New Definition of Malnutrition & the Role of Nutrition on Improving Health Condition in the Elderly

Siti Setiati

1. Cruz-Jentoft AJ, et al. Sarcopenia: European Consensus on definition and diaagnosis (EWGS). Age Ageing. 2010;39(4):412-232. Chen LK, et al. Sarcopenia in Asia: Consensus Report of the Asian Working Group for Sarcopenia. Journal of the American Medical Directors Association. 2014;15(2)

Sarcopenia

• Sarcopenia is generally defined as a decrease in skeletal muscle massand muscle strength or physical function, such as gait speed,observed in elderly individuals.

Geriatr Gerontol Int 2018; 18 (Suppl. 1): 7–12

GrimbyG et al ClinPhysiol. 1983;3:209–218; Flakoll P, et al. Nutrition. 2004;20:445–451

BaierS, et al. JPEN J ParenterEnteral Nutr. 2009;33:71–82

Janssen I, et al. J Appl Physiol. 2000;89:81–88.

The Impacts of Low Lean Mass

Wolfe R. AJCN 84:475-482, 2006

Malnutrition Leading to Muscle Loss in Elderly

Frailty

Muscle/Strength Loss

FactorsDecrease anabolic

hormonesNeurodegeneration

Inflammation or Cachexia Malnutrition Disuse Insulin Resistance

Vandewoude, M.F. Personal communication, 2014.

Age 75 31

Weight 56 56

Height 132 157

BMI 32.1 22.7

BMI only is NOT reflecting nutritional status

Same BMI, different Lean Mass

BMI = BW (Kg)BH (m)2

Asia Pacific J Clin Nutr.2003;12(1):80-4.

Note: postural changes in the elderly

BH (♂) = 69,38+ (1,924 x KH)

BH (♀) = 50,25 + (2,225 x KH)

Be aware of POSTURAL INSTABILITY in

the elderly

Measuring knee height

(KH)

Old Concept of Malnutrition

• Malnutrition is defined as:• BMI <18.5 kg/m2 OR

• Unintentional weight loss of >10% withinthe previous 3-6 months OR

• BMI <20 kg/m2, and unintentionalweight loss >5% within the previous 3-6months

BAPEN Malnutrition Advisory Group Guidelines

New Concept of Malnutrition

• Currently, the definition ofmalnutrition is not justonly looking at the BMIof a person, but also othercriteria

• Someone can havenormal BMI BUTmalnourished!

T. Cederholm et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clinical Nutrition 38 (2019) 1-9.

Phenotypic and Etiologic Criteria (GLIM 2019)

T. Cederholm et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clinical Nutrition 38 (2019) 1-9.

T. Cederholm et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clinical Nutrition 38 (2019) 1-9.

Diagnosing Malnutrition (ESPEN)

Definisi Malnutrisi

Kriteria Fenotip

↓ BB Tak Diinginkan IMT Rendah MASSA OTOT RENDAH

>5% dalam 6 bulan

ATAU

>10% dalam >6 bul

an

Catatan: malnutrisi b

erat jika >10% dala

m 6 bulan ATAU >2

0% dalam >6 bulan

usia <70 tahun <18,5

kg/m2

ATAU

usia >70 tahun <20 kg/m2

Catatan: untuk kriteria

malnutrisi berat di Asia, perlu

penelitian/ konsensus lebih

lanjut

AWGS:

DXA

♂ <7 kg/m2;; ♀ <5,4 kg/m2

BIA

♂ <7 kg/m2; ♀ <5,7 kg/m2

Laksmi, dkk

BIA Tanita MC-780MA

♂ <6,9 kg/m2; ♀ <5 kg/m2

Kriteria Etiologik

Asupan atau Asimilasi Makanan Renda

hInflamasi

↓ berapapun dari kebutuhan energi

selama >2 minggu

ATAU

≤50% kebutuhan energi selama >1 min

ggu

ATAU

Masalah GI kronik yang berdampak pa

Penyakit/ trauma akut

ATAU

Terkait penyakit kronik

WHO: Suatu keadaan kekurangan kelebihan atau ketidakseimbangan protein, energi

dan zat gizi lain yang dapat menyebabkan perubahan komposisi tubuh, penurunan

fungsi fisik dan mental

ESPEN

↓ BB signifikan yang tidakdiinginkan (>5% dalam 6 bulan atau>10% lebih dari 6 bulan)

ATAU

↓ signifikan massa tubuh (IMT <20 kg/m2) atau FFMI

Konsensus Global (GLIM):

kombinasi setidaknya 1 kriteria fenotip DAN 1 kriteria etiologi

PERGEMI. Pedoman Nasional Asuhan Nutrisi pada Lansia dan Pasien Geriatri. 2017.ESPEN guideline on clinical nutrition and hydration in geriatrics. 2018GLIM criteria. Clin Nutr.2019;38:1–9. Laksmi PW, et al. The need new cut-off value to increase diagnostic performance of BIA compared to DXA to measure muscle mass in Indonesian elderly. In press.

