This document is the accepted manuscript version of a published work that appeared in final form in Maturitas, Vol. 95 (January 2017), pp.63-64, doi: http://dx.doi.org/10.1016/j.maturitas.2016.09.005. First published online September 13, 2016 by Elsevier. © 2016 Elsevier Ireland Ltd. All rights reserved.Non peer reviewe

Hoffman, Richard

Maturitas

University of Hertfordshire Research Archive

Research ArchiveCitation for published version:Richard Hoffman, ‘Can the paleolithic diet meet the nutritional needs of older people?’, Maturitas, Vol. 95: 63-64, January 2017.DOI:https://doi.org/10.1016/j.maturitas.2016.09.005Document Version:This is the Accepted Manuscript version. The version in the University of Hertfordshire Research Archive may differ from the final published version. Copyright and Reuse: © 2016 Elsevier Ireland Ltd.This manuscript version is made available under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License CC BY NC-ND 4.0  ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.EnquiriesIf you believe this document infringes copyright, please contact the Research & Scholarly Communications Team at rsc@herts.ac.ukCan the paleolithic diet meet the nutritional needs of older people? 1 Richard Hoffman  2 School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, 3 AL10 9AB, UK 4 Tel. +44 1707 284526 5 Fax: +44 1707 285046 6 E-mail: r.hoffman@herts.ac.uk 7 Conflicts of interest: none 8 Key words: paleolithic diet, elderly 9  10 The paleolithic diet aims to emulate the dietary pattern of people of the "Old 11 Stone Age" and is currently one of the most fashionable diets in the world. 12 Although a few short-term studies have shown beneficial effects of this diet on 13 biomarkers for diabetes (see [1]) and cardiovascular disease [2, 3], studies using 14 disease endpoints are scarce. In the absence of these studies, one way to help 15 predict potential long term health outcomes in people following this diet, 16 including the elderly, is to determine if it is likely to meet their nutritional needs.  17 The paleo diet basically advocates lean meat, fish and shellfish, fruit, vegetables, 18 eggs, nuts and seeds. It excludes grains and cereals, dairy, processed foods, 19 refined sugars and added salt. A number of nutrient analyses of people following 20 a paleo diet have been carried out, albeit mainly on younger subjects (< 65 21 years). Protein intake on a paleo diet is generally found to be similar to or 22 slightly higher than on a normal diet. This high protein intake would be 23 particularly beneficial for the elderly because their protein requirements for 24 maintaining muscle mass and preventing sarcopenia may be higher than those 25 recommended for the general population [4]. Advice for the elderly on 26 consuming meat as the main source of protein - as is the case in the paleo diet - is, 27 however, controversial [5]. In the general population, there is evidence of an 28 association between consumption of red meat (though possibly not of white 29 meat such as chicken) and an increased risk of developing colorectal cancer, 30 though the evidence is probably confounded by factors like the type of red meat 31 (eg beef versus pork) [6] and the way the meat is cooked [7]. Subjects on a paleo 32 diet should however benefit from not consuming processed meat since the 33 evidence that processed meat increases the risk for colorectal cancer is strong. 34 As might be predicted from the high intake of fruit and vegetables in the paleo 35 diet, some micronutrients, including vitamins C and E and β-carotene, are 36 consumed in high quantities, while sodium intake has been found to be 37 substantially lower than in control diets [8, 9]. However, several short term 38 clinical studies have found that calcium intake in subjects following a paleo diet 39 is low, ranging from 355 - 395 mg/day [2, 8, 9]. Although, the optimal level of 40 calcium intake required specifically to reduce the risk of osteoporotic fractures is 41 currently the subject of considerable debate [10], these values are nevertheless 42 well below current recommended daily intake levels for healthy adults (700 mg 43 in the UK and 1200 mg in the US).  44 The paleo diet's low calcium content is probably attributable to the absence of 45 dairy and cereals, which the UK National Diet and Nutrition Survey found 46 contributed 42 % and 29 % respectively to the intake of calcium in the over 65's 47 [11]. It has been estimated that, for the US, adequate intake for calcium is not 48 possible with dairy-free diets while also meeting other nutrient 49 recommendations [12]. Modeling studies on the paleo diet have also confirmed 50 its difficulties in meeting current recommended intakes of calcium [13]. 51 Although calcium supplements are an option, these are at odds with the basic 52 philosophy of the paleo diet as one reflecting a Stone Age diet.  53 Dairy is also the main dietary source of iodine - essential for thyroid hormone 54 production. In the one study that has examined this, iodine intake on the paleo 55 diet was only about half the UK recommended requirement of 140 µg/day [8]. 