assessment della malnutrizione e bilancio ......protein and energy supplementation in elderly people...
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ASSESSMENT DELLA MALNUTRIZIONE
E BILANCIO ENERGETICO
NEL SOGGETTO ANZIANO
Gianni Biolo
Clinica Medica AOUTS
Dipartimento di Scienze Mediche, Chirurgiche e della Salute
Università di Trieste
Email: biolo@units.it
Congresso Nazionale Società Italiana di Gerontologia e Geriatria
Milano, 21-24 Novembre 2012
Protein and energy supplementation in
elderly people at risk from malnutrition
Cochrane Database Syst Rev 2009
0
-0.50 -0.40 -0.30 -0.20 -0.10 0.00 0.10
benefit arm
0 1 2 3 4 5
2.2 (95% CI 2.4 to 1.8) P<0.05
41 trials
% WEIGHT CHANGE
0
-0.50 -0.40 -0.30 -0.20 -0.10 0.00 0.10
benefit arm
1 0.9 0.8 0.7 0.6 0.5
RR 0.79 (95% CI 0.64 to 0.94) P<0.05
2461 malnourished people
MORTALITY
0
-0.50 -0.40 -0.30 -0.20 -0.10 0.00 0.10
benefit arm
1 0.9 0.8 0.7 0.6 0.5
RR 0.86 (95% CI 0.75 to 0.99) P<0.05
24 trials
COMPLICATIONS
62 trials
10,187 participants
commercial “sip-feeds”
intervention < 18 months
Tipo di diagnosiValutazione delle condizioni (tipo, gravità, durata) associate a rischio di malnutrizione
Valutazione dell’introito di alimenti e/o di perdite di nutrientiRischio con apporto alimentare insufficiente, attuale o prevedibile, per un periodo : 5 gg in pazienti già malnutriti 10 gg in pazienti normonutriti 7 gg in pazienti con ipercatabolismo moderato (azoturia 11-15 g/die)
o severo (azoturia >15 g/die)oppure con: Vomito / diarrea quotidiani > 5-7 gg
Valutazione del calo ponderaleRischio grave con perdita non intenzionale 5% in 1 mese o 10% in 3-6 mesi
Esami di laboratorioRischio con:Albuminemia < 3,5 mg/dlNumero linfociti < 1500/mm3
Giudizio clinicoBasato sull’anamnesi e sull’esame obiettivo (cachessia, edemi, ecc.)
PROPOSTA DI “SCREENING” NUTRIZIONALE INIZIALEPROPOSTA DI “SCREENING” NUTRIZIONALE INIZIALE
INACTIVITY ± INFLAMMATION ± ANOREXIA
-1.4
-1
-0.6
-0.2
0.2
kg
Eucaloric
Ambulatory
Hypocaloric
Ambulatory
Hypocaloric
Bed Rest
Eucaloric
Bed Rest
*
CHANGES IN
LEAN MASS (DEXA)
Malnutrizione acuta(ipermetabolismo,ipercatabolismo)
Digiuno(giorni)
Malnutrizione
cronica
StressacutoSemidigiuno
(mesi)
Stresssevero
CO
MPL
ICA
NZ
E - M
OR
TA
LIT
À
Deplezione proteica
Co
nsu
mo e
ner
get
ico
NORMALESTATO DI
NUTRIZIONE
SOVRAPPOSIZIONE DI MALNUTRIZIONE ACUTA O CRONICA E
STRESS METABOLICO E LORO SIGNIFICATO PROGNOSTICO
Modificata, da Pettigrew RA, Clin Gastroenterol, 1988
Malnutrizione acuta(ipermetabolismo,ipercatabolismo)
Digiuno(giorni)
Malnutrizione
cronica
StressacutoSemidigiuno
(mesi)
Stresssevero
CO
MPL
ICA
NZ
E - M
OR
TA
LIT
À
Deplezione proteica
Co
nsu
mo e
ner
get
ico
NORMALESTATO DI
