Nutrition plays a vital role in the health and function of elderly adults (1). Our previous blog discussed how protein requirements change throughout life and and many studies have also identified protein as a key nutrient for the elderly. As we’ll see below, increasing protein intake in these populations may improve muscle health and function, prevent sarcopenia (2), and help maintain energy balance, weight management (3), and cardiovascular function (4, 5, 6).

 

Why do older adults require more protein?

Compared with younger adults, elderly adult muscle is less responsive to the anabolic stimulus, or ‘muscle building qualities’, of protein and the amino acids it contains, making it harder to build and maintain one’s muscle mass. This lack of responsiveness can be overcome with higher levels of protein consumption, and therefore and increased consumption of essential amino acids (7, 8). As a result, protein has been identified as a key nutrient for muscle health in elderly adults, and a greater protein intake is required for maintenance of muscle mass with advancing age. 

Why is it important to keep muscle mass as you age?

Osteoporosis and other musculoskeletal disorders such as Sarcopenia, are the most common problems affecting the elderly (9, 10). Osteoporosis effects our bones, weakening them as we age, increasing the risks of fractures and reducing movement ability and quality. Therefore, bone health is a key concern for older adults and maintaining bone health optimal throughout our lives helps to maintain good bone density and reduce the risks and implications of osteoporosis (11). There is also now strong evidence to suggest that bone health can still be improved in the latter years of life, with supplementation of protein, calcium, and vitamin D (12) - so it is not too late to improve your diet! 

Prevention and Management of Sarcopenia 

Osteoporosis and sarcopenia are similar but not the same. While osteoporosis is a progressive condition that weakens your bones making them more fragile, Sarcopenia is a condition characterised by loss of skeletal muscle mass AND function. This can lead to significant functional limitations and up to 13% of 60+year olds and up to 50% of 80+ year olds have Sarcopenia (13). 

Sarcopenia and osteoporosis share an underlying features and reinforce each other in terms of negative outcomes. They are also both linked to nutritional deficits (14).

The effects of sarcopenia are: 

1. Increased risk of falls
2. Fractures
3. Hospital admissions and 
4. Longer hospital stays
5. Reduced quality of life

Creating a better balance between muscle protein synthesis (MPS), or ‘production’ of protein, and muscle protein breakdown (MPB), can help prevent sarcopenia (15). This is where proper nutrition comes in!

 

The Importance of Protein Quality,  Minerals & Exercise
The body needs sufficient amino acids to build muscle protein and keep the muscle healthy and the key essential amino acid required in this process is leucine (16). As a result, it’s important to consume high quality proteins sources which contain all the essential amino acids needed for stimulating MPS and reducing MPB (17, 18, 19, 20, 21).  In our previous blog, we saw how the recommended daily intake (RDI) of protein might not be sufficient to maintain optimal health and, given the reduced sensitivity to protein experienced by older adults, it would be advisable to opt for this population to opt for higher levels of protein intake, while maintaining a high protein quality. 

As you’ll see below, micronutrients such as calcium and vitamin D are also key in  maintaining good bone health and muscle function as we age. Consumption of vitamin D plays an important role in bone health and muscle function as it is needed by the body to absorb calcium. Since vitamin D is needed for increased bone and muscle strength, low levels of vitamin D can increase the risk of falls and fracture. As you’ll see below, there is often an overlap between the micro and macronutrients - a lot of the protein-rich foods contain calcium and vitamin D, and foods high in calcium and vitamin D that are from animals or dairy products are often high in protein.

Lastly, exercise is another important area to consider for elderly adults. Combining dietary modification and exercise can maximise the effects of muscle protein synthesis and resistance based exercise can contribute to healthier, stronger bones as we age.

In Summary

• A sufficient protein intake, with a rich variety of EEAs, calcium and vitamin D are ideal for maintaining the balance between MPS and MPB, which can help to prevent sarcopenia and stave off osteoporosis (13-17, 25, 26).
• Check out our table below to find good sources of protein, calcium and vitamin D that you can start introducing to your diet.
• It’s important to remember that prevention is always better than a cure… by starting to incorporate these principles into your diet and exercise regime early, you can keep yourself fitter, stronger and healthier for longer!

Excellent food sources of: 

Calcium	Protein	Vitamin D
Cow’s Milk  Yoghurt or Greek yoghurt Cheese containing 20% DV Calcium or more Ricotta Cheese  Beans e.g., black-eyed peas, white beans, soybeans  Collard greens, okra, kale, Chinese cabbage  Sardines and Salmon (canned with bones) Fortified foods e.g., plant milks and cereals	Eggs Milk Yoghurt Fish and seafood Poultry (opt for lean protein from white meat poultry such as chicken and turkey) Soya  Nuts and seeds Pork Beans and pulses	Oily fish – such as salmon, sardines, herring, and mackerel  Red meat  Liver Eggs Fortified foods – such as some fat spreads and breakfast cereals

Written by Abby Attenborough 

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(1) Baum, J.I. and Wolfe, R.R., 2015, September. The link between dietary protein intake, skeletal muscle function and health in older adults. In Healthcare (Vol. 3, No. 3, pp. 529-543). 