56 Some types of fish and shellfish are also good sources of iodine but - at least in 57 this study -  these did not compensate for the shortfalls. Iodised salt is available, 58 but its iodine content is low, availability of this product is poor in some countries 59 like the UK [14], and the paleo diet discourages added salt. Increased salt 60 consumption is not advisable, in any case.  61 Dairy and cereals are also important sources of other micronutrients, including 62 some (thiamine, riboflavin and iron) that have been reported to be reduced in 63 some studies of the paleo diet. Most of these nutritional assessments of the paleo 64 diet are based on young or middle aged subjects, but they do nevertheless raise 65 concerns that the absence of dairy products and cereals will prevent adequate 66 intake of some key micronutrients for the elderly. Although micronutrient 67 deficiencies frequently occur in the elderly who do not follow a paleo diet, it does 68 seem likely that the absence of dairy and cereals in this diet will exacerbate the 69 risk of deficiencies. Dairy also provides protein in the omnivore diet without the 70 need to trade off against cancer risks, as is the case with red meat. 71 The paleo diet has been reported to induce a feeling of satiety. This may be a 72 useful short term strategy to lose weight [15], but for many elderly people poor 73 appetite is a significant concern, so the benefit of a diet with high satiety is 74 questionable. In addition, the acceptability of any diet is key to compliance, and 75 there are anecdotal comments on the difficulty of adhering to a paleo diet as it 76 lacks many of the sources of carbohydrates (bread, pasta, etc) that form a major 77 part of many western meals [16]. 78 Long term studies on the health consequences of adhering to a paleo diet may 79 currently be lacking, but to quote Austin Bradford Hill "that does not confer upon 80 us a freedom to ignore the knowledge we already have, or to postpone the action 81 that it appears to demand at a given time".  The knowledge we have is that the 82 healthiest diet is one based on minimally processed foods, mostly coming from 83 plant foods [17]. Currently the diet with the strongest evidence for preventing 84 nutrient deficiencies and protecting long term health, including in the elderly, is 85 the plant-based Mediterranean diet [18]. 86 Contributor: RH is the sole author 87 Conflicts of interest: none 88 Funding: none was sought or secured to write this editorial 89 Provenance and peer review: commissioned; not externally peer reviewed 90  91 [1] S. Andrikopoulos. The Paleo diet and diabetes. Med J Australia. 205 (2016) 92 151-52. 93 [2] T. Jonsson, Y. Granfeldt, B. Ahren, U.C. Branell, G. Palsson, A. Hansson, et al. 94 Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 95 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 8 (2009) 96 35-49. 97 [3] R.L. Pastore, J.T. Brooks, J.W. Carbone. Paleolithic nutrition improves plasma 98 lipid concentrations of hypercholesterolemic adults to a greater extent than 99 traditional heart-healthy dietary recommendations. Nutr Res. 35 (2015) 474-100 79. 101 [4] J. Bauer, G. Biolo, T. Cederholm, M. Cesari, A.J. Cruz-Jentoft, J.E. Morley, et al. 102 Evidence-based recommendations for optimal dietary protein intake in older 103 people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 104 14 (2013) 542-59. 105 [5] M. Kouvari, S. Tyrovolas, D.B. Panagiotakos. Red meat consumption and 106 healthy ageing: A review. Maturitas. 84 (2016) 17-24. 107 [6] G. Lippi, C. Mattiuzzi, G. Cervellin. Meat consumption and cancer risk: a 108 critical review of published meta-analyses. Crit Rev Oncol Hematol. 97 (2016) 109 1-14. 110 [7] R. Hoffman, M. Gerber. Food Processing and the Mediterranean Diet. 111 Nutrients. 7 (2015) 7925-64. 112 [8] A. Genoni, P. Lyons-Wall, J. Lo, A. Devine. Cardiovascular, Metabolic Effects 113 and Dietary Composition of Ad-Libitum Paleolithic vs. Australian Guide to 114 Healthy Eating Diets: A 4-Week Randomised Trial. Nutrients. 8 (2016) 314-27. 115 [9] M. Osterdahl, T. Kocturk, A. Koochek, P.E. Wandell. Effects of a short-term 116 intervention with a paleolithic diet in healthy volunteers. Eur J Clin Nutr. 62 117 (2008) 682-85. 118 [10] I.R. Reid, S.M. Bristow. Calcium fortified foods or supplements for older 119 people? Maturitas. 85 (2016) 1-4. 120 [11] B. Bates, A. Lennox, A. Prentice, e. al 121 https://www.gov.uk/government/statistics/national-diet-and-nutrition-122 survey-results-from-years-1-to-4-combined-of-the-rolling-programme-for-123 2008-and-2009-to-2011-and-2012 (Accessed July 2016) 124 [12] X. Gao, P.E. Wilde, A.H. Lichtenstein, K.L. Tucker. Meeting adequate intake 125 for dietary calcium without dairy foods in adolescents aged 9 to 18 years 126 (National Health and Nutrition Examination Survey 2001-2002). J Am Diet 127 Assoc. 106 (2006) 1759-65. 128 [13] M. Metzgar, T.C. Rideout, M. Fontes-Villalba, R.S. Kuipers. The feasibility of a 129 Paleolithic diet for low-income consumers. Nutr Res. 31 (2011) 444-51. 130 [14] S.C. Bath, S. Button, M.P. Rayman. Availability of iodised table salt in the UK - 131 is it likely to influence population iodine intake? Public Health Nutr. 17 (2014) 132 450-54. 133 [15] T. Jonsson, Y. Granfeldt, C. Erlanson-Albertsson, B. Ahren, S. Lindeberg. A 134 paleolithic diet is more satiating per calorie than a mediterranean-like diet in 135 individuals with ischemic heart disease. Nutr Metab (Lond). 7 (2010) 85-99. 136 [16] T. Jonsson, Y. Granfeldt, S. Lindeberg, A.C. Hallberg. Subjective satiety and 137 other experiences of a Paleolithic diet compared to a diabetes diet in patients 138 with type 2 diabetes. Nutr J. 12 (2013) 105-12. 139 [17] D.L. Katz, S. Meller. Can we say what diet is best for health? Annu Rev Public 140 Health. 35 (2014) 83-103. 141 [18] M. Gerber, R. Hoffman. The Mediterranean diet: health, science and society. 142 Br J Nutr. 113 Suppl 2 (2015) S4-S10. 143  144 

Can the paleolithic diet meet the nutritional needs of older people?

Richard Hoffman

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Can the paleolithic diet meet the nutritional needs of older people?

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