Protein · Slower loss of muscle mass and strength ↑Bone mass density Slower rate bone loss...

Protein:The Currency of Functional

Independence

Debra Zwiefelhofer, RDN, LD

[email protected]

Understand of the important role protein has in

promoting functional independence in older adults.

Learn to differentiate the unintended weight loss

between sarcopenia, frailty, and geriatric failure to

thrive

Get ideas for promoting adequate energy and protein in

the diet of older adults.

Objectives

ANFP Annual Conference & Expo | Hyatt Regency Grand Cypress | Orlando, FL | August 2-5, 2015 2

Carbohydrates FUEL

Adequate energy is needed to fund basal metabolic rate

(BMR) + Activity

Key purpose: spare protein

Proteins BUILD

Amino acids are the body’s building blocks

Rebuild, strengthen, thicken muscle fibers

Key Point of Differentiation

3ANFP Minnesota State Meeting | St. Cloud | 2015

Metabolic Rate

Energy needed at rest

Range 1,000 – 2,500 kcal/day; average ~1,500

Variation due to: lean vs. fat mass, age and ???

BMR vs. RMR

Calculating BMR / RMR

Indirect calorimetry is gold standard

Scales – some calculate metabolic rate

Equations:

Harris-Benedict

Mifflin St Jeor

Energy


Study Findings for 46 adults >70y in LTC (data gathered

9/2013 – 3/2014)

Weights stable >6 mo.

Ages ranged 86.6 + 6.9 y

BMI 26.7 + 3.9

Measured RMR vs. Estimated

ALL equations over estimated energy

Six Equations:

Closest -> Mifflin St. Jeor (37 + 372 kcals/day)

Worst -> FAO/WHO/UNU and Owen

Range of over-estimation -> 10.1% - 189%

Range of underestimation -> 10.6% - 29.8%

Calculating Energy


Hicks J et al. Clinical Nutrition Week 2015 Int’l Abstract of Distinction J of Parenter Enteral Nutr. 2015;39:252.

Mifflin St. Jeor Formula:

10*wt(kg) + 6.25*Ht(cm) - 5*Age(yrs) -161 = resting energy

expenditure (female)

10*wt(kg) + 6.25*Ht(cm) - 5*Age(yrs) + 5 = resting energy

expenditure (male)

Activity

1.3=sedentary

1.4=walking/standing, no exercise

1.5=exercise

1.6=walking & exercise

1.8=heavy lifting & exercise

Mifflin St. Jeor + Activity = daily calorie target

Calculating Energy


Dietary protein + stored protein = amino acid pool

Body synthesizes ~250 grams new proteins daily

Replace old protein, repair tissue

Efficiency in protein utilization stops with growth

Protein


Fig. 1

Journal of the American Medical Directors Association 2013 14, 542-559DOI: (10.1016/j.jamda.2013.05.021)

Copyright © 2013 American Medical Directors Association, Inc.

Needs Don’t Change with Age

Protein metabolism is less efficient in older adults

Protein and Aging

Preserve and/or replace lean body mass

Maintain healthy immune system

Assist with normal cell repair

Promote wound healing

Promote functional independence

Protein is fundamental to every

system and function in the body!

0.8 g/kg not enough for >65 y

Current requirements based on N-

balance and not optimizing muscle

mass or functionality

[Healthy] elderly require 1.0-1.2 g/kg

BW high quality protein daily to

maintain / gain muscle

Requirement may be 1.2-2.0 g/kg BW for

repletion

Adequate [quality] protein intake per

meal is important

25 – 30 gram / meal target

Bauer J, et al. JAMDA 2013;14:542-559.

*Praddon-Jones D, et al. JCEM 2004;89:4351-4358

Praddon-Jones D, et al. Am J Clin Nutr 2008;87(suppl):1562S-1566S.

Loss of lean leg mass

during bed rest*

Benefits of Higher Protein Intake

Correlates to:

Slower loss of muscle mass and

strength

↑Bone mass density

Slower rate bone loss

Health ABC Study: subjects in highest

quintile of protein intake lost ~40% less

LBM than those in lowest quintile

70-100g animal protein vs. 30-60g

animal/ vegetable protein

Bauer J, et al. JAMDA 2013;14:542-559.

