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**Mingus** · January 3, 2007, 10:47 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes.

A link to the complete article who require subscription, I'll try to get it in the next days if someone else did'nt.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2006.00982.x

**AlaskaDenise** · January 4, 2007, 02:34 AM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

This is a similar study from 2 years ago....wonder if it's the same formula?

http://www.medscape.com/viewarticle/467012

<TABLE cellSpacing=0 cellPadding=0 width=410 border=0><TBODY><TR vAlign=top><TD width=410>From Journal of the American Geriatrics Society

Nutritional Formula Enhanced Immune Function and Reduced Days of Symptoms of Upper Respiratory Tract Infection in Seniors

Posted 01/20/2004
Bobbi Langkamp-henken, PhD, Bradley S. Bender, MD, Elizabeth M. Gardner, PhD, Kelli A. Herrlinger-Garcia, BS, Michael J. Kelley, PhD, Donna M. Murasko, PhD, Joseph P. Schaller, PhD, Joyce K. Stechmiller, PhD, Debra J. Thomas, MS, Steven M. Wood, PhD
</TD></TR></TBODY></TABLE>
Abstract and Introduction

Abstract

Objectives: To assess whether an experimental nutritional formula, given as a supplement, would reduce days of symptoms of upper respiratory tract infection (URTI) and affect antibody and lymphocyte proliferative responses to influenza vaccine.

Design: A prospective, randomized, double-blind, controlled trial was conducted between October 1999 and April 2000.
Setting: Assisted- and independent-living facilities in North Central Florida.
Participants: Sixty-six individuals, aged 65 and older.

Intervention: Subjects received 8 oz/d of an experimental formula containing antioxidants, zinc, selenium, fermentable oligosaccharides, and structured triacylglycerol or an isoenergetic, isonitrogenous control formula for 183 days.

Measurements: Subjects recorded daily symptoms of URTI. Antibody titers and lymphocyte proliferation to three influenza vaccine components were measured on Days 57 and 183.

Results: Eighteen subjects in the control group and 16 subjects in the experimental group consumed an average of 7 ounces of formula daily and completed the 183-day study. Median days of symptoms of URTI were 3 (range 0-69, total days=156) and 0 (range 0-49, total days=78) for the control and experimental groups, respectively (P= .049). On Day 57, seven of 17 (41%) subjects in the control group and 13 of 15 (87%) subjects in the experimental group achieved a fourfold or greater increase in serum antibody titer to A/Beijing (P=.012). Lymphocyte proliferation to influenza vaccine components was greater in the experimental (median=1,365 cpm, range=0-14,955 cpm) than the control group (median=136 cpm, range=0-4,270 cpm) (P=.013).

Conclusion: Subjects consuming an experimental nutritional formula experienced enhanced immune function and fewer days of URTI symptoms.
Introduction

Advanced age is associated with increased risk of nutrient deficiency and altered regulation of the immune system.<SUP>[1]</SUP> Nutrient deficiencies in the young or elderly can impair immune function; nutrient supplementation can restore normal immune capacity.<SUP>[2-4]</SUP> Consequently, there has been interest in determining whether nutrient supplementation in seniors could attenuate age-associated declines in immune function.<SUP>[3-8]</SUP>
<SUP></SUP>
Well-documented clinical and experimental studies report an age-associated decrease in immune function, including antibody response to vaccination.<SUP>[9-13]</SUP> Influenza infections significantly affect morbidity and mortality in the aged, and when vaccinated, seniors experience a lower antibody response than that observed in young healthy cohorts.<SUP>[9,14,15]</SUP>

One study noted that, in a population of 210 seniors hospitalized with influenza, 129 (61%) had been vaccinated against influenza, indicating a suboptimal response to the vaccine or less-than-adequate protection from the influenza vaccine.<SUP>[16]</SUP>
<SUP></SUP>
As early as the 1950s, single-nutrient deficiencies were known to suppress vaccine response.<SUP>[17]</SUP> More recently, it was shown that nutritional supplementation enhances antibody responses to influenza vaccination in seniors.<SUP>[4,5,8]</SUP> A few studies have investigated the influence of nutrient supplementation on immune function in seniors and found a clinically meaningful benefit, such as reduced infection rates or days of illness. A more recent study examined the effect of trace-element (zinc and selenium) supplementation on immune function and infections in institutionalized seniors (mean age 83).<SUP>[8]</SUP> Supplementation with trace elements corrected a selenium deficiency, enhanced antibody titers to influenza vaccination, and showed a trend toward fewer subjects with respiratory tract infections.<SUP>[8]</SUP> Another study reported better immune responsiveness and "fewer infection-related illnesses" with a multivitamin supplement than with a placebo in apparently healthy, independent-living elderly (mean age 75).<SUP>[4]</SUP> Other researchers have supplemented the diets of seniors and found no immunological benefit or reduction in acute respiratory tract infections.<SUP>[18-20]</SUP>
<SUP></SUP>
Research conducted in military personnel has shown immune dysregulation caused by stress that is similar to the immune dysregulation noted in the elderly (e.g., anergy and decreased proliferative response).<SUP>[21-24]</SUP> Several nutritional formulations had previously been tested until one was identified that minimized stress-induced immune dysregulation. The formula contained vitamins and minerals, with elevated levels of antioxidants (vitamins E, C, β-carotene), selenium, zinc, fructo-oligosaccharides (fermentable oligosaccharides), and structured lipids (a unique triacylglycerol containing long- and medium-chain fatty acids from canola and medium-chain triacylglycerols). Several of the nutrients included have been shown to enhance or support immune function in studies of seniors.<SUP>[7,25-27]</SUP> Fructo-oligosaccharides are readily soluble and fermentable to short-chain fatty acids in the large bowel, thus maintaining gastrointestinal health.<SUP>[28,29]</SUP> Structured lipids have been shown to enhance the absorption of lipid-soluble nutrients<SUP>[30]</SUP> and have the potential to be a unique energy substrate for metabolically active cells such as leukocytes.<SUP>[31]</SUP>
<SUP></SUP>
The objective of this study was to supplement the diet of relatively healthy independent- and assisted-living seniors with an experimental formula (containing protein, antioxidants (vitamins E, C, β-carotene), selenium, zinc, fructo-oligosaccharides, and structured triacylglycerol) and determine, in a prospectively designed study, whether seniors who were at risk of developing infections would have a reduced number of days of symptoms of upper respiratory tract infections (URTI) during the cold and influenza season (October 1999-April 2000). Antibody titers and lymphocyte proliferative response to influenza vaccine components were also measured as markers of immune function.

(the remainder of the article requires a subscription to medscape )

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**Mingus** · January 4, 2007, 10:18 AM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

Ok I have access!

