each participant was queried about their sociodemographic characteristics, physical and mental health conditions, lower extremity symptoms and problems, history of falls and fall injuries, health care utilization in the past year, and lifestyle behaviors itemized in Table 1. Assessment of most characteristics was by self-report using survey questionnaires designed by this study, along with a number of standardized instruments including the Tinetti Falls Efficacy Scale for fear of falling (19), Beck Anxiety Inventory,(20) CES-D Depression Scale (21), and the Short Portable Mental Status Questionnaire for cognitive impairment (18), and Activities of Daily Living for physical limitations.

Measurement of physical activity

Physical activity was measured objectively with an accelerometer (ActiGraph GT3X-Plus) worn by each participant during all waking hours for 7 consecutive days. A daily mean number of steps was calculated for each person, excluding any non-wearing days.
Self-reported measures of physical activity were assessed through the Community Healthy Activities Model Program for Seniors (CHAMPS) survey of frequency of exercise activities, both recreational and functional.(22, 23) Measures included 1) frequency of all exercise activities; frequency of moderate-to-high-intensity exercise; 3) frequency of performing physical activities in the home; 4) frequency of performing physical activities away from home; 5) frequency of walking for utilitarian purposes (e.g., walk to a food store in neighborhood); and 6) frequency of walking for recreational purposes (i.e., walk for at least 10 minutes for exercise in neighborhood).
To investigate differences in preferences for place of physical activity, participants were asked, “When performing physical activities away from home, do you usually do them indoors or outdoors?» Participants also were asked to choose from a list of 11 locations at which they perform physical activity at least once a month.

Statistical analysis

Participant characteristics were summarized by gender. Gender differences in sociodemographic, physical and mental health, and lifestyle factors were evaluated using Chi-squared tests for percentages or Wilcoxon rank-sum tests for continuous variables.
Gender differences in 7 physical activity measures were examined using regression models. For mean daily step count and CHAMPS frequency of all exercise activities, linear regression models were used. For the other 5 self-report physical activity measures that had skewed distributions, negative binomial regression models were used. The coefficients for female versus male gender were reported with and without covariate adjustment (see list of covariates in Table 2 footnote). To preserve degrees of freedom when adjusting for multiple covariates, a single composite adjustment score was derived for each outcome for each person using the entire set of adjusting factors as predictors in regression models. Each person’s composite score was then predicted as the sum of all the products of each specific regression coefficient multiplied by his/her value of the corresponding characteristic.(24) The composite score was used in the regression models to obtain covariate-adjusted coefficients for gender differences. Finally, gender differences in preferences for type and location of physical activity were tested using logistic regression models.

Results

Participants included 111 men and 103 women, 88% White, and had mean (SD) age of 74 (6) years, and a mean of 15 years of education (Table 1). Compared to men, more women had an annual income <$50,000 (p=0.02) and lived alone (p=0.001). Women also reported a higher degree of anxiety and a higher prevalence of respiratory disease and osteoporosis. A greater proportion of men had diabetes, and men had a slightly higher mean body mass index.

Table 1: Characteristics of participants (mean±SD or %)

As shown in Table 2, average daily step counts were approximately 16% higher for men than for women (p=0.008). Self-reported frequencies of all exercise activities and of moderate-to-vigorous intensity exercise activities also were significantly higher for men than women. However, women reported a higher frequency of physical activity inside the home. Adjustment for personal characteristics decreased the magnitude of the gender difference in physical activity frequencies by approximately 29%, although all differences remained statistically significant.

Table 2: Gender differences in selected summary scores of physical activity

Frequencies of physical activity away from home or for utilitarian and recreational walking did not notably differ by gender. It may be noted that utilitarian walking was very infrequent on average in this largely car-dependent population, with a mean frequency of 1.2 times per month.

As shown in Table 3, all 7 physical activity measures decreased with age when data from men and women are combined; significantly so for mean daily step counts and frequency of performing physical activity outside the home. Women showed a somewhat sharper decrease in frequencies of self-reported activities than did men, and men had a significant decrease in utilitarian walking, while women did not.

Table 3
Associations of physical activity measures with advancing age (5-year increase)

Among 190 participants who reported participation in any physical activity, 59% of women and 44% of men indicated exercising indoors more often (p=0.04), whereas 22% of women and 30% of men reported exercising outdoors more often (p=0.22). About 27% of men and 20% of women reported approximately equal frequencies for exercising indoors versus outdoors. The three most commonly cited locations for physical activity away from home for both genders were streets or sidewalks, shopping malls, and membership-only facilities (e.g., YMCA/YWCA, gym, yoga, martial arts). Substantial proportions of men and women visited religious centers, and civic places (e.g., senior center, town hall) (Table 4).

