Nutrition for Older people Caryl Nowson Chair Nutrition and Ageing. eplace.

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1 Nutrition for Older people Caryl Nowson Chair Nutrition and Ageing eplace.jpg

2 Nutrition for Older People Optimal body weight/size for older people Nutritional requirements of older people Nutrients of concern Strategies to address nutritional inadequacies Prevention of falls and fractures

3 Learning Objectives To understand the optimal Body Mass Index range for reduced mortality for those over the age of 65 years and how this differs from younger people. To understand the importance of maintaining optimal muscle mass and the synergistic role of diet and exercise in maintaining muscle mass. To understand the nutritional challenges for older people in meeting recommended levels of dietary intake of vitamins and minerals.

4 Learning Objectives To understand the optimal Body Mass Index range for reduced mortality for those over the age of 65 years and how this differs from younger people.

Australian Health Survey:2011-12 28% (3 in 10) Australians obese 11%

8 million adults Overweight and obesity 3 rd greatest contributor to

5 Australian Health Survey: % (3 in 10) Australians obese 11% (one in 10) in % Adults overweight or obese 44% in million adults Overweight and obesity 3 rd greatest contributor to burden of disease /$FILE/NHPA_HC_Report_Overweight_and_Obesity_Report_October_2013.pdf

6 BODY MASS INDEX: BMI Indicator of healthy weight range LOWEST MORTALITY Related to height BMI =Wt (kg)/ht m 2 APPROPRIATE ADULTS YEARS

7 Optimal body Size: BMI

8 BMI Mortality Risk: >65 years Meta-analysis: 32 studies: 197,940 individuals- average follow-up 12 years Healthy Weight range for older adults BMI Lowest mortality risk BMI 27.5 mortality (5%) mortality (8%) Winter JE, Macinnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: a metaanalysis.. Am J Clin Nutr Jan 22 Healthy BMI range 18.5 to 24.9 Overweight range 25 to 29.9 Obese BMI range > 30

9 Lowest BMI Mortality Risk: >65 years Meta-analysis 12% mortality risk BMI range of 21 < 22 ( normal ) 19% mortality risk BMI range 20 < 21 Mortality risk began to increase at BMI 33 (5%) Lowest risk: BMI about 27.5: (27-29 (HR: 0.90; 95% CI: 0.88, 0.92)) For older populations, being overweight was not found to be associated with an increased risk of mortality mortality risk at the lower end of recommended BMI range Winter JE, Macinnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: a meta-analysis.. Am J Clin Nutr Jan 22

OPTIMAL BMI TO REDUCE MORTALITY RISK 60kg = 9 stone 6 llb 90kg =

5-25 woman/man 1.65m, 5ft 5in tall Range: 50-68 kg man/women 1.

Macinnis RJ, Wattanapenpaiboon N, Nowson CA.

10 OPTIMAL BMI TO REDUCE MORTALITY RISK 60kg = 9 stone 6 llb 90kg = 14 stone 2lb YEARS Healthy weight range: BMI woman/man 1.65m, 5ft 5in tall Range: kg man/women 1.82m, 6ft tall Range: kg BMI = Wt (kg)/ht m 2 Winter JE, Macinnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: a meta-analysis.. Am J Clin Nutr Jan 22 >65 YEARS Healthy weight range: BMI woman/man 1.65m, 5ft 5in tall Range: kg kg man/women 1.82m, 6ft tall Range: kg kg

11 Learning Objectives To understand the importance of maintaining optimal muscle mass and the synergistic role of diet and exercise in maintaining muscle mass. Prevention of falls and fractures

Older Australians: severe or profound core activity limitation ~1/4 experience severe core activity limitation Most reported disabling conditions 50% arthritis 43% hearing 38% hypertension, CVD 30%,