___________________

<TABLE cellSpacing=0 cellPadding=4 width="100%" border=0><TBODY><TR><TD colSpan=2>Journal of the American Geriatrics Society
Volume 54 Issue 12 Page 1861 - December 2006
doi:10.1111/j.1532-5415.2006.00982.x</TD></TR><TR><TD colSpan=2>Volume 54 Issue 12</TD></TR><TR><TD colSpan=2 height=11> </TD></TR><TR><TD colSpan=2> </TD></TR><TR><TD class=abstracttitle colSpan=2>Nutritional Formula Improved Immune Profiles of Seniors Living in Nursing Homes</TD></TR><TR><TD class=maintextleftinclined colSpan=2>Bobbi Langkamp-Henken, PhD<SUP>*</SUP>, Steven M. Wood, PhD<SUP></IMG></SUP>, Kelli A. Herlinger-Garcia, BS<SUP>*</SUP>, Debra J. Thomas, MS<SUP></IMG></SUP>, Joyce K. Stechmiller, PhD<SUP></IMG></SUP>, Bradley S. Bender, MD<SUP>?</SUP>, Elizabeth M. Gardner, PhD<SUP></IMG>?</SUP>, Stephen J. DeMichele, PhD<SUP></IMG></SUP>, Joseph P. Schaller, PhD<SUP></IMG></SUP> and Donna M. Murasko, PhD<SUP></IMG>?</SUP> </TD></TR><TR><TD class=document-summary colSpan=2>OBJECTIVES: To assess whether an experimental nutritional formula (EXP) supports immune function in seniors living in long-term care facilities.
DESIGN: Prospective, randomized, double-blind, controlled trial conducted September 2002 through January 2003.
SETTING: North central Florida nursing homes.
PARTICIPANTS: Subjects aged 65 and older (n=157).
INTERVENTION: Subjects received 240 mL/d of EXP or standard liquid nutrition (CON) for 4 weeks before and 6 weeks after an influenza vaccination.
MEASUREMENTS: Influenza vaccine antibody responses, immunophenotyping, lymphocyte activation, cytokines, and clinical measures (fever, number of prescribed antibiotics).
RESULTS: Ninety-two subjects (n=40, CON; n=52, EXP) completed the study. Geometric mean antibody titers were similar between groups, yet the percentage of subjects with H1N1 antibody titers greater than 100 postvaccination was higher in the EXP group than in the CON group (43% vs 23%, P=.047). Similar trends were found for the percentage of subjects (intent to treat) with fourfold increases against the B/Hong Kong component (64% vs 46%, P=.09) or with H3N2 antibody titers of 40 or more (97% vs 89%, P=.06). EXP subjects had higher levels of influenza-activated lymphocytes (CD69<SUP>+</SUP>and CD25<SUP>+</SUP>). Cytokine production after mitogen activation was lower in EXP than CON subjects (interleukin (IL)-6: 20?3 vs 29?3 ng/mL, P=.045; IL-10: 310?60 vs 603?140 pg/mL, P=.06). Fewer EXP subjects were treated for fever (5% vs 16%, P=.02) or prescribed antibiotics (7 vs 11 new antibiotics/100 days of study, P=.06).
CONCLUSION: Seniors consuming the EXP formula demonstrated enhanced immune function, indicated by increased influenza vaccine response and lymphocyte activation, less fever, and fewer newly prescribed antibiotics than those consuming a standard ready-to-drink nutritional supplement.
</TD></TR><TR><TD class=document-body colSpan=2>Aging, frailty, and chronic diseases are associated with impaired immune function and are compounded by immune dysregulation from malnutrition.<SUP>1,2</SUP> Several immune parameters decline with age: lymphocyte activation/proliferative responses to mitogens, Fas-mediated apoptosis, helper T-lymphocyte function, B-lymphocyte numbers, delayed-type skin hypersensitivity, ability to generate high-affinity antibodies, and NK-cell cytotoxicity.<SUP>3</IMG>5</SUP> By contrast, other aspects of immune function increase with age: memory T-lymphocytes, Th2 cytokine profiles, and concentrations of autoantibodies.<SUP>4,6</SUP> These age-related immune changes contribute to greater risk of infection in frail seniors.
Residents of long-term care (LTC) facilities or nursing homes are particularly vulnerable to infection. In addition, LTC facilities provide environments that promote infectious outbreaks (i.e., influenza).<SUP>7</IMG>9</SUP> More importantly, residents who are infected experience high rates of mortality.<SUP>10</IMG>12</SUP> Because immune changes from aging and malnutrition are similar, nutrient supplementation may improve immune status and clinical outcome in frail seniors.<SUP>13,14</SUP>
In a relatively healthy population of seniors, it was previously found that a nutritional formula enhanced immune function as measured by antibody response to the influenza vaccine and reduced the number of days of symptoms of upper respiratory tract infections.<SUP>15</SUP> This formula contained vitamins, minerals, and nutrients important for immune function (protein, antioxidants (vitamins E, C, β-carotene), selenium, zinc, fructo-oligosaccharides (FOS), and structured triacylglycerol). In the present study, various markers of immune cell function were examined from a more-frail (potentially more-nutritionally deficient and immune dysregulated) population to explore mechanisms of nutrition-mediated immune benefit. Unlike the previous study, smokers and diabetics were included, which represented a more-heterogeneous population. Clinical outcomes examined included fever and newly prescribed antibiotics. Tolerance of the immune formula (EXP) was compared with that of a commercially available liquid nutritional formula (CON).
<TABLE cellSpacing=0 cellPadding=0 width="100%" border=0><TBODY><TR><TD class=maintextbldleft noWrap width=150 bgColor=#99ccff height=16> METHODS</TD><TD class=maintextright noWrap width=62 bgColor=#99ccff height=16>Go to:</TD><TD class=fulltextdmenu vAlign=center noWrap align=right width=92 bgColor=#99ccff height=16><SELECT class=fulltextdmenu onchange="GoTo(this, 'self')" name=select23><OPTION selected>Choose</OPTION><OPTION value=#>Top of page</OPTION><OPTION value="">METHODS <<</OPTION><OPTION value=#h19>RESULTS</OPTION><OPTION value=#h28>DISCUSSION</OPTION><OPTION value=#h29>ACKNOWLEDGMENTS</OPTION><OPTION value=#h30>REFERENCES</OPTION></SELECT></TD><TD vAlign=center noWrap align=right width=10 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=32 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=16 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=10 bgColor=#ffffff height=16></IMG></TD></TR></TBODY></TABLE>Subjects and Design
The institutional review board of the University of Florida (Gainesville, FL) approved this randomized, double-blind, controlled, parallel study of frail seniors residing in seven LTC facilities in north central Florida fed EXP or an isonitrogenous/isoenergetic standard liquid nutritional formula (CON; EnsurePlus<SUP>?</SUP>, Abbott Laboratories, Columbus, OH). The study was conducted in accordance with the Helsinki Declaration of 1975 and 1983 revision.
Informed consent was obtained from men and women aged 65 and older (n=157) with a body mass index (BMI) less than 30 kg/m<SUP>2</SUP>. Subjects agreed to discontinue consumption of vitamin, mineral, herbal, or dietary supplements with the exception of calcium, vitamin D, iron, fiber supplements, or vitamin B<SUB>12</SUB> injections. Inclusion also required eligibility to receive the U.S. Public Health Service influenza vaccine (2002?03) containing 15 μg of each of the following hemagglutinin antigens: A/Caledonia/20/99 (H1N1), A/Panama/2007/99 (H3N2), and B/Hong Kong/1434/2002 (Fluzone, Aventis Pasteur, Swiftwater, PA). Exclusion criteria included known intolerance to study formulas or vaccine components, immune system insufficiency or disease, severe swallowing disorder, dietary protein restriction, dialysis, current cancer radiation or chemotherapy treatment, and prednisone or prednisolone therapy greater than 10 mg/d. Subjects who refused the influenza vaccination at Week 4 were not included in the analysis.
Before randomization, a nurse practitioner examined subjects and recorded medical histories, current medications, and dietary supplement intake. Body weight was obtained using calibrated scales; height was measured or obtained from medical records. Group assignments for each facility were prepared based on stratifications (BMI (<22 kg/m<SUP>2</SUP> or 22?30 kg/m<SUP>2</SUP>), diabetes mellitus (yes/no), and smoking status (smoker/nonsmoker) and were balanced between EXP and CON. Upon randomization via sealed envelope, each subject was given a study number and group assignment. At baseline and for the duration of the 10-week study, subjects were instructed to consume one can per day (240 mL) of CON or EXP. Study coordinators distributed formulas, encouraged consumption, and recorded daily intake to the nearest quarter can. The formulas, manufactured under good manufacturing practices (Abbott Laboratories), were formulated to be isonitrogenous/isoenergetic, with similar appearance, aroma, and flavor. CON was EnsurePlus, whereas EXP contained higher levels of antioxidants (vitamins E, C, and β-carotene), B vitamins, selenium, and zinc than CON. EXP also contained structured triacylglycerol and a prebiotic (FOS). The nutrient content of EXP has been previously described.<SUP>15</SUP> Both formulas were labeled similarly to prevent subjects, staff, or others from identifying them. In addition to study formula intake records, compliance was assessed by measuring serum α-tocopherol and β-carotene concentrations (Craft Technologies, Inc., Wilson, NC) as described previously.<SUP>15</SUP> It was anticipated that subjects might not be able to consume all of the formula (240 mL) daily, so in an effort to evaluate the effect of formulas, an evaluable subject was defined as consuming an average daily intake of formula of 75% of the 240 mL (180 mL) or more. Intent-to-treat subjects were those who were randomized, vaccinated, and compared to make sure that the groups were comparable in study variables at baseline.
Nonfasting blood samples were obtained at baseline, vaccination (Week 4), and study end (Week 10). At baseline and study end, blood was drawn for a comprehensive metabolic profile, hemoglobin A1c, complete blood cell count (CBC) with differential, cytokine studies, lymphocyte activation markers, immune cell phenotypes, and compliance variables (serum α-tocopherol and β-carotene concentrations).
Antibody Response
Response to influenza vaccine was used as a marker of immune function. Peak responsiveness to the influenza vaccine was targeted at 6 weeks postvaccination, because some seniors seroconvert after the typical time point of 4 weeks.<SUP>16,17</SUP> Blood samples for vaccine responses were collected at vaccination and study end. Serum was separated and stored at ?20?C. Influenza antibody titers from all time points for a single subject were measured simultaneously using a modified hemagglutination inhibition procedure<SUP>15</SUP> and vaccine antigens from the World Health Organization Collaborating Center for Influenza, Centers for Disease Control and Prevention (Atlanta, GA).<SUP>18</SUP>
Mitogen and Antigen Responsiveness
Influenza Antigen Preparation for Cellular Stimulation Assays Influenza antigen for cellular stimulation assays was derived from influenza vaccine (same lot number and manufacturer) used to vaccinate the subjects. Before use in cell culture, the vaccine was dialyzed to remove preservative, potentially toxic to in vitro cell cultures, using Pyroclean (AlerChek Inc., Portland, ME) depyrogenated Amicon Ultra-15 10,000-molecular-weight-cutoff diafiltration units (Millipore Corp., Bedford, MA). Volume of dialyzed vaccine was brought to original volume with Dulbecco's phosphate-buffered saline (DPBS; BioWhittaker, Walkersville, MD). Hemagglutination of chicken erythrocytes (Colorado Serum, Denver, CO) indicated that influenza antigen activity of dialyzed vaccine was comparable with that of native vaccine.
Preparation of Samples for Determination of Lymphocyte Activation Markers Blood samples for immunophenotyping and cytokine production were collected at baseline, vaccination, and study end. Samples, packaged to maintain room temperature (i.e., packed in an insulated container within a Polyfoam shipping container), were transported to Abbott Laboratories for processing within 24 hours of collection. For cellular stimulation, whole blood samples were cultured for 48 hours at 37?C and 5% carbon dioxide (CO<SUB>2</SUB>) with phytohemagglutinin (PHA-L, Sigma-Aldrich, St. Louis, MO, 10 μg/mL), influenza antigen (final dilution 1:50 in complete culture medium (RPMI 1640; BioWhittaker) with 5% fetal bovine serum (Hyclone Laboratories, Logan, UT)) or complete-culture medium alone in a humidified incubator. After the stimulation period, samples were processed and analyzed using standard methods for flow cytometry.<SUP>19</SUP> Monoclonal antibodies labeled with fluorescein isothiocyanate (FITC), phycoerythrin (PE), peridinin chlorophyll protein (PerCP), or allophycocyanin (APC) and appropriate isotype control antisera combinations were used to identify CD25-, CD69-, CD8-, and CD2-positive or -negative cells. After staining, erythrocytes were lysed with a 0.15 M ammonium chloride solution; remaining leukocytes were washed using DPBS with 5% fetal bovine serum and fixed with 1% paraformaldehyde solution. Samples were evaluated, using a Becton Dickinson Immunocytometry Systems (BDIS, San Jose, CA) FACSCalibur<SUP>TM</SUP> or a BDIS FACSort<SUP>TM</SUP> flow cytometer; data were analyzed using BDIS Attractors software. Approximately 10,000 lymphocytes were counted for each determination. Lymphocyte subsets were expressed as percentages of total lymphocytes and absolute cell numbers.
Cytokine Production After Mitogen and Antigen Stimulation Peripheral blood polymorphonuclear cells (PBMCs) were isolated using Histopaque-1077 (Sigma-Aldrich). PBMCs were adjusted to a concentration of 1 ? 10<SUP>6</SUP> cells per mL with complete-culture medium and cultured with 10 μg/mL PHA-L, influenza antigen (final dilution 1:50 as above) or complete-culture medium alone for 48 hours in a humidified 37?C, 5% CO<SUB>2</SUB> incubator. After the stimulation period, cell cultures were centrifuged; supernatants were removed and stored at −80?C.
Cytokine analyses were performed using the Cytometric Bead Array (BD-Pharmingen, San Jose, CA) assay, which allows for simultaneous quantification of six cytokines (interferon-gamma (IFN-γ), tumor necrosis-α (TNF-α), interleukin (IL)-6, IL-10, IL-4, and IL-2) from one sample. Supernatants from all time points for a single subject were assayed on the same day to eliminate day-to-day assay variation.
Immune Cell Phenotypes
Blood samples were processed and analyzed using standard methods for flow cytometry.<SUP>19</SUP> Optimally titrated monoclonal antibodies, labeled with FITC, PE, PerCP or APC fluorochromes (BDIS), and appropriate isotype control antisera were mixed in three or four fluor combinations to identify CD3-, CD14-, and CD45-; CD56-/CD57-, CD28-, CD8-, and CD3-; CD45RA-, CD45RO-, CD4-, and CD8-; or CD56-, CD16-, CD19-, and CD3-positive and -negative cells in plasma-free blood. Approximately 10,000 events per sample were evaluated and expressed as a percentage of lymphocytes and absolute cell numbers.
Safety Variables and Clinical Outcomes
Blood was drawn at baseline and study completion for determination of safety variables (comprehensive metabolic profile, complete blood count (CBC) with differential, and hemoglobin A1c) and processed by Covenant Healthcare Laboratory, Inc. (Mayo, FL). Adverse events and changes in clinical status were noted at time of incidence and followed for 1 week after the final visit. Study coordinators recorded medications, including newly prescribed antibiotics, daily. Body weight was measured at each time point.
Statistics
All randomized and influenza-vaccinated subjects were included in an intent-to-treat analysis. A priori it was determined that subjects who were vaccinated, consumed a daily average intake of 180 mL or more, and completed at least 60 of the 70 days of study were considered protocol compliant and evaluable. Results are presented for intent to treat, but in an attempt to understand the effects of the experimental formulation, there was a focus on the compliant group (the group that consumed at least 75% of the products on a daily basis). Primary variables (response to influenza vaccine) were analyzed using repeated measures analysis implemented with the SAS procedure PROC MIXED (SAS Institute, Inc., Cary, NC). Comparisons were made between groups from subjects who achieved a >180 antibody (H1N1) or ≥40 antibody (H3N2 and B component) titer or percentage of subjects who experienced more than fourfold increase in antibody level. Analyses of lymphocyte populations were made using analysis of covariance using prevaccination levels as covariates with main effect for treatment. Factors in the model included feeding, visit, feeding-by-visit interaction, blocking for site, and covariate antibody level at baseline. Lymphocyte subsets, activated lymphocytes, CBC with differential, metabolic profile, and cytokines were compared between the two groups using the same model and cofactors as the primary variables. During the conduct of the study, a few blood samples at the final time point were inadvertently shipped to another location or delayed because of severe weather in transport and then shipped to Abbott Laboratories for analysis, resulting in samples being processed more than 24 hours after final blood draw. Because cytokine expression and activation may occur with holding blood, an analysis was performed with all samples (intent-to-treat and evaluable) and without the samples held for more than 24 hours. Pattern of activation was similar, but extended holding time influenced cytokines. Serum nutrient levels were compared. Clinical outcomes (fever and number of newly prescribed antibiotics) between groups were evaluated using the Cochran-Mantel-Haenszel comparison. P-values between .05 and .1 indicate marginally significant differences (clinically important), whereas P-values less than .05 indicate significant differences between the EXP and CON groups. Data are reported as mean?standard error of the mean unless otherwise noted.
<TABLE cellSpacing=0 cellPadding=0 width="100%" border=0><TBODY><TR><TD class=maintextbldleft noWrap width=150 bgColor=#99ccff height=16> RESULTS</TD><TD class=maintextright noWrap width=62 bgColor=#99ccff height=16>Go to:</TD><TD class=fulltextdmenu vAlign=center noWrap align=right width=92 bgColor=#99ccff height=16><SELECT class=fulltextdmenu onchange="GoTo(this, 'self')" name=select23><OPTION selected>Choose</OPTION><OPTION value=#>Top of page</OPTION><OPTION value=#h9>METHODS</OPTION><OPTION value="">RESULTS <<</OPTION><OPTION value=#h28>DISCUSSION</OPTION><OPTION value=#h29>ACKNOWLEDGMENTS</OPTION><OPTION value=#h30>REFERENCES</OPTION></SELECT></TD><TD vAlign=center noWrap align=right width=10 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=32 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=16 bgColor=#99ccff height=16></IMG></IMG></TD><TD noWrap width=10 bgColor=#ffffff height=16></IMG></TD></TR></TBODY></TABLE>Subjects
One hundred fifty-seven seniors (CON=76; EXP=81) consented or assented (legally authorized representative consented for subject) to participate from September 2002 through January 2003. One hundred forty-eight subjects were randomized, vaccinated, and included in intent-to-treat analysis (CON=72; EXP=76). Randomization yielded no differences in stratifications or sex between groups, although the mean age of subjects in the CON group was 2.6 years older than subjects randomized to EXP (P=.03), and more subjects in the EXP group had a history of cancer (P=.03, Table 1). There was a trend toward more subjects in the evaluable group of EXP who had experienced a stroke (P=.06). Ninety-two subjects CON=40; EXP=52) were considered compliant and evaluable. Reasons for noncompliance were inadequate intake (<180 mL average daily consumption of formula, CON=27; EXP=17), discharge from LTC (CON=1; EXP=0), consent withdrawal (CON=2; EXP=5), death (CON=2, EXP=2). Serum α-tocopherol and β-carotene increased significantly from baseline to final blood draws in evaluable and intent-to-treat cohorts of EXP but not CON subjects, P<.01 (Table 2).
Reasons for study discontinuation did not differ between groups. More subjects with a BMI less than 22 kg/m<SUP>2</SUP> (n=17 vs n=6, P=.05) and with diabetes mellitus (n=13 vs n=6) remained in the evaluable EXP group than in the evaluable CON group (Table 1). Also, at the screening visit, more subjects in the evaluable EXP group reported consuming nutritional/herbal supplements.
Antibody Response
Although there were no significant differences in geometric mean titers observed between groups, values for evaluable and intent-to-treat subjects for all three vaccine components tended to be higher in the EXP group (Table 3). The percentage of evaluable subjects with antibody titers greater than 100 for H1N1 (A/Caledonia) at 42 days postvaccination was higher in the EXP than the CON group (P=.047; Table 3), with a similar trend for subjects in the intent-to-treat analysis (P=.09). Trends were also observed in the percentage of evaluable subjects achieving fourfold increase or more over vaccination levels (response to vaccine) in antibody titer against the B/Hong Kong component (P=.09) in the EXP vs CON group. A higher percentage of intent-to-treat subjects achieving an antibody titer of 40 or more against H3N2 (A/Panama) component favoring the EXP group (P=.06) was also observed.
Mitogen and Antigen Responsiveness