Table 4
Self-reported location for performing physical activity at least once per month by gender (percent or mean±SD)

Based on the CHAMPS survey, in a typical month men were more likely than women to participate in golfing, heavy housework (e.g., washing windows, cleaning gutters), heavy gardening (e.g., shoveling, raking), and moderate-heavy strength training (Table 5). Activities more likely to be chosen by women were light housework (e.g., dusting, sweeping), yoga/tai-chi, and aerobic dance. The most common types of physical activity, performed at least once in a typical month, with over 40% of both genders reporting, were light housework, brisk walking, leisurely walking, and stretching.

Table 5
Percentages of men and women reporting that they would typically participate in the activity listed at least once in the past month

Discussion

Gender differences in health and health behaviors have received greater attention in recent years. A recent policy of the US National Institutes of Health (NIH) requires inclusion of sex/gender in study design to improve the scientific rigor of NIH-funded studies. Gender differences in amount of physical activity have been reported in many previous studies of older adults. However, the type, location and influential factors on physical activity remain poorly understood. This study contributes to the literature new data on gender differences in physical activity among older adults living in car-dependent urban and rural neighborhoods. To our knowledge, these gender differences have not been well documented in the literature, and should be carefully investigated to improve strategies for promoting active living in older populations.
This study observed that both objectively-measured and self-reported physical activity levels and frequencies were significantly higher among older men than women. Older men had higher levels and greater frequency of moderate-to-vigorous intensity physical activity, and higher frequency of exercising outside the home. Both levels and frequencies of physical activity decreased with age, especially for daily step counts and frequency of performing physical activity outside the home. Women had a faster decline in frequencies of self-reported activities. The data suggested the progressive decline in frequency as well as time going outdoors in both genders.
With respect to preferences of indoor and outdoor exercise locations, men and women also differed substantially. About 59% of women and 44% of men reported exercising indoors more often than outdoors. About 56% of men reported exercising outdoors more often or as often as indoors. The data indicated a greater importance of places to do outdoor exercise for older men. The data also confirmed the importance of public indoor and outdoor places for exercises for both men and women, that is, both streets or sidewalks and shopping malls are reported as the most frequent exercise places away from home. While a relatively high proportion of participants used membership-only facilities, substantial proportions of men and women visited other public indoor places such as religious centers, and civic places (e.g., senior center, town hall). The data highlight the importance of these public indoor and outdoor places for promoting active living in older age.
This study has several strengths as well as limitations worth noting. First, an area-based sampling and recruitment strategy was used to ensure both geographic and socioeconomic representativeness of the participants. We successfully recruited participants living in rural and urban neighborhoods with varied housing density. Participant physical activity was measured using both CHAMPS (self-report) and an accelerometer. Location preference of physical activity also was measured using a structured questionnaire. The combinations of these data allowed the study to examine gender differences in patterns as well as determinants of physical activity, including types, location, personal and environmental factors influencing physical activity behaviors and location preferences. Such integrated analyses yield fresh data about this older population that have not been reported in the literature. However, our study was limited in its relatively small size, single geographic location, and cross-sectional nature. Except for the global positioning system and accelerometer data, the study relied on self-report data which are subject to recall and social desirability bias. The study sample was relatively healthy, affluent and well educated. To better understand neighborhood impact on physical activity in older age, a larger and more diverse sample, especially including participants with physical limitations and multiple chronic diseases, is necessary. Our future studies will address these issues.
In conclusion, levels, types and locations of physical activity differed substantially between older men and women living in car-dependent rural as well as urban neighborhoods. Further investigation of the mechanisms of these gender differences is necessary. Careful consideration of these differences may improve healthy aging promotion programs, ensuring that the programs are applicable to both genders.

Conflict of Interest
All authors declare no conflict of interest.

Acknowledgement
This project was supported in part by a Life Science Moment Fund Award (PI: Li) of University of Massachusetts Center for Clinical and Translational Sciences which is funded by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR000161. Several instruments used in this project were created in a pilot study (PI: Li) supported by NIH-funded Women’s Health Initiative (HHSN268201100001C). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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