Review article
Sarcopenia, malnutrition and nutrient density in older people
Post Reproductive Health, formerly Menopause International 2014, Vol. 20(1) 19–21 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1754045314521552 prh.sagepub.com
Alison Smith
Abstract Both sarcopenia and malnutrition can have a significant impact on health and functional status in older people. Good nutrition and physical activity throughout life are protective factors. In addition to inadequate nutrient intake, reduced physical activity is known to increase the risk of developing sarcopenia. Progressive resistance training has been shown to be an effective intervention and there is also significant potential for whole diet interventions, many of which are also effective in treating malnutrition.
Keywords Malnutrition, omega 3 fatty acids, protein, sarcopenia, vitamin D
Sarcopenia is a syndrome characterised by progressive, generalised loss of skeletal muscle mass and strength, which in clinical practice can be determined by the presence of both low muscle mass and low muscle function. Sarcopenia affects 13–24% of 50–70 year olds, and 11–50% of those aged 80 or more. Sarcopenia can have a significant impact on health and functional status in older people because it causes: . . . . . .
Weakness/frailty Immobility Impaired muscle strength Increased risk of falls Reduced quality of life Increased mortality.
All these symptoms are also common to malnutrition, another health problem common in older people and linked with sarcopenia. The British Association of Parenteral and Enteral Nutrition defines malnutrition as a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome. There are currently no estimates of the approximate cost of sarcopenia to the UK health economy but in 2000 it was estimated to cost the USA $18.5 billion. By contrast, in 2007 malnutrition was estimated to cost the
UK more than 13 billion per year, because malnourished people require more healthcare resources including 65% more GP visits, 82% more hospital admissions and 30% longer hospital stays.1
Causes of sarcopenia and malnutrition Good nutrition and physical activity throughout life are certainly protective factors and there is some evidence that diet in early childhood may play a part in acquisition of muscle mass and its function in later life. In older age muscle mass, muscle function and rate of muscle loss certainly seem to reflect the peak attained in earlier life.2 Low nutrient intake, in particular low protein intake, is a significant risk factor for sarcopenia. Food intake falls as we age – decreasing by 25% between the ages of 40 and 70.2 This decreased food intake together with decreased appetite can combine to cause ‘anorexia of aging’ which is known to be one of the key causative factors for both malnutrition and sarcopenia.
Chiltern Clinical Commissioning Group, Chiltern District Council Offices, Amersham, Buckinghamshire, UK Corresponding author: Alison Smith, Chiltern Clinical Commissioning Group, Ground Floor, Chiltern District Council Offices, King George V Road, Amersham, Buckinghamshire, HP6 5AW, UK. Email: [email protected]
Downloaded from min.sagepub.com at UNIVERSITE DE MONTREAL on June 18, 2015
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Post Reproductive Health 20(1)
Causation of malnutrition is usually multi-factorial but includes: . . . . .
Reduced food intake Poor appetite Unintentional weight loss Reduced nutrient absorption Presence of several co-morbidities which are chronic and progressive and which limit food intake for any reason.
The most common type of malnutrition seen in older people in the UK is protein-energy malnutrition – simply a lack of adequate energy and protein in the diet. In addition to inadequate nutrient intake, reduced physical activity is known to increase risk of developing sarcopenia, and a sedentary lifestyle is a major risk factor for this condition.3 Together, reduced nutrient intake and reduced physical activity can become a vicious circle where declining muscle strength and physical capability increase risk of malnutrition and malnutrition may cause further decline in physical capability. It is important to remember that in older age, a sedentary lifestyle may not be a matter of choice, as older people have a greater likelihood of illness/hospitalisation causing periods of muscle disuse. Even seven days’ bed rest will result in rapid loss of muscle mass which is more difficult for older people to recover from.4
Treatment of sarcopenia Progressive resistance training has been shown to be an effective intervention in older people with sarcopenia but there is also significant potential for whole diet interventions in the management of sarcopenia. Evidence suggests that protein and vitamin D may have a treatment and/or preventative role.2 New evidence also suggests that the n-3 polyunsaturated fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may help stimulate muscle protein synthesis (anabolism).5 Anabolism is dependent on the level of absorbed essential amino acids (EAA) circulating in the blood; however, in older people the level of EAA required to produce muscle anabolism is increased. In older age, the body’s requirement for total protein may not change, but because of the decreased effectiveness of EAA, either more total protein, a greater nutrient density of EAA or higher quality protein may be required. On this basis, the optimal protein intake for older may be above current recommended level of 0.8–1 g protein per kg body weight per day.