NUTRIZIONE
NORMALESTATO DI
NUTRIZIONE
SOVRAPPOSIZIONE DI MALNUTRIZIONE ACUTA O CRONICA E
STRESS METABOLICO E LORO SIGNIFICATO PROGNOSTICO
Modificata, da Pettigrew RA, Clin Gastroenterol, 1988
INACTIVITY ± INFLAMMATION ± ANOREXIA
PRE-CACHEXIA Chronic disease + ↑CRP + anorexia +
weight loss ≤5%
CACHEXIA Chronic disease + ↑CRP + anorexia + weight
loss >5kg (or BMI <20 kg/m2) + at least three of
the following: dynapenia, fatigue, anorexia,
↓FFM index, abnormal biochemestry (↑CRP,
anemia, ↓albumin)
INACTIVITY ± INFLAMMATION - ANOREXIA
• Body weight • Body mass index (kg/m2)
NUTRITIONAL
ASSESSMENT
• Lean body mass (DEXA) • Fat-free mass (bio-impedance; anthropometry)
• Fat-free mass index (kg/m2)
9.6
17.820.3
39.9
0
25
50
Male Female
Perc
ent
Prevalence of nutritional depletion in a large
out-patient population of patients with COPD Vermeeren et al., Respir Med 2006
Malnutrition was defined as:
body mass index ≤21 kg/m2
fat-free mass index ≤15 (females) or ≤16 (males) kg/m2
INACTIVITY ± INFLAMMATION ± ANOREXIA
MUSCLE
DEPLETION
CONTRACTILE
IMPAIRMENT
Dynapenia
Fatigue
Disability and falls
Impaired ventilation
Osteoporosis
Bone fractures
METABOLIC
IMPAIRMENT
Anabolic resistance
Insulin resistance
Dyslipidemia
↓ glutamine
↓ myokines
Impaired immunity
FFM index <16 kg/m2 for men and
<15 kg/m2 for women
2115
cancer patients
15%
obesity
15%
sarcopenic obesity
SURVIVAL
Changes in fat mass (bioimpedence)
0
1
2
3 * §
(kg)
*, p<0.05 significant different from zero; §, p<0.05 versus near-neutral energy balance
Positive Energy Balance
Near-neutral Energy Balance
EFFECTS OF POSITIVE ENERGY
BALANCE ON BED REST-MEDIATED
MUSCLE ATROPHY
Changes in
fat-free mass
(bioimpedence)
*§
*
(kg)
Changes in vastus
lateralis thickness
(ultrasounds)
(cm)
-0.5
-0.4
-0.3
-0.2
-0.1
0
-5
-4
-3
-2
-1
0
* §
* §
*
*
§
-50
0
50
100
150
200
Δ (%
)
CRP
PLASMA MYELOPEROXIDASE ERYTHOCYTE GLUTATHIONE SYNTHESIS RATE
-10
-5
0
5
10
15
20
25
0
20
40
60
Δ (
%)
LEPTIN
0
10
20
30
40
Δ (%
)
GHRELIN
§
§
Δ (
%)
-50
0
50
100
150
200 §
Δ (%
) *, p<0.05 significant different from zero; §, p<0.05 versus lower energy balance
*
*
CROSS-TALK BETWEEN FAT
AND MUSCLE DURING
INACTIVITY AND AGING
POSITIVE
ENERGY
BALANCE
INFLAMMATION
REDOX UNBALANCE
MUSCLE
ATROPHY
ENERGY METABOLISM AND BODY COMPOSITION
0
700
1400
2100
2800
En
ergy (
kcal/
day)
0
35
70
Bod
y w
eig
ht
(kg)
RESTING
ENERGY
EXPENDIT.
ACTIVITY
RELATED
ENERGY
EXPENDIT.
ENERGY
EXPENDITURE
ENERGY
INTAKE
ENERGY BALANCE
LEAN
TISSUES
ADIPOSE TISSUE
BODY
COMPOSITION
male
31 yrs
male
66 yrs
female
73 yrs
0
700
1400
2100
2800
En
erg
y (
kca
l/d
ay
)
0
35
70
Bo
dy
wei
gh
t (k
g)
ENERGY BALANCE
LEAN
FAT ACTIVITY
RELATED
ENERGY
RESTING
ENERGY
EXPENDIT.
