Diet approach to manage sarcopenia

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1 Diet approach to manage sarcopenia TERRY TING DIETITIAN, MSC. MBA Background Consequence Decreased insulin sensitivity Diminished muscle strength Increased risk of fall and fracture Increased risk of physical disability Increased risk of mortality Problem size 45% elderly in U.S. 11.2% in men and 7.6% in women in HK aging population Financial burden $18.5 billion per year in U.S. High risk group > 30 yo Inactive lifestyle Undernutrition (energy, protein, vitamin D) Fact 1

2 Focus Ageing and muscle mass Lean muscle mass is lost at the rate of approximately 1% per year after 30 years of age Fat gain and muscle loss Gain 15kg fat and loss 7kg muscle from 30 to 60 yo 2

Factors contributing to alter nutrients intake in elderly Sensory change Refusal to meal Unable to eat Insufficient food and fluid Not assessable to food Depression or social

3 Factors contributing to alter nutrients intake in elderly Sensory change Refusal to meal Unable to eat Insufficient food and fluid Not assessable to food Depression or social isolation GI disorders Other diseases such as Parkinson s, COAD, heart diseases etc Key nutrients for sarcopenia prevention Protein & Vitamin D Quality v.s Quantity, and then How? 3

4 Protein Protein is an important nutrient for the maintenance of muscle mass in older adults Studies illustrate ingestion of protein deficient meals fails to stimulate protein synthesis Need to increase intake to prevent muscle loss in elderly Leucine in food Proteins from animals that naturally contain all the essential amino acids Leucine Precursor for protein synthesis and associate with muscle protein synthesis The most abundant of the three branched chain amino acids (BCAAs) in muscles Muscle building effect is only optimized when taken with the other essential amino acids 4

5 About protein intake Recommended Dietary Allowance for protein is 0.8 g/kg/day for healthy adults (FAO/WHO/UNU, 1985) Ingestion of 25 to 30g of protein per meal contains 5 8 g of essential amino acids, which are primarily responsible for stimulating muscle protein synthesis Current opinion in clinical nutrition and metabolic care,2009, 12(1), 86. The Society for Sarcopenia, Cachexia, and Wasting Disease convened an expert panel recommended a total protein intake of 1 to 1.5 g/kg/day J Am Med Dir Assoc. 2010;11(6): Elderly protein intake in HK Community Survey of 4000 elderly from community centers for the elderly and housing estates in Hong Kong Indicated that 82% of the participants achieved RDA recommendation for protein intake ISRN Geriatrics, USDA Agricultural Research Service 1996 Continuing Survey of Food Intakes showed that 40% of men and women aged 70 y consumed <100% of RDA for protein and, 16% consumed <75% of the RDA for protein Hospitalized elderly s protein intake in U.S. is taking 1g/kg/day Hospital J Am Geriatr Soc. 2008;56(6): Ranged from 26 66g protein per day Source: International Journal of Food Sciences and Nutrition (2002) 53, Source: Nutrients, 2013, 5(3), Source: International Journal of Food Sciences and Nutrition (2002) 53,

6 Daily protein recommendations by weight Considerations: Achievable + Optimal nutrition Weight (kg) 0.8g/kg/BW 25 to 30g of protein per meal 1 to 1.5g/kg/BW Local diet guideline for elderly Local healthy eating guideline: 5 to 6 oz of meat, fish, egg, and alternatives a day 1 to 2 servings of milk and alternatives Est. intake of protein according to the local guideline 35 to 56g per day Mean BW reported in a local sarcopenia study at CMC are: 54.1kg for man (0.6 1g/kg) 48.9kg for woman ( g.kg) 6

Vitamin D Vitamin D deficiency is approx. 26% noninstitutionalized Americans elderly and even higher in home bound and institutionalized elderly Lappe, J. M., & Binkley, N. (2015).

7 Vitamin D Vitamin D deficiency is approx. 26% noninstitutionalized Americans elderly and even higher in home bound and institutionalized elderly Lappe, J. M., & Binkley, N. (2015). Vitamin D and sarcopenia/falls. Journal of Clinical Densitometry. Chor, Leung, Griffiths, & Leung,. reported in their study with 4000 subjects that NONE of the subject meets RDA recommended Vitamin D intake in HK International Journal of Food Sciences and Nutrition, Volume 53, Issue 6, 2002 Vitamin D intake Depleted vitamin D levels may associated with low muscle strength and sarcopenia Clinical endocrinology, 2010, 73(5), Low serum 25(OH)D is associated with lower muscle mass, poorer performance in functional testing, and predicts greater muscle loss and disability development Lappe, J. M., & Binkley, N. (2015). Vitamin D and sarcopenia/falls. Journal of Clinical Densitometry. Individual with low vitamin D intake: < 20µ/day is considered as the high risk group for sarcopenia Source: Annals of Internal Medicine (Ann Intern Med 2010;153: ) Community Fall Prevention Campaign, Dept. of Orthopaedics and Traumatology, CUHK Evaluated 9 trials of vitamin D supplementation 5809 participants 7