Houston DK, et al. Am J Clin Nutr. 2008;87:150-155.

All Proteins are Not “Equal”

Two considerations:

Quality [essential amino acid

content; esp. leucine]

Digestibility and bioavailability

Good, Better, Best…but any

protein better than none

Plant proteins (soy)

Egg

Dairy (whey, casein) & (lean)

Meat

Higher in key amino acid leucine

Praddon-Jones D, et al. Am J Clin Nutr 2008;87(suppl):1562S-1566S

Symon TB, et al. Am J Clin Nutr. 2007;86:451-456.

ANFP Minnesota State Meeting | St. Cloud | 201513

Essential (indispensable) amino acid

Key metabolic trigger of process that initiates muscle

protein synthesis

The better the leucine intake the lower the overall

protein intake needs to be

Why Leucine?


Needed

for 2.5 g

leucine

12.8 –

[2 oz. ]

slices

whole

grain

bread

5 oz.

chicken

breast

~4 – 8 oz.

glasses

of milk

5 oz.

beef

roast

5.3 oz.

peanuts

4.6 eggs

Optimal Feeding of Protein

25 – 30 gm / meal (w/ 2.5-

2.8 gm leucine per meal)

OR, at minimum

Main high-protein meal at

midday

Litchford, MD. Nutr Clin Pract. 2014;29:428-434.

Fig. 2

Journal of the American Medical Directors Association 2013 14, 542-559DOI: (10.1016/j.jamda.2013.05.021)

Copyright © 2013 American Medical Directors Association, Inc.

As able…30-60 min. / day of endurance exercise

Resistance training 2-3 x/wk for 10-15 min.

Frail individuals

can gain muscle

strength and

function!


>70% of older Americans would benefit

from improved eating habits. White JV et al. Nutr Clin Pract. 2003;18:3-11.

27362482

19071831 17591535

0

500

1000

1500

2000

2500

3000

20-39 y 40-59 y >70 y

Males

Females

Energy (kcal/day) Intake of Adults

Usual Intake from Food

Source: What We Eat in America National Health and Nutrition Examination Survey (NHANES) 2009-2010

327

279

232232 219196

0

50

100

150

200

250

300

350

20-39 y 40-59 y >70 y

Males

Females

Carbohydrate (g/day) Intake of Adults



98 97

7268 6658

0

20

40

60

80

100

120

20-39 y 40-59 y >70 y

Males

Females

Fat (g/day) Intake of Adults



106100

7470 7060

0

20

40

60

80

100

120

20-39 y 40-59 y >70 y

Males

Females

Protein (g/day) Intake of Adults



Prevalence of Protein - Energy Malnutrition

in the Geriatric Population

6-15% in LTC Faz ia M e t .a l . JAMDA 2013; 14 :77-79

5-10% Community Dwellers

60% Hospitalized

35-85% in LTC Furman EF. J Geron to l Nu rs 2006;32:22-27

6% Community Dwellers

39% Hospitalized

51% Rehab

14% in LTC Ka iser MJ e t a l . J Am Ger ia t r Soc . 2010 ;58:1734 -1738 .

60% >65y in ER malnourished or at -risk Pere i ra GF e t a l . Ann Emerg Med . 2014 ;x :1 -7 . ( i n p ress)

MNA® better indicator of malnutrit ion than BMI in >85yrs.

Vitamins & Minerals

Over 40% of adults don’t meet the daily recommended

intakes for vitamins & minerals through diet alone

Calcium, Potassium, Magnesium,

Vitamins A, C, & E

For older adults also: Vitamin B12 & D

Older adults have increased need for:

Vitamin D & B12

Calcium & ?Zinc

The “only” decreased need:

Women have ↓ need for iron after menopause

Position of the American Dietetic Association: Nutrient Supplementation J Am Diet Assoc. 2009;109:2073-2085.

