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Journal of the American College of Nutrition, Vol. 17, No. 5, 448-453 (1998)
Published by the American College of Nutrition

Fatty Acid Nutriture in Hospitalized Elderly Women

Anne Schmuck, PhD,, Annick Villet, PhD, Nicole Payen, PhD, Josette Alary, PhD, Alain Franco, MD and Anne-Marie Roussel, PhD, FACN

GREPO (A.S., A.V., J.A., A-M.R.), Université Joseph Fourier, La Tronche; FRANCE
Laboratoire Interuniversitaire de Gérontologie de Grenoble (A.S., A.F.), CHU de Grenoble, FRANCE
Laboratoire de Biochimie A (N.P.), CHU de Grenoble, FRANCE

Address reprint requests to: Anne Marie Roussel, Pharm D, PhD, FACN, GREPO, UFR de Pharmacie, Domaine de la Merci, 38700 La Tronche, FRANCE


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objective: The aim of this study was to measure the fatty acid (FA) dietary intakes and the FA composition of plasma total lipids in a selected group of hospitalized elderly patients.

Methods: Twenty-three women aged 76 to 99 years were recruited. FA were analyzed in 5-day duplicate portions and in plasma by gas liquid chromatography.

Results: The hospitalized elderly women ingested an average of 5.22 megajoules (MJ) and 45.9 g of lipids per day. Polyunsaturated fatty acids (PUFA) represented 11.0% and saturated fatty acids (SFA) 53.6% of the lipid intake. Minimal recommendations for linoleic acid intake were reached in average, but 32% of the patients ingested less than 3 g of linoleic acid/d. Eighty-six percent received less than 0.5% of energy from {alpha}-linolenic acid and 64% had low intakes in very long-chain n-3 FA. In parallel, these patients presented several biochemical signs of essential fatty acids (EFA) insufficiency (decrease in linoleic acid, increase in monounsaturated fatty acids (MUFA), in n-7 FA and in indexes of {delta}-6 and {delta}-9 desaturase activities).

Conclusions: Hospitalized elderly patients have low PUFA intakes and show biochemical indices of EFA insufficiency. These patients might benefit from a nutritional supplementation providing both EFA and antioxidant micronutrients to limit the risk of skin troubles, immune system impairment and vascular disease often observed in institutionalized elderly subjects.

Key words: hospitalized elderly, fatty acids, dietary intake, EFA deficiency

Abbreviations: EFA=essential fatty acids • FA=fatty acids • FAME=fatty acid methyl esters • HDL=high-density lipoproteins • LDL=low-density lipoproteins • MJ=megajoules • MUFA=monounsaturated fatty acids • PUFA=polyunsaturated fatty acids • P/S=ratio of polyunsaturated to saturated fatty acids • RDA=recommended dietary allowances • RDI=recommended dietary intake • SFA=saturated fatty acids • TBARS=thiobarbituric acid reactive substances


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Because of the major role played by essential fatty acids (EFA) and their derivatives in lipid metabolism, platelet functions, immune system, inflammatory response, and epidermal functions [1], it is important to assure optimal EFA intakes. An adequate balance between n-3 and n-6 families is also required [2]. Elderly people represent a population at risk of nutritional imbalance due to low energy intakes and to altered food choices [3]. A possible alteration of FA metabolism upon aging has been reported. The activity of {delta}-6 desaturase seems particularly concerned, as shown in animals [4,5]. These modifications could worsen the consequences of low EFA dietary intakes in older subjects. However, only few studies have been dedicated to the determination of FA intakes in the elderly in relation with biochemical indicators of EFA status. Given the possible consequences of EFA deficiency, it is important to know the FA nutriture of populations at risk among which the institutionalized elderly. The present work was therefore undertaken to determine the actual FA dietary intakes and plasma concentrations in a group of hospitalized elderly patients.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
Twenty-three elderly women (mean age 86 years, range 76 to 99) hospitalized in the department of Gerontology of the Grenoble University Hospital were recruited. This population was composed of patients in rehabilitation following a femoral neck fracture and patients in long-term care (>2 months). Only those in stable medical condition without hepatic, renal, gastrointestinal, or malignant disease were selected.

None of the selected patients were receiving tube feeding but several of the long-stay patients needed assistance with or were dependent on others for feeding. Patients were receiving set meals composed of either regular diets or pureed foods, according to their dental or mental status. Menus were composed by dietitians to be well-balanced.