8 Vitamin D recommendation Exposing arms and legs for 5 to 30 min between 10a to 3p may meet Vit D requirement Obtain adequate Vit D in food is challenging Lappe, J. M., & Binkley, N. (2015). Vitamin D and sarcopenia/falls. Journal of Clinical Densitometry. 4000IU/day from all source (diet, supplements, and sunlight) is recommended to optimize Vit D status, 3000IU/day may from Vit D supplement Upper limit for vitamin D is 1,000 to 1,500 IU/day for infants, 2,500 to 3,000 IU/day for children 1 8 years, and 4,000 IU/day for children 9 years and older, Serum 25 Hydroxyvitamin D [25(OH)D] Concentrations and Health nmol/l ng/ml Health status <30 <12 Associated with vitamin D deficiency, leading to rickets in infants and children and osteomalacia in adults Generally considered inadequate for bone and overall health in healthy individuals Generally considered adequate for bone and overall health in healthy individuals >125 >50 Emerging evidence links potential adverse effects to such high levels, particularly >150 nmol/l (>60 ng/ml) Source: Institute of Medicine 2010 American geriatrics society workgroup on vitamin D supplementation for older adults, 2013 Life Stage Recommended Amount per day Source: Nation Instituted of Health, U.S Food content of Vit D Food Birth to 12 months Children 1 13 years Teens years Adults years Adults 71 years and older Pregnant and breastfeeding women 400 IU 600 IU 600 IU 600 IU 800 IU 600 IU Source: Nation Instituted of Health, U.S IUs per serving Cod liver oil, 1 tablespoon 1,360 Swordfish, cooked, 3 ounces 566 Salmon (sockeye), cooked, 3 ounces 447 Tuna fish, canned in water, drained, 3 ounces 154 Orange juice fortified with vitamin D, 1 cup (check product labels, as amount of added vitamin D varies) 137 Milk, nonfat, reduced fat, and whole, vitamin D fortified, 1 cup Yogurt, fortified with 20% of the DV for vitamin D, 6 ounces (more heavily fortified yogurts provide more of the DV) 80 Margarine, fortified, 1 tablespoon 60 Sardines, canned in oil, drained, 2 sardines 46 Liver, beef, cooked, 3 ounces 42 Egg, 1 large (vitamin D is found in yolk) 41 Ready to eat cereal, fortified with 10% of the DV for vitamin D, cup (more heavily fortified cereals might provide more of the DV) Cheese, Swiss, 1 ounce 6 Source: U.S. Department of Agriculture, Agricultural Research Service

9 Practical diet tips ADDING PROTEIN Include protein in breakfast Consume protein containing drinks Consider high protein snack/ dessert Use of protein powder supplement/ high protein milk supplement Enteral nutrition formula Basic oral formula Provide complete nutrition (macro and micro nutrient) 1 to 2 Kcal per ml of liquid Well tolerated by oral Require assessment and monitoring Contradiction: children, overweight, DM, renal disease, liver disease, GI disease, pancreatitis etc. Prescription is suggested ADDING VITAMIN D Sunlight exposure Include high vitamin D food (salmon, tuna etc ) Consider vit D fortified food (milk, cereal, soymilk, etc ) Consider to give vitamin D supplement Disease specific formula Complete nutrition with adjustment on some ingredients (carbohydrate, electrolytes etc..) Use with caution Require assessment and monitoring Contradiction: depends on types and combination of diseases Prescription is suggested 9

Enteral nutrition formula Basic oral formula To conclude SUMMARY Adequate protein and Vit D intake may preserve muscle mas and strength Protein and Vit D

specific formula SUGGESTIONS Qualitative and quantitative local research Education to public and healthcare providers Nutrition screening and assessment is

10 Enteral nutrition formula Basic oral formula To conclude SUMMARY Adequate protein and Vit D intake may preserve muscle mas and strength Protein and Vit D intake of local elderly are lower than recommended level to prevent sarcopenia Current local dietary guideline is designed for healthy individual Disease specific formula SUGGESTIONS Qualitative and quantitative local research Education to public and healthcare providers Nutrition screening and assessment is recommended for high risk group Optimal nutrients intake is essential to maintain health Dietary intervention is suggested for individual diagnosed with sarcopenia 10

