The consumption of certain food additive emulsifiers could be associated with the risk of developing type 2 diabetes

Peer-Reviewed Publication

In Europe and North America, 30 to 60% of dietary energy intake in adults comes from ultra-processed foods. An increasing number of epidemiological studies suggest a link between higher consumption levels of ultra-processed foods with higher risks of diabetes and other metabolic disorders.

Emulsifiers are among the most commonly used additives. They are often added to processed and packaged foods such as certain industrial cakes, biscuits and desserts, as well as yoghurts, ice creams, chocolate bars, industrial breads, margarines and ready-to-eat or ready-to-heat meals, in order to improve their appearance, taste and texture and lengthen shelf life. These emulsifiers include for instance mono- and diglycerides of fatty acids, carrageenans, modified starches, lecithins, phosphates, celluloses, gums and pectins.

As with all food additives, the safety of emulsifiers had been previously evaluated by food safety and health agencies based on the scientific evidence that was available at the time of their evaluation. However, some recent studies suggest that emulsifiers may disrupt the gut microbiota and increase the risk of inflammation and metabolic disruption, potentially leading to insulin resistance and the development of diabetes.

For more information: read Inserm's report on type 2 diabetes

For the first time worldwide, a team of researchers in France has studied the relationships between the dietary intakes of emulsifiers, assessed over a follow-up period of maximum 14 years, and the risk of developing type 2 diabetes in a large study in the general population.

The results are based on the analysis of data from 104 139 adults in France (average age 43 years; 79% women) who participated in the NutriNet-Santé web-cohort study (see box below) between 2009 and 2023.

The participants completed at least two days of dietary records, collecting detailed information on all foods and drinks consumed and their commercial brands (in the case of industrial products). These dietary records were repeated every six months for 14 years, and were matched against databases in order to identify the presence and amount of food additives (including emulsifiers) in the products consumed. Laboratory assays were also performed in order to provide quantitative data. This allowed a measurement of chronic exposure to these emulsifiers over time.

During follow-up, participants reported the development of diabetes (1056 cases diagnosed), and reports were validated using a multi-source strategy (including data on diabetes medication use). Several well-known risk factors for diabetes, including age, sex, weight (BMI), educational level, family history, smoking, alcohol and levels of physical activity, as well as the overall nutritional quality of the diet (including sugar intake) were taken into account in the analysis.

After an average follow-up of seven years, the researchers observed that chronic exposure – evaluated by repeated data – to the following emulsifiers was associated with an increased risk of type 2 diabetes:

• carrageenans (total carrageenans and E407; 3% increased risk per increment of 100 mg per day)

• tripotassium phosphate (E340; 15% increased risk per increment of 500 mg per day)

• mono- and diacetyltartaric acid esters of mono- and diglycerides of fatty acids (E472e; 4% increased risk per increment of 100 mg per day)

• sodium citrate (E331; 4% increased risk per increment of 500 mg per day)

• guar gum (E412; 11% increased risk per increment of 500 mg per day)

• gum arabic (E414; 3% increased risk per increment of 1000 mg per day)

• xanthan gum (E415; 8% increased risk per increment of 500 mg per day)

This study constitutes an initial exploration of these relationships, and further investigations are now needed to establish causal links. The researchers mentioned several limitations of their study, such as the predominance of women in the sample, a higher level of education than the general population, and generally more health-promoting behaviours among the NutriNet-Santé study participants. Therefore caution is needed when extrapolating the conclusions to the entire French population.

The study is nevertheless based on a large sample size, and the researchers have accounted for a large number of factors that could have led to confounding bias. They also used unique, detailed data on exposure to food additives, down to the commercial brand name of the industrial products consumed. In addition, the results remain consistent through various sensitivity analyses[1], which reinforces their reliability.

'These findings are issued from a single observational study for the moment, and cannot be used on their own to establish a causal relationship. They need to be replicated in other epidemiological studies worldwide, and supplemented with toxicological and interventional experimental studies, to further inform the mechanisms linking these food additive emulsifiers and the onset of type 2 diabetes. However, our results represent key elements to enrich the debate on re-evaluating the regulations around the use of additives in the food industry, in order to better protect consumers,' explain Mathilde Touvier, Research Director at Inserm, and Bernard Srour, Junior Professor at INRAE, lead authors of the study.

