Slides Posthauer October 2014 FINAL - Villanova University · 1 Welcome to the COPE ... meds...
Transcript of Slides Posthauer October 2014 FINAL - Villanova University · 1 Welcome to the COPE ... meds...
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Welcome to the COPE Webinar Series for Health Professionals!
October 29th 2014 webinar: The Impact of Sarcopenic Obesity on our Aging Population
Time: 12 noon – 1 PM EDTModerator: Rebecca Shenkman, MPH, RDN, LDN
Program Manager MacDonald Center for Obesity Prevention & Education
Handouts of the slides are posted at: www.villanova.edu/COPE
MacDonald Center for Obesity Prevention and Education (COPE) Goals
•Enhance Education
•Participate in Research
•Partner with agencies and organizations
•Provide Continuing Education
The Impact of Sarcopenic Obesity on our Aging PopulationMary Ellen Posthauer, RDN, LD, CD
Objectives: The learner will be able to:1. Explore the rationale behind moderate weight reduction for improved metabolic parameters in obese older
adults.
2. Identify key nutrient recommendations for sarcopenic obesity that are feasible and cost effective
3. Describe the role of exercise as an intervention for the prevention and treatment of sarcopenic obesity
Credits: This webinar provides 1 contact hour for nurses and1 CPEU for dietitians. Suggested CDR Learning Need Code: 4030, 2030, 8130; Level 2.
Notice: Villanova University College of Nursing Continuing Education is an accredited provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.
Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration.
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DISCLOSURE
Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses Credentialing Center of any commercial products displayed in conjunction with an activity.
THE IMPACT OF SARCOPENICOBESITY ON OUR AGINGPOPULATION
Mary Ellen Posthauer, RDN, CD,LD, FAND
October 29,2014
OBJECTIVES1. Explore the rationale behind moderate weight
reduction for improved metabolic parameters in obese older adults.
2. Identify key nutrient recommendations for sarcopenic obesity that are feasible and cost effective
3. Describe the role of exercise as an intervention for the prevention and treatment of sarcopenic obesity
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Sarcopenia Definitions
• Sarcopenia is operationally defined as a lean body mass more than 2 standard deviations below the young normal mean
– Baumgartner RN, et al. Mech Ageing Dev. 1999;107:123
• Reduction of muscle mass and strength that occurs with aging (may be independent of mass)
– Lauretani F, et al. J Appl Physiol 2003;95:1851
• Sarcopenia is defined as the loss of muscle protein mass, function and quality that accompanies advancing age.
– Zinna EM, et al. Cur Opinion Clin Nutr Metabolic Care 2003;61:87
From ages 20‐80
The cumulative decline in muscle mass reaches 40%
By 70 yrs
Muscle accounts for only ~27% of total body wt
From ages 30‐60
Gains ∼500 g of fat, loses ∼250 g of muscle every yr
Loss of Muscle, Gain of Fat
• Obesity was strongly associated w/ self-reported physical functional health, equivalent to being 11 yrs older for men & 16 yrs for women
• Associated w/ poorer functional status & independent predictor of survival
• Sarcopenic obesity was predictive of morbidity & mortality in both malignant & non-malignant disease (Honda et al 2007; Prado et al 2008).
Sarcopenic Obesity
Int J Obesity 28: 234, 2004
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• Unintentional wt loss >10 lbs lost in the last year
• Exhaustion, Poor endurance
• Low levels of physical activity
• Low walking speed
• Muscle weakness (grip strength)
Screening for Sarcopenia: Measuring Physical Function
Decreased grip strength orChair stand (time to rise from a seated position 5X) orDifficulty walking ¼ mile or Climbing 10 steps without resting
Grip strength is a powerful predictor of future mortality
Grip Strenght & Mortality
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Effect of Aging on Energy Intake and Expenditure
Decrease in total energy expenditure (TEE)
• RMR= 70% of TEE
• Thermic effect of food= 10%
• Physical activity= 20%
Elia M, Ritz P, Stubbs RJ. Total energy expenditure in the elderly. Eur J Clin Nutr 2000;54(suppl):S92–103.