12 Older Australians: severe or profound core activity limitation ~1/4 experience severe core activity limitation Most reported disabling conditions 50% arthritis 43% hearing 38% hypertension, CVD 30%, stroke 23% core activity limitation Most significant non-fatal burden aged yrs: musculoskeletal diseases: arthritis and osteoporosis (91%) neurological conditions including dementia (87%) diabetes (65%) Severe disability: more frequent females > 80 yrs (52%) v males (34%) healthy life expectancy Aust: born 2001: boy 7 yrs with a disease or disability girl - 9 yrs with a disease or disability 2/3 older Australians rate their health as good, very good or excellent (AIHW 2011a): (view their own health in the context of their peers health and what is expected for their age)

13 Muscle Body composition changes: Ageing 33% 40% By 70 yrs: loss 40% muscle mass & corresponding strength 19% 48% 35% 25% 48% fall

14 Sarcopenia: Age-related muscle loss ageing Number of fibres (vastus lateralis muscles men (18-82yrs) From age 80, no. fibres 50% younger men type 2 muscle fibres Strength: 30% per yr >60yrs Sedentary loss and twice as high number of motor units (extensor digitorum brevis) muscles constant 5 to 50 yrs decreased linearly 95yrs Faulkner JA, et al. Age-related changes in the structure and function of skeletal muscles Clinical and Experimental Pharmacology and Physiology (2007) 34,

years frail Frailty Degenerative loss of

associated with aging Sarcopenia: component of

$Mobility disorders: falls and fractures$ death Loss of functional Independence

15 Sarcopenia Chronic Disease free-living population 6-25% : > 65 yrs frail 25 40% > 80 years frail Frailty Degenerative loss of skeletal muscle mass, quality, and strength associated with aging Sarcopenia: component of the frailty syndrome impaired state of health Mobility disorders: falls and fractures activities of daily living disabilities risk of death Loss of functional Independence Strandberg TE, Pitkala KH. Frailty in elderly people. Lancet Apr 21;369(9570):

16 Osteoporosis, Falls & Fracture

$Up to half all women and 1/3 of men will have fragility fractures in their$ $9%: 30-day mortality rate after hip fracture 17%: those with acute medical$

17 Up to half all women and 1/3 of men will have fragility fractures in their lifetime Far more people will have a fragility fracture than will have a heart attack, cancer, or stroke. 9%: 30-day mortality rate after hip fracture 17%: those with acute medical problem 43% with pneumonia 65% with heart failure

$Osteoporosis in Australia Men 2010 : 20,900 hip fractures in Australia Women with osteoporosis: 71% > 80 years Every 5-6 mins: 1 person admitted 50% of people with one fracture due to osteoporosis$

18 Osteoporosis in Australia Men 2010 : 20,900 hip fractures in Australia Women with osteoporosis: 71% > 80 years Every 5-6 mins: 1 person admitted 50% of people with one fracture due to osteoporosis will have another 1/5 of those who fracture a hip will die within 6 months Survivors: 1/2 will not be able to walk without assistance, 1/2 half need full-time nursing care women Age-specific and sex-specific incidence of radiographic vertebral,hip, and distal forearm fractures Data derived from European Prospective Osteoporosis Study7 and General Practice Research Reference Australian National Consensus Conference MJA 1997;167:S1-S

Older People, Osteoporosis: Falls, Fracture Fall Risk of Falls Inc Age Low physical activity Low body weight low lean mass Low fat mass Low vitamin D status?

19 Older People, Osteoporosis: Falls, Fracture Fall Risk of Falls Inc Age Low physical activity Low body weight low lean mass Low fat mass Low vitamin D status? Other nutrients Protein Medications Medical conditions Diabetes,Depression Low BMD Inc Age Low physical activity Low body weight Low Lean mass Lower peak bone mass Low dietary calcium intake Low vitamin D Other nutrients? Low bone mineral density Fracture Each SD below reference mean BMD fracture risk 4 times. LaFleur et al. 2001

20 What we most need is Muscle NOT MORE VISCERAL BODY FAT

21 Why more Muscle? Falls - Fracture adiposity - insulin sensitivity - Type II Diabetes adiposity - risk cardiovascular disease (CVD) J or U shaped relationship BMI cancer & CVD BMI>30 risk cancer: BMI<25 risk cancer BMI >35 risk CVD: BMI < 20 risk CVD A. Romero-Corral, V.M. Montori, V.K. Somers et al.association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies Lancet, 368 (9536) (2006), pp Parr CL et al. Body-mass index and cancer mortality in the Asia-Pacific Cohort Studies Collaboration: pooled analyses of 424,519 participants. Lancet Oncol Aug;11(8): Kricker etal. Bodyweight and other correlates of symptom-detected breast cancers in a population offered screening. Cancer Causes Control Jan;23(1):

