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Juli-September 2006, Vol.25 No.3
Nutrition and immune system in the elderly
Rina K. Kusumaratna a
Department of Communty Medicine, Medical Faculty, Trisakti University
The number of individuals aged 60 years or older is projected to double as a proportion of the world’s population and to more than triple in number over the next 50 years. Aging is often associated with a dysregulation in immune function, particularly in T-cell responses, even in the healthy elderly. Adequate nutrition is important for optimal immune function. Specific nutrient deficiencies can aggravate the age-associated dysfunction in immune function and increase the risk of illness. Several micronutrients such as iron, zinc, and selenium are essential to specific and non-specific immune function and thus influence the susceptibility of the elderly to infectious diseases. Free radicals and oxidative stress have been recognized as important factors in the biology of aging and of many age-associated degenerative diseases. Therefore, dietary components with antioxidant activity have received particular attention because of their potential role in modulating oxidative stress associated with aging and chronic conditions. The nutritional deficiency impairs the immune response, exposure to viral pathogens, and will result in an increase in the severity of diseases. Nutritional deficiency in the elderly must be treated to reduce the risk of infection and possibly slow the aging process. Keywords : Nutrition, aging, immunity
Zat gizi dan sistem kekebalan pada lanjut usia
Jumlah penduduk berusia 60 tahun keatas diproyeksikan akan menjadi dua kali lipat dan akan menjadi tiga kali lipat pada 50 tahun mendatang. Proses penuaan seringkali dikaitkan dengan gangguan regulasi dari sistim kekebalan, khususnya pada respons sel T yang dapat terjadi bahkan pada lanjut usia (lansia) yang sehat. Zat gizi yang adekuat sangat penting untuk memelihara fungsi kekebalan yang optimal. Defisiensi zat gizi yang spesifik dapat memperberat gangguan fungsi sistem kekebalan akibat proses penuaan dan meningkatkan risiko terjadinya penyakit pada lansia. Beberapa zat gizi mikro seperti seng dan selenium sangat penting untuk fungsi kekebalan dan berpengaruh terhadap kerentanan lansia untuk terkena penyakit infeksi. Radikal bebas dan stress oksidatif sudah diketahui sebagai faktor risiko penting terhadap penyakit degeneratif yang berkaitan dengan usia. Dengan demikian asupan makanan yang mengandung bahan antioksidan sangat menarik perhatian karena peranannya yang potensial untuk mengatur stress yang bersifat oksidatif. Kekurangan zat gizi mengganggu respons kekebalan, mudah terkena virus patogen, dan mengakibatkan meningkatnya penyakit yang berat. Bila terjadi kekurangan gizi pada lansia harus diobati untuk menurunkan risiko timbulnya infeksi dan memperlambat terjadinya proses penuaan. Kata kunci : Zat gizi, penuaan, kekebalan
Rina K. Kusumaratna Bagian Kedokteran Komunitas Fakultas Kedokteran, Universitas Trisakti Jl. Kyai Tapa No.260, Grogol Jakarta 11440 Tel. 021-5672731 eks. 2504, Fax. 021-5660706 E-Mail : email@example.com
The United Nations Population Division estimated that this age group represented ~10% of the world’s population. The six classes of nutrients serve three general functions: (i) provide energy. One of the mayor consequences of this growing elderly population is the significant increase in health care expenses due to their susceptibility to infection. Our body needs nutrients for normal growth and development. or ~600 million people. especially in the elderly. Our body needs large quantities of carbohydrates. because the body requires it in relatively small quantities for cellular metabolic processes. Changes in immunity. vitamins. the vitamins and minerals are called micronutrients. (ii) regulate body processes and (iii) contribute to body structures. mainly with important decreases in cell-mediated immunity (CMI) and lower effect of non-specific and humoral immunity. with few elderly. these substances are called macronutrients. to one with more balanced numbers across age groups. this proportion will increase to 20% and will include >2 billion people. maintenance of cells and tissues. Changes that occur along the gastro-intestinal 141 . which is associated with aging.Universa Medicina Vol.(2) These changes will be most dramatic in the less developed countries. social and economic factors. The aging process increases population risk for nutrient deficiencies because of various physiological. urinary and genital tracts. proteins and lipids to serve the general functions. proteins.25 No.