Nutritional Guideline in

Elderly

ESPEN guideline on clinical nutrition and hydration in geriatrics, 2019

Paillaud E, Bories PN, Le Parco JC, Campillo B. Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up. Br J Nutr 2000;83:97-103.Miu KYD, et al. Effects of Nutritional Status on 6-Month Outcome of Hip Fractures in Elderly Patients. Ann Rehabil Med. 2017;41(6):1005-12.

M How much fluid (water, juice, coffee, tea, milk...) is consumed per day?

0.0 = less than 3 cups 0.5 = 3 to 5 cups 1.0 = more than 5 cups

Assessment (max. 16 points)

Screening score

Total Assessment (max. 30 points) .

K Selected consumption markers for protein intake

• At least one serving of dairy products(milk, cheese, yoghurt) per day

• Two or more servings of legumesor eggs per week

• Meat, fish or poultry every day

0.0 = if 0 or 1 yes0.5 = if 2 yes1.0 = if 3 yes

yes .

Last name: First name:

Sex: Age: Weight, kg: Height, cm: Date:

Complete the screen by filling in the boxes with the appropriate numbers. Add the numbers for the screen. If score is 11 or less, continue with the assessment to gain a Malnutrition Indicator Score.

Screening

Assessment

Malnutrition Indicator Score

24 to 30 points Normal nutritional status

17 to 23.5 points At risk of malnutrition

Less than 17 points Malnourished

L Consumes two or more servings of fruit or vegetables per day?

0 = no 1 = yes

Q Mid-arm circumference (MAC) in cm

0.0 = MAC less than 21 0.5 = MAC 21 to 22 1.0 = MAC greater than 22

O Self view of nutritional status

0 = views self as being malnourished 1 = is uncertain of nutritional state 2 = views self as having no nutritional problem

P In comparison with other people of the same age, how does the patient consider his / her health status?

0.0 = not as good 0.5 = does not know 1.0 = as good 2.0 = better

N Mode of feeding

0 = unable to eat without assistance 1 = self-fed with some difficulty 2 = self-fed without any problem

yes

yes

no

no

no

J How many full meals does the patient eat daily? 0 = 1 meal 1 = 2 meals 2 = 3 meals

.

.

.

.

.

.

R Calf circumference (CC) in cm

0 = CC less than 31 1 = CC 31 or greater

I Pressure sores or skin ulcers

0 = yes 1 = no

H Takes more than 3 prescription drugs per day

0 = yes 1 = no

G Lives independently (not in nursing home or hospital)

1 = yes 0 = no

Screening score (subtotal max. 14 points)

12-14 points: Normal nutritional status

8-11 points: At risk of malnutrition

0-7 points: Malnourished

For a more in-depth assessment, continue with questions G-R

F Body Mass Index (BMI) = weight in kg / (height in m)2

0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater

E Neuropsychological problems

0 = severe dementia or depression 1 = mild dementia 2 = no psychological problems

D Has suffered psychological stress or acute disease in the past 3 months?

0 = yes 2 = no

C Mobility

0 = bed or chair bound 1 = able to get out of bed / chair but does not go out 2 = goes out

B Weight loss during the last 3 months

0 = weight loss greater than 3kg (6.6lbs) 1 = does not know 2 = weight loss between 1 and 3kg (2.2 and 6.6 lbs) 3 = no weight loss

A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0 = severe decrease in food intake 1 = moderate decrease in food intake 2 = no decrease in food intake

Mi ni Nutritional Assessment

MNA®

References 1.

2.

Vellas B, Villars H, Abellan G, et al. Overview of the MNA® - Its History and Challenges. J Nutr Health Aging. 2006; 10:456-465.

Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for Undernutrition in Geriatric Practice: Developing the Short-Form MiniNutritional Assessment (MNA-SF). J. Geront. 2001; 56A: M366-377

3. Guigoz Y. The Mini-Nutritional Assessment (MNA®) Review of the Literature - Whatdoes it tell us? J Nutr Health Aging. 2006; 10:466-487.

® Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners

© Nestlé, 1994, Revision 2009. N67200 12/99 10M

For more information: www.mna-elderly.com

Macronutrients

• Calorie Requirement• Without metabolic stress: 25-30

kcal/kgBW• With metabolic stress: 30-35

kcal/kgBW

• Protein Requirement• Without metabolic stress: 1-1.2

gr/kgBW• With metabolic stress: 1-2

gr/kgBW

• Carbohydrate Requirement• 45-65% of the total calorie• Types: complex carbohydrate, 4

spoons/day for simple carbohydrate

• Fat Requirement• 20-35% of the total calorie• Saturated fat <10% of the calorie

and cholesterol <300 mg/day

• Fluid Requirement• 25-30 mL/kgBW

*All values are in g/kg/day. EAR: estimated average requirement. RDA: recommended daily allowance. RDI: recommendeddietary intake. NRI: nutrient reference intake.

Nowson C, O’Connell S. Protein requirements and recommendations for older people: a review. Nutrients. 2015;7:6874-6899.

Males Males Females Females

Age range (years) 51-70 70+ 51-70 70+

US EAR 0.66 0.66 0.66 0.66

Australian EAR 0.68 0.86 0.60 0.75

US RDA 0.8 0.8 0.8 0.8

Australian RDI 0.84 1.07 0.75 0.94

UK NRI 0.8 0.8 0.8 0.8

General recommendation (>65 year) 1.1-1.2 1.1-1.2

Recommendation with endurance and resistance exercise (>65year)

1.2 1.2

Recommendation for acute and chronic disease (>65 year) 1.2-1.5 1.2-1.5

Recommended 25-30 g per meal (>65 year)

Nutrient Reference Intakes and Recommended Dietary (Protein) Intakes for Elderly

Natural Sources of Vitamin D and Calcium

Chen LR, et al. Calcium and Vitamin D Supplementation on Bone Health: Current Evidence and Recommendations. International Journal of Gerontology. 2014;8:183-8.

Vitamin D:

• Sunlight

• Fish, such as sardines, salmon

• Mushroom

• Egg Yolk

Calcium:

• Dairy products, such as milk, yoghurt, tofu,tempeh

• Vegetables, such as spinach, broccoli

• Orange

• Published in 2017

• Frail elderly aged 65 years old, living in community or institutionalized• 19 eligible studies

• Tools: Frail criteria based on Fried (FRAIL), et al; MNA for nutrition; Diet Quality Index (DQI-R)

• Results:• Frailty syndrome is associated with low intakes of specific micronutrients.

• A higher protein intake was associated with a lower risk of frailty !!!...

• Quality of the diet is inversely associated with the risk of being frail

• Relationship between scores on both the Mini Nutritional Assessment (MNA) and frailty, and revealed anAssociation between MALNUTRITION and/or the RISK OF MALNUTRITION with FRAILTY

• 12-week double-blind RCT

• Population: 120 elderly subjects (70-85 y.o) with ≥1 of theCardiovascular Health Study frailty criteria (pre-frail or frail) and aMini Nutritional Assessment score ≤23.5

• Intervention (3 groups): Protein powder 0.8 or 1.2 or 15gr/kgBW/daily (along with usual diet and physical activity)

• Outcomes: appendicular skeletal muscle mass (ASM) and skeletalmuscle mass index (SMI) measured by dual-energy X-rayabsorptiometry; others: CHS frailty index, gait speed, TUG, HGS, etc

Park, et al. Am J Clin Nutr 2018;108:1026–1033.

Protein Only

• After the 12-wk intervention, ASM and SMI indicators, such as ASM/weight, ASM/BMI, andASM:fat ratio, were significantly HIGHER in the 1.5-G PROTEIN group than in the 0.8-g proteingroup

• For gait speed, there was a significant group time interaction between the 3 groups; thus, GAITSPEED was significantly HIGHER IN THE 1.5-G PROTEIN group than in the 0.8-g protein group atweek 12

Park, et al. Am J Clin Nutr 2018;108:1026–1033.

• Older adults with sarcopenia showed a significant increase in musclemass and better lower limb function following a course of vitamin Dand leucine-enriched whey protein supplementation (Bauer et al.2015)

• In 300 older women with a baseline 25OHD level under 60 nmol/l,significant improvements in TUG, were reported with 2000 IUvitamin D daily (Zhu et al., 2010).