Among the next steps, the research team will be looking at variations in certain blood markers and the gut microbiota linked to the consumption of these additives, to better understand the underlying mechanisms. The researchers will also look at the health impact of additive mixtures and their potential 'cocktail effects.' They will also work in collaboration with toxicologists to test the impact of these exposures in in vitro and in vivo experiments, to gather more arguments in favour of a causal link.

PFAS exposure from high seafood diets may be underestimated

 

A Dartmouth-led study suggests that people who frequently consume seafood may face an increased risk of exposure to PFAS, the family of ubiquitous and resilient human-made toxins known as "forever chemicals."

The findings stress the need for more stringent public health guidelines that establish the amount of seafood people can safely consume to limit their exposure to perfluoroalkyl and polyfluoroalkyl substances, the researchers report in the journal Exposure and Health. This need is especially urgent for coastal regions such as New England where a legacy of industry and PFAS pollution bumps up against a cultural predilection for fish, the authors write.

"Our recommendation isn't to not eat seafood—seafood is a great source of lean protein and omega fatty acids. But it also is a potentially underestimated source of PFAS exposure in humans," said Megan Romano, the study's corresponding author and an associate professor of epidemiology at Dartmouth's Geisel School of Medicine.

"Understanding this risk-benefit trade-off for seafood consumption is important for people making decisions about diet, especially for vulnerable populations such as pregnant people and children," Romano said.

The study paired an analysis of PFAS concentrations in fresh seafood with a statewide survey of eating habits in New Hampshire. National data indicate that New Hampshire—along with all of New England— is among the country's top consumers of seafood, which made the state ideal for understanding the extent of people's exposure to PFAS through fish and shellfish.

"Most existing research focuses on PFAS levels in freshwater species, which are not what people primarily eat," said Romano, who studies the effects of PFAS and other endocrine-disrupting chemicals in drinking water on New England communities. "We saw that as a knowledge gap in the literature, especially for a New England state where we know people love their seafood."

The study also drew on New Hampshire's extensive data on the sources and effects of PFAS, which are a staple of consumer products such as plastics and nonstick coatings. The molecular stability that makes PFAS versatile also makes them nearly indestructible, leading them to be called forever chemicals.

In humans, PFAS are associated with cancer, fetal abnormalities, high cholesterol, and thyroid, liver, and reproductive disorders. The chemicals have accumulated in soil, water, and wildlife, and studies have shown that nearly all Americans have measurable amounts in their blood.

"PFAS are not limited to manufacturing, fire-fighting foams, or municipal waste streams—they are a decades-long global challenge," said study co-author Jonathan Petali, a toxicologist with the New Hampshire Department of Environmental Services. "New Hampshire was among the first states to identify PFAS in drinking water. We're a data-rich state due to years spent investigating the impacts of PFAS and trying to mitigate exposure."

The researchers measured the levels of 26 varieties of PFAS in samples of the most consumed marine species: cod, haddock, lobster, salmon, scallop, shrimp, and tuna. The seafood studied was purchased fresh from a market in coastal New Hampshire and originated from various regions.

Shrimp and lobster clocked the highest concentrations with averages ranging as high as 1.74 and 3.30 nanograms per gram of flesh, respectively, for certain PFAS compounds, the researchers report. Concentrations of individual PFAS in other fish and seafood measured generally less than one nanogram per gram.

The prevalence of PFAS in the environment makes it difficult to know exactly where and how the chemicals enter the marine food chain, the researchers report. Some shellfish may be especially vulnerable to the buildup of PFAS in their flesh due to feeding and living on the seafloor, as well as their proximity to sources of PFAS that are near the coast. Larger marine species may ingest PFAS by eating smaller species that, like shellfish, are prone to having the compounds accumulate in their systems. 

Buttressing the study is a survey of 1,829 New Hampshire residents the researchers conducted to gauge how much seafood Granite Staters eat—and it's a lot.

The survey found that men in New Hampshire eat just over one ounce of seafood per day and women eat just under one ounce. Both are higher than what the National Health and Nutrition Examination Survey found for men and women in the Northeast, and more than 1.5 times the national average for both. Daily intake for New Hampshire children aged 2 to 11 years old was about 0.2 ounces, the highest end of the range for children nationwide.

About 95% of adults the researchers surveyed reported they ate seafood within the past year, and 94% of that group consumed fish or shellfish within the previous month. More than two-thirds of those respondents ate seafood within the past week.

