19/10/2017 PLACE DE LA NUTRITION ET DE L ACTIVITÉ. Olivier Bruyère PHYSIQUE DANS LA PRISE EN CHARGE DE LA SARCOPÉNIE. Université de Liège, Belgique

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1 PLACE DE LA NUTRITION ET DE L ACTIVITÉ PHYSIQUE DANS LA PRISE EN CHARGE DE LA SARCOPÉNIE Olivier Bruyère Université de Liège, Belgique Introduction Methods Results Conclusion The combination of a person s physical and mental capacities (known as intrinsic capacity) is a better predictor of their health and wellbeing than the presence or absence of disease. Introduction To be discussed today Physical activity physical excercises: recent meta analyses : focus on supplementation with one recent systematic review (WHO) Added value of food supplementation to physical activity: one recent systematic review (IOF ESCEO) + Meta analysis on protein supplementation (Liao et al 2017) 1

2 Quizz Quelles sont les recommandations de l OMS pour la pratique d activité physique minutes par jour d activité physique intensive minutes par jour d activité physique intensive minutes par jour d activité physique intensive Physical exercises The Wold Health Organization (WHO) recommends adults aged 65 years and older to do at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, or do at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity Physical activity includes recreational or leisure-time physical activity, transportation (e.g. walking or cycling), occupational (if the person is still engaged in work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities The WHO recommendations state that muscle-strengthening activities should be done involving major muscle groups, on 2 or more days a week 5 Physical exercises Muscle and physical performance targets: Exercises should preferably be dynamic Exercises should target the major muscle groups of the body using both concentric (lifting or pushing) and eccentric (smooth and controlled lowering) movements. Lower extremity muscle groups such as the knee and hip extensors, knee flexors, dorsi flexors and plantar flexors should be prioritized as they are critical for mobility, balance, and the prevention of falls. Progressive resistance training (PRT) protocols are necessary. PRT should be accomplished through altering one or more of the following variables: exercise intensity, total repetitions performed at the current intensity, repetition speed/tempo with submaximal loads, rest periods, training volume. Florence

3 Physical exercises Forest plot of studies comparing changes in 1RM strength in high- versus low-load training (Brad J. Schoenfeld et al 2017) 7 Physical exercises Forest plot of studies comparing changes in muscle hypertrophy in highversus low-load training (Brad J. Schoenfeld et al 2017) 8 Quizz Quelles sont les compléments alimentaires qui ont toujours montré des effets positifs sur la force musculaire chez la personne âgée? 1. Les protéines 2. Les acides aminés essentiels? 3. La DHEA? 4. La créatine? 5. Tous? 6. Aucun? 3

4 OBJECTIVE: To perform a systematic review to investigate the effects of protein, essential amino acids (EAA), β hydroxy β methylbutyrate (HMB), creatine, dehydroepiandrosterone (DHEA) and fatty acid supplementation on the muscle mass, muscle function and physical performance of elderly subjects DATABASES: MEDLINE/Ovid and EMBASE/Ovid and Cochrane INCLUSION CRITERIA: EXCLUSION CRITERIA: studies providing nutritional supplements in combination with another intervention Studies in which the nutritional intervention was energy restriction to promote weight loss Populations with a specific health condition (e.g., cirrhosis, cancer, diabetes, chronic kidney disease). STUDY SELECTION AND DATA EXTRACTION : Two independant researchers STUDY QUALITY: Jadad score 3528 studies identified through electronic database searches 23 RCTs published up to February 2016 included in this SR PRESENTATION BY NUTRITIONAL SUPPLEMENT: Proteins (n=4) Essential amino acids (EAA) (n=7) β hydroxy β methylbutyrate (HMB) (n=2) Dehydroepiandrosterone (DHEA) (n=4) Creatine (n=6) Fatty acid (n=0) 4

