The Potential for Functional Foods to Prevent and

The Potential for Functional Foods to Prevent and Treat Frailty Canadian Geriatrics Society 38 th Annual Scientific Meeting Montreal, QC April 19 -21, 2018 Alison M. Duncan, Ph. D. , R. D. Professor Dept. of Human Health & Nutritional Sciences University of Guelph

CFPC Co. I Templates: Slide 1 Faculty/Presenter Disclosure • Faculty: Alison Duncan • Relationships with commercial interests: – Grants/Research Support: Canadian Institutes for Health Research; Agriculture and Agri-food Canada; Ontario Ministry of Agriculture, Food and Rural Affairs; Heart and Stroke Foundation of Canada; Saskatchewan Pulse Growers; Weston Foundation – Speakers Bureau/Honoraria: None – Consulting Fees: Guiding Stars Licencing Company – Other: None

CFPC Co. I Templates: Slide 2 Disclosure of Commercial Support • This program has received financial support from NONE in the form of NONE. • This program has received in-kind support from NONE in the form of NONE. • Potential for conflict(s) of interest: – No potential for conflicts of interest to report – [Speaker/Faculty name] has received [payment/funding, etc. ] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. – [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc. ] a product that will be discussed in this program: [insert generic and brand name here].

CFPC Co. I Templates: Slide 3 Mitigating Potential Bias • Any specific food areas are presented in a research form and could apply to any product

Presentation Outline Functional foods background Older adults Frailty Research on nutrition and FF in frailty • Summary • •

Food influences Health • The concept of food affecting our health is longstanding • Consumers expect that their food is safe and they look for their food to be tasty, nutritious and have the potential to improve their health.

Evolution of Food and Health • Relation of food and nutrients to health has evolved • Traditionally to prevent deficiency disease • Now includes prevention of chronic disease • Evolution manifests in numerous policies • Key example is advance of functional foods • Extension of how we relate food and food constituents to health • Major influence on research activity in food, nutrition and health

What are Functional Foods? Simplest definition: Foods that may provide health benefits beyond basic nutrition Conventional food form Specific bioactive constituent enhanced content in the food added to the food Biological rationale to relate to health

Functional Food: Health Canada Definition A functional food is similar in appearance to, or may be, a conventional food that is consumed as part of a usual diet, and is demonstrated to have physiological benefits and/or reduce the risk of chronic disease beyond basic nutritional functions, i. e. they contain bioactive compound Health Canada, Policy Paper - Nutraceuticals/Functional Foods and Health Claims On Foods, 2002

What are Functional Foods? Addition of component(s) Food Concentration of component(s) Functional Food Modification of component(s)

Functional Foods are about BIOACTIVES • Bioactives are the key to a functional food Functional Food Bioactive Common Nutrients Plant-derived bioactive Animal-derived bioactive • Bioactives have a targeted role to confer the benefit of the functional food

Functional Foods are about FOOD MATRICES • Food matrices are the key to a functional food Is the food matrix familiar? How it the appearance and texture? Functional Food Matrix Is the bioactive bioavailable? Does the functional food taste good? • Choosing the right food matrix for the bioactive can be key to the success of a functional food

J Acad Nutr Diet. 2013; 113: 1096 -1103 It is the position of the Academy of Nutrition and Dietetics to recognize that although all foods provide some level of physiological function, the term functional foods is defined as whole foods along with fortified, enriched, or enhanced foods that have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis at effective levels based on significant standards of evidence.

Functional Foods and Health: Relevance to Older Adults • Functional foods have relevance to many areas of human health and this can apply to multiple life-stage and gender groups • Among these life-stage groups, older adults emerge as a highly relevant beneficiary of FF

Aging is Becoming More Common • Aging of the population will accelerate over the next 3 decades • The number of Canadian adults >65 years old is projected to increase from 4. 2 to 9. 8 million between 2005 and 2036 • The “older adults” share of the population will increase from 13. 2 to 24. 5% Statistics Canada , Census of Canada