Interestingly, simply increasing total protein intake may not be the whole answer. Some recent papers have suggested that timing of protein intake may be critical to maintaining muscle mass in those with increased EAA requirements for anabolism.3 In the UK, the typical protein ingestion pattern is little protein eaten at breakfast and lunch, with the majority consumed at the evening meal. This means that the evening meal may be the only meal of the day providing a sufficient level of absorbed EAA to stimulate anabolism.4 Researchers suggest that intake of high biological value protein should be distributed equally between three or more meals each day, with 20–30 g protein (containing 5–8 g EAA) consumed at each meal.4 High biological value protein sources include all animal proteins such as meat, fish, milk, cheese and eggs. Vitamin D may also have a direct effect on muscle function2 and vitamin D deficiency can be common in older adults because of reduced: . . . .
exposure to sunlight intake of vitamin D-rich foods ability to synthesise vitamin D ability to convert vitamin D within the kidneys.3
EPA/DHA are thought to be useful in the treatment of conditions with an inflammatory component including sarcopenia. Research has suggested that grip strength may increase with increased intake of oily fish, and that resistance exercise combined with EPA/ DHA supplementation could double strength and functional ability.6
Treatment of malnutrition The dietary treatment of both sarcopenia and malnutrition focus on increasing nutrient density of the diet. When treating malnutrition, the aim is usually to increase both energy (kcal) and protein intakes without significantly increasing portion size. Keeping portion sizes small is key because poor appetite is almost invariably a factor in malnutrition and large portion sizes can be off-putting to the person with little appetite. Basic, practical advice for treating both malnutrition and sarcopenia includes: . Eating little and often (three meals þ two to three small snacks between meals) . Eating high-protein foods at each meal (including at least two portions of oily fish per week) and choosing animal sources of protein frequently, if possible
Downloaded from min.sagepub.com at UNIVERSITE DE MONTREAL on June 18, 2015
Smith
21
. Eating a balanced diet every day including starchy carbohydrates, protein foods, milk and milk products and fruit and vegetables . Choosing foods that are energy dense . Adding high energy and protein ingredients to food to increase nutrient density (food fortification) . Choosing high-calorie drinks in preference to water (milky drinks are often encouraged) . Having regular exposure to sunlight between April and September or taking a vitamin D supplement if the former is not possible.
Conclusion For older people at risk of sarcopenia and/or malnutrition, the overall aim for healthcare professionals should be to help them remain nutritionally well and mobile and in so doing to avoid unnecessary acute admissions which are likely to further exacerbate both sarcopenia and malnutrition. Conflict of interest
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Elia M and Russell CA (eds). Combating malnutrition: Recommendations for action. A report by British Association of Parenteral and Enteral Nutrition (BAPEN), 2009. 2. Sayer AA, Robinson SM, Patel HP, et al. New horizons in the pathogenesis, diagnosis and management of sarcopenia. Age Ageing 2013; 42: 145–150. 3. Rom O, Kaisari S, Aizenbud D, et al. Lifestyle and sarcopenia – Etiology, prevention and treatment. RMMJ 2012; 3: e0024. 4. Breen L and Phillips SM. Skeletal muscle protein metabolism in the elderly: interventions to counteract the ‘anabolic resistance’ of ageing. Nutr Metab 2011; 8: 68. 5. Robinson S, Cooper C and Sayer A. Nutrition and sarcopenia: a review of the evidence and implications for preventive strategies. J Aging Res 2012; 2012: 510801. 6. Gray SR and Da Boit M. Fish oils and their potential in the treatment of sarcopenia. J Frailty Aging 2013; 2: 211–216.
None declared.
How To Cite Smith A. Sarcopenia, malnutrition and nutrient density in older people. Post Reproductive Health 2014; 20(1): 19–21.