Informed consent was obtained from the subjects or from a close family member for mentally-impaired patients. The study protocol was approved by the ethics committee of the hospital.

Diet Collection and Food Analyses
The dietary study was done in the hospitalized elderly patients during 5 consecutive days using the duplicate portion technique, as described previously [6,7]. Food analyses were performed for each patient on a 5-day food composite. Dietary total lipids were extracted and measured according to the AFNOR recommendations [8]. An aliquot of the dietary fat was frozen at -20°C for FA analysis. After saponification with a solution of 0.5 mol/L of sodium hydroxide in methanol, FA were transesterified with 14% (wt/vol) boron trifluoride in methanol (Sigma, France) at 95°C for 30 minutes [9,10]. Fatty acid methyl esters (FAME) were then extracted with hexane containing 0.005% (wt/vol) butylated hydroxytoluene and analyzed by GLC using a Varian Star 3400 CX (Varian, 91941 Les Ulis-Cedex, France) fitted with a flame ionization detector and a capillary column HP INNOVAX (60mx0.32 mmx0.15 µm) (Hewlett-Packard, 91947 Les Ulis-cedex, France). The make up and carrying gas was N2 at a flow rate of 1 ml/minute (head column pressure: 15 psi). The running conditions were: initial temperature 100°C during 5 minutes, followed by an increase (10°C/minutes) to 200°C for 20 minutes, followed by another increase (3°C/minute) to 230°C for 5 minutes. The injection and detection temperature were 230°C and 250°C respectively. FAME were identified by comparison with the retention times of FAME standards (Sigma, Saint Quentin Fallavier, France). Results were expressed as percentage of total FA (chain length between 14 and 22 carbon atoms). The daily FA intakes (g/day) were also calculated.

Blood Collection and Analysis
Fasting blood was collected between 6:00 and 7:30 a.m. on the last day of the diet collection using evacuated tubes (Becton Dickinson, Meylan, France). Ethylene diamine tetra-acetic acid-containing tubes were used for FA determination. Samples were kept on ice and centrifuged within 30 minutes. Plasma was stored at -80°C for FA analysis.

Fatty acids of plasma lipids were analyzed as follows. After addition of the internal standard, heptadecanoic acid (Sigma, France), total plasma lipids were extracted with a single phase system (hexane/isopropanol 3:2, by vol) [11,12]. FA were transesterified and extracted as described above. They were expressed in relative amount (%) and in absolute concentration (mmol/L).

Lipid peroxidation was monitored by fluorometric determination of thiobarbituric acid reactive substances (TBARS) in plasma as described by Richard et al [13].

Statistics
Statistical calculations were performed with the PCSM statistical software (Deltasoft, Meylan, France). Normality of data distribution was tested using the Kolmogorov-Smirnov test. Results were compared using the Student’s t-test. Data were analyzed for statistical significance with a probability level of 0.05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The hospitalized elderly women ingested an average of 5.22 MJ/day. Total lipids (45.9±14.0 g/day) and SFA represented respectively 32.8% and 17.6% of the energy intake (Table 1). Linoleic acid and {alpha}-linolenic acid represented 3.0% and 0.35% of the total energy intake, respectively. The composition of dietary fat is shown in Table 2. Dietary lipids contained 53.6% of SFA, 35.4% of MUFA, and 11.0% of PUFA. The ratio of PUFA to SFA (P/S) in the diets was 0.21. The two major FA were oleic acid and palmitic acid (29.9% and 29.0% of the FA intake, respectively). The minimal recommendation for linoleic acid (1% of energy intake) [14,15] was reached in all patients. Thirty-two percent of the subjects had linoleic acid intakes below the minimal range recommended by the National Research Council (3 g/day) [14]. Eighty-six percent received less than 0.5% of energy from {alpha}-linolenic acid. Only one patient reached the French recommendations for {alpha}-linolenic acid (0.8 g/day) [15]. The intake of very long-chain n-3 FA (C20:5, C22:5, and C22:6) corresponded to less than 0.1% of energy intake in 64% of the patients.