Lymphocyte Activation Markers White blood cell count (EXP: 6,880?245 cells/μL, baseline; 6,900?279 cells/μL, study end vs CON: 7,430?380 cells/μL, baseline; 7,130?367 cells/μL, study end), percentage of lymphocytes (EXP: 24.4?0.9%, baseline; 24.2?1.0%, study end, vs CON: 25.6?1.5%, baseline; 26.0?1.4%, study end), and T-lymphocyte subsets (CD4<SUP>+</SUP>or CD8<SUP>+</SUP>) did not differ between groups of evaluable subjects, but cell-activation-marker (CD69 and CD25) expression specific to influenza antigens was markedly higher in evaluable subjects in the EXP group (Figure 1A). T-lymphocyte populations contributing to these activation differences were CD2<SUP></IMG></SUP> (T-lymphocytes, Figure 1B) and CD2<SUP>+</SUP>CD8<SUP></IMG></SUP> subsets (helper T-cells, Figure 1C). Expression of activation markers in influenza-activated lymphocytes from subjects in the intent-to-treat group were not different between study groups with the exception of a higher trend in non-T-cells expressing CD69 and CD25 in the EXP group (73?7 vs 57?7, P=.10) and similarly in the number of total lymphocytes expressing CD69 and CD25 (162?11) versus the CON group (135?12; P=.09). No differences were seen between the EXP and CON groups in cellular activation to the mitogen PHA for the evaluable or intent-to-treat subjects (data not shown).
Cytokine Production Because length of time from blood draw influences cytokine expression, samples were analyzed by groups (<24 hours and all subjects). Upon PBMC stimulation with PHA, significantly lower IL-6 (P=.045) accompanied by a similar trend for IL-10 (P=.06) was noted in the EXP group at study end for evaluable subjects (Table 4). In mitogen-stimulated PBMCs from intent-to-treat subjects, IL-10 was lower (P=.04) at the final visit in the EXP group than in the CON group in samples processed within 24 hours. No other differences in cytokines were noted between groups in the intent-to-treat subjects. Influenza-specific cytokine secretion was low compared with PHA; no significant differences were noted between groups (data not shown).
Immune Cell Phenotypes Differences were observed at the final time point with respect to lymphocyte phenotyping; in the intent-to-treat groups, a higher percentage of cytotoxic T-lymphocytes (14% vs 13%; P=.06) and fewer memory cytotoxic T-lymphocytes (9.5% vs 10.4%, P=.03) were found in the EXP group than in the CON group. In the evaluable groups, there were more natural killer T (NKT)-lymphocytes (% and numbers) expressing CD56<SUP>+</SUP>/CD57<SUP>+</SUP>, CD28<SUP>+</SUP>, and CD3<SUP>+</SUP> in the EXP group than in the CON group (1.07%?0.06% vs 0.91%?0.07%, P=.08; 17?1 vs 15?1 cells/μL, P=.09) and more B-lymphocytes (148?7 vs 122?8 cells/μL, P=.02), as well as a higher percentage of na?ve T-helper lymphocytes (11.3% vs 10.5%, P=.06) and a lower percentage of memory cytotoxic T-lymphocytes (8.9% vs 9.8%; P=.01).
Safety Variables and Clinical Outcomes: Intent to Treat A comprehensive metabolic profile, CBC with differential, and hemoglobin A1c were safety measurements, and no mean differences were found between the EXP and CON groups with the exception of hemoglobin A1c and serum glucose levels. Hemoglobin A1c was slightly lower in subjects receiving EXP (5.4%?0.08% vs 5.3%?0.08%; P=.06) at the final blood draw. A similar trend for serum glucose levels was observed in EXP at the final time point (134.3?7.0 mg/dL vs 118.9?4.9 mg/dL; P=.07). No differences in serum albumin levels between groups were noted, although there was a slight increase in serum albumin levels from baseline to final time point (Table 2). There were similar numbers of subjects hospitalized during the study (CON=5, EXP=5). Body weights were not different between groups, nor were there differences in weight gains over the study (Table 1).
Clinical Outcomes
The number of subjects who dropped out of the study or experienced adverse events was similar between groups with the exception of fever. Fewer subjects consuming EXP experienced fever during the study (4/76, 5% vs 12/72, 16%; P=.02).
EXP subjects had 36 courses of newly prescribed antibiotics, accounting for 315 total days of prescribed antibiotics for 76 subjects (7 new antibiotics/1,000 days of study), whereas CON subjects had 55 courses of antibiotics, accounting for 478 total days for 72 subjects (11 new antibiotics/1000 days of study; P=.06). Similarly, there was a trend toward more days of antibiotic use in the CON group (10 days of antibiotics/100 days of study) than in the EXP group (6 days of antibiotics/100 days of study; P=.09). The reasons, for which physicians prescribed antibiotics were urinary tract (CON=29, EXP=14), respiratory tract (CON=18, EXP=6), and other infections (CON=7, EXP=11).
<TABLE cellSpacing=0 cellPadding=0 width="100%" border=0><TBODY><TR><TD class=maintextbldleft noWrap width=150 bgColor=#99ccff height=16> DISCUSSION</TD><TD class=maintextright noWrap width=62 bgColor=#99ccff height=16>Go to:</TD><TD class=fulltextdmenu vAlign=center noWrap align=right width=92 bgColor=#99ccff height=16><SELECT class=fulltextdmenu onchange="GoTo(this, 'self')" name=select23><OPTION selected>Choose</OPTION><OPTION value=#>Top of page</OPTION><OPTION value=#h9>METHODS</OPTION><OPTION value=#h19>RESULTS</OPTION><OPTION value="">DISCUSSION <<</OPTION><OPTION value=#h29>ACKNOWLEDGMENTS</OPTION><OPTION value=#h30>REFERENCES</OPTION></SELECT></TD><TD vAlign=center noWrap align=right width=10 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=32 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=16 bgColor=#99ccff height=16></IMG></IMG></TD><TD noWrap width=10 bgColor=#ffffff height=16></IMG></TD></TR></TBODY></TABLE>This study showed improvement in markers of immune function in a frail, elderly population consuming EXP. Potential mechanisms for the nutritional benefit were examined, and immune improvement was found to be associated with lymphocyte function. Furthermore, evidence of clinical benefit (less fever and antibiotic use) was observed in subjects consuming EXP. This study supports previous findings in less frail seniors and demonstrates that the combination of nutrients affects immune function in older people.<SUP>15</SUP>
Residents of LTC facilities are at high risk of malnutrition;<SUP>2,20,21</SUP> therefore, many seniors are given nutritional supplements in pill, liquid, or food form, but little evidence of immunological or clinical benefit of such strategies exists. A few studies have demonstrated improved immunity with nutritional supplementation; for example, one found that dietary supplementation of institutionalized older people (n=725) with minerals (zinc and selenium) increased antibody titer to the H3N2 component of the influenza vaccine, whereas vitamin supplementation (vitamin C, E, and β-carotene) offered no immunological benefit.<SUP>22</SUP> A study of 96 independently living individuals found improved nutritional status and decreased infection-related illnesses after 1 year of vitamin and trace element supplementation,<SUP>23</SUP> but questions regarding validity of this research have been posed.<SUP>24,25</SUP> Research regarding individual nutrient or vitamin supplementation have provided conflicting results; for example, one study supplemented diets of LTC residents with a multinutrient capsule and 200 IU vitamin E or placebo.<SUP>13</SUP> Over a 1-year period, there were fewer respiratory tract infections, primarily colds.<SUP>13</SUP> This is in contrast to a study of noninstitutionalized seniors supplemented with 200 mg α-tocopherol, a multivitamin supplement, both or a placebo and showed no effect on incidence of respiratory tract infections, although subjects experienced increased severity of respiratory tract infections with α-tocopherol supplementation.<SUP>26</SUP> Similarly, another study provided a multivitamin-mineral supplement to noninstitutionalized seniors and found no difference in incidence of infection over a 4-month period.<SUP>27</SUP>
Researchers have used vaccine response and antibody production to influenza to measure immune responsiveness after nutrient supplementation. One study supplemented the diets of older people in LTC with a multivitamin and mineral tablet and, despite significant increases in serum nutrient concentrations, found no difference between the supplemented and placebo groups with respect to antibody levels after influenza vaccination.<SUP>28</SUP>
The current study showed immunological benefit (improved lymphocyte responsiveness and antibody titers to the H1N1 component of the influenza vaccine) and clinical benefit (less fever and fewer prescribed antibiotics) in seniors taking a formula containing antioxidants, selenium, and zinc in combination with structured triacylglycerol and FOS.
Possible mechanisms for immune benefit from EXP were examined, and no difference was found in white blood cell populations or lymphocyte population subsets, with the exception of a few important subsets. For example, subjects in the group consuming EXP tended to have more cells expressing CD28 (costimulatory molecule), indicating potential for improved responsiveness. CD28 is a costimulatory molecule expressed on T-cells and NKT cells. Ligation of CD28 is necessary for T-cell receptor-mediated activation. Without CD28 ligation, naive T-cells activated though the T-cell receptor will become anergic (nonresponsive) or apoptotic. Although the role of CD28 with regard to NKT cells in humans has yet to be completely understood, animal studies have shown that CD28 costimulation of NKT cells results in increased cytokine production, increased antimetastatic capabilities, and increased cytotoxicity.<SUP>29</SUP> Also, there was a shift away from a more aged-like lymphocyte profile in the EXP group. Those in the EXP group had more na?ve T-helper cells and fewer memory cytotoxic lymphocytes than those in the CON group.
A key finding of this study was that EXP consumption increased specific activation (i.e., influenza-mediated activation) of the T-lymphocyte populations. Reports consistently indicate that lymphocyte activation and surface activation markers CD69 and CD25 typically decline with age.<SUP>10</SUP> CD69 is expressed on the surface of activated cells within 4 hours and remains elevated for up to 48 hours. CD25, a subunit of the IL-2 receptor, is expressed on the surface of activated cells within 24 hours and continues to increase expression for 120 hours or longer. The main differences between treatment groups of the current study were within specific influenza-activated T-lymphocyte populations expressing CD69 or CD25 or coexpressing CD69 and CD25. By evaluating these surface activation markers on lymphocytes exposed in vitro to the influenza vaccine antigens, it was found that subjects consuming EXP had more activated T-lymphocyte subsets (numbers and percentages), specifically, the subset of T-lymphocytes expressing CD2, CD69, and CD25 and lacking CD8 markers or putative helper T-cells (Figure 1). Because CD4 and CD3 expression downregulates upon activation, CD2 and CD8 were used in activation studies. CD8<SUP></IMG></SUP>CD2<SUP>+</SUP> cells are assumed to be helper T-cells, although some NK cells express CD2. Cellular responses or activation differences may have been more pronounced if the EXP group had been compared with a group not receiving nutritional supplementation.
In vitro activation results support the in vivo antibody response data as markers of improved immune function. Increases in helper T-cell antigen activation may indicate one mechanism of enhanced vaccine-specific antibody production. Approximately twice as many subjects (43% vs 23%, P=.047) consuming EXP as consuming CON achieved an H1N1 antibody titer greater than 100 (protective titer in older people).<SUP>30</SUP> Similar trends were detected with the other two components of the vaccine with respect to a fourfold increase or more (B component) or an antibody level of 40 or more (H3N2 component) in intent-to-treat analysis (Table 3).
Cytokine profiles were different between the two groups. Cytokines regulate immune function in a paracrine and/or autocrine fashion to dampen or stimulate cellular responses. IL-2 and IFN-γ typically decline with age,<SUP>8,14,23</SUP> whereas TNF-α, IL-6 (cytokines that influence inflammation), and IL-10 (immunosuppressive) typically increase with age.<SUP>2,31</IMG>33</SUP> In this study, EXP subjects produced lower levels of the proinflammatory IL-6 (P=.045, evaluable subjects) and immunosuppressive IL-10 (P=.06, evaluable subjects; P=.04, intent-to-treat subjects) upon stimulation than CON subjects. Increases in inflammatory and suppressive cytokines have been implicated in several chronic disease states; the observed differences in cytokine profile would be considered beneficial for seniors. Furthermore, decreases in IL-6 may reflect the smaller number of EXP subjects who experienced fever.
Subjects were stratified according to BMI, smoking status, and diabetes mellitus, yet more subjects who were diabetic or had a BMI less than 22 kg/m<SUP>2</SUP> in the EXP group completed the study. This suggests that frailer individuals with potentially the greatest nutritional needs completed the study as a result of consuming EXP rather than CON (Table 1). Even though the EXP group (evaluable) had more subjects in the "at risk" population, there were significantly greater improvements in immune outcomes than in the CON group.
Immune benefit by nutritional supplementation has recently been noted in a study of free-living subjects (aged <40). After vitamin and mineral supplementation, a subgroup of subjects with type 2 diabetes mellitus had fewer days of illness and less absenteeism from work.<SUP>34</SUP> Subjects with diabetes mellitus may receive the greatest benefit from nutritional supplementation, as in the current study, where more than twice as many subjects with diabetes mellitus in the EXP group then in the CON group completed the study.
The average body weight and BMI of the groups (intent to treat or evaluable) between baseline and final time points were not different in the current study. For many subjects, study formulas replaced between-meal liquid or high-calorie supplements administered with medications, yet immune differences were not simply the result of extra energy and protein. The CON and EXP formulas were both well tolerated, and no differences in formula-related complaints were noted. Serum α-tocopherol and β-carotene concentrations rose in the EXP group, indicating good compliance (Tables 2, P<.01).
The consistent increase in responsiveness to the influenza vaccine, T-cell activation, altered cytokine production, and cellular changes point toward an immunological benefit of EXP that is reflected by the improved clinical outcomes. There was significantly less fever requiring intervention in the EXP group and fewer newly prescribed antibiotics for upper respiratory and urinary tract infections. Changes were consistent and support previous findings.<SUP>15</SUP> It is unlikely, and probably undesirable given the complexity of the immune system, that nutritional supplementation would mediate large changes in immune function in older people. However, the nutritional approach of this study demonstrated a collection of improvements that presumably could reduce the risk of infection and improve quality of life. Others have identified that quality of life is correlated with immune function,<SUP>35</SUP> although this was not the focus of the current study. Therefore, the study of nutritional supplementation on improved immune function, which ultimately affects quality of life, is warranted.
In summary, EXP containing a structured triacylglycerol, protein, antioxidants, selenium, zinc, and FOS provided immunological benefit beyond that provided by a nutritional formula typically used in LTC environments. Furthermore, immunological changes provide evidence of a mechanism for the observed clinical outcomes. This study and previous work<SUP>15</SUP> provide evidence that EXP formula improves the quality of life of seniors, as demonstrated by fewer days of symptoms of upper respiratory tract infections, less fever, fewer antibiotics, improved lymphocyte responsiveness and vaccine response to influenza vaccine.
</TD></TR><TR><TD colSpan=2> </TD></TR><TR><TD class=document-body colSpan=2><TABLE cellSpacing=0 cellPadding=0 width="100%" border=0><TBODY><TR><TD class=maintextbldleft noWrap width=150 bgColor=#99ccff height=16> ACKNOWLEDGMENTS</TD><TD class=maintextright noWrap width=62 bgColor=#99ccff height=16>Go to:</TD><TD class=fulltextdmenu vAlign=center noWrap align=right width=92 bgColor=#99ccff height=16><SELECT class=fulltextdmenu onchange="GoTo(this, 'self')" name=select23><OPTION selected>Choose</OPTION><OPTION value=#>Top of page</OPTION><OPTION value=#h9>METHODS</OPTION><OPTION value=#h19>RESULTS</OPTION><OPTION value=#h28>DISCUSSION</OPTION><OPTION value="">ACKNOWLEDGMENTS <<</OPTION><OPTION value=#h30>REFERENCES</OPTION></SELECT></TD><TD vAlign=center noWrap align=right width=10 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=32 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=16 bgColor=#99ccff height=16></IMG></IMG></TD><TD noWrap width=10 bgColor=#ffffff height=16></IMG></TD></TR></TBODY></TABLE>The authors would like to thank Kamini Teelucksingh, Jennifer McFadden, Gina Mannion, Stephanie Hoke, Christine Hall, Heather Dials, Denise Denton, Carmelo Nieves, Jr., and Jan Hudgens, study coordinators; Suzanne Monnin, project manager; Jan Fonarow and Julie Shertzer, monitors; Geraldine Baggs, statistician; Carol Richardson, Joe Koile, and Julia Phillips, data management; John McEwen and John Cramblit, product development; Amy Marchio, Monica Tortorice, and Mary Hollingsworth, flavor development; Melissa Nameth, Lisa Bull, and Karen Goehring, laboratory technical support; and Fabrizis Suarez, MD, medical and safety surveillance. We also thank the physicians, nurses, dietitians, staff, and subjects at the LTC facilities; without their willingness to participate and hard work this study would not have been possible.
Financial Disclosure: This paper was presented in part at the 2004 Experimental Biology annual meeting. Langkamp-Henken B, Wood SM, Herrlinger-Garcia KA, Stechmiller JK, Thomas DJ, Bender BS, Schaller JP, Gardner EM, Murasko DM. Nutritional formula improved immune profiles in a nursing home population. FASEB J 2004;18:A9. Supported by Ross Products Division/Abbott Laboratories.
Steven M. Wood, Debra J. Thomas, Stephen J. DeMichele, and Joseph P. Schaller are employees of Ross Products Division/Abbott Laboratories, who developed the products used in the study and provided financial support of the study.
Bobbi Langkamp-Henken, the principal investigator and author of the study, received funding for this study from Ross Products Division, Abbott Laboratories, but did not receive any fees from, employment by, consultancy for, shared ownership in, or any close relationship with an organization whose interests, financial or otherwise, the publication of this article may affect. Similarly, the other authors (Herlinger-Garcia, Stechmiller, Bender, Gardner, and Murasko) did not receive any fees from, employment by, consultancy for, shared ownership in, or any close relationship with an organization whose interests, financial or otherwise, the publication of this article may affect.
Author Contributions: Bobbi Langkamp-Henken was principle investigator and oversaw the protocol development, protocol implementation, acquisition of subjects, data analysis, interpretation of data, and preparation of manuscript. Steven M. Wood developed the study concept and worked closely with the principle investigator in manuscript preparation. Kelli A. Herlinger-Garcia assisted in protocol development and played a significant role in subject recruitment and preparation of manuscript. Debra J. Thomas assisted in design of laboratory strategy of phenotyping and cytokine analysis as well as interpretation. Joyce K. Stechmiller was coinvestigator and assisted in protocol development and acquisition of subjects and medical histories. Bradley S. Bender was coinvestigator, provided medical oversight, and assisted in study design and interpretation of results. Elizabeth M. Gardner was coinvestigator and assisted in the study design of cellular analysis and interpretation of results. Stephen J. DeMichele assisted in study design and review of manuscript. Joseph P. Schaller assisted in study design, antibody analysis, and interpretation of results. Donna M. Murasko assisted in study design.
<TABLE cellSpacing=0 cellPadding=0 width="100%" border=0><TBODY><TR><TD class=maintextbldleft noWrap width=150 bgColor=#99ccff height=16> REFERENCES</TD><TD class=maintextright noWrap width=62 bgColor=#99ccff height=16>Go to:</TD><TD class=fulltextdmenu vAlign=center noWrap align=right width=92 bgColor=#99ccff height=16><SELECT class=fulltextdmenu onchange="GoTo(this, 'self')" name=select23><OPTION selected>Choose</OPTION><OPTION value=#>Top of page</OPTION><OPTION value=#h9>METHODS</OPTION><OPTION value=#h19>RESULTS</OPTION><OPTION value=#h28>DISCUSSION</OPTION><OPTION value=#h29>ACKNOWLEDGMENTS</OPTION><OPTION value="">REFERENCES <<</OPTION></SELECT></TD><TD vAlign=center noWrap align=right width=10 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=32 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=16 bgColor=#99ccff height=16></IMG></TD><TD noWrap width=10 bgColor=#ffffff height=16></IMG></TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>1. </TD><TD class=maintextleft>Baldelli MV, Boiardi R, Ferrari P, Basile E et al. Evaluation of the nutritional status during stay in the subacute care nursing home. Arch Gerontol Geriatr Suppl 2004, 39?43.