Downloaded from min.sagepub.com at UNIVERSITE DE MONTREAL on June 18, 2015
Sarcopenia, malnutrition and nutrient density in older people
Post Reproductive Health, formerly Menopause International 2014, Vol. 20(1) 19–21 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1754045314521552 prh.sagepub.com
Alison Smith
Abstract Both sarcopenia and malnutrition can have a significant impact on health and functional status in older people. Good nutrition and physical activity throughout life are protective factors. In addition to inadequate nutrient intake, reduced physical activity is known to increase the risk of developing sarcopenia. Progressive resistance training has been shown to be an effective intervention and there is also significant potential for whole diet interventions, many of which are also effective in treating malnutrition.
Keywords Malnutrition, omega 3 fatty acids, protein, sarcopenia, vitamin D
Sarcopenia is a syndrome characterised by progressive, generalised loss of skeletal muscle mass and strength, which in clinical practice can be determined by the presence of both low muscle mass and low muscle function. Sarcopenia affects 13–24% of 50–70 year olds, and 11–50% of those aged 80 or more. Sarcopenia can have a significant impact on health and functional status in older people because it causes: . . . . . .
Weakness/frailty Immobility Impaired muscle strength Increased risk of falls Reduced quality of life Increased mortality.
All these symptoms are also common to malnutrition, another health problem common in older people and linked with sarcopenia. The British Association of Parenteral and Enteral Nutrition defines malnutrition as a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome. There are currently no estimates of the approximate cost of sarcopenia to the UK health economy but in 2000 it was estimated to cost the USA $18.5 billion. By contrast, in 2007 malnutrition was estimated to cost the
UK more than 13 billion per year, because malnourished people require more healthcare resources including 65% more GP visits, 82% more hospital admissions and 30% longer hospital stays.1
Causes of sarcopenia and malnutrition Good nutrition and physical activity throughout life are certainly protective factors and there is some evidence that diet in early childhood may play a part in acquisition of muscle mass and its function in later life. In older age muscle mass, muscle function and rate of muscle loss certainly seem to reflect the peak attained in earlier life.2 Low nutrient intake, in particular low protein intake, is a significant risk factor for sarcopenia. Food intake falls as we age – decreasing by 25% between the ages of 40 and 70.2 This decreased food intake together with decreased appetite can combine to cause ‘anorexia of aging’ which is known to be one of the key causative factors for both malnutrition and sarcopenia.
Chiltern Clinical Commissioning Group, Chiltern District Council Offices, Amersham, Buckinghamshire, UK Corresponding author: Alison Smith, Chiltern Clinical Commissioning Group, Ground Floor, Chiltern District Council Offices, King George V Road, Amersham, Buckinghamshire, HP6 5AW, UK. Email: [email protected]
Downloaded from min.sagepub.com at UNIVERSITE DE MONTREAL on June 18, 2015
20
Post Reproductive Health 20(1)
Causation of malnutrition is usually multi-factorial but includes: . . . . .
Reduced food intake Poor appetite Unintentional weight loss Reduced nutrient absorption Presence of several co-morbidities which are chronic and progressive and which limit food intake for any reason.
The most common type of malnutrition seen in older people in the UK is protein-energy malnutrition – simply a lack of adequate energy and protein in the diet. In addition to inadequate nutrient intake, reduced physical activity is known to increase risk of developing sarcopenia, and a sedentary lifestyle is a major risk factor for this condition.3 Together, reduced nutrient intake and reduced physical activity can become a vicious circle where declining muscle strength and physical capability increase risk of malnutrition and malnutrition may cause further decline in physical capability. It is important to remember that in older age, a sedentary lifestyle may not be a matter of choice, as older people have a greater likelihood of illness/hospitalisation causing periods of muscle disuse. Even seven days’ bed rest will result in rapid loss of muscle mass which is more difficult for older people to recover from.4
Treatment of sarcopenia Progressive resistance training has been shown to be an effective intervention in older people with sarcopenia but there is also significant potential for whole diet interventions in the management of sarcopenia. Evidence suggests that protein and vitamin D may have a treatment and/or preventative role.2 New evidence also suggests that the n-3 polyunsaturated fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may help stimulate muscle protein synthesis (anabolism).5 Anabolism is dependent on the level of absorbed essential amino acids (EAA) circulating in the blood; however, in older people the level of EAA required to produce muscle anabolism is increased. In older age, the body’s requirement for total protein may not change, but because of the decreased effectiveness of EAA, either more total protein, a greater nutrient density of EAA or higher quality protein may be required. On this basis, the optimal protein intake for older may be above current recommended level of 0.8–1 g protein per kg body weight per day.