But people in New Hampshire do not eat seafood uniformly. More than half of the people who ate seafood in the week before the survey lived on the state's coast or near the border with Massachusetts. More than 60% of people with a household income below $45,000 per year reported consuming seafood at least once per week, whereas people with higher household incomes reported eating seafood less often.  

Of the species the researchers tested for PFAS, shrimp, haddock, and salmon were consumed by more than 70% of the adults who ate seafood once a month or more. Lobster was eaten by just over 54% of these adults. Salmon, canned tuna, shrimp, and haddock were the most commonly consumed species among children.

Federal guidelines for safe seafood consumption exist for mercury and other contaminants, but there are none for PFAS, said Celia Chen, a co-author of the study and a research professor in the Department of Biological Sciences at Dartmouth.

"Top predator species such as tuna and sharks are known to contain high concentrations of mercury, so we can use that knowledge to limit exposure. But it's less clear for PFAS, especially if you start looking at how the different compounds behave in the environment," said Chen, who leads several federally funded projects examining how and where PFAS accumulate in aquatic food webs in New Hampshire and Vermont.

The establishment of safety guidelines would help protect people who are especially susceptible to pollutants, said Kathryn Crawford, the study's first author and an assistant professor of environmental studies at Middlebury College.

"Seafood consumption advisories often provide advice for those individuals that is more conservative than for the rest of the population," said Crawford, who began the project as a postdoctoral researcher in the Romano Lab at Dartmouth. "People who eat a balanced diet with more typical, moderate amounts of seafood should be able to enjoy the health benefits of seafood without excessive risk of PFAS exposure."

Natural supplement to prevent postpartum blues

 

Product now available in the U.S. with global distribution plannedA new study published in the Lancet discovery science  journal eClinicalMedicine has confirmed that a novel natural supplement—invented, researched, developed and commercialized at the Centre for Addiction and Mental Health (CAMH)—prevents postpartum blues, and reduces symptoms of postpartum depression over the following six months after giving birth.

Up to 8 out of ten new mothers experience postpartum, or ‘baby,’ blues, characterized by mood swings, crying spells, anxiety and difficulty sleeping. The condition usually begins within the first few days after delivery and may last for up to two weeks. Postpartum blues strongly raises the risk of postpartum depression, a serious mental illness affecting 13 per cent of mothers. Postpartum depression has important health care consequences: impairing quality of life, increasing risk for future depressive episodes and suicide, and is associated with cognitive and emotional effects in children. Until now, options for widespread prevention have been lacking for either condition.

The study, entitled Dietary Supplement for Mood Symptoms in Early Postpartum: A Double-Blind Randomized Placebo Controlled Trial, involved more than 100 postpartum participants between January 2019 and December 2022 who either took four doses of the natural supplement several days after giving birth, or a matching placebo. Within the supplement group, two-thirds (66 per cent) experienced either no symptoms or only negligible symptoms of postpartum blues. Furthermore, in the following six months, participants who received the supplement experienced less symptoms of depression with none reaching the clinical threshold of postpartum depression six months after giving birth.

“Globally 140 million births take place every year. Most women then experience postpartum blues, which, when severe, increases the likelihood of getting full-blown postpartum depression at least fourfold. Our study showed that both postpartum blues and later symptoms of depression were lower in women who received the dietary supplement,” said Dr. Jeffrey Meyer, inventor of the nutraceutical and study senior author. “Providing this specialized dietary support in the first few days after giving birth is a crucial window to avoid depressive symptoms which is tremendously important given there is considerable risk that they may recur and have lifelong impact.”

Dr. Meyer has been investigating postpartum blues for more than 15 years. His previous imaging research found that a protein called MAO-A rises dramatically in the brains of postpartum women and this protein removes important brain chemicals—like serotonin and dopamine—that support normal mood. It also acts as an oxidant and is linked to the development and progression of certain mental illnesses. To combat this effect, the nutraceutical is made up of a patented unique combination of natural ingredients, including blueberry extract, which contain antioxidants, and amino acids that replenish essential neurochemicals in the brain to support healthy mood and the ability to concentrate under stress. The supplement was well tolerated and women who took it tended to report less symptoms, in part due to less drowsiness, headache and restlessness. The researchers previously showed that the amino acids in the supplement do not affect their total concentrations in breast milk, which was expected since these amino acids are already found in proteins in breast milk.     