BODY
COMPOSITION
0
700
1400
2100
2800
En
erg
y (
kca
l/d
ay
)
0
35
70
Bo
dy
wei
gh
t (k
g)
ENERGY BALANCE
LEAN
FAT
ACTIVITY
RESTING
ENERGY
EXPENDIT.
BODY
COMPOSITION
AG
EIN
G
MUSCLE DEPLETION
&
INCREASED FAT MASS
0
20
40
60
80
100
30 40 50 60 70
BODY WEIGHT
LEAN MASS
FAT MASS
Age (years)
kg
CROSS-SECTIONAL STUDY
252 healthy subjects with normal body mass index, 35 to 65 years
BODY WEIGHT AND COMPOSITION
Clinica Medica – University of Trieste
REDUCED ENERGY
REQUIREMENT
IN CANCER
PATIENTS
PHYSICAL
ACTIVITY
ENERGY
INTAKE
5000
5250
5500
5750
6000time effect P = 0.02.
(kJ
/d)
RMR Weight and Body Composition Changes during
and after Adjuvant Chemotherapy in Women with Breast Cancer J Clin Endocrinol Metab 2004
CHEMOTHERAPY PRE 2 wk 6 wk
LEAN MASS 39
40
41
42
43
21
22
23
24
kg kg
time effect P < 0.05
time effect P < 0.05
FAT MASS
ENERGY
EXPENDITURE
ENERGY
REQUIREMENT
• Indirect calorimetry (O2 consumption)
• Equations
based on
• Body weight
• Body composition (proportional to lean mass)
• Correction factors for physical activity
• Correction factors for degree of systemic inflammation activation
≈
The majority of sick elderly patients require at least 1 g protein/kg/day and around 30 kcal/kg/day of energy, depending on their activity.
ANABOLIC RESISTANCE OF AGEING
INCREASED PROTEIN REQUIREMENT
• INACTIVITY
• AGEING
• ACUTE AND CHRONIC DISEASE STATES WITH ACTIVATION OF SYSTEMIC INFLAMMATION
ANABOLIC RESISTANCE
The majority of sick elderly patients require at least 1 g protein/kg/day and around 30 kcal/kg/day of energy, depending on their activity.
ENERGY METABOLISM AND BODY COMPOSITION
0
700
1400
2100
2800
En
ergy (
kcal/
day)
0
35
70
Bod
y w
eig
ht
(kg)
RESTING
ENERGY
EXPENDIT.
ACTIVITY
RELATED
ENERGY
EXPENDIT.
ENERGY
EXPENDITURE
ENERGY
INTAKE
ENERGY BALANCE
LEAN
TISSUES
ADIPOSE TISSUE
BODY
COMPOSITION
Exercise Training for Physical Frailty
in Very Elderly PeopleFiatarone et al., New Engl J Med 1994
Randomized, placebo -controlled trial. 100 frail nursing home residents. Progressive resistance exercise training over a 10 -week period.
Exercise Training for Physical Frailty
in Very Elderly PeopleFiatarone et al., New Engl J Med 1994
-4
-2
0
2
4
6
TRAINING
CONTROL
P<0.05
-4
-2
0
2
4
6
TRAINING
CONTROL
P<0.05
Randomized, placebo -controlled trial. 100 frail nursing home residents. Progressive resistance exercise training over a 10 -week period.
Perc
en
tch
an
ges
in t
hig
hm
uscle
mass
Exercise Training for Physical Frailty
in Very Elderly PeopleFiatarone et al., New Engl J Med 1994
Randomized, placebo -controlled trial. 100 frail nursing home residents. Progressive resistance exercise training over a 10 -week period.
Exercise Training for Physical Frailty
in Very Elderly PeopleFiatarone et al., New Engl J Med 1994
-4
-2
0
2
4
6
TRAINING
CONTROL
P<0.05
-4
-2
0
2
4
6
TRAINING
CONTROL
P<0.05
Randomized, placebo -controlled trial. 100 frail nursing home residents. Progressive resistance exercise training over a 10 -week period.
