PowerPoint Presentation · 3/5/2018 1 ANFP Regional Meetings The Journey to Excellence Nutrition Interventions for Sarcopenia Prevention and Treatment Liz Friedrich, MPH, RDN, CSG,

3/5/2018

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ANFP Regional MeetingsThe Journey to Excellence

Nutrition Interventions for Sarcopenia

Prevention and Treatment

Liz Friedrich, MPH, RDN, CSG, LDN, FAND, NWCC

March 15, 2018

ANFP Spring Regional Meetings | 2018

Objectives

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• State good food sources of protein

• State at least three interventions that can be used to increase protein available to residents in long-term care

• Understand what types of physical activity can be used to treat sarcopenia in residents in long-term care

• Understand the importance of respecting patient preferences while meeting protein needs

ANFP Spring Regional Meetings | 2018 3

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Regulatory Requirements in LTC

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State Operations Manual Appendix PP - Guidance to Surveyors for Long

Term Care Facilities (Rev. 173, 11-22-17)

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

New CMS rules (November

2017) have a more intense

focus on patient-centered

care and care planning


Who decides what

interventions to order for

your patients?

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Sarcopenia

“Loss of muscle

mass that occurs

with aging”

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Sarcopenia

“Syndrome characterized

by progressive and

generalized loss of

skeletal muscle mass and

strength with a risk of

adverse outcomes such

as physical disability, poor

quality of life, and death”.

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Proteins

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Protein Needs

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ConditionProtein Needs (g/kg)

Academy Pocket Guide to Nutrition

Assessment

Protein Needs (g/kg)Recent literature

Healthy Adult 0.8

Older adult > 65 years1.0

1.0-1.2 (PROT-AGE

study)

Pressure injury 1.25-1.5

Critical Illness 1.5-2.0

Sarcopenia 1.0-1.5 (Morley)

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Do Older Adults Get Enough Protein?

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Maybe not!

Decreased intake associated with aging (“anorexia of aging”)

Difficulty with shopping, food prep, etc.

Difficulty eating, chewing, or swallowing

Cognitive issues that might affect food intake


“Incomplete Proteins”

From plant sources, not animal sources

No need to combine “incomplete” proteins with “complete” proteins.

As long as a variety of protein foods are consumed in a day, all needed amino acids will be consumed.

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High Biological Value Protein

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Research suggests that protein intake should be evenly

distributed throughout the day to maximize protein

synthesis

Meal Distribution

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Dietary Source of Protein-Animal Foods

Food Grams protein

Beef, 3 ounces cooked 22 grams

Chicken, 3 ounces cooked 22 grams

Fish, 3 ounces cooked 20 grams

1 cup cow’s milk, 2% 10 grams

5.3 ounces Greek yogurt, vanilla 13 grams

6 ounces vanilla lowfat yogurt 8 grams

Egg, 1 large 6 grams

Cheese, 1 slice processed American 3 grams

Cheese, 1 slice American 4 grams14


Dietary Source of Protein-Plant Foods

Food Grams Protein

Tofu, 3 ounces soft 5 grams

Edamame, ½ cup 5 grams

Almonds, 1 ounce (23) 6 grams

Peanuts, 1 ounce 7 grams

Peanut butter, 2 Tbsp 7 grams

Baked beans, ½ cup 6 grams

Pinto beans, ½ cup 10 grams

Refried beans, ½ cup 6 grams

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Dietary Source of Protein-Beverages

Beverage Grams

Protein

Cow’s milk, 1 cup 10 grams

Soy milk, 1 cup 10 grams

Almond Milk, 1 cup 1 gram

Orange juice, ½ cup 1 gram

Coffee, 8 ounces 0 grams

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Protein Content of Average Breakfast

Food Protein Content

Juice, ½ cup 1 grams

Oatmeal (prepared without milk), ½ cup 5 grams

Whole wheat toast, 1 slice 4 grams

Scrambled egg, 1 6 grams

Milk, 2%, 1 cup 10 grams

1 cup coffee 0 grams

Condiments 0 grams

Total 26 grams

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Protein Content of Average Lunch

Food Grams Protein

Roast beef, 2 ounces 14 grams

Baked Potato, 1 medium 4 grams

Glazed carrots, ½ cup 1 gram

Dinner Roll, whole wheat, 1 2 grams

2% milk, 1 cup 10 grams

Condiments 0 grams

Sherbet, ½ cup 1 gram

Total 32 grams

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Protein Content of Average Dinner

Food Grams Protein

Spaghetti noodles, 1 cup 7 grams

Meat sauce, ½ cup 18 grams

Whole wheat roll, 1 2 grams

Vegetable medley, ½ cup 2 grams

2% milk, 8 ounces 10 grams

Condiments 0 grams

Chocolate cake, 1 piece 5 grams

Total 44

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What Do Your Patients Actually Eat?

