Multivitamin/Mineral Supplementation – The Key of Healthy Ageing (Part 1)

The Importance of Countering Micronutrient Inadequacy 

Frailty is a condition in which multiple physiological systems decline in function due to loss of homeostasis. Multi-dimensional factors such as physical, psychosocial, and cognitive ability play a part in its development. Frailty has been reported to be associated with adverse outcomes such as mortality, fractures, and falls. Therefore, frailty must be prevented to ensure a healthy life expectancy without disease, particularly among older adults at an increased risk of frailty⁵.

Dietary quality is essential for promoting health and lowering the risk of diet-related frailty. In particular, various vitamins and minerals, such as vitamin A, B complex, D, calcium, iron, zinc, etc., are required for maintaining physiological functions. Thus, the deficit in one or more micronutrients would hinder normal physiological functions, resulting in adverse health outcomes. A recent review by Kiani et al. (2022) reported that micronutrient deficiency would lead to intellectual impairment, poor growth, perinatal complications, degenerative diseases associated with ageing and higher morbidity and mortality⁶. While older adults are more susceptible to adverse outcomes, preventing micronutrient inadequacy among this population is of paramount importance.

Of note, nutritional deficiency is a severe disease condition in which the levels of nutrients are significantly reduced, leading to complications and mortality⁶, whereas nutrient inadequacy is the suboptimal levels of nutrients that increase the risk of health problems.

Although a consensus on the clinical definition of micronutrient inadequacy is yet to be available, the abnormalities in micronutrient levels can be identified by blood tests. Additionally, patients with inadequate micronutrients could be differentiated based on symptoms. Examples of major symptoms of deficiency in selected micronutrients are listed in Table 16.

Table 1. Examples of micronutrients deficiency conditions

In view of the potential adverse outcomes, preventing micronutrient inadequacy is crucial. Fortunately, this can be readily achieved through supplementation and food-based approaches.

The Risk of Micronutrient Inadequacy among Older Adults 

It is important to realise that the risk of micronutrient inadequacy is not limited in older adults. However, age and intake are the main contributing factors, given that micronutrient intake by older adults is generally not adequate. Remarkably, the amount of total food intake does not necessarily reflect the micronutrient intake since the micronutrient contents are variable in different kinds of food and can be changed upon food processing. Accordingly, a cross-sectional study by Houshialsadat et al. (2023) reported a negative association between quintiles of energy contribution of ultra-processed foods and dietary diversity (β=− 0.43, p<0.001). The overall micronutrient content was lower in the diet fraction dominated by ultra-processed foods than non-ultra-processed food diet fraction¹⁵. Thus, while the vitamin, mineral, and dietary fibre contents in highly processed food are very low, the older individuals who often consume them are unlikely to intake adequate micronutrients. This partially explains why micronutrient inadequacy is still possible despite the right amount of food intake.

The meta-analysis by Borg et al. (2015), which included 37 clinical studies accounting for >28,000 community-dwelling older adults aged ≥65 years in 20 different Western countries, indicated that the percentage of the population at risk for inadequate intakes of thiamine, riboflavin and vitamin D from food alone was >30% for both men and women. Regarding mineral intake, ≥30% of the population was at risk for inadequate intakes of calcium, magnesium and selenium from food alone (Figure 1A and 1B)¹⁶. The results highlighted the high prevalence of inadequacies in micronutrient intake among the older population.

Figure 1A. Mean percentage of men and women aged ≥65 years at risk for inadequate intake of vitamins¹⁶

Figure 1B. Mean percentage of men and women aged ≥65 years at risk for inadequate intake of minerals¹⁶

In the scenario of Hong Kong, the Total Diet Study (2014) conducted by the Centre for Food Safety of the Food and Environmental Hygiene Department (FEHD) reported that >90% of Hong Kong adults had dietary calcium intake less than recommended level, and >80% had insufficient iron intake. Dietary intake of copper, magnesium, manganese, molybdenum and phosphorus were also inadequate as per recommended intakes¹⁷.