• RMR 2‐3% every decade after 20
• Majority of decline is loss of fat free mass(FFM)
• Thermic effect of food= 20% lower in older men than younger
• physical activity accounts for 50% of in TEE
Hormonal Changes
Aging is associated with a decrease in growth hormone secretion, decline in serum testosterone and resistance to leptin leading to:• Decrease in FFM • Increase in fat mass• Decreased ability to down‐regulate appetite
Matsumoto AM. Andropause: clinical implications of the decline in serum testosterone levels with aging in men. J Gerontol A Biol Sci Med ci 2002;57:M76–99.Moller N, O’Brien P, Nair KS. Disruption of the relationship between fat content and leptin levels with aging in humans. J Clin Endocrinol Metab 1998;83:931– 4.
Quality of Life
• Nurses’ Health Study: BMI & age inversely associated with physical function, pain issues and limitations due to physical problems
• SF- 36 noted obesity is associated with health related QOL for older adults- physical functioning and limitations
http://www.drbrantigan.com/patient/SF36tosonly.pdf
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Weight Loss Alone
Positive• Decrease fat mass/ lean body mass
• Young adults 75% loss is fat tissue & 25% FFM, similar in older adults
• 5‐10% weight loss can improve metabolic abnormalities including insulin‐resistant metabolism
Negative• Could exacerbate age‐related loss of muscle mass & sarcopenia
Dengel DR, Hagberg JM, Coon PJ, Drinkwater DT, Goldberg AP.Effects of weight loss by diet alone or combined with aerobic exercise on body composition in older obese men. Metabolism 1994;43:867‐71.141.
Gallagher D, Kovera AJ, Clay‐Williams G, et al. Weight loss in postmenopausal obesity: no adverse alterations in body composition and protein metabolism. Am J Physiol Endocrinol Metab 2000;279:E124
Weight Change in Older Adults
If weight is lost, it is primarily LBM
If weight is gained, it is primarily fat
Therefore, weight loss, even when subsequently
corrected, is a risk factor for sarcopenia
Newman AB et al. Am J Clin Nutr 2005;82:872-878
Benefits of Exercise + Diet
• RCT of obese older adults found no substantial difference in loss of FFM following a 10% weight loss diet & exercise vs. control who did not lose wt
• Regular exercise can decrease diet induced only loss of FFM
BanksM,Klein S, Sinacore D, Siener C, Villareal DT. Effects of weight
loss and exercise on frailty in obese elderly subjects. J Am Geriatr Soc
2005;53:S16(abstr).
• Moderate weight loss + exercise improves both physical function and health‐related QOL
• Can result in improved insulin sensitivity and decrease in intrahepatic fat
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Weight Loss & Bone Mineral Density
• Women 32‐72 total BMD of 1‐2%/ wt. loss of 10%
• Bone loss proportional to amount of wt. loss
• Wt loss alters plasma concentration of hormones involved in bone metabolism & markers of bone turnover
Jensen LB, Quaade F, Sorensen OH. Bone loss accompanying voluntaryweight loss in obese humans. J Bone Miner Res 1994;9:459–63.Jensen LB, Kollerup G, Quaade F, Sorensen OH. Bone mineralschanges in obese women during a moderate weight loss with and withoutcalcium supplementation. J Bone Miner Res 2001;16:141–7. Armamento‐Villareal R, Sadler C, Napoli N et al. Weight loss in obese older adults increases serum sclerostin and impairs hip geometry but both are prevented by exercise training. 2012;J.Bone Miner.Res 27:1215‐1221.
Weight Loss + Exercise & BMD
• RCT ‐30 obese older adults of diet vs. diet & exercise = loss of muscle mass & muscle strength
• RCT‐ 27 obese older adults of diet vs diet & exercise=bone mineral density but not in spine
• RCT‐107= improved function but loss of LBM & hip BMD suggesting need for Ca & D or anti‐resorptive therapy during wt. loss (Villareal 2012)
Frimal TN, et al. Exercise attenuates the weight loss induced reduction in muscle mass in frail obese older adults Med Sci Sports Exerc 2008; 40:1213-1219. Villareal DT et.al. Effect of with loss and exercise therapy on bone metabolism and mass in obese older adults: a one-year randomized controlled trial. J Clin Endocrinol Metab. 2008; 98:2181-2187..