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  		Table 1. FA Dietary Intakes (% of Total Energy Intake) in Relation to Recommendations

 

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  		Table 2. Composition of Fatty Acid Dietary Intake

 
The FA composition of total plasma lipids is shown in Table 3. A high relative content in 16:0, 18:1n-9, 16:1n-7, and 18:1n-7 was observed along with a low relative content in 18:2 n-6 compared to laboratory reference values. The ratio of 16:1n-7 to 18:2n-6, used as an indicator of linoleic acid deficiency [16], was increased in the hospitalized elderly subjects. Indexes of {delta}-6 and {delta}-9 desaturase activity [16] were also increased in the hospitalized elderly (Table 3).


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  		Table 3. Fatty Acid Composition of Total Plasma Lipids

 
The total cholesterol and HDL-cholesterol concentrations were low (5.38±1.11 and 1.18±0.30 mmol/L, respectively) whereas LDL-cholesterol and triglyceride concentrations (3.54±0.98 and 1.43±0.48 mmol/L, respectively) were close to usual laboratory values.

Lipid peroxidation was estimated by the measurement of TBARs in plasma. The TBARs plasma concentration was in the range of normal values obtained in free-living subjects aged 65 to 79 recruited for another protocol. However the ratio of TBARs to PUFA appeared significantly increased in plasma of hospitalized elderly patients compared to the healthy elderly subjects (0.59±0.11 vs 0.49±0.08 µmol/mmol, respectively, p<0.01).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our study provides detailed analytical data about FA ingested by hospitalized elderly patients. There are very little data about the FA dietary intakes of institutionalized elderly subjects, probably because of obvious difficulties in estimating the dietary intakes of very aged and often disabled people. Data concerning FA intakes in free-living elderly people are more numerous. However, usually only data about total saturated, monounsaturated, PUFA, and sometimes linoleic acid are provided [17–19]. The preciseness of these data can be questionned because food composition tables were used in a majority of cases. Furthermore, Dabadie et al [20] showed that the composition of fat remaining on the dishes at the end of the meal was different from that of the fat ingested. Conversely, in the duplicate diet technique, the closest copy of ingested portions is reproduced and chemically analyzed.

The average fat intake measured in our population is lower than most data obtained in institutionalized [21] and in free-living elderly subjects [17–19] using food composition tables. Our data are strikingly close to those obtained by the chemical analysis of hospital meals provided to healthy French middle-aged subjects [20]. The partition of FA in dietary fat is different from current recommendations [14,15,22]. For an optimal prevention of cardiovascular disease, SFA should represent less than 10% of the energy intake [14]. The value obtained here is 17.6%. In addition, palmitic acid and myristic acid, known to have the highest hypercholesterolemic effect [23] represented 70% of the SFA on average. This could be harmful in terms of cholesterolemia and therefore of cardiovascular morbidity. However, Krumholz et al [24] recently showed that hypercholesterolemia or low HDL-cholesterol may not be important risk factors for cardiovascular diseases in subjects older than 70 years. Actually, our hospitalized subjects presented rather low cholesterol concentrations in plasma. From recent studies, it has appeared that low cholesterolemia corresponds to an important risk of malnutrition in elderly subjects [25]. Below 4.13 mmol/L, the risk of mortality increases [26]. Twenty-two percent of our patients were below this range. The low total cholesterol values found in the hospitalized patients were mainly related to low HDL-cholesterol concentrations. This could be related to living conditions and insufficient physical activity. Moreover, Wilson et al [27] showed that total and LDL-cholesterol levels increase until age of 55 to 60 years in men and 70 to 75 years in women, and then start to decline. The cholesterol concentrations have probably already declined significantly in our patients. Therefore, the consumption of a high-SFA diet may not be as harmful in this population of 86 years-old patients as it would be in younger adults, provided adequate amounts of EFA are ingested.

The linoleic acid intake of the patients was below the optimal recommendation for French elderly people (5 to 8 g/day) [15]. One-third of the patients failed to ingest the minimum of 3 g/day recommended by the National Research Council [14]. According to Bjerve [28] the minimal recommendation for {alpha}-linolenic acid is 0.29 g/day in the near absence of long-chain n-3 FA. Twenty-two percent of our patients failed to ingest this amount, whereas 91% percent of the intakes were below the French recommendation for elderly subjects (0.8 g/day) [15]. A degradation of PUFA in foods before consumption could account for these low intakes, particularly in the case of arachidonic acid and n-3 FA. These FA are highly unsaturated and sensitive to oxidation [29]. Current recommendations do not provide values concerning the needs of elderly subjects for very long-chain PUFA. However, it has been suggested that 20:4n-6 and 20:5n-3, the precursors of eicosanoids, could also become essential for older subjects because of an impairment of desaturase activity with aging [4,5]. Further studies should be undertaken to define the specific needs of older subjects for these long chain PUFA. Relative to energy, the 18:3n-3 intake measured here is very close to the one calculated by Asciutti-Moura et al [21] (0.34% vs. 0.35%).