<SCRIPT type=text/javascript> genCitLink(8, 'b1', '15207394'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b1', '%3F%26aulast%3DBaldelli%26aufirst%3DMV%26spage%3D 39')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>2. </TD><TD class=maintextleft>Keller HH. Malnutrition in institutionalized elderly. How and why? J Am Geriatr Soc 1993;41:1212?1218.
<SCRIPT type=text/javascript> genCitLink(8, 'b2', '8227896'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b2', 'A1993MF52800008'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b2', 'issn%253D0002-8614%2526vol%253D41%2526firstpage%253D1212'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b2', '%3F%26aulast%3DKeller%26aufirst%3DHH.%26volume%3D 41%26spage%3D1212')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>3. </TD><TD class=maintextleft>Castle SC. Clinical relevance of age-related immune dysfunction. Clin Infect Dis 2000;31:578?585.
<SCRIPT type=text/javascript> genCitLink(16, 'b3', '10.1086%252F313947'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b3', '10987724'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b3', '000089838700028'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b3', 'issn%253D1058-4838%2526vol%253D31%2526firstpage%253D578'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b3', '%3F%26aulast%3DCastle%26aufirst%3DSC.%26volume%3D 31%26spage%3D578%26id%3Ddoi%3A10.1086%2F313947')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>4. </TD><TD class=maintextleft>Meyer KC, Ershler W, Rosenthal NS et al. Immune dysregulation in the aging human lung. Am J Respir Crit Care Med 1996;153:1072?1079.
<SCRIPT type=text/javascript> genCitLink(8, 'b4', '8630547'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b4', 'A1996TY52700029'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b4', '%3F%26aulast%3DMeyer%26aufirst%3DKC%26volume%3D15 3%26spage%3D1072')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>5. </TD><TD class=maintextleft>Ginaldi L, Loreto MF, Corsi MP et al. Immunosenescence and infectious diseases. Microbes Infect 2001;3:851?857.
<SCRIPT type=text/javascript> genCitLink(16, 'b5', '10.1016%252FS1286-4579%252801%252901443-5'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b5', '11580980'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b5', '000171004400009'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b5', 'issn%253D1286-4579%2526vol%253D3%2526firstpage%253D851'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b5', '%3F%26aulast%3DGinaldi%26aufirst%3DL%26volume%3D3 %26spage%3D851%26id%3Ddoi%3A10.1016%2FS1286-4579%2801%2901443-5')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>6. </TD><TD class=maintextleft>DeVeale B, Brummel T, Seroude L. Immunity and aging: The enemy within? Aging Cell 2004;3:195?208.
<SCRIPT type=text/javascript> genCitLink(20, 'b6', '10.1111%252Fj.1474-9728.2004.00106.x'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b6', '15268753'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b6', '000223138300008'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b6', '%3F%26aulast%3DDeVeale%26aufirst%3DB%26volume%3D3 %26spage%3D195%26id%3Ddoi%3A10.1111%2Fj.1474-9728.2004.00106.x')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>7. </TD><TD class=maintextleft>Garibaldi RA, Brodine S, Matsumiya S. Infections among patients in nursing homes: Policies, prevalence, problems. N Engl J Med 1981;305:731?735.
<SCRIPT type=text/javascript> genCitLink(8, 'b7', '7266615'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b7', 'A1981MG29100004'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b7', 'issn%253D0028-4793%2526vol%253D305%2526firstpage%253D731'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b7', '%3F%26aulast%3DGaribaldi%26aufirst%3DRA%26volume% 3D305%26spage%3D731')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>8. </TD><TD class=maintextleft>Loeb M, McGeer A, McArthur M et al. Surveillance for outbreaks of respiratory tract infections in nursing homes. Can Med Assoc J 2000;162:1133?1137.
<SCRIPT type=text/javascript> genCitLink(8, 'b8', '10789627'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b8', '000086592500011'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b8', 'issn%253D0820-3946%2526vol%253D162%2526firstpage%253D1133'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b8', '%3F%26aulast%3DLoeb%26aufirst%3DM%26volume%3D162% 26spage%3D1133')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>9. </TD><TD class=maintextleft>Moran D. Infections in the elderly. Top Emerg Med 2003;25:174?181.
<SCRIPT type=text/javascript>genSfxLinks('b9', '%3F%26aulast%3DMoran%26aufirst%3DD.%26volume%3D25 %26spage%3D174')</SCRIPT></TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>10. </TD><TD class=maintextleft>Goodwin JS. Decreased immunity and increased morbidity in the elderly. Nutr Rev 1995;53:S41?S44.
<SCRIPT type=text/javascript> genCitLink(8, 'b10', '7644153'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b10', 'A1995RD26400007'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b10', '%3F%26aulast%3DGoodwin%26aufirst%3DJS.%26volume%3 D53%26spage%3DS41')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>11. </TD><TD class=maintextleft>Patriarca PA, Arden NH, Koplan JP et al. Prevention and control of type A influenza infections in nursing homes. Benefits and costs of four approaches using vaccination and amantadine. Ann Intern Med 1987;107:732?740.
<SCRIPT type=text/javascript> genCitLink(8, 'b11', '3116900'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b11', 'A1987K850900022'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b11', '%3F%26aulast%3DPatriarca%26aufirst%3DPA%26volume% 3D107%26spage%3D732')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>12. </TD><TD class=maintextleft>Pawelec G, Solana R. Immunosenescence. Immunol Today 1997;18:514?516.
<SCRIPT type=text/javascript> genCitLink(16, 'b12', '10.1016%252FS0167-5699%252897%252901145-6'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b12', '9386344'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b12', 'issn%253D0167-5699%2526vol%253D18%2526firstpage%253D514'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b12', '%3F%26aulast%3DPawelec%26aufirst%3DG%26volume%3D1 8%26spage%3D514%26id%3Ddoi%3A10.1016%2FS0167-5699%2897%2901145-6')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>13. </TD><TD class=maintextleft>Meydani SN, Leka LS, Fine BC et al. Vitamin E and respiratory tract infections in elderly nursing home residents: A randomized controlled trial. JAMA 2004;292:828?836.
<SCRIPT type=text/javascript> genCitLink(16, 'b13', '10.1001%252Fjama.292.7.828'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b13', '15315997'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b13', '000223378300023'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b13', '%3F%26aulast%3DMeydani%26aufirst%3DSN%26volume%3D 292%26spage%3D828%26id%3Ddoi%3A10.1001%2Fjama.292. 7.828')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>14. </TD><TD class=maintextleft>Girodon F, Lombard M, Galan P et al. Effect of micronutrient supplementation on infection in institutionalized elderly subjects: A controlled trial. Ann Nutr Metab 1997;41:98?107.
<SCRIPT type=text/javascript> genCitLink(8, 'b14', '9267584'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b14', 'A1997XN45000004'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b14', '%3F%26aulast%3DGirodon%26aufirst%3DF%26volume%3D4 1%26spage%3D98')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>15. </TD><TD class=maintextleft>Langkamp-Henken B, Bender BS, Gardner EM et al. Nutritional formula enhanced immune function and reduced days of symptoms of upper respiratory tract infection in seniors. J Am Geriatr Soc 2004;52:3?12.
<SCRIPT type=text/javascript> genCitLink(20, 'b15', '10.1111%252Fj.1532-5415.2004.52003.x'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b15', '14687308'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b15', '000187451000002'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b15', '%3F%26aulast%3DLangkamp-Henken%26aufirst%3DB%26volume%3D52%26spage%3D3%26i d%3Ddoi%3A10.1111%2Fj.1532-5415.2004.52003.x')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>16. </TD><TD class=maintextleft>Gardner EM, Bernstein ED, Dran S et al. Characterization of antibody responses to annual influenza vaccination over four years in a healthy elderly population. Vaccine 2001;19:4610?4617.
<SCRIPT type=text/javascript> genCitLink(16, 'b16', '10.1016%252FS0264-410X%252801%252900246-8'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b16', '11535308'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b16', '000171035500005'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b16', 'issn%253D0264-410X%2526vol%253D19%2526firstpage%253D4610'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b16', '%3F%26aulast%3DGardner%26aufirst%3DEM%26volume%3D 19%26spage%3D4610%26id%3Ddoi%3A10.1016%2FS0264-410X%2801%2900246-8')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>17. </TD><TD class=maintextleft>Rastogi S, Gross PA, Bonelli J et al. Time to peak serum antibody response to influenza vaccine. Clin Diagn Lab Immunol 1995;2:120?121.
<SCRIPT type=text/javascript> genCitLink(8, 'b17', '7719904'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b17', 'A1995QA64900022'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b17', 'issn%253D1071-412X%2526vol%253D2%2526firstpage%253D120'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b17', '%3F%26aulast%3DRastogi%26aufirst%3DS%26volume%3D2 %26spage%3D120')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>18. </TD><TD class=maintextleft>Kendal A, Pereira M, Skehel J. Concepts and Procedures for Laboratory-Based Influenza Surveillance: The Hemagglutination Inhibition Test for Influenza Viruses. Atlanta, GA: Centers for Disease Control, Department of Health and Human Services, 1982.
<SCRIPT type=text/javascript>genSfxLinks('b18', '%3F%26aulast%3DKendal%26aufirst%3DA')</SCRIPT></TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>19. </TD><TD class=maintextleft>Cordle CT, Winship TR, Schaller JP et al. Immune status of infants fed soy-based formulas with or without added nucleotides for 1 year: Part 2. Immune cell populations. J Pediatr Gastroenterol Nutr 2002;34:145?153.
<SCRIPT type=text/javascript> genCitLink(16, 'b19', '10.1097%252F00005176-200202000-00008'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b19', '11840031'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b19', '000173784300008'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b19', '%3F%26aulast%3DCordle%26aufirst%3DCT%26volume%3D3 4%26spage%3D145%26id%3Ddoi%3A10.1097%2F00005176-200202000-00008')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>20. </TD><TD class=maintextleft>Clarke DM, Wahlqvist ML, Strauss BJ. Undereating and undernutrition in old age: Integrating bio-psychosocial aspects. Age Ageing 1998;27:527?534.
<SCRIPT type=text/javascript> genCitLink(8, 'b20', '9884014'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b20', '000075449800031'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b20', 'issn%253D0002-0729%2526vol%253D27%2526firstpage%253D527%2526iss% 253D4'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b20', '%3F%26aulast%3DClarke%26aufirst%3DDM%26volume%3D2 7%26spage%3D527')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>21. </TD><TD class=maintextleft>Ruiz-Lopez MD, Artacho R, Oliva P et al. Nutritional risk in institutionalized older women determined by the Mini Nutritional Assessment test: What are the main factors? Nutrition 2003;19:767?771.
<SCRIPT type=text/javascript> genCitLink(16, 'b21', '10.1016%252FS0899-9007%252803%252900125-4'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b21', '12921887'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b21', '000184765300011'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b21', '%3F%26aulast%3DRuiz-Lopez%26aufirst%3DMD%26volume%3D19%26spage%3D767%2 6id%3Ddoi%3A10.1016%2FS0899-9007%2803%2900125-4')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>22. </TD><TD class=maintextleft>Girodon F, Galan P, Monget AL et al. Impact of trace elements and vitamin supplementation on immunity and infections in institutionalized elderly patients: A randomized controlled trial. MIN. VIT. AOX. geriatric network. Arch Intern Med 1999;159:748?754.
<SCRIPT type=text/javascript> genCitLink(16, 'b22', '10.1001%252Farchinte.159.7.748'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b22', '10218756'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b22', '000079670600016'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b22', 'issn%253D0003-9926%2526vol%253D159%2526firstpage%253D748'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b22', '%3F%26aulast%3DGirodon%26aufirst%3DF%26volume%3D1 59%26spage%3D748%26id%3Ddoi%3A10.1001%2Farchinte.1 59.7.748')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>23. </TD><TD class=maintextleft>Chandra RK. Effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects. Lancet 1992;340:1124?1127.
<SCRIPT type=text/javascript> genCitLink(16, 'b23', '10.1016%252F0140-6736%252892%252993151-C'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b23', '1359211'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b23', 'A1992JX13400004'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b23', 'issn%253D0140-6736%2526vol%253D340%2526firstpage%253D1124'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b23', '%3F%26aulast%3DChandra%26aufirst%3DRK.%26volume%3 D340%26spage%3D1124%26id%3Ddoi%3A10.1016%2F0140-6736%2892%2993151-C')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>24. </TD><TD class=maintextleft>White C. Three journals raise doubts on validity of Canadian studies. BMJ 2004;328:367.
<SCRIPT type=text/javascript> genCitLink(16, 'b24', '10.1136%252Fbmj.328.7436.367'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b24', '14962868'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b24', '%3F%26aulast%3DWhite%26aufirst%3DC.%26volume%3D32 8%26spage%3D367%26id%3Ddoi%3A10.1136%2Fbmj.328.743 6.367')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>25. </TD><TD class=maintextleft>Carpenter KJ, Roberts S, Sternberg S. Nutrition and immune function: A 1992 report. Lancet 2003;361:2247.
<SCRIPT type=text/javascript> genCitLink(16, 'b25', '10.1016%252FS0140-6736%252803%252913755-5'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b25', '12842391'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b25', '000183815600039'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b25', '%3F%26aulast%3DCarpenter%26aufirst%3DKJ%26volume% 3D361%26spage%3D2247%26id%3Ddoi%3A10.1016%2FS0140-6736%2803%2913755-5')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>26. </TD><TD class=maintextleft>Graat JM, Schouten EG, Kok FJ. Effect of daily vitamin E and multivitamin-mineral supplementation on acute respiratory tract infections in elderly persons: A randomized controlled trial. JAMA 2002;288:715?721.
<SCRIPT type=text/javascript> genCitLink(16, 'b26', '10.1001%252Fjama.288.6.715'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b26', '12169075'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b26', '000177408100032'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b26', 'issn%253D0098-7484%2526vol%253D288%2526firstpage%253D715'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b26', '%3F%26aulast%3DGraat%26aufirst%3DJM%26volume%3D28 8%26spage%3D715%26id%3Ddoi%3A10.1001%2Fjama.288.6. 715')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>27. </TD><TD class=maintextleft>Chavance M, Herbeth B, Lemoine A, Zhu BP. Does multivitamin supplementation prevent infections in healthy elderly subjects? A controlled trial. Int J Vitam Nutr Res 1993;63:11?16.
<SCRIPT type=text/javascript> genCitLink(8, 'b27', '8320052'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b27', 'A1993LB27600002'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b27', '%3F%26aulast%3DChavance%26aufirst%3DM%26volume%3D 63%26spage%3D11')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>28. </TD><TD class=maintextleft>Allsup SJ, Shenkin A, Gosney MA et al. Can a short period of micronutrient supplementation in older institutionalized people improve response to influenza vaccine? A randomized, controlled trial. J Am Geriatr Soc 2004;52:20?24.
<SCRIPT type=text/javascript> genCitLink(20, 'b28', '10.1111%252Fj.1532-5415.2004.52005.x'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b28', '14687310'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b28', '000187451000004'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b28', '%3F%26aulast%3DAllsup%26aufirst%3DSJ%26volume%3D5 2%26spage%3D20%26id%3Ddoi%3A10.1111%2Fj.1532-5415.2004.52005.x')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>29. </TD><TD class=maintextleft>Hayakawa Y, Takeda K, Yagita H et al. Differential regulation of Th1 and Th2 functions of NKT cells by CD28 and CD40 costimulatory pathways. J Immunol 2001;166:6012?6018.
<SCRIPT type=text/javascript> genCitLink(8, 'b29', '11342617'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b29', '000170948500021'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b29', 'issn%253D0022-1767%2526vol%253D166%2526firstpage%253D6012'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b29', '%3F%26aulast%3DHayakawa%26aufirst%3DY%26volume%3D 166%26spage%3D6012')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>30. </TD><TD class=maintextleft>Govaert TM, Sprenger MJ, Dinant GJ et al. Immune response to influenza vaccination of elderly people. A randomized double-blind placebo-controlled trial. Vaccine 1994;12:1185?1189.
<SCRIPT type=text/javascript> genCitLink(16, 'b30', '10.1016%252F0264-410X%252894%252990241-0'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b30', '7839722'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b30', 'A1994PG67100006'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b30', 'issn%253D0264-410X%2526vol%253D12%2526firstpage%253D1185'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b30', '%3F%26aulast%3DGovaert%26aufirst%3DTM%26volume%3D 12%26spage%3D1185%26id%3Ddoi%3A10.1016%2F0264-410X%2894%2990241-0')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>31. </TD><TD class=maintextleft>Castle SC, Uyemura K, Crawford W et al. Age-related impaired proliferation of peripheral blood mononuclear cells is associated with an increase in both IL-10 and IL-12. Exp Gerontol 1999;34:243?252.
<SCRIPT type=text/javascript> genCitLink(16, 'b31', '10.1016%252FS0531-5565%252898%252900064-3'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b31', '10363790'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b31', '000079382300009'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b31', '%3F%26aulast%3DCastle%26aufirst%3DSC%26volume%3D3 4%26spage%3D243%26id%3Ddoi%3A10.1016%2FS0531-5565%2898%2900064-3')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>32. </TD><TD class=maintextleft>Gardner EM, Murasko DM. Age-related changes in type 1 and type 2 cytokine production in humans. Biogerontol 2002;3:271?290.
<SCRIPT type=text/javascript> genCitLink(16, 'b32', '10.1023%252FA%253A1020151401826'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b32', '12237564'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b32', '000177874500003'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b32', '%3F%26aulast%3DGardner%26aufirst%3DEM%26volume%3D 3%26spage%3D271%26id%3Ddoi%3A10.1023%2FA%3A1020151 401826')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>33. </TD><TD class=maintextleft>Rink L, Cakman I, Kirchner H. Altered cytokine production in the elderly. Mech Ageing Dev 1998;102:199?209.
<SCRIPT type=text/javascript> genCitLink(16, 'b33', '10.1016%252FS0047-6374%252897%252900153-X'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b33', '9720652'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b33', '000074845900007'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(256, 'b33', 'issn%253D0047-6374%2526vol%253D102%2526firstpage%253D199'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b33', '%3F%26aulast%3DRink%26aufirst%3DL%26volume%3D102% 26spage%3D199%26id%3Ddoi%3A10.1016%2FS0047-6374%2897%2900153-X')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>34. </TD><TD class=maintextleft>Barringer TA, Kirk JK, Santaniello AC et al. Effect of a multivitamin and mineral supplement on infection and quality of life. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2003;138:365?371.
<SCRIPT type=text/javascript> genCitLink(8, 'b34', '12614088'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b34', '000181257300001'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b34', '%3F%26aulast%3DBarringer%26aufirst%3DTA%26volume% 3D138%26spage%3D365')</SCRIPT> </TD></TR></TBODY></TABLE><TABLE summary=""><TBODY><TR><TD vAlign=top align=right width=20>35. </TD><TD class=maintextleft>Castle SC, Uyemura K, Rafi A et al. Comorbidity is a better predictor of impaired immunity than chronological age in older adults. J Am Geriatr Soc 2005;53:1565?1569.
<SCRIPT type=text/javascript> genCitLink(20, 'b35', '10.1111%252Fj.1532-5415.2005.53512.x'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(8, 'b35', '16137288'); </SCRIPT> <SCRIPT type=text/javascript> genCitLink(128, 'b35', '000231509000017'); </SCRIPT> <SCRIPT type=text/javascript>genSfxLinks('b35', '%3F%26aulast%3DCastle%26aufirst%3DSC%26volume%3D5 3%26spage%3D1565%26id%3Ddoi%3A10.1111%2Fj.1532-5415.2005.53512.x')</SCRIPT> </TD></TR></TBODY></TABLE></TD></TR><TR><TD colSpan=2> </TD></TR><TR><TD colSpan=2> </TD></TR><TR><TD colSpan=2>Journal of the American Geriatrics Society
Volume 54 Issue 12 Page 1861 - December 2006</TD></TR></TBODY></TABLE>