(3) Nutrition in the elderly Aging is associated with physiological and economical changes that compromised nutritional status. The clinical outcome of impaired immunity is an increased incidence of common infections affecting the upper and lower respiratory. There are six classes of nutrients in food. minerals and water. reduced IL2 production and proliferation of lymphocytes. in 1999. sensory abilities. Impaired immune response in aging may be partly due to underlying nutritional deficiency. (4) Human growth hormone stimulates skeletal and muscle growth. organ system and immune function. where the population age structure will change rapidly from one that is predominantly young. It requires a higher concentration of a flavor to detect it. and its production declines with age.3 INTRODUCTION The proportion of age individuals has rapidly increased in the second half of the twentieth century in both Western and Developing Countries ( 1 ) The number of individuals aged 60 years or older is projected to double as a proportion of the world’s population and to more than triple in number over the next 50 years. Nutritional status plays an important role in the functions of the immune system. as well as regulation of daily body processes. Epidemiological and clinical data suggest that nutritional deficiency is a risk to immune competence and increases the risk of infection. include decreased delayed-type hypersensitivity (DTH) responses. The aging process has been described to be associated with decreased immune functions. reduction in serum IgA as well as decreased antibody titer after vaccination. providing fuel for physical activity and metabolic processes. It also contributes to loss of bone. such as carbohydrates. They project that by the year 2050. and may contribute to loss of appetite and poor intake. To support the immune system the body requires nutrients. defined as substances in food that the body can use to obtain energy. lipids. muscle mass and strength. Environmental. (5) Also declining with age is the perception of taste. synthesize tissues or perform regulatory functions. pharmacological and psychological stresses often increase age-related changes in body composition.
Two classes of vitamins exist fat-soluble (A. If all older people are to maintain or acquire a healthy lifestyle. thus as a result the elderly are more susceptible than younger adults to infections and illness. (3. Some supplements are important as cofactors for antioxidant enzyme activity. etc.(12) Antioxidant nutrients play a central role in maintaining the antioxidant or oxidant balance in immune cells and in oxidative stress protection. zinc. selenium. vitamin B6. thus altering the susceptibility to infectious disease.(11) Several micronutrients are significant immuno-modulators and thus are critical in determining the outcome of host microbe interactions. There are two types of immune function. (9) Considering that older people are at risk of malnutrition. Dysregulation of immune function on humans may contribute to increasing the incidence of infection. etc. In the elderly. vitamin E. The increase in disease frequency associated with aging suggests that immune responsiveness is decreased in the elderly. iron. this study indicates that food insufficient elderly people are an especially vulnerable population. Immune system in the elderly The most basic defense mechanism of the human body is the immune system. and preserving adequate function. vitamin B12. The supplements enhance metabolic functions. Also. (4) Vitamin A. higher risk of being underweight. iodine. gaps in the safety net must be identified and remedied and food assistance and nutrition education efforts improved. Moreover.) are essential minerals that 142 the body needs in small amounts. folic acid. vitamin C. help to detoxify harmful substances.885 people of 65 years of age and over in the US showed that older people who reported food insufficiency: lower mean intake of several nutrients. innate and acquired immunity. Minerals are inorganic elements. antioxidant activity or recycle antioxidants after quenching free radicals. the requirement for dietary energy and most micronutrients (vitamins and minerals) does not decrease. and K) and watersoluble vitamins (B vitamins and vitamin C). especially eating disorders. Dietary supplements protect the body from accelerated aging process in various ways. E. and a well-balanced diet is important to prevent an inadequate intake of macro and micronutrients. lower mean serum levels of certain nutrients. inflammatory and cancerous diseases in the elderly and prolonged recovery period of illness. aging is associated with higher incidence . absorption and elimination of waste products. zinc and selenium are some of the micronutrients that have been shown to influence host resistance mechanism. Vitamins are organic substance that the body needs in minuscule amounts. lower dietary variety.8) A study included 3. riboflavin. calcium. and in poor or fair health. D. lower intake of the vegetable and meat groups. the body’s defense mechanisms begin to weaken.Kusumaratna Nutrition and immune system in elderly (GI) tract affect GI function that could interfere with food intake. then outreach to the food insufficient elderly must be developed and implemented. categorized as major minerals (sodium.(7) However.(10) The function of minerals is involved in a variety of structural and regulatory functions. phosphorus. Micronutrients in the elderly Micronutrients consist of two components namely vitamins and minerals. magnesium. Human malnutrition is usually a complex syndrome of multiple nutrient deficiencies. elderly people are two to 10 times more likely to die of a variety of infections than younger adults.) and trace element (iron. beta-carotene. (6) Under-nutrition is common in the elderly population that indicates poor dietary practices caused by age-related decline.
