Nutrition Interventions for Frailty and Sarcopenia/media/Files/Activity Files... · Nutrition Interventions for Frailty and Sarcopenia ... 28 Days 6% Young Control ... ACE Unit pilot

UTMB Claude D. Pepper Older Americans Independence CenterUTMB Claude D. Pepper Older Americans Independence Center

Nutrition Interventions for Nutrition Interventions for Frailty and SarcopeniaFrailty and Sarcopenia

Elena Volpi, MD, PhDClaude D. Pepper Older Americans Independence Center

Institute for Translational Sciences

University of Texas Medical Branch at Galveston

Institute Of Medicine, Food and Nutrition BoardNutrition And Healthy Aging In The Community Workshop

Washington, DC, October 5-6, 2011


OutlineOutline

• Frailty and sarcopenia

• Protein intake and mechanisms of sarcopenia

• Importance of protein quantity and intake

distribution pattern

• Special considerations for hospitalized older adults

• Vitamin D

• Summary and conclusions


Frailty and Sarcopenia Frailty and Sarcopenia

CYCLE OF FRAILTY

Chronic undernutrition

Sarcopenia ↓Insulin sensitivity

Osteopenia

↓ VO2max

↓Energy expenditure

↓Activity

↓Walking speed

Disability

Dependency

Immobilization Impaired balance

↓StrengthPower

FallsInjuries

↓Resting metabolic rate

AgingDisease

MedicationsEnvironment

Death Modified from Fried et al. Sci. Aging Knowl. Environ. 2005


SarcopeniaSarcopenia

Universal, progressive and

involuntary decline in lean

body mass and function

associated with aging,

primarily due to loss of

skeletal muscleRoubenoff and Castaneda, JAMA, 2001

InChianti Cohort - Lauretani et al. J Appl Physiol 2003


Strength and Mortality in Older AdultsStrength and Mortality in Older Adults

Newman et al. J Gerontol A Biol Sci Med Sci, 2006

Health ABC Study 2,292 healthy older adults, 70-79 yr at enrollment


OutlineOutline






• Vitamin D



Aging Attenuates the Meal Stimulated Aging Attenuates the Meal Stimulated Increase in Muscle Protein SynthesisIncrease in Muscle Protein Synthesis

Perc

ent

per

hou

r

0

0.02

0.04

0.06

0.08

0.10

0.12

Fasting Meal

*

Young AdultsOlder Adults Volpi et al. J Clin Endocrinol Metab, 2000


Muscle Protein Synthesis is Resistant to the Muscle Protein Synthesis is Resistant to the Anabolic Effect of Insulin in Older AdultsAnabolic Effect of Insulin in Older Adults

Rasmussen et al., FASEB J, 2006Fujita et al. Diabetologia, 2009

Young Adults Prandial DoseOlder Adults Prandial Dose

Fasting Insulin0

0.02

0.04

0.06

0.08

0.10

0.12

Perc

ent

per

hour

#*

#*

Older Adults High Dose


Cellular Mechanisms of Resistance to Cellular Mechanisms of Resistance to Anabolic Stimulation in Older AdultsAnabolic Stimulation in Older Adults


Endothelial Dysfunction Contributes to Endothelial Dysfunction Contributes to Resistance to Anabolic Stimulation in EldersResistance to Anabolic Stimulation in Elders

Basal Insulin

Youn

gSu

bjec

tO

lder

Subj

ect

Timmerman, et al., J Clin Endocrinol Metab, 2010; and Diabetes, 2010


Pharmacological Vasodilation Restores the Anabolic Pharmacological Vasodilation Restores the Anabolic ResponseResponse of Muscle to Insulin in Older Adultsof Muscle to Insulin in Older Adults

Older ControlOlder Sodium Nitroprusside

0

5

10

15

20

25

30* †

Fasting Insulin Fasting Insulin0

20

40

60

80

100

120

140

160

180

nmol

⋅min

-1⋅10

0 m

l leg

-1

*#

Timmerman, Lee et al., Diabetes, 2010

Muscle Perfusion (Nutritive Flow) Muscle Protein Synthesis


Aerobic Exercise Restores the Muscle Protein Aerobic Exercise Restores the Muscle Protein Anabolic Response to a Mixed Meal in EldersAnabolic Response to a Mixed Meal in Elders

0

20

40

60

80

100

120

0

0.5

1

1.5

Fasting Meal

* †Muscle Perfusion (Nutritive Flow)

Fasting Meal

* †

Muscle Protein Synthesis

* P<0.05 vs. Basal† P<0.05 vs. Control

ControlExercise Timmerman et al., FASEB J 2010 (abstract)

Perc

ent/

hour


OutlineOutline






• Vitamin D



7 g Essential Amino Acids 18 g Essential Amino Acids

Response of Muscle Protein Synthesis To Response of Muscle Protein Synthesis To Essential Amino Acids Depends on Leucine Dose Essential Amino Acids Depends on Leucine Dose

Volpi et al, AJCN, 2003Young adultsOlder adults

0

10

20

30

40

50

60

1.7 g Leucine(~15 g protein)



Perc

ent

chan

ge f

rom

fas

ting

*

* * *

Katsanos et al, AJP, 2006


Muscle Protein Synthesis in Older Adults: Muscle Protein Synthesis in Older Adults: Protein MealProtein Meal