• Most prevalent nutritional deficiency for older adults worldwide regardless of race or ethnicity
• Adults > 51 yrs of age only 4% met or exceeded the adequate intake (NHANES 1999‐2000)
Vit D Deficiency a Major Problem
(Holick NEJM 2007;Hanegau et al. 2008;
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• Essential for maintaining muscle mass & function in aging people
• Helps preserve the Type II muscle fibers that are prone to atrophy in the elderly
Vitamin D
Montero‐Odasso et al. 2005
Vitamin D Supplements
Sarcopenia Recommendations for Vitamin D
• 25(OH) Vit D levels should be measured in all sarcopenic patients (A)
• Vit D supplementation in doses sufficient to raise levels above 100 nmol/L should be given as an adjunctive therapy (A)
• Either Vit D2 or D3 is an acceptable replacement (A)
• Doses of 50,000 IU of Vit D a wk are safe (A)
Level A= minimum of single randomized placebo control trial or meta‐analysis Source: Nutritional recommendations for the management of sarcopenia for the Society for Sarcopenia, Cachexia and Wasting Disease. Morely et.al J Am Med. Dir Assoc: 2010; 11:391‐396.
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Carefully weigh risk vs benefits of weight loss plans
Is weight loss appropriate for all obese individuals with sarcopenia?
Will a restricted diet reduce the individual’s ability to
consume adequate nutrients to maintain health?
What are the risks associated with
obesity treatment?
Weight Loss Therapy
Moderate energy deficient diet plan
• focus on high quality protein
• consider vitamin/mineral
supplements
Increase physical activity
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Weight Loss Therapy
Behavior & cognitive strategies
• problem solving
• goal setting
• social support
• self-monitoring
• stress management
• relapse prevention
Nutrition Assessment• Food and Nutrition Related History: food intake, food availability, physical activity, nutrition QOL, meds ,herbal supplements ,previous diets
• Anthropometric Measurements: weight history, BMI
• Biochemical Values: glucose, electrolytes, any relevant tests
• Nutrition‐Focused Physical Findings: physical appearance, chewing, swallowing concerns,
• Client History: age ,gender, race, socioeconomic status, support system,
Estimating Energy Requirements
• RMR= Indirect calorimetry (IC) is most accurate
• Mifflin‐St.Jeor most accurate when IC not an option
• Use ABW + activity and/or injury factor
Academy of Nutrition and Dietetics. AND Evidence Analysis Library.
• Example: 78 year old male. 5’ 10” and 360 lbs. BMI 51.65 obese class III, moderate activity level
• 2830 kcalories/day
• Minus 500‐700 kcalories to lose 1‐2 lbs./week
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Gradual loss has been tied to protein deficiency, lack of exercise, & increased
frailty among the elderly
The human body reacts to protein deficiency by taking AA away from muscle
tissue & other areas of the body
The process, in which the body basically metabolizes itself (catabolism) can lead to
muscle loss & weakness
Protein + Exercise Sarcopenia
Ensure Adequate Protein Intake
15%‐38% of older men eat less than the RDI for protein.
27%‐41% of older women eat less than the RDI for protein.
Morley J et. al. Nutritional recommendations for the management of sarcopenia J Am Med Dir 2010;11:391‐396.
Factors Influencing Protein Intake in Older Adults1. Inadequate intake= appetite loss or GI disturbances
2. Reduced ability to utilize available protein=insulin resistance, protein anabolic resistance, immobility
3. Increased need for protein= inflammatory disease, increased oxidative modification of protein, catabolic conditions ass. /acute & chronic diseases
All Lead to Loss of Functionality
Evidence‐Based recommendations for optimal dietary protein intake in older people: a Position Paper from the PROT‐AGE Study Group, JAMDA 2013
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What Does the Evidence Suggest for Optimal Protein Intake for Older Adults
• Positive association between protein ingestion & muscle mass (PORT‐AGE study group JAMDA 2013)
• Protein spread equally between breakfast lunch and dinner (Paddon‐
Jones 2009)
• If needed, additional protein supplementation should given between meals (Wilson MM 2002)
Improves muscle mass
Bone health
Insulin sensitivity
Modulates inflammation
Protein Intake Great than RDA
Iglay, et al, Am J Clin Nutr 85: 2007; Kerstettler, et al, J Clin Endo Metab. 84: 1999; Nuttal, Metabolism 55: 2006; Pederson, et al, Mech Ageing Dev 124: 2003
Health, Aging, and Body Composition Study
• Assessed association between dietary protein intake and changes in LBM over 3 years
• 2056 healthy older adults
• Food frequency questionnaire & measured changes in LBM using DEXA
• Adjusted for potential confounders such as smoking, physical activity
• Participants / highest quintile of protein intake lost approx. 40% less LBM than those in lowest quintile of intake
Houston K,et al Dietary protein intake is associated with lean body mass changes in older, community dwelling adults: The Health, Aging and Body composition (Health ABC) Am J Clin Nutr 2008;87:150‐156.