to CD5+ cells. a higher mortality related to infections. their ability to mature in lymphoid tissues also decreases with age. During infection. in relation to decreased thymus function. Barringer(17) showed that a multivitamin and mineral supplement reduced the incidence of participant-reported infection and related absenteeism in participants with type-2 DM and high prevalence of sub-clinical micronutrient deficiency. It has been reported that undernourished elderly subjects are more likely to have pulmonary infection. malnourished elderly.3 of infections and subsequently. C-reactive proteins and a variety of other proteins. (8) Catabolic response occurs with all infections including sub-clinically and not accompanied by fever. compared with healthy elderly without any nutritional deficiencies. Scrimshaw and Giovanni ( 1 6 ) showed evidence of adverse effects on immunity in several macro and micronutrients deficiencies.25 No. primarily from skeletal muscle.(1) Numerous studies have investigated the age-related changes in immune responses. increased monoclonal immuno-globulins and increased autoantibody levels. Some studies had summarized that undernutrition in the elderly appeared as one of the main factors that could influenced low immune response in the elderly. iron and zinc. with low protein intakes. showed alterations in T lymphocyte subsets together with lowered T lymphocyte proliferation and IL-2 release. although low serum folate concentrations was found in Lesourd study. The results suggested that even mild infections could adversely affect nutritional status and deficiency of almost any nutrient will impair immunity and resistance to infection. T helper 1 subset (TH-1) to TH-2. mainly changes in cell-mediated immunity that is associated with changes to the equilibrium of peripheral T and B lymphocyte subsets. Bogden (15) also reported that deficiency of zinc impairs cellmediated Immunity by reduced lymphocyte proliferation response. found that age-associated with decline in total-T and T-helper cells occurred only in the presence of protein energy malnutrition (PEM). endocrine changes are initiated that lead to the mobilization of amino acids from the periphery. i. T cell subsets were observed in both healthy and well-nourished elderly.Universa Medicina Vol. naïve to memory. (19) In elderly subjects with PEM. both animal trials and humans. Effect of protein-energy malnutrition on immune responses in the elderly Infections are more common in undernourished than in well-nourished persons. Nutrition had strong influence on the immune system of the elderly. B 12. Aging is also associated with other pathologies related to immune dysfunction. It decreased the ratios of mature to immature. lymphokines. all parameters of cell mediated immunity are 143 . and CD5. Under the stimulus of interleukin-1 released by leukocytes. amino acids as an anabolic response are diverted from normal pathways for the synthesis of immunoglobulins. The ability of stem cells decreases with age. In many pulmonary-infected elderly individuals.e. Both protein energy malnutrition (PEM) and aging had cumulative effects on immune responses that induced a sharp decline in immunity in aged. CD3-. (18) On the other hand. it is not surprising that some aspect of immunity was strongly influenced by nutritional deficiencies. (13) Lesourd (14) examined the effect of aging (healthy elderly) with or without PEM. Thus. Aging induced dysregulation of the immune system. CD4+ concentrations have been reported as low as those found in patients with AIDS. Similar adverse findings on immune function also were reported for elderly deficient in vitamins B 6. higher incidence of cancer. Increases in immature CD2+.
and the study was conducted over 2 years with institutionalized elderly in “apparently good health” with a priori life expectancy of 3 years. The group treated with antioxidant vitamins showed increased monocyte functions (IL-1 production). and antibody response. The supplementation induced decreases in lipid peroxidation. The optimal dose level of vitamin E per-day that caused this immune response was 200 mg. In contrast. and cytokine synthesis. lymphocyte proliferation and IL-2 production. (13) Recent studies have shown that supplementing the elderly with single nutrients or mixture of vitamins and minerals at levels that exceed the Recommended Dietary Allowances (RDA) significantly improves certain indices of the immune response. the increase in antibody titers after influenza vaccine was higher in the trace-element group and reduced the incidence of infection. CD4+). PEM can modify the clinical symptoms of inflammation in undernourished elderly individuals. also may 144 be linked to the transition of harmless viruses to virulent ones and may have an impact on viral disease. or placebo. and increased natural killer-cell activity. ( 1 ) PEM induces not only low lymphocyte counts and functions but also low polymorphonuclear and monocyte function. Selenium and vitamin deficits were corrected with supplementation within 6 months. The result showed that in “healthy” elderly.