Physical Activity and Muscle Muscle mass Exercise risk CVD risk cancer musculo-skeletal disease risk dementia cognition physical performance obesity (BMI>30) -

Physical Activity and Risk of Cognitive Impairment Among Oldest-Old Women. Am J Geriatr Psychiatry. 2013 Jul 3 Ho SC, et al.

22 Physical Activity and Muscle Muscle mass Exercise risk CVD risk cancer musculo-skeletal disease risk dementia cognition physical performance obesity (BMI>30) - adiposity risk Type II Diabetes insulin sensitivity risk low BMI (BMI <20) appetite Wang S et al. Physical Activity and Risk of Cognitive Impairment Among Oldest-Old Women. Am J Geriatr Psychiatry Jul 3 Ho SC, et al. redictors of mobility decline: the Hong Kong old-old study. J Gerontol A Biol Sci Med Sci Nov;52(6):M Fiatarone MA, ed al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med Jun 23;330(25):

23 How to keep and build muscle Keep physically Active Weight bearing exercise Progressive Resistance Training Adequate Nutrition Energy &

24 Benefits of Weight bearing activity: - mobility balance flexibility aids weight maintenance gait velocity muscle strength falls? appetite? protein retention? bone maintenance resistance training Raymond MJ, et al. Systematic review of high-intensity progressive resistance strength training of the lower limb compared with other intensities of strength training in older adults. Arch Phys Med Rehabil Aug;94(8): Multiple-component group exercise significantly reduced rate of falls (RR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise. Interventions for preventing falls in older people living in the community. Gillespie LD, et al. Cochrane Database Syst Rev Sep Silva RB et al. Exercise for Falls and Fracture Prevention in Long Term Care Facilities: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc Jul 13.

25 Protein

26 PROTEIN, FRACTURE, BONE MINERAL DENSITY(BMD): Systematic Review Fracture: 3 large studies: 2 +ve, 1 protein calcium interaction Bone Mineral Density: 11 studies: 7 +ve 2 protein calcium interaction 1 no association 1 ve association Good evidence (level III-2 to IV) older people consuming higher protein ( g/kg/d) reduced fracture & higher BMD mean protein 1.3 g/kg/d) fracture & BMD

27 Protein + Exercise

28 Protein & Muscle Mass: frail elderly 24 weeks: RCT parallel PRT + placebo OR PRT + protein (2 X15g/d) frail elderly (78 yrs) BMI ~28kg/m 2 Protein intake 1g/kg Protein grp 1.3g/kg Lean body mass protein grp 37-43% leg strength 16-18% points physical performance PRT PROGRESSIVE RESISTANCE TRAINING 1.3kg* *treatment time interaction P=.006 Frailty (Fried): unintentional weight loss, weakness, self-reported exhaustion, slow walking speed, low physical activity (1 or 2 pre-frailty, 3 or more frailty) PRT progressive resistance-type exercise program(2 sessions/wk 24 weeks) N=31 N=31 Tieland M. et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc 2012;13(8):713-9.

training enhances lean tissue mass and muscle strength and reduces circulating IL-6

29 Daly RM, O'Connell SL, Mundell NL, Grimes CA, Dunstan DW, Nowson CA. Protein-enriched diet, with the use of lean red meat, combined with progressive resistance training enhances lean tissue mass and muscle strength and reduces circulating IL-6 concentrations in elderly women: a cluster randomized controlled trial. Am J Clin Nutr Jan 29 Funded by Meat & Livestock Aust

Study Aim To investigate whether increasing dietary protein, when

intake of lean red meat (2Xday) (~80g/ (28g protein /meal), combined

30 Study Aim To investigate whether increasing dietary protein, when combined with resistance training enhanced muscle mass, strength and function in older women. Study Hypothesis Modest increase dietary protein through an increased intake of lean red meat (2Xday) (~80g/ (28g protein /meal), combined with progressive RT will lead to greater gains in muscle mass, strength and function compared to PRT Control carbohydrate diet

Key Findings 1.40 1.30 Δ* (mean ± SEM) 14wk, RCT, Twice-weekly PRT in vitamin D replete older women (mean age 72 years) (47 control v 53 protein): Protein Group (1.3 g/kg/d) 0.