**Mingus** · January 4, 2007, 10:19 AM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

Complement

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<TABLE><TBODY><TR><TD class=maintextleft colSpan=2>Article published online 07 Dec 2006</TD></TR><TR><TD></TD></TR><TR><TD class=maintextbldleft>Affiliations
</TD></TR><TR><TD class=maintextleft>From the <SUP>*</SUP>Food Science and Human Nutrition Department and <SUP></IMG></SUP>College of Nursing, University of Florida, Gainesville, Florida; <SUP></IMG></SUP>Ross Products Division, Abbott Laboratories, Columbus, Ohio; <SUP>?</SUP>College of Medicine, University of Florida and North Florida/South Georgia Veterans Health System, Gainesville, Florida; <SUP></IMG></SUP>MCP Hahnemann School of Medicine, Philadelphia, Pennsylvania; and <SUP>?</SUP>College of Arts and Science, Drexel University, Philadelphia, Pennsylvania.
</TD></TR><TR><TD></TD></TR><TR><TD class=maintextbldleft>Correspondence
</TD></TR><TR><TD class=maintextleft>Address correspondence to Steven M. Wood, PhD, Ross Products Division, Abbott Laboratories, 105500 RP3-2, 625 Cleveland Avenue, Columbus, OH 43215. E-mail: steven.wood@abbott.com </TD></TR><TR><TD class=maintextbldleft>
Image Previews
</IMG>
[Full Size] Figure 1. Activation of lymphocytes from evaluable subjects in response to influenza antigens. Percen...

</IMG>
[Full Size] Table 1. Characteristics of Seniors Residing in North Central Florida Nursing Homes for Evaluable<SUP>*</SUP> an...

</IMG>
[Full Size] Table 2. Compliance and Serum Concentrations

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[Full Size] Table 3. Antibody Responses to Components of the Influenza Vaccine

</IMG>
[Full Size] Table 4. Cytokine Concentration After Mitogen Stimulation Before Feeding (Baseline Visit) and 6 Weeks...

</TD></TR><TR><TD class=maintextleft>To cite this article
Langkamp-Henken, Bobbi, Wood, Steven M., Herlinger-Garcia, Kelli A., Thomas, Debra J., Stechmiller, Joyce K., Bender, Bradley S., Gardner, Elizabeth M., DeMichele, Stephen J., Schaller, Joseph P. & Murasko, Donna M. (2006)
Nutritional Formula Improved Immune Profiles of Seniors Living in Nursing Homes.
Journal of the American Geriatrics Society 54 (12), 1861-1870.
doi: 10.1111/
j.1532-5415.2006.00982.x</TD></TR><TR><TD><HR align=center noShade SIZE=1></HR></TD></TR></TBODY></TABLE>
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**Mingus** · January 4, 2007, 10:21 AM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

Complete PDF Article for a nice print !

See ya later
_______________________________

Attached Files

Ederly formula.pdf (144.8 KB, 203 views)

**Mingus** · January 4, 2007, 12:10 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

This is a similar study from 2 years ago....wonder if it's the same formula?

Yes Denise, this is the first study they reffered in that last one.
I'll try to find it complete later.

This recent study is the double-blind controlled clinical trial & they focus in that. It is an important study, very serious.

For that one the relevant quotes wich don't give much details on the formula are these.

Residents of long-term care (LTC) facilities or nursing homes are particularly vulnerable to infection. In addition, LTC facilities provide environments that promote infectious outbreaks (i.e., influenza).<SUP>7</IMG>9</SUP> More importantly, residents who are infected experience high rates of mortality.<SUP>10</IMG>12</SUP> Because immune changes from aging and malnutrition are similar, nutrient supplementation may improve immune status and clinical outcome in frail seniors.<SUP>13,14</SUP>
In a relatively healthy population of seniors, it was previously found that a nutritional formula enhanced immune function as measured by antibody response to the influenza vaccine and reduced the number of days of symptoms of upper respiratory tract infections.<SUP>15</SUP> This formula contained vitamins, minerals, and nutrients important for immune function (protein, antioxidants (vitamins E, C, β-carotene), selenium, zinc, fructo-oligosaccharides (FOS), and structured triacylglycerol). In the present study, various markers of immune cell function were examined from a more-frail (potentially more-nutritionally deficient and immune dysregulated) population to explore mechanisms of nutrition-mediated immune benefit.

However, the nutritional approach of this study demonstrated a collection of improvements that presumably could reduce the risk of infection and improve quality of life. Others have identified that quality of life is correlated with immune function,<SUP>35</SUP> although this was not the focus of the current study. Therefore, the study of nutritional supplementation on improved immune function, which ultimately affects quality of life, is warranted.
In summary, EXP containing a structured triacylglycerol, protein, antioxidants, selenium, zinc, and FOS provided immunological benefit beyond that provided by a nutritional formula typically used in LTC environments. Furthermore, immunological changes provide evidence of a mechanism for the observed clinical outcomes. This study and previous work<SUP>15</SUP> provide evidence that EXP formula improves the quality of life of seniors, as demonstrated by fewer days of symptoms of upper respiratory tract infections, less fever, fewer antibiotics, improved lymphocyte responsiveness and vaccine response to influenza vaccine.

**Shannon Bennett** · January 4, 2007, 12:14 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

We imported another supplement study also containing macronutrients done in 1999. I'll see if I can't find it.

edited to correct date of study.

**Mingus** · January 4, 2007, 12:17 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

Ok Denise I got the complete article of the previous article about the nutritionnal formula.

Here it is...

______________________________________________

http://www.medscape.com/viewarticle/467012

<TABLE cellSpacing=0 cellPadding=0 width=410 border=0><TBODY><TR vAlign=top><TD width=410>From Journal of the American Geriatrics Society

Nutritional Formula Enhanced Immune Function and Reduced Days of Symptoms of Upper Respiratory Tract Infection in Seniors

Posted 01/20/2004
Bobbi Langkamp-henken, PhD, Bradley S. Bender, MD, Elizabeth M. Gardner, PhD, Kelli A. Herrlinger-Garcia, BS, Michael J. Kelley, PhD, Donna M. Murasko, PhD, Joseph P. Schaller, PhD, Joyce K. Stechmiller, PhD, Debra J. Thomas, MS, Steven M. Wood, PhD

</TD></TR></TBODY></TABLE>
Abstract and Introduction

Abstract

Objectives: To assess whether an experimental nutritional formula, given as a supplement, would reduce days of symptoms of upper respiratory tract infection (URTI) and affect antibody and lymphocyte proliferative responses to influenza vaccine.
Design: A prospective, randomized, double-blind, controlled trial was conducted between October 1999 and April 2000.
Setting: Assisted- and independent-living facilities in North Central Florida.
Participants: Sixty-six individuals, aged 65 and older.
Intervention: Subjects received 8 oz/d of an experimental formula containing antioxidants, zinc, selenium, fermentable oligosaccharides, and structured triacylglycerol or an isoenergetic, isonitrogenous control formula for 183 days.
Measurements: Subjects recorded daily symptoms of URTI. Antibody titers and lymphocyte proliferation to three influenza vaccine components were measured on Days 57 and 183.
Results: Eighteen subjects in the control group and 16 subjects in the experimental group consumed an average of 7 ounces of formula daily and completed the 183-day study. Median days of symptoms of URTI were 3 (range 0-69, total days=156) and 0 (range 0-49, total days=78) for the control and experimental groups, respectively (P= .049). On Day 57, seven of 17 (41%) subjects in the control group and 13 of 15 (87%) subjects in the experimental group achieved a fourfold or greater increase in serum antibody titer to A/Beijing (P=.012). Lymphocyte proliferation to influenza vaccine components was greater in the experimental (median=1,365 cpm, range=0-14,955 cpm) than the control group (median=136 cpm, range=0-4,270 cpm) (P=.013).
Conclusion: Subjects consuming an experimental nutritional formula experienced enhanced immune function and fewer days of URTI symptoms.
Introduction

Advanced age is associated with increased risk of nutrient deficiency and altered regulation of the immune system.<SUP>[1]</SUP> Nutrient deficiencies in the young or elderly can impair immune function; nutrient supplementation can restore normal immune capacity.<SUP>[2-4]</SUP> Consequently, there has been interest in determining whether nutrient supplementation in seniors could attenuate age-associated declines in immune function.<SUP>[3-8]</SUP>
Well-documented clinical and experimental studies report an age-associated decrease in immune function, including antibody response to vaccination.<SUP>[9-13]</SUP> Influenza infections significantly affect morbidity and mortality in the aged, and when vaccinated, seniors experience a lower antibody response than that observed in young healthy cohorts.<SUP>[9,14,15]</SUP> One study noted that, in a population of 210 seniors hospitalized with influenza, 129 (61%) had been vaccinated against influenza, indicating a suboptimal response to the vaccine or less-than-adequate protection from the influenza vaccine.<SUP>[16]</SUP>
As early as the 1950s, single-nutrient deficiencies were known to suppress vaccine response.<SUP>[17]</SUP> More recently, it was shown that nutritional supplementation enhances antibody responses to influenza vaccination in seniors.<SUP>[4,5,8]</SUP> A few studies have investigated the influence of nutrient supplementation on immune function in seniors and found a clinically meaningful benefit, such as reduced infection rates or days of illness. A more recent study examined the effect of trace-element (zinc and selenium) supplementation on immune function and infections in institutionalized seniors (mean age 83).<SUP>[8]</SUP> Supplementation with trace elements corrected a selenium deficiency, enhanced antibody titers to influenza vaccination, and showed a trend toward fewer subjects with respiratory tract infections.<SUP>[8]</SUP> Another study reported better immune responsiveness and "fewer infection-related illnesses" with a multivitamin supplement than with a placebo in apparently healthy, independent-living elderly (mean age 75).<SUP>[4]</SUP> Other researchers have supplemented the diets of seniors and found no immunological benefit or reduction in acute respiratory tract infections.<SUP>[18-20]</SUP>
Research conducted in military personnel has shown immune dysregulation caused by stress that is similar to the immune dysregulation noted in the elderly (e.g., anergy and decreased proliferative response).<SUP>[21-24]</SUP> Several nutritional formulations had previously been tested until one was identified that minimized stress-induced immune dysregulation. The formula contained vitamins and minerals, with elevated levels of antioxidants (vitamins E, C, β-carotene), selenium, zinc, fructo-oligosaccharides (fermentable oligosaccharides), and structured lipids (a unique triacylglycerol containing long- and medium-chain fatty acids from canola and medium-chain triacylglycerols). Several of the nutrients included have been shown to enhance or support immune function in studies of seniors.<SUP>[7,25-27]</SUP> Fructo-oligosaccharides are readily soluble and fermentable to short-chain fatty acids in the large bowel, thus maintaining gastrointestinal health.<SUP>[28,29]</SUP> Structured lipids have been shown to enhance the absorption of lipid-soluble nutrients<SUP>[30]</SUP> and have the potential to be a unique energy substrate for metabolically active cells such as leukocytes.<SUP>[31]</SUP>
The objective of this study was to supplement the diet of relatively healthy independent- and assisted-living seniors with an experimental formula (containing protein, antioxidants (vitamins E, C, β-carotene), selenium, zinc, fructo-oligosaccharides, and structured triacylglycerol) and determine, in a prospectively designed study, whether seniors who were at risk of developing infections would have a reduced number of days of symptoms of upper respiratory tract infections (URTI) during the cold and influenza season (October 1999-April 2000). Antibody titers and lymphocyte proliferative response to influenza vaccine components were also measured as markers of immune function.