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What Do Your Patients Actually Eat?

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Translating Evidence Into Practice

80 year old woman with sarcopenia

➢159 pounds

➢Protein Needs: 1.0-1.5 grams/kg body weight/ day (72-109 grams/day)

➢Eats 50% of meals. Does not drink milk

➢Can her needs be met without a supplement?

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Translating Evidence into Practice

Who decides what


your patients?

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Skim milk powder

Milk or half and half

Cheese

Eggs

Peanut butter

Cottage cheese

Greek yogurt

Easy Ways to Add Protein

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Change scrambled egg to a 2-egg omelet with cheese (13 grams).

Add one-two links of sausage (4-9 grams).

Add ½ cup cottage cheese (12 grams)

Add 5.3 ounces of Greek Yogurt (14 grams).

Add 1-2 Tablespoons of peanut butter to spread on toast (4-9 grams).

Add a high-protein beverage of choice such as commercial oral nutrition supplement (8-9 grams).

Fortify hot cereal and/or and eggs using non-fat dry milk powder or commercial protein powder.

Easy Ways to Add Protein at Breakfast

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Use milk instead of water to prepare hot

chocolate, cream soups, and hot

cereal

Increase amount of protein in

sandwiches

Add non-fat dry milk to soup, pudding,

cooked cereal, scrambled eggs, casseroles, etc.

Provide foods fortified with protein using commercial

protein


Hot cereals

Mashed potatoes

Eggs

Casseroles

Hot chocolate

Home-made milk shakes

Recipes are available

Use Recipes for Fortified Foods

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Obtain food and lifestyle preferences; involve patient/surrogate in selecting interventions

• Individualize diet

• Remove therapeutic and/or texture restrictions

Increase protein, especially at breakfast, to space protein more evenly throughout the day

Provide HBV sources of protein at meals (milk, yogurt, large portions of meat and eggs)


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▪Oral Nutrition

Supplements (ONS)

▪Given on meal trays or

between meals

▪Given with medication

passes

Beverages

Pudding

Bars

Fortified cookies

Ice cream products

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Provide oral nutritional supplements and medical foods as needed

Estimate calorie and protein needs, review intake, and rovide medical foods and supplements as needed

Consider protein and calorie content per volume of supplement

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Serve a form of ONS that the patient will consume

Involve patient and/or their surrogate in selecting supplements

Taste-test various supplements for acceptance


• ONS are generally suggested to be given between meals rather than with meals

Provide supplements between meals and/or

with med passes to meet “standard of care”

• Research indicates that that protein intake should be equally spaced throughout the day

Supplement with meals to equalize protein

intake throughout the day ?????

Timing of ONS

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Choosing ONS

Monitor and evaluate

effectiveness of supplement

Change timing or form of

supplement to meet

patient’s needs

Change flavor to avoid

flavor fatigue

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Document if an individual

declines nutrition

interventions

Update Care Plan to reflect

changes

Choosing ONS

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2008 Physical Activity Guidelines

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For substantial health

benefits, do one of the

following:

150 minutes (2 hours and 30

minutes) each week of

moderate-intensity aerobic

physical activity (such as

brisk walking or gardening)

75 minutes (1 hour and 15

minutes) each week of

vigorous-intensity aerobic

physical activity (such as

jogging or swimming laps)

An equivalent combination

of moderate- and vigorous-

intensity aerobic physical

activity

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Exercise for Older Adults


Adults ages 65 years and older gain substantial health benefits from regular physical activity, and these benefits continue to occur throughout their lives.

For adults aged 65 and older who are fit and have no limiting chronic conditions, the guidelines are the same as those for all adults.

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When older adults cannot do

150 minutes of moderate-

intensity aerobic activity a

week because of chronic

conditions, they should be as

physically active as their

abilities and conditions allow

2008 Physical Activity Guidelines-Older Adults

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Older adults should do exercises that maintain or improve balance if they are at risk of falling.

Older adults should determine their level of effort for physical activity relative to their level of fitness



Older adults with chronic

conditions should

understand whether and

how their conditions affect

their ability to do regular

physical activity safely

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Endurance exercise, 30 minutes per day at levels that are safe and tolerated.