30 g of Protein4 oz beef patty

(~320 kcal)

* *

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

Fasting Meal

Perc

ent

per

hour

Young adultsOlder adultsSymons et. al. AJCN, 2007

90 g of Protein12 oz beef patty

(~960 kcal)

* *

Fasting Meal

Symons et. al. J Am Diet Assoc, 2009

50%


Protein Intake Pattern Across Meals in Protein Intake Pattern Across Meals in Adults 70 yr and OlderAdults 70 yr and Older

Source: NHANES 2007-2008

Breakfast Lunch Dinner 0

10

20

30

40

50

14 g 16 g 32 g

Average reported intake ~1 g/kg

Reported Distribution

Breakfast Lunch Dinner

30 g 30 g 30 g

Ideal Distribution Max. Muscle Protein Synthesis

Calculated ideal intake ~1.3 g/kg

Paddon-Jones & Rasmussen, Curr Op Clin Nutr Metab Care 2009

~20%~23%

~46%

~33% ~33% ~33%


OutlineOutline






• Vitamin D



Age (yrs)

Func

tion

Patterns of Functional Loss and DisablementPatterns of Functional Loss and Disablement

Independence

Dependence

40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90


Hospitalized Older Adults Are Hospitalized Older Adults Are Very Inactive Very Inactive

Home Hospital0

50

100

150

200

250

300

350

Home Hospital0

1000

2000

3000

4000

5000

6000

Steps per Day Minutes Active per Day

Fisher et al. JAGS 2011


Total Daily Steps and Early Mobilization Total Daily Steps and Early Mobilization Predict Hospital Length of Stay in Older AdultsPredict Hospital Length of Stay in Older Adults

Fisher et al. JAGS 2011 Fisher et al. Arch Int Med 2010

Step Change from 1st to 2nd Hospital Day

Complete Hospital Days

0 1 2 3 4 5 6 7

Tota

l Ste

ps (m

edia

n)

0

100

200

300

400

500

600

700

n=58

n=19

n=38

n=47

n=34n=28

n=77

Number of Steps and LOS

Early Mobilization and LOS


Inactivity Induces Significant Muscle LossInactivity Induces Significant Muscle Lossin Older Adultsin Older Adults

-1500

-1000

-750

-500

-250

0

250

Loss

of

lean

leg

mas

s (g

)

-2000

Young “Stress model”28 Days

6%

Young Control28 Days

2%

Older Adults10 Days

9%

Paddon-Jones et al. J Clin Endcrinol Metab, 2004Kortebein et al. J Gerontology, 2008

While consuming the protein RDA


Hospitalized Older Patients May Not Hospitalized Older Patients May Not Eat Adequate Amounts of ProteinEat Adequate Amounts of Protein

Paddon-Jones, ACE Unit pilot data

0

20

40

60

80

100

Protein

PresentedConsumed

Gram

s pe

r m

eal

Carbohydrate Fat


Excess Dietary Amino Acids Can Prevent InactivityExcess Dietary Amino Acids Can Prevent Inactivity--Induced Reductions in Muscle Protein Synthesis Induced Reductions in Muscle Protein Synthesis

0

0.01

0.020.03

0.040.05

0.06

0.070.08

0.090.1

Day 1 Day 10

24 h

r Pr

otei

n Sy

nthe

sis

(%/h

)

*

Normal Diet Normal DietNormal Diet +Amino Acids

#

Normal Diet +Amino Acids

30%

Ferrando et al. Clin Nutr 2010Normal diet protein content: 0.8 g/kg/day


OutlineOutline






• Vitamin D



OutlineOutline






• Vitamin D



SummarySummaryIn older adults:• Total daily protein intake is a predictor of sarcopenia• Response of muscle protein synthesis to amino acids is impaired at

lower intakes• Maximal stimulation of muscle protein synthesis is achieved at

intakes of ~3 g of leucine corresponding to ~30 g of whole protein• Immobilization reduces appetite, protein/energy intake and the

response of muscle to anabolic stimulation by nutrients• Supplementation with amino acids can improve muscle metabolism

during immobilization• Low vitamin D status is associated with reduced physical

functioning• Vitamin D supplementation may reduce the risk of falls


Conclusions and Research NeedsConclusions and Research Needs• Adequate protein intake is essential for muscle mass and function in

older adults

• Protein is the only macronutrient that has no inactive reservoir (i.e. it is stored in active tissues, mainly muscle, or converted to energy)– Is the current protein DRI adequate to maintain function in seniors?

– Aside from total intake, should we also consider daily intake distribution?

• Protein intake should be adjusted according to health status andactivity level– What is the optimal protein intake for hospitalized/inactive seniors?

– What is the optimal protein intake for active seniors?

• Vitamin D intake may be another key nutrient for the reduction of the risk of falls and frailty in older adults– Is the current RDA for Vit. D optimal to maintain physical functioning?


[email protected]/scoa/pepper/index.asp

Grow old along with me!The best is yet to be,the last of life,for which the firstwas made

Robert Browning

mailto:[email protected]

http://www.utmb.edu/scoa/pepper/index.asp

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Nutrition Interventions for Frailty and Sarcopenia/media/Files/Activity Files... · Nutrition Interventions for Frailty and Sarcopenia ... 28 Days 6% Young Control ... ACE Unit pilot