Methods

Subjects

Ambulatory men and women, aged 65 and older, were recruited from six assisted-living and seven independent-living facilities in Gainesville and Ocala, Florida, during September and October 1999. The study was conducted from October 1999 through April 2000. Subjects were excluded if they were taking vitamin K-dependent anticoagulant medication; allergic to any components of the study or control formula; ineligible to receive the influenza vaccine; currently being treated for Alzheimer's disease, insulin-dependent diabetes mellitus, or renal, hepatic, gastrointestinal, or immune system insufficiency or disease; receiving treatments known to affect the immune response; or receiving supplemental oxygen for at least 12 hours continuously per day. Subjects who would not agree to discontinue taking dietary supplements (other than calcium, vitamin D, iron, vitamin B<SUB>12</SUB> injections, or fiber), had smoked within the past 5 years, or had a body mass index (BMI) of 32 kg/m<SUP>2</SUP> or greater were excluded. Informed consent was obtained from all subjects or their surrogate after the nature of the study and procedures had been explained. The study protocol and informed consent were in accordance with the Helsinki Declaration of 1975 and the 1983 revision and were approved by the institutional review board at the University of Florida.
Before randomization, a nurse practitioner recorded a detailed medical history, body weight and height were measured to calculate BMI, and subjects completed the Determine Your Nutritional Health questionnaire (NHQ).<SUP>[32]</SUP> Subjects were then stratified by age, sex, and score on the NHQ and randomized based on the stratification sequence to receive the experimental or an isoenergetic, isonitrogenous control formula (Table 1). Each independent- or assisted-living facility was stratified and randomized individually.
Study Design

A prospective, randomized, parallel, double-blind, controlled design was used. On study Day 0 (baseline), a nonfasting blood sample was collected and analyzed for vitamin E concentrations, clinical chemistries, and hematology, as well as lymphocyte proliferation and antibody titers to influenza vaccine components. Clinical chemistries and hematology analyses were performed at a central laboratory facility (SmithKline Beecham, Tampa, FL).
Randomization envelopes were opened to determine study group assignment, and all subjects were instructed to consume one 8-ounce can of control or experimental formula (Table 1); both groups received the same low-potency vitamin/mineral supplement tablet (Multi-Vites with Minerals, Vitamin Power, Freeport, NY (Table 1)) daily for the next 183 days. This was to ensure that all subjects received some supplemental vitamins and minerals along with their normal diets. Subjects completed daily case report forms for study formula and multivitamin intake, symptoms of URTI, and gastrointestinal tolerance for 183 days. Symptoms of URTI were analyzed from study Day 15 forward (169 days used for analysis). This design excluded any infections present but not yet symptomatic at enrollment and evaluated subjects' ability to complete daily case report forms. Subjects unable to record information on their own were identified within the first 15 days; thereafter, nursing personnel or study investigators verbally presented the questions on the case report forms to these subjects daily and recorded their responses.
On study day 15?2 days, subjects were vaccinated with a single lot of Influenza Virus Vaccine, Trivalent, Types A and B Fluogen (lot #03079P, Parkedale Pharmaceuticals, Rochester, MI). The U.S. Public Health Service formulated this vaccine for the 1999-2000 season; it contained 15 ?g of each of the following hemagglutinin antigens: A/Beijing/262/95 (H1N1), A/Sydney/5/97 (H3N2), and B/Yamanashi/166/98 (B/Beijing/184/93-like). This antigen composition was the same as the 1998-1999 influenza vaccine. On study day 57?3 days (42 days postvaccination), a nonfasting, postvaccination blood sample was collected for determination of serum vitamin E, and influenza antibody titers and lymphocyte proliferation to vaccine components. This postvaccination point was selected based on other studies<SUP>[33,34]</SUP> and to ensure that antibody responses had peaked.<SUP>[34]</SUP> In addition, some seniors seroconvert to the influenza vaccine after 4 weeks.<SUP>[35]</SUP> Blood samples were obtained at the conclusion of the study (Day 183?3, final blood draw) for clinical chemistries, hematology, serum vitamin E, and lymphocyte proliferation and antibody titers to vaccine components.
Subjects were instructed to continue their previous life style (including diet and exercise) and to incorporate study formulas into their diet without changing body weight during the study. Subjects were weighed at baseline, once each month, and on Day 183. Adverse events were collected throughout the study and for an additional 30 days after cessation of formula consumption.
Outcome Variables

The primary variable was the number of days with symptoms of URTI recorded by the subjects daily. Possible symptoms included cough, running or congested nose, sore throat, stiffness or chills, fever, achiness, and headache. Combinations of two or more symptoms, including one or more of the first three listed symptoms, were defined as a day of URTI symptoms. An URTI was defined as symptoms lasting two or more consecutive days. A new URTI was defined as an initial infection separated from a new URTI episode by 5 or more symptom-free days.
Secondary variables included antibody response and lymphocyte proliferation to influenza vaccine components at baseline, postvaccination (Day 57), and final study time points (Day 183). Additional outcome variables included symptoms of gastrointestinal intolerance (diarrhea, constipation, bloating, flatulence, nausea, and vomiting). Serum vitamin E (α-tocopherol) was measured at baseline, postvaccination, and final study time points as a marker of the experimental group's compliance. The control formula contained no added α-tocopherol, whereas the experimental formula contained 135 mg α-tocopherol (all natural form, RRR-α-tocopherol) per 8-ounce serving.
Antibody Titers

Blood for determination of antibody response to the components of the influenza vaccine was collected in SST-Gel Clot Activator Vacutainer Tubes (Beckton Dickinson, Franklin Lakes, NJ). Serum was separated, frozen, and shipped on dry ice for analysis to Ross Products Division, Abbott Laboratories (Columbus, OH). Baseline, postvaccination, and final influenza antibody titers were quantitated simultaneously using a modified hemagglutination inhibition (HI) procedure used by the World Health Organization Collaborating Center for Influenza, Centers for Disease Control and Prevention (Atlanta, GA).<SUP>[36]</SUP> Modifications to the HI method included a doubling of the reagent dilution volumes (25-50 ?L) and a 2-hour incubation (second hour at 4 ?C) instead of 30 minutes for agglutination pattern development. HI antibody titers are reported as the reciprocal of the highest serum dilution causing complete inhibition of chicken red blood cell agglutination. Subjects with a fourfold or greater increase in antibody titer to a vaccine component were considered responders.
Lymphocyte Proliferation

Venous blood was collected at the same time of day in two 10-mL ethylenediamine tetraacetic acid-coated tubes and shipped overnight on ice to the Medical College of Pennsylvania Hahnemann School of Medicine (Philadelphia, PA) to assess lymphocyte proliferation. Blood samples were received at approximately the same time of day, and immediately upon arrival, lymphocytes were separated, and influenza-induced proliferation to previously dialyzed 1999-2000 trivalent influenza virus vaccine at a 1:200 dilution in complete media was assessed using the same lot of vaccine as administered to subjects, as previously described.<SUP>[9]</SUP> Proliferation was expressed as net counts per minute (cpm).

<CENTER>net cpm = (cpm with influenza components)
? (cpm with media alone)
</CENTER>Preliminary studies showed that the proliferative response of samples held overnight was not less than 80% of the response of samples run immediately (within 4 hours of blood draw).
Vitamin E Concentrations

Blood for determination of vitamin E concentrations was collected in serum SST-Gel Clot Activator Vacutainer Tubes. Serum was separated, frozen, and shipped on dry ice for analysis by Craft Technologies, Inc. (Wilson, NC). High-performance liquid chromatography was used to identify and quantitate α-tocopherol using modifications of methods.<SUP>[37]</SUP> Serum vitamin E concentrations were determined and compared by normalizing the concentration to the total lipid (from the clinical chemistries) in the serum, because vitamin E is a lipid-soluble nutrient.
Statistical Analysis

Sample size determinations were based on the days of infection as described in a previous study.<SUP>[4]</SUP> By extracting midpoints of line segments of that study's figure, the number of days of URTI was determined to be 48 days with a standard deviation (SD) of 17 (the previous study reported a SD of approximately 6). The current study was different in that subjects were followed for 6 months (during cold and influenza season), versus 12 months in the previous study. Using the more conservative variance estimation, a sample size of 48 (24/group) would have 80% power to detect a 30% difference in mean days of symptoms of infections using a two-group t test with a .05 two-sided significance level.
The days with symptoms of URTI and several other variables were not normally distributed or ordinal in nature; therefore, the Wilcoxon rank sum test was used for analysis. Categorical variables with more than two categories, such as ethnicity and reason for exit, were analyzed using the chi-square test. Categorical variables with only two categories, such as sex and questions with yes/no responses, were analyzed using Fisher exact test. Variables that approximated a normal distribution, such as age, height, weight, BMI, NHQ total score, clinical chemistries, hematology (except for platelets and differential), log of influenza antibody, and α-tocopherol, were analyzed using the two-sample t test at each time point.
Subjects completing the 183 days of study were classified as study completers. All enrolled subjects were evaluated in an intent-to-treat analysis. Results from this group were also evaluated at each time point with all available data. (Individuals who dropped from the study did not provide follow-up blood samples. Nor were URTI symptom data collected from the time the subjects stopped consuming the assigned formula.) Results were considered statistically different at the two-tailed 0.05 alpha level. Statistical analysis was performed with SAS statistical software (SAS Institute, Inc., Cary, NC).

Results

Sixty-six subjects were enrolled in the trial. Twenty-three of the 32 subjects in the control group and 25 of the 34 subjects in the experimental group were still participating in the study at the Day 57 blood draw. Eighteen subjects in the control group and 16 subjects in the experimental group completed the trial and were designated study completers. The number of subjects who dropped from the study was not different between groups. Formula-related reasons for withdrawing were as follows: taste (one control, one experimental), gastrointestinal cramping (one experimental), diarrhea (one control), flatulence (one control, one experimental), vomiting (one experimental), and weight gain (four experimental). Three subjects were withdrawn from the study because of a suspected food-drug interaction between the protein concentration in the control and experimental formulas and the anti-Parkinson medication carbidopa-levodopa.<SUP>[38]</SUP> One 95-year-old subject in the control group died of natural causes. Three subjects were withdrawn after they relocated after a stroke (one control, one experimental) or fall (one experimental). Fourteen subjects asked to be discontinued from the study for unspecified reasons (eight control, six experimental). In addition, because of technical problems or the unavailability of a subject due to a family emergency (one experimental), not all laboratory data were available for all subjects at all time points.
Average BMI was not different in the experimental and control groups at baseline (Table 2) or over the course of the study for all subjects (intent-to-treat) or study completers. Additionally, mean weight change and mean change in BMI were not different between the experimental and control groups over the course of the study for the intent-to-treat subjects or study completers (data not shown). The most frequent reason for withdrawing from the study was unwanted weight gain. One subject in the experimental group asked to be taken off the study when a weight gain of 3.6 kg (5.5% above baseline weight) occurred over the first 8 weeks of supplementation. At one assisted living facility, the staff physician removed all his subjects from the study because of weight gain. These subjects, all in the experimental group, gained an average of 6.1?1.2 kg (8.6%?2.1% above baseline) over the first 11 weeks.
There were no differences in age, number of subjects who resided in assisted living facilities, or sex between the control and experimental groups for study completers and intent-to-treat subjects (Table 2). Health status, serum albumin (Table 2), NHQ responses, lymphocyte count, and total lipids (data not shown) were not different between the experimental and control groups for study completers and intent-to-treat subjects at any time point. Twelve of the 34 study completers (35%) and 29 of the 66 (44%) intent-to-treat subjects took a multivitamin/mineral supplement before baseline; this was not different between study groups.
The α-tocopherol/total lipid ratio (?1,000) was 5.95?0.35, 5.43?0.41, and 4.09?0.23 of study completers fed control formula and 5.27?056, 6.91?0.43, and 6.08?0.33 of study completers fed experimental formula at baseline, postvaccination, and final blood draws, respectively. There were no differences in baseline α-tocopherol/lipid ratio or α-tocopherol concentrations between groups (data not shown) for the study completers or intent-to-treat subjects (data not shown). The subjects who were fed the experimental formula achieved a higher mean serum α-tocopherol concentration and α-tocopherol/lipid ratio at postvaccination (study completers) and final blood draws (study completers and intent-to-treat) than the subjects who were fed control formula (P=.019).
The median days with cold and influenza symptoms per subject who completed the study were 3 (range 0-69) for subjects fed the control formula and 0 (range 0-49, P=.049, Figure 1) for subjects fed the experimental formula. For intent-to-treat subjects, median days with symptoms per subject were 1 (range 0-69) in the control group and 0 (range 0-49, P=.076) in the experimental group. Of the study completers, 13 of 18 subjects fed the control formula recorded a total of 156 days of symptoms, whereas six of 16 subjects fed the experimental formula recorded a total of 78 days of symptoms (P=.08). For the intent-to-treat subjects, 16 of 29 subjects fed the control formula recorded a total 172 days of symptoms, whereas nine of 30 subjects fed the experimental formula recorded 115 days of symptoms (P=.07).

<TABLE cellSpacing=1 cellPadding=3 width=410 align=center bgColor=#eeeeee border=0><TBODY><TR vAlign=top><TD width="15%"></TD><TD>Figure 1. (click image to zoom) For the study completers, median days with symptoms per subject were 3 (range 0-69) in the control group and 0 (range 0-49, P=.049) in the experimental group; 13 of 18 subjects in the control group recorded a total of 156 days of symptoms, and six of 16 subjects in the experimental group recorded a total of 78 days of symptoms (P=.08).

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The number of new infection episodes in study completers included 17 fed the control formula and 13 fed the experimental formula (P=.24). Eight subjects accounted for 17 new infections in the control group, and four subjects accounted for 13 new infection episodes in the experimental group. Nine of the new infections in the experimental group were from a single subject who was diagnosed during the study with swallowing problems resulting in frequent aspiration.
Antibody titers to each of the three components of the influenza vaccine were measured at baseline, postvaccination, and final blood draws. The percentage of subjects with protective influenza antibody titers (>/=40 HI units) at any time for any of the three vaccine components was not different between the control and experimental groups for study completers or intent-to-treat subjects. However, of all 66 participants, fewer subjects (P=.010) had a protective titer at baseline to the A/Beijing component of the vaccine (n=31) than to A/Sydney (n=45) or B/Yamanashi (n=65) (Figure 2).

<TABLE cellSpacing=1 cellPadding=3 width=410 align=center bgColor=#eeeeee border=0><TBODY><TR vAlign=top><TD width="15%"></TD><TD>Figure 2. (click image to zoom) Geometric mean antibody titer with 95% confidence limits shown as error bars to the three components of the influenza vaccine at baseline (Day 0), 42 days postvaccination (Day 57), and final (Day 183) blood draws for study completers in the control (white bars) and experimental groups (black bars), *P=.052 for experimental versus control for corresponding day.