CAMH has partnered with international women’s health supplement and pharmaceutical company Exeltis via a licensing agreement to bring the product to market under the name Blues Away®. Exeltis has maintained the natural health product approach in their preparations and manufacture for widespread distribution of the supplement. It is expected that the product will be available for sale in the U.S. beginning April 11, 2024.  It is also in the process of being brought to other global markets—including Canada—with the pace of approvals being dependent on each country’s regulatory requirements and reviews. 

“We are thrilled to unveil the culmination of years of dedication and collaboration in the form of our groundbreaking nutraceutical for postpartum blues prevention. It is great that we are able to simultaneously share our clinical research around this product while also partnering with a  global women’s health industry leader to make it available to the new mothers who need it,” said Klara Vichnevetski, Director of Industry Partnerships and Technology Transfer. CAMH has nurtured this innovation from its inception, guiding it from bench to bedside where it can make an immediate and profound difference in the lives of millions of women and their families.”

A limitation of the study was that, of th

Study suggests pretzel size affects intake by governing how quickly a person eats and how big their bites are

 

The size of an individual snack piece not only influences how fast a person eats it, but also how much of it they eat, according to a new study led by researchers at Penn State. With nearly a quarter of daily calorie intake in the United States coming from snacks, these findings may have implications for helping people better understand how eating behavior impacts calorie and sodium intake.

The team of food scientists investigated how the size of pretzels influences eating behavior — overall intake, eating rate, bite size and snacking duration — and found that people eat larger pretzels quicker with larger bites. They also found that while people ate smaller pretzels slower and with smaller bites, and ate less overall, they still had higher intake of sodium. Their results are available online now and will be published in the June issue of Appetite.

Seventy-five adults participated in the study, eating snacks three different times in the Sensory Evaluation Center. The oversized snack was about 2.5 servings of one of three sizes of pretzel — small, medium or large. To calculate eating rate and bite size, the researchers video recorded each snacking session, noting how many minutes each participant spent snacking and the number of bites. They also measured how much each participant ate in both weight and calories.

When participants were given the same amount of food, how much they ate — in both snack weight and calories — depended on unit size, with study participants consuming 31% and 22% more of the large pretzels compared to the small and medium sized pretzels, respectively. Size of the pretzel also influenced eating rate and bite size, with the largest pretzel size yielding the fastest eating rate and largest mean bite size.

The researchers also reported that, after accounting for eating behavior, the pretzel size alone did not significantly affect how much a person ate, suggesting the eating behavior the different pretzel sizes prompted was driving total intake. Their results suggest larger pretzel size induces a person to eat more quickly and take bigger bites.

Together, these findings indicate that unit size influences intake by affecting eating behavior and they show that food characteristics such as unit size can be leveraged to moderate snack intake, explained corresponding author John Hayes, professor of food science and director of the Penn State Sensory Evaluation Center.

“The study suggests that food structure — texture, size and shape — can be used to modulate eating behavior and food intake,” he said. “Food geometry, specifically unit size, is of particular utility for snack foods. We're interested in how the material properties of foods can be harnessed to help people eat less without impacting their enjoyment.”

The relationship between pretzel size and sodium intake was obvious but previously overlooked, noted Madeline Harper, a graduate student in food science and lead author on the study. She explained that eating more smaller pretzels likely results in higher sodium consumption. The smaller size has more surface area for the same weight, so the researchers hypothesize that more total salt on the surface means that a snacker would consume more sodium eating them.

“So, we're suggesting that if you're trying to watch your calorie intake or are trying to reduce the amount that you're eating in a snack, then maybe a smaller pretzel would meet your needs better, because of the inherent way the size of the pretzel affects your eating rate,” she said. “But if you're more worried about hypertension or the amount of sodium you're consuming, the larger pretzel might be better for you, because you'll consume less sodium in that treatment, even though you might consume more grams of pretzel.”

Paige Cunningham, postdoctoral scholar in the Department of Food Science and the Department of Nutritional Sciences at Penn State, and Ciaran Forde, professor and chair in Sensory Science and Eating Behaviour Group in the Division of Nutrition, at Wageningen University, contributed to the research.  