(20) Antioxidant levels in the supplementation were of physiologic doses: 1 to 3 times the RDAs.Kusumaratna Nutrition and immune system in elderly decreased beyond the levels found with “normal” aging: T cell number (CD3+. In addition. Selenium supplementation showed enhanced proliferation of activated T cell. Seroconversion rates after tetanus toxoid or influenza vaccine are shown to be lower in elderly people suffering from malnutrition. gluthatione peroxidases (selenoproteins) hinder the propagation of free radicals and reactive oxygen. enhanced the response to antigen stimulation of lymphocyte. trace element (Se & Zn) or Vitamin (E. Therefore. Selenium deficiency could impair both cellmediated immunity and B cell function. there is a low release of IL-1 in the undernourished during infection and although these patients are really infected. in part by reducing the susceptibility of . lymphocyte proliferation. but a longer period (1 year) was needed to restore zinc deficit. After vaccination. C. Meydani(24) have conducted several studies using a large range of vitamin E supplements for several months. The fact that nutrient-nutrient interactions and multiple nutrient deficiencies often occur in the elderly. but in some no signs of fever are shown. not only are antibody levels lowered in the elderly suffering from malnutrition. An epidemiological study indicate that the antioxidant properties of vitamin E and polyphenols present in green tea may contribute to reducing the risk of cardiovascular disease. lymphocyte proliferation. but antibody affinity is also reduced. diminishing the production of inflammatory prostaglandin and leukotrien from hydroperoxide intermediate. the elderly are at greater risk for low intake of several vitamins and minerals known to influence the immune response. Harshman et al studied(23) supplementation with trace element selenium acted both as an antioxidant and anti-inflammatory agent. increased the ability of lymphocytes to become cytotoxic for tumor cell destruction. !-carotene) or a combination of both. for example. Antibody response also is lowered in the undernourished elderly population. (20-22) The role of nutrition in immunity in the elderly Immunological vigor declines with age. contributing to increase morbidity and mortality in the elderly. vitamin E supplements increased delayed type hypersensitivity. Another study used four-leg supplementation. By acting as scavengers. Adequate protein status is important for determining lymphocytes counts.
and decreasing the expression of adhesion molecules and monocyte adhesion. namely (i) alterations in immune responses occur early in the course of reduced micronutrient intake. and the age of the subject.3 low density lipoproteins to oxidation. (25) Thus. decreasing the vascular endothelial cell expression of proinflammatory cytokines. often causes immunodeficiency leading to increased frequency and severity to infection. (ii) the extent of immunology impairment depends on the type of nutrient involved. Nutrition deprivation. its interaction with other essential nutrients. Physiological and pathological situations in which nutrition acts as a primary or secondary determinant of immune function impairment(22) 145 .25 No. (Table 1). in elderly individuals. (iv) for many micronutrients excessive intake is associated with impaired immune responses.Universa Medicina Vol. five general concepts have been advanced that value the effect of micronutrient on immune responses. diet is restricted and the absorption of nutrients is reduced in metabolic function that might need supplementation of certain nutrients. the immune system is clearly deprived of the components needed to generate an effective immune response. (26) Without adequate nutrition. the severity of deficiency. (22) Table 1. particularly the risk of infection and mortality. and (v) test of immuno-competence are useful in assessment of safe lower and upper limits of micronutrient intake. the presence of concomitant infection. (iii) immunology abnormalities predict outcome. such as protein energy malnutrition (PEM). However.
including minerals such as selenium and zinc. 48: 3943 Insel P. Masro AM. 8: 2-5.Kusumaratna Nutrition and immune system in elderly Older and obese individuals tends to have high prevalence of common infections. Buranap S. The role of nutrition in immunity in the aged. 176: 1053-7. 8. Effect of antioxidative vitamins on immune function with clinical application. Ferry M. The multiple effects of nutritional deficiencies on immune function also increase the frequency and severity of infections. Livingstone B. Supplementation with micronutrients. infection. Brandolini M. Proc Nutr Soc 1999. 7. Aging. In: Nutrition and immune function. and immunity: an overview. Aging. Nutr Rev 1998. 63: 233-46. 357-65. Meydani A. 616-22. p. 60: S40-S5. 3. Tucker KL. p. Accessed July 1. 