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For subjects completing the study, there was a trend toward greater geometric mean antibody titer in the experimental group than in the control group for A/Beijing at the postvaccination time point (Day 57) in study completers (P=.052) (Figure 2). For intent-to-treat subjects, there were no significant differences in geometric mean titers between the control and experimental groups for any of the three vaccine components (data not shown).
The percentage of subjects who responded to A/Beijing as indicated as a fourfold increase in antibody titer at the postvaccination time point was higher for the experimental than the control groups for study completers (13 of 15 or 87% vs 7 of 17 or 41%; P=.012) and intent-to-treat subjects (17 of 23 or 74% vs 7 of 21 or 33%; P=.014). No differences were observed between the experimental and control groups in percentage of subjects who responded to A/Sydney and B/Yamanashi postvaccination or to any of the vaccine components at the final blood draw for study completers or intent-to-treat subjects (data not shown).
Thirteen of 15 (87%) subjects in the experimental group of the study completers had an influenza antibody titer of 40 or greater and a fourfold increase in antibody titer at the postvaccination blood draw for A/Beijing. By contrast, six of 17 (35%) subjects in the control group showed similar changes (P=.004). Similarly, 17 of 23 (74%) subjects in the experimental group and six of 21 (29%) subjects in the control group in the intent-to-treat analysis had an influenza antibody titer of 40 or greater and a fourfold increase in antibody titer at the postvaccination blood draw for A/Beijing (P=.005). No differences in these combined antibody measurements were observed between the experimental and control groups for the other two vaccine components in study completers or intent-to-treat subjects (data not shown).
Lymphocyte proliferative responses to vaccine components were measured at baseline, postvaccination, and final blood draws. Proliferation was significantly greater in the experimental group than the control group at the postvaccination blood draw (P=.013) (Figure 3) but not at baseline or final blood draws for study completers and intent-to-treat subjects (data not shown).

<TABLE cellSpacing=1 cellPadding=3 width=410 align=center bgColor=#eeeeee border=0><TBODY><TR vAlign=top><TD width="15%"></TD><TD>Figure 3. (click image to zoom) Lymphocyte proliferation to vaccine components at the postvaccination blood draw. The median proliferative response (denoted by the line on each dot plot) was significantly greater in the experimental group than control group (study completers (<SUP>*</SUP>P=.013) represent 16 controls and 15 experimental subjects; intent-to-treat (<SUP>?</SUP>P=.022) represents 20 control and 23 experimental subjects). Proliferation is expressed as net counts per minute (cpms) after lymphocytes were stimulated with the same lot of vaccine and pulsed with tritiated thymidine. Cpms were measured using a scintillation counter detecting the incorporated tritiated thymidine in lymphocytes.

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Clinical chemistry and hematology measurements were determined at baseline and final blood draws. Mean clinical chemistry and hematology measurements for all groups and at all time points were within normal ranges, with the exception of total cholesterol. Study completers had a total cholesterol of 5.6?0.3 mmol/L (218?12 mg/dL) and 4.8? 0.2 mmol/L (186?8 mg/dL) at baseline in the control and experimental groups, respectively (P=.040), with 5.5?0.3 mmol/L (213?13 mg/dL) and 4.9?0.1 mmol/L (188?6 mg/dL) at the final blood draw in the control and experimental groups, respectively (P=.09). Total cholesterol was not different between groups at either time point for intent-to-treat subjects.
Gastrointestinal symptoms were evaluated as a measure of oral tolerance. There were no differences in gastrointestinal intolerance between subjects drinking the control and experimental formulas.

<TABLE cellSpacing=0 cellPadding=0 width=570 border=0><TBODY><TR><TD><TABLE cellSpacing=0 cellPadding=0 width=570 border=0><TBODY><TR vAlign=top><TD width=570>Discussion

The purpose of this study was to determine whether supplementing the diet of relatively healthy independent- and assisted-living seniors with a formula containing nutrients known to enhance immune function could reduce days of symptoms of URTI during cold and influenza season. It was found that subjects consuming the experimental nutritional formula had significantly fewer days of symptoms of URTI, better antibody response to influenza A/Beijing (H1N1), and greater lymphocyte proliferative response to influenza vaccine components postimmunization than control subjects.
Seniors are a heterogeneous population with respect to nutrient needs; therefore, subjects were stratified before randomization based on age, sex, and NHQ scores.<SUP>[32]</SUP> Nutritional status was not different between groups based on baseline BMI and serum albumin (Table 2). Mean BMI and serum albumin indicated that subjects were normal to slightly overweight with adequate protein status (Table 2). Although median nutrition scores for the NHQ showed good nutritional status for subjects in the control and experimental groups, there were subjects who scored at high nutritional risk within each group.
It is not uncommon for apparently healthy elderly populations with normal body weight and protein nutriture to have micronutrient deficiencies that impair immune function.<SUP>[6,8,39]</SUP> In a population of healthy independent-living subjects aged 90 and older, one study showed that the prevalence of micronutrient deficiency was highest for selenium, vitamin B<SUB>6</SUB>, and zinc, followed by vitamin A, and to a lesser extent, folate, vitamin E, and vitamin B<SUB>12</SUB>.<SUP>[39]</SUP> Another study found that, in apparently healthy, independently living subjects aged 59 to 85, zinc deficiency was common, whereas deficiency in β-carotene, ascorbate, and α-tocopherol was less common.<SUP>[6]</SUP>
Nutrient supplementation in excess of the dietary reference intakes modulates immune function in seniors. When the diet of healthy seniors who had normal serum vitamin E concentrations was supplemented for 4 months with four times greater (60 mg/d), 13 times greater (200 mg/d), and 53 times greater (800 mg/day) vitamin E levels than the current recommended dietary allowance (RDA),<SUP>[40]</SUP> serum vitamin E concentrations were greater than with placebo, and delayed-type hypersensitivity and antibody titers to hepatitis B were enhanced.<SUP>[7]</SUP> Optimal enhancement of immune parameters was observed with 200 mg/d vitamin E.<SUP>[7]</SUP>
In the current study, to meet the diverse nutrient needs of an elderly population, an experimental nutritional formula containing 360 kcal/237 mL and 13 g of protein plus vitamins, minerals, antioxidants, fructo-oligosaccharides, and structured triacylglycerol was formulated. Vitamins and minerals (zinc, selenium, α-tocopherol, vitamin C, and B vitamins) with known immune-enhancing properties in seniors were added at concentrations exceeding the dietary reference intakes.<SUP>[2,7,8,19,27,41]</SUP> The experimental formula may have been of benefit to subjects for different reasons; for example, one subject might have benefited from the zinc, whereas another might have benefited from the elevated concentrations of vitamin E, selenium, or other nutrients included in the formula. Another benefit of the experimental formula could have come from the structured triacylglycerol, which may have increased the absorption of fat-soluble nutrients important for immune function.<SUP>[30]</SUP> The design of the study does not allow for the identification of individual components but demonstrates an immune benefit of the combination of vitamins, minerals, structured triacylglycerol, and protein.
Serum α-tocopherol concentrations were measured at baseline, postvaccination, and final blood draws as an indication of compliance. Many of the subjects recruited for the study reported frequently taking vitamin E-containing multivitamin and mineral supplements before the study. On study Day 0, subjects were asked to discontinue any supplements and were given the study supplement along with a low-potency multivitamin/mineral supplement to consume daily (Table 1). The lack of a washout period before baseline may explain the elevated α-tocopherol concentrations. Average baseline α-tocopherol concentrations ranged from 33 to 46 ?mol/L (1.4-2.0 mg/dL) and were greater than the baseline concentrations of 25 to 27 ?mol/L reported by others.<SUP>[7]</SUP> Rise in serum α-tocopherol concentrations and self-reported formula intake by subjects in the experimental group suggest good compliance for study completers.
A possible limitation of this study is that nutrient deficiencies may have occurred in the control group because subjects were asked to discontinue dietary supplements and consumed the control formula in place of items in their diet. However, this is not likely, because all subjects were given a low-potency multivitamin/mineral tablet daily that provided more than one-third of the RDA or adequate intake for vitamins A, D, C, B<SUB>6</SUB>, and B<SUB>12</SUB>, thiamine, riboflavin, pantothenic acid, and copper.
Another potential limitation of this study is the high dropout rate. Previous studies in seniors that administered a single-nutrient or multivitamin/mineral supplement and examined immune function reported a dropout rate in the range of 11% to 30% for 4 months to 2 years.<SUP>[6-8]</SUP> Unlike these previous studies that provided the nutrients in pill form, the experimental and control formulas in the present study were provided in the form of an 8-ounce liquid drink containing energy and protein in addition to the added micronutrients. Fourteen of the 32 subjects were withdrawn or dropped from the study for formula-related issues such as gastrointestinal problems (n=7), suspected protein-drug interactions (n=3), and weight gain (n=4). These additional formula-related concerns are not a problem with a micronutrient pill.
Four subjects in the experimental group dropped out because of unwanted weight gain. In a frail elderly population in which unintentional weight loss and undernutrition are a common problem, a nutritional supplement that produced weight gain would be a benefit, but there may be concern that increased body weight may suppress immune function.<SUP>[42]</SUP> To this end, antibody response (influenza antibody titer >/=40 and >/=fourfold increase in influenza antibody titer) in the intent-to-treat subjects with a BMI of less than 25 was compared between groups. In the subjects with BMI of less than 25, 12 of 13 (92%) subjects consuming the experimental formula responded to influenza vaccination, but only four of 14 (29%) of those consuming the control formula responded (P=.034), indicating a benefit beyond providing energy and extra protein, which is a common practice in nursing homes. In the intent-to-treat subjects with a BMI of 25 or greater, five of 10 subjects (50%) in the experimental group and two of seven (29%) in the control group responded to the vaccine, indicating that even elderly people with BMIs of 25 or greater (low risk of malnutrition) received immunological benefit from the experimental formulation.
Higher postvaccination antibody titers for the A/Beijing component of the vaccine were only observed in subjects consuming the experimental formula. Subjects in this study appeared to have protective antibody titers to A/Sydney and B/Yamanashi at baseline, making it difficult to determine formula-related differences with these components (Figure 2). Published evidence has shown that higher baseline antibody titers correlate with smaller increases in anti-influenza type-specific responses after vaccination.<SUP>[43]</SUP> Therefore, it is likely that a low baseline A/Beijing antibody concentration facilitated its use as an immunological marker of immune function and an opportunity to evaluate the immunological benefit of an experimental nutritional formula. Similarly, investigators in one study fed a complete nutritional supplement or a noncaloric placebo drink to seniors for 6 months and then vaccinated the subjects against influenza.<SUP>[44]</SUP> Seniors consuming the supplement experienced a larger mean increase in antibodies against A/Sydney than the control group, whereas there was no difference for the other two components. Clinical outcomes were not measured in another study.<SUP>[44]</SUP> The current study used the response to vaccination as a marker of immune function, using the conventional measurement (a fourfold increase in antibody or a postvaccine titer of 40 or greater) and found a difference in antibody response for one component. A clinically meaningful difference between the experimental and control groups (reduction in the number of days of symptoms of URTI) was also found.
Several published reports have described the effect of nutrient intake on immune parameters, but few studies have related nutrient intake to changes in immune function and clinical outcomes in seniors. Noteworthy findings of this study included the enhancement of humoral and cell-mediated immune markers (greater antibody response to the A/Beijing component of the influenza vaccine, increased proliferative response to the entire influenza vaccine), together with a clinically relevant reduction in total days of URTI symptoms in study completers consuming the experimental formula. These data suggest a strengthening of the immune system of seniors fed the experimental formula. Because antibody titers and lymphocyte proliferation to influenza vaccine components were higher in subjects consuming the experimental formula, it is possible that the fewer days of URTI symptoms were due to influenza infections, but no attempt was made to identify symptom-causing agents, and influenza is only one of several pathogens capable of producing acute URTI symptoms noted in this study.<SUP>[45]</SUP>
In conclusion, this is one of the first studies to demonstrate a clinically meaningful benefit of a complete nutritional formula on the immune system of independent- and assisted-living seniors. In an elderly population, in which only 30% to 70% of those vaccinated are likely to be protected from hospitalization due to influenza, it may be possible to modulate immune function and ultimately reduce URTI symptoms with nutritional supplementation.
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Acknowledgements
The authors would like to thank David Scholl, Maria Del Carmen Soler, and Laura Moffatt, study coordinators; Suzanne Monnin, project manager; David Wahrenberger, statistician; John McEwen and J. Mike Simpson, product development; and Amy Marchio, flavor development. We would also like to thank Sophia Li and the nurses, staff, and subjects at the assisted-living and independent-living facilities. Without their hard work and effort this study would not have been possible. This is a Florida Agricultural Experiment Station Journal Series, Number R-08403.

Reprint Address
Correspondence Address correspondence to Bobbi Langkamp-Henken, PhD, Food Science and Human Nutrition Department, PO Box 110370, Gainesville, FL 32605. E-mail: RJHenken@<span style="color:#0000ff"...ufl.edu</span>

References for:
Nutritional Formula Enhanced Immune Function and Reduced Days of Symptoms of Upper Respiratory Tract Infection in Seniors