CTV News March 2013: Seniors at Nutritional Risk • • Statistics Canada report 15, 000 Canadians >65 years old Healthy Aging Arm, Canadian Community Health Survey Used SCREEN nutritional screening tool to ask about cooking and eating habits, nutritional intake, changes to body weight and health 34% were at nutritional risk • Opportunity to address this issue with functional foods

• Data from the M 3 study; first Canadian study to comprehensively examine determinants of food intake in LTC • N=632 residents (32 LTC homes in 4 provinces) • Intakes of 9 of 20 nutrients were inadequate • >90% inadequate intakes of: vitamin D, vitamin E, potassium and magnesium (males) • >50% inadequate intakes of: folate, vitamin B 6, calcium, zinc and magnesium (females)

FRAILTY is a severe expression of aging • Cumulative decline in multiple physiological systems • Confers a state of vulnerability after even small stressor events • Increases the risk of falls, disability, and death • Multifactorial cause which includes nutrition Mc. Guigan et al. , 2017

More than half of older adults are pre-frail to frail Hoover M et al. , Stats Canada; Canadian Community Health Survey (CCHS) 2009 -2010 data

Nutrition can determine frailty • Systematic review of 19 studies (2005 -17) that examined frailty in relation to nutrition • Frailty associated with: – Low intakes of select micronutrients (folate, vitamin C, vitamin D, vitamin E) and protein – Low antioxidant capacity of the diet – Low diet quality – Malnutrition risk BMC Geriatrics (2017) 17: 108

Frailty is related to overall diet • Risk of frailty is reduced in those with – highest Mediterranean diet score – Prudent dietary pattern (vegetables and olive oil) compared to a Western dietary pattern (refined break, processed mean, low fruits and vegetables)

Food-First Approach for Healthy Aging • Low compliance to supplements • Foods provide essential nutrients • Bioavailability is often superior in foods vs supplements • Increase quality of life • Need to consider many factors that affect food intake in older adults Functional foods offer an expanded opportunity to consider a food-first approach

Frailty is related to specific foods J Am Geriatr Soc 63: 1852– 1860, 2015. • Many foods are not only nutrient-dense but also naturally contain bioactives • Studies show these foods can impact risk and biomarker of frailty in older adults • Paves the way for functional food research

Functional Food Bioactives of Relevance to Frailty Vitamin D Vitamin E Folate Potassium Magnesium Calcium Vitamin B 6 Create a functional food to address frailty Plant- and Animal- Derived Bioactives Protein

• Classic example of a functional food • Included first core step to determine if bioactive is bioavailable in target group Objective to characterize bioavailability and efficacy of fortifying bread with vitamin D 3 • Bun fortified with 5000 IU vitamin D and 320 mg calcium consumed by 40 LTC residents for 12 wks • Measured vitamin D levels and markers of bone health at 3 month intervals Am J Clin Nutr 2009; 89: 1132– 7.

The vitamin D fortified bun increased serum 25 (OH) D to optimal levels (<75 nmol/L) by 3 months Am J Clin Nutr 2009; 89: 1132– 7. Lumbar and hip bone mineral density also significantly increased over the year.

• Bun fortified with 5000 IU vitamin D and 320 mg calcium consumed by 40 LTC residents for 12 wks Objective to determine effect of vitamin D fortified bun on quality of life nursing home residents • Romanian version of a European Qo. L questionnaire (QUALEFFO-41) at baseline and 12 months; 41 questions in 5 domains (pain, physical function, social function, general health perception, mental function) • Qo. L sores significantly improved on total, pain, daily activities and locomotion J Med Food. 2014; 17: 625 -34

Functional Food Research Example Spearmint Tea for Arthritis

RESEARCH EXAMPLE Spearmint Tea for Arthritis Spearmint high in bioactive rosmarinic acid (RA) • • High-RA spearmint reduces joint inflammation in horses • • HNRU testing high-RA TEA in adults with osteoarthritis • • Funded by OMAFRA Food Research Program

Project Mint Tea o Double-blind, randomized clinical trial o University of Guelph developed High-Rosmarinic Acid Spearmint Plant (Fletcher et al 2005). o n=46 adults with knee OA o 2 cups tea daily for 16 weeks o Pain, stiffness, and physical disability assessed with a standardized arthritis questionnaire o Physical function assessed with a 6 -minute walk test (6 MWT) and stair climb task

PMT Results: WOMAC Pain Scores p=0. 0015* p=0. 07 Mean Age 60. 7 years BMI 32. 8 kg/m 2 Men/Women n=14/32 # Years OA 7. 8 years The high-ros. A tea and control tea groups both experienced decreased pain. The decrease was only significant in the high-ros. A tea group.

