assessment della malnutrizione e bilancio ......protein and energy supplementation in elderly people...

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: [email protected]

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


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


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.



-4

-2

0

2

4

6

TRAINING

CONTROL

P<0.05

-4

-2

0

2

4

6

TRAINING

CONTROL

P<0.05


Perc

en

tch

an

ges

in t

hig

hm

uscle

mass






-4

-2

0

2

4

6

TRAINING

CONTROL

P<0.05

-4

-2

0

2

4

6

TRAINING

CONTROL

P<0.05


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


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



MUSCLE TNF-alpha IN FRAIL ELDERLY HUMANSet al., The FASEB Journal 2001


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


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


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


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


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


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


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


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


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


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


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


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


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


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

assessment della malnutrizione e bilancio ......protein and energy supplementation in elderly people...

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