importance of nutrition for healthy...

Importance of nutrition for healthy aging

2nd CCNMC – Portoroz, 2013

Lubos Sobotka 3rd Department of Medicine

Metabolic Care and Gerontology Medical Faculty – Charles University

Hradec Kralove Czech Republic

Life expectancy without disability in the European Union: Ø 61.3 years for men Ø 62 years for women Life expectancy: Ø 76.7 years for men Ø 82.6 years for women

Present situation

The acutely ill elderly person



The acutely ill elderly person

...is in increased need of, nutritional, rehabilitative and psychological care to avoid partial or complete loss of independence. Sarcopenia, is a frequent comorbid situation.

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příjem 3 měsíce 6 měsíců 9 měsíců

kontrola

Effect of acute illness on Barthel index in seniors > 78ys

Hegerová a spol 2010


time

Health

Dependence

Illness

Critical pint

Immobility

Death

Infection

Organ failure

Sepsis MOF

Surgery


time

Health

Dependence

Illness

Critical pint

Immobility

Death

Surgery Infection

Organ failure

Sepsis MOF


time

Health

Dependence

Illness

Critical pint

Immobility

Death

Infection

Organ failure

Sepsis MOF

Surgery


The relationship between nutritional status and patients’ outcomes is of particular interest in chronically critically ill patients, that is, patients who survive the life-threatening phase of critical illness have prolonged hospitalizations and many complications because of their dependence on critical care support services


Malnutrition – hidden killer


Long term fasting - Mr. Levanzin

Before fasting

After fasting


Bennedict 1920

Owen OE et al. 2005 2nd CCNMC – Portoroz, 2013

Adaptation to starvation


Cahill GF 2006

Adaptation to starvation

kg kcal Fat 15 141.000 Protein 12 40.000 Glycogen Liver 0.2 400 Glycogen Muscle 0.5 800 Glucose 0.02 80

Energy depots in a 70 kg healthy person

Hill 1992 2nd CCNMC – Portoroz, 2013

Inflammation promotes muscle catabolism

TNFα, IL-1, IL-6, INFγ


Cytokines

TNFα, IL-1, IL-6, INFγ

Inflammation and cytokines

inflammation

Insulin resistance


glutamin

AA - alanin

glucose

FA

lactate

Inflammation and substrate flux

inflammation CRP, albumin


Immobility

Consequence of acute illness

Inflammation

Malnutrition

Loss of muscle mass


kg kcal Fat 15 141.000 Protein 12 40.000 Glycogen Liver 0.2 400 Glycogen Muscle 0.5 800 Glucose 0.02 80

Energy depots in a 70 kg healthy person

Hill 1992 2nd CCNMC – Portoroz, 2013

SM, skeletal muscle; FFM, fat-free mass; ASM, arm skeletal muscle; LSM, leg skeletal muscle; VAT, visceral adipose tissue; IMAT, intramuscular adipose tissue; TBBMC, total-body bone mineral content. *P < 0.05, **P < 0.001.

Song MY et al. Am J Clin Nutr 2004

Age related changes in body composition – 2 years


SM, skeletal muscle; FFM, fat-free mass; ASM, arm skeletal muscle; LSM, leg skeletal muscle; VAT, visceral adipose tissue; IMAT, intramuscular adipose tissue; TBBMC, total-body bone mineral content. *P < 0.05, **P < 0.001.

Song MY et al. Am J Clin Nutr 2004 2nd CCNMC – Portoroz, 2013

Age related changes in body composition – 2 years

Catabolic reaction

Muscle wasting

Loss of function – immobility of the elderly, problems with physiotherapy, respiratory muscle weakness, pneumonia, falls, pressure sores, etc.


Immobility

Multimodal approach

Inflammation

Malnutrition

Loss of muscle mass


Lean body mass - effect of 10 days of bed rest in healthy elderly -

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Before Afer

Kortebein P et al, JAMA 2007

kg

Change = -3.2%


Lower extremity mass (DEXA) - effect of 10 days of bed rest in healthy elderly -

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Before Afer


kg

Change = -6.3%


Isokinetic muscle strength

- effect of 10 days of bed rest in healthy elderly -

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Before Afer


Nm

/s

Change = -15.6%


Muscle fractional synthetic rate - effect of bedrest -

0,02

0,03

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0,05

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0,1

Before Afer


%/h

Change = -30.0%


Muscle mass is dependent on physical activity

Immobilization before surgery decreases LBM, muscle mass, muscle function and muscle protein synthesis.

Bed is dangerous for elderly person as well as Ferrari car for young boy.