Perc
en
tch
an
ges
in t
hig
hm
uscle
mass
RESISTANCE EXERCISE TRAINING DECREASES SKELETAL
MUSCLE TNF-alpha IN FRAIL ELDERLY HUMANSet al., The FASEB Journal 2001
RESISTANCE EXERCISE TRAINING DECREASES SKELETAL
MUSCLE TNF-alpha IN FRAIL ELDERLY HUMANSet al., The FASEB Journal 2001Greiwe
0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTERBEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTERBEFORE AFTER
0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
P<0.01
BEFORE AFTER0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
P<0.01
BEFORE AFTERBEFORE AFTER
RESISTANCE EXERCISE TRAINING DECREASES SKELETAL
MUSCLE TNF-alpha IN FRAIL ELDERLY HUMANSet al., The FASEB Journal 2001
RESISTANCE EXERCISE TRAINING DECREASES SKELETAL
MUSCLE TNF-alpha IN FRAIL ELDERLY HUMANSet al., The FASEB Journal 2001Greiwe
0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTERBEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTERBEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTERBEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTERBEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTERBEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTERBEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTERBEFORE AFTER0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
0
25
50
75
100T
NF
-alp
ha
mR
NA
(arb
itra
ryu
nit
s)
P<0.01
BEFORE AFTERBEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTERBEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTERBEFORE AFTER0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
0,0
1,0
2,0
3,0
4,0
TN
F-a
lph
ap
rote
inco
nte
nt
(pg
/mg)
P<0.01
BEFORE AFTERBEFORE AFTER
0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
P<0.01
BEFORE AFTER0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
P<0.01
BEFORE AFTERBEFORE AFTER0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
P<0.01
BEFORE AFTERBEFORE AFTER0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
0
2
4
6
Pro
tein
syn
thes
isra
te (
g/h
)
P<0.01
BEFORE AFTERBEFORE AFTER
AVERAGE ANNUAL CHANGE IN FEV1 (ML/YR) IN THE LOW PHYSICAL ACTIVITY GROUP, AND ADDITIONAL RELATIVE CHANGE† (95% CI) IN THE MODERATE AND HIGH PHYSICAL ACTIVITY GROUPS (LINEAR REGRESSION MODEL)
2007
AVERAGE ANNUAL CHANGE IN FEV1 (ML/YR) IN THE LOW PHYSICAL ACTIVITY GROUP, AND ADDITIONAL RELATIVE CHANGE† (95% CI) IN THE MODERATE AND HIGH PHYSICAL ACTIVITY GROUPS (LINEAR REGRESSION MODEL)
2007
-30
-20
-10
0
10
20
30
40
50
GLUCOSE AND
INSULIN
AMINO ACIDS
nm
ol
PH
E/m
in x
100 m
l le
g v
ol.
REST
POST-EXERCISE
MUSCLE PROTEIN BALANCE
FASTING
*
*
*: P<0.05 POST-EXERCISE VS. REST
NS
AJPENDO 1995
AJPENDO 1997
Diabetes 1999
SHORT-TERM BED REST IMPAIRS AMINO ACID-INDUCED
PROTEIN ANABOLISM IN HUMANS
J Physiol 2004
ANABOLIC SENSITIVITY AND RESISTANCE
IN EXERCISE AND BED REST
EXERCISE BED REST
Adjusting for covariates (age at inclusion, BMI at inclusion, and BMD of the femoral neck at inclusion) a significant (P < 0.05) difference was seen in the response to training between the two groups.
Strength improvements from 6 to 24 wk, a significant difference was apparent between groups: nutrient group, 9±3% vs. control, 1±2% (P
< 0.05).
• INACTIVITY
• SYSTEMIC
INFLAMMATION
ANABOLIC
RESISTANCE
MUSCLE
ATROPHY
INCREASED
FAT MASS
METABOLIC VICIOUS CYCLE IN AGEING AND CHRONIC DISEASES
EXERCISE +
ENERGY BALANCE
• INACTIVITY
• SYSTEMIC
INFLAMMATION
ANABOLIC
RESISTANCE
MUSCLE
ATROPHY
INCREASED
FAT MASS
PROTEIN
INTAKE
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