The Importance of Lean Body Mass & Muscle in Healthy Ageing: Latest Evidence Nicolaas E Deutz, MD, PhD. Professor, Ponder Endowed Chair Editor-in-Chief Clinical Nutrition and Clinical Nutrition ESPEN Director Center for Translational Research in Aging & Longevity.  Department of Health & Kinesiology, Texas A&M University

Aging and Body Mass Index 20-49 50-59 60-69 70-79 80-99 Body Mass Index (kg/m2) Predicted Mortality (%) Predicted probability of death as a function of body mass index (BMI) calculated from the logistic model for each of 5 age groups. Potter JF, et al. J Gerontol. 1988;43(3):M59-M63

Relation between BMI and Muscle Mass Correlation between BMI and FFMI in 186,975 healthy white-ethnic individuals. R = 0.6225, P <0.001. FFMI = Fat-Free mass/heigth2 FFM = mainly muscle tissue Franssen et al. J Am Med Dir Assoc. 2014;15(6):448 e1-6

How often is Malnutrition present? Community 5% - 11% Institutionalized Patients 30% - 60% Hospitalized Patients 35% - 65% Nursing Homes 85% By 2030, nearly 20% of USA population will be 64 years or older 85% of elderly Americans have 1 or more chronic diseases Wilson, AJM, 1998, Rush, ARN, 1997

Sarcopenia (loss of muscle mass) Adults over the age of 60 have more often loss of muscle mass (sarcopenia) than loss of bone mass (osteoporosis) Sarcopenia (“poverty of flesh”) is the loss of skeletal muscle mass and strength related to aging Sarcopenia has large impact in many older adults and leads to a fast loss of quality of life Sarcopenia Less Muscle Mass Sensation of Increased Effort Fewer Physical Activities Muscle Loss

Consequences of loss of muscle mass Reduced strength and function in older adults limit their daily activities more vulnerable to become severely ill when they have an infection or are treated for another illness Higher mortality

Physical activity and muscle loss Physical activity of older adults becomes less that leads to muscle loss reduced need for calories Body responds with less desire to eat Older adults start to eat less during the day and thus reduce their protein intake

Protein intake in Older Adults Deutz et al., Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33(6):929-36.

Protein intake in Older Adults Deutz et al., Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33(6):929-36.

Ways to increase muscle mass At the moment, sarcopenia cannot be treated with any form of medication, unlike osteoporosis. The main treatment options to increase muscle size are: Exercise programs with weight-bearing exercises Increasing protein intake + higher quality of protein Deutz et al., Clinical Nutrition 2014

Recommendations for Older Adults Deutz et al., Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33(6):929-36.

Recommendations for Older Adults Deutz et al., Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33(6):929-36.

Which proteins are optimal? Which proteins have the higher biological value? Higher biological value (BV) indicates that less is needed! Are there specific requirements of certain proteins/amino acids in chronic disease states? Whey/Casein Dairy Protein: 96 Human milk: 95 Chicken egg: 94 Soybean milk: 91 Cow milk: 90 Cheese: 84 Rice: 83 Defatted soy flour: 81 Fish: 76 Beef: 74.3 Immature bean: 65 Full-fat soy flour: 64 Soybean curd (tofu): 64 Whole wheat: 64 White flour: 41 Wikipedia

24h balance studies in healthy subjects Relation between intake and net balance Kim et al., AJP 2014

Chronic wasting disease Chronic diseases Normal Chronic wasting disease Characterized by muscle wasting Cancer Chronic Obstructive Pulmonary Disease (COPD) Chronic Heart Failure Chronic Renal Failure

Disturbed nutritional status in chronic diseases and higher mortality 10-30% of patients with a stable chronic disease are underweight or have recent involuntary weight loss. Muscle loss despite normal body weight (hidden depletion) in 30-60% of patients Engelen ERJ 1994, 2011 Landbo et al, AJRCCM 1999

Excellent relation between intake essential amino acids and net protein Synthesis Quality of Supplement related to amount of EAA Leucine does not seems to make the EAA more anabolic Engelen, Deutz et al. Ann Oncology 2015

Muscle wasting in chronic diseases even in those patients who have normal/over weight! when (involuntary) body weight changes in time during disease progression after treatment during nutritional intervention Careful nutritional assessment of muscle mass is crucial in chronic diseases

Change in lean mass Deutz et al, Clinical Nutrition 2013

How to improve protein intake and metabolism in chronic diseases? Increase muscle buildup & Reduce muscle breakdown Protein intake needs to be high Quality of protein intake needs to be optimal Exercise Inflammation needs to be reduced >> 1.5 g/kg bw E.g. Fish oil Milk proteins Specific (essential) amino acids HMB MULTIDISCIPLINARY APPROACH (Resistance) exercise

Optimal protein intake (and exercise) are critical in older adults and chronic diseases There could be a role for specialized nutritional components like HMB