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Ensure Adequate Protein Intake
It is recommended that the total protein intakeshould be 1 to 1.5 g/kg/day (B) It is suggested that a leucine-enriched balance
essential amino acid mix may be added to thediet (B)
Level B= Small trials Source: Nutritional recommendations for the management of sarcopenia for the Society for Sarcopenia, Cachexia and Wasting Disease. Morely E et.al J Am Med. Dir Assoc: 2010; 11:391‐
396.
Role of Essential Amino Acids
• Primary source of protein stimulus
• Leucine maybe the most effective & a determinant of quality
• Consumption of leucine‐rich protein sources may be a key strategy that helps prevent/delay sarcopenia
Combaret et al., 2005
Antioxidants
• Aging is associated with increased levels of oxidative stress leading to damaged cell membranes & proteins responsible for many chronic diseases resulting from an inability of the immune response to initiate an adequate cellular defense.
• Oxidative stress has also been implicated in sarcopenia
• Antioxidants are effective in combating oxidative damage
Antioxidants
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Antioxidants• Low serum selenium concentrations are associated with poor grip
strength among older women living in the community
• Low serum selenium resulted in increased IL(6) = low physical function & sarcopenia (Beck 2007, Lauretani 2007)
• Dietary carotenoids comprise an important component of the antioxidant defense system that helps keep the inflammatory cytokines in check
• There is evidence that older adults with low plasma carotenoids levels are more likely to have elevated IL‐6 concentrations, poor muscle strength
Richard D. Semba*, Fulvio Lauretani, and Luigi Ferrucc. Carotenoids as protection against sarcopenia in older adults. Arch Biochem Biophys. 2007 February 15; 458(2): 141–145h.
• The 6 major dietary carotenoids (α‐carotene, β‐carotene, β‐cryptoxanthin, lutein, zeaxanthin, and lycopene) comprise an important component of the antioxidant defense system in humans
• Carotenoids protect against oxidative stress by quenching singlet oxygen, scavenging free radicals, inhibiting lipid peroxidation, & modulate proinflammatory cytokines
Semba RD, Blaum , Guralnik JM, et al. Carotenoid and vitamin E status are associated with indicators of sarcopenia
among older women living in the community. Aging Clin Exp Res. 2003;15:482‐487
Carotenoids
Carotenoids
Studies suggest intake of carotenoids or carotenoid‐rich foods may be protective against decline in muscle strength & developing walking disability among older community‐dwelling adults
Semba et al., 2003; Cesari et al., 2004; Semba et al., 2007
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• EPA (eicosapentaenoic acid) has been found to preserve muscle mass under various physiological conditions.
• DHA (docosahexaenoic acid) has anti‐inflammatory effects, which scientists believe may be of value in managing sarcopenia.
Omega‐3 fatty acid
Tisdale 2006; Roubenoff 2003; Fritsche 2006
Suggested Diet Plan
• Focus on carbohydrate and high quality protein distributed evenly between meals(1.0‐1.5 gr/kg/day)
• Encourage consumption of sources of Ca/vit D
• Consider vitamin D supplement
• Include fruits/veggies antioxidants
Incorporate Exercise
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Four Components of Exercise for Older Adults
• Resistance Training: KEY
• Aerobic activity
• Flexibility
• Balance
• Decrease frailty & improve muscle strength
• Repetitive activity,heart rate
• Ankle flexibility, maintain lower back strength
• Decrease risk of falls
• Physician – assess physical ability to begin exercise & clears for program
• RD/RDN‐monitors diet and weight decline & adjusts as needed
• Physical therapist and/or certified trainer develop exercise program and work with individual
Interdisciplinary Approach
Supervised Exercise Program
• Goal: 2hr 30 min of moderate aerobic activity3‐5 days wk
• Resistance: 2 or more days a wk, work major muscle groups
• Flexibility: improves ability to perform ADL
• Balance: assists in fall prevention
• Aerobic:endurance, walking, cycling, dancing swimming
• Resistance: hand held weights, rubber bands, tubes
• Flexibility: stretching, tai chi, yoga
• Balance: ability to rise from chair unassisted, stand on one foot alone or supported
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Community Programs
• Silver Sneakers Fitness Program : Medicare health plans and Medicare Supplement carriers
• Local wellness centers or Y programs
• Invest in a step counter: start low 500 steps & increase
Hydration: Important with Exercise
• Drink water before &after exercise
• Vary choices with meals & during the day : low fat milk, vegetable juice, low calorie soft drinks, lemonade, coffee, ice tea, water
Exercise for Frail Older Adult
• 55.6% of patients hospitalized for >12 days had LBM depletion
• 3‐4 fold increased likelihood of disability
• Older adults recover much more slowly
• Resistance exercise improves strength & frailty
Kortebein, P 2008, Binder EF 2002
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Summary• Assess all obese older adults with sarcopenia to determine if weight loss is appropriate
• Initiate exercise for all sarcopenic older adults
• Weight loss programs should include an exercise component (aerobic & resistance training) plus behavior modification, self‐monitoring, goal setting and social support
Summary
• Weight loss should be gradual and meals should include high quality protein consumed in equal quantities at each meal
• Consider leucine, antioxidants, vit D, & omega‐3 fatty acids
QUESTIONS?