Foote JA, et al. J Am Coll Nutr. 2000;19:628-640.

Multiple Medical Conditions*

*Among fee -for -service Medicare Beneficiaries, 2010

Age-related loss of muscle mass AND strength

Not specific to frail individuals

Observed in “healthy”; well-nourished elderly

Lean mass >2 SD below the young normal mean

Sarcopenic obesity…loss of lean muscle with excess adipose tissue

Presents as: physical disabil ity, functional impairment, decreased physical performance, loss of independence, falls

Diet helps; strength training is key

Sarcopenia

Thomas, DR. Asia Pacific Geriatric Congress Hong Kong October 2012

Praddon-Jones, D et al. Am J Clin Nutr. 2008;87(Suppl):1562S-1566S.

Frailty Syndrome

Prevalence: 3-6% of 65–70 yrs. and >16% aged 80+ Fried’s Frailty Syndrome Phenotype:

Weight loss >4.5 kg in past year

Exhaustion – often or most of the time

Very low to no physical activity

Low walking speed (<15’ in >6-7 sec)

Low hand grip strength

Etiology → many Treatable? Or, GFTT?

Multiple issues increase the complexity

Prevention: Strength training

Adequate protein and iron

Staying generally active

Fried LP, et al. J Gerontol Med Sci. 2001;56A:M416-M156.

Sarcopenia

-muscle loss

-↓ muscle quality

Frailty

-fatigue

- ↓ activity

- ↓ weight

-cognitive impairment

-social isolation

↓ Physical

Function

-↓ muscle strength

-slow gait speed

-poor balance

Common and overlapping in older adults

Frail person may not be sarcopenic

Sarcopenic person is often, but not always,

frail

Sarcopenia vs. Frailty

Cesari M et al. Frontiers in Aging Neuroscience. 2014;6:Article 192

Geriatric Failure to Thrive (GFTT)

GFTT is not “normal”

Recognize & Intervene

Late-l ife syndrome defined by: Wt. loss >5% of baseline

↓ appetite….dehydration ….poor nutrition

Inactivity

Depression

Impaired immune function

Low cholesterol levels (<160 mg/dl and declining)

4 common syndromes; predictive of adverse outcomes: impaired physical function

malnutrition

depression

cognitive impairment

Robertson RG, Et al. Am Fam Physician. 2004;70:343-350.

Prevalence:

~5%-35% community

dwelling elders

~25%-40% nursing

home residents

Assessing Geriatric Failure to Thrive

Indications:

Depression Cognitive Impairment

Malnutrition Functional Impairment

Failure to Thrive

Investigation

Lab / diagnostics

MMSE, ADL, IADL, “Up & Go Test”

Geriatric depression scale

MNA ®

Rx review

Chronic disease evaluation

Assess environment

Adapted from Robertson RG, Et al. Am Fam Physician. 2004;70:343-350.

Assessing Geriatric Failure to Thrive

Depression

• Psychotherapy

• Antidepressants

• Modify environment

Malnutrition

• SLP Eval

• Treat oral pathology

• Review diet restrictions

• Inc. feedings

• Nutr. Supplements

• Tube feed?

Cognitive Impairment

• Optimize living conditions

• Treat depression

• Treat malnutrition

• Treat infection

• Dementia-delaying Rx

Functional Impairment

• PT

• OT

• Modify environment

With results, continue to treat.

If no/ minimal result conduct care planning. Repeat evals/end-of-life / hospice

The Challenge


31

How do we get

older people

eating better?

We all “market & sell” ideas, plans, requests….

Know your audience

Message gain be “gain-framed” or “loss-framed”

Getting People to Follow the Plan


Wansink B and Pope L. Nutrition Reviews. 2014;73:-11.

Characteristic Gain-framed may be more

effective

Loss-framed may be

more effective

Level of

involvement in the

issue

Low involvement High involvement

Certainty of

outcome

Certain Uncertain

Preference for risk Risk-adverse Risk-seeking

Need for cognition Heuristic processing Piecemeal processing

Research suggests that people respond best to ‘gain -

framed’ health messages for following coarse of action

Do not have highly detailed knowledge of health/nutrition

Not susceptible to ‘fear-based’ or ‘loss-based’ message

Getting People to Follow a Plan


Wansink B and Pope L. Nutrition Reviews. 2014;73:-11.