Include progressive resistance training when possible; consider 2-3 times per week for 10-15 minutes or more per session

Increase dietary protein intake or provide supplemental protein as needed to achieve total daily intake of at least 1.2 g/kg/day

Consider prescribing a 20-g protein supplement after exercise sessions

Exercise Recommendations PROT-AGE

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Physical Activity for Long-Term Care

Residents

▪Decrease the sedentary

time of LTC residents

▪Use simple strategies to

encourage residents to

move

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Residents

Adding/enhancing

physical activity

programs in a facility

should be planned

facility-wide, with

knowledge and consent

of the administrator and

medical director

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Residents

Walk to dine programs

Organize events that

require residents to leave

their rooms

Optimize space to promote

mobility

Organize group activities

that encourage activity

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Potential Benefits of Exercise

for LTC Residents

Data is positive for

▪Improved ADL performance

▪Improved physical function

Data is mixed for

▪Benefits to mobility and physical function of those with dementia

▪Positive effect on depressive symptoms

▪May improve incidence of falls

▪May improve quality of life

▪May contribute to decreased risk of sarcopenia

▪May improve health outcomes and decrease use of medications

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Potential Barriers to Exercise for Residents in

Long-Term Care Facilities

▪Health Status

▪Environmental barriers

▪Lack of space

▪Lack of storage for equipment

▪Organizational barriers

(staffing and funding)

▪Staff attitudes/worry about

pushing residents to be active

▪Work load demands

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Resistance Exercise

Use rubber

bands, light

weights, or body

weight

Must conform to

abilities of each

individual

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Simple Ways to Increase Activity

Encourage residents to “wheel themselves”

Encourage residents to help themselves with ADL’s

Encourage activities department to provide “sit-er-cise, beach ball games, dances, etc

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Simple Ways to Increase Activity

Encourage visits by

animals

Use video games that

encourage activity

Encourage use of arms

and legs, even when

sitting

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▪4 minute warm up (range of motion exercises)

▪8 minutes balance/coordination (Standing balance, walking

forward with direction changes, walked along a straight line)

▪15 minutes strength (13-15 repetitions of chair, elastic band

exercises, calf raises)

▪15 minutes aerobic (5, 3-minute bouts of walking with strength

or balance/coordination between bouts)

▪3 minutes cool down

One Proposed Physical Activity Program

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Surveyors will be

looking for evidence of

▪ Resident and/or their

surrogate being involved

in decisions

▪Resident exercising their

right to make choices

and/or refuse care

Regulatory Requirements in Long-Term Care

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Who decides what


your patients?

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References

▪ Baronski S, Ayello EA. Wound Care Essentials: Practice Principles . Wolters Kluwer. 2016.

▪ Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study group. J Am Med Dir Assoc . 2013:14(8):542-559.

▪ Bell CL, Tamura BK, Masaki KH, Et al. Factors associated with weight loss, low BMI, and malnutrition among nursing home patients: a systematic review of the literature. J AM Med Dir Assoc. 2013;14(2):94-100.

Cramer JT, Cruz-Jentoft AJ, LandiF, et al. Impacts of high-protein oral nutrit ional supplements among malnourished men and women with sarcopenia: a multicenter, randomized, doubled-blinded, controlled trial. JAMDA. 2016 (17):1044-1055.

De Souto Barreto P, Morley JE, Chodzko-Zajko C et al. Recommendations for physical activity and exercise for older adults living lin long term care facilit ies: a taskforce repot.JAMDA.2016.

Escott-Stump S. Nutrition and Diagnosis-Related Care. 8th edition. Wolters Kluwer; 2015.

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References

Morley JE. Argiles JM, Evans W J et al.

Nutritional recommendations for the management of sarcopenia. J Am Med Dir

Assoc. 2010;11(6):391-396

National Nutrient Database for Standard

Reference. U.S. Department of

Agriculture. https://ndb.nal.usda.gov/ndb/

Neidert K, Carlson M, eds. Nutrition Care

of the Older Adult: A Handbook for

Nutrition Throughout the Continuum of

Care. Chicago IL: Academy of Nutrition and Dietetics; 2016.

Paddon-Jones D, Rasmussen BB. Dietary

protein recommendations and the prevention of sarcopenia. Current Opin

Clin Nutr Metabol Care. 2009;12(1):86-

90.

Santarpia L, Contald F, Pasanisi F.

Dietary protein content for an optimal

diet: a clinical view . J Cachexia

Sarcopenia Muscle. 2017: W iley Online Library. doi: 10.1002/jcsm.12176.

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Where Do You Go From Here?

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Documents

PowerPoint Presentation · 3/5/2018 1 ANFP Regional Meetings The Journey to Excellence Nutrition Interventions for Sarcopenia Prevention and Treatment Liz Friedrich, MPH, RDN, CSG,