3 g/kg/body weight higher dietary protein intake to induce anabolic response to resistance training 1.20 1.3 ± 0.1 g/kg/d (91g/d) g/kg/d 1.10 1.00 1.1 ± 0.

31 Key Findings Δ* (mean ± SEM) 14wk, RCT, Twice-weekly PRT in vitamin D replete older women (mean age 72 years) (47 control v 53 protein): Protein Group (1.3 g/kg/d) 0.5kg greater Increase lean mass 21% greater in leg extension strength Conclusion Older women require 1.3 g/kg/body weight higher dietary protein intake to induce anabolic response to resistance training ± 0.1 g/kg/d (91g/d) g/kg/d ± 0.1 g/kg/d (75g/d) Baseline 4 wks 8 wks 12 wks 16 wks RT + protein 40% RT + Control CHO 19% Between group Difference 21% Total Body Lean Mass 2.5 p< *** RT + Protein n= 48 CHO Control n=43 Daly RM, O'Connell SL, Mundell NL, Grimes CA, Dunstan DW, Nowson CA. Protein-enriched diet, with the use of lean red meat, combined with progressive resistance training (PRT) enhances lean tissue mass and muscle strength and reduces circulating IL-6 concentrations in elderly women: a cluster randomized controlled trial. Am J Clin Nutr Jan *** p<0.001 vs baseline RT+ Control CHO RT+ Protein

32 Summary: Protein recommendations for optimal health & function: >65+ yrs At least 1.3g/kg/day High biological value protein sources At least 3 meals per day At least (25-30g): for two meals per day Progressive resistance exercise at least twice per week

33 Key Nutrition Factors Prevention risk falls & fracture Nutritional Prevention vitamin D dietary calcium nutritional risk: body weight, malnutrition dietary protein Prevention: Frailty Progressive Resistance Training

34 Learning Objectives To understand the nutritional challenges for older people in meeting recommended levels of dietary intake of vitamins and minerals. Nutrients of concern Strategies to address nutritional inadequacies

35 Nutritional Issues for Older People Older People: greater variation in health status Current Australian Nutrient Reference Values recognizes 3 age groups < 51years, years, >70 years Lower energy expenditure, therefore lower energy intake BUT higher dietary requirements therefore inadequate intakes likely BMI now higher

36 Vitamin D 2/09/images/ jpg dsox.us/prain/ jpg g hic.com/news/2004/09/imag es/040910_awastack.jpg Nursing home residents 35 nmol/l 25 (OH)D3 Sun rich cultures nmol/L 25 (OH)D 3 Life guards mmol/L

Prevalence Vit D Deficiency Hostel Residents n=373 Nursing Home Residents n=767 31% Australian adults inadequate vitamin D status (serum 25-hydroxyvitamin D [25-OHD] level < 50 nmol/l) > 50% in women

37 Prevalence Vit D Deficiency Hostel Residents n=373 Nursing Home Residents n=767 31% Australian adults inadequate vitamin D status (serum 25-hydroxyvitamin D [25-OHD] level < 50 nmol/l) > 50% in women during winter spring and in people residing in southern states Rates of insufficiency higher in high risk groups 19% frankly deficient 31% marginal or lower 44% frankly deficient 59% marginal or lower Daly RM, Gagnon C, Lu ZX, et al. Prevalence of vitamin D deficiency and its determinants in Australian adults aged 25 years and older: a national, population-based study. Clin Endocrinol (Oxf) 2011 Level of deficiency <25nmol/L frank <50 nmol/l marginal