“Mrs. Jones, I’d love for you to drink your milk

so you can continue to take those nice walks

with your grandkids when they visit.”

Instead of

“Mrs. Jones if you don’t eat more food with

calcium and protein you’re going to keep

losing bone density [and break bones].”



“Mr. Smith eat-up so you

will feel better for bingo

this afternoon”

“One more bite Mr.

Smith and you’ll make

your wife so happy”



Equally portion protein across meals

Think Differently


Layman DK 2009 Nutr and Met.

Kim, IY 2014 Am J Physiol Endocrinol Metab.

Adequate Protein?


Breakfast Lunch Dinner

Juice Seafood Alfredo [3

oz. meat]

Shepherd’s Pie [2

oz. meat]

Cereal ½ c Kale ½ c Cauliflower

Canadian Bacon [1

oz.]

½ Apple Roll w/ Butter

1 sl Toast ½ c Mousse ½ Banana

Milk [8 oz.] Milk [8 oz.] Milk [8 oz.]

Total Pro: 18 Total Pro: 29 Total Pro: 30

25-30g Protein


Breakfast Lunch Dinner Snack

Orange Juice Meatloaf [4 oz] Vegetable Soup

Breakfast

Sandwich [1 egg, 1

oz. ham, 1 oz.

cheese in English

Muffin]

Whipped potatoes

with Gravy

Turkey Sandwich

[Bun, 3 oz. meat +

lettuce, tomato]

High protein bar

Milk or Yogurt 4 oz. Green Beans Chips Milk 4 oz. (or juice)

Vanilla Ice Cream Canned Peaches

Milk 4 oz. Milk 4 oz.

Total Pro = 28 Total Pro = 29 Total Pro = 29 Total Pro = 15-20

Eggs aren’t just for breakfast [and vice versa]

Breakfast ideas?

Yogurt → “plain”, smoothie, parfait

Sandwiches

Canadian Bacon & Cheese

Ham & Cheese

Peanut Butter

Other meats????

Sausage (rope kind)

E.g. sausage and potato skillet

Cheeses (and bread)

Mozzarella cheese sticks

Addressing The Egg Situation…

39

Protein Rich Snacks

Food Serving Size Protein (g)

Greek Yogurt, non-fat 5-6 oz. 11-13

Protein bars 1 bar 8-16+

Low-fat cottage cheese 1/2c 12

Almonds 1/4c 8

Pumpkin Seeds 1/4c 7

Milk 8 oz. 8

(String) Cheese 1 oz. 6-8

Boiled egg (large) 1 6

½ Bread & Meat

Sandwich

1 slice + 1 oz. 8-10

Vanilla Ice Cream ½ c 2


9g if a High-Pro VIC

13g w/instant breakfast

↑ to 2 oz. meat + 6-7g

Use ONS for “milk” on cereal, as coffee creamer, as

base for cream soup, in mashed potatoes…etc.

“Poor man’s” ONS = add instant breakfast or dry milk

powder to milk

Adding Protein (& Calories)


Low-fat Milk Standard ONS High Protein ONS

Calories / Ounce 15 31 31

Protein gm /

Ounce

1 1.25 1.75


Other Ideas?

Protein and calories are critical to health and well -

being at all ages – especially for the older person

Protein needs don’t change with age.

Protein utilization is less efficient in older adults

Current RDA is inadequate

Older adults need 1.2 – 1.5 g/kg high quality proteins to

offset anabolic resistance and promote muscle protein

synthesis

In Conclusion

43

B a u e r , J e t a l . E v i d e nc e - ba sed r e c o m m en da t i o ns f o r O p t i m a l d i e t a r y p r o t e i n i n t a k e i n o l d e r p e o p l e : a

p o s i t i o n p a p e r f r o m t h e P R O T -AGE s t u d y g r o u p . J A M D A . 2 0 1 3 ; 14 :5 42 -5 59 .