11 Reference A. J. Cruz Jentoft, J. P. Baeyens, J. M. Bauer et al., Sarcopenia: European consensus on definition and diagnosis, Age and Ageing, vol. 39, no. 4, Article ID afq034, pp , View at Publisher View at Google Scholar View at Scopus Devries MC, Phillips SM. Supplemental protein in support of muscle mass and health: advantage whey. J Food Sci Mar;80 Suppl 1:A8 A15. Fulgoni VL., 3rd Current protein intake in America: Analysis of the National Health and Nutrition Examination Survey, Am J Clin Nutr. 2008;87:1554S 1557S. [PubMed] Gaillard, C., Alix, E., Boirie, Y., Berrut, G., & Ritz, P. (2008). Are elderly hospitalized patients getting enough protein?. Journal of the American Geriatrics Society, 56(6), Henry, C. J. K., Woo, J., Lightowler, H. J., Seyoum, T. A., Yip, R., Lee, R.,... & Shing, S. (2002). Brief communication: energy and protein intake in a sample of hospitalized elderly in Hong Kong. International journal of food sciences and nutrition, 53(6), Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, Kerstetter JE, O'Brien KO, Insogna KL. Low protein intake: The impact on calcium and bone homeostasis in humans. J Nutr. 2003;133: [PubMed] Lappe, J. M., & Binkley, N. (2015). Vitamin D and sarcopenia/falls. Journal of Clinical Densitometry. Lesourd B, Decarli B, Dirren H. Longitudinal changes in iron and protein status of elderly Europeans. SENECA Investigators. Eur J Clin Nutr. 1996;50:S16 S24. [PubMed] Morley JE, Argiles JM, Evans WJ, et al. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc. 2010;11(6): Paddon Jones D, Sheffield Moore M, Zhang XJ, et al. Amino acid ingestion improves muscle protein synthesis in the young and elderly. Am J Physiol Endocrinol Metab. 2004;286:E321 E328. Reference Paddon Jones, D., & Rasmussen, B. B. (2009). Dietary protein recommendations and the prevention of sarcopenia: Protein, amino acid metabolism and therapy. Current opinion in clinical nutrition and metabolic care,12(1), 86. R. R. Wolfe, S. L. Miller, and K. B. Miller, Optimal protein intake in the elderly, Clinical Nutrition, vol. 27, no. 5, pp , View at Publisher View at Google Scholar View at Scopus Robinson, S., Cooper, C., & Aihie Sayer, A. (2012). Nutrition and sarcopenia: a review of the evidence and implications for preventive strategies. Journal of aging research, Scott, D., Blizzard, L., Fell, J., Ding, C., Winzenberg, T., & Jones, G. (2010). A prospective study of the associations between 25 hydroxy vitamin D, sarcopenia progression and physical activity in older adults. Clinical endocrinology, 73(5), U.S. Department of Agriculture, Agricultural Research Service USDA National Nutrient Database for Standard Reference, Release 24. Nutrient Data Laboratory Home Page, link disclaimer. USDA Agricultural Research Service. Data tables: results from USDA's 1996 Continuing Survey of Food Intakes by Individuals and 1996 Diet and Health Knowledge Survey. Online ARS Food Surveys Research Group. Internet: (accessed 4 December 2006). Vellas BJ, Hung WC, Romero LJ, et al. Changes in nutritional status and patterns of morbidity among free living elderly persons: A 10 year longitudinal study. Nutrition. 1997;13: [PubMed] Volpi E, Kobayashi H, Sheffield Moore M, Mittendorfer B, Wolfe RR. Essential amino acids are primarily responsible for the amino acid stimulation of muscle protein anabolism in healthy elderly adults. Am J Clin Nutr. 2003;78: W. F. Nieuwenhuizen, H. Weenen, P. Rigby, and M. M. Hetherington, Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake, Clinical Nutrition, vol. 29, no. 2, pp , View at Publisher View at Google Scholar View at Scopus Yoshizawa F, Kimball SR, Vary TC, Jefferson LS. Effect of dietary protein on translation initiation in rat skeletal muscle and liver. Am J Physiol Endocrinol Metab. 1998;275:E814 E820. Dideriksen, K., Reitelseder, S., & Holm, L. (2013). Influence of amino acids, dietary protein, and physical activity on muscle mass development in humans. Nutrients, 5(3), Chor, J. S. Y., Leung, J., Griffiths, S., & Leung, P. C. (2012). Assessment of Malnutrition in Community Chinese Elderly: A Hidden Problem in a Developed Society. ISRN Geriatrics,

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Vitamin D: How to Translate the Science of the New Dietary Reference Intakes for This Complex Vitamin More Is Not Always Better!

April 2012 Volume 50 Number 2 Article Number 2TOT7 Return to Current Issue Vitamin D: How to Translate the Science of the New Dietary Reference Intakes for This Complex Vitamin More Is Not Always Better!