PMT Results: 6 -Minute Walk Test Although not significant, the high-ros. A tea group walked further at Week 16, while the control tea group walked the same distance at each time point.

Eggs as a Potential Functional Food for Frailty • Nutrient-dense providing key nutrients (protein, vitamin D) of concern for older adults • High quality protein • Prime food matrix for inclusion of bioactives • Versatile food and can be consumed in different textures and formats

Egg Bioactives: Omega-3 fatty acids • Omega-3 fatty acids: essential ALA and longer chain EPA and DHA • ALA is widely available but EPA and DHA are limited to fatty fish • EPA and DHA widely studied for health benefits of relevance to older adults • Eggs can be a source of EPA+DHA through manipulation of the feed of the laying hen Source: Linus Pauling Institute

Egg bioactives: Xanthophylls • Xanthophylls lutein and zeaxanthin are carotenoids found in egg yolk • Accumulate in the macular retina of the eye and collectively called the macular pigment • Reduce photostress and AMD • Amount in eggs is low compared to green leafy vegetables • Can enhance amount in eggs

J. Nutr. 2004; 134: 1887 -1893. • Bioavailability of bioactive is a core issue • Bioavailability of lutein may be enhanced when dissolved in a lipid matrix (egg yolk) • Healthy men consumed lutein in different forms for 9 days • Serum lutein was increased most with the lutein-enriched egg compared to spinach and lutein supplements

Brit J Nutr. 2017; 117: 108 -123 • Randomized clinical trial in 46 adults who consumed a L and Z-enriched egg (feed supplementation) or a control egg for 8 weeks • Serum L and Z increased more in enriched egg • Visual acuity significantly better in the enriched compared to the standard egg • LDL-chol, TG no change • Total-chol increased for both eggs Blue: enriched egg; red: control egg

Functional Food Research Example Older Adults’ Understanding of Functional Foods

Results: Awareness and Consumption of Functional Foods Top most frequently consumed functional food products (n=200)

Results: Functional Food Matrices and Bioactives Food Matrices Bioactives

Results: Health Areas as they Relate to Functional Foods Health areas addressed through the consumption of Antioxidants in functional foods Health areas addressed through the consumption of Dietary Fibre in functional foods

Nutrition in Disguise Improving the nutritional quality of food for older adults Goal to improve the protein and micronutrient density of foods provided in retirement and long term care • Practices a FOOD-FIRST strategy to mitigate risk of malnutrition and frailty in older adults • Evidence-based • Work with a chef to develop and modify highly consumed foods

Nutrition in Disguise Literature Reviews Micronutrient inadequacies, food preferences; micronutrient interventions; food interventions Food product development Chef with nutrition expertise in collaboration with research team Palatability Testing Chef with nutrition expertise in collaboration with research team Recipe Scaleup For use in residential settings, consider cost of production (labour, ingredients)

Considerations for Success of a Functional Food for Frailty Value chain Retention of bioactive Functional food for frailty Regulations and Cost Consumer acceptance

Summary • The Canadian population is aging and older adults are at nutritional risk • Frailty is a severe expression of aging and is common in Canadian older adults • Nutrition contributes to frailty and a food-first approach can help • Functional foods can address gaps in nutrients needs and incorporate bioactives to address disease risk • Continued innovation and progress can contribute to a food-first approach for frailty prevention and management

Acknowledgements • • • Canadian Frailty Network Agri-food for Healthy Aging (A-HA) Research Institute for Aging (RIA) OMAFRA Weston Foundation Research Participants • University of Guelph Students