Claude Pichard


Immobility

Multimodal approach

Inflammation

Malnutrition

Loss of muscle mass


Liver Spleen

lactate glucose

glucose lactate

Deutz NEP et al 1992

Glucose and lactate metabolism after operation


saline

TNF-α

Inhibition of hepatic ketogenesis by TNG-α in rats postabsorptive state

Beylot M 1992 2nd CCNMC – Portoroz, 2013

M. Balage et al. 2009

Low grade inflammation Decreases post-absorptive muscle protein

synthesis


Control Inflammation

Acharyya S et. al, 2005

Loss of type II fibers in inflammation


Immobility

Multimodal approach

Inflammation

Malnutrition

Loss of muscle mass


Energy intake in the group of elderly patients

Sullivan DH. et al, 1999 2nd CCNMC – Portoroz, 2013

Sullivan DH. et al, 1999

Nutrition and mortality after acute illness


Nutrition and mortality after acute illness

Sullivan DH. et al, 1999 2nd CCNMC – Portoroz, 2013

Dvir D et al. 2006

Negative energy balance and ICU complications


Anthropometric variables, energy intake and nosocomial infections

n

No infection 116

One infection 38

>One infection 31

P

Weight (kg) 61.2 ± 1.5 58.9 ± 3.1 51.3 ± 1.7 0.0079

BMI (kg/m²) 23.8 ± 0.5 24.0 ± 1.2 21.2 ± 0.7 0.046

MAC (cm) 27.1 ± 0.4 26.7 ± 1.0 24.1 ± 0.7 0.011

TST (mm) 11.6 ± 0.5 12.9 ± 1.3 9.5 ± 0.8 0.064

BST (mm) 4.9 ± 0.3 5.9 ± 0.9 3.1 ± 0.3 0.011

Energy intake (kcal/day)

1717 ± 40 1474 ± 91 1284 ± 74 <0.001

BMI, body mass index; MAC, mid-arm circumference; TST, tricipital skinfold thickness; BST, bicipital skinfold thickness. Paillaud E et al. Age and Ageing

2005


How to screen nutritional risk in the older patients ?


Stratton RJ et al 2004


Is there difference in nutrients composition?

Energy


•  Twenty-seven healthy elderly volunteer subjects (13 women and 14 men, ages 67–82 y)

•  REE measured with a hood-type open-circuit respiratory calorimetry system.

•  TEE were determined using doubly labeled water for a 14-d period

Energy expenditure in the elderly

Seale JL A et al. 2002 2nd CCNMC – Portoroz, 2013

Seale JL A et al. 2002

REE Kcal/d 1600 1230


Total energy expenditure in the elderly

Seale JL A et al. 2002

TEE Kcal/d 2900 2250


Gaillard C et al. 2006

REE adjusted per kilogram of body weight as a function of BMI in elderly people



Protein


Bos C et al. Am J Clin Nutr 2000

Short-term protein and energy supplementation activates nitrogen kinetics and accretion in poorly nourished elderly subjects - protein.


Phenylalanine net balance across the leg increased significantly during oral supplementation in young and elderly

subjects

Volpi E. et al. 2000 2nd CCNMC – Portoroz, 2013

•  Energy expenditure is related to FFM

•  Energy and protein intakes in acutely ill elderly patients are similar to adult subjects.

Ø  Protein intake: 1.5 – 2 g•kg-1•day-1

Ø  Energy intake: 30 – 35 kcal•kg-1•day-1

Energy and protein intake in the elderly



Micronutrients


Lee JS et al. J Nutr 2001

Nutrient

Nutrient intake in the elderly


ü  Vitamin and mineral deficiencies are more prevalent in elderly than in younger subjects.

ü  Many older patients will already have impaired status of trace elements and vitamins at the time they commence nutritional support.

ü  There is good evidence from the United Kingdom and from the United States that up to 40% of individuals aged 65 or more have an inadequate intake of one or more vitamins or minerals (ascorbate,folate,B12,thiamine, riboflavin, magnesium, iron and zinc) with low blood concentrations

Finch,S et all. National Diet and Nutrition Survey: people aged 65 yearts and over. London:The Stationery Office, 1998 Lee JS, Frongillo EA. Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J Nutr 2001;131:1503–1509


Nutritional support is indispensable

part of medical care

Start right now!


Nutritional supplementation during acute illness in elderly patients randomized, double-blind, placebo-controlled trial

Gariballa S et al. 2006

Sieber et al 2002

Empty fridge and readmission of old patients to the hospital

Artificial nutrition in ICU in the elderly

Nasogastric or nasojejunal tube

Percutaneous gastrostomy

Parenteral nutrition

Nutritional support must not decrease physical activity in elderly patients!


Role of physical activity

Physical training increases fractional synthesis rate of mixed muscle

protein

Short KR et al. Am J Physiol 2004 2nd CCNMC – Portoroz, 2013

Daily 600 kcal & 24 g protein

+

2 x 5 min ergometry & 30 min rehabilitation


-8000-7000-6000-5000-4000-3000-2000-1000

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kontrola sipping

Energy deficit

Dědková a spol 2010


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kontrola sipping

LBM change

Dědková a spol 2010


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kontrola

Barthel index



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test

Barthel index



ü  There is high risk of PEM in elderly patients undergoing surgery.

ü  Acute inflammation and immobility aggravate loss of muscle mass.

ü  Loss of muscle mass contributed to systemic inflammatory response.

ü  Muscle loss and chronic disability can predispose the elderly to a cycle of depression, anorexia, and even mental impairments.

ü  Physical activity and physiotherapy should be integral part of preoperative nutrition support in the surgical elderly patients

Key messages


Seeking magic bullet

Linear way of thinking

&

20th ESPEN Course - Gödöllô, Hungary 2013

Czech version of Mediterranean diet

Good definition of nutritional goals is necessary to prevent confusions


Important implication

It must be known in all patients whether their nutritional state is such, that it leads to diminished

healing or recovery in disease and after surgery and trauma!


Knowing the goals of treatment and patient work is important

Lacemaker – J Vermeer


Thank you

Knowing the goals of treatment and patient work is important

Lacemaker – J Vermeer


Thank you

Outcome based medicine

importance of nutrition for healthy...

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