Consistent with these marginal EFA intakes, the hospitalized patients presented several biochemical signs suggesting an EFA malnutrition. A proportion of 18:2n-6 below 28% and a proportion of 16:1n-7 above 2.6% of total FA indicate EFA deficiency according to Siguel et al [30]. These criteria were met in 70% and 87% of our hospitalized patients, respectively. Only one subject presented none of these signs. As previously observed in EFA-deficient subjects [16], these patients presented a low P/S ratio and a low proportion of n-6 FA in blood lipids. An increase in the proportion of n-7 FA was also observed. The high indexes of {delta}-6 and {delta}-9 desaturase activities were also in favor of an EFA insufficiency in our patients [16]. It is noteworthy that the proportion of subjects presenting biochemical signs of EFA insufficiency was much higher than the proportion of subjects with 18:2n-6 intakes below minimal recommendations. This is in agreement with the lack of significant correlation between the intake of linoleic acid and its concentration in plasma (data not shown). Although this should be interpreted with care due to the small sample size, it suggests an impairment of linoleic acid absorption and metabolism in these patients.

Besides insufficient dietary intakes, other factors could contribute to EFA insufficiency in these patients. Metabolic disturbances related to aging could be one, the average age of the subjects being 86 years. A rise in the proportion of oleic acid, a decrease in n-6 FA, total PUFA and P/S ratio were already described in plasma and cell lipids of elderly subjects compared to younger controls [19,20,31,32]. In the present study, we also observed these differences between hospitalized elderly subjects and laboratory reference values obtained from younger subjects (25 normolipidemic women aged <55 years). All these studies suggest an alteration of the plasma FA profile upon aging and hospitalization. A study with a group of free living older subjects is being carried out to respectively determine, first the effects of age and second those of hospitalization.

PUFA are known to be one of the main targets of free-radical attack. Therefore, oxidative stress could impair EFA insufficiency through lipid peroxidation. Lipid peroxidation is generally reported to increase with age [33,34]. Schäfer and Thorling [35] showed the importance of expressing lipid peroxidation products relative to the available fatty acids. In the present case, the ratio of TBARS to PUFA was significantly higher in the hospitalized elderly compared to the value obtained in free-living elderly women. This suggests an increased relative lipid peroxidation in the hospitalized elderly patients. This is consistent with the high indexes of {delta}-6 and {delta}-9 desaturase activity expressed respectively as show in Table 3, by the ratio 16:1n-7/18:2n-6 and 20:3n-6/18:2n-6 in hospitalized elderly women. Indeed, Cabré et al [36] suggested that an increased oxidative stress could lead to enhanced desaturation and elongation of EFA to maintain the long-chain PUFA status of cell membranes.

In conclusion, the present study showed that hospitalized elderly patients present marginal EFA intakes and biochemical signs of EFA deficiency which could be partly related to an increased lipid peroxidation in these subjects. It is not possible to define if the observed decreased PUFA in hospitalized women is related to hospitalization or aging. Further studies are needed to compare these results with those obtained in an age-matched control group. However, dietary interventions could be considered in institutionalized elderly patients. They could limit the risk of skin troubles, immune system impairment, and vascular disease often observed in institutionalized elderly subjects, which may be partly related to EFA deficiency.


   ACKNOWLEDGMENTS
 
This work was supported in part by the Rhône-Alpes Region and the Aguettant laboratory (Lyon, France).

We are grateful to L. Sauze, C. Tavel-Besson, and Y. Grateloux for technical assistance, and to the staff of the Geriatric department (Pavillon E. Chatin) for helping with the diet collection. We thank C. Garcia de La Rosa and the dietitians’ department of the Grenoble Hospital (J. Vaccari).

The reading of this manuscript by Dr. R.A. Anderson, PhD, is greatly acknowledged.

Received August 1, 1997. Accepted April 1, 1998.


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 ABSTRACT
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 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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