C e s a r i M , e t a l . S a r c o pe n i a a n d p h ys i c a l f r a i l t y : t w o s i d e s o f t h e s a m e c o i n . F r o n t i e r s i n A g i n g

N e u r o sc i en ce . 2 0 1 4 ; 6 :A r t i c l e 1 9 2 .

F o o t e J A e t a l . O l d e r a d u l t s n e e d g u i d a nce t o m e e t n u t r i t i o na l r e c o m m en da t i o ns . J A m C o l l N u t r .

2 0 0 0 ; 1 9 : 62 8 - 64 0 .

H i c k s J , M a l o S , O m o r i S , e t a l . C l i n i ca l N u t r i t i o n W e ek 2 0 1 5 I n t e r n a t i on a l A b s t ra c t o f D i s t i nc t i o n . A n

E x a m i n a t i on o f M e a s u re d vs P r e d i c te d R e s t i ng M e t a b o l i c R a t e I O l d e r A d u l t s L i v i n g i n L o n g - Te rm C a r e .

J P E N . 2 0 1 5 ; 3 9 : 252 .

H o u s t on D K , e t a l . D i e t a ry p r o t e i n i n t a k e i s a s s o c i a te d w i t h l e a n m a s s c h a n c e i n o l d e r c o m m un i t y -

d w e l l i ng a d u l t s : t h e H e a l t h A g i n g a n d B o d y C o m p os i t i o n ( H e a l th A B C ) S t u d y . A m J C l i n N u t r .

2 0 0 8 ; 8 7 : 15 0 - 15 5 .

K i m I - Y , S c h u z l e r S , S c h r ad e r A , e t a l . Q u a n t i t y o f d i e t a r y p r o t e i n i n t a k e , b u t n o t p a t t e r n o f i n t ak e ,

a f f e c t s n e t p r o t e i n b a l a n ce p r i m a r i l y t h o u g h d i f f e re nc es i n p r o t e i n s yn t h e s i s i n o l d e r a d u l t s . A m J

P h y s i o l E n d o c r i no l M e t a b . 2 0 1 4 ; 30 8 : E21 - E28 .

L i t c h f o rd M D . C o u n t e r ac t i n g t h e t r a j e c t o r y o f f r a i l t y a n d s a r c o pe n i a i n o l d e r a d u l t s . N u t r C l i n P r a c t .

2 0 1 4 ; 2 9 : 42 8 - 43 4 .

P r a d d on -J on es , D . e t a l . R o l e o f d i e t a r y p r o t e i n i n t h e s a r c o pe n i a o f a g i n g . A m J C l i n N u t r .

2 0 0 8 ; 8 7 ( su pp l ) : 15 2S - 15 6S .

R o b e r t son R G a n d M o n t a gn i n i M . G e r i a t r i c f a i l u r e t o t h r i ve . A m F a m P h ys i c i an . 2 0 0 4 ; 7 0 :3 43 - 3 50 .

S ym o ns T B , e t a l . A g i n g d o e s n o t i m p a i r t h e a n a b o l i c r e s p o n se t o a p r o t e i n - r i ch m e a l . A m J C l i n N u t r .

2 0 0 7 ; 8 6 : 45 1 - 45 6 .

W an s i nk B . a n d P o p e L . W he n d o g a i n - f r ame d h e a l t h m e s sa ge s w o r k b e t t e r t h a n f e a r a p p e a l s? N u t r i t i on

R e v i ew s . 2 0 1 4 ; 79 :4 - 11 .

W hi te J V , e t a l . N u t r i t i o n i n c h r o n i c d i s e a se m a n a gem e n t i n t h e e l d e r l y . N u t r . C l i n P r a c t . 2 0 0 3 ;1 8 : 3 - 11 .

References


Thank you!

Protein · Slower loss of muscle mass and strength ↑Bone mass density Slower rate bone loss...

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Transcript of Protein · Slower loss of muscle mass and strength ↑Bone mass density Slower rate bone loss...