38 Vitamin D status (25OHD) and disease Level 1 Vitamin D (plus calcium) for falls (Murad et al. 2011, Kalyani et al. 2010, Latham et al. 2003, Bischoff-Ferrari et al. 2009) and fractures (DIPART, 2010, Institute of Medicine (IOM), 2011) All cause mortality (Autier et al. 2007, Melamed, 2008, Rejnmark 2012, Thomas et al 2012) Meta-analysis RCTs vitamin D supp 4 falls & fracture 3 mortality Nowson CA, McGrath JJ, Ebeling PR, Haikerwal A, Daly RM, Sanders KM, Seibel MJ, Mason RS; Working Group of Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia. Vitamin D and health in adults in Australia and New Zealand: a position statement. Med J Aust Jun 18;196(11):686-7

39 Vitamin D: Effect on days falls/fracture (compliance >50%) 2-year randomised, double-blind placebo controlled >25 & <90 nmol/l 25(OH)D (not deficient) All 600 mg Calcium vitamin D (10,000 IU D2 1/wk or 1000IUn(25ug) 1/d) placebo OR ever falling 0.70 ( ) (30% reduction) OR ever fracture 0.68 ( ) 8 people needed to be treated for one year to prevent one fall Flicker et al. JAGS 2005 Nov Falls Vitamin D Placebo Fractures Vitamin D Placebo

40 Summary: vitamin D Vitamin D supplementation: reduction in rate of falls by 30% in residential care vitamin D supplementation greatest effect in decreasing falls in: older people who are frail low/suboptimal serum vitamin 25 D levels Adequate calcium intake required

41 Dietary Vitamin D intake Mean daily intake: females 2ug, males 2.6 ug Margarine: 48% canned fish: 16%

Recommended Vitamin D intakes in Australian Food:

(400IU) Adequate Intake Adults (>70yrs) 15ug (600IU)

$at least 25µg/day fracture 20 teaspoons/day = ` 10 µg$

42 Recommended Vitamin D intakes in Australian Food: margarine Adequate Intake Adults (51-70yrs) 10ug (400IU) Adequate Intake Adults (>70yrs) 15ug (600IU) Vitamin D content (>55 <160µg /kg) 10µg/100g RCT: dose at least 25µg/day fracture 20 teaspoons/day = ` 10 µg (400 IU) Mackeral 100g 8.6µg Sardines 100g 6.8 µg Cod liver oil 30g 34µg

Vitamin D Sources 5µg/1000ml AI (51-70yrs) 10ug 10, 200ml glasses/day AI (>70yrs) 15ug 15, 200ml glasses/day 5% 10% vitamin D requirement from dietary sources.

43 Vitamin D Sources 5µg/1000ml AI (51-70yrs) 10ug 10, 200ml glasses/day AI (>70yrs) 15ug 15, 200ml glasses/day 5% 10% vitamin D requirement from dietary sources. main source of vitamin D is exposure to sunlight. serum 25-hydroxyvitamin D (25-OHD) level of 50 nmol/l at the end of winter is required for optimal musculoskeletal health. moderately fair-skinned people, a walk with arms exposed for 6 7 minutes mid morning or mid afternoon in summer, and with as much bare skin exposed as feasible for 7 40 minutes (depending on latitude) at noon in winter, on most days, is likely to be helpful in maintaining adequate vitamin D levels in the body Nowson CA, McGrath JJ, Ebeling PR, Haikerwal A, Daly RM, Sanders KM, Seibel MJ, Mason RS; Working Group of Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia. Vitamin D and health in adults in Australia and New Zealand: a position statement. Med J Aust Jun 18;196(11):686-7

44 Calcium: Effect on Fractures Meta analysis fracture: Ca or Ca + Vitamin D % RR 0.88(0.83,0.95) 17 studies: 52,625 >50 yrs: treat 3.5years: 12% risk reduction Tang BMP, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in older people: a metaanalysis. Lancet 2007