Interestingly, simply increasing total protein intake may not be the whole answer. Some recent papers have suggested that timing of protein intake may be critical to maintaining muscle mass in those with increased EAA requirements for anabolism.3 In the UK, the typical protein ingestion pattern is little protein eaten at breakfast and lunch, with the majority consumed at the evening meal. This means that the evening meal may be the only meal of the day providing a sufficient level of absorbed EAA to stimulate anabolism.4 Researchers suggest that intake of high biological value protein should be distributed equally between three or more meals each day, with 20–30 g protein (containing 5–8 g EAA) consumed at each meal.4 High biological value protein sources include all animal proteins such as meat, fish, milk, cheese and eggs. Vitamin D may also have a direct effect on muscle function2 and vitamin D deficiency can be common in older adults because of reduced: . . . .
exposure to sunlight intake of vitamin D-rich foods ability to synthesise vitamin D ability to convert vitamin D within the kidneys.3
EPA/DHA are thought to be useful in the treatment of conditions with an inflammatory component including sarcopenia. Research has suggested that grip strength may increase with increased intake of oily fish, and that resistance exercise combined with EPA/ DHA supplementation could double strength and functional ability.6
Treatment of malnutrition The dietary treatment of both sarcopenia and malnutrition focus on increasing nutrient density of the diet. When treating malnutrition, the aim is usually to increase both energy (kcal) and protein intakes without significantly increasing portion size. Keeping portion sizes small is key because poor appetite is almost invariably a factor in malnutrition and large portion sizes can be off-putting to the person with little appetite. Basic, practical advice for treating both malnutrition and sarcopenia includes: . Eating little and often (three meals þ two to three small snacks between meals) . Eating high-protein foods at each meal (including at least two portions of oily fish per week) and choosing animal sources of protein frequently, if possible
Downloaded from min.sagepub.com at UNIVERSITE DE MONTREAL on June 18, 2015
Smith
21
. Eating a balanced diet every day including starchy carbohydrates, protein foods, milk and milk products and fruit and vegetables . Choosing foods that are energy dense . Adding high energy and protein ingredients to food to increase nutrient density (food fortification) . Choosing high-calorie drinks in preference to water (milky drinks are often encouraged) . Having regular exposure to sunlight between April and September or taking a vitamin D supplement if the former is not possible.
Conclusion For older people at risk of sarcopenia and/or malnutrition, the overall aim for healthcare professionals should be to help them remain nutritionally well and mobile and in so doing to avoid unnecessary acute admissions which are likely to further exacerbate both sarcopenia and malnutrition. Conflict of interest
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Elia M and Russell CA (eds). Combating malnutrition: Recommendations for action. A report by British Association of Parenteral and Enteral Nutrition (BAPEN), 2009. 2. Sayer AA, Robinson SM, Patel HP, et al. New horizons in the pathogenesis, diagnosis and management of sarcopenia. Age Ageing 2013; 42: 145–150. 3. Rom O, Kaisari S, Aizenbud D, et al. Lifestyle and sarcopenia – Etiology, prevention and treatment. RMMJ 2012; 3: e0024. 4. Breen L and Phillips SM. Skeletal muscle protein metabolism in the elderly: interventions to counteract the ‘anabolic resistance’ of ageing. Nutr Metab 2011; 8: 68. 5. Robinson S, Cooper C and Sayer A. Nutrition and sarcopenia: a review of the evidence and implications for preventive strategies. J Aging Res 2012; 2012: 510801. 6. Gray SR and Da Boit M. Fish oils and their potential in the treatment of sarcopenia. J Frailty Aging 2013; 2: 211–216.
None declared.
How To Cite Smith A. Sarcopenia, malnutrition and nutrient density in older people. Post Reproductive Health 2014; 20(1): 19–21.
Downloaded from min.sagepub.com at UNIVERSITE DE MONTREAL on June 18, 2015