Apart from food intake, the changes in body composition of older adults also contribute to micronutrient inadequacy. Notably, the reduced lean body mass and increased fat stores result in reduced metabolic rate and energy requirements, respectively18. Importantly, the changes to the gastrointestinal (GI) tract on the utilisation of nutrient intake also affect the nutritional status among older adults. While suboptimal oral health is common among older adults, this would reduce appetite and, hence, food intake. On the other hand, the reduced GI motility and volume of digestive juices would lower the efficiencies of food digestion and absorption. Remarkably, the occurrence of age-related comorbidities, such as dementia and sarcopenia, would decrease the ability to self-care, increase frailty and morbidity, limit access to food¹⁹. This would potentially result in a vicious cycle of ill-health. 

Interestingly, age-related changes in the gut microbiota also play a role in the development of micronutrient inadequacy. The gut microbiota of older adults is characterised by a reduced bacterial diversity, shifts in the dominant species, a decline in beneficial microorganisms, an increase in facultative anaerobic bacteria, and a decrease in the availability of total short-chain fatty acids (SCFAs)²⁰. Particularly, Jackson et al. (2016) reported that there was a negative association between frailty and gut microbiota diversity²¹.

Thus, the optimisation of the overall nutritional status for older adults has to consider the factors in different aspects, including the amount and types of food consumed, the individual’s physiological conditions, and their lifestyle factors.

Nutritional Requirements - An Individualised Consideration 

Nutrition needs vary by age, sex, physiological state, and lifestyle of the individuals. For instance, athletes need more protein, vitamin D, and adequate zinc than people who are not too active. In addition to behavioural factors, Jophlin et al.  (2024) illustrated that patients with alcohol use disorder (AUD) may have nutritional deficiencies, especially isolated nutrient deficiencies, such as thiamine or zinc deficiencies²². By virtue of the physical and physiological differences between individuals, the management of nutritional inadequacy has to be tailored individually.

Meeting the Nutritional Needs of Older Adults by MVM Supplementation 

Micronutrient inadequacies would increase the risk of adverse health outcomes in older adults, such as immune function, frailty, osteoporosis, etc., through multiple pathways related to cell differentiation, oxidative stress, muscle and bone metabolism, inflammation, and decreased immunity²³. As aforementioned, the micronutrient intake of many older adults is insufficient. Accordingly, MVM supplementation would facilitate older adults to meet their micronutrient requirements.     

A randomised, double-blind, placebo-controlled study by Michels et al. (2023), which recruited 35 healthy men aged >67 years, indicated that MVM supplementation for at least 6 months improved blood concentrations of pyridoxal phosphate, calcifediol, α-tocopherol, and β-carotene concentrations. Remarkably, those in the placebo group showed declines in blood vitamin concentrations and an increased prevalence of suboptimal vitamin status during the study period (Figure 2). Moreover, MVM supplementation was reported to limit declines in cellular oxygen consumption rate in monocytes²⁴. Based on the results, MVM supplementation is needed to ensure optimal vitamin status. It potentially plays a role in maintaining immune health in older adults.

Figure 2. Differences in the changes in blood micronutrient concentrations in participants with MVM supplementation against those with placebo²⁴

In addition to increasing nutritional intake, high-quality clinical data showing the effectiveness of MVM supplementation in improving health outcomes in older adults are emerging. For instance, in the recent clinical study by Kim and Park (2023), which involved 2,478 people aged ≥65 years who participated in the Korea National Health and Nutrition Survey 2018–2020. The results revealed that the proportion of insufficient nutritional intake ranged from 6.2% to 80.5% for men and 21.2% to 82.4% for women, depending on the nutrients. Essentially, the results further showed that MVM supplementation (n=308) was associated with lower rates of inadequate nutritional intake compared to the food-only group (n=2,170, Figure 3A and 3B)²⁵.

Figure.3 The percentage of older adults whose intake was below the estimated average requirement in (A) males and (B) females²⁵, EAR: estimated average requirement, MVMS:MVM supplementation

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References

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