Keywords
dizziness - aging - nutrition
Introduction
The elderly are at risk for nutritional disorders and malnutrition, including undernutrition
and nutrient deficiencies and imbalances. Several age-related physical, clinical,
economic, and social factors can compromise nutritional status; furthermore, changes
in the body composition of elderly people and sedentary lifestyles reduce energy requirements
and daily energy intakes. The highly intercorrelated nature of the consumption of
dietary components makes it difficult to evaluate specific unconfounded effects through
observational studies.[1]
[2]
Eating patterns have been considered risk factors for various metabolic and circulatory
changes that cause several symptoms including dizziness, especially among elderly
individuals.[3]
[4] Dizziness is a change in balance characterized by the illusion of movement of the individual
or the environment that surrounds them. Rotational dizziness is called vertigo.[5] This symptom is highly prevalent worldwide, affecting ∼2% of young adults, 30% at
65 years, and up to 50% in the elderly over 85 years.[6]
Especially in the elderly, a lack of regular physical activity, low level of physical
fitness, and nutritional disorders are risk factors for several metabolic and circulatory
changes that cause various symptoms, such as dizziness and even benign paroxysmal
positional vertigo (BPPV).[1]
[7]
Current evidence shows that good dietary habits in the elderly can improve their quality
of life. The prevalence of malnutrition is increasing in this population and is associated
with declines in functional status, impaired muscle function, decreased bone mass,
immune dysfunction, anemia, reduced cognitive function, poor wound healing, delayed
recovery from surgery, higher hospital readmission rates, and mortality.[8]
Malnutrition is defined as a state in which a deficiency, excess, or imbalance of energy, protein,
and other nutrients causes adverse effects on body form, function, and clinical outcome.[9]
There is evidence to suggest that dietary habits such as low sodium can alter inner
ear fluid homeostasis and auditory function. The experiments indicate that the endolymph
compartment has a built-in mechanism for maintaining a low-sodium concentration while
keeping ionic balance with the surrounding perilymph and serum.[10]
The labyrinth system, which depends on a continuous supply of energy, is influenced
by the circulating levels of glucose and hormones, which depend on the generation
of energy by adenosine triphosphate. Data in the literature estimate that the occurrence
of glucose metabolic disorder is between 42 and 80% in patients with tinnitus and
dizziness, whereas 2.5 to 15% of the population presents asymptomatic hypoglycemia
or some affection of glucose tolerance curves. In Brazil, glucose metabolic disorder
has already been considered the most frequent cause of labyrinthic metabolic dysfunctions.[11]
[12]
Vertigo is the most common type of dizziness and BPPV is the most common cause of
vertigo in adults. It has an estimated prevalence of 3.2% in women and 1.6% in men.
It is considered the most common cause of dizziness in the elderly, and 30% of people
had the condition at least once.[13]
[14]
In the United States, BPPV has an estimated prevalence of 2.4% in the general adult
population, and although this disorder affects people throughout life, it tends to
affect individuals aged 50 to 70 years and therefore affects payroll taxes and the
health.[15]
Based on the considerations presented, this study aimed to investigate the possible
association between the presence of BPPV with the practice of food habits in the elderly.
Methods
This cross-sectional study was approved by the Human Research Ethics Committee.[16] It is part of a broader investigation, the EELO Project (from Portuguese: studies
on aging and longevity), which has been conducted in Londrina since 2009. The city
of Londrina (∼500,000 inhabitants) is situated in the north region of Paraná state,
Brazil. The city has a population of 43,610 elderly people enrolled in the 38 primary
care units in the urban city area. The sample was a randomly stratified set, considering
the gender and the five regions of the city (15% from the central region, 27% from
the northern region, 23% from the southern region, 19% from the eastern region, and
16% from the western region). The study included individuals aged 60 years and over,
of both genders, who were living independently and classified at level 3 or 4 as proposed
by Spidurso.[17] This classification evaluates the independence level of the elderly, with level
1 indicating a lack of self-mobility and level 5 indicating athletes. Elderly who
had any illness or limitation that would prevent the testing, such as physical or
mental disabilities, were excluded from the sample. All the participants signed an
informed consent form. Four hundred ninety-six subjects were included in this part
of the study. BPPV was found in 117, and 53 of them had recurrent BPPV confirmed by
the questionnaire.
The dietary information was collected by means of the dietary 24-hour recall methods.[18] The interviews were conducted on three different days: one day on the weekend and
two in the middle of the week. With the aid of photo album with pictures of portion
sizes and foods, the interviews took place with notation of the food consumed in the
order of dialed meals. The types of food, the quantities consumed, and how they were
prepared were recorded. The quantities of these foods were reported in household measures
and converted into grams or milliliters. Dietary data were processed and analyzed
with the nutritional evaluation software Avanutri online.[19] The analysis of dietary intake of protein, carbohydrate, lipid, fiber, and cholesterol
took into account the recommended dietary reference intakes.[20]
The presence of vertigo was established through questions about vertigo (attacks,
symptoms, and familiar history of vertigo), and the diagnosis of BPPV among study
participants with vertigo was established with the Dix-Hallpike maneuver and answers
on the questionnaire about vertigo.[21]
The chi-square test was performed, and p ≤ 0.05 was considered statistically significant. The significance of food habit variables
and the variables carbohydrates, polyunsaturated fat, monounsaturated fat, saturated
fat, lipids, protein, and fiber were all considered.