Screening with a PSA test has a small impact on prostate cancer deaths but leads to overdiagnosis

Peer-Reviewed Publication

CANCER RESEARCH UK

The largest study to date investigating a single invitation to a PSA blood test* to screen for prostate cancer has found it had a small impact on reducing deaths, but also led to overdiagnosis and missed early detection of some aggressive cancers. 

The CAP trial, published in the Journal of the American Medical Association (JAMA) and carried out by researchers from the universities of Bristol, Oxford and Cambridge, involved over 400,000 men aged 50-69. Just under half received a single invitation for a PSA test as part of the trial. 

After following up for 15 years, there was a small difference in the number of men who died from prostate cancer between the two groups – nearly 7 men out of every 1,000 in the group invited for screening had died from prostate cancer, compared to nearly 8 men out of every 1,000 in the group who hadn’t been invited for screening. 

The results of the trial show that an estimated 1 in 6 cancers found by the single PSA screening were overdiagnosed. 

Cancer Research UK warns that overdiagnosis** of prostate cancer is the main worry with PSA testing for early detection. This can result in the unnecessary treatment of cancers that would not have caused any harm in someone’s lifetime. Overdiagnosis can have a negative psychological impact, and treatment of prostate cancer may cause physical side effects including the possibility of infection following a biopsy, erectile dysfunction, and bladder and bowel problems.  

Cancer Research UK also raises awareness of the importance of listening to your body and getting to know what's normal for you. If you notice a change that doesn’t go away or is new, then speak to your doctor. 

If a man has urinary symptoms*** – most of which are caused by a non-cancerous enlargement of the prostate – he can contact his GP for advice, and this may include a PSA test.  

Professor Richard Martin, lead author and Cancer Research UK scientist at the University of Bristol, said: 

“Our studies have been measuring the effectiveness of the PSA test with hundreds of thousands of men for 15 years. The key takeaway is that the small reduction in prostate cancer deaths by using the test to screen healthy men does not outweigh the potential harms. 

“This results in some men going on to have invasive treatment that they don’t need, many years earlier than without screening, and the test is also failing to spot some cancers that do need to be treated. We need to find better ways to spot aggressive prostate cancers, so we can treat them early.” 

Prostate cancer is the 2nd biggest cancer killer of men in the UK, causing 12,000 deaths a year. There is currently no national screening programme for the disease. The UK National Screening Committee (NSC)****, which reviews the evidence for screening programmes, doesn’t currently recommend screening for prostate cancer because it is unclear that the benefits outweigh the harms. 

Despite being widely used to decide when to send men with urinary symptoms for further checks, when used to screen for prostate cancer, research has shown that the PSA test is inaccurate - it increases detection of low-risk prostate cancers and misses some high-risk ones. 

There have been improvements in diagnosing and treating the disease in the years since this trial began, including the introduction of MRI before biopsy. These changes may help to prevent some harms associated with PSA testing, but more research is needed into ways to find aggressive cancers that need to be treated. 

Naser Turabi, director of evidence and implementation at Cancer Research UK, said: 

“Prostate cancer remains the second most common cause of cancer death in men in the UK. Despite breakthroughs in treating the disease, there’s more we can do. 

“The evidence shows that using a single invitation for a PSA test for a prostate cancer screening programme is likely to do more harm than good for men. 

“We are funding research to help us find ways of diagnosing the disease early to reduce mortality, and we have trials taking place to find the best treatment for men with prostate cancer.  Our search is not over – we're determined to find ways to accurately detect aggressive prostate cancer early and identify those at highest risk.” 

Early prostate cancer usually has no symptoms so early detection is challenging. To try and save more lives from the disease, Cancer Research UK is funding more trials and research into prostate cancer. This includes speeding up diagnosis for men with aggressive disease with new blood, urine or genetic tests so they can start treatment sooner. 

Other research, such as the STAMPEDE trial, is aiming to find the best treatment for men with advanced prostate cancer to further improve survival and quality of life. The charity has spent £21 million on prostate cancer research over the last two years to improve outcomes for patients. 

Dr Neil Smith, GP for Cancer Research UK and GP Lead for Lancashire and South Cumbria Cancer Alliance, said: 

“With prostate cancer causing 12,000 deaths in the UK every year, we completely understand why men want to know if they have the disease, even when they don’t have symptoms. However, this research highlights that a PSA test for early detection can do more harm than good – it's simply not accurate enough and can lead to some men having tests and treatment that they don’t need.  