[J Am Geriatr Soc 52(1):3-12, 2004. ? 2004 Blackwell Publishing]
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Kawakami K, Kadota J, Iida K et al. Reduced immune function and malnutrition in the elderly. Tohoku J Exp Med 1999;187: 157-171.
Meydani SN, Ribaya-Mercado JD, Russell RM et al. Vitamin B-6 deficiency impairs interleukin 2 production and lymphocyte proliferation in elderly adults. Am J Clin Nutr 1991;53: 1275-1280.
Chandra RK, Joshi P, Au B et al. Nutrition and immunocompetence of the elderly: Effect of short-term nutritional supplementation on cell-mediated immunity and lymphocyte subsets. Nutr Res 1982;2: 223-232.
Chandra RK. Effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects. Lancet 1992;340: 1124-1127.
Chandra RK, Puri S. Nutritional support improves antibody response to influenza virus vaccine in the elderly. BMJ 1985;291: 705-706.
Bogden JD, Bendich A, Kemp FW et al. Daily micronutrient supplements enhance delayed-hypersensitivity skin test responses in older people. Am J Clin Nutr 1994;60: 437-447.
Meydani SN, Meydani M, Blumberg JB et al. Vitamin E supplementation and in vivo immune response in healthy elderly subjects. A randomized controlled trial. JAMA 1997;277: 1380-1386.
Girodon F, Galan P, Monget AL et al. Impact of trace elements and vitamin supplementation on immunity and infections in institutionalized elderly patients: A randomized controlled trial. Arch Intern Med 1999;159: 748-754.
Bernstein ED, Gardner EM, Abrutyn E et al. Cytokine production after influenza vaccination in a healthy elderly population. Vaccine 1998;16: 1722-1731.
Murasko DM, Nelson BJ, Silver R et al. Immunological response in an elderly population with a mean age of 85. Am J Med 1986;81: 612-618.
Thoman ML, Weigle WO. The cellular and subcellular bases of immunosenescence. Adv Immunol 1989;46: 221-261.
Hallgren HM, Bergh N, Rodysill KJ et al. Lymphocyte proliferative response to PHA and anti-CD3/Ti monoclonal antibodies, T cell surface marker expression, and serum IL-2 receptor levels as biomarkers of age and health. Mech Ageing Dev 1988;43: 175-185.
Moulias R, Devillechabrolle A, Lesourd B et al. Respective roles of immune and nutritional factors in the priming of the immune response in the elderly. Mech Ageing Dev 1985;31: 123-137.
Sprenger MJ, Mulder PG, Beyer WE et al. Impact of influenza on mortality in relation to age and underlying disease, 1967-89. Int J Epidemiol 1993;22: 334-340.
Nicholson KG, Kent J, Hammersley V et al. Acute viral infections of upper respiratory tract in elderly people living in the community: Comparative, prospective, population based study of disease burden. BMJ 1997;315: 1060-1064.
Falsey AR, Cunningham CK, Barker WH et al. Respiratory syncytial virus and influenza A infections in the hospitalized elderly. J Infect Dis 1995;172: 389-394.
Ludovici PP, Axelrod AE. Circulating antibodies in vitamin-deficiency states. Pteroylglutamic acid, niacin-tryptophan, vitamins B12, A and D deficiencies. Proc Soc Exp Biol Med 1951;77: 526-530.
Graat JM, Schouten EG, Kok FJ. Effect of daily vitamin E and multivitamin-mineral supplementation on acute respiratory tract infections in elderly persons: A randomized controlled trial. JAMA 2002;288: 715-721.
Fortes C, Forastiere F, Agabiti N et al. The effect of zinc and vitamin A supplementation on immune response in an older population. J Am Geriatr Soc 1998;46: 19-26.
Pallast EG, Schouten EG, de Waart FG et al. Effect of 50- and 100-mg vitamin E supplements on cellular immune function in noninstitutionalized elderly persons. Am J Clin Nutr 1999;69: 1273-1281.
Moore RJ, Friedl KE, Tulley RT et al. Maintenance of iron status in healthy men during an extended period of stress and physical activity. Am J Clin Nutr 1993;58: 923-927.
Shippee R. Physiological and immunological impact of U.S. Army special operations training: A model for the assessment of nutritional intervention effects on temporary immunosuppression. In: Food and Nutrition Board IoM, Committee on Military Nutrition Research ed. Military Strategies for Sustainment and Nutrition and Immune Function in the Field. Washington, DC: National Academy Press, 1999, pp 163-184.
Bernton E, Hoover D, Galloway R et al. Adaptation to chronic stress in military trainees. Adrenal androgens, testosterone, glucocorticoids, IGF-1, and immune function. Ann N Y Acad Sci 1995;774: 217-231.
Lee DJ, Meehan RT, Robinson C et al. Immune responsiveness and risk of illness in U.S. Air Force Academy cadets during basic cadet training. Aviat Space Environ Med 1992;63: 517-523.
Wood SM, Beckham C, Yosioka A et al. Beta-carotene and selenium supplementation enhances immune response in aged humans. Integr Med 2000;21: 85-92.
Bogden JD. Studies on micronutrient supplements and immunity in older people. Nutr Rev 1995;53: S59-S64.
Delafuente JC, Prendergast JM, Modigh A. Immunologic modulation by vitamin C in the elderly. Int J Immunopharmacol 1986;8: 205-211.
Niness KR. Inulin and oligofructose: What are they? J Nutr 1999;129: 1402S-1406S.
Bornet FR, Brouns F. Immune-stimulating and gut health-promoting properties of short-chain fructo-oligosaccharides. Nutr Rev 2002;60: 326-334.
Tso P, Lee T, DeMichele SJ. Randomized structured triglycerides increase lymphatic absorption of tocopherol and retinol compared with the equivalent physical mixture in a rat model of fat malabsorption. J Nutr 2001;131: 2157-2163.
DeMichele SJ, Bistrian BR. Structured triacylglycerols in clinical nutrition. In: Mansbach CM, Tso P, Kuksis A, eds. Intestinal Lipid Metabolism. New York: Kluwer Academic/Plenum Publishers, 2001, pp 403-419.
Posner BM, Jette AM, Smith KW et al. Nutrition and health risks in the elderly. The Nutrition Screening Initiative. Am J Public Health 1993;83: 972-978.
Gardner EM, Bernstein ED, Dran S et al. Characterization of antibody responses to annual influenza vaccination over four years in a healthy elderly population. Vaccine 2001;19: 4610-4617.
Rastogi S, Gross PA, Bonelli J et al. Time to peak serum antibody response to influenza vaccine. Clin Diagn Lab Immun 1995;2: 120-121.
Levine M, Beattie BL, McLean DM et al. Characterization of the immune response to trivalent influenza vaccine in elderly men. J Am Geriatr Soc 1987;35: 609-615.
Kendal A, Pereira M, Skehel J. Concepts and Procedures for Laboratory-Based Influenza Surveillance: The Hemagglutination Inhibition Test for Influenza Viruses. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1982.
Nomura AM, Stemmermann GN, Lee J et al. Serum micronutrients and prostate cancer in Japanese Americans in Hawaii. Cancer Epidemiol Biomarkers Prev 1997;6: 487-491.
Pincus JH, Barry KM. Dietary method for reducing fluctuations in Parkinson's disease. Yale J Biol Med 1987;60: 133-137.
Ravaglia G, Forti P, Maioli F et al. Effect of micronutrient status on natural killer cell immune function in healthy free-living subjects aged >/=90 y. Am J Clin Nutr 2000;71: 590-598.
Food and Nutrition Board Institute of Medicine. Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Washington, DC: National Academy Press, 2000.
Meydani SN, Barklund MP, Liu S et al. Vitamin E supplementation enhances cell-mediated immunity in healthy elderly subjects. Am J Clin Nutr 1990;52: 557-563.
Samartin S, Chandra RK. Obesity, overnutrition and the immune system. Nutr Res 2001;21: 243-262.
Bernstein E, Kaye D, Abrutyn E et al. Immune response to influenza vaccination in a large healthy elderly population. Vaccine 1999;17: 82-94.
Wouters-Wesseling W, Rozendaal M, Snijder M et al. Effect of a complete nutritional supplement on antibody response to influenza vaccine in elderly people. J Gerontol A Biol Sci Med Sci 2002;57A: M563-M566.
Falsey AR, McCann RM, Hall WJ et al. Acute respiratory tract infection in daycare centers for older persons. J Am Geriatr Soc 1995;43: 30-36.
Food and Nutrition Board Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press, 1997.
Food and Nutrition Board Institute of Medicine. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin and Choline. Washington, DC: National Academy Press, 1998.
Food and Nutrition Board Institute of Medicine Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press, 2001.

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**Shannon Bennett** · January 4, 2007, 12:23 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

Here is the ressearch to which I was referring. We obviously need to focus on improved nutrition in our elderly. And, I strongly suspect that the minimum daily requirement studies done for vitamins do not meet the needs of our geriatrics.

Post # 19 in the Research thread on the Traditional and Alternative Medicine Forum. http://www.flutrackers.com/forum/showthread.php?t=5632

Effect of micronutrient supplementation on infection in institutionalized elderly subjects: a controlled trial.

Girodon F, Lombard M, Galan P, et al.

Ann Nutr Metab. 1997; 41(2):98-107.

To determine the impact of a trace element and vitamin supplementation on infectious morbidity, a double-blind controlled trial was performed on 81 elderly subjects in a geriatric center during a 2-year period. Subjects were randomly assigned to one of four treatment groups, and received daily: placebo; trace elements/zinc 20 mg; selenium 100 micrograms); vitamins (vitamin C 120 mg; beta-carotene 6 mg; alpha-tocopherol 15 mg); or a combination of trace elements and vitamins at equal doses. (1) Before supplementation, low serum values in vitamin C, folate, zinc and selenium were observed in more than two thirds of the patients. (2) After 6 months of supplementation, a significant increase in vitamin and trace element serum levels was obtained in the corresponding treatment groups: a plateau was then observed for the whole study. (3) Subjects who received trace elements (zinc and selenium) alone or associated with vitamins had significantly less infectious events during the 2 years of supplementation. These results indicate that supplementation with low doses of vitamins and trace elements is able to rapidly correct corresponding deficiencies in the institutionalized elderly. Moreover, zinc and selenium reduced infectious events

Impact of trace elements and vitamin supplementation on immunity and infections in institutionalized elderly patients: a randomized controlled trial. MIN. VIT. AOX. geriatric network.

Girodon F, Galan P, Monget AL, et al.

Arch Intern Med. 1999 Apr 12; 159(7):748-54.

BACKGROUND: Antioxidant supplementation is thought to improve immunity and thereby reduce infectious morbidity. However, few large trials in elderly people have been conducted that include end points for clinical variables. OBJECTIVE: To determine the effects of long-term daily supplementation with trace elements (zinc sulfate and selenium sulfide) or vitamins (beta carotene, ascorbic acid, and vitamin E) on immunity and the incidence of infections in institutionalized elderly people. METHODS: This randomized, double-blind, placebo-controlled intervention study included 725 institutionalized elderly patients (>65 years) from 25 geriatric centers in France. Patients received an oral daily supplement of nutritional doses of trace elements (zinc and selenium sulfide) or vitamins (beta carotene, ascorbic acid, and vitamin E) or a placebo within a 2 x 2 factorial design for 2 years. MAIN OUTCOME MEASURES: Delayed-type hypersensitivity skin response, humoral response to influenza vaccine, and infectious morbidity and mortality. RESULTS: Correction of specific nutrient deficiencies was observed after 6 months of supplementation and was maintained for the first year, during which there was no effect of any treatment on delayed-type hypersensitivity skin response. Antibody titers after influenza vaccine were higher in groups that received trace elements alone or associated with vitamins, whereas the vitamin group had significantly lower antibody titers (P<.05). The number of patients without respiratory tract infections during the study was higher in groups that received trace elements (P = ".06)." Supplementation with neither trace elements nor vitamins significantly reduced the incidence of urogenital infections. Survival analysis for the 2 years did not show any differences between the 4 groups. CONCLUSIONS: Low-dose supplementation of zinc and selenium provides significant improvement in elderly patients by increasing the humoral response after vaccination and could have considerable public health importance by reducing morbidity from respiratory tract infections

The effectiveness of vitamin C in preventing and relieving the symptoms of virus-induced respiratory infections.

Gorton HC, Jarvis K.

J Manipulative Physiol Ther. 1999 Oct; 22(8):530-3.

BACKGROUND: An ever increasing demand to evaluate the effect of dietary supplements on specific health conditions by use of a "significant scientific" standard has prompted the publication of this study. OBJECTIVE: To study the effect of megadose Vitamin C in preventing and relieving cold and flu symptoms in a test group compared with a control group. DESIGN: Prospective, controlled study of students in a technical training facility. SUBJECTS: A total of 463 students ranging in age from 18 to 32 years made up the control group. A total of 252 students ranging in age from 18 to 30 years made up the experimental or test group. METHOD: Investigators tracked the number of reports of cold and flu symptoms among the 1991 test population of the facility compared with the reports of like symptoms among the 1990 control population. Those in the control population reporting symptoms were treated with pain relievers and decongestants, whereas those in the test population reporting symptoms were treated with hourly doses of 1000 mg of Vitamin C for the first 6 hours and then 3 times daily thereafter. Those not reporting symptoms in the test group were also administered 1000-mg doses 3 times daily. RESULTS: Overall, reported flu and cold symptoms in the test group decreased 85% compared with the control group after the administration of megadose Vitamin C. CONCLUSION: Vitamin C in megadoses administered before or after the appearance of cold and flu symptoms relieved and prevented the symptoms in the test population compared with the control group
Antimicrobial properties of Allium sativum (garlic).

Harris JC, Cottrell SL, Plummer S, et al.

Appl Microbiol Biotechnol. 2001 Oct; 57(3):282-6.

Although garlic has been used for its medicinal properties for thousands of years, investigations into its mode of action are relatively recent. Garlic has a wide spectrum of actions; not only is it antibacterial, antiviral, antifungal and antiprotozoal, but it also has beneficial effects on the cardiovascular and immune systems. Resurgence in the use of natural herbal alternatives has brought the use of medicinal plants to the forefront of pharmacological investigations, and many new drugs are being discovered. This review aims to address the historical use of garlic and its sulfur chemistry, and to provide a basis for further research into its antimicrobial properties

[Preventive action of an immunomodulator on respiratory infections in elderly subjects].

Hugonot R, Gutierrez LM, Hugonot L.

Presse Med. 1988 Jul 27; 17(28):1445-9.

Three hundred and fourteen elderly subjects admitted to chronic medical centers were given either RU 41740 (n = 155) or a placebo (n = 159) at the rate of one course per month during three months. RU 41740 was administered in doses of 2 mg per day during 8 days in the first course and 1 mg per day during 8 days in the second and third courses. The subjects were followed up and regularly examined every three months for one year. The incidence of acute infectious episodes was evaluated in both groups. Compared to those patients who received the placebo, the number of subjects without infection was significantly higher in the treated group during the 0-6 months and the 0-9 months periods and during the 12 months of observation. The number of infectious episodes was reduced during the 0-3 months and 0-9 months periods and throughout the 12 months of the trial. The mean duration of pulmonary infections that occurred during the 0-6 and 0-9 months periods was reduced. Finally, there was a significant decrease in the duration of antibiotic therapy during the 0-3, 0-6, 0-9 months periods and during the 12 months of observation. The drug was well tolerated. This study showed that RU 41740 is effective in protecting elderly and therefore fragile subjects against respiratory infections

**Mingus** · January 4, 2007, 12:58 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

Originally posted by Shannon

We obviously need to focus on improved nutrition in our elderly.

Yes,

Sadly they keep the exact formulation secret but we have strong clue here of what it is.

It is not uncommon for apparently healthy elderly populations with normal body weight and protein nutriture to have micronutrient deficiencies that impair immune function.<SUP>[6,8,39]</SUP>
<SUP>(...)</SUP>
When the diet of healthy seniors who had normal serum vitamin E concentrations was supplemented for 4 months with four times greater (60 mg/d), 13 times greater (200 mg/d), and 53 times greater (800 mg/day) vitamin E levels than the current recommended dietary allowance (RDA),<SUP>[40]</SUP> serum vitamin E concentrations were greater than with placebo, and delayed-type hypersensitivity and antibody titers to hepatitis B were enhanced.<SUP>[7]</SUP> Optimal enhancement of immune parameters was observed with 200 mg/d vitamin E.<SUP>[7]</SUP>
In the current study, to meet the diverse nutrient needs of an elderly population, an experimental nutritional formula containing 360 kcal/237 mL and 13 g of protein plus vitamins, minerals, antioxidants, fructo-oligosaccharides, and structured triacylglycerol was formulated. Vitamins and minerals (zinc, selenium, α-tocopherol, vitamin C, and B vitamins) with known immune-enhancing properties in seniors were added at concentrations exceeding the dietary reference intakes.<SUP>[2,7,8,19,27,41]</SUP>

A good way to reduce mortality & morbidity should be to find that exact formula & diffuse it trought the internet

Since it have a double blind controlled trial to back it up, the medical staffs can readily use it & promote it.

**Anne** · January 4, 2007, 01:07 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes.

wonderfull

Zn acts with lymphocytes and fibroblasts, it seems to me. ( Zn enhance immunity in elderly , cicatrisation of skin )
anyone knows what are structured triacylglycerol ?

**Shannon Bennett** · January 4, 2007, 01:43 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

We imported several studies regarding the need for both zinc and selenium in humans. Evidently the research has fallen onto barren ground. It isn't only the aged that need increased amounts of these supplements, but all ages would benefit. There is a danger of taking too much selenium which in severe cases can lead to permanent damage and even death. The amount a person typically eats is in direct correlation to how much is present in the soils used for food production. It should be possible however to find an average amount in typical Western diets.

**AlaskaDenise** · January 4, 2007, 09:32 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes.

Originally posted by Anne

wonderfull

Zn acts with lymphocytes and fibroblasts, it seems to me. ( Zn enhance immunity in elderly , cicatrisation of skin )
anyone knows what are structured triacylglycerol ?

I spent considerable time last night trying to answer that question. It appears its a manufactured oil - with different length molecules. In studies it is compared with cocoa butter. It sounds to me as if they're trying to create fat-sourced calories without all the drawbacks of some fats.

It's manufacutred commercially as SALATRIM - good-fat-taste wtihout the bad fat properties.

But I'm no scientist - see http://pubs.acs.org/cgi-bin/abstract...?sessid=6006l3

.

**AlaskaDenise** · January 4, 2007, 09:36 PM

Re: Nutritional formula improved immune profiles of seniors living in nursing homes. *!*

Fructo-oligosaccharides, aka FOS, sources are: Jeruslaem artichoke tuber, chicory root, leeks, onion, garlic, oats, barley, rye

See article about benefits at:
http://www.medicinalfoodnews.com/vol01/issue6/fructo

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