Results
Based on a sample of 487 subjects, 117 had BPPV and 370 did not. Of 117 elderly patients
with BPPV, 37 (31.62%) had inadequate nutrition. Of the 370 without BPPV, 97 (26.21%)
had inadequate nutrition.
We did not observe a significant association (p = 0.3064) between food habits and BPPV in the total population (odds ratio =1.3017;
[Table 1]).
Table 1
Full distribution of the number of patients with BPPV and food habits
|
Food habits
|
BPPV
|
|
Yes (%)
|
No (%)
|
|
Inadequate nutrition
|
37 (31.62)
|
97 (26.21)
|
|
Adequate nutrition
|
80 (68.37)
|
273 (73.78)
|
|
Total
|
117
|
370
|
Abbreviation: ARR, absolute risk reduction; BPPV, benign paroxysmal positional vertigo;
NNH, number needed to harm.
Note: Odds ratio = 1.3017; confidence interval 0.8272–2.0483; ARR = 5.41%; NNH = 19;
χ2
corr = 1.303 (p = 0.3064).
Of the 117 people who had BPPV, 102 (87.17%) had inadequate carbohydrate intake and
15 (12.82%) did not. And of the 370 people without BPPV, 330 (89.18%) had inadequate
carbohydrate intake and 40 (10.81%) had normal intake. The Mann-Whitney test was used
for statistical analysis between inadequate carbohydrates and BPPV and gave a value
of U = 19,351.50 and p = 0.0419, a statistically significant difference (see [Table 2]).
Table 2
Full distribution of the number of patients with BPPV and inadequate carbohydrate
consumption
|
BPPV
|
|
Inadequate carbohydrates
|
Yes (%)
|
No (%)
|
|
Yes
|
102 (87.17)
|
330 (89.18)
|
|
No
|
15 (12.82)
|
40 (10.81)
|
|
Total
|
117
|
370
|
Abbreviation: BPPV, benign paroxysmal positional vertigo.
Note: U = 19351.50 (p = 0.0419).
Of the 117 people who had BPPV, 82 (70.08%) had polyunsaturated fat intake and 35
(29.91%) did not. Of the 370 people without BPPV, 289 (78.10%) had polyunsaturated
fat intake and 81 (21.89%) did not. For statistical analysis between polyunsaturated
fat and BPPV, we performed the Mann-Whitney test, which gave a value of U = 18470.00 and p = 0.0084, a statistically significant difference (see [Table 3]).
Table 3
Full distribution of the number of patients with BPPV and diet rich in polyunsaturated
fatty acids
|
BPPV
|
|
Polyunsaturated fat
|
Yes (%)
|
No (%)
|
|
Diet rich in polyunsaturated fatty acids
|
82 (70.08)
|
289 (78.10)
|
|
Normal diet in polyunsaturated fatty acids
|
35 (29.91)
|
81 (21.89)
|
|
Total
|
117
|
370
|
Abbreviation: BPPV, benign paroxysmal positional vertigo.
Note: U = 18,470.00 (p = 0.0084).
We did not observe a significant association between inadequate protein intake (p = 0.78), inadequate intake of saturated fats (p = 0.97), inadequate intake of lipids (p = 0.43), and inadequate intake of monounsaturated fats (p = 0.79), but there was important significance between BPPV and inadequate fiber intake
(p = 0.03; [Table 4]).
Table 4
Frequency of BPPV in relation to inadequate intake of protein, saturated fats, monounsaturated
fats, lipids, and fibers
|
Inadequate nutrition
|
BPPV, n (%)
|
No BPPV, n (%)
|
p Value
|
|
Inadequate protein[a]
|
101
|
325
|
0.7
|
|
Inadequate saturated fat[b]
|
117
|
368
|
0.97
|
|
Inadequate lipids[c]
|
35
|
95
|
0.43
|
|
Inadequate monounsaturated fat[d]
|
82
|
266
|
0.79
|
|
Inadequate fiber[e]
|
117
|
356
|
0.03
|
Abbreviation: BPPV, benign paroxysmal positional vertigo.
a χ2
corr =0.186.
b G (Yates) = 0.010.
c χ2
corr = 0.816.
d χ2
corr = 0.142.
e G (Yates) = 4.624.
Discussion
In this study, we observed the association of BPPV with a diet of inadequate carbohydrate
intake, rich in polyunsaturated fatty acids, and insufficient fiber intake.