45 Compliance with Ca supplements 2790 > 80%compliance 24% reduction Doubled RR 0.76(0.67,0.86) Low compliance 4% reduction ns Tang BMP, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in older people: a meta-analysis. Lancet 2007 RR 0.96(0.91,1.01) 85% consumed 50-59% supplements Only 9% took at least 80% supplement

46 Calcium Recommendations Women <55 yrs Men up to 74yrs Ca mg/day >74+ years, & women >54 yrs 1110mg 1300 Ca mg/day 9.5 MJ and 8.3MJ Energy 16 % 9% 11.8 MJ 9.6MJ Energy/day (2800kcal 2300kcal) 7.1 MJ 6.2MJ Energy 1700kcal 1500kcal 40% 45%

47 Dietary Calcium Calcium predominantly in milk/milkbased foods Intakes of calcium in adults in Australia average about 850 mg 40% comes from non-milk sources To meet recommended dietary calcium intake for 75+ years cups milk/day or equivalent high calcium foods

48 Typical Daily Intake: Residential Care: Breakfast Breakfast Toast/marg Porridge 70ml milk Tinned Fruit Tea/Coffee 25ml milk Morning Tea Milo 1 Banana

49 Lunch Lunch Braised Pork Creamed Potato, Pumpkin Peach Custard Tea/milk Bread/ margarine Afternoon Tea Milk

50 Dinner Dinner Vegetarian Lasagne Creamed Potato Florentine Vegetables Toast/margarine Orange Juice Tea/milk ¾ Left ¾ Left Supper Milk ¼ Left

51 Milk Intake: full cream Cereal 70ml Tea 25ml Milo 45ml Tea 25ml Milk 120ml Tea 25ml Milk 90ml Total 400mls If all milk milo used total milk 475mls (2.4 glasses)

52 Camilla 80+ years Total daily Intake % DRV Energy Protein Calcium Vitamin D 5.8MJ 52g 717mg 1.4μg 94% 100% 55% 9%

Orange Juice with added Calcium + Vitamins A, C & Folate 250ml glass: Ca 100mg 250mls Ca

slices (74g) Ca 200mg Calcium fortified cereal Per 30g serve: Ca 200mg With ½ cup milk:

on cereal) 1 cereal (30g) 200 1 orange juice (150ml) 60 Total Ca mg/day 1000 unfortified

53 Orange Juice with added Calcium + Vitamins A, C & Folate 250ml glass: Ca 100mg 250mls Ca fortified milk/product Bread Ca mg* with added Calcium +fibre *Ca fortified 2 slices (74g) Ca 200mg Calcium fortified cereal Per 30g serve: Ca 200mg With ½ cup milk: Ca 359mg Serves Calcium fortified foods Ca mg 2 slices bread glass milk 500 (1/2 on cereal) 1 cereal (30g) orange juice (150ml) 60 Total Ca mg/day 1000 unfortified 300 Difficult to achieve RDI for calcium without use of calcium fortified foods or supplements

54 Older people eat less and are less active Older people have higher dietary requirements for vitamin D and calcium Interactions: diet, environmental factors Dietary requirements may be altered by other factors eg: exposure to sunlight dietary calcium salt physical activity

55 Key Points: Older people Diet & lifestyle factors important to maintain quality of life and life expectancy Lower body weight (within healthy weight range associated with higher mortality Malnutrition is under-diagnosed Difficult for older people on reduced energy intakes to meet nutrient requirements Insufficient vitamin D status: widespread

56 Prevention of falls and fractures Protein Resistant Training Adequate Energy Intake Adequate Protein Adequate vitamin D status Adequate Dietary Calcium

57 Key Points: Older people Diet & lifestyle factors important to maintain quality of life and life expectancy Lower body weight (within healthy weight range associated with higher mortality Malnutrition is under-diagnosed Difficult for older people on reduced energy intakes to meet nutrient requirements Insufficient vitamin D status: widespread

Prevention of falls and fractures

$Prevention of falls and fractures$ ILSI SEA Region - Optimum Health & Nutrition for our Ageing populaiton. Australia - October 2012. www.ilsi.org/sea_region Prevention of falls and fractures http://www.narowing.org/men/brian%20best%20balance.jpg