(2) Morais, J.A., Chevalier, S. and Gougeon, R., 2006. Protein turnover and requirements in the healthy and frail elderly. The journal of nutrition, health & aging, 10(4), p.272.

(3) Wilson, M.M.G., Purushothaman, R. and Morley, J.E., 2002. Effect of liquid dietary supplements on energy intake in the elderly. The American journal of clinical nutrition, 75(5), pp.944-947.

(4) Hu, F.B., Stampfer, M.J., Manson, J.E., Rimm, E., Colditz, G.A., Speizer, F.E., Hennekens, C.H. and Willett, W.C., 1999. Dietary protein and risk of ischemic heart disease in women. The American journal of clinical nutrition, 70(2), pp.221-227.

(5) Obarzanek, E., Velletri, P.A. and Cutler, J.A., 1996. Dietary protein and blood pressure. Jama, 275(20), pp.1598-1603.

(6) Stamler, J., Elliott, P., Kesteloot, H., Nichols, R., Claeys, G., Dyer, A.R. and Stamler, R., 1996. Inverse relation of dietary protein markers with blood pressure: findings for 10 020 men and women in the INTERSALT study. Circulation, 94(7), pp.1629-1634.

(7) Katsanos, C.S., Kobayashi, H., Sheffield-Moore, M., Aarsland, A. and Wolfe, R.R., 2006. A high proportion of leucine is required for optimal stimulation of the rate of muscle protein synthesis by essential amino acids in the elderly. American Journal of Physiology-Endocrinology and Metabolism, 291(2), pp.E381-E387.

(8) Moore, D.R., Churchward-Venne, T.A., Witard, O., Breen, L., Burd, N.A., Tipton, K.D. and Phillips, S.M., 2015. Protein ingestion to stimulate myofibrillar protein synthesis requires greater relative protein intakes in healthy older versus younger men. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 70(1), pp.57-62.

(9) Sözen, T., Özışık, L. and Başaran, N.Ç., 2017. An overview and management of osteoporosis. European journal of rheumatology, 4(1), p.46.

(10) Gheno, R., Cepparo, J. M., Rosca, C. E., & Cotten, A., 2012. Musculoskeletal disorders in the elderly. Journal of clinical imaging science, 2, 39. https://doi.org/10.4103/2156-7514.99151

(11) Greer FR, Krebs NF. Optimising bone health and calcium intakes of infants, children, and adolescents. Paediatrics. 2006;117(2): 578-85

(12) Iuliano-Burns S, Woods J, King K, Ghasem ZA, Wang X-F, Wang Q et al. A dairy-based protein, calcium and vitamin D supplement reduces falls and femoral neck bone loss in aged care residents: a cluster randomised trial. Journal of aging research and clinical practice. 2012; 1(2): 141-6

(13) Morley JE & Anker SD. Prevalence, incidence, and clinical impact of sarcopenia: facts, numbers, and epidemiology—update 2014. J Cachexia Sarcopenia Muscle. 2014;5(4):253–259. 

(14) Reiss, J., Iglseder, B., Alzner, R., Mayr-Pirker, B., Pirich, C., Kässmann, H., Kreutzer, M., Dovjak, P., & Reiter, R. (2019). Sarcopenia and osteoporosis are interrelated in geriatric inpatients. Sarkopenie und Osteoporose sind bei geriatrischen Krankenhauspatienten miteinander assoziiert. Zeitschrift fur Gerontologie und Geriatrie, 52(7), 688–693

(15) Fry CS & Rasmussen BB. Skeletal muscle protein balance and metabolism in the elderly. Curr Aging Sci. 2011;4(3):260–268. 

(16) Bauer J, Biolo G, Cederholm T et al., 2013. Evidence–based recommendations for the optimal dietary protein intake in older people: A position paper from the PRO–AGE study Group. J Am Med Dir Assoc. 14(8):542–559. 

(17) Candow DG, Forbes SC, Little JP et al., 2012. Effect of nutritional interventions and resistance exercise on aging muscle mass and strength. Biogerontology. 13(4):345–358. 

(18) Kanda A, Nakayama K, Sanbongi C et al. Effects of whey, caseinate, or milk Protein Ingestion on muscle protein synthesis after exercise. Nutrients. 2016;8(6):e339. 

(19) Tipton K, Elliott T, Cree M et al. Ingestion of casein and whey protein results in muscle anabolism after resistance exercise. Med Sci Sports Exerc. 2004;36(12):2073–2081. 

(20) Xu Z, Tan Z, Zhang Q et al. The effectiveness of leucine on muscle protein synthesis, lean body mass and leg lean mass accretion in older people: a systematic review and meta-analysis. Br J Nutr. 2015;113(1):25–34. 

(21) Chanet A, Verlaan S, Salles J et al. Supplementing breakfast with a vitamin D and leucine–enriched whey protein medical nutrition drink enhances postprandial muscle protein synthesis and muscle mass in healthy older men. J Nutr. 2017;147(12):2262–2271.