• Meta-analysis showed beneficial effect of daily vitamin D (with dosesranging from 800 to 1000 IU) in older subjects with improvements inbalance and muscle function (Muir and Montero-Odasso, 2011).

Review. Year: 2017

Bone Reports 8 (2018) 163–167

Vitamin D and Calcium

• An RCT of 625 older residents of assisted-living facilities reportedsignificantly fewer falls in subjects on calcium (600 mg daily) andvitamin D2 (initially 10,000 IU weekly, then 1000 IU daily) for 2 yearsversus calcium alone (Flicker, 2005)

• An annual oral dose of 500,000 IU of vitamin D3 increased theincidence of falls in over 2000 community-dwelling older women(Sanders et al., 2010).

• US Preventive Services Task Force (Meta-Analysis) demonstrated 17%reduction in falls in response to vitamin D and its analogues(calcitriol and alfacalcidol) (Michael et al., 2010)

Bone Reports 8 (2018) 163–167

Review. Year: 2017

• Vitamin D increased muscle proteinsynthesis; enhance the stimulatingeffect of leucine and insulin onprotein synthesis rate in musclecells

• Vitamin D status and VDR expressionin skeletal muscle are reduced inelderly people, and associated witha significant loss of muscle function

Year: 2014

R. Rizzoli et al. / Maturitas 79 (2014) 122–132

Protein and Vitamin D

• Protein intake of 1.0–1.2 g/kg BW/d, with at least 20–25 g of high-quality protein. An average daily protein (such as can be supplied by dairyprotein) with each main meal (breakfast, lunch, dinner) during the day.

• Regular physical exercise 3–5 times per week should be under-taken, which may be combined with protein intake in proximity toexercise, for optimal muscle reconditioning.

• Vitamin D intake at 800 IU/d to maintain serum 25-(OH)Dconcentration >50 nmol/L (>20 ng/mL)

R. Rizzoli et al. / Maturitas 79 (2014) 122–132

Year: 2014

• 13 weeks double-blind RCT study

• Populations: 380 (control: 196, active: 184) non-malnourished olderparticipants (>65 y.o) with mobility limitations and reduced musclemass

• Mild to moderate limitations in physical function (SPPB score 4-9)• Low skeletal muscle mass index (≤37% in men and ≤ 28% in women)

• Interventions:• Protein products: 20 g whey protein (3 gr total leucine), 800 IU vitamin D,

500 mg of calcium, and a mixture of vitamins, minerals, fibres twice daily

• Control: iso-caloric product

Year: 2019

Hill TR, et al. Calcified Tissue International (2019) 105:383–391

Vitamin D, Calcium, and

Leucine

• Prevalence of low Serum25(OH)D decreased in theactive group

• Serum IGF-1 change duringintervention wassignificantly differentbetween active and controlgroups

• Serum calcium (correctedfor albumin) increasedslightly after 13 weeks inthe active treatment grouponly

• Total body BMD increasedin the active group only,and the improvement wassignificantly different fromcontrol

Hill TR, et al. Calcified Tissue International (2019) 105:383–391

Whey Protein Supplementation

• Whey protein is high digestibility, quickabsorption and rich content of essential aminoacids (EAAs)

• Leucine is a high proportion of the branched-chain amino acid (AA) in Whey protein, (one ofthe crucial factors for THE STIMULATION OF MPS) IMPROVE POSTPRANDIAL MUSCLE PROTEINSYNTHESIS

• One randomized controlled trial (RCT) showedthat whey protein stimulates gains in lean bodymass and strength in healthy elder men (Whey +Exercise showed the best result)

The Differences between Whey and Casein

Whey

• Still has it liquid form even whenmixed with gastric acid

• Faster gastric emptying

• Faster to be absorbed

Casein

• Becoming a curd when mixed with gastric acid

• Delay gastric emptying

• Takes time to be absorbed

1. Fried MD, et al. 1992; 2. Clemens,R.A, et al. 2002

Has 7x higher cystein compared to casein important in GSH development

antioxidant properties

Protein Comparison

Conclusion

• There are several physiological changesin elderly that may make elderly moreprone towards malnutrition

• There is a new definition ofmalnutrition, which involving leanmass measurement

• Screening of malnutrition need to bedone for each elderly to detectmalnutrition as early as possible

• Whey Protein, Calcium, and Vitamin Dare proven to be beneficial inimproving bone and muscle health