The elderly often have reduced appetite and energy expenditure, which can occur along
with a decline of biological and physiological functions, reduction of lean body mass,
and changes in cytokine and hormonal levels. Other disturbances include changes in
fluid electrolyte regulation, delayed gastric emptying, and diminished senses of smell
and taste. In addition, pathologic changes of aging such as chronic diseases and psychological
illness can lead to bad nutrition in the elderly. Nutritional assessment is important
to identify, along with treating patients at risk.[8]
Vertigo, tinnitus, and hearing loss are common complaints among the elderly in industrial
countries. Numerous agents are known to incite vertigo, tinnitus, and hearing loss,
such as hyperinsulinemia and hyperlipidemia. According to the study of Kaźmierczak
and Doroszewska,[22] who assessed the occurrence of hyperinsulinemia and hyperlipidemia in patients suffering
from vertigo, tinnitus, or hearing loss of unknown origin, only hyperlipoproteinemia
did not differ between patients and control subjects. However, the authors concluded
that disturbances of metabolism by glucose, such as diabetes mellitus and hyperinsulinemia,
may be responsible for inner ear diseases, whereas the disturbance of lipid metabolism
remains vague. Micronutrient insufficiency and high saturated fat intake have been
associated with chronic diseases.[23] The study also reported that disturbances of glucose may be responsible for inner
ear diseases.[23] We also detected an excess of carbohydrates; these nutrients are interconvertible,
raising each other through degradation of its components: 85% excess carbohydrate
becomes fats (lipids) in the individual by the liver, increasing the lipids, cholesterol,
and triglycerides in the blood, which may cause accumulation of sodium and potassium
in the inner ear.
Huffman et al confirmed our data showing that a lack of fiber leaves the human body
unprotected, without the minimum number of regulators provided by a good diet.[23] Fiber has an effect on lipid metabolism (propionate) and glucose (acetate, propionate,
and butyrate), delaying absorption of glucose and starch hydrolysis, helping to maintain
electrolyte balance of blood capillaries and also assisting the vestibule-cochlear
apparatus health.
British dietary recommendations are to decrease total fat intake to less than 30%
of daily energy consumption and saturated fat to less than 10%. The energy and fat
intake seems to be reduced on the diet rich in polyunsaturated fatty acids. Insulin
sensitivity and plasma low-density lipoprotein cholesterol concentrations are improved
with a diet rich in polyunsaturated fatty acids compared with the diet rich in saturated
fatty acids.[24] However, other literature has reported that the elderly interviewed in large urban
centers of Brazil have not joined the new trend of developed countries; consumption
of traditional foods were replaced by processed foods of easy preparation causing
dyslipidemia and excess of sodium, damaging the natural physiology chemical level
in the inner ear among other comorbidities.[25]
In this study, we detected a diet high in polyunsaturated fatty acids ([Table 3]). Reviewing the literature, we could observe that polyunsaturated fatty acids, when
processed (hydrogenated), can be transformed into trans fats, which are harmful to
health. However, we cannot analyze this information by itself; an individual who consumes
excess fat (even good fat) and carbohydrates can still eat a low concentration of
dietary fiber, which is likely to have dyslipidemia affects in the ear. Even though
not much data regarding disorders of lipid metabolism exist in the literature, the
ingestion of high amounts of polyunsaturated fats and trans fat could be related in
part to lipid metabolism disorders.[26]
Mantello et al wrote that the changes in glucose metabolism are the main metabolic
changes that lead to vestibulocochlear disorders.[27] As the labyrinthine structures possess an intense metabolic activity, glucose is
necessary for energy production and for maintaining proper concentrations of sodium
and potassium in the endolymph.[27] Some habits, such as alcohol, tobacco, sugar, salt, saturated fats, and caffeine,
in addition to physical inactivity, should be banned from the lives of patients with
vertigo because they can exacerbate symptoms of cochleovestibular and make vestibular
compensation even slower.[28] We suggest that the same procedures are taken in cases of BPPV, intensely studied
here, for the same reasons cited above.
Through these results, we emphasize the importance of a multidisciplinary care team,
expanding the procedures and results to prevention and treatment and minimizing episodes
of recurrent BPPV in the elderly.
Conclusion
The association between BPPV with inadequate carbohydrate intake and a diet rich in
polyunsaturated fatty acids and inadequate fiber intake has been observed. These associations
deserve more in-depth study.
These data represent an important tool for better understanding the overall health
and comorbidities of the elderly, assisting with the reasoning and awareness of a
necessary change in their lifestyle; through guidelines and nutritional treatments,
alongside multidisciplinary care, the team can help to decrease hearing symptoms of
BPPV.
This study showed the importance of further studies associating the relationship between
BPPV and the types of food habits. Further research is needed to develop a prevention
and rehabilitation of BPPV with associate food habits.