5 Characteristics of included studies: Publication year Countries 9/23 Europe 13/23 USA/Canada 1/23 Australia Sex 14/23 mixed men/women 4/23 only women 5/23 only men Sample Follow up subjects 5 days 2 years Jadad score 7/23 excellent quality 12/23 good quality 4/23 poor quality Outcome 19/23 muscle mass 20/23 muscle strength 9/23 physical performance Population 4/23 : nursing home residents 2/23 : frail community dwelling 17/23 : healthy community dwelling PROTEINS 4 RCTs 1) 208 Caucasian adults 2) 65 pre frail and frail elderly 3) 196 well nourished healthy older postmenopausal women 4) 106 nursing home residents Dose varied from 20g to 45g of protein per day Good quality of studies Results: muscle mass compared muscle strength compared physical performance compared to placebo Protein 0/4 RCTs 0/3 RCTs 1/2 RCTs EAA 0/4 RCTs 1/6RCTs 3/4 RCTs Creatine 1/4 RCTs 2/6 RCTs 0/1 RCT Limited effects DHEA 0/4 RCTs 0/3 RCTs / HMB 2/2 RCTs 1/2 RCTs 0/2 RCTs Fatty acids / / / PA and nutrition Olivier Bruyère ESSENTIAL AMINO ACIDS 7 RCTs 1/7 hospitalized elderly 1/7 nursing home residents 5/7 healthy community dwelling Dose varied from 2.5g to 15g per day (10 days 3 months) Quality of studies (4 good, 3 poor) Results: muscle mass compared muscle strength compared physical performance compared to placebo Protein 0/4 RCTs 0/3 RCTs 1/2 RCTs EAA 0/4 RCTs 1/6RCTs 3/4 RCTs Creatine 1/4 RCTs 2/6 RCTs 0/1 RCT DHEA 0/4 RCTs 0/3 RCTs / HMB Limited effects 2/2 RCTs 1/2 RCTs 0/2 RCTs Fatty acids / / / 5

6 CREATINE 6 RCTs 1/7 hospitalized elderly 1/7 nursing home residents 5/7 healthy community dwelling Protocol of supplementation very heterogeneous (5 days 24 weeks) Quality of studies (2 excellent, 3 good, 1 poor) Results: physical muscle mass compared muscle strength compared performance compared to placebo Protein 0/4 RCTs 0/3 RCTs 1/2 RCTs EAA 0/4 RCTs 1/6RCTs 3/4 RCTs Creatine 1/4 RCTs 2/6 RCTs 0/1 RCT DHEA 0/4 RCTs 0/3 RCTs / HMB 2/2 RCTs 1/2 RCTs 0/2 RCTs Fatty acids / / Limited effects / PA and nutrition Olivier Bruyère DEHYDROEPIANDROSTERONE 4 RCTs 1/7 hospitalized elderly 1/7 nursing home residents 5/7 healthy community dwelling Dose 50mg/day 100mg/day (3 months 23 months) Quality of studies (2 excellent, 3 good, 1 poor) Results: physical muscle mass compared muscle strength compared performance compared to placebo Protein 0/4 RCTs 0/3 RCTs 1/2 RCTs EAA 0/4 RCTs 1/6RCTs 3/4 RCTs Creatine 1/4 RCTs 2/6 RCTs 0/1 RCT DHEA 0/4 RCTs 0/3 RCTs / HMB 2/2 RCTs 1/2 RCTs 0/2 RCTs Fatty acids / / / No effect B HYDROXY Β METHYLBUTYRATE 2 RCTs 1) 50 elderly 1.5 g of CaHMB 24 weeks 2) 24 older adults on bed rest 3 g of CaHMB Quality of studies (1 excellent, 1 good) Results: physical muscle mass compared muscle strength compared performance compared to placebo Protein 0/4 RCTs 0/3 RCTs 1/2 RCTs EAA 0/4 RCTs 1/6RCTs 3/4 RCTs Creatine 1/4 RCTs 2/6 RCTs 0/1 RCT DHEA 0/4 RCTs 0/3 RCTs / HMB 2/2 RCTs 1/2 RCTs 0/2 RCTs Fatty acids / / / Limited effects 6

7 Effects of these supplementations on muscle health are rather limited low quality of evidence (GRADE) some studies showed a significant but small effect of supplementation on one component of muscle activity High heterogeneity of these studies protocols First SR assessing effect of nutrition only (without PA) Quizz Pour augmenter la force musculaire, il est possible de combiner activité physique et compléments alimentaires : 1. C est meilleur que l AP seule 2. C est meilleur que un CA seul 3. C est moins bien que l AP ou un CA seuls 4. Cela dépend du type de complément 5. Cela dépend du type d activité 6. Cela dépend du complément et de l activité 21 7