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Additional References1.Semba RD, Blaum C, Guralnik JM, et al. Carotenoid and vitamin E status are associated with indicators of sarcopenia among older women living in the community. Aging Clin Exp Res. 2003;15:482‐487.2. Cesari M, Oahor B, Bartali B, et al. Antioxidants and physical performance in elderly persons: the Inve (InCHIANTI) study. Am J Clin Nutr. 2004;79:289‐294.3. Semba RD, Varadhan B, Bartali B, et al. Low serum carotenoids and development of severe walking disability among older women living in the community: the Women’s Health and Aging Study I. Age Ageing. 2007;36:62‐67.4.Ferrucci L., Harris TB, Guralnik JM. Serum IL‐6 level and the development of disability in older persons. J Am Geriatr Soc. 1999 Jun;47(6):639‐465. Richard D. Semba,* Fulvio Lauretani, and Luigi Ferrucci. Carotenoids as protection against sarcopenia in older adults. Arch Biochem Biophys. 2007.458(2): 141‐145.6. Tisdale MJ. Clinical anticachexia treatments. Nutr Clin Pract. 2006 Apr;21(2):168‐74.7.Roubenoff R. Catabolism of aging: is it an inflammatory process? Curr Opin Clin Nutr Metab Care. 2003 May;6(3):295‐9.8.Fritsche K. Fatty acids as modulators of the immune response. Annu Rev Nutr. 2006;26:45‐73.9. Evidence ‐Based Recommendations for optimal dietary protein intake in older people: A Position Paper from the PORT‐AGE study group JAMDA 2013; 14(8):542‐559.10. Thomas, D Sarcopenia.Clinics in Geriatric Medicine 2010. (2):231‐46.11 Houston K,et al Dietary protein intake is associated with lean body mass changes in older, community dwelling adults: The Health, Aging and Body composition (Health ABC) Am J Clin Nutr 2008;87:150‐156
Exercise Resources
• https://www.presidentschallenge.org/informed/digest/docs/june2010digest.pdf (Exercise Comes of Age)
• http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html
• http://www.nia.nih.gov/health/publication/exercise‐physical‐activity‐your‐everyday‐guide‐national‐institute‐aging‐1
• http://nihseniorhealth.gov/exerciseforolderadults/healthbenefits/01.html
• http://www.helpguide.org/life/senior_fitness_sports.htm (this guide has information on exercises for those who maybe chair bound)
Evaluations and CE Certificates
• Everyone who has completed the webinar will be emailed a link to the evaluation.
• The email will be sent to the email address that you used to register for the webinar.
• Please complete the evaluation soon after you receive the email. The evaluation does expire after 3 weeks. Once expired, you cannot obtain a certificate.
• Once the evaluation is completed, the CE certificate will be emailed separately within 2 business days.
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COPE’s November Professional Webinar
Anne McGrorty DNP, RN, CPNPAlison McGrorty, MD
Date: Wednesday November 12th
Time: 12:00PM ‐ 1:00PM ESTCE Credit: 1.0 contact hour, 1.0 CPEU
To register, go to villanova.edu/cope and click on Webinar Series
A Pediatric Evidence Based Teaching Plan: Foundation of a
Social Media Intervention
Questions and Answers!
Moderator: Rebecca Shenkman, MPH, RDN, LDN
Email: [email protected]
Web site: villanova.edu/COPE
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