“You know your body best – so if you do notice any unusual changes, contact your GP. It probably won’t be cancer, but if it is, then spotting it earlier means that treatment is more likely to be successful.” 

 

Active workstations may improve cognitive performance

 

Peer-Reviewed Publication

MAYO CLINIC

 A recent Mayo Clinic study suggests that active workstations incorporating a walking pad, bike, stepper and/or standing desk are successful strategies for reducing sedentary time and improving mental cognition at work without reducing job performance. Extended sedentary behavior, whether at work or home, increases a person's risk of preventable chronic diseases.

"Our findings suggest that it is feasible to blend movement with office work that previously would have been done during long periods of sitting. Active workstations may offer a way to potentially improve cognitive performance and overall health, simply by moving at work," says Francisco Lopez-Jimenez, M.D., a preventive cardiologist at Mayo Clinic and senior author of the study.

The research involved 44 participants in a randomized clinical trial where four office settings were evaluated over four consecutive days at Mayo Clinic's Dan Abraham Healthy Living Center. Study findings are published in the Journal of the American Heart Association. The settings included a stationary or sitting station on the first day, followed by three active workstations (standing, walking or using a stepper) in a randomized order. Researchers analyzed participants' neurocognitive function based on 11 assessments that evaluated reasoning, short-term memory and concentration. Fine motor skills were assessed through an online typing speed test and other tests.  

When participants used the active workstations, their brain function either improved or stayed the same, and their typing speed slowed down only a bit. However, the accuracy of their typing was not affected. The study revealed improved reasoning scores when standing, stepping and walking as compared with sitting. 

"Being sedentary is the new smoking when it comes to your cardiovascular health, and office workers may spend a large part of their eight-hour workday sitting at a computer screen and keyboard. These findings indicate that there are more ways to do that work while remaining productive and mentally sharp. We would do well to consider an active workstation in the prescription for prevention and treatment of conditions like obesity, cardiovascular disease and diabetes," says Dr. Lopez-Jimenez.

Better nutrition can lead to better brain healths

 

“Insights & Implications in Gerontology: The Vital Role of Nutrition in Brain Health,” a new publication from the Gerontological Society of America, explores nutritional choices that have been shown to improve cognition and decrease the risk of cognitive impairment and dementia in older adults.

Consumption of a healthful diet is a behavioral strategy that can help to prevent the development of dementia as people age, the publication says. It also reports on the roles of vitamins and minerals in nutrition and brain function and focuses on how to implement person-centered conversations about the impact of diet and nutrition on overall wellness, including brain health.

Using a person-centered approach that ties conversations about nutrition to patient goals is an effective strategy for starting conversations about diet and health, according to Kathryn Porter Starr, PhD, RDN from Duke University School of Medicine and Durham VA Medical Center, who served as one of the faculty who oversaw the publication’s development.

“Broaching the topic of diet and nutrition can be challenging. I start by asking patients what their goals are,” she said. “These goals could include physical goals such as maintaining muscle mass, cognitive goals such as preserving memory, as well as functional goals such as being able to travel or play with grandchildren. Linking information about nutrition to helping adults achieve their goals is an effective strategy for stimulating motivation to implement healthy changes.”

The Mediterranean-DASH Diet Intervention for Neurodegenerative Delay, or MIND diet, is an example of a dietary pattern that is associated with improved cognition. This dietary pattern focuses on the consumption of vegetables (especially green leafy vegetables), nuts, berries, beans, whole grains, fish, poultry, and extra virgin olive oil while limiting red meat, processed meats, butter and margarine, regular cheese, pastries and sweets, and fried foods. People who consume this dietary pattern have been found to be the equivalent of 7.5 years younger in terms of cognitive abilities. The publication includes more details about the MIND diet and other dietary patterns that support healthy nutrition.

Ideally, individuals are able to obtain all necessary nutrients from their diet. However, the risk for inadequate vitamin and mineral intake increases as people age, and some people may benefit from consumption of fortified foods and or dietary supplements to enhance their nutritional status.

“I would love for everybody to get all of their micronutrients from food,” Starr said. Unfortunately, for most older adults, it’s really challenging to do that due to physiological changes that occur with aging and certain disease states that affect absorption, so we often recommend a multivitamin.”