8 DATABASES: MEDLINE/Ovid and EMBASE/Ovid INCLUSION CRITERIA: Same inclusion criteria as the previous SR EXCLUSION CRITERIA: al intervention = energy restriction to promote weight loss ; populations with a specific health condition (e.g. cirrhosis, cancer, diabetes, chronic kidney disease, etc.) STUDY SELECTION AND DATA EXTRACTION : Two independant researchers STUDY QUALITY: Jadad score studies identified through electronic database searches 20 new RCTs published since April RCTS identified by Denison et al new RCTs 37 RCTs included in this SR PRESENTATION BY NUTRITIONAL SUPPLEMENT: Proteins (n=13) Essential amino acids (EAA) (n=3) β hydroxy β methylbutyrate (HMB) (n=3) Multi nutrient (n=5) Creatine (n=5) Vitamin D (n=2) Other (n=6) 23 Characteristics of included studies: Publication year Countries 12/37 Europe 11/37 USA/Canada 7/37 Asia 4/37 South America 3/37 Australia Age range of participants years Sex 22/37 mixed men/women 10/37 only women 5/37 only men Sample subjects Follow up 4 weeks 18 months Jadad score 12/37 excellent quality 15/37 good quality 10/37 poor quality Methodology 22/37 two group comparison (exercise + nutrition / exercise only) 11/37 four group comparison (control group with no intervention / exercise only / nutrition only / exercise + nutrition) 3/37 three group comparison, 1/37 five group comparison we used only results from 2 groups; one receiving exercise + nutrition and one receiving exercise only 18/37 used a double blind 24 8

9 Main results: Muscle mass Muscle strength Physical performance Significant increase Significant added Significant increase Significant added Significant Significant added with exercises effect with nutrition with exercises effect with nutrition increase with effect with exercises nutrition Protein 11/12 RCTs 3/12 RCTs 12/12 RCTs 3/12 RCTs 9/9 RCTs 0/9 RCTs EAA 2/3 RCTs 0/3 RCTs 2/3 RCTs 0/3 RCTs 2/2 RCTs 0/2 RCTs HMB 3/3 RCTs 1/3 RCTs 2/3 RCTs 0/3 RCTs 2/2 RCTs 0/2 RCTs Multinutrient 2/4 RCTs 0/4 RCTs 3/5 RCTs 1/5 RCTs 3/4 RCTs 0/4 RCTs Creatine 5/5 RCTs 4/5 RCTs 5/5 RCTs 4/5 RCTs 3/4 RCTs 1/4 RCTs Vitamin D 0/1 RCTs 0/1 RCTs 2/2 RCTs 0/2 RCTs 2/2 RCTs 1/2 RCTs Other 4/6 RCTs 0/6 RCTs 3/5 RCTs 0/5 RCTs 4/5 RCTs 2/5 RCTs 25 Effet of interventions on: Muscle mass: Increase with physical exercises : 80% of RCTs (27/34) No results: frail subjects with limited mobility Additional effect of nutrition : 23.5 % of RCTs (8/34) 4 using creatine, 3 using proteins, 1 using HMB High effect of physical activity Muscle strenght: Increase with physical exercises : 83% of RCTs (29/35) Additional effect of nutrition : 23 % of RCTs (8/35) 4 using creatine, 3 using proteins, 1 using multi nutrient Physical performance Increase with physical exercises : 93% of RCTs (26/28) No results : frail subjects / hospitalized subjects Additional effect of nutrition : 18 % of RCTs (5/28) Limited added effect of nutrition 1 using multi nutrient, 1 using creatine, one using vitamin D, one using tea catechin, one using magnesium oxide 26 WITH RESISTANCE TRAINING, THIS IS NOT THE SAME CD Liao et al. Am J Clin Nutr Aug 16. We included 17 RCTs; the overall mean ± SD age and body mass index (BMI; in kg/m 2) in these RCTs were 73.4 ± 8.1 y and 29.7 ± 5.5, respectively. Compared with RET alone, PS combined with RET may have a stronger effect in preventing aging-related muscle mass attenuation and leg strength loss in older people, which was found in studies with a mean BMI 30 and in studies with a mean BMI <30. Clinicians could use nutrition supplement and exercise strategies, especially PS plus RET, to effectively improve the physical activity and health status of all older patients. 27 9

10 Conclusion Effects of PA & PE are very well documented Effects of these supplementations on muscle health are rather limited Limited effect of nutritional supplementation on muscle mass, muscle power and physical function. Inconsistent positive effects were observed for some specific supplementations but the results only concerned one aspect of the muscle. Large RCTs are needed to provide evidence for appropriate clinical recommendations. However, it is better if combined with resistance training! Probably a PRODUCT specificity: importance of the quality of the supplementation! 28 Merci! 10