135: 2644-50. Kann PH. Lesourd B. high-intensity and heavy training can suppress various immune response parameters. Mulligan C. Therefore. Commensal bacteria may exert a dual function: the stimulation of mucosal mechanisms of defence and the maintenance of homeostasis of the immune response. Micronutrient malnutrition. Moreau K. a pilot study. Bhaskaram P. J Nutr Health Aging 2004. SmiciklasWright H. The effect of exercise on immune response is multifaceted. depending upon the type of exercise and the intensity of training. 6. 11. J Nutr 2005. Available at: http:// www. presents. Turner ER. could reduce morbidity from respiratory infections among the aged. 4. nutritional status and infection in the developing world. Because the immune response needs rapidly dividing cells and highly activated secreting cells to be efficient. Int J Vit Nutr Res 1997. exposure to viral pathogens. Meydani SN. J Infect Dis 1997. Alterations of sensory perceptions in healthy elderly subjects during fasting and refeeding. The nutritional deficiency impairs the immune response. 12. Nutrition and aging of the immune system. Lesourd B. Molls RR. 9. Ahluwalia N. . Mazari L. and future. Lesourd BM. Reference 1. USDA Center for Nutrition Policy and Promotion. 2000. Nutrition and immunity in the elderly. all nutrients that interfere with cell division and metabolism may influence immune response. 13.131: 2417S-23S. Ahluwalia N. Grimble RF. Perspective aging and infectious disease: past. it is accepted that while moderate exercise enhances immune functions. Yoshikawa TT. The primary activity of mucosal immune response is to protect the mucosa by blocking microbial. Nutrition and aging in developing countries. 2. 2002. toxin and antigen. Nutritional status predicts primary subclasses of T cells and the lymphocyte proliferation response in healthy older women. Food insufficiency and the nutritional status of the elderly population. 2006. nutritional 146 deficiency must be treated in the elderly to reduce risk of infection and possibly slow down the aging process. Ross D. 14. and will result in an increase in the severity of diseases. 56: 113-25. In: Nutrition. Nutr Rev 2005. 10. Under nutrition strongly influences immune response in the elderly since many nutrients interact with immune system. Boston: Jones and Bartlett Publisher.gov/cnpp/Insights/Insight18. CONCLUSION The importance of adequate macronutrient and micronutrient intake throughout the life course to maintain health is essential. nutrition and immune function. Handte G. J Nutr 2001. Mazari L. This indicates that aging and the undernourished had cumulative effects on immune response of the elderly that could be detectable both in cell-mediated and humeral immunity. Ahmed T.usda. 67: 312-20. Simon M. 7: 290-6. Clinical effects of growth hormone on bone: a review. 58: 685-95. In general. The Aging Male 2004. Gerontology 2002. Nutr Rev 2002. 2002. Probiotics have proved helpful in prevention of infectious diarrhea and shortening of the episodes. Life cycle: the adult years.PDF. London: CABI Publishing. Mazari L. 5.
p. In: Nutrition and Immune Function. Ann NY Acad Sci. 20. 23. 2002. Synergism of nutrition. 159: 748-54. 288: 71521. J Nutr Health Aging 2004. Can J Diet Prac Res 2005: 66: 98-102. Montero A. Meydani SN. The relevance of selenium to immunity. Meydani M. 2001. Am J Clin Nutr 1997. Giovanni P. Am J Clin Nutr 1997. 24. 57: S66-69. 138: 365-71. 26. 171-86. Bogden JD.. infectious/ inflammatory diseases. Monget AL. 8: 28-35. Aldoori W. Nova E. Marcos A. Scrimshaw NS. Impact of trace elements and vitamin supplementation on immunity and infections in institutionalized elderly patients: a randomized controlled trial. Vitamin E supplementation and in vivo immune responses in healthy elderly subjects. Ann Intern Med 2003. Scouten EG. 66: 478S-84S. Hughes DA. 277: 1380-6. 19. Blumberg JL. Antioxidants vitamin and immune function. Harshman MR. J Am Med Assoc 1997. Nutrition and immunity in the elderly: modification of immune responses with nutritional treatments. Brunet-Leconte P. 928: 226-35. Eur J Clin Nutr 2003. Lesourd BM. J Nutr Health Aging 2004. Periosi P et al. Foley KL. Kirk JK. 66: 464S-72S. Michieluitte R. 16. infection and immunity. Changes in the immune system are conditioned by nutrition.25 No. Barringer TA.3 21. Graat JM. Meydani M. 18. Galan P. Girodon F. Kok FJ. Santaniello AC.Universa Medicina 15. Influence of zinc on immunity in the elderly. Nutrition interventions in aging and age-associated disease. 22. 18: 48-52. Nutrition: a major factor influencing immunity in the elderly. Effect of daily vitamin E and multivitamin mineral supplementation on acute respiratory tract infections in elderly persons: a randomized controlled trial. Arch Intern Med 1999. 25. Boutron-Ruault MC. J Am Med Assoc 2002. Lesourd BM. Effect of a multivitamin and mineral supplement on infection and quality of life: a randomized controlled trial. cancer. 147 . 17. Vol. UK: CABI Publishing.